plying outdated drugs or drugs of questionable value, billing The report concludes with recommendations for reducing drug errors, over-tranquilization, adverse reaction, and for preventing kickbacks. Specifically, the Subcommittee strongly recommended that HEW announce regulations forthwith for Section 242 enacted by the Congress in 1972. This section makes offering or accepting a kickback a crime punishable by a $10,000 fine, a year in jail or both. The law has not yet been implemented and enforced. MAJOR POINTS OF SUPPORTING PAPER No. 3 "DOCTORS IN NURSING HOMES: THE SHUNNED RESPONSIBILITY" Supporting Paper No. 3 concludes that physicians have shunned their responsibility for the care of nursing home patients. Except for a small minority, doctors are infrequent visitors to nursing homes. The report says that doctors avoid nursing homes for many reasons: -There is a general shortage of physicians in the United States, estimates vary from 20,000 to 50,000. -Increasing specialization has left smaller numbers of general practitioners, the physicians most likely to care for nursing home patients. -Most U.S. medical schools do not emphasize geriatrics to any significant degree in their curricula. This is contrasted with Europe and Scandinavia where geriatrics has developed as a specialty. -Current regulations for the 16,000 facilities participating in Medicare or Medicaid require comparatively infrequent visits by physicians. The some 7,200 long-term care facilities not participating in these programs have virtually no requirements. -Medicare and Medicaid regulations constitute a disincentive to physician visits; rules constantly change, pay for nursing home visits is comparatively low, and both programs are bogged down in redtape and endless forms which must be completed. -Doctors claim that they get too depressed in nursing homes, -Physicians complain that there are few trained personnel -Physicans claim they prefer to spend their limited time The report adds that the absence of the physician from the nursing home setting means placing a heavy burden on the nurses, who are asked to perform many diagnostic and therapeutic activities for which they have little training. But there are few registered nurses (65,235) in the Nation's 23,000 nursing homes. These nurses are increasingly tied up with administrative duties such as ordering supplies and filling out Medicare and Medicaid forms. The end result is that unlicensed aids and orderlies with little or no training provide 80 to 90 percent of the care in nursing homes. The report concludes that the physician's absence results in poor medical care and to some degree, in poor nursing care. Poor care has many dimensions, it means: -No visits, infrequent, or perfunctory visits. -The telephone has become a more important medical instrument in nursing homes than the stethoscope. -No physical examinations, proforma or infrequent examinations. -Some patients receive insulin with no diagnois of diabetes. -Significant numbers of patients receive digitalis who have no diagnosis of heart disease. -Large numbers of patients taking heart medication or drugs which might dangerously lower the blood pressure, do not receive blood pressure readings even once a year. -Some 20 to 50 percent of the medications in U.S. nursing homes are given in error. -Less than 1 percent of all infectious diseases in the United States are reported-a special problem in nursing homes where patients have advanced age and lessened resistance. This fact was graphically proven in 1970 when 36 patients died in a Salmonella epidemic in a Baltimore, Md. nursing home. -Physicians do not view the bodies of patients who have died in nursing homse before signing death certificates. The report offers recommendations designed to promote interest in geriatrics among the present and future generations of physicians with the belief that absent greater physician interest the litany of nursing home abuses will continue. MAJOR POINTS OF SUPPORTING PAPER No. 4 "NURSES IN NURSING HOMES: THE HEAVY BURDEN (THE RELIANCE ON "" UNTRAINED AND UNLICENSED PERSONNEL) Supporting Paper No. 4 is entitled: Nurses in Nursing Homes: The Heavy Burden. The report examines reasons why there are so few nurses in today's nursing homes (56,235 for 23,000 nursing homes). It will report that the few nurses who do work in long-term care facilities are overworked and tied down with administrative duties. This means that 80-90 percent of the care is provided by untrained aides and orderlies sometimes hired literally off the street and paid the minimum wage. Most have less than a high school education, no training or prior experience and they (aides) show a