"The data revealed a troubling trend: when private-equity firms acquired nursing homes, deaths among residents increased by an average of ten per cent."
That is why, as per [1] the hammer is about to fall on private equity and it's total finantialization of markets. The finantialization per-se is harmful as per the quote, but the worse is that there are often board members seating on competing enterprises, which is kind of incredible that it is possible.
How does one "financialize" a nursing home? When people talk about the financialization of corporate America, they're usually talking about how GE and Caterpillar went from being manufacturing companies to being lending companies that also manufacture stuff. Or how airlines turned from transportation companies into banks that fly for a side-gig.
I will note that private equity was involved in none of these situations.
It does by the fact that private equities are purely financial institutions with massive economic and legal leeway, able to buy all the nursing homes. From a market perspective that already creates a distortion, which is the point of the article i linked.
On top of that, financialization is counter to the social aspects of nursing home. Support or quality of life improvements of their users is marked as expenses, while from a social perspective they are gains. Furthermore the service is not very elastic as many people just do not have an alternative but to require nursing home services. The alternative being they load working age relatives, externalizing the costs. In many countries to open a company you set it up as a social contract, where society allows you to open a business because it believes it improves society. If it does not, it will not take long for the law or lawmakers to come after you. That seems to be the case.
If there's more supply you could expand. The ideal situation from the owner point of view is you extract the entire net worth of the tennant and then move them on (coffin or just kick them out), while at the same time spending the least amount possible.
You don't want them dying too quickly as that's leaving money on the table, but you don't want to have to evict them once they run out of money
Bonus points if you can extract money from relatives too
While I agree that the damage is minimal to them - the point is that protecting them behind the meaningless label of "private equity" outright shields them.
More importantly, nobody invests with the Piccolo group, they invest with a pension plan that invests with a mutual fund that invests with a hedge fund that has a portion invested with Piccolo.
I worked at a place that ultimately was owned by Apollo and I was there when it came out that the CEO had ties to Jeffery Epstein. It didn't change too many people's opinion of him (it was not very high to begin with).
The parent comment should not be downvoted. It should be upvoted. Its because sociopaths are allowed to get away with doing these things behind 'corporate entities' that this kind of psychopathy can happen. Its because we not only allow such sociopaths to live in our midst, but also we held them in high esteem and allow them to occupy positions of power in our society that these things continue to happen. And until we stop doing those, they will keep doing what they are doing.
Interesting seeing all the yarmulkes. It went from being a catholic run to a jewish run nursing home. Could this story be seen as an expression of their respective value systems?
Very few people will die when Advance Publications runs The New Yorker into the ground due to extreme cost cutting measures designed to marginally increase investor return.
At least, I'm assuming that very few people will die. I'm not a magazineologist.
Not excusing the Portopiccolo Group at all, but it sounds like half the problem is labor shortage. There was (is?) a severe shortage of nurses last year and a nursing home is an undesirable place to work.
I think there's some cost cutting going on too, not sure, but during Covid, the home that Grandma was in got much, much worse. They simply never had staff to help any longer, and this was (formerly) a good place to be.
We tried to move her around, but Grandma died a few months ago, with us constantly fighting to get proper care for her in places that seemed to get progressively worse over time.
Just had constant fights to make sure anyone was checking on her or taking care of her or anything at all and seeing constant signs that everything vaguely medically related is horribly under-staffed.
This is a very large factor - nurses and CNAs working at nursing homes will often jump at the chance to work at a "real" hospital (or even McDonalds, if the pay gets high enough).
Of course, a shortage means they aren't paying enough (at $100/hr they'd have no limit of applicants) but they may not be able to adjust fast enough.
> Not excusing the Portopiccolo Group at all, but it sounds like half the problem is labor shortage.
The problem is enormously complex.
First, there's been a labour shortage in geriatric care for years.
Then the pandemic came along and exacerbated things.
Meanwhile, elder care in highly supportive settings is very labour intensive, which means it's expensive.
But it's also a service people have no choice to buy. i.e., eventually some percentage of elders will require full time care, and right now, in most of the western world, that means an institutional setting.
And the consumers of the product are some of the least represented in our political systems. Even with organizations like the AARP, the reality is the needs of an aging population get about as much attention as the needs of the poor.
When you combine a product with very high and inelastic demand, combined with high costs, and no consumer advocacy, and then privatize that service, guess what: the quality of the product is going to go down in order to cut costs and maximize profits.
Given that the primary cost of elder care is staffing, that creates downward pressure salaries, which drives even more people out of an already very challenging industry.
The answer is simple: Elder care should be a publicly delivered service.
But, the neoliberal answer is to Privatize All The Things. And so here we are.
> The answer is simple: Elder care should be a publicly delivered service.
It is. Medicare pays for almost all Elder care. Which of course is the problem - private pay nursing homes are way better than the publicly funded ones because Medicare pays far less.
Or at you implying that the Government should directly own nursing homes, and hire the staff directly? That has a whole different set of problems - don't advocate for that without understand what you are asking.
You end up with centralized decision making for something very local.
