Category Archives: Long-term Care Industry

Kansas City Public Television & the Damaging Consequences of Nursing Home Misinformation

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Dave Kingsley

Cavalier Distribution of Unsupportable Financial Information Causes Physical Harm and Shorter Lives

     Kansas City Public Television (KCPT) is presenting an upcoming program entitled “The State of Aging in Kansas City.”  The program as advertised includes a panel discussion and a documentary film. I was shocked to see false claims by the American Health Care Association –  the industry lobby – included in the promotional material for the program.  For instance, the promo repeats AHCA falsehoods that “nearly 60% of nursing homes are operating at a financial loss” and that “Nearly three of every four facilities are concerned about closure due to staffing shortages.” 

    This is blatantly false information and serves to shield the industry from responsibility for widespread neglectful care of patients while investors are earning robust returns. It is obvious that KCPT has given the for-profit nursing home industry a major amount of influence in the development of their promotional material without fact checking the industry’s financial claims or consulting with credible scholars and advocates engaged in nursing home research. 

    Any widespread distribution of nursing home financial misinformation is a devastating blow to efforts at significant reform of the Medicaid and Medicare funded skilled nursing business. Therefore, patients in poorly run nursing homes continue to experience unnecessary pain, discomfort, and shortened lives because of lobbyists’ propaganda.

    The industry’s bogus hardship claim is a primary barrier to changing the despicable way elderly and disabled patients are treated in so many long-term care facilities.  The AHCA has immense resources to spread a false narrative –– with $128 million in 2021 revenue (https://www.aha.org/system/files/media/file/2022/11/2021-aha-form-990.pdf) and affiliates in all 50 states.  Hence, the “we can’t afford to do better” defense serves to undermine serious demands by advocates for stricter regulation and an increase in the quality of care.

    Public television has unwittingly placed its imprimatur on industry propaganda.  There is scant evidence that the nursing home industry is experiencing widespread loss.  Conversely, an abundance of available evidence suggests that historically and during COVID, the nursing home business has been and remains highly lucrative.

Responsible Journalism and Integrity Requires a Correction by KCPT

    Apparently, “The State of Aging in Kansas City” will kick off with a town hall & panel discussion on September 5th.  The town hall and a documentary will be shown on KCPT on September 14th.  Although I was consulted by the independent filmmaker about a year ago who asked that I meet with him to discuss nursing home finance.  I did that on a couple of occasions, but I did not know exactly what his project was about.  He did say that he was working on a documentary for public television.  I didn’t think much about it until I saw the promo and his name attached to the documentary.

       The filmmaker told me he had nothing to do with the promotional material and directed me to the person who was responsible for it.  I sent that person – who will also MC the townhall meeting –  a lengthy email explaining the problems with the information in his promo to which I attached couple of articles that I had authored with my colleague Charlene Harrington, Professor Emeritus at the University of California, San Francisco.  His response was, in my view, terse and dismissive.

    I have not seen the documentary and cannot speak to its contents.  Hopefully, it will help the public with an understanding of the issues facing patients, families, advocates, scholars, and legislators in understanding how we can arrive at a fair return to investors for an acceptable level of care.  At this time, we cannot do that because of the raw, rank, political power of the nursing home, hospital, real estate, and finance industries (i.e., medical industrial complex) inside the Washington, D.C. beltway and the 50 state capitols.

    For those of us who spend a good proportion of our waking hours in an attempt to counter industry propaganda and provide objective, scientific information, public television misinformation, dispensed to its widespread viewing audience, is like a kick in the solar plexus. It is very difficult to overcome corporate falsehoods in this post-truth era, but it is psychologically devastating when the hard work in attempting to do that is undermined by local public television.

Labor Conditions in the Nursing Home Industry:  An American Disgrace

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Dave Kingsley

What is U.S. Policy Regarding a Living Wage for Healthcare Workers

   It is difficult to establish exactly what CMS and state agencies are doing these days to audit, investigate, and regulate the nursing home industry.  But I think we can safely say that it is very little.  One thing we know is that the long-term care business is labor intensive.  Hands on, direct care is the sine qua non of nursing home operations.  Without the workers who risked their lives during COVID (approximately 2000 died because of the pandemic), corporations could not have continued to earn robust returns for their investors.

    Labor issues in the nursing home industry are escaping notice of legislatures, the media, scholars, and reform commissions.  Consequently, the public in general is unaware of the injustices perpetrated on workers in the form of poverty wages and poor working conditions – including violation of labor rights under the National Labor Relations Act.  Although operators were provided with lavish amounts of COVID relief, it appears that workers did not share in these allocations even when large amounts of revenue were extracted on behalf of investors.

High Poverty Areas of the U.S. and Poverty Wages:  The Injustice of Place and Internal Colonization

    Large regions within the United States such as the Mississippi and Arkansas Deltas, South Texas, and Appalachia, and large ghettos and barrios are beset with high levels of poverty, low economic development, and a dearth of opportunities through education and upward mobility.  These areas lack cultural amenities and healthcare access.  The poor whites residing in the poorest areas of the U.S. have been losing ground in their overall health and life expectancy.  In some places, people of color are in the majority and have historically had poor health care access and shorter lives.

    One would think that an injection of government funds through long-term care services and other healthcare programs e.g., Medicare and Medicaid would significantly contribute to a rise in the standard of living in these impoverished, economically underdeveloped places.  In other words, the trillions of dollars in federal and state budgets dedicated to healthcare should provide an economic boost to economically disadvantaged areas. However, rather than contributing to development of impoverished counties and regions, the long term care industry is exploiting them through excessively low wages.

