The current situation in healthcare delivery throughout the United States is bad, and among long-term care providers the situation is grim. And this is from an optimist.
Or, a former optimist. Now, I’m not so sure.
Unavoidable Facts
There is a shrinking supply of nursing homes, and the available workforce is constrained.
Sector advocacy groups are describing occupancy as “stabilizing,” but this is an artifact of sampling and not descriptive of across-the-board reality. Those nursing centers serving the preferred 10% of the hospital discharges, which are Medicare Part A or managed-care beneficiaries, with coverage several times higher than Medicaid beneficiaries, will continue to survive, although they too are having difficulty finding and retaining workforce.
The $600 day Medicare Part A beneficiary doesn’t help the SNF if it can’t staff the admission. Meanwhile, Medicaid beneficiaries continue to make up the bulk of occupancy and utilization for chronic long-term care, and serving this population causes providers to lose money – hour after hour, day after day, week after week. Things will not get any better as Medicare Part C (the mislabeled “Medicare Advantage” programs) continues to exert downward pressure on payments.
The recent public health tri-demic of resurgent COVID, RSV, and seasonal flu has created a surge in demand and utilization at hospitals, exacerbating the already constipated discharge functions at most. Progressively more hospitals are having difficulty discharging patients because of unavailable nursing home placements or home care visits.
Who’s the Optimist?
Into this Dickensian scene, we hear a growing chorus of optimists describing how, because of the leading-edge baby boomers, demand is going to skyrocket. Only a year ago, I anticipated that the surging demand from the aging baby boom population would require the adaptive reuse of everything from Motel 6s to college dormitories. Now I’m not so sure.
Qualitatively, the baby boom population will not accept or tolerate conditions such as exist in most nursing centers in the United States. Just as this cohort has redefined every phase of life through which its 64 million members have traveled, it will redefine and therefore quantitatively change all of our historically reliable indexes and algorithms for calculating utilization. Qualitative rejection will fundamentally disrupt models of quantitative demand.
The benchmark inflection point for demand in long-term care is 85 years of age. This may get extended by a year or two as the benefits associated with better, healthier lifestyle choices become manifest. By the year 2030, demand for long-term care supports and services will be significantly increasing, but now I am convinced that the quantitative demand for nursing centers will not grow proportionate to the overall population because of the qualitative rejection of the decrepit, unfit for purpose product, which we call nursing homes.
If not this, then WHAT?
How will demand be fulfilled? Not by hiring lots of amenable domestic and foreign workers, even though at least one national private duty home care provider has said this is its plan. Unless there is a surge – even a doubling – of the unemployment rate, and a sudden reversal of nationalistic, xenophobic tendencies, there will not be sufficient low-wage workforce to meet the needs. In fact, there probably isn’t now. The demand from 2030 forward will have to be met by a creative, patchwork quilt of family and nonprofessional caregivers, mutual support groups, and ambient technologies.
Without a doubt, nobody in the United States wakes up in the morning in 2024 and says: “Great! I’m moving into a nursing home today!” Do we really think that this will change in the next six years?
Is there hope for REAL change?
There is a sophisticated planning model called Critical Junctures that has been used to predict when and how governments and populations reject the status quo and make massive, pivotal change. Looking for a glimmer of hope, I studied these models last year and wrote about them, believing that the long-term care jalopy in the United States would soon break down completely, thereby approaching a Critical Juncture.
Now, I’m not so sure.
Nursing homes continue to close, home care agencies are unable to staff shifts, social service agencies cannot keep up with demand, community hospitals are operating at a loss, patients that should be discharged from hospitals to nursing care are sent home without care and, in an absolutely punitive, “don’t distract me with the facts” approach, the Biden administration appears ready to implement staffing requirements which will further crush the sector.
I thought I had seen the worst. Now, I am not so sure.