The government-owned Butler County Care Facility is the “last resort” for medical care for some poor and elderly residents; that’s why county commissioners are reluctant to shut it down despite having to give the home a $1.1 million bailout.
The 109-bed facility is one of 34 county-run nursing homes left in Ohio. The nursing homes were mandated in all 88 counties when the first facility was built in 1830 to serve the infirm, poor and homeless. Many of the facilities closed after the state legislature lifted the mandate and counties opted to let the private sector handle nursing care as government budgets shrank.
But Butler County has maintained its county-run nursing home despite its financial challenges in recent years. The care facility has had to borrow $1.1 million from the County Commission since 2013 to bill budget gaps, largely because of the shifting rules and funding levels of Medicaid reimbursement. Because of the debt it owed commissioners, non-union employees at the Butler County Care Facility were deemed ineligible for pay-for-performance raises this year.
Still, the three Republican commissioners say the facility has value and should be preserved.
“Government can’t run anything well, not as well as the private sector. It just can’t; shouldn’t be in the business,” said Commissioner Don Dixon. “This is one of those things where your heart tells you one thing, and your head tells you something else.
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“Do you want to continue to provide that safety net for the truly indigent?” he said. “As long as we can continue to make the county facility a break-even proposition, I’m on board with that.”
Gov. John Kasich’s 2011 budget erased $20.06 per day from the Butler County Care Facility’s Medicaid rate, bringing it down to $173.43. The per patient daily rate at the care facility is $190, which doesn’t include extras such as therapy.
“When Gov. Kasich came in, he told the nursing home industry to either get on the bus, or we’re going to run you over. Well, the industry didn’t get on the bus, and he ran us over,” said Chuck Demidovich, administrator of the Butler County Care Facility. “It was about a $600,000 decrease in a year, and we got a whopping two months notice of it.”
There are now only 34 of 88 county-run homes left, according to Bill Cunning, executive director of the Dayspring Assisted Living and Care Facility in Richland County. He said many homes have closed because of broken budgets and because county officials didn’t believe they should be in the health care business after the legislature lifted the mandate.
“In the early ’80s, the state legislature said you have three options: you can close your doors, you can build a new facility or upgrade your facility so you can get Medicaid or Medicare, or you can turn it into assisted living for the underprivileged,” Cunning said.
Richland County is purely assisted living and subsists on a tax levy, which voters recently agreed to double, Cunning said. He said he doesn’t believe his county’s residents would have wanted to convert to a full-fledged nursing home “because there are so many places out there that do that, and they can make ends meet.”
There are about 995 nursing homes in Ohio. The daily rate for the Butler County home for Medicaid is $190, and for Medicare it is “all over the board” depending on the services needed, ranging from $131 to almost $600 per day.
The federal government puts the average cost at $204 for a semi-private room and $225 for a private room. The statewide average occupancy rate was 82 percent last year, the Butler County Care Facility has 100 people living there now, so it is 92 percent occupied.
Demidovich said he will be going to the commissioners asking for a $10-$15 per day rate hike because they haven’t raised rates in eight years, and “we’re now charging the private-pay less than we charge Medicaid, and that’s not right.”
The home has already paid the commissioners back $372,000 of what it borrowed, and plans on sending another $250,000 soon, Demidovich said. The facility ended up with a $778,290 surplus last year, and Demidovich hopes to clear his debt completely this year.
County Administrator Charlie Young said he has a lot of faith in Demidovich and he is an asset to the county. But whether the county should stay in the nursing home business is “a question we have to ask ourselves,” he said.
“We have not engaged in any significant debate on whether they ought to remain, but it is a question that the commissioners have to ask themselves and revisit occasionally,” Young said. “We owe it to the taxpayers.”
Commissioner Cindy Carpenter said the county’s facility is often a last resort for some residents.
“There are many referrals made to the county care facility for individuals who are refused by other facilities,” she said. “We are taking care of complicated cases. Some may be mentally ill and also medically fragile or have skilled nursing needs and other issues in their lives, and our care facility has been a resource to accept individuals that can’t find admission to other nursing homes.”
The Care Facility’s budget ran into the negative by $237,682 in 2012 and $125,672 the following year. Demidovich borrowed $375,063 in 2013 and $750,000 last year from the County Commission. The Medicaid rates have been inching back up since 2011 and hit a 12-year high of $196.25 in 2013. But the rate bump came with a price. In 2011 and 2012, the facility suddenly had to pay for ambulance, oxygen and wheelchair bills out of their Medicaid rate.
“Every two years based on the state budget and what they stick in the budget and don’t stick in the budget, affects what we’ve got to pay for,” Demidovich said. “We got creamed with ambulance bills.”
Part of last year’s loan, $250,000, was because the state started a pilot program called MyCare Ohio to see if insurance companies could bring down the cost of long-term care. There was a glitch getting the program going and reimbursement from the insurance companies was delayed. Demidovich had to borrow the money to make payroll for August, but says the kinks seem to have been worked out.
“Insurance companies are starting to get their act together, we’re getting paid within 30 days,” he said. “We used to get paid within 10 days with Medicaid.”
