The Price of Justice

The four principles of biomedical ethics (bioethics), credited to Tom L. Beauchamp and James F. Childress, are Autonomy, Beneficence, Non-Maleficence and Justice.  Dorothy’s story primarily focused upon the first three and, although certainly there was injustice done to her and to her family, this time I address justice as it relates to the elder and disabled population in post-acute care as a whole.

The “average private pay rate” in a California nursing home is $8515.00 per month.  In a 30 day month, that comes to $283.00 per day.  However, very few people are able to pay this amount for “long term care” which I use here to describe the kind of care provided to someone who needs inpatient 24/7 care for a chronic illness rather than short term recovery.  Most such individuals end up receiving Medicaid which we call Medi-Cal in California because . . . well, because we’re California!

So, what does Medi-Cal pay a nursing home?  In California it ranges between $180 and $232 per day depending upon the size of the facility and the county in which it is located (Long Term Care Provider Manual, Facility Per Diem, March 2017).  Compare this to the average daily cost of care in an acute care hospital which ranges from $2140 to $3500 per day (in California). (bit.ly/HospitalCost) .

But doesn’t Medicare pay something?  Yes, it does but only for a short term, up to 100 days (with an out-of-pocket co-pay of $164.50  for days 21-100) and then only if the patient qualifies for “skilled” nursing or therapy as defined by Medicare.  Additionally, Medicare payment is available only after a three day hospital stay and, as outlined in a recent New York Times article, patients are frequently placed on “observation” status rather than “admitted” to the hospital, thus losing their ability to have Medicare pay anything at all for inpatient post-acute care. (bit.ly/NYTMedObs) There is currently a court case challenging this practice but, at present, this is the current state of affairs.

So, back to justice (and thanks for sticking with me thus far).  One would expect that a hospital stay would be costlier than a stay in a skilled nursing facility but according to the statistics above, it is over ten times more expensive.  A nursing facility does not need to have expensive diagnostic equipment, a surgical suite, etc. but it does need to have 24/7 care provided by nursing assistants, medication and treatment administration by RNs and LVNs, as well as overall supervision by other RNs including a Director of Nursing.  It needs to have a licensed administrator, consulting pharmacist and an MD medical director as well as a dietician, social services staff, dietary services, housekeeping, maintenance, and laundry.  This is not an exhaustive list, of course.  Add to this the fact that these facilities today are highly regulated and care for patients far more medically complex than ever before.  Compared to patients for whom I provided care as a working nurse 30 years ago, at least a third would have been in an acute care hospital back then.

I believe, from what I have personally seen, that the vast majority of nursing facility staff and management team members strive to provide good care.  Despite the fact that most serve a predominantly Medi-Cal population and receive less than one-tenth of what a hospital is paid, they do well within this budget.  Further, there aren’t long lines of nurses and nursing assistants waiting for the opportunity to work in a nursing home.  Even I must admit that, when I first graduated from nursing school, I first went to work in a hospital because I didn’t want to be a nurse who worked in “those places.”  I quickly learned that the nursing home environment was a place where I could really use my nursing skills and where the physicians, who only made monthly visits, could depend upon me to be their eyes and ears; most of them listened to my recommendations with respect.

There are certainly anecdotal stories, like Dorothy’s, about things that clearly should not have happened.  However, I have also seen beautifully written thank you notes written by grateful patients and families.  Are there things that I would like to see that would improve long term care?  Absolutely. For those with the physical and mental ability to remain in their own home or in a lower level of care, I would like to see care brought to them.  When inpatient care is needed, I would like to see truly person-centered, individualized care in cheerful private rooms filled with personal mementos to provide comfort.  I would like to see meals and personal care given on a schedule based upon individual desires.  Overall, I would like to see medical needs met in a far less medicalized environment and increased support for psycho-social needs, particularly at the end of life.

Justice.  Sometimes we get what we pay for.