Greetings Relatives/Frens/Humans, the Chinle, Arizona, Navajoland Nursing Home is scheduled to go before the Navajo Nation Council Health, Education & Human Services Committee Dec. 9. I looked for info on Navajos in nursing homes during COVID-19 and didn’t find any news. I did find good information from the AARP or American Association of Retired Persons about Nursing Homes. It’s a lot of information but a good read to inform yourself about what’s happening in Nursing Homes across the country. And with the Report by the Chinle Navajoland Nursing Home, which is scheduled to be provided by Chinle Nursing Home Director Wayne Claw.
Jill Jim, director of the Navajo Nation Department of Health, is also on the Health, Education & Human Services Committee proposed agenda and so she should have data regarding Navajo elders in Nursing Homes during this COVID-19 pandemic. And for Clarification, Jill Jim is not a medical doctor. She has a PhD. But President Nez & Vice President Lizer promote her as Dr. Jill Jim and I have not heard her explain that she is a medical doctor. I’m hoping that since President-elect Biden & Vice President-elect Harris selected Jill Jim to represent the Navajo people that the Navajo people will Finally see a copy of the Navajo Nation Comprehensive COVID-19 Response Plan, which I have been requesting since March 2020. I’ve also been asking for the Names of the medical experts, not health experts, that have been advising Nez-Lizer since Day One of the COVID-19 Pandemic, when Nez & Lizer & Jill Jim & Navajo Area Indian Health Service Director Roselyn Tso & Chief Medical Officer Loretta Christensen repeatedly announced that Navajo elders were the most Vulnerable to COVID-19 and needed to be Protected. So what have Nez, Lizer, Jim, Tso, and Christensen provided in the Navajo Nation Comprehensive COVID-19 Response Plan to Protect Navajo Elders and their caregivers, who could be Nursing Home staff or Family members.
Nursing Homes’ Flawed Business Model Worsens COVID Crisis
To understand the industry’s shortcomings, look at laws going back 85 years. by Harris Meyer, AARP, December 7, 2020
To understand who or what is to blame for the more than 100,000 deaths caused by the coronavirus among residents and staff of U.S. long-term care facilities between March and Thanksgiving, it’s useful to consider a devastating calamity that hit in 2005: Hurricane Katrina.
In the days, weeks and months after New Orleans was overwhelmed with flooding from the hurricane, critics pointed to the slow response from the federal government, decisions made by the city’s mayor and the state’s governor, a delay in engagement from the U.S. president, the greed and influence of private businesses, and even the stubbornness of the city’s residents as the causes for all the pain that had occurred. And many of the charges had some level of truth. But in time, two simple but profound causes were ultimately found to be the root of what happened: bad infrastructure decisions that dated back decades — in New Orleans’ case, a poorly maintained, inadequate levee system — and a storm of such magnitude that once 23 of the levees were breached, little could be done to prevent 80 percent of the city from going underwater.
Experts foresee a similar reckoning for what has been happening in America’s nursing homes during the COVID-19 pandemic. Yes, they say, fingers can and should be pointed at how elected officials, regulators, owners and others responded to the crisis. But the American nursing home industry exists as it does today because of federal laws and regulations that go back 85 years. The infrastructure these laws created, no matter how well intended, didn’t anticipate the future, nor could it foresee a health storm of this magnitude, speed and deadliness.
To fully understand the underlying causes of the nursing home debacle of the past nine months, AARP spoke with dozens of experts, from scientists and researchers to historians, doctors, nursing home staff and industry heads. The interviews revealed large and small mistakes made at every level, from the federal government to states, local health departments and individual nursing homes. Here’s what they told us.
The nation’s 15,600 nursing homes generated about $166 billion in revenue in 2017—a little more than what U.S. hotels took in by renting out their rooms. And nursing homes receive about the same amount for most of their residents as nice hotels get for a night’s stay.
But the similarities end there. For example, roughly 30 percent of nursing homes are owned by nonprofit organizations predominantly affiliated with religious groups, ethnic aid societies and social service agencies. They strive to maximize revenue and efficiency, but any unspent revenue is used to improve and expand their facilities and services.
The remaining 70 percent of homes are for-profit — free to pay out income to owners once they cover operating expenses and other obligations. Owners include national chains, regional chains and stand-alone facilities. About 1 in 7 for-profit homes are controlled by private equity investors — something that can be problematic, as I’ll explain shortly.
To understand nursing homes’ finances, you have to start with their revenue. Three-fifths of the nation’s 1.3 million nursing home residents’ fees are paid by Medicaid, the federal-state insurance program for low-income Americans. These older adults (and people with disabilities) often spend their remaining years in a nursing home, at taxpayers’ expense.
How profitable is the Medicaid business? It depends on whom you ask. The average Medicaid payment, which varies by state, is around $200 per resident per day. But unlike a hotel charging that price, nursing homes have to provide hands-on care that many residents need with their daily activities. They also must provide meals, medical services and more.
Nursing home operators consistently say that $200 doesn’t cover their costs. Industry critics aren’t so quick to agree, citing owners’ opaque finances and multiple income sources (more on that later). “We don’t know whether Medicaid rates are too low or not,” says
Charlene Harrington, a University of California, San Francisco, professor emerita who has studied nursing homes for decades.
