OLD TOWN, Maine — Betty LeBretton’s recent fall wasn’t serious.
“We were having a fire drill,” the 83-year-old explained Monday. “I was reaching for my housecoat, and I slipped and fell on my knees and then right down on my face.” A tiny abrasion on her forehead and another on her nose mark the incident.
LeBretton is fortunate in more ways than one. Had she been more seriously injured and been admitted to a hospital, she might have risked losing her room at The Meadows, a 16-bed assisted living facility on a quiet side street in Old Town.
Already scrambling to make up revenues lost in recent funding cuts, assisted living programs around the state are bracing for the next round of budget reductions, now in the planning stages at the Department of Health and Human Services in Augusta.
The Meadows, like many other assisted living facilities, is funded almost entirely by reimbursements from MaineCare, Maine’s Medicaid program. Gerri Viitala, administrator of The Meadows, said facilities like hers are struggling with a recent MaineCare rule change.
Implemented in August, the change dramatically reduces the “bed-hold” reimbursement paid to facilities when a resident is admitted to a hospital, nursing home or inpatient rehabilitation program. For years, the daily rate has been about $95 a day, she said, essentially the same amount paid when the resident is present in the home. But now the rate has dropped to $25, and if the resident is away for a total of more than 30 days in a calendar year, the payment ceases altogether.
“The cost to the facility to keep the bed open is the same,” Viitala said. “We have the same number of staff, the same utility bills. The only thing we’re not doing is meals. Everything else stays the same. We’re losing $70 a day, but we’re not saving any money.”
Viitala said the upshot of this change — although it has not happened at The Meadows yet — is that assisted living facilities may be forced to give up space to new residents, displacing longtime residents and creating a backlog in hospitals, nursing homes and rehabs. If the rule change had been in effect in 2007, she said, “we would have had 85 bed-hold days without any payment … and we would have wound up $9,000 in the hole. We’re a small facility running on bare bones, and for us, that’s a lot of money.”
Facilities that, like The Meadows, provide room and board to the elderly as well as some basic personal assistance, are known in Augusta as PNMIs, or private, nonmedical institutions. It’s a broad category that also includes residential facilities for mentally and physically disabled adults and children who are medically stable and do not need round-the-clock professional nursing care. Of the many PNMIs in Maine, there are about 125 that serve primarily the elderly, providing a supervised, supportive home to almost 4,400 residents age 55 and older.
In addition to coping with the reduced bed-hold payments, Maine’s PNMIs are bracing for a new round of cuts. As Maine DHHS strategizes to carve $110 million out of its budget for the next biennium, other reductions seem inevitable. Stringent reimbursement formulas, tightened eligibility standards and other proposed changes have the potential to make it harder to qualify for PNMI admission and more costly to provide the level of care that is needed. It could even make some current PNMI residents ineligible, forcing them to relocate to other, possibly less safe, housing.
Rick Erb is president and chief executive officer of the Maine Health Care Association, which represents PNMIs that serve Maine’s senior citizens. About 10 years ago, Erb said, Maine policymakers elected to scale back the number of people living in nursing homes and large, state-run institutions such as Augusta Mental Health Institute, Bangor Mental Health Institute and the Pineland Center for people with mental retardation.
“They had to find new places for a lot of people to live,” Erb said, and PNMIs were identified as an important link between independent living and the restrictive environment of the nursing homes. The state crafted reimbursement rules that made the development of a network of PNMIs attractive, he said, but now the funding is being undercut, putting the system at risk.
At DHHS, Kathy Bubar, director of integrated services, said Monday that the state is well aware of concerns about changes in PNMI funding and is working closely with providers to find workable solutions.
When the PNMI system was first created, “rates were established which likely are unsustainable over time,” she said. In addition to Maine’s own budget crisis, cost-conscious federal Medicaid regulators are on alert for any state payment structures that strain federal guidelines, Bubar said.
Bubar said it is possible that some current PNMI residents might lose their eligibility and have to relocate. The state will work with such individuals and their families to find appropriate alternatives, she said, since federal regulations preclude “grandfathering” existing residents.
The state also hopes to increase the availability of home-based care, so elderly Mainers can live safely in their homes, Bubar said. But she acknowledged that the budget situation makes it unlikely that the Medicaid-paid home care system will expand significantly anytime soon.
At The Meadows, Viitala said she has about 30 people on a waiting list and “families calling every day” to see about placing loved ones.
Home-based care can help some seniors stay safe in their homes, she said. But for many who, like LeBretton, are too vulnerable to live alone but not needy enough for a nursing home, she added, PNMIs are an essential link in the health care system.