You are misunderstanding the problem - the issue is not privatization, the issue is that Medicare does not pay enough, and nursing homes try to find private pay clients to make up the shortfall.
> You are misunderstanding the problem - the issue is not privatization, the issue is that Medicare does not pay enough, and nursing homes try to find private pay clients to make up the shortfall.
It's both.
America has chosen the worst of both worlds: public under-funding and private delivery.
Private delivery leads to cutting corners to maximize profits.
Lack of sufficient public funding exacerbates the issue.
The solution is to fix the public funding problem by properly investing in the system, and killing private delivery.
nit: Medicaid. Medicare will pay for inpatient rehab after hospital stays and the like, but long term care essentially requires becoming destitute so that Medicaid will pay. A large part of middle-upper-middle class "estate planning" consists of passing wealth to kids well before the lookback period. The private pay burn rate is like $150k/yr last time I checked.
I don't think there is any easy answer. Spending drastically more on the problem is necessary, but obviously not sufficient. Then again, dying from laying in your own feces ("bed sores") when you're 80+ years old isn't the worst way to go out in the US.
Seriously? Let's see, the two industries where the government has gotten deeply involved, healthcare and education, are so comically expensive one doesn't even know where to begin. How in the world is complete government subsidization, which will basically just turbocharge demand by making it "free", going to solve the problem? The bottleneck (as you correctly note) is labor, if you can't fix that then anything to increase demand is just going to make it wildly more expensive and completely dysfunctional.
> Let's see, the two industries where the government has gotten deeply involved, healthcare and education, are so comically expensive one doesn't even know where to begin.
The US government is not directly delivering either of those systems.
The US government is using public funds to subsidize private delivery, and doing it with virtually no cost controls to ensure those private companies aren't gouging the public.
The rest of the world has figured out how to make public healthcare and education work. The fact that the US can't is an indictment of US political leadership and, frankly, cultural values.
> the two industries where the government has gotten deeply involved, healthcare and education, are so comically expensive one doesn't even know where to begin.
Education and healthcare are two examples of inherently social enterprises. Allowing profit-seeking firms into these spaces has caused nothing but trouble.
Having CEOs in charge of healthcare and education is as stupid of an idea as having government planners deciding the price of cars and how many cars each factory will produce per year.
Most enterprises are capitalistic, but some like education and healthcare are inherently social.
> Elder care should be a publicly delivered service
Figured this proposal would be on here somewhere. There are government-run nursing homes, always have been, even in America. People do everything they can to avoid them, because they're way worse than the private ones.
"Just run them better" is not a plan of action. As with all things, incentives breed outcomes. What actions would you take to improve public-funded outcomes here?
> The answer is simple: Elder care should be a publicly delivered service.
Would you put your parents into a facility run by the same people who run the NYC public school system or the DC Metro?
I’m not a “neoliberal” by temperament. I want to believe the government can do stuff in an efficient and non-abusive way. I’m just repeatedly disappointed.
the people who run government funded health facilities are a different set of people that run education or transportation. Only the funding source is the same.
Would you put your parents in a nursing home paid for by Medicare? I would, because I saw the care my grandmother received from such a facility.
> the people who run government funded health facilities are a different set of people that run education or transportation. Only the funding source is the same.
They’re the same people. Government employees, belonging to the same unions, subject to the same incentives.
> Would you put your parents in a nursing home paid for by Medicare? I would, because I saw the care my grandmother received from such a facility
Medicare and Medicaid go out of their way to not be “publicly delivered services.” Medicare pays for privately managed elder care facilities, which may well be owned by a private equity company.
> They’re the same people. Government employees, belonging to the same unions, subject to the same incentives.
Similarly, private equity is the same people with the same incentives as Enron, Toys R Us, Sears, and other major collapses. I'm not sure this is a good argument except as to say that nobody should run anything?
Government is supposedly less efficient, I'm not sure this is a bad thing, and I'm not sure government is worse at health care than private industry when we are talking about care for the bottom X% (25%?) of society that can't do private payment.
Except food also has inelastic demand (without it you starve and die), and has a pretty close to perfect market, and prices are not driven to infinity.
Healthcare in America is about as far away from "capitolism"(sic) as one could possibly get.
Due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. Employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals.
If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in prices rising to infinity. The furthest thing possible from a "perfect capitol(sic) market".
Air also has inelastic demand.
It is just that it is too cheap (that doesn't mean that the producers make a good profit) to produce an enormous quantity of it (even though fresh food is perishable), so much, that even the US and the EU agree on agricultural quotas and/or increasing tariffs over a certain quota of imported quantity.
For Switzerland & Germany the way the incentives work are different than in the US, but the market for compulsory health insurance is very strictly regulated and the cost distribution for healthcare is distributed across public and private entities (particularly for very expensive treatments, rare diseases, treatments involving machines of great complexity/cost [like for proton therapy]).
