It was a summer evening in August when the text message arrived from my aunt: “Give me a call your mother is in the hospital.” It is a message that anyone with aging parents certainly dreads, yet one that we try to be prepared for. In the weeks following my mom’s hospitalization was a lesson about the disastrous state of housing for older people who find themselves needing supportive environments to recover and live healthy lives. And no, more money won’t solve the problem. The mindless chant, “Medicare for All,” has a particular irony for me now six weeks after this all began.
Out of respect for my mom, I’m not going to go into detail about her condition. The purpose of this post is purely rational and without going into it, I despise sympathy whether in the form of desultory “Happy Birthdays” or “so sorry to hear about your mom.” But I’ll share the narrative to buttress the point I am making above about Medicare and housing. I also despise maudlin anecdotes so popular on the left. So we’ll keep it to the point.
My mom’s trip to the hospital began in the emergency department where she was stabilized and it was determined she hadn’t suffered any serious trauma or injury. However, she needed hospitalization. The system is set up in such a way that really fine and talented people in emergency rooms do their jobs and get people out of the emergency room, either home, to the morgue, or to a hospital room and recovery. Their job does not include follow up or managing beyond that narrow band of intervention.
Similarly, the hospital room comes with another set of different and disconnected individuals. I was not there in the room yet, but my aunt described doctors – not my mom’s primary physicians – conferencing in a corner about my mom’s condition. I spoke with an earnest intern who did her best to answer my questions. “What’s next?” and “Will she recover?” At the time it was difficult to get an answer about her underlying condition, the emergency, and their relationship. Was the end near? Or would this be just a hospital trip we’d look back on in the future as a blip?
I kept expecting someone in a white coat with a stethoscope around her neck to appear and lay it all out for me with charts and graphs and the usual hoped for “bed side manner” albeit via Zoom. That never happened. Instead, when the data and various thresholds were reached for the hospital professionals, we were told, essentially, she can’t stay here, she needs to go to a nursing home or what is termed, a “skilled nursing facility.” The idea here is that hospital’s function to get people as far as they can on a continuum of care, stabilized, and out of harm’s way. After that, they are just a cost and someone else needs that room.
At the time, I took the “skilled” part seriously. I know these facilities from having been on the board and worked at health system with a skilled nursing facility. I even pulled a weekend shift as the manager of the place several years ago. Let’s face it; you don’t want to go to a nursing home. At best, however, you hope that it is a milestone toward recovery, and less costly than a hospital bed both in terms of money and psychologically.
Speaking of costs, by this point we are ten days into this story. At the time of her transfer, my mom was being covered by her insurance. Naively (see my hopes for Marcus Welby to appear above) I just assumed (see the hazards of assumption) that her insurance was “taking care” of all this. A caseworker at the hospital told me she was “looking for a place that would take her insurance.” Again, that implied “coverage,” you know, it would all be “taken care of.” Never did anyone at the selected facility ask, “How are you going to pay for this.”
After the dust settled from that transfer I had arrived, but we couldn’t see my mom since Covid-19 restrictions meant no entry into the nursing home. So we waited. And waited. As the days went by, I looked into the insurance situation. As it turns out, the nursing home stay was covered by Medicare, that much touted government insurance plan that is being suggest for “all.” As it turns out, Medicare only covers about 100 days of a nursing stay and cuts off coverage routinely at 21 days. By now, I was getting concerned.
Just before day 21 I got a call about our first NOMNC letter or Notice of Medicare Non-Coverage. Because I was aware this was coming, I was not overly concerned. But the “business office” at the nursing home was happy to let me know that private pay was upwards of $8000 per month or about $275 per day and that they’d be assuming (that word again) private pay for days after the end of Medicare coverage. Now, the determination of non-coverage by all appearances is part of a game of cost containment. Everyone gets kicked off at day 21 (I’m writing as a consumer, not an expert), and then a round of appeals begins with what’s called a QIO or a Quality Improvement Organization. The volley of appeals and responses is remarkably efficient, the first one took minutes to file and was granted the next day.
