The Truth About Elderly Care

By 2050, 19 million people will be 85 or older in this country. I will be age 97 in 2050 and I am certain that I will have passed to the great beyond by that milestone. Thank God. No one in my family has approached a century of living: my mother died at 80 and my father lost his battle with cancer one week shy of his 90th birthday. I do not consider it a feather in my cap to achieve longevity for its own sake, but only if a good quality of life accompanies the realization of it. However, life expectancy for women in 2021 is 81 years and two months. I am content to reach that decade.

Much like the hospice industry, for-profit long-term care facilities continue to be vulnerable to predation by financial conglomerates and private-equity firms. Two-thirds of nursing homes and hospice providers are for-profit companies which isn’t necessarily bad. Major corporations, investment firms. and independent owners have been attracted to the elderly care and hospice industries for years. Elderly care is a booming business. The hospice space is not a bad one to be in; it can amass profits of over $20 billion annually. And the Centers for Medicare and Medicaid (CMS) pay long-term care providers $264 billion annually. But there is no assurance that the bulk of the money goes to patient care and adequate staffing instead of to executive and administrative salaries and shiny new buildings.

On December 31, there was an article in the New York Times by E. T. Kim that addressed the assault on patients in nursing homes by Covid-19. It is a problem that ensnares hospice patients as well because a majority of hospice care is delivered to patients that reside in nursing homes. When I worked as a hospice chaplain, 90% of my patients lived in skilled-nursing facilities. In too many for-profit companies, long-term care continues to be understaffed, poorly regulated by both state and federal oversight agencies, and lenient accounting requirements. For example, in for-profit hospice and skilled-nursing companies, there are no caps on how government-allocated money is earmarked for profits and bureaucracy.

As it stands, there is no accountability that any increase in funding by Medicare or Medicaid goes to patients or for adequate staffing. According to Elizabeth Halifax, a registered nurse and an expert in eldercare, “the increase in funding for nursing homes during Covid showed no real improvement in staffing or resources for PPE.” A USA Today article by J. Spector and D. Robinson stated that “a probe by the New York Attorney General Office found Covid-19 deaths of nursing home residents in the state were undercounted by 50% as poor infection-control practices and understaffing fueled the coronavirus crisis. There was no reason for the mass casualties of Covid deaths in nursing homes. The money is available; it’s a problem of allocation. So where did that money go?

The nursing aides who provide the bulk of care still earn substandard wages in too many nursing homes and hospice companies. Subsequently, long-term care and often hospice care has been designed (since its commercialization) to fail years before Covid-19 reared its ugly head. When I began my career in hospice in 2010, these problems were already evident. I visited my patients in 20 different nursing homes and the red flags were waving then. No one who has worked in the industry would be surprised to see that many facilities were ripe for this level of patient suffering and death inflicted by a pandemic in 2020.

CMS and other federal regulatory agencies should be given the resources they need to investigate and fine providers for health, safety, and compliance violations. Many of the fraudulent and ethical issues that I dealt with in my own company could only have been addressed by a union. The incoming Biden administration must strengthen worker’s rights in nursing homes and the hospice industry to organize and protect working conditions and the rights of staffers.

When I visited my patients in nursing homes, I was appalled at the workload and poor salary for Certified Nursing Assistants (CNAs). The reason that 40-60% of Covid-19 deaths occurred in nursing homes was that the staffing situation was woefully inadequate and under the former presidential administration, CMS cut fines and called off regular inspections. Also, the administration allowed temporary nursing assistants with little training to fill in for CNAs. There is a CNA shortage because of low wages and under-staffing in the for-profit sector of the industry.

So what are the next steps? After the scathing 2019 Office of Inspector General report from the HHS Department on hospice failures across the nation in the last decade, we are still trying to address most of those vulnerabilities in the hospice space. And after the pandemic is over, the Biden administration will need to deal with the mistakes made by the Federal and State governments and deal with the lack of accountability by too many for-profit executives, administrators, and investors in the ways in which they have failed patients, families, and staff during the pandemic.

In my upcoming book, “Surviving Hospice: A Chaplain’s Journey into the Business of Death.” I include a chapter on how to vet an elderly care facility to determine the quality of its services.

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