> Similarly, private equity is the same people with the same incentives as Enron, Toys R Us, Sears, and other major collapses
Right, and the key difference is that there are several other options for all of those things. When private enterprises become unsustainable, they go out of business. When government programs become unsustainable, we increase their budget. With private enterprises, it becomes possible for other alternatives to be introduced in parallel — neither Enron, Toys R Us, nor Sears are monopolies, and with their demise, we still have plenty of energy, toys, and retail. That's not the case for government endeavors.
That said, many countries have solved this problem through the provision of competing state-owned enterprises (state capitalism), which are often traded on public stock markets. This is pretty common in the Scandinavian countries, as well as the East Asian Tigers.
> I'm not sure government is worse at health care than private industry when we are talking about care for the bottom X% (25%?) of society that can't do private payment.
As we all know, there are several countries that are able to pay for care in a way that the government is the monopoly payer (i.e. single-payer), but there are also countries that are able to pay for care in a way that there are multiple payers, with similar (if not better) outcomes. Switzerland and the Netherlands both have purely private health insurance systems, and there's no sign of that changing any time soon, and both enjoy excellent health outcomes with broad approval of their respective healthcare systems (https://www.forbes.com/sites/theapothecary/2011/04/29/why-sw...).
Even in the US, we're essentially running this A/B test with Medicare (ironically). When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare.
- 48% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly that the CBO projects that by 2023, the majority of beneficiaries with choose the private over the public option. The CBO further projects this proportion to increase to 61%(!!) by 2032. (https://www.kff.org/medicare/issue-brief/medicare-advantage-...)
- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan (https://www.commonwealthfund.org/publications/issue-briefs/2...)
This might be the best comment I've ever received in reply.
It seems like it's either a shared social failure where everyone has access to the same semi-inefficient gov't monopoly, or it's an uneven distribution with some guaranteed failures that are exceptionally painful for a smaller number of people. The net amount of pain/suffering is constant, it's just how we distribute it.
This is my experience too. My sister has a doctorate in physical therapy and focuses on aid for the elderly. My whole family assumed that given the need that it’d pay well. Turns out everything is run by corporations that incentivize working employees to death and providing care that is billable but not necessary and refusing care that is necessary but less efficiently billable. She loves working with the elderly but the system makes the career so demoralizing.
> What they often do is form a corporation or an LLC or any kind of corporate form, and the legal owner will be the corporate form, not the true owners. So they have insulated themselves from any connection between the operations and the health care and themselves.
> Often we see the actual property that the health facility is on put into a separate LLC and—owned by the same owners, of course—however, they then lease themselves that building. There’s also various ways that they can further vertically integrate through pharmacies, through staffing companies, through housekeeping and hospitality companies.
> All of these can be owned by the same individuals theoretically but placed into separate corporate forms and transact in business with one another. And so really it’s just kind of musical chairs of moving money around from one pocket to another.
Before PE firms' take over of nursing homes, many nursing homes are run by entities controlled by doctors. In such places, they don't hire enough CNA nurses. You know what such nurses do? Just do critical stuff; everything else, they just mark it as done, without having done. (for instance, if nurses are asked to check blood pressure of some patients every 2 hours, they don't do it, they just put yesterday's numbers, and sign off). I knew a nurse, who did it. And she learned it from her colleagues at the same nursing facility.
This is what happens, when one tries to force nurses to do overwork for $30 per hour (2015 rates for nursing homes in southern California).
It's worse than that, it's a perfect storm of bureaucracy.
Something bad happens. It's determined to be the fault of a CNA or the procedures (never the doctors and rarely the nurses are blamed, always the CNA).
The procedure is updated at the state level to require MORE things to be done, but there is no time to actually do them, so something happens again.
More documentation and procedures are added, and the cycle repeats.
This doesn't make sense. Let's fix a smaller, bureaucratic problem by allowing the entire industry to be taken over by people that purposefully exploit grey legal areas and transfer life quality into dollars and cents?
If nurses are lying, thats a poor management system. Punish the bad actors, not the patients
Nurse is given 50 hours of work for an 8 hour shift. Do you want the nurse to do the essential work and mark the rest as complete even if it wasn't, or do you want the nurse to just ignore what their coworkers are doing, not check off all the boxes, and get fired?
I want a system that can audit systematic records falsification leading to severely worse outcomes for human subjects and punish that company/hospice/nursing home/hospital/etc. accordingly.
Yea, I've been in places that have those types of systemic issues and in general those places sucked to be at and work at. Would hope those with enough morals recognize the situation and bail. As mentioned, there 'skillset' or willingness to do certain activities is sorely needed in this current labor market and has been needed for some time.
I agree. I recently lost an elderly family member for whom I was the one responsible for care management. He bounced between the nursing home and hospital a few times due to significant water retention.
The nursing home was a -good- nursing home and they still couldn’t follow the daily weight check order until I sent them an email calling it out on the hospital discharge paperwork as a medical order, and noting where I had been told in writing that they had only been doing monthly weight checks per the facility’s standing order.
It was very frustrating. When I would have a call with his nurse case manager or emails with his social worker, those would sometimes happen at 8 or 9 in the evening, because that’s when they could get to it. And that was one of the better places.
