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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.

Many nursing homes and hospice care organizations are now for-profit institutions. There is ample evidence they are putting profits ahead of people and that taking a deadly toll during the pandemic.

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.

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’.

  • The situation in Canada is similar, although certain areas do seem to have some effective oversight. The best seniors nursing home in our area is operated by the city and is not for profit. We have a friend there and there has been almost no Covid infection in there. Meanwhile a for profit “home” not far away was decimated by Covid 19 when it got in.
    The best thing any person can do for their aging parents is to keep them OUT of a nursing home. It may be difficult, but remember how much most parents have done for their children over the years to give them a start in life. No matter who they are, the elderly are owed compassion at least, but compassion is not on the menu in a lot of the establishments which are collecting money and are supposed to be taking care of them.

  • The bottom line for For-profit “care” homes is that they are in it to make pofits – they are not philantropic institutions. How that panned out specifically during the Covid pandemic is utterly horrible, with totally incomprehensibly horrific situations for frail helpless elderly. It has been shocking to see the ghastly circumstances by which some of these elder – that have contributed God knows how much to our society – were left to rot, without anything that can be called “care”. Owners of such entities deserve to be tried by jury, relieved of their disgusting profitsjailed, and given the same experience that they exposed the elder in their “care” to. And Government has to step in: with stringent standards, and yes – surprize inspections.

  • As lvn at a profit/corporate protected nursing home I’m amazed how they bully staff and residents. THANKS FOR SPEAKING TRUTH .It’s time to open the doors and let the truth be told…Elite healthcare is the most unprofessional and impersonal physician care I have ever experienced as a nurse. No hands on Dr. In Denton,Tx has answering service will not speak to nursing staff,just log book of who Np should see pertaining to fall and illness. Even the facilities 100s owed by them are poor ventilated run down establishment that should have been bulldozed years ago, lead pipes,leaking toliets,and mold infested flooring even asbestos tile. Daybreak Ventures and Creative Solutions are two companies engaged in these practices. Sister companies of each other horrible state findings of neglect and infections even a loss toe found in residents bed. We have to stand up for the least of our brothers and sisters who cannot and are not being allowed to speak up for themselves due to corporate representatives whitewashing the truths. Navasota nursing and rehab and Fortress nursing and rehab are just two I have worked with.God speed help for the elderly

  • This statement is completely misleading:

    “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.”

    That’s not what this study says– which is “The estimates show that private equity ownership increases short-term mortality by 10%”

    Short term mortality, not deaths.

    Further on they say “We find that going to a private equity-owned nursing home increases the probability of death during the stay and the following 90 days by 1.8 percentage points, about 10% of the mean. . .. In the context of the health economics literature, this is a very large effect.”

    Maybe in the context of health economic literature it’s larger, but in general statistics?

    Meanwhile nowhere in the article proper do the authors state the probability of dying IN a nursing home or WITHIN 90 days of discharge. Where can you find that number? Well, lookee here, it is on page 42, Table 1, Panel B. And what is the probability?

    In a all nursing homes studied, private equity and others, that probability is 17% with a HUGE standard deviation of 38%. The probability for PE owned facilities?

    18% — ONE percentage point higher.

    Sorry, given that standard deviation, these comparison statistics are meaningless.

    • You do realize that “mortality” is the term that identifies the number of deaths per population, right? That means deaths – people who have died – as a percentage of patients, in this case, in the short term, which is now – during the Covid epidemic. There’s no way twist or spin this inexcusable situation into anything other than unacceptable profit-mongering.

    • Michael, that’s not how the authors described their finding — it’s about the likelihood of dying while in a nursing home or within 90 days of leaving. And they looked at numbers before the epidemic.

      Now what they do is go through arithmetical twisting and turning to take that increase in mortality probability, multiply by the number of patients, and deduce the “years lost” and by an ADDITIONAL inference, the lives lost.

      It’s an elaborate statistical sand castle.

    • Dr. Warraich writes the truth. I am a registered nurse with 30+ years experience in several different nursing homes in RI and MA, and I have found this is always the case. The only residents who get good care are the ones who are frequently checked in on by their loved ones. The staff almost always work short handed, residents have to wait extended periods of time for the bathroom. That’s only the tip of the iceberg for neglect in a nursing home. I could have written this very same sad article 45 years ago when I was a CNA. Almost anyone who has worked in a facility would agree with me, unless they are the owners!

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