What Is Assisted Living?

Much has been made in this column of the problems faced by the nursing home industry, but the fact is that assisted living--long-term care's "fair-haired boy"--has come in for its own share of lumps of late. Almost everyone knows about last year's Wall Street firestorm, where the leading publicly listed assisted living companies saw their stocks lose nearly 70% of their value. But the problems of assisted living go deeper--actually, to the heart of what is meant by the term "assisted living."

This became apparent to me when I recently attended the first legislative conference sponsored by the Assisted Living Federation of America (ALFA). In several spirited and frank discussions, industry leaders mulled over some very profound questions--for example, do we really want to sell based on "aging in place"? Does Medicaid have a role in increased affordability? What is "good" vs. "bad" regulation?

Without giving a blow-by-blow account of who said what--there isn't space for that here--these were the dilemmas that surfaced, at least as I understood them:

Aging in place: Most, if not all, assisted living customers do not want to move again. They want their assisted living residence to be their final home, no matter what. But, for providers, that means providing clinical services of increasing intensity. Where should they draw the line? What sorts of promises should they make? When does licensure become an issue? Mistakes here could lead to some very unhappy customers, and probably that OBRA-style regulation that everyone in this industry so rightly fears.

Medicaid: Nearly 40 states now have waivers in place that would allow some sort of Medicaid funding, at least for the healthcare component of assisted living. But what if Medicaid rates don't meet provider expenses? Can we have some sort of assisted living "Lite" for the poor (e.g., double occupancy)? And, once again, what about the Medicaid "slippery slope," i.e., the development of federal and state regulations to monitor these public expenses?

Regulation: "Good" regulations might be those governing customer disclosure and contracting. "Bad" regulations would be those mandating staffing and staff training and leaving no flexibility in determining care management of a particular resident. "Flexible" regulation, accounting for individual circumstances, would work best in this field--but isn't "flexible regulation" an oxymoron? As far as quality of care goes, aren't customers themselves the best judges? On the other hand, is there any way to keep government out of the picture if and when the "horror stories" start to emerge? After all, politicians have outraged constituents to answer to.

The upshot is that assisted living is still defining itself every day. Now that it is no longer Wall Street's "flavor of the year," it has its work cut out for it: keeping customers happy, defining and sticking with its limits, and working hard to make sure that the regulatory shoe never drops.

Assisted living remains a place for customer-oriented innovation. Indeed, some conference attendees reflected that nursing homes got into trouble by losing sight of their customers. But assisted living has its own problems, and grizzled nursing home industry veterans might be forgiven a muttered, "Welcome to the world, kid."