About a month ago (mid-March), CMS introduced a pilot program called the Medicare Care Choices Model. Basically, this pilot program will allow Medicare beneficiaries to access, via certain participating hospice organizations, dual benefits; hospice and curative treatments, concurrently. Under the current Medicare Hospice Benefit, a patient with a terminal illness or condition, certified likely to die in 6 months or less by a physician, can enroll into the Hospice Benefit but in doing so, forgoes the traditional coverage for curative treatments under traditional Part A. Essentially, by electing the Medicare Hospice Benefit, the patient has decided not to pursue an aggressive path of cure or curative interventions or treatment (chemotherapy, radiation therapy, artificial hydration/nutrition, etc.) opting instead for palliative care, symptom management, and a progressive path toward natural death.
In the Medicare Care Choices Model, Hospices that apply and are selected to participate in the program will provide services available under the Medicare hospice benefit for routine home care and inpatient respite levels of care that are not separately billable under Medicare Parts A, B, and D. The services must be available 24 hours per day and across all calendar days per year. CMS will pay a $400 per beneficiary per month fee to the participating hospices for these services. Providers and suppliers furnishing curative services to beneficiaries participating in Medicare Care Choices Model will continue to bill Medicare for the reasonable and necessary services they furnish. Per CMS, the ideal hospice applicants for program participation can demonstrate a history of providing care/case coordination to patients, across a continuum of providers and suppliers.
Returning to the title of this post: Is this progressive on the part of CMS? The truth is best answered – “not really”. There are a number of current issues with regard to the Medicare Hospice benefit, care utilization, end-of-life care in general, and yes, the ACA at play. Under the ACA/Obamacare, the Secretary of HHS has a mandate to implement changes to the Medicare Hospice benefit no earlier than October 1, 2013. Abt and Associates (consultants) has been gathering and analyzing data on lengths of stay, place of care, length of stays in hospice by diagnosis, costs of care, etc. The Medicare Care Choices Model is in certain respects, a trial balloon element in the process of overhaul for the Medicare Hospice benefit.
Another operative element or issue and one that hospices are all too familiar with of late is the utilization pattern changes that are occurring across the spectrum of end-of-life care. Hospice referral patterns haven’t changed much but the nature of the referral has. Additionally, census trends for most hospices are flat and when viewed with/against lengths of stay, the trends are actually “down”. In short, an evolving dichotomy for hospice referrals is occurring. The referrals are modestly increasing in many urban/suburban regions but at the expense of the length of stay. The patient is finally referred at the end of his/her life, after all curative options are exhausted. Per CMS, 44 percent of Medicare patients use the hospice benefit at end-of-life but in a continuing pattern, at the end of life resulting in shorter and shorter stay increments.
Back to the question in the title of the post, this initiative is less about promoting or integrating hospice earlier, though the outcome of earlier intervention could occur. What CMS is tinkering with or intending to impact, is the continued growth of very expensive medical care in the last months of life. The two greatest drivers for Medicare spending in the U.S. are the cost of caring for “lifestyle” diseases (chronic diseases such as Type II diabetes) and care provided within the last six months of a person’s life. The latter is the target for this program. The premise is as such. If, by integrating hospice into the equation sooner, having removed the curative or interventional obstacle, patients will transition earlier to palliative care, foregoing certain last rounds of inpatient, interventionist care and thereby, save the government money. The patient and the curative care team (the physician, hospitals, etc.) will be less loathe to refer to hospice and address the prospect of treatment futility (even though that prospect is real) since, under this program, the patient may continue to pursue as much interventional and curative approaches as desired.
My quick analysis is that this program, while a novel approach, doesn’t really achieve any of the objectives intended (savings, better care, easier transitions, earlier transitions, more appropriate care, etc.). My reasons and conclusions are as follows;
- The issue of when a patient chooses to opt for end-of-life care versus curative care is more an American cultural/social issue than a public policy issue. As Americans, we are inculcated that death is bad, life is premiere. Our health insurance, especially now with ACA reforms, has virtually no limits on the treatment we can access (no lifetime minimums and no pre-existing condition limitations). Our media (television, print, other) is full of advertisements of procedures, drugs, providers that offer hope and cure. Watch a Cancer Treatment Center of America spot – a prime example. Physician specialists aren’t trained to forego what may clearly be futile care but instead, to press forward and to convey options and hope. In fact, the number of physician specialty groups that I have spoken with over the years validates this point emphatically: “Hospice is futility. We provide hope”. This element is the leading cause of late stage referrals when in validation, futility is truly evident as the patient is nearly dead or the final rounds of whatever treatment have shown no result.
