Monthly Archives: March 2022

Don’t Believe the Propaganda: The Nursing Home Industry is Doing Very Well – Even in a Down Market

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Dave Kingsley

Stocks Have Been Dropping Rapidly Since the End of November – But Not in the Nursing Home Business. Why?

The nursing home industry has a well-funded, highly effective, lobbying-propaganda arm that has been effective in convincing the public that providers are not paid enough to provide decent, medically ethical care. That is a lie. The evidence is overwhelming that the industry’s hardship pleas are merely a propaganda effort at squeezing ever more money out of the taxpayers without providing a correlative improvement in care.

The stock market is one of the many sources of evidence supporting my claim that the nursing home industry is doing just fine during these economic uncertain times. Although the the Dow, S&P, and NASDAQ have dropped precipitously since the end of November, stock prices of the major players in the nursing home industry have held their own or have made major upward swings. For instance, the Ensign Group stock increased by nearly 10% during the same period that the DOW fell 7%, the S&P dropped 10%, and the NASDAQ declined by 17%.

The stability (see discussion of volatility below) and steady upward trend of stock overall in the public-funded long-term care/skilled nursing business suggests that the industry is not subject to the vicissitudes of the overall “market economy.” That is indeed the case because it is an industry that is not part of a market economy. The corporations in the nursing home industry listed on a public exchange are not capitalist enterprises. They are a growing part of the U.S. economy that is a partnership between government and corporations in which corporations have steadily gained the upper hand over government.

The characteristics of the government-corporation partnership – otherwise known as corporatism or statism – is guaranteed revenue, a restricted market, i.e. no competitive market in which prices are negotiated. Nursing home corporations are reimbursed for their costs plus adjustments for inflation. Furthermore, the underlying source of revenue is derived from commercial real estate, i.e., the facilities in which patients are maintained with minimal care.

The power of the industry over its government partner has allowed for financial machinations and accounting maneuvers that hide a significant portion of gains in revenue, operating margins, and, most importantly, cash flow from facilities to parent corporations. States are responsible for auditing cost reports submitted by facilities for the purpose of determining daily Medicare and Medicaid reimbursement rates. The auditing and financial oversight of cost reports are weak – allowing extremely flawed cost reports to pass audit review.

The lucrative nature of commercial real estate with a generous government guarantee of producing revenue plus a stable stream of government funds into medical services have not gone unnoticed by institutional investors such as BlackRock and Vanguard. The overwhelming voting shares in nursing home industry corporations are owned by these asset managers. Hence, pension funds, college endowments, and other large pools of capital have been invested in multi-billion dollar corporations that are setting the trends in long-term/skilled nursing care in the U.S.

Volatility is a Big Deal in the Markets: It Tells Us a Lot About the Past & Future of a Company.

Stocks have been mostly trending down in the past few months due to supply chain crisis, oil price fluctuations, conflict in the Ukraine, inflation hysteria, and uncertainties related to COVID. The market has also been highly volatile, which means stock prices are swinging widely in price. I won’t go into great detail about the technical aspects of volatility. Suffice it to say that a volatility of 1 means that the stock doesn’t move up and down much but a volatility of 0 means it never fluctuates – a theoretical situation that doesn’t happen.

Stock may trend up over time but it will tick down and up on the way up. If it swings widely that suggests that it is far more speculative and traders are buying and selling it at a rather rapid pace. For instance, stocks listed on the NASDAQ with recent IPOs tend to be more volatile because they tend to be risky tech stocks back by venture capitalists willing to take a chance on the next big thing.

Stock of a corporation with a guaranteed market in which competition is restricted and earnings are robust will increase over time with only minor day-to-day fluctuations. That is what is noticeable about the stock in corporations comprising the nursing home industry. Not all of its members have increased their stock price over the past few months, but even the few that have lost ground have not seen the kind of downward swings seen across the board on the Dow, S&P, and NASDAQ.

Liz Fowler – New Top CMS Official – Is Too Deeply Enmeshed with the Medical-Industrial Complex

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Dave Kingsley

The Industry-Government Revolving Door

I remember a trip to the White House in 2012 with a group sponsored by the Committee to Preserve Social Security & Medicare. The purpose of the trip was to lobby against proposed cuts in SS and MC – two highly successful and popular government programs (funded mostly by the beneficiaries of the programs). President Obama had earlier almost caved into Republican demands for devastating cuts in both programs. Subsequently, the President appointed a commission (The Simpson-Bowls Commission) loaded with budget cutters and deficit hawks intent on recommending deep cuts to the programs.