What is clear is that the share of this revenue spent on paying and training personnel isn’t enough. The industry’s staff turnover is high, and there’s a critical shortage of people qualified to provide patient care. This detracts from residents’ well-being at any time, but it’s proven especially dangerous in 2020.
And $200 a day isn’t enough to fund a deep well of supplies or to have private rooms available that might reduce the spread of infection. It has been especially inadequate this year, when facilities faced suddenly skyrocketing costs for infection-control supplies and tests.
Well before the coronavirus blindsided the industry, the numbers were bleak. Consider the most recent report of the government’s Medicare Payment Advisory Commission. In 2018, MedPAC found, nursing homes had an operating profit margin of negative 3 percent on patients paid for by Medicaid and other non-Medicare sources. In other words, for every $100 they took in for these residents, they spent $103 on their care — clearly a losing proposition. During the pandemic, no doubt the math got worse.
If caring for Medicaid residents is such a poor business, how have nursing homes stayed afloat all these years? The answer is, chiefly, Medicare. While Medicare doesn’t pay for long-term nursing home care, it does cover skilled services and therapy for up to 100 days after a patient is discharged from a hospital. And it pays very well. In 2019, for example, Genesis HealthCare received $535 per resident per day from Medicare — about 2½ times the $215 it got for Medicaid patients.
Yes, Medicare residents usually need more care than Medicaid residents. Even so, Medicare is more profitable: For every $100 that nursing homes receive on behalf of these patients, an average of $10 is left over after subtracting the cost of the care — not a loss of $3.
The upshot is that nursing homes rely on a relatively small number of well-paying residents to make up for the money they say they lose on the rest. “It’s not a structure anyone would have designed from the outset,” says R. Tamara Konetzka, a professor of health services research at the University of Chicago.
Not surprisingly, nursing homes strive to admit more Medicare patients to offset what they say are losses on Medicaid. But that can lead to bad care decisions, Konetzka says, such as encouraging nursing homes to send Medicaid residents to the hospital so they can return as higher-paying Medicare patients.
This year, some nursing homes evicted Medicaid residents in favor of COVID-19 patients receiving care at the higher Medicare rate, according to The New York Times and other news outlets. Inappropriate discharges have long been a top complaint to long-term care ombudsmen nationwide; AARP Foundation has fought the practice in the courts.
Beyond the problematic payment system, researchers and policymakers question whether the for-profit ownership structure of most nursing homes is the best model for delivering care.
A number of research studies have found that for-profit nursing homes generally have significantly lower staffing levels and quality of care than nonprofit facilities, as measured by the Nursing Home Compare quality star rating system run by the government’s Centers for Medicare & Medicaid Services (CMS).
Of particular concern to industry followers are the estimated 10 percent of America’s nursing homes owned by private equity (PE) investment groups. Bankrolled by institutional investors and wealthy individuals, these PE firms typically buy businesses, make efficiency and/or cost-cutting changes to increase their apparent value, then sell them within three to five years. PE firms often borrow money against the businesses’ assets and receive management fees as well as a share of profits when the enterprises are sold.
Here’s their usual practice as it pertains to nursing homes, according to Harvard University professor of health care policy David Grabowski and other researchers: A firm will buy a nursing home, then place its buildings and other real estate — nursing homes’ most valuable asset— in a separate holding company. Other companies also owned by the investors will start providing management, laundry, supplies and other services to the nursing home. These ownership structures make it hard to figure out who is responsible for the quality of care and how to recover damages if a resident is injured, says Ashvin Gandhi, a health economist at UCLA who has studied private equity and nursing homes.
Once a nursing home starts paying these related companies, says Grabowski, the home may appear to be struggling, while at the same time the owners are making money from their other entities. The nursing home itself ends up saddled with debts incurred to pay off lenders who financed the PE firm’s purchase.
“The main reason these for-profit companies are in the nursing home business is to extract money through management contracts and lease agreements,” UCSF’s Harrington says. “They scream they have no money, but they’ve legally taken money out through all these related-party transactions.”
Deals like these have been going on for more than 20 years. Other for-profit firms have engaged in similar practices, separating out their real estate holdings and striking management and supply deals with related firms.
“Every dollar they squeeze out of a nursing home for profit is a dollar that isn’t going to the care of the residents,” says Patrick Woodall, a senior researcher at Americans for Financial Reform, a national coalition of consumer and civil rights groups.
Solutions, sadly, seem far off. “People get concerned when stories of poor nursing home care come out,” Konetzka says. “But politicians never run for office on a platform of raising taxes to improve Medicaid reimbursement.”
The industry itself isn’t always eager for change; it often lobbies at both the federal and state levels to oppose long-term care reforms.
Ultimately, a group effort will be necessary, says Bob Kramer, founder of the National Investment Center for Seniors Housing & Care: “It will take partnerships between the federal government, states, the long-term care industry and insurers to change the system and ensure that people can afford the care they need.”