- There is no financial incentive to change or alter the care provided. In the Choices model, the patient may access curative care and receive hospice services. The hospice receives $400 more per month (for care coordination) and all other provides bill Medicare for their interventions, services, etc. If CMS is relying on the care coordination skills of the hospice to facilitate better choices by the patient, his/’her family and/or the other providers, they are truly foolish. These groups have no financial incentive to partner on best choices and unless, CMS provides regulatory boundaries or payment incentives aligned to certain behavior, the savings will be minimal.
- There isn’t a real incentive for patients to enroll in this pilot project, other than they can get routine home care, respite, etc. benefits from the hospice. In reality, patients who are going to pursue curative options aren’t thinking hospice options. Likewise, the providers offering the curative interventions aren’t talking hospice options at this point. Our current healthcare system doesn’t function on this integrate plane. Thus, there truly is no motivation across the actors (hospice, curative providers, patients, families) to change current behavior. In fact, I see a risk for new avenues of improper utilization, qualification and abuse. Enrollment in hospice under this program is going to be challenging to qualify and quantify as in theory, where is the point of terminality (without intervention, death is likely in 6 months).
It will be interesting to watch how this program rolls-out and how CMS addresses or attempt to address the nuanced and overt regulatory issues that today, are separate and distinct by benefit programs. Likewise, it will be interesting to see how patient utilize, if they do to any extent, this hybrid model. The economist in me tells me that the concept and programmatic approach makes financial sense but operatively, this isn’t a slam-dunk in terms of ever working in the real world. There are simply too many behavioral impediments today for this to be a truly successful model.
The 2009-2011 Wisconsin budget (Act 28) incorporates a specific change to how the state defines property tax exemption for non-profit senior housing projects. Up to this point, the existing statutory law was vague and providers were left to contend with a precedent set by an even more vague Supreme Court decision (Columbus Park) and patchwork legislation authored to counteract or more appropriately, counter-balance the Columbus Park decision. Below is a brief summary of the recent history of non-profit senior housing and property tax issues.
- Prior to Columbus Park: Wisconsin Statutes 70.11 created a category of exemption for benevolent homes for aged. The exemption category as poorly defined as it was, fundamentally allowed 501(c)3 providers to argue that their federal exemption and the use of the property for “benevolent” purposes met the definition, provided that the exemption was sought for 10 acres or less. Limited challenges were made by Assessors to this definition or to the broad interpretation used by non-profit senior housing providers. Perhaps the statutory challenges most noted up and until Columbus Park occurred in the City of Milwaukee.
- In the City of Milwaukee v. The Milwaukee Protestant Home, the City argued that a planned expansion of the Protestant Home funded entirely by new, non-refundable endowments from residents who would still be required to pay monthly rental fees and required to financially qualify, was not justifiably exempt. The basis of the City’s argument was that the new facility was too luxurious, catered only to the wealthy, pre-screened residents to limit the needy, did not provide medical care on-site, and used a health screening to eliminate residency to anyone in need of care. The Court decided in favor of Milwaukee Protestant Home stating, among other things less relevant to the core exemption issue, that Benevolent does not mean “charity” and as such, a Home can be benevolent and charge fees. Effectively, the Court said that benevolence can and does in this case mean, allowing people of moderate means to live out their final years, even if the same is not considered charitable. The Court also said that a new, free-standing housing project must be viewed along-side or as an integral part of the entire sponsoring organization, not in a “vacuum”.
- In the City of Milwaukee v. Friendship Village of Milwaukee, the city argued that a planned expansion called Freedom Village, built with “refundable” resident endowments and where residents would continue to pay a monthly rental charge, was not justifiably tax-exempt. As in the case of Milwaukee Protestant Home, Freedom residents were pre-screened as to ability to pay, one resident in a couple needed to be 55 or older, and each resident had to able to live independently (a medical screen). Residents were provided with a $50 per day credit if skilled care was later required and, as part of their contracts, could opt to convert at a later date, to residency at Friendship Village thereby waiving their refund from Freedom in exchange for residency and care provided at Friendship. As in the Protestant Home case, the City offered all of the same arguments (too exclusive, no on-site medical care, excluded the needy, etc.) and the facility did not permit residents to live-out the remainder of their years as was the case with the Protestant Home. The Court reaffirmed the Protestant Home decision stating that benevolent did not mean free and that the Freedom contract provision allowing residents to convert to occupancy at Friendship Village with no additional charge when care was needed, provided the means for residents to “live out their years”.