I'm honestly dumbfounded. My grandma and grandpa, whom I was close with and enjoyed spending significant time with, were in a few assisted living type facilities for the last 10 years or so. I felt bad for them (they never liked the food, and loneliness is always a problem) but I felt equally bad for the staff (RNs, CNA, 'med-aides'). My grandparents just simply grew up in a different time and had different expectations so they would always be complaining about something or wanting this or wanting that. I felt terrible for the staff to have to deal with them.
The experience has solidified my mindset. I _will not_ live in a 'home' when I'm old, and will not let my mom enter on of those facilities.
I was going to write a comment laying out an admonishment to keep loved ones in their own homes, and hiring in-home help. But really, it's the luck of the draw depending on their specific medical condition. Like for example if someone has Alzheimer's I don't see how that could ever work DIY unless you spent some extreme amount of money.
So really, it's a very strong suggestion - don't let your family members go to a nursing home lightly. Hospitals will often push for it as the only option, and sometimes it may be necessary for a time, but really think about the situation for yourself. Think of nursing homes as existing mainly because euthanasia is illegal and repugnant to many people.
I've now had close experience with two family members who have ended up at one for inpatient rehab (one during covid, one afterwards), and they're fucking death traps. And this was a facility that another family member had worked at for some time as the head physical therapist, and they recognized the last name!
I don't know if private equity was involved, but as the top-level comment points out the continual screw tightening overwork incentive is there regardless.
I agree. The current system incentivizes lying. If a healthcare worker tells the truth about not being able to complete something, they often open themselves up to civil and criminal liability for negligence and failing to meet standard of care. Meanwhile, lying in paperwork is only an issue if something ever progresses to a lawsuit. It’s pretty much don’t ask, don’t tell.
Systematic, unbiased auditing and extreme penalties not just for the individual but for the business employing the person are sorely needed.
In the abstract that’s true. In reality, these are people who have families to feed and if the choices are to lie on paperwork or to lose your job and likely have your workplace report you for negligence to cover themselves, most people choose to do the essential work and lie about the rest. Retaliation is a huge issue in medicine and attempting to push back against the systems and people in power is often futile.
I am with you on fixing problems. The issue is not nurses, the doctors who run these nursing homes are culprit. They are as bad as PE guys. That's my point.
"The data revealed a troubling trend: when private-equity firms acquired nursing homes, deaths among residents increased by an average of ten per cent."
They're mixing terms. CNAs are certified nursing assistants, not full fledged nurses. They're paid significantly less and do a massive amount of the work at care facilities.
There was a glut of RNs, CNAs that time. Almost all CNAs want to work in a hospital; no RN/CNAs want to work in nursing homes. Nursing homes are the last choice for these people. This CNA friend, who told me about how CNAs work at nursing homes, now works for the state prison. And she makes $160K a year with overtime. And she lives in some socal desert, where this state prison is located. She was happy to get a job there, because of $100K jump in salary.
Not that there is anything the least bit good to say about nursing homes run by distant, uncaring, profit-obsessed managers...but also consider the brutal economic reality of 24x7 care, at even the best possible nursing home. (Excluding facilities for the actual wealthy, where cost isn't much a concern.)
To have ONE bottom-rung direct care staffer available, 24x7x365, and paid ~$12/hour... After employer-contributed payroll taxes, unemployment insurance, and workman's comp. insurance, figure the home's actual cost is $15/hour. $15 x 24 x 365 is $131,400.00 per year. More-skilled staff (you do want a nurse or few around, right?) are proportionally more. Plus, even the leanest-run facility will need a few folks cooking the residents' meals, doing their laundry, doing physical therapy, handling paperwork in the office, etc. The most humble of donated buildings (so we're imagining no mortgage payments) still requires ongoing maintenance, utilities, & such.
Add all this up, and you can easily hit $250,000/year per bottom-most-rung direct care staff person.
Now, assume that you (or the society you're doing thought experiments on) can't actually afford $250,000/year for each and every person who needs nursing home care. What fraction of that "one per one" care are you willing to settle for? Notice that even at "one per ten" staffing, your cost of running the facility is still $25,000 per resident per year. Multiply that by as many millions, or tens of millions, as need such care. (Yes, one per ten is well below the legal minimums in many states.)
Does your society have the actual resources to do that? If "yes" - are you really comfortable with how capable, caring, and responsible the bottom-rung caregivers willing to accept ~$12/hour to clean up incontinent and disoriented elderly folks at 3am actually are? And you're aware that our "suitable building was donated" fudge is a really big fudge?
Oops, also - that nursing home bill only covers the nursing home care. If your residents need to have some medications, doctor office visits, occasional hospital stays when (say) they fall & break something - that's all additional costs & resources.
It's a complex situation no doubt. There is massive shenanigans in the billing aspect of this (thus the attraction of profit hungry assholes).