Magnolia, Arkansas and the Greenhouse Cottages of Wentworth Place

    Greenhouse Cottages of Wentworth, Magnolia, Arkansas

In my last blog post, I wrote about the shockingly low wages paid to CNAs doing 80% of the work in Alta Vista Nursing & Rehab –  an Ensign Group facility (see “NAFTA and Working Home Wages in the Rio Grande Valley”).  Most nursing home corporations along the corridor consisting of cities such as Brownsville, Harlingen, McAllen, and other cities with sister cities across a bridge to Mexico are paying poverty wages while extracting robust amounts of earnings and COVID relief money (more about them in a later post).

    I am hypothesizing that pricing and reimbursement of industry for services are uniform across states without regard for the price of labor and yet set a floor under returns to the industry that advantages investors. Conversely, labor costs are allowed to float in local labor markets.  This is an injustice.  Labor in poor areas is suppressed while rich areas benefit from wages at the high end.  As I collect data on wages, hours, and working conditions in the nursing home industry, I’m seeing this pattern.  Let’s take Greenhouse Cottages of Wentworth Place in Magnolia, Arkansas as an example.

    Magnolia is a community of 10,000 people located in Columbus County, Arkansas, which is one of the poorest counties in Arkansas with poverty level nearing 25%.  The county is not far from the Louisiana border in South Central Arkansas.  Greenhouse Cottages of Wentworth Place is a large facility with 135 beds and 2022 revenue of $11,648,420.  Based on its income statement, the facility had operating income (operating net) of $719,547.

    In addition to operating income, $522,998 in nonpatient revenue from COVID relief was noted on the facility’s income statement.  Hence, with a net income of $1,242,998, the company had a 10.7% net income in 2022.  However, the company claimed $7,198,189 in expenses to its real estate entity, therapy services company, home office allocations, and employee leasing (i.e., outsourcing labor to its labor contracting service).  $6,163,519 of claimed related parties expenditures were allowed by the state.

Wages at the Greenhouse Cottages of Wentworth

    An examination of wages for the Greenhouse Cottages of Wentworth reveals exceeding low nursing wages for a company with an impressive net income and huge payouts to subsidiaries of the parent corporation.  In 2022, the average RN wage was $34.48.  Looking at RN wages at the facility for years 2016 through 2022, the average hourly wage for RNs increased from $31.62 to the 2022 wage of $34.48.  If $31.62 in 2016 kept pace with inflation, it would be equivalent to $39.61 in 2022.

    In 2016, CNAs were paid $10.57 at the facility.  That low base amount rose slightly above inflation over the years ($13.93 versus $12.49 in 2021).  In 2022, CNA pay averaged $15.71 due to President Biden’s Executive Order raising the minimum wage for federal contractors to $15.00 per hour. 

    Over the three years that COVID was raging, the facility received $3,548,321 in COVID relief.  There is no evidence that this was shared with the workers.  I suspect that we will find that to be a standard practice throughout the nursing home industry.

Is a Huge Increase in Reimbursement Justified without Consideration of Workers

    As lobbyists and propagandists for the industry with negligeable pricing research and  evidence continue to claim that reimbursement is too low, CMS proposes that operators be rewarded with a $2.2 billion increase due to a 6.4% “net market basket update to the payment rates” (see “CMS SNF Final Rule Seen as Insufficient for Payment Rates While Advancing Unfair Measures, Skilled Nursing News, July 31,2023).  Given massive amounts of COVID relief funneled into the industry and ongoing subpar pay for the direct care workforce, we need clear and decipherable data and rationale for this increase.

NAFTA & Nursing Home Wages in the Rio Grande Valley

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Dave Kingsley

The Ensign Group’s $10.82 per Hour CNA Labor in Brownsville, Texas

The Alta Vista Rehabilitation & Healthcare Center pictured above is owned and operated by The Ensign Group – the largest (and rapidly expanding) American nursing home chain. This facility came to the attention of those of us working on a study of The Ensign Group (hereinafter referred to as Ensign) by The Center for Healthcare Information and Policy – a recently incorporated 501(C)(3) nonprofit dedicated to healthcare research.

In collecting data on Ensign’s 2021 cost reports, we noticed that base CNA wages for this facility were excessively low at $10.82 per hour. Typically, 2021 CNA base wages (hourly wage excluding fringe benefits) average approximately $17.00 per hour with $13.00 at the very low end of the distribution.

Brownsville is in the Rio Grande Valley of Texas, connected by a bridge across the Rio Grande River to Matamoros, Mexico. The North American Free Trade Agreement liberalized the process of obtaining a work permit in the U.S. for Mexican citizens. Therefore, residents of Matamoros cross the bridge every day to work in Brownsville, Harlingen, and other Texas cities on the border. The minimum wage in Mexico is approximately 50 cents (U.S.) per hour.

Workers earn about $2.00 U.S. in the auto Maquiladora plants on the Mexican side of the border. Therefore, a wage of nearly $11 per hour is very attractive to Mexican citizens attempting to care for themselves and their families. It is in the best interests of the Mexican workers and the nursing home industry to garner CNA training and work permits for the border workforce. My interviews with workers in the U.S. nursing home system suggest that the Mexican culture and respect for elders lend themselves to a very capable and excellent immigrant workforce from Mexico.

However, the abject poverty of Mexico is an opportunity for exploitation of workers by the nursing home industry. It is important for U.S. legislators and regulators to take a serious look at this problem.

Why is Ensign Paying their Brownsville Workers Excessively Low Wages?

Why is Ensign Paying their workers less than a living U.S. wage? Because they can. Because the nursing home industry is financialized, protection and enhancement of shareholder value is the industry’s moral and ethical summum bonum – the highest and guiding ethical value of the corporate culture.

