Letter to the Editor--We'll See What Happens

I am copying Anna Mathews, whom I've been working with for nearly a month.  Feel free to verify that my predictions have been spot on over the past month. I hope that you'll give consideration to my Letter to the Editor.  I'm also sharing the original Op-Ed that I sent in on March 3.  I had another Op-Ed rejected over a week ago that I've subsequently published on Medium (https://medium.com/@jzucker_46471/is-there-a-geriatrician-in-the-room-e5599859e11).  Geriatricians like myself are being shut out because we don't have the clout to get our opinions published, at least so far.  We've been six weeks ahead of everyone else in understanding what was going to happen.  I'd be happy to write another Op-Ed if you're interested.

Michael R. Wasserman, MD, CMD

President, California Association of Long Term Care Medicine

To the Editors:

Gerard Baker ("A Murky Crisis Meets all-too-certain pundits, April 18) need look no further than the Journal to find the lack of "patience, balance and reasoned judgement" he speaks of.  On February 29, with the report from the Kirkland, Washington, nursing home, geriatricians across the country, with clinical judgement honed by years of experience, knew what the coronavirus would do to older adults in congregate living settings such as group homes, assisted living facilities and nursing homes.  

On March 3, I sent an Op-Ed piece to the Journal, titled, "Coronavirus Unmasks Nursing Home Industry Issues." It was rejected.  Within a few weeks, the Journal first reported that some nursing homes were being hit hard by the COVID-19 infection.  Over the past six weeks I've tried sharing our expert predictions through various avenues.  I've written articles and have been quoted in both print and television media.  On March 25, CBS National News interviewed me and I told them that "nursing homes would become our killing fields."  This was aired on March 31.  While some have listened, few seem to have heard the cries of experts in geriatrics and long term care medicine who've dedicated their lives to serving older adults.

It wasn't until last weekend that the reports of further tragedies in nursing homes came to light.  A second Op-Ed detailing the critical need to fully engage and hear the voices of the real experts was rejected by various editorial boards, including the Journal.  The stories have mounted, while reporters write stories of government efforts to protect nursing home residents.  These stories have been factually correct, but comprehensibly wrong.  On April 17, a letter to the editor from the "American Seniors Housing Association" ("Assisted Living: After Option for Older Folks") stated the utterly incomprehensible, that "assisted-living residents are much safer living in our communities than they would be living by themselves..."  

While there are such communities where this is true (I'm associated with one), for the majority of assisted living facilities and nursing homes this is factually incorrect.  It demonstrates both the ignorance and arrogance of a long term care industry driven primarily by the real estate interests that I wrote about in my March 3rd Op-Ed.  

The Coronavirus can be devastating to older adults in congregate living settings.  In order to even begin to protect older adults in these settings, three things are required:  Stellar infection prevention, an abundance of personal protective equipment (PPE), and really available testing.  This knowledge is within the purview of experts in geriatrics and long term care medicine.  We're the ones with the "patience, balanced and reasoned judgement."  It's time that the media, local, state and and federal government officials listen to us.

Michael Wasserman, MD, CMD, is a Board Certified Geriatrician, a Certified Medical Director, and President of the California Association of Long Term Care Medicine.

-----Original Message-----
From: MICHAEL WASSERMAN
To: edit.features
Sent: Tue, Mar 3, 2020 6:25 pm
Subject: Op Ed-Coronavirus Unmasks Nursing Home Industry Issues

The Coronavirus is shining a spotlight on the vulnerability of people living in nursing homes.  I am not only a board certified geriatrician and certified nursing home medical director, but I’ve been the CEO of an organization overseeing the largest nursing home chain in California (I left that position 15 months ago).  As more nursing home residents die from the Coronavirus, the underlying faults in the nursing home industry will become increasingly relevant.  I hope that you give consideration to my Op Ed.

Michael R. Wasserman, MD, CMD

President, California Association of Long Term Care Medicine

Coronavirus Unmasks Nursing Home Industry Issues

The significant death rate in a Washington nursing home is a stark reminder of the vulnerability of nursing home residents.  It also shines a spotlight on two competing forces in the nursing home industry.  The first are the incredible human beings that work on the front lines of nursing homes, certified nursing assistants, who don’t earn a living wage.  What are these remarkable people supposed to do if they’re feeling under the weather?  Do they stay home? Can they afford to remain out of work for two weeks, or longer?  The second force to be reckoned with are the nursing home owners, whose wealth is primarily built on their real estate assets.  I believe that many of them could care less about the lives of the residents or the staff in their facilities.  For them, the real estate is immune to the Coronavirus.  The same can not be said for the remarkable human beings that care for the vulnerable older adults that live in nursing homes.  We will see more residents die because we haven’t addressed the real issues impacting quality care in the nursing home industry.