But this didn’t rattle the business office; “Yeah, they’ll keep sending NOMNCs and you just keep appealing until the appeals run out, then it’s $275 per day.” Remember, this was more than three weeks into my mom’s stay. What about my mom’s long term care (LTC) insurance? That’ll cover everything, right? Not so fast. The LTC covers per month a nursing home up to $2000, assisted living at $1200, and home care at $1000. Let’s do some math. That means the nursing home, with LTC would drop to $200 per day, roughly the price of a king room at the snazzy Hotel Chaco in Old Town – and the Chaco has a pool and no Covid-19 restrictions!
How about just taking mom home and hiring a home health care assistant for 24 hour care, something that was recommended? That’s covered too, right? Sure, but a home health assistant runs at $25 per hour, and at 24 hour shifts would be $18,000 minus $1000 of course. Assisted living? That runs about $3000 or so, or more like $100 per day. A “decent” spot, not the Chaco, but nice, runs more like $4500 per day, or $150.
But here’s another little fact I found out. The LTC policy has what’s called a 90 day clause; that means that even when the claim is approved, coverage doesn’t begin until 90 days after the departure from the hospital, or November, with the first payment beginning in December. We’re on the hook until then. “Hmmmm,” the business office asked, “What about Medicaid? Does she have more than $2000 in assets?” Well, yes, she does. Most people do.
Have you ever wondered why people bankrupt themselves when they are old and need a place to live? I just found out a few weeks ago. The locales are priced for the Kardashians but are not places anyone would want to spend a vacation or a significant part of their lives and they are largely not covered by Medicare or regular insurance policies. Wealthy people could hire their own nurse at the Chaco, poor people would likely end up staying at the nursing home with Medicaid coverage. Everyone else with more that $2000 is faced with either winning the lottery or going bankrupt.
The options are to burn those assets down to zero and then qualify for Medicaid. And Medicare? The system functions for older people with chronic health issues the way the Tank Man functioned against the Chinese crackdown against dissidents in 1989; a sort of last, hopeless stand until a deluge of housing costs washes over.
Because I got engaged, and hassled through a lot of these issues on my mom’s behalf, I think we’re going to avoid some significant costs that had we been absorbed in the emotional aspects of this perhaps might have escaped our notice. No single person was ever engaged with my mom’s health outcomes or her financial situation. None. From the very beginning, everyone was doing her job well but in isolation. Orderlies measured out medication, meals were served, boxes were checked, and hand offs were made. Not once in Zoom calls was anyone person or team tracking her progress across the various systems. Paging Dr. Welby, paging Dr. Welby!
Worse, people overwhelmed with grief, no insurance, or simply no concept of what is going on, might never engage with the various elements of this system at all. A different family could have easily felt that the nursing home was the best solution and felt no other option available until the first big bills arrived. Maybe then they’d motivate to change venues, but by then whatever assets available might be expended or reduced. A poor family that indeed might qualify for Medicaid may never even know that these options exist while the business office just shifts the resident to “private pay.”
As for the health elements of these disconnected systems, there is no doubt that the problem is not money at all, but the lack of coordination and coherent visibility of the people being processed through it. Many of the people working in the system are hourly workers with a set of tasks; meals, paperwork, or transportation. There was one person at the nursing home that was outstanding and was a lifeline, helping with paperwork and at the end helping us make a smooth transition to assisted living. But she was the exception, not the rule. And my guess is she’s not getting a bonus for her work on our case.
The one person I found in the system with a rational self-interest was the person who places people in assisted living. I asked her, “Who do you work for?” a kind of hostile sounding question. But my point was in all of this, nobody had any incentive – a profit motive for lack of a better word – for good outcomes except for the assisted living people doing it as a business. The placement person works for assisted living facilities and her business is based on good outcomes, not shuffling paperwork.
Concluding this post (next one is an advice column for you if you’re facing this in the future), I’d say that I am more convinced than ever that when self-interest is misaligned or misdirected (like quitting time) outcomes suffer and can even be tragic. The government here was rationing, trying to cut Medicare costs. The hospital was handling immediate health concerns not long-term health outcomes. The nursing home was managing over 100 beds filled with people with a myriad of issues, backgrounds, and finances.
Nowhere, throughout this experience, and especially not from Medicare, was there any management across systems toward good outcomes – health or financial – for the older person struggling. I shudder at the thought of Medicare for All, that, like Housing is a Human Right, beckons to a future of scarcity, rationing, and functional disinterest in other people’s wellness in favor of survival.