More Immigration Leads to Better Nursing Home Care, Says New Paper

“The paper found “strong and consistent evidence that increased immigration leads to improved patient care,” as well as a decline in hospitalizations corresponding with an increase in female immigrants.”

Private equity ownership is killing people at nursing homes

“When private equity firms acquire nursing homes, patients start to die more often, according to a new working paper published by the National Bureau of Economic Research.

Private equity acquisitions of nursing homes is a pressing topic: Total private equity investment in nursing homes exploded, going from $5 billion in 2000 to more than $100 billion in 2018. Many nursing homes have long been run on a for-profit basis. But private equity firms, which generally take on debt to buy a company and then put that debt on the newly acquired company’s books, have purchased a mix of large chains and independent facilities — making it easier to isolate the specific effect of private equity acquisitions, rather than just a profit motive, on patient welfare.

Researchers from Penn, NYU, and the University of Chicago studied Medicare data that covers more than 18,000 nursing home facilities, about 1,700 of which were bought by private equity from 2000 to 2017.

Their findings are sobering.

The researchers studied patients who stayed at a skilled nursing facility after an acute episode at a hospital, looking at deaths that fell within the 90-day period after they left the nursing home. They found that going to a private equity-owned nursing home increased mortality for patients by 10 percent against the overall average.”

“the increased mortality is concentrated among patients who are relatively healthier. As counterintuitive as that may sound, there may be a good reason for it: Sicker patients have more regimented treatment that will be adhered to no matter who owns the facility, whereas healthier people may be more susceptible by the changes made under private equity ownership.

Those changes include a reduction in staffing, which prior research has found is the most important factor in quality of care. Overall staffing shrinks by 1.4 percent, the study found, but more directly, private equity acquisitions lead to cuts in the number of hours that front-line nurses spend per day providing basic services to patients. Those services, such as bed turning or infection prevention, aren’t medically intensive, but they can be critical to health outcomes.”

“The combination of fewer nurses and more antipsychotic drugs could explain a significant portion of the disconcerting mortality effect measured by the study. Private equity firms were also found to spend more money on things not related to patient care in order to make money — such as monitoring fees to medical alert companies owned by the same firm — which drains still more resources away from patients.”

“The researchers make a point in their opening to stipulate that private equity may prove successful in other industries. But, they warn, it may be dangerous in health care, where the profit motive of private firms and the welfare of patients may not be aligned”

Nursing homes need fixing. Here’s where to start.

“Although less than half of 1 percent of the U.S. population resides in nursing homes, they account for nearly 40 percent of all Covid deaths. Nursing homes are supposed to help residents remain safe and healthy, but the opposite turned out to be the case: When it came to the coronavirus, residents in nursing homes were more vulnerable, not less.”

“rebuilding nursing home facilities is an expensive and long-term solution to an immediate crisis. I’ve been studying long-term care settings for many years, and I think there’s a quicker and possibly even more effective approach we can take in the short term to ensure better care for our seniors in the post-Covid era: improve staffing.

It’s no secret that nursing home staff are paid relatively poorly for incredibly demanding work. Certified nurse aides who provide over 90 percent of direct resident care are often paid at or near minimum wage — the same wages as entry-level workers in retail establishments or fast-food chains. Nursing staff are also underpaid; registered nurses and licensed practical nurses who work in nursing homes are often paid below their counterparts who work in hospitals and other health care settings.

What’s more, nursing home staff often lack essential benefits, like health insurance and paid sick leave. That means nursing home workers are incentivized to come to work even when sick — how does that make sense when they are caring for medically vulnerable residents during a pandemic?

Nursing homes are also very hierarchical workplaces with lower-level staff having little autonomy and control in their jobs. Not surprisingly, being undervalued and unempowered makes it hard to recruit and retain individuals to work in nursing homes.

The result is that many facilities around the country often have dangerously low levels of staffing. Additionally, the average U.S. nursing home was recently found to have an annual staff turnover rate of 128 percent. This suggests an average facility’s staff completely changes over the course of a year, and many nursing homes have even higher turnover rates — as much as 300 percent — suggesting the staff changes every four months. If some part of good nursing home quality depends on the relationship between staff and residents, it’s hard to see how those relationships can develop when staff keep changing.”

“There are a number of things we can do to improve this situation. Here are a few ideas”

“One solution would be to increase the number of direct care workers by raising the federal minimum staffing standards in nursing homes. The federal standards are relatively low and have not been updated in over 30 years. Many states set staffing levels above the federal standards and these state policies have generally been found to increase staff.”

“Another idea is to raise minimum wages to increase nursing home staff pay. Many certified nurse aides would see their hourly wages increase under the $15 minimum wage proposed by the Biden administration. In the absence of a broader minimum wage hike, policymakers could also increase wages specifically for nursing home and other long-term care workers.”

“The elephant in the room is what additional Medicaid or other public funding would be necessary to pay for greater staffing and higher wages. The nursing home industry will inevitably push back against any “unfunded mandates.” The Medicare Payment Advisory Commission has found overall nursing home operating margins are currently thin based on the Medicare cost reports. However, there is quite a bit of variability in profitability across facilities. It is also unclear whether some facilities are accurately reporting their costs. Resident advocates have questioned whether a sufficient amount of existing public nursing home funds are spent on staffing. Thus, higher Medicaid funding will be necessary to improve staffing levels and wages, but it needs to be paired with the next suggestion.”

“We currently lack transparency in how nursing homes spend public dollars on staffing and other areas. Nursing homes are required to submit Medicare cost reports each year to detail their revenues and spending, but these data are known to be incomplete, especially in the context of increasingly complicated corporate ownership arrangements. A series of financial reporting and oversight steps need to be taken to tighten the requirements for facilities. The bottom line is that regulators need to be able to follow the public’s money and ensure it is being spent on staffing as policymakers intended.”

“Beyond putting more money into wages, policymakers might also consider ways in which they could provide financial support to allow additional education and training to certified nursing assistants and licensed practical nurses seeking upward mobility within a facility. For example, some nursing homes currently have ladder programs that provide nursing assistants with financial support in seeking nursing degrees. These programs could be expanded through direct reimbursement via Medicare and Medicaid.”

“Improving wages and benefits is a necessary but insufficient step towards valuing nursing home caregivers; we also need to begin to value the work these individuals do and the individuals that do it. If you can believe it, this might be harder than increasing staffing standards and wages. Finding additional money is one thing — changing the culture around nursing home staffing is another.”

How public health failed nursing homes

“The unfolding tragedy in American nursing homes, where patients are dying in clusters, is another consequence of the coronavirus testing debacle.

While America wasn’t looking, family visitors, staff and other health professionals unknowingly brought the virus into long-term care facilities, spreading it among the population least likely to withstand it.

On top of that, the shortages of protective gear for health workers exacerbated the situation because nursing homes, hospices and other outpatient settings have a tough time getting scarce equipment like masks and gowns, provider groups said.”

“On top of that, the shortages of protective gear for health workers exacerbated the situation because nursing homes, hospices and other outpatient settings have a tough time getting scarce equipment like masks and gowns, provider groups said.”