Society has cared for it's elderly basically forever, and _now_ we're saying it's too expensive? As the article mentioned, the incentive for the religious group running these places was theological and human centric. Those religious groups are/have collapsed so there is this giant vacuum attracting all the wrong people. I honestly can't believe there isn't enough money in the 'system' to provide decent care for the vast majority of elderly. The numbers cited today (likely correct) aren't sustainable b/c it's basically free money to harvest (at the cost of human comfort). Regulate the industry and prosecute the bad actors. If member's of congress had family in these facilities, it would like be solved. They likely don't for the same reasons they don't have the same healthcare benefits as most Americans. Disconnected from reality.
(I say this as someone well aware of the costs of nursing homes, and specialized care.)
> Society has cared for it's elderly basically forever, and _now_ we're saying it's too expensive?
Because individuals used to look after their own elderly. Now there's a lot more institutions involved, meaning a lot more other people work, meaning a lot more other people need wages paid.
It's a bad, crappy job that no one wants to work in, and no one wants to pay high fees for looking after mum and dad
Correct. I don't disagree. However, in my experience increased money and scale (i.e tens of millions of people need this assistance) don't seem to be helping the problem. In my head I think its similar to the problems of public education in America. We pay extremely high $/kid on public education due in some areas, it doesn't improve outcomes. It's like the whole model is un-scaleable or something.
Eh, not true. Communities looked after their elderly. We've just removed any aspect of community from society. Individualism to a fault is causing these problems.
I've been thinking about this a lot lately, and it seems there are many causes. Increased ability to move, and desirability of moving (school, jobs, exploration). Bad city design (at least in North America, we have a car problem) meaning it's difficult to have a local community. The decline in religious involvement and no replacement lined up. A culture of extreme individualism to the point of absurdity.
These all seem tractable, but it is sad that we've let it get to this point. I feel there is a shifting in the wind though. At least for younger people, American capitalism and individualism seems to be viewed with increasing skepticism.
The answer is much simpler, there used to be much less elderly per working person (and that only covers modern times, too, in a country with massive in-migration of new working people; plus it's obvious it's going to get worse): http://vis.stanford.edu/jheer/d3/pyramid/shift.html
That is also why Social Security seemed like a good idea at one time.
The pyramid shape for traditional (generally pre-modern-medicine) societies is very, very different from the shape for modern, "wealthy" societies. In the former, infirm old folks are a lot rarer. Add in far larger, tighter family networks, and the "women care for the old" social standards, and the "outside of what families quietly manage themselves" portion of the problem, which society needs to deal with, is vastly smaller.
Seems like the reduction of everything into market-based economies has some limits! Maybe we should break from the frankly radical notion that all problems can be solved and all relations understood in this way.
My parents have noticed the costs are quite high and the lack of interest among their children in taking care of them. Whenever they mention it, I just assure them that robots will be tasked with taking care of them in a decade or two, so whoever is working on that, please get to it.
Science fiction gave us the obvious economic answer with "Logan's Run" and "Soylent Green" many years back.
Maybe I misread your calculation but to me it seems you assigned to every "patient" (excuse the word) dedicated 24x7 on call and basically all that supporting stack, thus the 250k/person/year - not even the nursing homes for wealthy offer this kind of service. And even the start of the 131k is actually three persons manning the phone... so to me the calculations seem totally off, difficult to build an argument on bad math. Not at least, everywhere in the world there are functioning nursing homes so the concept can obviously work, so I really don't get your point.
No - I am using "one 24x7 bottom-lever care giver" as my (admittedly simplistic) unit of measure, for nursing home staffing. (Yes, I know there are wide variety of care options with visiting nurses, "independent" housing, etc. - where the staffing is definitely not 24x7. In my part of the U.S., the term "nursing home" seems reserved for facilities which are the (mostly) long-term primary residences of people needing some type(s) of 24x7 semi-skilled physical and medical care.)
How many residents (or patients, or ...) each 1 staffing unit has to care for is brought in later. I briefly assumed 10 residents per staffing unit.
(I am not sure how to interpret your "even the start of the 131k is actually three persons manning the phone" comment. Though from my own experience - quite a bit of staff time is consumed by talking on the phone with the family members of residents, with outside doctors & such for residents, with insurance providers for residents, with pharmacies, etc., etc.)
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I will note that private equity was involved in none of these situations.
On top of that, financialization is counter to the social aspects of nursing home. Support or quality of life improvements of their users is marked as expenses, while from a social perspective they are gains. Furthermore the service is not very elastic as many people just do not have an alternative but to require nursing home services. The alternative being they load working age relatives, externalizing the costs. In many countries to open a company you set it up as a social contract, where society allows you to open a business because it believes it improves society. If it does not, it will not take long for the law or lawmakers to come after you. That seems to be the case.
Better to keep them barely alive with the minimum funding possible
You don't want them dying too quickly as that's leaving money on the table, but you don't want to have to evict them once they run out of money
Bonus points if you can extract money from relatives too
Most people would take the millions in profit even if their name is on some obscure nerd website as being naughty.
At least, I'm assuming that very few people will die. I'm not a magazineologist.
We tried to move her around, but Grandma died a few months ago, with us constantly fighting to get proper care for her in places that seemed to get progressively worse over time.
Just had constant fights to make sure anyone was checking on her or taking care of her or anything at all and seeing constant signs that everything vaguely medically related is horribly under-staffed.
