Flora Jean Buso groans when she thinks about her teeth.

A four-year resident of Mount Si Transitional Health Center, Buso, 70, lost her only set of dentures one year ago.

Since then, her diet and her dignity have suffered. While her gums have tightened up, she sticks mainly to soft foods at mealtime.

“It can get painful,” Buso said. “I would go in my room and just be in tears. I’d look at the food and say, ugh, I can’t handle this.” She dreams of fresh carrots and celery, “a nice fresh tomato, being able to eat the whole thing.”

Buso’s got a long while yet to wait for new teeth. In January, the Washington Department of Social and Health Services cut adult vision, dental, podiatry and hearing services, excepting emergency treatments, for Medicaid recipents. Small prescription co-pays were also eliminated for some Medicare patients. Wash. Gov. Chris Gregoire plans to reinstate adult services as part of her budget for the next biennium in July.

Dependent on Medicaid, Buso receives about $60 a month for personal expenses. She’s managed to save $700 for a $1,000 set of dentures, but the wait, and financial struggle, is hard.

“I would have to put everything on hold,” Buso said. Her money also goes to some personal items, like the conditioner that she needs for her hair. The rest of her monthly allowance goes to the center.

Buso knows she couldn’t stay at the Transitional Center without Medicaid, but cuts to the system affect her well-being.

“People need to know that the elderly are suffering because of this,” she said. “It’s like we’re a lost commodity. We’re just as valuable and important as everybody else. It’s hurtful for me that I can’t have the things I need.”

Medicaid shortfall?

Elizabeth Marsh, director of the Transitional Center, sees Buso’s teeth as an example of how Medicaid cuts are affecting her building and her residents. As residents’ benefits are removed, the burden on the business grows.

“You have to provide 24-hour skilled nursing, meals, snacks, supplements, over-the-counter medication, wheelchairs, mattresses,” Marsh said, all for about $150 a day.

Pointing to shortfalls, Transitional Health center owner Regency Pacific calculates that it has a $28 daily deficit per Medicaid resident. This month, the company says that will rise to $48.

“In the past, we’ve been able to supply the hearing, vision, dental, podiatry, ambulance rides, drugs and we’ve absorbed that,” said Ray Fitchette, chief operations officer for Regency. “We’re at that breaking point.”

“The rate of compensation goes down, but the requirements to meet levels of care stay in play,” said Gary Weeks, a consultant to Regency and former CEO of the Washington Health Care Association. “You’re getting to the tipping point.”

Labor is one of the few areas where for-profit care centers can make cuts. In the last two years, staff at Mount Si Transitional Health Center fell by 25 percent, from roughly 80 to 60 employees.

Weeks said that reimbursements are at the point that many facilities and mom-and-pop group homes are turning away Medicaid residents. With an aging population, Weeks asks “where are these people going to go? All of a sudden, beds are not available. You’ve got a giant ball of baby boomers who need care. It’s not going to be there.”

Bed tax match

Regency is advocating new legislation that would impose a bed tax or fee on nursing home residents, with the aim of bringing in federal matching dollars.

House Bill 1722 and Senate Bill 5581 would create a Nursing Home Safety Net Assessment, chargeable to residents based on their level of care. The assessment would run between $1 and $21 per day per patient, with the option for some nursing homes to be exempt.

Fitchette calls the fee, collected by 37 other states, “a fantastic, smart, logical way” to fix the Medicaid gap.

“We can backfill the shortfall,” he said. “There is money left over that the state can push into the general fund. To have $30 million extra really makes sense today.”

Ken Callahan, a spokesman for Washington Department of Social and Health Services, said the state doesn’t necessarily agree with Regency Pacific’s figures on Medicaid deficits. However, he admitted that the state is in a tough economic situation. His department provides information to legislators to make their decisions, and does not have a stance on the assessment.

“These bills are still a work in progress,” he said.

Providence Health & Services, a non-profit long-term care organization with about 630 residents, opposes the bed tax.

Providence Chief Executive Robert Hellrigel told the Record that his group will not support bills, saying they put a significant tax on private-pay residents “in an attempt to prop up a long-term care system that has failed to evolve to meet the needs of people in our communities.”

“People who pay for long-term care services with their own resources already subsidize the care of their neighbors in the Medicaid program in Washington,” Hellrigel said in a statement. “This bill, as currently drafted, also provides $30 million for the 2011-2013 biennium to be supplanted to the general fund, which will not benefit nursing homes or their residents.  In adding to the subsidy of Medicaid residents in Washington State nursing homes, the bill asks private paying nursing home residents to fill in the deficit in our state budget.

“The bill, as drafted, increases the cost of long-term care in Washington State without deriving any measureable benefit to the quality of care provided,” Hellrigel added. “Cost increases without any expectation for improvement in quality of care or customer satisfaction is not a principle we can support.”

There is also significant concern that the Center for Medicare and Medicaid Services will not approve certain provisions of the bill, which threaten many of the assumptions and the projected outcomes of the legislation, Hellrigel stated.

Providence remains willing to discuss ways to craft a sustainable system for paying for long term care services, he added.

“Only as a result of that effort being seriously undertaken are any conversations about new revenue appropriate,” Hellrigel said.

Weeks counters that costs will affect private paying residents more in the long term without the assessment.

“They’re worried that the state will grab all of the money and none will come back to nursing homes,” he said. “The reality is if you don’t do this, (private) residents are still going to pay more. They have to.”

At for-profit nursing homes, Medicaid-supported residents far outweigh private payers, Fitchette said.

“We’re not going to balance our daily rate on the Medicaid downside by increasing private pay,” he said. “Our percentage of private pay is so small.”

Weeks points to the state of Oregon, where facilities are compensated roughly $50 more per day per patient. That means more staff stability, he said.

“The reason they can do that is 10 years ago, they started a nursing home assessment fee,” Weeks added.

“Our chance to make this happen is greater this year than it’s ever been before,” he said. “We’re trying to develop a real continuum of care. We’re trying to do that for the community, so we can function as one, so we know that residents don’t slip through the cracks.”

“These are all people who were functioning human beings, who contributed to this country,” Marsh said. “They deserve to be taken care of.  I don’t have a problem with my tax dollars going to that.

“We’re not asking for the moon,” she added. “We’re asking to be able to give good, basic care.”