BEAVER, Utah — Through a little-known federal funding stream, Utah nursing homes owned by cities or counties are eligible for additional taxpayer dollars meant to improve the quality of care for the elderly and disabled residents who live or stay there.
It all adds up to big money. Over the last decade, state records show nursing homes participating in the Upper Payment Limit program have received $1 billion in federal funds they wouldn’t have otherwise had access to.
But despite all that extra money, a new analysis of publicly available federal data — commissioned by a local law firm — found that, since 2017, the quality of care at these facilities has been worse than at nursing homes that aren’t getting all that extra money – with lower overall ratings and staffing scores and worse deficiency scores in inspections.
“When you look at really every available metric to determine, ‘are these facilities doing better with the money that they’ve been given?’ They’re not. They’re just not,” said Barry Toone, an attorney working with the Elder Care Injury Group, of the data. “The program does not appear to be working the way that it was supposed to work.”
The Elder Care Injury Group — which is pursuing multiple medical malpractice complaints against facilities that are part of the program — provided FOX 13 News with its underlying analysis, which the station reviewed and spot checked against public data.
Both the nursing home industry and the Utah Department of Health and Human Services (DHHS) have pushed back on the analysis, which they say is not based on an “apples-to-apples comparison.”
The law firm’s findings come as some patients have complained about poor quality care at facilities that are part of the program, and as federal inspection reports continue to highlight problems within them.
“There are real people in here who are suffering,” said Doni Hunt Webb, a resident at a southern Utah nursing home that receives Upper Payment Limit funds.
One nursing home that’s received $26 million through the program since 2016 has been named as the state’s Special Focus Facility, meaning it has been identified as having a pattern of persistent and pervasive care issues.
Twelve other government-owned facilities that receive extra money currently have a special alert on the Centers for Medicare and Medicaid’s Care Compare website, warning consumers that each one has been “cited for potential issues related to abuse.” Four of those nursing homes are on the list of candidates to receive additional oversight from federal regulators.
A FOX 13 News review of court records also found nearly 20 Utah families are currently suing facilities in the program, alleging in many cases that poor quality care led to the death of their loved ones.
“When we look at these facilities, a lot of these Upper Payment ones are not the ones getting the highest reviews,” noted Nate Crippes, an attorney with the nonprofit Disability Law Center, which is concerned about conditions in these facilities (but is not party to any of the lawsuits against them). “And we’re seeing a lot of problems in them.”
The nursing homes in the program, he added, stand out because they are receiving “much larger reimbursement rates than non-UPL facilities yet continue to demonstrate serious quality concerns,” including high turnover and insufficient staffing in some.
While still behind non-Upper Payment Limit facilities, data does show quality ratings and inspection scores have improved slightly among nursing homes in the program since 2017, while staffing metrics have declined overall since that time.
A ‘long game’
If you ask Utah’s nursing home industry about these analyses, they’ll tell you critics have the program all wrong.
Before the Upper Payment Limit, they say, Utah’s long-term care system for seniors “was in crisis.” Nursing homes with Medicaid patients were receiving almost $100 less per patient per day than it cost to provide services to them. Some were losing “millions of dollars each year.” A few were on the verge of closure.
After the program was created in 2013 and began allowing nursing homes to receive the substantially higher Medicare reimbursement for Medicaid patients, they say facilities have been able to offset those losses and increase staff wages, upgrade aging facilities and make other improvements.
"The changes have been just amazing in these 10 years,” said Beaver Valley Hospital CEO Scott Langford in a video about the Upper Payment Limit. “Not only has it improved the facilities for the elderly in the state of Utah, virtually every part of the state has been touched by this program.”
The city-owned hospital Langford represents is itself owned by the city of Beaver in central Utah. It currently owns the licenses for more than 40 of the state’s nursing homes, from Logan to St. George.
Both Beaver Valley and Gunnison Valley — another city-owned hospital that is a major participant in the Upper Payment Limit — declined on-camera interviews for this story. So did the Utah Department of Health and Human Services and the Utah Health Care Association, which represents the state’s long-term care industry.
But in written statements, all pushed back on the Elder Care Injury Group’s analysis, arguing that it isn’t fair to compare Utah’s Upper Payment Limit facilities to nursing homes that don’t accept Medicaid, in part due to the more complex health needs of those patients.