turnover rate of 75 percent a year. MAJOR POINTS OF FORTHCOMING SUPPORTING PAPERS Supporting Paper No. 5, The Continuing Chronicle of Nursing Home Fires examines the reasons for 4,800 nursing home fires in 1971 and why 60 to 70 percent of U.S. nursing homes continually have one or more major fire deficiencies. Supporting Paper No. 6, What can be Done in Nursing Homes: Positive Aspects in Long-Term Care will make the case that it is unjust to condemn all nursing homes. There are many fine homes in America. This paper attempts to explain what makes them what they are. Supporting Paper No. 7, The Role of Nursing Homes in Caring for Discharged Mental Patients will examine in detail the current trend to "dump" thousands of mental patients from state hospitals into nursing homes, and questions the ability of nursing homes to deal effectively with these patients. Supporting Paper No. 8, The Access of Minority Groups to Nursing Homes, will ask why there are so few members of minority groups in nursing homes. It concludes that discrimination, social and cultural differences, cost, lack of information and individual choice all contribute to the present reality: only 4 percent of the 1 million nursing home patients are members of minority groups. Supporting Paper No. 9, Profits and the Nursing Home: Incentives in Favor of Poor Care, examines the role of the profit motive, the adequacy of present nursing home reimbursement, the effect of reimbursement formulas and the general profitability of the nursing home industry. One finding: between 1969 and 1972 the 106 publicly traded nursing home chains had a 116 percent increase in average net income. II. THE NEW YORK TIMES SERIES AND THE SUBCOMMITTEE'S NEW YORK HEARINGS In October of 1974, the New York Times began a series of articles on nursing home problems, written by John Hess. The articles, grounded on extensive research, soon attracted attention to financial manipulations (to defraud the government) and to the poor care which inevitably resulted. The leads originated by Mr. Hess, as well as others, were pursued by Assemblyman Andrew J. Stein, Chairman of the New York Assembly's Temporary Committee to Investigate Living Costs and the Environment.1 The central figure in the New York probe soon became Dr. Bernard Bergman, a substantial shareholder in a publicly traded nursing home chain called Medic-Home Enterprises. Dr. Bergman was reputed to have additional nursing home holdings not only in New York but in other States as well. In December, the Office of the Welfare Inspector General of the State of New York to some degree estimated the number of "Bergman-related" homes in New York at about 55. This report also disclosed apparent irregularities in the books of the Towers Nursing Home in New York City which was owned by Dr. Bergman. In an attempt to pursue these matters further, Assemblyman Stein directed subpoenas to some 25 nursing homes most with alleged ties to Bergman. Attorneys for these nursing homes challenged the Stein subpoenas in New York State court, charging that the Stein Commission lacked authority to investigate nursing homes. At this point, 1 See coverage in Newsweek, February 23, 1975, p. 23. Senator Moss directed the Subcommittee staff to structure hearings in New York to be conducted by the Subcommittee on Long-Term Care. Some 40 subpoenas were issued by the Subcommittee to operators and vendors who had been under scrutiny by the Subcommittee including most of the facilities subpoenaed by the Stein Commission. In his opening statement in the first New York hearing on January 21, 1975, Senator Moss spelled out the Subcommittee's legislative concerns indicating the direction and purpose of the hearings. Senator Moss called New York's cost related reimbursement an "incentive to spend and spend because whatever is spent will be returned with a profit." He added: "The system as it operates in New York would make defense contractors drool with envy. Since all states are required to adopt a cost related reimbursement formula by July 1976, it behooves us to take a good look at what you have here," he said." Other issues emphasized by Senator Moss: -The adequacy of present ownership disclosure provisions which require anyone with a 10 percent interest or greater, to disclose his interest to the State. -The adequacy of New York nursing home cost and financial disclosure law. -The possibility of kickbacks between nursing homes and suppliers such as pharmacists, linen, food or contract cleaning vendors. -The adequacy of present regulations protecting the mishandling of patient accounts or personal expense money by nursing home operators. Testifying at this hearing, Assemblyman