- Columbus Park and After: With the Columbus Park decision, the courts began to slowly redefine the interpretation of Wisconsin Statute Chapter 70 as well as to abandon the basis used to uphold the exemptions found in the Protestant Home and Friendship Village cases.
- In the Columbus Park Housing Association v. City of Kenosha, the Wisconsin Supreme Court ruled that non-profit associations renting housing units to low-income elderly were not exempt from property tax as specified in Chapter 70 (WI State Statutes) unless the tenants themselves could or would be exempt from taxes had they owned the units. Essentially, the Court said that the only way a non-profit that was renting units to low-income seniors could be exempt was if the seniors themselves were exempt non-profits. This decision became widely known as creating or establishing the “rent use clause”. In effect, the Court decided that the only permitted use for rent proceeds derived from low-income projects was property maintenance and debt retirement. Prior to this point, it was widely accepted and essentially reaffirmed by the Protestant Home and Friendship Village cases that a benevolent association could use rent proceeds for any purpose that furthered or was in concert with, the reason or justification for federal tax exemption and the mission of the benevolent association (e.g., subsidizing other programs within the association). In 2004, Governor Doyle signed Wisconsin Act 195 which was created to reverse the Columbus Park decision. This Act prohibited local assessors from collecting property taxes from non-profit providers of low-income housing. The Act however, did not address with clarity, the “rent-use” dilemma.
- In Attic Angel Prairie Point v. City of Madison, a Dane County judge ruled that senior housing was not necessarily a benevolent activity unto itself. The entrance fees at the time ranged from $230K to $450K and were structured on a life-lease arrangement. Under this arrangement, residents received 90% of the fee as a refund when they left or vacated their unit. The contract also provided for a “priority” admission to other Attic Angel care facilities but no guarantee of admission. While Attic Angel argued the fundamentals found in the Protestant Home and Friendship Village cases (benevolent association status, life lease arrangements, etc.), the Court found that the only use or purpose for Prairie Point was to provide housing to middle and upper income individuals, absent any health care guarantees or provision on-site and in a manner highly similar to other taxable housing developments. Because the case was decided within a Circuit Court, no value of precedent could be used in other cases, a basic ruling on the exemption issue had occurred sufficient enough to garner attention within the non-profit community and across state-wide municipalities, namely with assessors.
With the passage of Wisconsin Act 28 (the Budget bill), new provisions are now in-place beginning January 0f 2010 that establish the basis for property tax exemption for benevolent homes for the aged. The law clarifies the exemption test and creates presumed categories of exemption for CBRFs, SNFs, Hospice (those that operate places of residence) and RCACs as defined under Chapter 50 of the Statutes. The Act also expanded the number of acres that could be exempt from property tax from 10 to 30.
With respect to residential units or senior housing units, the Act provides that a benevolent association may exempt those units with fair market values less than or equal to, 130% of the average equalized value of residential units in the county where the project is located. The Act also provides specific exemptions for low-income senior housing provided by non-profit, benevolent associations and removes the requirement that the rent be used specifically for debt repayment or property maintenance. This same provision regarding “rent use” applies to other categories of senior housing as well.
Where I expect the issues to arise with respect to the new provisions in Act 28 are around the determination of fair-market value and the potential carve-out of certain units in a project having values in excess of 130% of the equalized value while others do not. In effect, some units may be determined as taxable while others qualify for tax-exemption. How an allocation of property tax to the taxable portions is determined will no doubt raise a series of court challenges. Similarly, as the units themselves are typically within a larger complex, often with extensive and at times, quite opulent common space, determining fair market value of the unit will be an interesting exercise. Truth be told, fair market value for the unit is not by assessment definition, the price charged for the unit. Fair market value would require a determination of value based on an assessment and/or appraisal methodology and I anticipate wide interpretations coming forth across the various county assessors throughout the State.
In summary, while Wisconsin Act 28 goes quite a ways in clarifying the issue of property tax exemption for benevolent homes for the aging and senior housing projects, the “waters” remain somewhat murky. It will be interesting to watch how the process unfolds and where the lines are drawn (likely via the courts) on the open issues of fair-market values and how taxes end up allocated on units within a project that don’t meet the 130% equalized value threshold.