Facilities that aren’t part of the program, Beaver Valley said, “serve different populations and are often supported by private-pay and insurance resources using more diversified operating models. They provide a different service to a different type of patient.”
DHHS pointed to the most recently released quarter of federal data, which it said shows facilities part of the program have similar overall scores as national facilities, including non-Medicaid ones and “substantially higher” quality scores.
The Utah Health Care Association also noted in an email to FOX 13 News that almost every nursing home that qualifies for the program is part of it, and that equating "roughly 80 facilities to 20 facilities that aren’t on the program isn’t a level comparison.”
Toone, on the other hand, argues that it is a level comparison. He notes that the Upper Payment Limit ensures Medicaid facilities receive the same reimbursements as Medicare ones, meaning quality “should be at least equal to the non-UPL facilities.”
He also added that the firm’s analysis of federal data shows Utah facilities that aren’t in the program have higher patient acuity than Upper Payment Limit facilities but still “significantly outperformed” them.
In a fact sheet provided to FOX 13 News, Beaver Valley said federal data reflects “snapshots of challenges” and national pressures that affect both its nursing homes and others across the country.
“When issues are identified with facilities licensed by Beaver Valley Hospital,” it added, "these are addressed, and steps are taken to improve care.” Ultimately, the hospital argues, the Upper Payment Limit "is a long game, with the goal of sustained improvements that continue to strengthen the quality of eldercare in Utah over time.”
Langford, Beaver Valley’s CEO, also pushed back on accusations that federal funds haven't been properly spent for the benefit of nursing home patients, noting that the hospital has followed “all state and federal regulatory requirements of the UPL program since its inception in 2013.”
“All funds from this program, which is one of the most rigorously regulated of its kind in the country and provides more than $100 million annually at no additional cost to Utah taxpayers, have been used strictly for their intended purpose of providing care to Utah’s most vulnerable seniors,” he continued in an email.
“Unfortunately,” Langford added, “malpractice attorneys who focus on suing nursing homes continue to misrepresent and exploit the complexities of this program for their own self-interest.”
DHHS, which exercises oversight of the administration of the Upper Payment Limit program, told FOX 13 News that it does “not track specific spending related to how UPL monies are being used.” Beaver Valley and Gunnison Valley also did not provide specific breakdowns of how money has been spent overall at the facilities they own.
“The funds are used to run the facility including staffing, training, wages, facility improvements, capital etc.,” Gunnison Valley said in response to the request from FOX 13 News. “We trust our managers to use the funds as needed for each individual facility as each facility is unique.”
Oversight and operations
This isn't the first time the Upper Payment Limit has come under scrutiny.
In 2017, a legislative audit raised concerns about Beaver Valley’s administration of the program and called for additional oversight and transparency of spending.
Among their findings, auditors noted that nursing homes were using a little less than half of the federal dollars flowing through the program, while Beaver Valley collected the remaining 51% for seed funding and administration fees.
Of the funds that went to the nursing facilities, auditors found the majority were used for “renovations and other expenses.” They also said they saw “little oversight” of the $6 million Beaver Valley had received at that time in “administrative overhead.”
Those were among the most concerning parts of the audit for Hunt Webb, a resident at St. George Rehabilitation.
“There's not that many people in Beaver,” she said in an interview with FOX 13 News. “I don't understand why they're allowed to take the money from nursing homes.”
Hunt Webb is a 55-year-old former social worker who sought long-term care at the southern Utah nursing home about seven years ago, after the severe nausea and vomiting she developed during her first pregnancy led to chronic and debilitating health issues that required full-time care.
As she grew more frustrated by the quality of that care, a series of internet searches she made last year led Hunt Webb to discover that the facility she lives in is owned by Beaver Valley Hospital.
At first, she was surprised. But after she found and read the legislative audit, she started to get angry.
Hunt Webb eventually took those frustrations to Beaver Valley Hospital’s Facebook page, where she posted that the facility and her care were “beyond disgusting” but that there were “no other options,” since the hospital also owns other nursing homes in her area.
She and the other disabled and elderly patients in Beaver Valley facilities, she alleged, were “enduring abuse and neglect” while the hospital benefited from the funds in the program.
