When Wymore's Good Samaritan Center closed in 2017, Virginia Swift was forced to leave the nursing home in the town in which she had grown up and move 14 miles down the road to another home.
The move wasn't too far. Residents in nursing homes in other rural towns have had to move farther away from their communities when their hometown nursing center closed.
Since 2015, 27 nursing homes in Nebraska have closed and four have announced closure, with about half of the total closures coming this year. That number is expected to increase, said Heath Boddy, CEO of Nebraska Health Care Association.
"There are still facilities that are trying to make it month-to-month, quarter-to-quarter, at this point, seeing if they can cash-flow and find a way to be solvent," Boddy said.
Even if it was not far, Swift's move was not an easy one. She testified at a legislative hearing in March on a bill (LB181) that would fund a study of long-term care sustainability.
Swift, 64, who can't walk, told senators she had grown up in Wymore and spent time as a schoolgirl at the nursing home she would eventually move into, helping with programs for residents, visiting them and making table decorations, trick-or-treating and singing Christmas carols.
She become a resident herself in 2015, after her home was destroyed by a flood. Most of the residents in the home were local, she said, and had lived in Wymore since they were born, the town where they had gone to school, worked and where their families lived close by.
Their intent was to live out their last days there, Swift said, being visited by local volunteers, seeing high school girls on prom night who would stop by to show off their dresses. They enjoyed continuing connections with their families, neighbors, local businesses and churches.
"Its closing had a big impact on the town," she testified.
The latest four nursing homes to announce closure, all purchased by Azria Health this month, had a combined 205 state-licensed beds in Blue Hill, Milford, Columbus and Utica, and about 240 employees.
The closings are primarily because state payments to nursing homes certified for Medicaid recipients are below the cost of providing their care, Boddy said. Even with money appropriated this session by the Legislature, those homes are getting about $30 a day per Medicaid resident less than the cost of provided care.
Around 53% of nursing home residents rely on Medicaid for their stay.
Nebraska Health and Human Services plans to begin a new method of payment for long-term care facilities beginning July 1, with a phase-in over two years.
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Jeremy Brunssen, deputy director in the Medicaid division, explained on the department's website that the current cost-based model is difficult to understand and for providers to predict and manage year-to-year. It's complicated and not transparent, he says.
HHS spokeswoman Julie Naughton said the department also is updating the regulations governing the payment, with the proposal to move toward a new methodology that focuses on "payment equity and quality."
The new payments would be centered on a base rate that is adjusted for patient acuity, and then further adjusted for high quality, Naughton said. Senators have referred to it as a flat rate.
Those interested can follow the department’s progress on updating the payment methodology at the Department of Health and Human Services website.
The new rates have not been revealed. But Boddy said it's possible they would be based on the average cost of care in Nebraska, which is about $190 per resident, per day, with a range of $120 to $250, so some facilities would get an increase and some a significant decrease.
Under the current way of paying nursing homes, 29 of them dealt with rate reductions this year, and the rest had no change or had increases, Boddy said.
Naughton said while Medicaid pays for services for Medicaid beneficiaries, several other industry dynamics can impact facilities, including their operating efficiency and quality, the ability to recruit and retain staff, occupancy and demand from consumers.
Omaha Sen. Sara Howard, chairwoman of the Legislature's Health and Human Services Committee, said there are no other states she knows of considering moving to a flat-rate payment for nursing homes. She predicts it would be difficult for nursing homes to operate off a flat rate. In small towns, the margins are "very, very slim," Howard said.
Also, she said, having no cost method included in new regulations would mean less transparency, "that we truly need in order to be able to provide appropriate oversight as to how the rates are being set."
The cost method now in regulations reflects cost of care, how many Medicaid recipients are in the facility, the payer mix and staff ratios.
At a hearing on Lincoln Sen. Kate Bolz's LB181, which would recommend changes to the policy and funding of Medicaid long-term care services, she warned senators about nursing home closures and said skilled- and assisted-nursing facilities are crucial to the quality of life for those who require long-term care. They are also vital to small communities, with many of them among the biggest employers.
The number of Nebraskans aged 85 or older is projected to double over the next two decades.
For those who need nursing home care, Boddy said, he is "very concerned" about what access is going to look like.
"I think we're very soon going to see a time when families are going to face tough decisions to drive long distances to see loved ones who need the services of long-term care facilities."