The insurance company component added another new issue for Demidovich and his people to deal with. Pharmacy bills used to go directly to Medicaid, now the home has to foot that bill. Demidovich said he had one patient whose IV cost $680 a day, and he was only receiving $300 in reimbursement for that resident.
To combat these budget challenges Demidovich laid off 10 staffers last year, saving about $280,000, but he said any cost-cutting moves he’s making will not be at the expense of patient care.
“I didn’t cut a single staff member off the floor, I cut administrative costs. I now spend Saturdays doing payroll here because I had to lay off my personnel director,” he said. “We’ve cut up front, but I will not take away from the residents. That’s what we’re here for; that’s the only thing we’re here for.”
The home is down to 128 employees caring for residents of the 109-bed facility. Fairfield resident Alice Havens has nothing but praise for the staff at the facility that has been caring for her 82-year-old mother since August. She said the home is always clean, there is no “nursing home smell” and a nurse who saw that her mother had bruising and swelling on her leg, came back the next day, even though she wasn’t working that wing, to check on her. The bruising turned out to be a blood clot which they caught in time because of the concerned nurse.
“The dedication your staff shows gives me great peace after having to place my mother in a care facility,” Havens wrote in a letter to Demidovich. “I know they will watch her, take care of her needs and call us if they need to.”
The employees, a good number of them have been there 25-plus years, have not received raises — union members got lump sum $500/$550 stipends the past two years — in years, in fact they took a six percent pay cut back in 2010.
Susan Geckler, the head of nursing at the facility, has been there 25 years. She said the fact that so many staffers have been working together for so long makes her job easier, and that’s why she has stayed. Living with the knowledge that the state could change their fortunes at any time she said is just a fact of life.
“In health care today, at least from my little corner of the world, we live with that in the back of our thoughts all the time,” she said. “We try to be prepared, you obviously cannot always be, but we try to focus on caring for the residents and keeping them as content as we can. The things that are out of our control are out of our control.”
Demidovich, who was a gubernatorial appointee to the Unified Long-term Care System work group, said he supports Kasich’s and former Gov. Ted Strickland’s goals of trying to keep the elderly in the least restrictive environment possible. At the time the work group was formed 70 percent of Medicaid funds were going to nursing homes and 30 percent for services to help the elderly stay home. The governors wanted a 50/50 split, hence the Kasich rate reduction in 2011, he said.
“People do better, recover better at home, if they‘ve got supportive service at home. Doesn’t mean everybody can go home and get care,” Demidovich said. “The big push has been for adult day services and home health services, transportation for the elderly to go back and forth to doctor’s appointments. Some real basic things that were never happening before. To me it’s a good shift.”
Sam Rossi, communications director for the Ohio Department of Medicaid, said the governor’s budget that was just released last week, also put a focus on Medicaid reform, like the 2011 spending plan, only this time money is going to be spent, not reduced.
“We plan to increase nursing facility reimbursement by $61 million over the next two years and also reform the decade-old methodology for payment calculations,” he said.
Demidovich said he’ll have to see the “fine print” to know what the new state budget will mean for the facility.
As part of his quest to balance his budget Demidovich told the commissioners during budget hearings he would be eliminating the adult daycare program. After partnering with Jerome Kearns at Job and Family Services he was able to get transportation costs — $80,000 to $100,000 — shifted off his budget to Medicaid and Medicare, because the county does not have a strong transportation system.
The program, which fits in with the state’s goals, can serve up to 20 adults on any given day. Family members who work or need a place for their loved ones to interact with others, for $45 a day — the state average is $52 — can send them to the care facility.
“They’ll have a hot lunch, they’ll have socialization they’ll have games and they go home and they’re tired,” Assistant Administrator Janie Gustin said. “Their families like that because they sleep at night, so that’s helpful.”
John Durst, who was waiting his turn to play bean bag toss at the center recently, said he loves the three days a week he spends there.
“The friendship, they’re all friends,” the 85-year-old West Chester Twp. resident said. “You’re never alone here, if you are it’s your own fault.”
Demidovich has lots of plans in the works for the home, in part to serve his shifting clientele. About 48 percent of his residents are under the age of 50 and many only stay four to six months. They created a little bistro area for the residents a couple months ago; there are computer areas; they are turning the employee break room into a craft room and the wing Demidovich planned to use for heroin detox will now be home for dementia patients. He is reserving the wing with private baths for the short timers.
The administrator got a chilly response from some county officials when he proposed turning a wing into detox and now he has also turned a cold shoulder to the idea.
“We kept running into so many obstacles under the nursing home bill of rights, it wasn’t going to work. You have to provide the environment for someone to detox and if you can’t provide it and provide the security and the safety of it you shouldn’t do it,” he said. “I learned my lesson, we took a couple people in and they burned us, they drove us crazy.”
Commissioner T.C. Rogers said he has pondered whether the county should get out of the business, but he has thought better of it.
“There are still examples where the people for whatever reason don’t have the money,” he said. “So it is our responsibility, I believe, to take of those that can’t take care of themselves.”