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Nursing home crisis won't fix itself
By Joan Fitzgerald, Globe Staff, 2/26/2002
Last week the Department of Health and Human Services released a report
revealing that more than 91 percent of the nation's nursing homes
are inadequately staffed. Rather than establishing minimum staffing
levels, which President Bush claimed would be too costly, the administration
plans on letting market forces resolve the shortage.
The fallacy of the market solution is that pay rates for direct care
workers in nursing homes are essentially set by government reimbursements,
not by labor supply and demand. The government pays about 60 percent
of direct care worker wages through Medicaid and Medicare.
Insufficient government reimbursement is a key cause of the understaffing
crisis. The average starting wage for nurse aides in nursing homes
is $6.70 per hour, yielding an annual income of $14,000 for full-time
workers, mostly without benefits.
Nationally, the average wage for nurse aides in nursing homes is $7.93,
suggesting there is little opportunity for advancement. Low wages
are a big part of the reason more than 40 states have critical shortages
of nurse aides. During the boom economy of the late 1990s, nurse aides
could earn more in retail jobs. Many nursing homes have staff turnover
rates of 80 to 100 percent.
High turnover imposes costs. Replacing a nurse aide costs almost $4,000
in advertising, orientation of new workers, lower productivity of
new workers, and temporary labor. An intangible cost of turnover is
the deterioration of care due to new caregivers not knowing patients'
special needs.
Understaffing means that those who do stay on the job are overworked.
Studies by the National Network of Career Nursing Assistants show
that nursing assistants cannot perform their five main responsibilities
- bathing, feeding, eliminating, ambulating, dressing - for 20 patients
in an eight-hour shift, a typical workload.
Currently, the total amount of nursing care per resident-day in nursing
homes is 3.52 hours, mostly done by nurse aides. The National Citizens'
Coalition for Nursing Home Reform recommends 4.42 hours per day, depending
on the caseload mix of the nursing home. The coalition advocates for
a minimum standard of 4.13 hours, the same as that suggested in the
DHS study.
The costs imposed by overworking caregivers are enormous. Incontinence
is considered part of the aging process when it is often the result
of nurse aides not having enough time to take residents to the toilet
more frequently. The results of incontinence in ulcers and infections
cost $3.26 billion annually in treatment. The National Citizens' Coalition
for Nursing Home Reform estimates that between $2 billion and $12
billion could be saved by preventing pressure sores through more frequent
turning, massage, mobility, and proper skin care. Another $1 billion
in hospital treatments for fractures and infections could be prevented
if staffing and training improved and chemical restraints were reduced.
HHS estimates the cost of establishing minimum safe staffing levels,
at $7.6 billion, is prohibitive (an 8 percent increase). The Bush
administration suggests we need more analysis of the quality-cost
tradeoff to justify such an increase. Based on cost estimates of inadequate
care, this conclusion is penny wise and pound foolish.
What is the solution? The Bush solution quoted in a New York Times
story on Feb. 18 was to publish data on the number of workers at each
nursing home because ''nurse staffing levels may simply increase due
to the market demand created by an informed public.''
In fact, people are quite well informed about the poor pay and overwork
in nursing home direct care jobs. That is why there is such a shortage
of workers. It's elderly people who aren't adequately informed; they
are often in no condition, financially or physically, to shop around
as informed consumers. That's why public policy needs to set decent
minimum standards that ensure adequate care. In addition, federal
and state policy has to improve the pay and quality of direct care
jobs and increase training standards.
Some states are legislating minimum staff-to-patient levels, expanding
training requirements, and increasing wages. Thirty-six states and
the District of Columbia have increased staff-to-patient ratios. One-third
of the states require more than the federally mandated 75 hours of
training for certified nursing assistants. Eighteen states have implemented
pass-throughs, which require that a percentage of increased state
reimbursement to long-term care providers is spent on increasing wages
and/or benefits for paraprofessional caregivers.
Clearly, more federal guidance is needed to ensure that adequate nursing
home care is available in all states.
Joan Fitzgerald is associate director of the Center for Urban
and Regional Policy at Northeastern University.
This story ran on page A15 of the Boston Globe on 2/26/2002. ©
Copyright 2002 Globe Newspaper Company.
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