Although the Brownsville facility netted $2,298,733 operating income on net patient revenue of $8,847,305 (26% net after expenses for interest, taxes, and depreciation), employees did not share in that financial success. The company expended $1,573,153 on nursing care. If they had increased that by 50%, their net would have been reduced to 17% – which would thrill the owners of any enterprise. The facility also reported nearly a million dollar allocation to the Ensign home office and related parties. Furthermore, we usually note that CNA hours comprise around 60% of total nursing hours. At Alta Vista, 91,889 hours of the total 112,566 nursing hours were allocated to CNAs – 82%.

The labor mark up on the more than impressive earnings from this facility by a $3+ billion C corporation benefits investors but is not shared with workers. In other words, the labor market is determinative of wage rates while a price for the service is set by state governments at a level guaranteeing a robust return to shareholders and high executive pay.

The financial structures of corporations operating in the nursing home space are not a major factor in wages, hours, working conditions and staffing. Corporate type, e.g., REITs, private equity firms, C corporations, limited partnerships, LLCs, or any other type of corporation will not drive wages and staffing in this industry. Rather, an attitude toward labor and the perception of the value and worth of people doing the hands on work with patients needing skillful and empathetic care are the deciding factors in how we pay our care givers in nursing homes.

As long as the industry can use its political power to exploit workers, it will. It is ironic that nursing home reform commissions and congressional hearings have ignored the plight of workers while extensively noodling with the industry over ever more complicated billing systems. The industry will find plenty of techniques for leveraging billing systems to their advantage. What they won’t do is invest in a loyal, experienced, and trained workforce.

H.H.C. OF MARION COUNTY v. TALVESKI DECISION ISSUED ON THURSDAY:  THE SUPREME COURT HANDS NURSING HOME PATIENTS AND THEIR FAMILIES A MAGNIFICENT HUMAN RIGHTS VICTORY!

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Dave Kingsley

Thanks to Susie and Ivanka Talveski, Seven Supreme Court Justices, and Individuals and Organizations Filing Amicus Briefs, the Federal Nursing Home Rights Act Has Been Strongly Reinforced.

    In a decision written by Justice Ketanji Brown Jackson and reported on Thursday, the U.S. Supreme Court held that unambiguous provisions of the Federal Nursing Home Rights Act (FNHRA) are enforceable by private individuals under Section 1983 of the Civil Rights Act of 1871 (H.H.C. of Marion County v. Talveski[1]). This is a big deal because it means that practices such as use of chemical restraints and arbitrary transfer are illegal and a cause for action in federal courts.  Patients and their families cannot be restricted only to medical malpractice suits in state courts and/or to state administrative remedies.

    Susie Talevski, an attorney, initially filed a suit in Federal District Court on behalf of her mother Ivanka after her father Gorgi Talveski was arbitrarily transferred to a facility an hour and a half from their home.  The transfer occurred after the Talveski family consulted with outside physicians and hired a neurologist to evaluate the regimen of drugs administered to Mr. Talveski.  It appeared that his health deteriorated after the drug regimen was initiated and improved after six powerful psychotropic medications were terminated from the regimen.

    In conversations with Susie and her colleagues in Indiana, I’ve learned that it is very difficult to navigate the Indiana tort liability laws and even make it into state courts with a suit against a nursing home.  As in most states, awards for victims of medical malpractice are capped and not more than a hand slap in Indiana.

    Furthermore, as most of us who advocate for nursing home patients know, there is no real remedy at the state level in most states for any type of redress when abuse and neglect occur. Administrative remedies through state agencies tend to end up in the “nothing to see here” file.

    In the final analysis, patients and families have the best chance for redress in federal courts when nursing homes illegally violate rights granted by FNHRA.  I applaud Susie’s courage in fighting this case all the way to Supreme Court.  In agreement with H.H.C. of Marion County’s claim that she didn’t have standing to sue in federal court, the district court threw out her case.  She appealed to the 7th Circuit, which overturned the decision of the district court. H.H.C. of Marion County appealed, and the Supreme Court granted certiorari.

H.H.C. of Marion County v. Taleveski Should not be Below the Radar, but it is.

    On Thursday, the Supreme Court voting rights decision and the indictment of former President Donald Trump grabbed all of the headlines and H.H.C. of Marion County v. Talveski seems to have escaped media notice. I hope this case is discussed widely and in depth by advocates and scholars.  The back story and the legal implications of the case are far more extensive and complicated than I want to deal with in this brief blog post. Protection of the right to be free from chemical restraints and capricious behavior of nursing home providers should not be left to state tort law and/or the whim of state agencies, many of which have a propensity to protect the interests of the industry at the expense of patients and families.  Certainly, Indiana has one of the most anti-consumer torts laws in the U.S. 

    It was shocking to read the argument of the U.S. Solicitor General on behalf of the provider (H.H.C. of Marion County) before the Supreme Court.  She claimed that administrative channels at the state level were sufficient to insure FNHRA rights. This naivete on his part is one more example of how out of touch federal administrative agencies are in assuming that individuals are not in serious jeopardy of having their rights violated or ignored within individual states.

The ”Medicaid Unwinding:” An Orwellian Euphemism for Abject Cruelty & Profound Ignorance

    Fortunately, the Talveski family, the 7th Circuit, and seven Supreme Court justices could see that individual civil rights granted to all U.S. citizens by Congress should be protected in the federal courts under the Civil Rights Act of 1871, Section 1983.  The precedents for this case have pertained mostly to Medicaid rights in general. 

