National Nurses United

5 pg_6 pg copy 6/2/11 3:16 PM Page 18 they're really upset about is that they are not making as much profit off them as they used to or expect to. SNFs still have plenty of opportunities to bill Medicare. For one thing, the prospective payment system for post-acute care isn't a single flat rate like it is on the med-surg floor of the hospital, said David Grabowski, an associate professor of healthcare policy at Harvard Medical School. It's what's called prospective per diem, meaning hospitals are paid daily for each type of patient they have in their SNFs. What's more, the CMS payment system for post-acute care pays according to the level of therapy each patient receives, also dubbed the resource utility group (RUG). So it could be argued, Grabowski said, that hospitals have "incentives to keep patients every day and to provide more services." In fact, a December 2010 report by the U.S. Department of Health and Human Services Office of the Inspector General found that from 2006 to 2008, skilled nursing facilities increasingly billed for higherpaying reimbursement categories even though their patient populations had not changed. Titled "Questionable Billing by Skilled Nursing Facilities," the report also found that for-profit SNFs were "far more likely" than nonprofit or government SNFs to bill for higher-paying RUGs and that a number of facilities had suspect billing. The report basically concluded that some SNFs may be cheating and overbilling Medicare for levels of care that patients did not need. In California, nursing home operators were also successful in lobbying the Legislature in 2005 to pass AB 1629, a law that increased their Medi-Cal reimbursements without requiring anything of them, such as investing part of their increased income in improved staffing. "Essentially, the Legislature gave nursing homes a blank check," said Harrington. "Why would they raise their staffing?" Harrington believes SNFs can be self sustaining, but that they just can't be expected to be a profit center for the hospital. "The way hospitals work is they have a lot of overhead and to function, they spread that overhead out over all units," she said. "So they're [assigning] all this operating overhead onto their skilled nursing facilities. As a result, their overhead is much higher than freestanding nursing homes, but they get the same reimbursement from Medicare and Medicaid that the freestanding ones do. If the SNF specializes in Medicare, which a lot of the hospital-based ones do, it's more expensive to operate them." Konetzka seemed to agree on this point. "I don't think these closures are really the result of the prospective payment system," she said. "It's still an open question whether SNFs really are money losers, but they are more and more likely to be closed because the margins overall are so slim." Unfortunately, hospitals today are run as businesses, where units that don't make enough money get the ax. So SNFs all over the Bay Area are in the process of losing beds despite being nearly full. In 2009, RN Jonica Brooks' employer, California Pacific Medical Center in San Francisco, planned to close 82 percent of its SNF beds, but outcry from nurses forced it to reconsider. The hospital promised to maintain 62 SNF beds. But a long-term planning document for the hospital, which is owned by the not-for-profit hospital chain Sutter Health, still called for all the beds to disappear by the end of 2010. The city's comptroller believes the city is already facing a 30 percent shortage in SNF beds. Sutter and CPMC's disregard for the community's needs infuriates Brooks. "I don't have sympathy for my medical center," she concluded. "They're very profitable—they make a huge profit—and they 18 N AT I O N A L N U R S E enjoy their tax-free status. They're not for profit, so damn right they need to step up to the plate and care for those who have nowhere else to go." W hen SNFs first started, they handled higher-acuity patients than the typical nursing home, but the care provided was still routine. The primary duties for the RNs, LPNs, and nurses' aides were to monitor patients for bedsores, ensure they took their medications, assess them for fall risks and nutrition, and assist them with meals, bathing, and the activities of daily living. But over the last 20 years, the acuity of patients in SNFs has skyrocketed. Today's SNF patients often need extensive lab work, can have serious wounds needing wound vacs, may be on ventilators, are often on multiple antibiotics and IV fluids, may need blood transfusions—the list goes on. "All patients are going to nursing homes sicker," said Grabowski of Harvard Medical School. "It's a much sicker patient population than it's ever been. I don't think a lot of people appreciate that about today's nursing home population." As hospitals have maximized profit by moving patients out of inpatient beds and into attached skilled nursing facilities, these units are handling increasingly complex medical cases with much more pressure for the RNs working there. Or, as Brooks remembers a physician at her hospital saying, "It's skilled nursing, but it's not skilled nursing—it's a med-surg unit." The situation is the same in skilled nursing facilities across the country. At the Erie County Medical Center SNF in western New York, physician's assistant Helen Doemland says that "the world of skilled nursing is changing. They are little hospitals." Doemland's SNF, a public facility, has 69 beds, all dedicated to different purposes: chronic vent stat beds for patients who will not wean, dialysis beds, sub-acute rehab beds, and behavioral health beds. Doemland is responsible for deciding which patients are sent to the SNF and when the patients are ready to be discharged. Due to closures of other nursing home beds in the state, Doemland's SNF ends up caring for the sickest of the sick. All the patients who have more money, qualified for at-home rehabilitation programs, or have family support already went somewhere else. Those with no support, no money, and who are often medically non-compliant end up at her SNF. She also gets psychiatrically unstable patients—those with untreated mental illnesses or drug addictions, sometimes both. She gets patients with no discharge plan and nowhere to go. "We're not really dealing with little old ladies with dementia who just need their meds passed and ADLs done for them," said Doemland. "We're dealing with people with complex medical issues. There are certain things that home care agencies aren't designed to handle so they come to us. As a result, our nurses need to be more like hospital nurses than long-term care nurses." The problem is SNFs weren't intended to handle such patients. Because the units are technically nursing homes and not part of the hospital, different laws and regulations apply to them. For instance, California's minimum staffing laws that require one nurse for every five patients in medical-surgical units don't apply to SNFs. Indeed, by law, nursing homes only have to have one RN on duty for day shifts—even if the unit has 100 beds, said Harrington. "Some freestanding nursing homes have 45 patients per RN," she said. "In Montana, there are 75 patients per RN. Hospitals have to W W W. N A T I O N A L N U R S E S U N I T E D . O R G M AY 2 0 1 1

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