Don Davis

On The Costs Of Care, Or, You Don't Want Every Item On This Menu

Filed By Don Davis | August 12, 2009 12:00 PM | comments

Filed in: Living
Tags: Budget, economic policy, health care reform, Long-Term Care, Medicaid, Medicare, politics

[Author's note: this a another of the "summer archive" stories you'll be seeing over the next couple of weeks, and if you plan on attending a "health care town hall" I hope you'll keep this discussion in mind.]

I don't know if you've been thinking about it, but the costs of long-term care have been on the mind of some friends of mine lately.

For reasons that we won't go into here, they are in the process of pricing long-term care at care facilities. Yesterday afternoon, we had a chance to have a look at the "menu" of services (the facility's term) that can be purchased at this particular location.

If you are facing this issue in your own family, if you are a taxpayer thinking about how we plan to fund long-term care in the future, or if, one day, you expect to be old yourself, this conversation will surely matter.

To protect the innocent, I won't be mentioning names today, but here's what you need to know:

The location in question is an "assisted living facility" located near Seattle. It is somewhat upscale, but by no means "posh", and it is a residence of substantial size, with dozens of clients living there. It is not a "mom and pop" business run out of a house, but instead a more corporate operation.

First, The Rent

The first thing you are charged for is the "apartment" in which you reside and some basic services to go with it. Those services include "finishing the place" with blinds and appliances, weekly housekeeping and linen, and the power and the water and the cable ("Basic Extended").

You're also paying for the 24-hour staff presence, "recreation" services, and scheduled transportation.

Also included: two meals daily, but not breakfast.

Telephone charges are not included.

The cost, for a single person: $1900 per month for a studio, $2300 for a one bedroom, and $2800 for a two-bedroom. There are nicer "views" available, which add about $400 to each price. Adding a second person costs $600 extra every month.

But Wait, There's More

You will note that this price does not include medical and "personal" services. For that, we will turn to the actual "menu".

"Old wood to burn! Old wine to drink! Old friends to trust! Old authors to read!"

--Francis Bacon, Apothegms. No. 97.

Start with the basics: a daily wake-up call is $50/month; having a load of personal laundry washed every week or having a staff member make the bed daily adds $70 monthly. Housekeeping is $30/hour...so hopefully the resident can clean their own apartment.

Breakfast is $95 each month.

To determine what additional needs you might have, a nursing assessment is conducted at the time of admission.

If it's determined that the resident needs bathing assistance, costs work like this:

If the resident can wash themselves, but need to be watched during the shower, that service, once a week, is $165 monthly. If the resident needs a staff member to help them shower, add $60 (If two staff members are required, that's an extra $140 monthly).

Can the resident dress themselves?

A daily reminder to change clothes costs $100/month. If a staff member needs to spend under 10 minutes a day to help the resident dress, that's $175/month, if 15 - 20 minutes of assistance is required, that's $250 monthly.

Can the resident take care of their own personal grooming? If they can't, that adds $150 to the monthly charges.

Speaking Of Personal Care

There are also "toileting programs".

Having the staff remind you to go to the bathroom costs $200/month (this also covers the occasional incontinence event), and having a staff member monitor you in the bathroom raises the rate to $275 (this also covers the occasional "bowel accident").

A "structured toileting program" runs $350, and if you need to be checked for bowel accidents regularly, or need someone to wipe for you, or have regular accidents requiring changes of clothing, that's $425 a month added to the bill.

Some people have had surgical procedures that require them to use a bag attached to their colon for waste removal. The site where the bag is attached is called a "stoma site", and the service associated with stoma care is at least $250 monthly at this facility. Supplies (such as colostomy bags) are not included in this price.

Can the resident walk to meals on his or her own?

If yes, but they need a verbal reminder to go to meals, that's $175/month. If the resident requires assistance to get to the dining room, that's $225 monthly...and if it takes longer than 5 minutes on average to assist the resident, that adds $275 to the bill each month.

Special diets, prescribed by a physician, add $500 to the monthly bill.

Can the resident take their own medications?

If not, the minimum charge is $230 monthly, which covers up to 5 medications daily, "served" two times a day.

If the client takes more than five meds daily (or takes meds more than twice daily) that cost could potentially increase by another $165/ month.

Oxygen service: add another $150 monthly.