According to the AARP, more than 43,000 long-term care residents and staff have died from COVID-19, representing over a third of the nation’s known coronavirus deaths, according to a Kaiser Family Foundation tally. While dire, this figure is an undercount, experts warn, because not all states are publicly reporting data yet. In many states more than half of coronavirus deaths are connected to long-term care facilities.
Although each state is required to report confirmed COVID-19 cases and deaths in nursing homes to the Centers for Disease Control and Prevention (CDC) — and individual facilities are required to report that information to residents and their families — they are not required to share these publicly. Some states, therefore, are choosing not to.
Most states are releasing some information on nursing home cases and deaths. But “it’s truly a patchwork of inconsistent data,” says Elaine Ryan, AARP vice president for state advocacy and strategy integration. The same goes for assisted living and other types of long-term care facilities, which, unlike nursing homes, are regulated by the states.
Some states are reporting the names of facilities with cases and deaths; others are releasing just the total number across all long-term care facilities. Certain states monitor all types of long-term care facilities, but others track only nursing homes. Some report daily; others, weekly. In short, the variations are huge.
On June 4 the Centers for Medicare & Medicaid Services (CMS) posted its first set of federal COVID-19 nursing home data on a new website. Although it captures data from all states, 12 percent of the nation’s 15,400 Medicare and Medicaid homes have not submitted figures for the count. New data is slated for June 18; however, the CMS plans to release just weekly updates after that.
AARP is advocating for consistent daily updates. “There’s a serious problem in these facilities,” Ryan says, “and we need to know where the outbreaks are so we can target additional resources to help save lives.”
The AARP has a list that tells you which states are publicly reporting, what they are reporting and how to find the information. Many of the states are updating their data more frequently than the CMS website, so it is wise to check both. Note: The AARP is updating its list as new data become available. Delays in updates are common, so check the time stamp when looking at this information. https://www.aarp.org/caregiving/health/info-2020/coronavirus-nursing-home-cases-deaths.html#
PROPOSED AGENDA
HEALTH, EDUCATION AND HUMAN SERVICES COMMITTEE
24th NAVAJO NATION COUNCIL
Regular Meeting, December 09, 2020, 10:00 a.m.
PRESIDING : Honorable Daniel E. Tso, Chairperson
Honorable Carl Roessel Slater, Vice-Chairperson
PLACE : Via Telecommunications –
Call In Number: 1-669-900-6833 Mtg. ID: 979-985-0956
Window Rock, Navajo Nation (Arizona)
□ Paul Begay, Jr. □ Charlaine Tso
□ Carl Roessel Slater □ Daniel E. Tso
□ Pernell Halona □ Edison J. Wauneka
1) CALL MEETING TO ORDER; ROLL CALL; INVOCATION; ANNOUNCEMENTS
2) RECOGNIZE GUESTS AND VISITING OFFICIALS
3) REVIEW AND ADOPT THE AGENDA
m: s: v: Yeas: Nays: Not Voting: Absent:
4) REVIEW AND ADOPT THE JOURNAL(S): November 09, 2020; November 20, 2020;
November 23, 2020
m: s: v: Yeas: Nays: Not Voting: Absent:
5) RECEIVING REPORT
a. Report on Chinle Navajoland Nursing Home Presenter: Wayne Claw, CEO, Chinle Navajoland Nursing Home; Honorable Carl R. Slater
m: s: v: Yeas: Nays: Not Voting: Absent:
b. Report on Proposed “Change” (for clarification) to the “Application Content” Requirements Contained within the Grant/Contract Conversion Maintenance Handbook Presenters: Patricia
Gonnie, Acting Superintendent of Schools, DODE; Darrick Franklin, ODAC Manager, Office of Dine Accountability and Compliance (ODAC)
m: s: v: Yeas: Nays: Not Voting: Absent:
6) OLD BUSINESS
a. Report on Update on FY2023 Budget Formulation Consultation from NDOH Presenters:
Dr. Jill Jim, NDOH Executive Director; Honorable Carl R. Slater
m: s: v: Yeas: Nays: Not Voting: Absent:
7) NEW BUSINESS
a. Legislation 0290-20 An Action Relating to Resources and Development, Health, Education and Human Services and Naabik’iyati’ Committees; Supporting Senate Bill 4529, “Tribal Connect Act of 2020” Sponsor: Honorable Amber Kanazbah Crotty; Co-Sponsor: Honorable Daniel E. Tso
(Eligible for Committee Action November 29, 2020)
m: s: v: Yeas: Nays: Not Voting: Absent:
b. Other –
m: s: v: Yeas: Nays: Not Voting: Absent:
8) CLOSE OF MEETING; ANNOUNCEMENTS; ADJOURNMENT
Adjournment Motion: s: v: Yeas: Nays:
THIS AGENDA SUBJECT TO CHANGE: The public is advised that the Navajo Nation Council Agenda and the Agendas of the Standing Committees
are not final until adopted by a majority vote of the Navajo Nation Council or the Standing Committees at a Navajo Nation Council or a Standing
Committee meeting pursuant to 2 N.N.C. §§163 and 183, Navajo Nation Council Rule of Order No. 7, and Standing Rule of Order No. 8.
