Haider Warraich is a cardiologist, researcher, and writer at the VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School. Views expressed are not employers’. He wrote the below as an editorial for StatNews.
Nursing homes and hospice care are supposed to provide safe refuges for older people and those near the ends of their lives. During the Covid-19 pandemic, they have been just the opposite.
Nursing home residents account for 1% of the United States population but make up 35% of Covid-19 deaths. Even in this incredibly high-risk group, residing in a for-profit nursing home further increased the risk of Covid-19 infection or death.
To date, six studies have evaluated the impact of nursing home ownership status on Covid-19. All six showed that the risk of infection or death from Covid-19 was significantly higher in for-profit nursing homes. The staffs at for-profit nursing homes don’t fare much better: Not only do nurses in for-profits have to take care of more patients, they also have less access to personal protective equipment.
Private equity investment fundamentally changes nursing homes: It increases deaths by 10% among nursing home residents while quality of care, as evidenced by staffing and other measures, drops even as costs rise for both Medicare and patients. Conversely, when ownership changes from for-profit to nonprofit, care quality improves. This is also a matter of racial justice, since for-profit nursing homes and hospices are more likely to care for Black and Hispanic patients.
Far from scrutiny, many state legislatures are being successfully pressed by lobbyists to shield nursing homes from lawsuits. Even as they deliver poorer care, many for-profit nursing homes have received millions in government funds to shore them up. Many private-equity investors are now indulging in dubious business practices, such as buying nursing homes then renting the building back to the nursing home operator and charging excess management fees.
Private equity has also successfully infiltrated hospice care. Hospice is a service provided mostly in people’s homes by nurses and social workers for individuals expected to live for six months or less. Borne out of a movement to provide humane care to people and their caregivers at the end of life, two-thirds of hospice agencies in the U.S. are now for-profit companies. Research that several colleagues and I published last year shows that even as the cost of hospice care is increasing, the quality of care is plummeting.
This has to do with patients receiving care in for-profit hospices, which provide poorer staffing, fewer community benefits, and enroll patients who stay in hospice longer and therefore accrue more revenue, while requiring less intensive care, such as that needed for people with dementia. There is increasing convergence between for-profit nursing homes and hospice, as more than 20% of nursing homes and hospices now have common ownership, often as part of a chain.
As the Covid-19 pandemic has revealed, age is far more than a number and older individuals are among the most vulnerable members of society. Many are alone, with few friends or family members to watch out and advocate for them. When I care for patients in the hospital, even my most diligent work can mean nothing if they receive poor care at the nursing facility to which they are discharged.
Nursing homes and hospices have been not traditionally been scrutinized like hospitals or other entities in health care. That must change. The evidence suggests that tens of thousands of individuals, many of them people of color, died during the Covid-19 pandemic simply because they happened to be in facilities that prized profits.
Instead of shielding them from scrutiny, lawmakers should be doing more to ensure that facilities entrusted with caring for older adults are operating at a high level. In a new report, the New York attorney general recommended eliminating immunity provisions for nursing homes so accountability is not waived. That would increase transparency in the business practices of for-profit facilities.
And while the U.S. Department of Justice has caught many for-profit nursing homes and hospices engaging in fraud, a more systemic effort is needed. The Biden administration and Congress should prioritize studying for-profit business practices in elder care.
The Centers for Medicare and Medicaid Services has devised a grading system to rank how well nursing homes perform. A study published in the Journal of the American Medical Association found that those with higher rankings, primarily due to better nurse staffing, had fewer Covid-19 cases. For-profit nursing homes are twice as likely to have poorer rankings than nonprofits, making the case that these rankings should be linked to reimbursements that nursing homes receive.
The mark of a strong and ethical country is how it cares for its elders. There has never been a more important time to stand up for them and oppose for-profit corporate interests whose sole interest appears to be enriching themselves instead of helping older people and those nearing the ends of their lives.