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[BN] Watchdog

New York's top nursing homes less likely to admit poor

New York's top nursing homes admit poor people at a lower rate than the state's worst nursing homes despite regulations prohibiting discrimination.

That is especially true for one-third of the poor people who enter New York nursing homes – those whose bills are paid from Day One by Medicaid.

Across the state, these nearly 22,000 people were twice as likely to be admitted to one-star than five-star homes, The Buffalo News determined from state Department of Health data from 2017. In Western New York, they were four times more likely to be admitted to one-star homes.

The situation is better for poor people who started out with their nursing home bills paid for by Medicare, the federal program that provides health care for those over 65. Statewide, they were slightly more likely to wind up in top-rated nursing homes than in the worst.

Why would five-star nursing homes admit one group of poor people at a greater rate than the other?

Advocates and relatives contend it comes down to money. Medicaid pays nursing homes the lowest reimbursement, an average of $216 a day in Erie and Niagara counties. Medicare pays nursing homes more than double that, about $475 a day on average, according to estimates from Buffalo-area nursing home operators.

State and federal regulations prohibit nursing homes from discriminating against individuals because of their payment source, and executives at top-rated nursing homes said they do not.

Some operators of five-star nursing homes in Western New York said their Medicaid admission rates are low because most of their residents are seniors admitted for short stays to get rehabilitative services, which is usually covered by Medicare whether a resident is poor or not. None of the top-rated nursing homes that said their business model focuses on short-term rehab patients would provide statistics on their short-term and long-term admissions. The state said it does not keep that information.

Nursing homes, the executives said, look at many factors when considering admissions, including the level of care needed.

Becky DelPrince is an Erie County Medical Center vice president who oversees the hospital’s patient discharge planners. She acknowledged in an interview last December that it is difficult to place poor patients into the best nursing homes.

When asked why, DelPrince said: “They don’t give us a reason. They just don’t offer the patient a bed.”

When Medicaid pays

Across New York, top-rated five-star nursing homes actually admit more poor people on Medicaid than one-star nursing homes – a reflection of the fact that there are twice as many five-star homes as there are one-stars.

But the raw admission numbers don't tell the whole story.

At the five-star nursing homes, 7 percent of the new residents in 2017 were Medicaid admissions – poor people whose bills were paid by Medicaid from Day One. 

At the one-star nursing homes, 15 percent of the new residents were Medicaid admissions.

Executives at some of Western New York's top nursing homes said the data the state Department of Health provided to The News does not accurately reflect the poor people in their facilities.

About two-thirds of the people eligible for Medicaid admitted to nursing homes, about 36,000 individuals, were also enrolled in the Medicare program. In those cases, Medicare usually pays the nursing home bills for up to 100 days.

Those dual-enrolled individuals are not listed as Medicaid admissions even though they are poor and Medicaid-eligible, the executives said.

That's true, said Jeffrey Hammond, a spokesman for the Health Department.

But when all Medicaid-eligible people are counted – including those whose bills are initially paid by Medicare – the poor were still admitted at greater rates at one-star than five-star homes, by a small margin, according to state data. At one-star homes, 32 percent of admissions were Medicaid-eligible, compared with 27 percent at top-rated homes.

Medicaid bed ‘unavailable’

Kathleen Cattrall says that in 2012 she was told her mother would have to leave Our Lady of Peace Nursing Care Residence in Lewiston when her mother’s payment source switched from Medicare to Medicaid, which pays a lower reimbursement.

Kathleen Cattrall and her mother, Janis, at Niagara Rehabilitation and Nursing Center in Niagara Falls. Janis Cattrall died in the one-star nursing home in 2015. (Photo courtesy of Kathleen Cattrall)

“They informed us they did not have a Medicaid bed for her. They literally told me she is going to have to leave as soon as possible,” Cattrall said. “She had been at Our Lady of Peace for rehab and we expected she would be placed in long-term care there.”

"I visited higher-ranked nursing homes pleading with administrators to find a room for mom," Cattrall said.

The only facility that would admit Janis Cattrall was the one-star Niagara Rehabilitation and Nursing Center in Niagara Falls.

Janis Cattrall, 90, who suffered from severe arthritis and dementia, died there in 2015. 