We were in a room with all of the top Obama White House staff, which included Liz Fowler. At the time, I had not heard of Ms. Fowler. It didn’t take long for me to learn that she was President Obama’s point person on the Affordable Care Act. The route to that job, I soon learned, was from a John Hopkins PhD in Health Care Policy & Management, through the major health insurance company WellPoint, and then to the Senate Finance Committee under Chairman Max Baucus – a staging point for moving from government service to a high paid job lobbying – a revolving door between the Senate and K-Street.

It is my belief that Senator Baucus “put” Liz Fowler in the White House to insure that President Obama did the right thing vis a vis industry in the design of a health care program that would funnel enormous amounts of business to private insurers and pharmaceutical corporations. Indeed, she left the White House soon after passage of the law for a job with Johnson & Johnson – a major corporate beneficiary of Obamacare.

Liz Fowler’s Move Back to Government

Liz Fowler’s bio (posted by CMS) conveniently excised her first career at WellPoint (https://www.cms.gov/about-cms/leadership/center-medicare-medicaid-innovation). Furthermore, it says nothing about her years with J&J after leaving the Obama White House. It is interesting to note that the bio says, “She also played a key role drafting the 2003 Medicare Prescription Drug, Improvement and Modernization Act (MMA).” My question is, “Was she working for WellPoint at the time?” The MMA propelled the Republican mission of privatizing Medicare forward at a breathtaking pace. It also included a new prescription drug plan (Part D) in which government negotiation of drug prices with major pharmaceutical companies was disallowed.

Ms. Fowler’s new job at CMS is not insignificant. Indeed, as Deputy Administrator and Director of the Center for Medicare and Medicaid Innovation (CMS Innovation Center), she will have a say over the kinds of innovation in care we need to see in delivery of medical services in nursing homes, hospitals, and clinics. Financial innovation in the nursing home industry has been vast in the past 40 years while innovation in care for patients has been practically nil.

Advocates Need to Seek Liz Fowler’s Removal from CMS

Taxpayers deserve to be represented by government officials who best represent their interests. Innovation in government funded healthcare will require a considerable amount of financial innovation that is fair to patients and taxpayers, availability of data, and transparency. Let’s take the big one: negotiation of drug prices. The excessive costs of pharmaceuticals reflects a toxic, perverse, symbiotic relationship between government and industry. That is not capitalism – it is statism – a necessarily corrupt and debauched form of economics.

Nursing home innovation will require major changes in operations that will humanize treatment and raise standards of medical ethics – which are sorely lacking at this time. Those innovations will reduce the amount of excess capital flowing from treatment facilities to investors.

Much needed innovations include data collection processes that provide valid and reliable data for evaluating the effectiveness of industry’s utilization of tax dollars versus excessive investor extraction of taxpayer provided capital. Also, data will be of no use to advocates, scholars, and the public in general if it is not readily accessible. That is not the case now, which is inexcusable in a super-wealthy country with unlimited resources for providing something as simple as a sophisticated, easily accessed, data system.

Unless Ms. Fowler has had an epiphany and a conversion experience, she does not, as a top official, belong in an agency taxpayers and program beneficiaries depend on for regulation, patient protection, and systems for monitoring provider activity. The tactic of corporate shills in government is the “tweak,” which typically changes little and reinforces corrupt, inhumane, and costly programs. The U.S. healthcare system is a disgrace and an embarrassment because of a corrupt relationship between industry and government the likes of which have never seen in U.S. history. It is time to stop thinking that the system can be transformed or even improved while the revolving door continues to revolve.

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What Does Ageism in the Media Look Like? Michelle Cottle’s Article re “The Villages” in the New York Times Today – That’s What It Looks Like.

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Dave Kingsley

The Villages Is Not a Place I Want to Be in Elderhood. No One I Know Wants to Be There Either.