    During COVID, the Federal Matching Percentage (FMAP) for state Medicaid programs was increased by a hefty percentage for the purpose of preventing the administrative burden on Medicaid beneficiaries who are required to reapply each year and prove their eligibility for the program.  As a condition for receiving the FMAP uplift, states could not disenroll individuals from the Medicaid program.  The number of people receiving Medicaid benefits, i.e., had access to medical care, grew at a vast rate.  That program ended on May 1st, and now the so-called unwinding, i.e., kicking people off, has resulted in a precipitous drop in enrollees. 

  With weak state regulation of healthcare providers, it is likely that states will regularly violate the rights of U.S. residents to medical care.  Especially in states with far-right wing legislatures, harassment of poor individuals and families needing medical care and other assistance is ordinary and ongoing.  In Arkansas, a state that tried for a waiver from CMS to force Medicaid enrollees to undergo drug tests, the current governor, Sara Huckabee Sanders, has come up with “Arkansas Renew” as the Orwellian label for her disenrollment program.

    All realms of human rights and civil rights are critically important if we are to retain a semblance of Democracy.  Drugging and disappearing people into out of the way institutions is one of the most chilling and horrifying practices imaginable in any society.  Certainly, it is characteristic of fascist, authoritarian governments.  That it happens on behest of corporations attempting to optimize return for shareholders, executives, and other special interests, doesn’t make it any less odious.

[1] https://www.supremecourt.gov/opinions/22pdf/21-806_2dp3.pdf.

Gray Panthers’ Statement on the American Nursing Home System: “Restructure the Industry and Defund the Existing System.”

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Dave Kingsley

Reissuing an Important & Elegantly Written Document by the National Council of Gray Panthers Networks.

    A couple of years ago, the Gray Panthers issued a statement on the nursing home industry in the United States.  Entitled “Restructure the Industry and Defund the Existing System,” it was elegantly written and to the point of what we need in public discourse regarding the suffering of institutionalized disabled and elderly Americans in long-term care – suffering due to the precedence of shareholder value over humane care.  Hence, the document is well worth reading today since recognized reform movements in Washington, D.C. over the past couple of years have been sympathetic to the industry and unwilling to confront the truth.

    The authors were too modest to take credit and list their names on the statement.  I assume that Jan Bendor, Art Persyko, Lydia Nunez, and Clint Smith had a hand in writing it.  But perhaps it involved more members or perhaps all of the GP Senior Housing Committee.

    The following are excerpts from the summary:

    “The ‘enemy’ is a monster created by federal policy, allowing for-profit corporations to own chains of long-term care facilities, and lavishing on the owners the incentives and benefits in our tax laws regardless of their performance in caregiving.”

    “These corporations are engaged in buying and selling of real estate with very favorable tax rewards.  The corporations can practice medicine and also profit from Medicare, Medicaid, and other programs that can be hijacked for the corporation’s benefit rather than for the benefit of those in their care.”

Problems & Recommendations

    In stating the problems on page 2, focus of the statement was on lack of accountability for the massive loss of life due to COVID, weak regulation by government agencies, underpaid staff in understaffed facilities, and the political clout of the industry through lobbying.  Recommendation appropriately included accounting of Medicare length of stay fraud, wrongful discharges that occur, accountability for misreporting of data regarding harm and finances, overuse of antipsychotics.

   Download the Gray Panther Statement on Nursing Homes Here:

2021-08-09-Nursing-Home-Crisis-Action-to-Restructure-NHI-3Download

If the U.S. Moved in the Direction the Gray Panthers are Suggesting, Americans May Not Hate the Thought of Needing Long-Term Care in a “Nursing Home.”

Inside the Washington, D.C. beltway reform efforts are beset with influence from the powerful forces that have a vested interest in keep the nursing home system the way it is. It is time for some honest discussion about why the status quo is only gaining strength with a small tweak here and there that serve as appearances and nothing more.

THE STATE OF NURSING HOME FINANCIAL REPORTING IN POST TRUTH-AMERICA.

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Dave Kingsley

American Tolerance of Corporate Deceit & Predatory Economics is Perplexing

    Misinformation can be harmful and even deadly. We have seen evidence of this maxim during the COVID crisis. We have seen it in the debate over climate change and in so many other critical issues confronting society. In post-truth America, it has become acceptable to put forth any mistruth or unverified and unverifiable claim and escape embarrassing denunciation, excoriation and censure. In no case is this more apparent than in the mistruths spread by for profit corporations in the nursing home business.

    It isn’t difficult to compile objective evidence that nursing home industry hardship pleas of low profits, thin margins, and other such claims are false and misleading.  The American Health Care Association/National Center for Independent Living, the industry’s lavishly funded propaganda organ, consistently spreads the narrative that corporations in the Medicaid and Medicare funded long-term care business are struggling financially and need a significant increase in reimbursements.

    A highly qualified financial sleuth isn’t needed for debunking the industry’s financial narrative of low profits and struggling investors.  Therefore, it may be difficult to understand how nursing home reform commissions and politicians escape public opprobrium for ignoring the patently obvious. However, it should be understandable that the finer points of nursing home finance isn’t on most peoples’ radar. We need to put it on everyone’s radar.

The Nursing Home Industry is Lying to the American People and Getting by with It

    The truth is that the federal and state governments allow for a charade in which facility-specific costs are submitted without any clarity about cash flowing to holding companies and parent corporations. We don’t really know how much Medicaid and Medicare revenue in the privatized nursing home system is extracted for dividends, and executive pay. ONE BIG EXCEPTION, HOWEVER, IS THE ENSIGN GROUP.

