When it comes to nursing home staffing and wages, problems abound with appropriate care. In past columns I have bemoaned the pittances paid to nursing aides. These workers perform jobs that very few people would do and are grossly underpaid. There is a bill in the Rhode Island legislature, H56-12 that would increase salaries for these front line workers and provide a daily average of 4.1 hours of direct nursing care per resident, a standard laid out in 2000 by the RI Department of Health. The House passed the legislation but it languishes in the Senate. Get on the dime, Speaker, Nick Mattiello!
Speaker Mattiello has paused its passage since he is listening to the president of the nursing home trade association. The president is correct that insufficient funds are paid to nursing homes so the legislation mandates could lead some to insolvency. The solution is not rocket science. Reimbursement for Medicaid patients must increase forthwith in order to mitigate bankruptcy.

The COVID-19 outbreak has highlighted the inadequacy of the nursing home system both in Rhode Island and in the nation. Approximately 75 percent of Rhode Island deaths were among residents in nursing homes and assisted living facilities because of staff shortages and access to protective equipment. There also exists a perverse incentive that led to Coronavirus outbreaks, namely the reimbursement level being higher if a facility took coronavirus patients discharged from hospitals.

HARPER’S (September 2020) published an investigative report of elder abuse in this country emanating from COVID-19 and reimbursement principles. The virus found its most ideal conditions in the warehouses storing American elderly population (Harpers, p. 44) where the business model for nursing homes is a shell game. Initially, the patient is covered by Medicare which pays a higher amount for treatment and rehabilitation, but only for a limited time. By the time Medicaid kicks in, the amount is far less for care and a nursing home may only make it worthwhile by cutting corners.

The number of for-profit nursing homes exacerbates the problem of cutting corners and/or accept COVID-19 patients, where reimbursement is higher (average $699 per day), notwithstanding the reality that many facilities had little resources to handle the illness. Under President Ronald Reagan, nursing home regulations were dismantled and his administration virtually ceased inspections. REIT companies burgeoned with portfolios of nursing home facilities. Private equity firms gobbled up nursing homes and health facilities and “lease” the home at inflated prices to landlord companies owned by them.

At present, Rhode Island has 84 nursing homes of which about 80 percent are for-profit entities. No doubt they are trying hard to deliver services but the divergence of reimbursement from funding sources is a tempting formula to cut corners. The CARES Act pumped $ 5 billion without strings attached to nursing homes. Without oversight and families able to gauge treatment, the recipe to cut corners is there. These facilities are now also looking to the Republicans to grant them immunity from civil or criminal liability.
So, with the lip service of caring for seniors, it’s time for legislators to put money where their mouths are. Create a study commission for a long overdue oversight and cost structure, but implement the staffing and treatment recommendation which has been languishing for 20 years. Elderly and handicapped patients are waiting.

Arlene Violet is an attorney and former Rhode Island Attorney General.