Of course, a shortage means they aren't paying enough (at $100/hr they'd have no limit of applicants) but they may not be able to adjust fast enough.
of their own doing.
"Within two weeks, management laid out plans to significantly cut back nurse staffing."
The problem is enormously complex.
First, there's been a labour shortage in geriatric care for years.
Then the pandemic came along and exacerbated things.
Meanwhile, elder care in highly supportive settings is very labour intensive, which means it's expensive.
But it's also a service people have no choice to buy. i.e., eventually some percentage of elders will require full time care, and right now, in most of the western world, that means an institutional setting.
And the consumers of the product are some of the least represented in our political systems. Even with organizations like the AARP, the reality is the needs of an aging population get about as much attention as the needs of the poor.
When you combine a product with very high and inelastic demand, combined with high costs, and no consumer advocacy, and then privatize that service, guess what: the quality of the product is going to go down in order to cut costs and maximize profits.
Given that the primary cost of elder care is staffing, that creates downward pressure salaries, which drives even more people out of an already very challenging industry.
The answer is simple: Elder care should be a publicly delivered service.
But, the neoliberal answer is to Privatize All The Things. And so here we are.
It is. Medicare pays for almost all Elder care. Which of course is the problem - private pay nursing homes are way better than the publicly funded ones because Medicare pays far less.
Or at you implying that the Government should directly own nursing homes, and hire the staff directly? That has a whole different set of problems - don't advocate for that without understand what you are asking.
You end up with centralized decision making for something very local.
You are misunderstanding the problem - the issue is not privatization, the issue is that Medicare does not pay enough, and nursing homes try to find private pay clients to make up the shortfall.
It's both.
America has chosen the worst of both worlds: public under-funding and private delivery.
Private delivery leads to cutting corners to maximize profits.
Lack of sufficient public funding exacerbates the issue.
The solution is to fix the public funding problem by properly investing in the system, and killing private delivery.
I don't think there is any easy answer. Spending drastically more on the problem is necessary, but obviously not sufficient. Then again, dying from laying in your own feces ("bed sores") when you're 80+ years old isn't the worst way to go out in the US.
The US government is not directly delivering either of those systems.
The US government is using public funds to subsidize private delivery, and doing it with virtually no cost controls to ensure those private companies aren't gouging the public.
The rest of the world has figured out how to make public healthcare and education work. The fact that the US can't is an indictment of US political leadership and, frankly, cultural values.
Education and healthcare are two examples of inherently social enterprises. Allowing profit-seeking firms into these spaces has caused nothing but trouble.
Having CEOs in charge of healthcare and education is as stupid of an idea as having government planners deciding the price of cars and how many cars each factory will produce per year.
Most enterprises are capitalistic, but some like education and healthcare are inherently social.
Across multiple countries, only the United States has this problem.
Figured this proposal would be on here somewhere. There are government-run nursing homes, always have been, even in America. People do everything they can to avoid them, because they're way worse than the private ones.
Right.
Would you put your parents into a facility run by the same people who run the NYC public school system or the DC Metro?
I’m not a “neoliberal” by temperament. I want to believe the government can do stuff in an efficient and non-abusive way. I’m just repeatedly disappointed.
Would you put your parents in a nursing home paid for by Medicare? I would, because I saw the care my grandmother received from such a facility.
They’re the same people. Government employees, belonging to the same unions, subject to the same incentives.
> Would you put your parents in a nursing home paid for by Medicare? I would, because I saw the care my grandmother received from such a facility
Medicare and Medicaid go out of their way to not be “publicly delivered services.” Medicare pays for privately managed elder care facilities, which may well be owned by a private equity company.
Similarly, private equity is the same people with the same incentives as Enron, Toys R Us, Sears, and other major collapses. I'm not sure this is a good argument except as to say that nobody should run anything?
Government is supposedly less efficient, I'm not sure this is a bad thing, and I'm not sure government is worse at health care than private industry when we are talking about care for the bottom X% (25%?) of society that can't do private payment.
Healthcare has inelastic demand, so the perfect market would drive the price to infinity (that is, demand as much money from patients as possible).
Oh look, that's exactly s what's happening!
For people who love capitolism, Americans are surprisingly uneducated on the concept.
Healthcare in America is about as far away from "capitolism"(sic) as one could possibly get.
Due to Federal mandates and tax incentives, health insurance is predominately provided by employers rather than the individual market (unlike Switzerland, Germany, or the Netherlands). What we're seeing in healthcare costs is analogous to what you might see happen to airline ticket costs if we all got our air tickets through our employers: the vast majority of us would fly business class, while the unemployed would be simply unable to pay for business class fares out of pocket. Employers (especially medium-to-large businesses) have a much higher purchasing power (and hence, willingness to pay) than individuals.
If you take this behavior and combine it with the fact that health insurers' profit margins are capped by law, insurers pay more absolute dollars for treatments (which doctors happily accept), charge more to employers (who are generally less price conscious vs individuals), thus bring in more absolute revenue, and therefore more profit because a capped profit percentage of a higher revenue is higher than a capped percentage of lower revenue. It's somewhat counter-intuitive, but the policy combination of an employer mandate and insurance profit cap results in prices rising to infinity. The furthest thing possible from a "perfect capitol(sic) market".