Her daughter says she now knows it is against the law for nursing homes to discriminate against Medicaid recipients.

“At the time, I didn’t know Our Lady of Peace could not kick mom out. I am shocked and I am angry that mom, first of all, had to relocate, and secondly, that she wasn’t given an equal opportunity to stay at a higher-rated nursing home,” Cattrall said.

A spokesperson for Our Lady of Peace, which is owned by Ascension Health Senior Care, declined to comment on Janis Cattrall's circumstances but said the home is committed to assisting the poor.

"As part of that mission, we continually welcome new admissions who are Medicaid and Medicaid-pending," said Molly Gaus. "Today, Our Lady of Peace currently serves 250 residents and 66 percent of those are Medicaid beneficiaries and we welcome new Medicaid admissions frequently."

In 2017, Medicaid admissions accounted for 4 percent of Our Lady of Peace's new residents.

State enforcement lacking

The Health Department is responsible for enforcing regulations that prohibit nursing homes from discriminating against Medicaid recipients.

Nursing homes in New York are required to admit a minimum number of Medicaid-eligible people. The state sets the threshold based on a complicated formula.

Hammond, the Health Department spokesman, did not provide an answer when asked repeatedly how many times the state enforced those regulations in the last five years. Instead, he said anyone with a complaint should contact the Health Department “so appropriate action can be taken.”

The Health Department, he said, expects all nursing homes "to meet the Medicaid admissions threshold as long as they operate, subject to adjustments, exceptions and other stipulations within the regulations."

In Erie County, the Medicaid-eligible threshold was 21.7 percent of all admissions in 2017. Only half of the 37 nursing homes there met that mark, according to state data.

In Niagara County, only three of the 10 nursing homes met the threshold of 16.8 percent.

Some five-star nursing homes across the state fell far below their threshold:

• Lockport Rehab and Health Care Center had one Medicaid admission out of 189 total admissions.

• At North Westchester Restorative Therapy and Nursing Center, in Westchester County, zero out of 655 total admissions were Medicaid admissions.

• At Belair Care Center on Long Island, one out of 1,436 total admissions was a Medicaid admission.

Meanwhile, at some one-star Buffalo area nursing homes, the rate of Medicaid admissions was much higher.

Thirty-seven percent of the 113 people admitted at Emerald North Nursing and Rehabilitation Center – now known as the Buffalo Community Healthcare Center – were Medicaid admissions in 2017. Fiddlers Green Manor Rehabilitation and Nursing Center had the same percentage.

In the Bronx, at the one-star Riverdale Nursing Home, nearly two-thirds of the 60 total admissions were Medicaid admissions.

Across New York, nursing homes charged residents who paid their own bills an average of $148,555 a year in 2017, according to the Health Department.

But Medicaid paid the nursing homes an average of $86,505 a year – or $62,050 a year less per resident.

Nursing homes "chase after the highest dollar amount,” said Richard Mollot, executive director of the national Long Term Care Coalition, which advocates for nursing home residents.

Top nursing homes respond 

Operators of five-star nursing homes in Western New York point out that most of the residents in their facilities have their bills paid by Medicaid.

Across the state, Medicaid paid for 62 percent of the days residents spent in five-star nursing homes, according to Health Department statistics. But that includes residents who were not poor when they were admitted – people who had personal savings, Medicare coverage or private insurance. As those resources ran out, the residents became indigent and Medicaid took over.

Statewide, Medicaid paid for 71 percent of the days residents spent in one-star nursing homes, according to Health Department statistics.

“There is no barrier to individuals with Medicaid coverage at any of our facilities – including our highest rated,” said Chuck Hayes, a spokesman for the Elderwood chain of nursing homes. The chain includes Elderwood at Lancaster, a five-star home where 1 percent of new residents were Medicaid admissions in 2017.

Hayes and other officials at area five-star homes said their Medicaid admission rates are low because their business model focuses on admitting residents who need short-term rehabilitation care, rather than long-term custodial care. Even if residents are poor, Medicare usually pays for short-term rehabilitation.

"If you just look at the numbers, somebody who is successful in rehabbing the vast majority of patients and returning them home is by their very nature discharging them before their Medicare benefit expires," said F. James McGuire, chief executive officer of the McGuire Group, which owns five top-rated local nursing homes.

