Remind me to stay out of a PE-owned nursing home

When I was growing up, there was a rest home around the corner. It was an old house, populated by old folks with meager pensions and no family to take them in. I don't think they provided any nursing care. The residents - there might have been a dozen of them - were out and about, or at least sitting on the rockers on the front porch. At some point, the rest home expanded and added a modern wing out back. There was one old coot - The Runner - who, wearing gray suit pants and a white shirt buttoned up to the neck: no coat, no matter the weather, would run from the rest home to downtown Worcester and back, a roundtrip of six miles or so, pretty much every day.

My grandmother, who lived not far from the rest home, perched in her kitchen looking out at the comings and goings of the neighborhood, kept tabs on him. We would be sitting at Nanny’s kitchen table, enjoying a cup of tea and a brown-edge cookie, and she would announce, “There he goes,” or “Here he comes.”

My grandmother lived to be 97, but fortunately didn’t have to go into a rest home – or a nursing home - end of life.

She lived with – and kept house for – my quasi-bachelor uncle until he died (when Nanny was 92). She then went to live with my Aunt Margaret.

By then, the neighborhood elder scene had been augmented by the addition of a nursing home, a modern and swanky (to our eyes) low-slung sprawling one story building that went up in the field that partially abutted Nanny’s property. At some point, Nanny’s older brother Pat ended up in Clark Manor. He would sometimes come to the window overlooking Nanny’s and she would wave to him.

But Nanny was spared having to be in a nursing home – spared by my Aunt Margaret’s goodness and by the fact that her health remained very strong until the end of her life. Other than her arthritic knees – knees that had plagued her since middle age – Nanny had no health issues. She required no medical care that I can recall.

My Chicago grandmother died with even more of her boots on than Nanny. Grandma lived independently (with her creepy second husband) until her death at 78. 

Aunt Margaret died with her boots on, too.

A couple of years before she died, I took Margaret to visit her cousin Mary, who was then in a nursing home. It was a brutally cold day, and, unfathomably, the nursing home parking lot had icy patches scattered about. (Maybe having people slip and break their hips was good for business.) As Margaret and I crept along, she told me that she hoped she wouldn’t end up in a nursing home. Fortunately, she didn’t. One day, 25 years ago next week in fact, she went down for a nap (on the same daybed where Nanny had died nearly 20 years earlier, under the same afghan my mother had made for Nanny) and never woke up.

My mother almost died with her boots on. She spent the last nine months of her life in a wonderful assisted living facility, where she had a very cute one BR apartment with a balcony  - her first “bachelor girl flat” we kidded her when we moved her in. She was totally independent while living there – still driving, still volunteering, still traveling (three trips planned at the time of her death: Chicago for a family wedding; Cape May, NJ to look at old Victorians; and Vienna-and-Prague), still going to Mass every day – the facility was conveniently just across the street from her parish church – but was assisted with two meals a day and someone to wash her sheets and towels for her. As my mother’s health failed after a heart attack, and she hung on, touch and go in the ICU, we were told that she would not be able to live independently if she survived. In fact, she would be bed-bound. That was it for my mother. No way she wanted that to happen.

She asked that the doctors stop doing anything to prolong her life. So they did. And she died.

In some ways, my mother’s sister, my Aunt Mary, was more fortunate than my mother. My mother was 81 when she died; Mary made it to 93. And for most of those extra years, she was just a wonder. My sister Kathleen and I went out to Chicago for Mary’s 90^th birthday, and if someone had told us it was her 75^th birthday, we wouldn’t have blinked an eye. She was vigorous and, in her own words, “hadn’t lost any of her [considerable] marbles.” She was a wonderful and amazing woman.

After years on her own in a cute little apartment she’d moved into after my uncle had died and her kids had all flown the nest, she had gone into an assisted living facility, where she  was able to have her own private digs and furniture. And then, in the final year of her life, she began experiencing significant health issues. After a hospitalization, she was no longer independent enough – nearly blind, with difficult walking -  to go back to her apartment in assisted living, and had to move into a nursing home.

Even though she had a roommate, it was a nice enough place. Her kids did whatever they could to make it homey. And they and the grandkids visited all the time. But it wasn’t home. And Mary – one of the strongest people I’ve ever known, with a great sense of humor and not one scintilla of self-pity in her (even when warranted) – spent the last few months of her life sad and depressed, waiting to die, wanting to die.

No one but no one wants to end up in a nursing home. 

But some people do. And with our aging population, it's not a bad business to be in.

That's why private equity firms have gotten interested in investing in them. 

More's the pity.

A recent economic analysis found that patients in nursing homes owned by buyout firms — which raise money from outside investors to make acquisitions across a range of industries, including health care — have a 1.7 percentage point higher chance of dying during their stays and for 90 days after leaving the homes. While that might not seem like a huge increase, it amounts to more than 20,000 additional deaths over the 12-year period of the study. (Source: CBS News)

Why are there more fatalities in a PE-owned nursing home?

It should come as no surprise that it's the profit motive.

Once PE gets their mitts on a nursing home they start looking at how to rev up profits, and that means cost-cutting. So when private equity takes over:

...the number of hours provided by frontline nursing assistants typically declined by 3%, while overall staffing slips by 1.4%, the study found. Patients in private equity-owned nursing homes are also more likely to be given antipsychotic medications, according to the study.

I guess if you dope old folks up, they don't require as much TLC. And you don't have to listen to them complaining. Sigh. 

The majority (70%) of nursing homes in the U.S. are run as for-profits. But there’s for-profit and then there’s for-profit. And private equity is all about the profit.

Needless to say, the PE industry disputes the findings about poorer outcomes. And there is in fact a study that suggests that they’ve done better managing COVID.

Still…

No one but no one wants to end up in a nursing home. But if the time comes, I’m making a mental note to make sure to inquire about what sort of outfit owns the joint.