For Switzerland & Germany the way the incentives work are different than in the US, but the market for compulsory health insurance is very strictly regulated and the cost distribution for healthcare is distributed across public and private entities (particularly for very expensive treatments, rare diseases, treatments involving machines of great complexity/cost [like for proton therapy]).
Right, and the key difference is that there are several other options for all of those things. When private enterprises become unsustainable, they go out of business. When government programs become unsustainable, we increase their budget. With private enterprises, it becomes possible for other alternatives to be introduced in parallel — neither Enron, Toys R Us, nor Sears are monopolies, and with their demise, we still have plenty of energy, toys, and retail. That's not the case for government endeavors.
That said, many countries have solved this problem through the provision of competing state-owned enterprises (state capitalism), which are often traded on public stock markets. This is pretty common in the Scandinavian countries, as well as the East Asian Tigers.
> I'm not sure government is worse at health care than private industry when we are talking about care for the bottom X% (25%?) of society that can't do private payment.
As we all know, there are several countries that are able to pay for care in a way that the government is the monopoly payer (i.e. single-payer), but there are also countries that are able to pay for care in a way that there are multiple payers, with similar (if not better) outcomes. Switzerland and the Netherlands both have purely private health insurance systems, and there's no sign of that changing any time soon, and both enjoy excellent health outcomes with broad approval of their respective healthcare systems (https://www.forbes.com/sites/theapothecary/2011/04/29/why-sw...).
Even in the US, we're essentially running this A/B test with Medicare (ironically). When you turn 65, you have the option to enroll either in "Original Medicare", which is what we usually think of when we talk about "single payer healthcare in America", or you can enroll in Medicare Advantage (aka Medicare "Part C"), where the premiums that would go to the CMS instead go to private insurers like Humana, United, Oscar Health, Aetna, Clover, etc. These plans replace Original Medicare.
- 48% of Medicare beneficiaries are on private Medicare Advantage plans instead of the public "Original Medicare". Because everyone is entitled to "Original Medicare", this is purely voluntary. This number has been growing so rapidly that the CBO projects that by 2023, the majority of beneficiaries with choose the private over the public option. The CBO further projects this proportion to increase to 61%(!!) by 2032. (https://www.kff.org/medicare/issue-brief/medicare-advantage-...)
- For most beneficiaries, Medicare Advantage costs about 40% less than Original Medicare and are, on average, of higher quality than Original Medicare (https://healthpayerintelligence.com/news/medicare-advantage-...)
- In Urban areas, Medicare Advantage costs less per capita to administer than Medicare — and that's not including the extra Medicare Part D insurance that you would have to buy if you're on the Original Medicare plan (https://www.commonwealthfund.org/publications/issue-briefs/2...)
I personally don't think ...
It seems like it's either a shared social failure where everyone has access to the same semi-inefficient gov't monopoly, or it's an uneven distribution with some guaranteed failures that are exceptionally painful for a smaller number of people. The net amount of pain/suffering is constant, it's just how we distribute it.
https://perfectunion.us/a-place-to-die-for-profit-health-car...
> What they often do is form a corporation or an LLC or any kind of corporate form, and the legal owner will be the corporate form, not the true owners. So they have insulated themselves from any connection between the operations and the health care and themselves.
> Often we see the actual property that the health facility is on put into a separate LLC and—owned by the same owners, of course—however, they then lease themselves that building. There’s also various ways that they can further vertically integrate through pharmacies, through staffing companies, through housekeeping and hospitality companies.
> All of these can be owned by the same individuals theoretically but placed into separate corporate forms and transact in business with one another. And so really it’s just kind of musical chairs of moving money around from one pocket to another.
https://news.ycombinator.com/item?id=31728350
This is what happens, when one tries to force nurses to do overwork for $30 per hour (2015 rates for nursing homes in southern California).
Something bad happens. It's determined to be the fault of a CNA or the procedures (never the doctors and rarely the nurses are blamed, always the CNA).
The procedure is updated at the state level to require MORE things to be done, but there is no time to actually do them, so something happens again.
More documentation and procedures are added, and the cycle repeats.
If nurses are lying, thats a poor management system. Punish the bad actors, not the patients
Yea, I've been in places that have those types of systemic issues and in general those places sucked to be at and work at. Would hope those with enough morals recognize the situation and bail. As mentioned, there 'skillset' or willingness to do certain activities is sorely needed in this current labor market and has been needed for some time.
The nursing home was a -good- nursing home and they still couldn’t follow the daily weight check order until I sent them an email calling it out on the hospital discharge paperwork as a medical order, and noting where I had been told in writing that they had only been doing monthly weight checks per the facility’s standing order.
It was very frustrating. When I would have a call with his nurse case manager or emails with his social worker, those would sometimes happen at 8 or 9 in the evening, because that’s when they could get to it. And that was one of the better places.