    With an annual revenue in 2022 of over $3 billion, the Ensign Group is the largest single provider of nursing home care in the United States.  It is also the only publicly listed company that earns revenue solely from Medicaid and Medicare funded long-term care.  More importantly for understanding the financial realities of the nursing home business, it is a publicly listed corporation and therefore must file financial reports with the Securities & Exchange Commission (SEC).

    The Ensign Group annual 2021 10-K report submitted to SEC notes a net income of 8.5 percent and earnings before interest, taxes, depreciation, and amortization (EBITDA) of 13.7 percent.  However, an examination of their six facilities in Kansas reveal a combined net revenue of $55,567,680 and a combined operating negative net of -3,201,123 (-5.7%).  Five of the six facilities reported a negative net income.

Facility-Specific Cost Reports:  How the Big Lie Works.

     A review of Ensign Group cost reports in one state, i.e., Kansas, provides insight into how the misleading state-specific and facility-specific financial  system works.  Ensign operates six facilities in the state of Kansas.  Comparing the facility-specific cost reports to the consolidated financial report submitted by Ensign to the SEC is instructive in demonstrating the inadequacy of the cost reports as a measure of financial performance.

    For instance, Table 1 contains cost report data from an Ensign owned facility known as Riverbend Nursing Home in Kansas City, Kansas (incorporated and licensed as Big Blue, LLC). The data indicates that the facility, with a slight negative net operating income, lost money (this is 2021 data). It is typical for facility cost reports to show a very low or negative income but that doesn’t reflect what parent corporations are earning from the operations.

Table 1:  Net Operating Margin

Form CMS 2540-10:  Home Office Allocation & Related Parties

    Parent Corporations with a chain of facilities incorporated as LLCs can claim an allocation to their home office based on corporate expenses for operating each facility.  The “home office allocation” appears to be a large allowance for expenditures that are not fully clarified, not decipherable by the public, and, I believe, not understood by state auditors.  For instance, Table 2, includes claims for Ensign home office allocation and payments to their subsidiaries paid for insurance and real estate.

Table 2: Part I, Riverbend Form CMS 2540-10

Corporate Hubris:  They Don’t Need to Answer Questions Required by Law

    A state auditor with whom I had a conversation recently asked me if I had any insight into the home office allocation that might be helpful for auditing purposes.  This person knew that I had been looking at cost reports across the U.S. and thought practices in other states might be something of a guide.  That the auditor wasn’t sure about how to evaluate funds extracted from revenue and sent up the chain of LLCs (often shell companies) to home offices tells us much.

    The auditor is in fact not the problem.  Statutes governing Part I of Form CMS-2540-10 (42 CFR 413.17) states that “such cost must not exceed the amount a prudent and cost conscious buyer would pay for comparable services, facilities, or supplies that could be purchased elsewhere.”  Commonsense suggests that pricing goods and services sold to related parties requires some sophisticated and extensive analyses. Do states have the regulatory capacity to do that?  Advocates and scholars need to raise that issue with legislators and demand to see any evidence supporting decisions to approve claimed expenditures to related parties.

Part II of Form CMS 2540-10:  How Vague Can They Be?

    Part II of Form CMS 2540-10 requires far more detail than shown in Table 2, which reflects the exact data submitted by the Ensign Group for its facilities. For instance, the statute requires that an entity listed in Column 4 “enter a percent of ownership in the provider.”  That may not be a logical question because Ensign corporate owns everything.  Gateway Healthcare is a shell company that merely hides the flow of capital, avoids taxes, and protects the facility from liability.  Theoretically, Gateway owns 100% of Riverbend, but Ensign owns 100% of Gateway (an LLC incorporated in Nevada).

Therefore, Ensign’s facility-specific cost reports merely ignore statutory reporting requirements. That appears to be acceptable to state auditors. This kind of “catch us if you can” hubris is typical when an industry has an extraordinary amount of money to spread around in Washington and the 50 state legislatures.

Table 3: Part II, Riverbend Form CMS 2540-10

Summary:  CMS Allows States to Regulate Nursing Homes & Looks the Other Way

    CMS is not likely to fix the corrupt and inadequate nursing home financial reporting system. They will noodle with advocates and mull over all sorts of well-founded and sensible proposals but without pressure from legislators to counter the industry’s power in Washington and in the 50 states, the status quo will prevail. 

The political will just isn’t there at the national level. We need to change that.  Advocates are likely to make more progress at the state level by compiling cost reports in their respective states and take their analyses to the media and state representatives.     The critical – life and death – nature of this problem should lead the public to revolt if they understand it and have the evidence to clearly see that the industry narrative is false.

  Lack of staff and poor quality of care leads to shortened lives and considerable suffering.  That could be fixed by stopping the excessive extraction of cash sent up the line to investors and executives. That will only be stopped by a narrative based on verifiable fact and a coordinated effort to spread that narrative in the media and among state legislators. Financial data may not seem interesting on the evening television news or in the print media.  But we are obligated to make it understandable, interesting.

THE ENSIGN GROUP 4TH QUARTER REPORT:  MARVELOUS IF YOU ARE AN INVESTOR (BUT NOT IF YOU ARE AN EMPLOYEE AND/OR A TAXPAYER).

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    As I noted a couple of days ago, The Ensign Group (Ensign) was scheduled to release its 4th quarter financial report and hold a conference call.  They did that. This blog post will provide a basic overview of their 4th quarter and annual results.[1] I will be reporting on the Centene Corporation and the real estate investment trusts in the weeks ahead.