Yesterday, Governor Jim Doyle signed AB 75 (now Act 28) otherwise known as the Wisconsin Budget Bill, inclusive of 81 vetoes unlikely to be overridden in the Assembly. Amid fanfare and small accolades for passing “on time” (today is the deadline) a new budget, is the harsh reality that this budget kicks off a new era in Wisconsin tax policy. For the first time in Wisconsin’s history, residents will experience a triple taxation in the form of their healthcare and of course, the inevitable result of higher healthcare costs. Wisconsin to date was not widely known as a “low cost” healthcare state and thanks to this budget, will keep that “booby” prize designation for some time to come.
If per chance, you have read my other posts regarding the Medicaid shell game that is perpetrated during budget preparations, you will have an inkling as to how Wisconsin tax payers and healthcare consumers just got triple shafted by this budget. In the final analysis and “budget”, the gouging occurred in plain sight and to my dismay, without too much opposition from consumers, providers, or politicians. In plain language, here is what just occurred.
- Under the guise of capturing additional Federal matching dollars, the budget jacks-up the nursing home bed tax from $75 to $150 immediately (tomorrow) and then again, by another $20 next year. Unless you believe in Peter Pan, the Tooth Fairy and the Easter Bunny (Santa Claus is off limits of course), you know that this tax will be passed on to residents capable of paying privately for their room and board. As the tax occurs on every licensed bed, providers with the greatest census comprised of private paying residents will feel a disproportionate share of this tax “pain” as they are forced to pass it along to their residents and the resulting Medicaid rate increase of 2% will fall woefully short of making up the “paid in” difference versus the “receipt” difference via the rate increase. Conclusion: Nursing home residents see their costs go up and providers see their costs go up – strike one.
- Nursing homes in this budget are not alone as hospitals now fall under the spell of the “shell game”. With this budget, hospitals now will pay a “revenue” based tax, again under the guise of attracting Federal matching dollars to bolster Medicaid reimbursement. Similar to the repeat dilemma that nursing homes experience, hospitals will quickly realize that the tax that they pay in plus the added Federal match doesn’t quite translate dollar for dollar into reimbursement improvement. In actuality, the sleight of hand legislature and the Governor will “sift” a few million here and there from this new “pot”, moving it hither and yonder to balance other “bloated and unfunded” elements of the State budget. And of course, like in the nursing home scenario, hospitals will pass this tax on to their paying customers thereby inflating the costs of hospital based healthcare for each and every resident in Wisconsin that carries insurance or pays for their care privately. Conclusion: Hospital care just got more expensive and that expense will be passed on via insurance rates and costs of care to anyone who can afford to pay – strike two.
- The final leg of the tripartite tax stool is perhaps the toughest to understand for most people and the least direct. This leg is the Federal stimulus and matching funds leg that is referenced as the source to be tapped via raising the nursing home bed tax and creating the new hospital tax. Simply stated, to understand this leg is to understand that Washington and the Feds have no money that did not already come in the form of taxes paid. In other words, the money being used to match the nursing home and hospital taxes is taxes already paid by individuals and business in Wisconsin. The cruel irony is that we will be paying new taxes for nursing home beds and hospital care that will be used to return taxes already paid and in exchange, receive the reward of higher cost healthcare. Even more bizarre is the fact that the taxes once paid to the Feds and theoretically returned via a match with the new healthcare taxes, will be skimmed by the Legislature and Governor for uses other than for which they were taken in the first place; clearly not for lowering the cost of healthcare. Conclusion: The Feds never had any new source of money and never will save the taxes already paid by taxpayers – strike three.
I leave you with a simple economic lesson tied directly to this subject – Governments are not sources of money, people and businesses are sources of money and ultimately, people are truly the only source. In a climate where healthcare is already too expensive and the economy is lack-luster at best, raising taxes via healthcare in any fashion to theoretically redistribute dollars from another source is simply bad economic policy. There is absolutely no chance in this scheme for the healthcare consumer or for providers for that matter, to come out ahead and sadly, their loss will come at the expense of all tax paying citizens and businesses in the State.
A while back I wrote about the annual/bi-annual shell game that is perpetrated in Wisconsin with the Medicaid program – specifically, the SNF funding and reimbursement components thereto. Now that the Joint Finance Committee of the Legislature has completed its budget process, we can see, fully exposed, how much of the shell game has really been played.