The experience has solidified my mindset. I _will not_ live in a 'home' when I'm old, and will not let my mom enter on of those facilities.
So really, it's a very strong suggestion - don't let your family members go to a nursing home lightly. Hospitals will often push for it as the only option, and sometimes it may be necessary for a time, but really think about the situation for yourself. Think of nursing homes as existing mainly because euthanasia is illegal and repugnant to many people.
I've now had close experience with two family members who have ended up at one for inpatient rehab (one during covid, one afterwards), and they're fucking death traps. And this was a facility that another family member had worked at for some time as the head physical therapist, and they recognized the last name!
I don't know if private equity was involved, but as the top-level comment points out the continual screw tightening overwork incentive is there regardless.
Systematic, unbiased auditing and extreme penalties not just for the individual but for the business employing the person are sorely needed.
We want nurses to do their actual jobs to administer health based assistance to seniors.
First search result:
"Registered nurses in California earn an average of $124,000 per year (or $59.62 per hour)"
Show your work.
To have ONE bottom-rung direct care staffer available, 24x7x365, and paid ~$12/hour... After employer-contributed payroll taxes, unemployment insurance, and workman's comp. insurance, figure the home's actual cost is $15/hour. $15 x 24 x 365 is $131,400.00 per year. More-skilled staff (you do want a nurse or few around, right?) are proportionally more. Plus, even the leanest-run facility will need a few folks cooking the residents' meals, doing their laundry, doing physical therapy, handling paperwork in the office, etc. The most humble of donated buildings (so we're imagining no mortgage payments) still requires ongoing maintenance, utilities, & such.
Add all this up, and you can easily hit $250,000/year per bottom-most-rung direct care staff person.
Now, assume that you (or the society you're doing thought experiments on) can't actually afford $250,000/year for each and every person who needs nursing home care. What fraction of that "one per one" care are you willing to settle for? Notice that even at "one per ten" staffing, your cost of running the facility is still $25,000 per resident per year. Multiply that by as many millions, or tens of millions, as need such care. (Yes, one per ten is well below the legal minimums in many states.)
Does your society have the actual resources to do that? If "yes" - are you really comfortable with how capable, caring, and responsible the bottom-rung caregivers willing to accept ~$12/hour to clean up incontinent and disoriented elderly folks at 3am actually are? And you're aware that our "suitable building was donated" fudge is a really big fudge?
Oops, also - that nursing home bill only covers the nursing home care. If your residents need to have some medications, doctor office visits, occasional hospital stays when (say) they fall & break something - that's all additional costs & resources.
Society has cared for it's elderly basically forever, and _now_ we're saying it's too expensive? As the article mentioned, the incentive for the religious group running these places was theological and human centric. Those religious groups are/have collapsed so there is this giant vacuum attracting all the wrong people. I honestly can't believe there isn't enough money in the 'system' to provide decent care for the vast majority of elderly. The numbers cited today (likely correct) aren't sustainable b/c it's basically free money to harvest (at the cost of human comfort). Regulate the industry and prosecute the bad actors. If member's of congress had family in these facilities, it would like be solved. They likely don't for the same reasons they don't have the same healthcare benefits as most Americans. Disconnected from reality.
(I say this as someone well aware of the costs of nursing homes, and specialized care.)
Because individuals used to look after their own elderly. Now there's a lot more institutions involved, meaning a lot more other people work, meaning a lot more other people need wages paid.
It's a bad, crappy job that no one wants to work in, and no one wants to pay high fees for looking after mum and dad
I've been thinking about this a lot lately, and it seems there are many causes. Increased ability to move, and desirability of moving (school, jobs, exploration). Bad city design (at least in North America, we have a car problem) meaning it's difficult to have a local community. The decline in religious involvement and no replacement lined up. A culture of extreme individualism to the point of absurdity.
These all seem tractable, but it is sad that we've let it get to this point. I feel there is a shifting in the wind though. At least for younger people, American capitalism and individualism seems to be viewed with increasing skepticism.
That is also why Social Security seemed like a good idea at one time.
https://en.wikipedia.org/wiki/Population_pyramid
The pyramid shape for traditional (generally pre-modern-medicine) societies is very, very different from the shape for modern, "wealthy" societies. In the former, infirm old folks are a lot rarer. Add in far larger, tighter family networks, and the "women care for the old" social standards, and the "outside of what families quietly manage themselves" portion of the problem, which society needs to deal with, is vastly smaller.
Science fiction gave us the obvious economic answer with "Logan's Run" and "Soylent Green" many years back.
How many residents (or patients, or ...) each 1 staffing unit has to care for is brought in later. I briefly assumed 10 residents per staffing unit.
(I am not sure how to interpret your "even the start of the 131k is actually three persons manning the phone" comment. Though from my own experience - quite a bit of staff time is consumed by talking on the phone with the family members of residents, with outside doctors & such for residents, with insurance providers for residents, with pharmacies, etc., etc.)
[1] https://www.alternet.org/2008/07/billionaires_are_gouging_yo... [2] https://www.youtube.com/watch?v=bcsxGxzrTsc