    It is important to note that the late Roy Christensen, Ensign founder, and current/past Ensign executives were and are very sophisticated financiers.  Christensen founded Beverly Enterprises in the 1960s, sold it, and taught business at Brigham Young University until he founded the Ensign Group in 1999.  Most Ensign executives and board members have an association with the Marriot School of Business at BYU.  There is no other nursing home corporation like the complexly organized Ensign. It is becoming increasingly complex to the advantage of shareholders and executives but apparently not to taxpayers, patients, and employees (as I will demonstrate below).

Highlights of Ensign 4th Quarter Results

  • Earnings per share of $4.14 – an increase of 13.7% over the prior year.

  • Earnings per share for the quarter of $1.06 – an increase of 23.3%.

  • Consolidated revenues for the year were $3.025 billion – an increase of 398.5 million or 15.1% over the prior year.

  • Net income was $60.5 million for the quarter – an increase of 24.1% over the prior year quarter.

  • For the year, adjusted net income was $235.7 million – an increase of 13.8% over the prior year.  Given an annual 2022 revenue of 3.025 billion and a net income of $235.7 million, percent net income was 7.8%.  However, Earnings Before Interest, Taxes, Depreciation & Amortization EBITDA – a more important cash flow statistic – was $383.5 million or 12.6%).

  • The company’s liquidity is increasingly strong with $316 million in cash and cash equivalents on its balance sheet and a $593.3 million line of credit.

It’s All About the Real Estate

    Quarterly reports, annual reports, and proxy statements can become eye glazing for the public.  The way we need to look at Ensign and the rest of the nursing home industry is this:  Medicaid and Medicare (mostly Medicaid) provide revenue that sustains a real estate industry.  Hence, direct care services are robbed for the sake of shareholder interests.

    In the past couple of decades, tax code adjustments have resulted in a financial transformation of long-term and skilled nursing business.  Limited liability entities, private equity firms, real estate investment trusts, and individual/family trusts have blossomed like tulips in Springtime.  Ensign is a cutting-edge bellwether of financialization, and the tax arbitrage associated with it. Let’s take the separation of property from operations (OPCO/PROPCO).[2]  Property has been increasingly separated into  separate subsidiaries of parent corporations or sold to REITs and leased back.  However, Ensign has upped that game.  The following indicates the segmentation of the company into separate entities – most of which were not discussed in the quarterly report.

    The above graphic does not include a couple of later entities – Standard Bearer (a captive[3] REIT) and a captive insurance company.[4]  A spinoff has tax advantages for shareholders.  Added advantages for Ensign in its spinoff of property into CareTrust REIT include avoidance of capital gains taxes and increased corporate assets/value.  CareTrust is an “umbrella partnership real estate investment trust,” otherwise known as an UPREIT.  By transferring property to an UPREIT, rather than selling it, capital gains taxes are avoided, the transferee receives “operating units” (OPUs), and receives returns from the triple net leases to other nursing homes (under triple net leases, leasees pay insurance, maintenance, and taxes – what a deal!). 

    As the above diagram indicates, Ensign undertook a spinoff in 2016 by spinning out its assisted living facilities into the Pennant Group – an Ensign spinoff. Ensign leases property to the Pennant Group and retains a major share of the stock.  This model illustrates the OPCO/PROPCO set up in which property becomes a tradable commodity rather than a necessary tool for producing care.  Finance dominates production.

Financialization

    Financialization throughout the U.S. economy has dampened economic growth.  Furthermore, stagnant wages, a diminishing upwardly mobile middle-income class, wealth transfer to super-rich individuals and corporations, and a low-wage underclass are due to the separation of finance from productivity.[5]  Nowhere is that phenomenon more apparent than in the U.S. government-funded healthcare system.  The massive real estate substrate of industrialized medical care is draining resources from care.  There is no rational justification for exceedingly low pay, and poor care when so few are making so much from the trillions of dollars poured by Americans into the health care system.

Summary

    From a financial and technical perspective, this post has been somewhat superficial.  Nevertheless, we need to outline the overall financialized, industrialized, government-funded U.S. healthcare system and have a very serious public conversation about how the hardworking and patriotic people of the U.S. are being fleeced.  I will be clarifying and filling in the concepts that I have introduced in this post. In the future you will see more regarding UPREITs and OPUs, shell companies (Ensign has over 400 subsidiaries, all are LLCs, all incorporated in Nevada), and other financial machinations that are robbing American taxpayers.

[1] You can listen to the conference call and download the text of the call here:  https://investor.ensigngroup.net/news-releases/news-release-details/ensign-group-reports-fourth-quarter-and-fiscal-year-2022-results

[2] For a very good discussion of REITs, Financialization, and nursing homes, see Rosemary Batt & Eileen Applebaum (July 9th, 2022), “The Role of Public REITs in Financialization and Industry Restructuring.”  Working Paper No. 189.  Washington, D.C.:  Institute for New Economic Thinking.

[3] A REIT with the property of only one corporation – The Ensign Group in this case.

[4] An insurance company that underwrites only the entity that incorporates it.

[5] For a very good discussion of financialization, see:  Rana Foroohar (2017), Makers and Takers:  How Wall Street Destroyed Main Street.  New York:  Crown Publishing.

THE ENSIGN GROUP AND CENTENE CORPORATION ANNOUNCE DATES FOR PRESENTATION OF 4TH QUARTER, 2022 RESULTS

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    The Ensign Group and Centene Corporation have announced dates for presentation of 4th quarter, 2022 results – February 3rd and February 7th respectively.   Ensign and Centene are the two largest and the only publicly listed corporations earning the bulk of their revenue from Medicaid. The Ensign Group is engaged exclusively in long-term and skilled nursing care.  Centene primarily provides Medicaid managed care services to states.