Wisconsin, like all states in the nation, has a deficit – no suprise. Wisconsin also, like most states, has watched its deficit level grow over the past few months as tax receipts have been lower than projected, primarily of course due to the overall poor economy, lack of jobs, loss of business revenue, real estate sales doldrums, etc. Where Wisconsin is different is the approach the Governor and the Legislature have taken to crafting a budget that addresses the deficit (I’ll state plainly right up front – “addresses” should not be read as “fixes”).
The Wisconsin solution to addressing budgetary shortfalls is to “ratchet” and I mean “crank” up taxes and fees. This is plainly obvious when the Medicaid program is reviewed, even without a microscope – the shell game is visible for all to see. The sleight-of-hand trickery is to extract taxes (rarely are they called this so plainly) either openly or hidden in the form of fees, from every imaginable source, under the guise of achieving additional Federal matching dollars, all while cutting actual spending and siphoning off the additional revenue to “balance the budget”. The reality is, the budget won’t be balanced as not only does the “math” become funky but the pork politics that weaves throughout the budget will not allow true deficit reduction let alone balancing to occur. Fundamentally, the only thing that will truly balance the budget is an economic recovery; a return to a period of sufficient prosperity where revenue from taxes from all sources rises as a result of a healthy business environment (business does well, employs people, pays wages, the people pay taxes, consume again via purchasing homes, etc.). In Wisconsin, the proposed budget is so economically regressive (increased spending, increased pork, increased taxes) that state induced recovery via the budget is nigh on to impossible (positively impractical).
I know – this post is about Medicaid not politics but frankly, not understanding one makes the other harder to understand. On Medicaid, here’s the meat of the Joint Finance Committee’s “budget”. NOTE: There is truly nothing “joint” about this Committee proposal as de facto, the Committee is controlled (dominated) by the Governor’s party. It for all intents and purposes is the Governor’s budget, negotitated within his party and beholding to the Governor’s special interests and the interests of the party (see the “pork” spending within the budget to get a full dose of the special interests at play).
- Nursing Home Funding: Double the bed tax from current $75 to $150 in 09-10 and then, jump to $170 in 10-11 (don’t believe that this level will necessarily hold). The tax will be used to fund a 2% increase in the Medicaid rate. See my first post on the Wisconsin Medicaid Shell Game to catch how this swindle really works and why 2% doesn’t mean 2% and where likely, a chunk of the income Federal match will go.
- Medicaid Program Cuts: Reduce overall program spending by $580 million – no specifics on where and how but no entity is protected.
- Medicaid Funding/CPE Funding for County Nursing Homes: This funding actually increases – providing $10M in General Purpose Revenue to offset county nursing home operating deficits. Surprisingly (or perhaps not), the provision also includes protections, keeping any surplus funding achieved within the allocation – not allowing the State to keep any overrages.
- Family Care: Wisconsin’s Medicaid waiver program picks ups nearly $9M in funding with a specific directive to reduce the waiting lists for enrollment in Milwaukee County.
- Assisted Living License Fees: Increase by 27%.
- Hospital Tax: Originally set at $165 million, increased by the Committee and planned to be raided by the Governor. Theoretically, the funds gained are supposed to go to hospitals via Medicaid increases – won’t happen anywhere near the dollars raised – just like with Nursing Homes.
So what can be foretold through these shenanigans? The answer is simple. More taxes and less Medicaid dollars to go around. The frank reality is that literally, millions more in taxes will be shuffled through Wisconsin’s Nursing Homes and Hospitals into the great black hole of the State budget deficit. The illusion that somehow, these taxes will achieve significant or even moderate improvements in Medicaid payments is just that – “smoke and mirrors”. The dollars gained, matched by federal dollars, will be siphoned off proportionately and the meager remains doled out with any eye dropper to providers. Even worse, once a tax is in place, it becomes ready “powder” for unchecked politicians to spend wherever they “deem” the need is highest. Literally, the analogy is similar to a teenager with no job having unfettered access to mom and dad’s credit or debit card.