Michelle Cottle, a member of the New York Times editorial board, has demonstrated the type of dangerous stereotypes regarding so-called “Baby Boomers” that recur frequently in mainstream media. In her article today with the blaring headline “The Nihilism of The Golden Years,” she generalizes from attitudes and behavior of a few elderly residents of a senior housing and entertainment enclave in Florida to a group of people born between 1946 and 1964 that now comprises most of the 65+ population in the United States.

I’ve seen a documentary on the Villages and am frankly somewhat embarrassed for my fellow elderly Americans who choose a second childhood over a life of productivity, societal contributions, and family and community leadership. If that is indeed a fair statement about the people who choose to move there in their retirement years. I’ve never been to the Villages, so all I know is what I’ve heard, seen in the media, and learned from the documentary.

Ms. Cottle presents the residents of The Villages as hedonistic and politically oriented toward Trump’s MAGA movement. Two-thirds of a full two page spread was filled with photojournalism displaying golf courses, golf carts, dancing to “Jimmy Buffet’s Margaritaville,” and MAGA demonstrations. This may or may not fairly describe the people living in The Villages, but the article drags the entire group of 65+ Americans into the negativism she focuses on people living there. For instance, toward the end Ms. Cottle writes, “Big Government is eyed with skepticism, even as the aging populace commands an increasing larger chunk of the federal budget for programs such as Social Security and Medicare.”

That article also states that “Baby boomers long accustomed to setting the agenda are being eased out of their slot atop the sociopolitical ladder – especially conservative white boomers.” According to Ms. Cottle, the underlying problem, in the final analysis, are aging Americans: “…the community is a distillation of the cultural crosscurrents at play in an America that is simultaneously graying and diversifying.” I don’t think I need to tell the readers of this blog post how many ugly stereotypes and ill informed generalizations are included in these types of statements.

Scapegoating the Elderly

“Isms,” whether they be racism, sexism, ageism, or any other type of ism such as those against sexual orientation, and religion, are dehumanizing and damaging to the victims of stereotyping. In many cases they are dangerous and can lead to physical harm – indeed often do. A psychological boundary is placed around groups of individuals who are themselves often very diverse and then misinformation is used to scapegoat them. For instance, an aging population or the elderly in general are not causing an increase in the cost of government. That is well accepted in the literature. I have debunked that myth in my own research. I would be happy to supply a list of references to support that.

Not one bit of Social Security is “on budget.” Approximately two-thirds of all Medicare expenditures are paid into the program through payroll taxes, premiums, and other out of pocket expenses. Traditional Medicare and Social Security have administrative costs equal to 1.5% and .9% of revenue respectively. So Ms. Cottle is ill informed and misinforming her readers. These two programs are a model of government run retirement and medical programs. If that doesn’t remain as such, it won’t be the fault of the beneficiaries.

“The Nihilism of The Golden Years” Does Not Represent the 65+ Population of the U.S.

The 65+ population is comprised of veterans, poor people, middle class people, people who have worked hard throughout their lives, and on and on and on when we talk about 70 million Americans 65 years of age or older. They have raised families, robbed banks, worked for corporations at a variety of levels. Some have made a fortune, some are living in dire poverty, some are struggling to live on pensions and Social Security. The variety of people 65 or older is so diverse that it would take a book or volumes to describe it. What we all have in common are needs for healthcare, housing, and basic other living necessities.

Turning a group of people born in an 18 year span of time into a “thing” with negative characteristics is a form of human thinking that has led to more human tragedy and suffering than any other mental disposition characteristic of homo sapiens. It is one reason that we can institutionalize elderly people in subhuman nursing homes and mistreat them. They are seen as a “silver tsunami,” a disaster, a problem. What else are we going to do with them?

Attitudes Need Work in The United States

At Kansas University Medical School, I taught class after class of marvelous graduate students headed into health care professions. I designed and validated an attitudinal survey to measure their attitude toward the elderly. In the next few blog posts, I will report some results from that survey and write about the need to change the way we think of aging. Here is a hint at the findings from my survey: To the item “In the next 20 years, the 65+ population will have the greatest impact on health care costs,” only 12 of 100 of the students responded strongly disagree or disagree. Two were uncertain and the rest either agreed or strongly agreed. This is false and scapegoating. It should concern us.