    Given that Medicaid is means-tested and lower tier poverty medicine, it is notable that these two corporations have experienced rapid revenue growth and high earnings while lavishing executives with generous compensation packages.

    In this post, I will review Ensign Group’s 3rd Quarter, 2022, results, which will be a point of comparison for the upcoming 4th Quarter results and cover more of Centene’s financial performance and executive pay in a later post.  The purpose of this post is to focus attention on the dissonance between claims of industry-wide low earnings made by American Health Care Association – the nursing home industry’s propaganda organ – and public information available through the Securities and Exchange Commission.  The AHCA’s claims are not verifiable because closely held corporations aren’t required to make their consolidated financial statements public.


   Selected Ensign Group 3rd Quarter, 2022 Results

  • Revenue, Three Months Ended September 30: 
    $770,005,000 (compared to 668,530,000 2021 3rd Quarter).

  • Revenue, Nine Months Ended September 30:
    $2,215,936,000 (compared to $1,934,319 to 2021).

  • Net Income 3rd qtr. 2022:
    $56,242,000 (7.3%)
    Compared to $48,344,000 3rd qtr. 2021 (7.0%)

  • Net Income, Nine Months Ended 2022:
    $2,215,936,000 (compare to $1,934,319,000).

Executive Compensation

    We will not know Ensign executive compensation until the company releases its proxy statement in April.  The following are 2021 compensation data for executives:

  • Barry R. Port, CEO:  $7,421,472 (13.9% increase over 2020 compensation).

  • Suzanne Snapper, CFO: $6,532,955 (19.5% increase over 2020).

  • Chad Keech, CIO: $4,275,539 (17.7% increase over 2020).

  • Spencer Burton, President and Chief Operating Officer: $5,029,146 (9% increase over 2020)

Ensign Stock Has Been Increasing During Stock Market Down Year:

    Between late 2021 and the end of 2022, the NASDAQ had declined by 30%.  It was a bad year.  However, Ensign stock was trading at $77.20 on November 29, 2021.  It closed at $94.00 yesterday (February 1, 2023) – a 22% increase.

    Christopher Christensen, CEO Emeritus owns $1,478,499 shares of Ensign stock).  The value of Mr. Christensen’s stock increased in value by $24,838,783. 

    The three beneficial owners: BlackRock (15.1% or 8,340,870 shares), Wasatch Advisors (11.1% or 6,121,470 shares) and Vanguard (11% or 6,104,354 shares).

We must insist on truthful information from the industry receiving taxpayer funds for providing medical care to Americans experiencing poverty. As the only public information we are receiving suggests, investors and executives are excessively rewarded while wages and salaries for direct care workers remain seriously low. If the bulk of financial information is hidden behind a veil of secrecy, taxpayers and their representatives do not have a voice in determining what we should be receiving for what we are paying.

MEDICAID IS POOR PEOPLES’ MEDICINE & POOR PEOPLES’ MEDICINE IS POOR MEDICINE.

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By:

Dave Kingsley

The Southern Segregations’ Plan to Institutionalize Racism and Inequality

In a conversation with Lyndon Johnson prior to passage of Medicare and Medicaid, the late segregationist Congressman Wilbur Mills of Arkansas told President Johnson that across town from his mother in Arkansas, “…a Negro woman has a baby every year. He went on to explain that every time he went home, his mother complained that the “Negro woman now got eleven children.  He proposed that welfare should be designed to let “the states pay for more than a small number of children if they want to.”

Joseph Califano, Jr., President Johnson’s Secretary of Health Education & Welfare (HEW) in the room at the time noted that Johnson turned to him after Mills left and said,

 “You hear that good, now.  That’s the way most members feel. They’re just not willing to say it publicly unless they come from redneck districts.”

Most member of congress aside, Mills was not your run of the mill congressman.  He was the influential Chairman of the exceedingly powerful and critical House Ways and Means Committee.  He was a product of Southern one-party politics run by the all-powerful Southern planter class.  Mills and his Southern brethren in the Senate and House had in 1957 signed and issued the “Southern Manifesto” – a protest against Brown v. Board of Education and the civil/human rights enveloped within the Supreme Court decision. 

As I will explain, these segregationists had designed and legislated a precursor to Medicaid into existence. The passage of the Mills-Kerr program in 1960 included the framework of Title 19 of the Social Security Act in 1965 (Medicaid).  Medicaid became Kerr-Mills 2.0.  Designed into Kerr-Mills was devolution of power over federal welfare to states, which would allow them to arbitrarily place onerous administrative burdens on qualified applicants and maintain a lower status for African Americans.  They were successful in keeping Hill-Burton funded hospitals segregated for ten years after Brown v. Board of Education had declared that “separate is not equal.”

The Concepts of Kerr-Mills – Especially the Power of States Over Welfare – Are Barriers to Transforming an Embarrassingly Bad U.S. Medical System

Like the Hill-Burton Act of 1945, which initiated a massive hospital building program across the U.S., Medicaid is funded by the states with federal matching funds.  Administration and regulation of Medicaid funded nursing homes have been left to the states.  Long-term care and skilled nursing operators have benefited from lax oversight and political power in state houses.  As should have been expected, legislatures and agencies have been captured by deep pocketed industrialists and are therefore likely to serve the interests of operators at the expense of ethical and humane medical care.

States and powerful interests have devised ways to siphon off Medicaid funds for the benefit of corporations and special interests.  Consequently, poverty medicine is enriching corporations and wealthy individuals (see previous posts on this blog re: The Ensign Group & Centene Corporation) while the medical care and health of poor Americans have been deteriorating.  For instance, the state of Indiana discovered a loophole in federal law that allowed the state to buy nursing home licenses from for-profit corporations and skim a considerable amount of nursing home funding off for other purposes.  The nursing homes continued to run the facilities and extract their usual cash flow as before.