On average, the five McGuire homes had a 5 percent Medicaid admission rate in 2017.

“We are not using their payer status as a discriminator. We are looking at their clinical status and discharge plan,” said Stephen Mercurio, president of the McGuire Group.

Hayes, of the Elderwood chain, said Medicaid admission rates do not reflect a facility’s “true relationship with the Medicaid population.”

“Rehab patients stay for much shorter periods of time and typically these patients are private pay or Medicare – more turnover on these units equate to higher rates of admissions,” Hayes said.

Joyce A. Markiewicz, a top executive at Catholic Health, which owns four high-rated nursing homes, said one-star facilities have more Medicaid admissions because they do not hire as many physical and occupational therapists or registered nurses to provide rehabilitation services.

“So my guess is that a lot of these one-star facilities are staffing with limited nursing care and don’t have the additional therapies in their buildings ... because they are not doing rehab. They’re long-term,” Markiewicz said.

Operators of one-star homes say that is false.

One-star homes use the same business model as five-star facilities, with a focus on providing short-term rehabilitation care, they said.

“It is every nursing home’s business model to take subacute patients. That is typically a higher payer than straight Medicaid,” said Chris Luterek, vice president for business development for the Absolut Care nursing home chain, which runs both one- and five-star facilities.

Operators of five-star nursing homes said they usually don't know if a prospective resident is on Medicaid when they decide whether to admit the person. Hospitals often give nursing homes only a couple of hours to decide whether to accept a patient.

Mecurio acknowledged the McGuire Group's applications ask prospective residents if they are covered by Medicaid. But he said there is usually not enough time for hospital patients to fill out the applications.

Operators of some one-star nursing homes disputed that. The staff at Buffalo Community Healthcare Center can find out within two hours if a person is on Medicaid, said Jay Lawrence, a spokesman.

"You know who the payer is," said Luterek, an Absolut executive for nearly a decade.

Harriet Rucki, left, was admitted in 2015 to Absolut Center for Nursing and Rehabilitation at Aurora Park. The nursing home in East Aurora was rated at one star by the federal government. Rucki's daughter, Judith Rucki, on right, said she wanted her mother to go to a higher-rated nursing home. (Courtesy of Judith Rucki)

Woman was ‘not marketable’

After Harriet J. Rucki, 92, fell at an assisted living facility, she spent several days at Millard Fillmore Suburban Hospital for “observation,” according to her daughter.

Because Rucki had not been officially admitted as a hospital patient, Medicare and other insurance would not pay her nursing home costs, but Medicaid would, the daughter said she was told.

"A social worker at the hospital said I had 24 hours to get my mother out of the hospital and that she needs to go to rehab," said Judith A. Rucki.

The daughter said she gave hospital officials the names of two five-star nursing homes where she wanted her mother to go.

The social worker asked how much Rucki could pay, the daughter said.

"It boiled down to how much money does she have. So when I scrambled to come up with figures and gave the numbers to the social worker, she said none of those nursing homes will take her," Judith Rucki said.

The social worker told them not to apply to five-star homes because Rucki did not have enough money, the daughter said. So Rucki did not.

Instead, Rucki applied for Medicaid and was admitted to Absolut Center for Nursing and Rehabilitation at Aurora Park, a one-star home, Judith Rucki said.

During the admission process at the East Aurora nursing home, the daughter said, an Absolut manager tried to explain to her why her mother could not get into a higher-rated home. "The Absolut manager told me my mother ‘was not marketable,’ " Judith Rucki said.

She asked what that meant. The Absolut manager told her to get into a higher-ranked nursing home "you need to have the equivalent of $12,000 to $15,000 a month and pay that for 24 months,” Judith Rucki said.

Harriet Rucki stayed in the one-star nursing home until her death at 94 in December 2017.

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Below is a searchable database showing every nursing home in New York, its location by city and county, its federal star rating (5 is  best, 1 is worst), its number of poor people admitted on Medicaid in 2017, its total admissions in 2017, and the percentage of its admissions that were Medicaid admissions. To search for a specific nursing home or all of the nursing homes in a city or county, click the magnifying glass symbol on the top right and type in the name of the home, the city or the county. 

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