Nursing homes came into existence because frail older adults needed a place to live.  The industry was founded on real estate concepts.  Whether privately owned, or owned by a REIT, the main financial value of a nursing home is actually its real estate.  The owner of the real estate receives rental income, and has an asset that appreciates.  The asset itself can be used as collateral to borrow additional cash.  That cash can be used to buy more real estate, or  invest in other businesses.  Real estate dynamics, such as rent increases, create financial pressures on the operations of nursing homes.  This pressure pervades the entire industry and severely hampers opportunities to improve the quality of care. Any nursing home administrator will tell you of the pressures they are under to make ends meet.  The substantial value of the real estate should offer opportunities to take this pressure off, rather than increase it.  But most of the owners of the real estate just don’t care.

CNA’s are the heart and soul of nursing homes.  They perform work that few people want to do, for low wages, in a highly regulated and stressful environment.  Many of these caregivers absolutely love their jobs!  They are the most caring and compassionate individuals I have ever met.  In many ways they are the wealthiest people I know.  The currency with which they are wealthy is compassion. The LVN’s and RN’s who provide care, as well as other nursing home staff such as housekeepers, laundry personnel, social services, therapists, and maintenance are also chock full of the currency of compassion.  Nursing homes are filled with people who care.  Those people are to be applauded and cherished.  They need to know that they are appreciated.  My favorite question to ask CNA’s who’ve worked in a home for 30 years was how they sleep at night.  Most of them have told me that they sleep like babies.  I know nursing home owners who have all the financial security in the world who can’t say this.  Unfortunately, while the currency of compassion helps CNA’s sleep at night, it doesn’t put food on their tables or a roof over their heads.  If they are forced to miss over two weeks of work due to the Coronavirus, what will they do?  We need to take a long hard look at the value these incredible individuals provide in one of the most complex working environments around.  We need to reexamine the business model of nursing homes and determine the most effective and fair way to utilize our limited resources.

The Coronavirus is about to put the nursing home industry to the test.  As the frontline nursing home staff develop early symptoms, they will be forced with a difficult decision.  Do they go to work, or do they call in sick?  From a public health perspective, there is no question as to what we need them to do.  Furthermore, from what we know about the incubation period of the virus, they will need to stay home for at least two weeks.  It is highly unlikely that they will have an adequate amount of vacation or sick leave to do this.  What is the nursing home industry prepared to do about that?  There are already huge workforce pressures in the industry that will make finding replacement staff next to impossible.  Staffing is a key element to delivering adequate care in nursing homes.  How will the industry respond to a sudden lack of adequate numbers of frontline staff?

Which brings me back to the impact of real estate on nursing homes.  Real estate owners exert extraordinary financial pressure on nursing facilities.  In large organizations, the real estate holdings are of significant value.  Operational profitability actually pales in comparison to the financial value of leveraging the real estate.  This severely hampers efforts to improve clinical quality.  The real estate owners cry that they have nothing to do with clinical care or operations. Nothing could be further from the truth!  In order to effectively address the issues that are about to become front and center in nursing homes, we must shift the financial focus from real estate to supporting the compassionate caregivers that comprise the heart and soul of the industry.  How about leveraging the real estate to improve the lives of the staff that is needed to provide the care?

As nursing homes confront the Coronavirus, we must recognize and appreciate that the front line staff are our greatest asset.  Most of them truly enjoy their jobs, and they are metaphorically rich in the currency of compassion.  However, we must evaluate the fairness of a system where the Coronavirus will bring these incredible people to financial ruin.  It’s time that we all take a long hard look at the financial priorities of the nursing home industry.  Real estate should not be the financial driver.  Notably, when a nursing home is found to have deficiencies, the operations are penalized financially, but the real estate goes unscathed.  How do we expect nursing homes to solve their operational problems while taking morale deflating punishment and financial penalties?  At the same time, the real estate appreciates, and the leveraged value of the real estate continues to bring relatively “free money” into the pockets of the owners.  As the Federal Reserve lowers interest rates in the wake of the Coronavirus, the leveraged owners of the real estate benefit, while staff are burdened financially and residents die.  What would happen if the owners of the property, or the REIT’s, were held responsible for the quality of care in the facility?  In the spirit of capitalism, perhaps they would have a greater incentive to see effective change occur!  Let’s hope that something good can come out of the Coronavirus outbreak.  This can be our impetus to unmask the real issues behind the challenge of bringing quality care to the nursing home industry.

Michael Wasserman, MD, CMD, is a Board Certified Geriatrician, a Certified Medical Director, and President of the California Association of Long Term Care Medicine.