Beaver Valley said in a fact sheet that the "vast majority of UPL funds are used by nursing facilities to provide patient care,” while the “remaining, much smaller portion is used by the hospital to improve access to care and health services provided by the hospital.”
A she looks around her nursing home, Hunt Webb said she doesn’t understand how St. George Rehabilitation has spent the $20.9 million state records show it's received through the Upper Payment Limit since 2017. But she doesn’t feel the funds have done much to improve her care.
"It was supposed to provide for more staffing,” she said of Upper Payment Limit dollars. "It's CNAs; it's extra staff that we don't get."
While federal data shows St. George Rehabilitation’s health inspection rating and overall staffing have improved slightly over the years, the facility currently has a “below average” staffing rating from the Centers for Medicare and Medicaid Services.
St. George Rehabilitation declined an on-camera interview for this story. An administrator told FOX 13 News in an email that the facility prefers to “personally connect with our residents” rather than involve the media.
Like other nursing homes that are part of the program, St. George Rehabilitation isn’t actually operated by Beaver Valley. Though the hospital and other government entities that participate in the program hold the licenses for the facilities, day-to-day operations are largely overseen by private management companies.
Hunt Webb’s nursing home, for example, is operated by the Ensign Group, a private equity chain with about 300 facilities across the country.
"They’re really only owners in name,” Crippes said of Beaver Valley and the other government entities involved in the program. “They’re not operating the facilities. They’re not there.”
For Toone, it all raises questions about whether the funds in the program are being siphoned away from patient care and "into private-equity coffers and large for-profit chains.”
“As much as the industry likes to talk about how they can barely meet their budgets,” he argues, “the reality is those kinds of corporations aren’t drawn to industries like this if they’re not going to make good money.”
Beaver Valley told FOX 13 News that its role in the program is to “oversee compliance,” while “seasoned elder care facility managers” provide day-to-day patient care.Under the Upper Payment Limit, it added, “Beaver Valley oversees and empowers these experts to do what they do best,” ensuring residents receive care “from professionals with the right skills, training and compassion.”
'A program that was designed to do good’
After the legislative audit, the Department of Health and Human Services implemented a Quality Improvement Program in 2018, in an effort to address concerns about the need for greater state oversight.
To qualify for continued funding, facilities are now required to either improve from the previous year or score better than the national average on at least six of nine metrics.
In a recent training for nursing facilities, DHHS Quality Improvement Director Trent Brown said the program helps demonstrate “that the additional resources that come in from those UPL payments are being used to improve quality of care as well as quality of life for nursing facility residents.”
He added that it can also be a “very strong defense mechanism for the facilities who participate when being questioned about the supplemental payments.”
Eleven facilities in the program were put on probation for not meeting quality requirements in 2024, according to documents obtained through an open records request. DHHS told FOX 13 that the program seems “to be effective” when comparing the metrics it tracks for Upper Payment Limit facilities against national ones.
But Toone — noting other metrics comparing these facilities to the ones here in Utah that aren’t receiving extra money — argues the Quality Improvement Program doesn't “appear to be working” and wants to see additional requirements for facilities.
“I would like to see UPL dollars tied directly to staffing ratios that are considered acceptable and wages that are considered acceptable so we could see the stabilization of staffs within these facilities,” he said. “If we could tie those dollars to those kinds of things, that’s when you’re going to see the results that you were supposed to see.”
The number of nursing staff hours per resident per day is one of several metrics that facilities are currently judged on.
Crippes, with the Disability Law Center, agrees that staffing should be a more significant metric and urged the state to consider additional payment methods for the program that would enhance quality, “such as incentivizing spending on direct care staff.”
“We would also encourage the state to redirect its investments away from a costly UPL model and instead focus on home and community-based services which would allow people who are aging and people with disabilities to remain at home — services that cost much less and have better outcomes,” he added.
For his part, Toone said he believes the Upper Payment Limit could be a positive for Utah’s nursing homes. But he said it's important that policymakers ensure the money actually improves patient care for “the most vulnerable members of our population.”
“Utahns should care that good taxpayer dollars — and we’re talking about a lot of money here — are used the way they are supposed to be used,” he said. “Especially when you have a program that was designed to do good.”
You can view the full Beaver Valley Hospital audit HERE.