Having studied cost reports submitted by thousands of nursing home facilities, I can safely conclude that the states shield the industry from exposing cash flow into and out of the system.  If you can complete daunting tasks of gaining access to legally required and public cost reports (or pay a considerable sum for them) you will discover that you are dealing with closely held corporations that are not required to make their financial statements public. Therefore, you can follow the money to a point.  But the pools of payments to their parent corporations’ shell companies are kept secret.  The public cannot see consolidated balance sheets, income statements, and cash flow statements of parent corporations and holding companies.

Without clear and honest financial information, no amount of reform of what most everyone agrees is a bad system is possible.  The industry can and does engage in misinformation and falsehoods to maintain myths that the biggest problem in long-term and skilled nursing care is skimpy government funding.

The Ensign Group, America’s Largest Nursing Home Corporation, Reports Strong Third Quarter 2022 Results

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By:

Dave Kingsley

A Business Success Story

Since its founding in 1999, The Ensign Group (Nasdaq:  ENSG) has experienced remarkable financial success and growth. (See, e.g., Kingsley & Harrington (2021) *.  That trend continues.  The company reported a 3rd quarter 2022 revenue of $770 million – an increase of 15.2% over the same quarter in 2021 – and raised its expected 2022 revenue from $3.01 billion to $3.03 billion – an increase of 14% over 2021 and exceeding 2020 by 32%. 

With a net quarterly income of $56,761,000 on a revenue $770,005,000 for the quarter, Ensign’s net was a positive 7.3%.  The company reported Earnings Before Interest Taxes, Depreciation & Amortization or EBITDA (a far more important metric from a cash flow perspective) of 12.5%.

Across all industries and sectors, a net and EBITDA of 7.5% and 12.5% respectively reflect robust earnings.  CEO Barry Port stated that, “Given the improvements we continue to see in occupancies, skilled mix and reimbursement, we are raising our annual 2022 earnings guidance again to $4.10 to $4.18 per share.”  The company has 57 million shares outstanding.

Asset Management Firms/Institutional Investors are Bullish on Ensign Group Stock

On Friday, October 28, 2022, Ensign stock, which has been outperforming the DOW and S&P, closed at $89.96 per share. Since the beginning of a rapid decline in the market on November 29, 2021, the DOW has dropped from 35,135 to 32,861 and the S&P has declined from 4,655 to 3,901 (as of the closing bell on Friday, October 28, 2020) – declines of 6.5% and 16% respectively.  Conversely, Ensign stock has increased from $77.20 per share to $89.96 in the same period – a 16.5% increase.

At the date of Ensign’s issuance of its 2021 proxy statement, beneficial owners included BlackRock (15.1%), Wasatch Advisors (11.1%), and Vanguard (11.0%).  Hence, stock is concentrated in three asset management firms owning 37.2% of the company’s shares on behalf of pension, college endowment, insurance, sovereign wealth, 401K, and other pools of capital.  Executives and board members own 4.7% of the 57 million shares.  Ninety percent of Ensign stock is owned by asset management firms such as T. Rowe Price, State Street, PIMCO, etc. – in addition to the 40+ percent owned by BlackRock, Wasatch, Vanguard, and executives/BOD members (5% is required for beneficial ownership).

CEO Barry Port’s 2021 compensation package of $7,421,472 is approximately 209 times the typical CNA wage over one year of full-time work. CFO Suzanne Snapper’s compensation totaled $6.5 million, CIO Chad Keetch and COO Spencer Burton were awarded $4.3 million and $5.0 million respectively.  Compensation of $23,259,112 for the four top executives in 2021 was an increase of 37% over the $16,961,920 they were awarded in 2020.  

Ensign’s Path to Dominance in the Long-term & Skilled Nursing System

In the past quarter, Ensign added 20 facilities (mostly in Texas) to its portfolio of 268 healthcare operations, 26 of which also include senior living operations, across 13 states.  But this doesn’t tell the whole story.  At the end of 2021, the company’s skilled nursing facilities were embedded in a network of 400 subsidiaries (all LLCs incorporated in Nevada).  These subsidiaries have been set up as property, insurance, management, and other ancillary service LLCs which appear as related parties on Ensign facility cost reports (examples of 5 facilities in the Kansas City area will be used as illustrations below).

During the past decade, Ensign has spun out a considerable amount of real estate (nursing homes and assisted living facilities) into two separate corporations:  the CareTrust Real Estate Investment Trust (skilled nursing facilities) and the Pennant Group (assisted living properties).  The company has an interlocking financial and management relationship with both spin off corporations, the details of which are beyond the scope of this post.

As referenced earlier, my colleague Charlene Harrington and I published a study we conducted last year of Ensign growth and development.  Based on the board bios and the background of founder Roy Christensen, we noted a strong relationship between the company and the Marriott School of Business at Brigham Young University.

Ensign executives and board members are highly sophisticated finance and real estate professionals. Their astounding success stems from sophisticated real estate and financial structures that have been devised to maximize cash flow from Medicaid, Medicare, and generous tax advantages.  As noted above, Ensign executives have been richly rewarded by their board for their financial performance.

*”The Financial & Quality Metrics of a Large Publicly Traded U.S. Nursing Home Chain in the Age of COVID-19,” International Journal of Health, 1-13, 2022.  For a copy of the article, contact David E. Kingsley, dkingsley@new.tallgrasseconomics.org, 785 550 3576.