We're Not Done Yet

While all that seems expensive...we haven't come to the big-ticket item yet.

There will be residents who will require "memory support".

The simplest form of this service provides "redirecting, reassurance, orientation to surroundings, responding to questions/concerns that arise from diminished short term memory" and several checks daily to ensure the resident is on the property. Those who receive this level of service are also physically escorted to meals. The service costs $300 per month.

For $400 the resident is walked back from meals, and a staff member provides verbal cues to get the resident dressed. The resident will also be "convinced" to bathe, if need be.

If the resident requires physical cues to perform the same tasks, the cost jumps to $550 (and at this stage the resident might require two staff members to get them to perform personal hygiene).

The highest level of care also provides someone to check on the resident every two hours, and costs $800 monthly.

This is hardly a complete list: for example, there are charges for making appointments and other "clerical" services, for "concierge" service, and for other incidentals.

However, there's one other significant charge about which you should be aware, and that's the cost for nursing services.

Wound care that involves changing a dressing, and takes less than 5 minutes, is $15 for each occurrence. This service must be provided by a licensed nurse. If you add it up, it works out to $180/hour that the facility is charging you for the services of an LPN/LVN (depends on where you live) who is not likely to be making above $25/hour. (Each dressing change that lasts from 5 - 10 minutes costs $20; meaning at least $120/hour.)

Add it all up, and the chances that you'll be paying at least $3000 a month are (in the words of Johnny Mathis) awfully good.

"If Mr. Selwyn calls again, shew him up; if I am alive I shall be delighted to see him; and if I am dead he would like to see me."

--Henry Fox, the First Baron Holland

So how is all this relevant, you might ask?

The National Cost

How about this: we are about to enter an age where millions of Americans will require this sort of long-term care...and many of us do not have $3000 per month available to pay for this kind of care.

How many? It is estimated that 70 million Americans will be 65 or over by 2030, and if the numbers from 1999 continue to be valid, roughly 30% of those people will be living in an institutional setting.

20 million people, at $3000 a month, equals $60 billion that will be required to cover the cost of long-term care for this group--each and every month. That's $720 billion a year.

So how do we deal with the problem when it hits us?

I don't know. But consider this: it is going to be tough to reduce these costs, if only because these are tasks that are not well suited for automation. These are services, for the most part, that require one-on-one care (or even two-on-one care), and those who provide the care will want pay raises, which we will want to provide, in order to help keep the quality of care at a high level.

You should also know that there are substantial costs associated with "fixing broken workers". The fact that workers are often required to assist clients that are physically large or physically awkward puts a lot of these workers out on injury leave. The unhappy fact is that understaffing is a common way to try to control labor costs in nursing facilities, adding to the injury problem these workers face.

How bad is the healthcare injury problem? Ironically, the Bureau of Labor Statistics tells us health care facilities are the most dangerous work environment in the United States.

"General medical and surgical hospitals (NAICS 6221) reported more injuries and illnesses than any other industry in 2007--more than 253,500 cases."

To put it another way, there are basically two kinds of healthcare workers: the ones with back injuries, and the ones who don't yet have back injuries.

As we wrap this thing up, let's ask that question we ask almost every time: what have we learned today?

If you hadn't already been thinking about it, it is fantastically expensive to have to receive care at an assisted-living facility, and soon there may be as many as 20 million Americans who will be in that situation...or something even more expensive, such as "skilled nursing facilities" (more commonly referred to as "nursing homes").

We could be looking at having to find $720 billion (in today's dollars) to cover the annual cost of that care.

It is going to be very tough to reduce those costs, unless you can develop ways to deliver the same care in a less-expensive environment, or you can find a way to reduce the number of people who will require such care.

Considering the cost of "memory care", money invested in Alzheimer's mitigation today might pay huge dividends later.

So that's the deal: there is a giant bill that's coming due, we better be thinking about it now. One way or another, this will become one of the biggest fights in American politics as we move into the middle third of this century--so we can either get ready for it now, or we can all act surprised later.

Of course, if enough of us require "memory care"...then I guess that surprised look on our faces won't be an act, eh?


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Even if you purchase the insurance, there is no guarantee that the insurance company will be in business or choose to honor your policy once you really need it. Thank you for writing about this.

that could not be more true, and in the end the taxpayer might have to be the "payer of last resort", suggesting we really can't ignore all of this.