The news for providers and consumers of healthcare in Wisconsin is that the economics just got worse – much worse. There is no place to continue to dump the increase taxes providers will face as consumers can’t bear the brunt, Medicaid doesn’t pay enough to recapture the taxes imposed, the Feds foretell Medicare cuts and/or freezes and health insurers won’t cover the tab. Unfortunately, like the shell games played on the streets of New York, the person playing against the “sleight of hand” artist loses every time. In this case, providers and consumers are the losers and the Legislature and the Governor is the con artist.
Here we go again, another round of the bi-annual Medicaid shell game to theoretically increase Medicaid SNF rates in Wisconsin. If you aren’t familiar with this trick, watch closely because the moving parts are designed to confuse you – hence the illusion.
The trick starts with the State having a continuing budget deficit overall. Don’t be confused by the Governor’s rhetoric regarding the economy being principally behind this enormous deficit as it has been present for quite some time, albeit perhaps a bit higher now due to the economic slow-down and the continued, escalating pace of statewide spending.
The next part of the trick is a bit more subtle; the Medicaid program’s deficit is woven in as part of the discussion. Yes, within the enormity of the State deficit is the Medicaid’s program deficit – also not new.
Here comes the meat of the trick. The State wishes to increase the Medicaid bed tax “again” in order to create additional federal matching dollars to fund a Medicaid rate increase which isn’t really a rate increase at all, calculated to be approximately 2%. The illusion comes in with the tax increase which is greater that 2%, a de facto 100% increase over the present bed tax. Where the shells get moved and the slight-of-hand occurs is when the State openly admits that it will likely skim a portion (probably sizable) of the dollars gained via the federal match (plus potential stimulus money) to fund other deficits not necessarily tied to the Medicaid SNF formula, perhaps within other areas of the program or broader within the totality of the State black hole.
Still don’t see the trick or the illusion? There is more to follow. At the same time the State is asking to raise the bed tax to fund the rate increase that won’t really be an increase and to skim some of the federal matching dollars for other uses, they are looking to cut $415 million in expenditures from the Medicaid program, no doubt within the SNF/Long-term Care arena as well as other Medicaid programs. In addition, the State is proposing increasing survey and certification fees, license fees and other fees for SNF providers.
Confused yet? Looking to find out how this shell game ends up? Alright, I’ll play the role of Penn and Teller and debunk the illusion but I caution the reader, the “unveiling” may not lead to clarity.
- Jumping the bed tax to gain 2% in the Medicaid rate doesn’t produce any real rate increase for the SNF providers. In fact, only those providers that have a disproportionately high Medicaid census would stand to see any “net gain” from the increase. For example, a provider with a 40% Medicaid census will pay more in “bed tax” dollars than reap in new Medicaid dollars via the rate increase. In simpler terms, the outflow is far in excess of the inflow.
- Medicaid rates are not full rates in the first place. Patients/Residents have a co-pay or liability if you will, typically based on their Social Security and other income. If this income as it traditionally does, inflates at a rate equal to 2% or more, the Medicaid increase that is supposed to theoretically be realized by the provider is effectively offset or diminished greatly by the rise in the liability of the individual resident or patient. Bottom-line: while the new ‘rate” may be reflected as 2% higher, it isn’t being paid by Medicaid, likely by the patient himself or herself.
- Raising the bed tax dramatically shifts additional costs to the resident/patient as I am unaware of any facility that can afford to “assume” the increase without passing it on. Raising the tax will only serve to diminish funds of current residents/patients “quicker”, pushing them toward Medicaid faster. This is the cruel irony of this whole illusion and the most insidious part of these “dumb” proposals.
- Rates, fees, and all other regulatory costs are going up – not reflected in the Medicaid increase. Net these increases against the Medicaid 2% increase and the increase will likely be closer to zero and certainly, not 2%. In simpler terms, if the government gives you a $1 to pay for addiitional costs but takes a new quarter for your license, a dime for something else and a nickel for another something else, you didn’t really get a whole “dollar”.
The encore that Wisconsin wishes you to continue to watch year in and year out, in spite of the ludicrosity of the shell game is the actual Mediciad SNF program itself. For years, Medicaid rates have produced deficits in Wisconsin nursing homes. The care costs substantially more than the program pays for and the bed tax has only hastened these deficits. The program is so inadequate that for facilities that take care of a disproportionate share of Medicaid residents, closure has become the refrain within the industry. For facilities that can manage to maintain a workable payer mix, bed reductions and overt payer discrimination has become the modus operandi. Frankly, it is time for this “show” to close for good as the reviews stink, the trick is old and the players are getting dated.