In 2010, the Centers for Disease Control and Prevention (CDC) reported that nationwide about 123,600 nursing home residents were sent to an emergency room within a 90-day period for injuries they sustained while residing in nursing homes. This staggering statistic reveals a serious problem with American nursing homes. According to the CDC report, an incredible 40 percent of those ER visits were completely preventable.
So, who pays for these nursing home mistakes? Well, in most cases, taxpayers end up footing the bill through Medicare payments. The New York Times did a report on this issue back in 2015, which revealed just how serious this problem is. Experienced nursing home injury lawyers know this problem all too well, because it is a common subject that comes up during lawsuits against southern Illinois nursing homes that try to avoid liability for injuries to residents.
Medicare Payments for Nursing Home Injuries
Remarkably, about 22 percent of nursing home residents who stayed in a facility for 35 days or less suffered an injury due to medical malpractice at the nursing home. An additional 11 percent of these Medicare beneficiary nursing home residents experienced temporary injuries at nursing homes.
The cost to Medicare is enormous. In a 2014 report by the U.S. Department of Health and Human Services, the Inspector General discovered that Medicare paid approximately $2.8 billion (with a capital “B”) paying for injuries caused by nursing homes in 2011 alone. While more recent numbers are not available, given the increased cost of care, one can only assume that this number is skyrocketing.
Why is Medicare Paying for Nursing Homes’ Mistakes?
It’s all about greed – plain and simple. The majority of Illinois nursing homes today are owned and operated by private corporations. Unlike most southern Illinois hospitals, they are not non-profits. Nursing homes have four ways to get paid for care:
- Long-term care insurance. Residents with long-term care insurance are rare. But these insurance policies are limited to about 1 or 2 years of payments. They also do not pay the full cost in most instances.
- Private Pay. This is pretty straightforward. Some patients with the means to pay cash simply pay the full “rack rate” for nursing home care. These are a dream for nursing homes, but these types of residents are a tiny fraction of all patients in rural communities. Most cannot afford the nearly $8,000 average cost per month.
- Medicaid. Illinois Medicaid is the primary payor for the vast majority of nursing home residents. When people age and require skilled nursing services, they usually spend their money until they qualify for Medicaid. Then the state takes over paying the bill, but at a much lower rate. In most cases, Medicaid pays about 15-20 percent of the total cost, if that. As one might imagine, this is not ideal for nursing home corporations.
- Medicare. As DHHS revealed in the 2014 report, Medicare pays about 84 percent more than Medicaid. That’s a huge difference in revenue. But Medicare is not designed to pay for long-term stays. In fact, Medicare only pays for the first 100 days (with gradually declining rates), but it only pays if all the following conditions apply.
Conditions Required for Medicare to Pay
Medicare Part A is available to all Americans who have reached 65 without charge. But Part A coverage has strict limitations and requirements:
- It only covers up to 100 days of nursing home care per event
- The Medicare beneficiary must go to the nursing home within 30 days of hospitalization
- The hospitalization must have lasted at least 3 days (not counting the date of discharge), so outpatient does not count
- The nursing home care must be directly related to the reason for hospitalization
- The care received in the nursing home must not be available in-home, and it must be delivered per the orders of a physician (MD), physician’s assistant (PA), or nurse practitioner, and the care must be provided on a daily basis
- Once the nursing home or a licensed physician determines that the resident is unlikely to recover or will need longer admission, Medicare stops
- If at any point it becomes clear the resident will not be able to return home within 30 days, Medicare will stop
Where Things Typically Go Wrong
The Center for Medicare Advocacy reported that from 2003 to 2008, staffing problems remained one of the biggest reasons for nursing home injuries. Here’s how this plays out in many cases.
A resident is admitted to a nursing home for a chronic medical condition, following a lengthy hospitalization or surgery. Upon admission, the nursing home begins receiving Medicare dollars at first, then upon Medicare stopping payments, Medicaid kicks in. At some point during the nursing home admission, the resident suffers a serious injury. They are transferred to a hospital for treatment, where Medicare then begins paying for this “new event or illness.” The resident receives treatment that is paid for by Medicare, and then returns to the nursing home for long-term care, again temporarily being paid for by Medicare until Medicaid kicks in again. As you can see, each time the resident is injured, the nursing home actually profits!