Stein and two staff assistants told the Subcommittee of the financial manipulations and poor care they had discovered through their investigations. A Stein Commission chart showed what was described as multiple real estate transactions involving the Willoughby Nursing Home for the asserted purposes of inflating Medicaid costs. Another display alleged that expenditures varied up to 400 percent for specific services such as housekeeping or laundry, implying extravagance of kickbacks. Another exhibit indicated that 22 out of 25 homes were "bankrupt," according to reports they submitted to the State Health Department. And yet investors continued to pay high amounts to purchase these homes.3 Dr. Jay Dobkin, Chief Medical Resident at Morrisania City Hospital, testified that a "nursing home case" had become a term in hospital jargon for dehydrated patients with bed sores brought in from nursing homes. Anastasia Hopper former Chief of New York City Inspectors and Miss Irene Jarvis, R.N., former city inspector, testified from their experience as to the poor care in some New York Homes and described their frustrations when their recommendations for discipline were ignored.5 Dr. Bergman, testifying under oath, disputed charges made against him in the public press and by the Stein Commission. He asserted that he had an operating interest in only two nursing homes. He did acknowledge interest in the real estate of other New York homes. He 2 "Trends in Long-Term Care," part 23, hearings not yet in print. 3 Hearings cited in footnote 2. 4 Hearings cited in footnote 2. 5Hearings cited in footnote 2. denied that his homes offered poor care of that he had indulged in any financial manipulation for purposes of inflating Medicaid costs. Following the lengthy Bergman statement, Senator Moss asked a few questions of Dr. Bergman, stating that more detailed questioning would come at a subsequent hearing after the staff and the U.S. General Accounting Office had a chance to evaluate Bergman records supplied that morning. February 4 was set as the date. Just prior to adjournment Senator Moss allowed Special Counsel Gary Naftalus to ask a series of questions which related to Dr. Bergman's alleged attempts to seek political influence and favor. Dr. Bergman acknowledged that he had talked with Speaker of the Assembly Stanley Steingut and that he (Bergman) had met with Speaker Steingut and his Counsel, Daniel Chill, in Governor Nelson Rockefeller's office. Dr. Bergman denied Governor Rockefeller was present and denied that any influence was sought." Dr. Bergman failed to appear at the second hearing on February 4. His attorney argued that the initial subpoena did not carry over to the second meeting. Senator Moss conferred with Senators Charles Percy, Harrison Williams and Pete Domenici who were present and then stated that he would seek to hold Dr. Bergman in contempt. Samuel Dachowitz. Bergman Certified Public Accountant, who certified Bergman's net worth at $24 million in 1973, asserted his constitutional rights and did not testify. Speaker Steingut denied any wrong-doing on his part, testifying under oath that he had neither used his influence on behalf of Dr. Bergman nor sought to quash the Stein investigation." Meeting in Executive Session the full Senate Special Committee on Aging considered the pending contempt of Congress citation against Dr. Bergman. With 17 Senators present the Committee voted to hold the contempt citation in abeyance issuing the full Committee's subpoena commanding Dr. Bergman's appearance in Washington on February 19. Dr. Bergman did appear at the hearing but asserted his constitutional rights against self incrimination. III. INVESTIGATIONS AND STUDIES NOW UNDERWAY Governor Edward Carey of New York appointed a Special Prosecutor, Joseph Hines, to investigate possible criminal violations. He also appointed a blue ribbon Commission under New York's Moreland Act and named famed attorney Morris B. Abram to head it. Both panels continue their investigations. But the publicity of the New York nursing home investigations had a ripple effect into other states on the East Coast and eventually to all parts of the U.S. Undoubtedly, the Subcommittee's reports have also spurred these investigations: In California an investigation is underway after a nursing home operator charged under oath that elderly alcoholics are being held prisoner by some facilities in order to collect the patients' Medicaid or Social Security checks. See coverage in New York Times, Jan. 22, 1975, pp. A1 and 41. 7 See New York Times, Feb. 5, 1975, p. A1; "Trends in Long Term Care," part 24. 8 "Trends in Long-Term Care," part 25. 5 Hearings cited in footnote 2. 9 |