Data Analytics, The Stock Market, & Healthcare Justice

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Dave Kingsley

Current public relations carried on by the hospital and nursing home
industries are based on bogus claims designed to mislead the public. The
variety of wealthy lobbying organizations for the medical-industrial complex
are promoting false narratives based on either an invalid interpretation of
financial data (intentional) or making claims of hardship, e.g. “low net
margins” that are not supported by solid, scientific, factual information
(also intentional).

Big and increasingly dominant hospital and nursing home corporations have
sophisticated data analytic departments on which they rely for management
decisions affecting cash flow and shareholder interests. These multi-billion-dollar
companies determine razor thin margins acceptable for minimal staffing, pay,
food quality, training, and equipment. Even the smaller chains are implementing
productivity enhancement efforts with software designed to determine maximum
acceptable acuity levels for billing and cash flow.

Unfortunately, providers of long-term/skilled nursing care (i.e. nursing
homes operators) are not applying advanced technology and data analytics to
quality of care. I follow industry trade publications and financial reports and
can find no evidence that providers are employing sophisticated analyses to
efforts for optimizing the health and quality of care at a cost that returns a
reasonable value to executives and shareholders rather than a return that can
pass muster with regulators and legislators.

Because much essential financial data pertaining to tax supported medical
care operations are hidden from public view or nearly impossible to wrest out
of government agencies, advocates for patient and employee justice in hospitals
and nursing homes are in an asymmetrical fight with lobbyists. Because the
nursing home industry is more of a real estate/finance industry than a
medical/patient care industry, the lobbying power in federal and state
legislatures constitutes a juggernaut that can only be defeated through an
organized advocacy effort that fights for transparency and fully utilizes what
is available now to feed into a truthful narrative for media, legislative, and
research actions.

What Is The Stock Market Telling Us About The Financial Condition of
Nursing Homes & Hospitals After Two Years of COVID?

Some data pertaining to the financial condition of nursing homes and
hospitals are readily available from the U.S. Securities & Exchange
Commission (SEC). I have been tracking the stock of publicly listed
corporations with operations in nursing homes and hospitals. Most nursing home
corporations listed on a public exchange are real estate investment trusts
(REITs) that are becoming increasingly powerful in the long-term care/skilled
nursing business (they trade and lease real estate but also operate
facilities).

The last three months have not been good for the equities market. Stock
prices have been falling precipitously. But that’s not the case for stocks of
corporations in the business of providing tax funded medical care.

Brookdale Senior Living & The Ensign Group

Let’s consider the two biggest nursing home operators listed on a public
exchange that are not REITS: Brookdale Senior Living and The Ensign Group.
Since late November, the DOW has dropped approximately 3%, the S&P has
declined by 6.5%, and the NASDAQ has fallen by 17%. But these nursing home
corporations have gone in the opposite direction.

Closing price of Brookdale November 29, 2021 – $6.30 Close on February 26,
2022 – $7.00

Closing price of Ensign November 29, 2021 – $77.20 Close on February 26,
2022 – $82.19

So, Brookdale stock is up by 11% and Ensign stock is up 6.5% during the same
period we’ve seen a drop in the markets like we haven’t seen since March of
2020 when they crashed due to COVID but recovered rather quickly.

Most of the REITs heavily involved in the nursing home business have seen
their stock rise during the time that the market has been falling rapidly.
Welltower, the big one, is up 1%. Ventas, the other big one, is up nearly 8%.

Publicly listed hospital corporations are doing well also. HCA stock has
climbed from $229 in late November to $253 at the close yesterday – a 10.5%
increase. Tenet jumped from $74.46 to $85.71 since November 29th – a 15%
increase!

Why is the stock of these hospital and nursing home corporations doing so
well when the market is in correction territory? The primary reason is this:
they are heavily subsidized by the taxpayers. Indeed, their prices are set by
state agencies much like like utility company rates are set. They submit their
costs and are reimbursed for those costs plus increases for inflation and
healthy percentage increases above costs. Furthermore, they are structured for
each facility to pay lease expenses and other ancillary expenses to other
corporations they own.

Don’t believe the industry’s hardship pleas. That is all a lie. It is a
scurrilous behavior indeed for the American Health Care Association – the
nursing home industry lobby – and the American Hospital Association to be
putting out false information to snow the taxpayers who are so generous with
their subsidies for executive pay and shareholder dividends.