Disproportionate Impact on Rural Illinois Communities
In rural parts of central and southern Illinois, the effects of this systemic problem can be felt in a very real way. The majority of small community hospitals in Illinois are nonprofits that operate on lean budgets. Further, Medicaid patients make up the lion’s share of revenue for these hospitals. When low-income patients are repeatedly treated for nursing home injuries, these hospitals bill Medicare for treatment. However, Medicare also has a policy of not paying for healthcare-acquired conditions, also known as “never events.”
If a resident suffers one of these never events, there’s a good chance Medicare will deny payments. Even if Medicare does pay, it’s often at a significant reduction in typical charges. To put this in perspective, Johns Hopkins University reports that U.S. hospitals spend upwards of $34 billion on fall-related treatment alone in any given year.
Common Injuries for Southern Illinois Nursing Home Residents
Among the many ways nursing homes can mess up care, there are about 5 primary injuries that cost the most to treat:
- Falls & Fractures. At Jerome, Lindsay & Salmi, LLP, we regularly fight to hold nursing home companies accountable for their neglect and abuse of southern Illinois seniors. In one rural nursing home, we learned that out of a random selection of 10 patient charts, the State of Illinois discovered 6 of them had experienced a fracture at the facility within the last 30 days. That strongly suggests that in just one small rural nursing home, upwards of 60 percent of residents were suffering from preventable injuries at any given time. The typical hip fracture costs more than $100,000 to treat, and some reports suggest that as many as 20 percent of all seniors with a fractured hip die within a year of suffering their injuries.
- Bedsores & Wounds. Medicare considers preventable wounds and pressure ulcers (aka bedsores) to be a “never event,” meaning they should never occur in a healthcare environment. But many nursing home residents throughout our region suffer from painful, disfiguring and life-threatening skin ulcers, most of which are due to poor hygiene, lack of staffing, and a general disregard for proper patient care.
- Infections. Some infections are due to known medical conditions, while many others are acquired in the facility because of poor hygiene and bad infection control procedures. Nurses who are not trained or properly supervised may cross-contaminate wounds, not use sterile instruments, or fail to notify physicians of signs and symptoms until it’s too late.
- Medication Errors. Sadly, medication errors are extremely common. Many family members never even find out that their loved one died from a medication error until years later. Nursing homes have failed to give medications, given the wrong ones to the wrong patients, or overdosed patients. When dealing with already vulnerable and weakened immune systems, it only takes one error to be fatal.
- Deaths. Ultimately, all humans die. But they should not die prematurely due to failed nursing home care. Likewise, taxpayers and local community hospitals should not bear the burden of paying for the mistakes of wealthy private corporations that are not even located in our region.
Who Are Nursing Home Companies?
This is perhaps the most startling aspect of the problem. Many people in southern Illinois assume that the local nursing home down the street is owned and operated locally. This is almost never the case. Instead, hundreds of Illinois nursing homes are owned and managed by large corporations outside of the state altogether.
One large New York nursing home conglomerate operates dozens of rural facilities throughout our state. In fact, chances are good that if you are reading this from southern Illinois, one of their nursing homes is within an hour of you. Another large corporate nursing home company is located in Bloomington, from where they remotely manage facilities all over downstate. Likewise, a major California corporation runs a lot of facilities in the metro-east St. Louis area.
Taking Action to Protect Your Loved Ones
For families who are fed up with the poor quality of care and want to fight back, there’s only one way to hold these big companies accountable. The Illinois Nursing Home Care Act is a complex statutory scheme that gives you the right to fight back and seek compensation. Suing a nursing home is tough work, but at Jerome, Lindsay & Salmi, LLP, we take pride in years of excellent results. If you have a loved one in a nursing home, and you believe they are being abused or neglected, you should contact our firm immediately to discuss it further.
Likewise, most families don’t discover a problem until after their loved one has passed away. If you have lost a parent or spouse in a downstate nursing home, don’t wait too long to inquire. Call our firm today. We can set up a time to speak privately about the matter. We will never charge you a consultation fee, and all calls are strictly confidential. You and your family may be entitled to substantial monetary compensation. More importantly, however, you may be in a great position to hold these owners and their negligent staff accountable for their wrongdoing. By making it costly for the nursing home, you are doing your part to improve care and force nursing homes to change their ways.
by JAYE R. LINDSAY
One part combat veteran, one part former firefighter/EMT and truck driver, and 100% devoted to helping clients achieve the results they desire.
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