Certified Nursing Assistants, or CNAs, do inglorious work. They are often on the frontlines of nursing homes, helping patients bathe, eat and use the bathroom. McDavid Rodriguez said he knows that patients can often feel embarrassed when getting help with basic functions.
“I always told them, ‘Hey, if you need help, don't be scared. I'm here for you,’” said Rodriguez, who spent two years in high school training to be a CNA.
While Rodriguez liked being useful, he said, the work’s hard and the pay is poor. He and his colleagues sometimes asked for a raise only to be rebuffed.
“They refused to increase it," he said. "And if they did, it was by a few cents. It's never been like a dollar — not even one dollar.”
After four years as a CNA, Rodriguez is now an Amazon shopper at Whole Foods. His pay has gone up by $3 an hour.
“It's no wonder that individuals leave this workforce,” said David Grabowski, a professor of health care policy at Harvard Medical School whose research focuses on aging and longterm care facilities. “This industry wasn't exactly starting from a position of strength. COVID has been a crisis on top of a crisis.”
The pandemic has shined a harsh spotlight on nursing homes. Despite less than 1% of the population living in nursing homes and longterm care facilities, they account for about a third of all COVID-19 deaths. Now, two new national studies show that, even before the pandemic, the nursing home industry was in a dire situation. The studies paint a picture of places where it is unappealing to work and risky to stay.
Grabowski co-authored the first national study of staff turnover in nursing homes before the pandemic, published this month in Health Affairs. The study found an extraordinarily high rate of staff turnover, with an average of over 100%.
“That means the average nursing home in the U.S. has their entire nursing home staff change over the course of the calendar year,” he said. “And we found that some nursing homes had turnover as high as 300%, suggesting the staff is turning over every four months.”
That doesn't necessarily mean that all employees leave during a year. A facility with 10 staff members could have 100% turnover if everyone leaves and is replaced by a new person or if one job is filled 10 different times because the new hires keep leaving.
Either way, Grabowski said, “this is a horrible way to provide good quality nursing home care.”
A second national study also painted a bleak picture.
Private equity firms have been a growing force in healthcare. Atul Gupta at the University of Pennsylvania and his colleagues wanted to find out whether a private equity firm taking over a nursing home is good for patients.
The answer was a resounding "no." The researchers found that deaths went up 10%.
“You don't expect to find these type of mortality effects, and so we double checked it, triple checked it, quadruple checked it,” he said.
The numbers held up, and a troubling trend emerged: Nursing homes that were bought by private equity firms were spending more on things not related to patient care — like interest payments, lease payments and management fees — while the number of frontline nurses decreased and measures of patient well-being decreased. Gupta also found more antipsychotic drugs were used. He speculates that is to keep patients docile with fewer CNAs around.
But some say private equity is not necessarily at fault for the problems at U.S. nursing homes.
“Private equity is not involved in the day-to-day decision making around these things,” said Jay Wagner, who works at the global real estate services firm Cushman and Wakefield. He focuses on senior living and skilled nursing facilities and advises private equity firms.
Wagner said one way that private equity firms make money is through a leveraged buyout, but another ways is by buying a nursing home and then selling off the buildings. The cash can go to the investors while the nursing home operator starts paying rent for the facility they used to own.
But, Wagner said, even to those in private equity the nursing home industry is pretty unappealing.
“It's a very challenging business, candidly,” he said. “It's an extremely low margin business that is fraught with a lot of reputational risk and a lot of regulatory oversight.”
Wagner said the senior living sector — including retirement communities and assisted living — is far more appealing.
“There is a real night and day comparison between nursing and senior housing,” Wagner said.
The staff, the patients and even the owners sometimes struggle in the nursing home industry, and everyone blames the payment system. Some point to Medicaid’s notoriously low reimbursement rates, while others point to the fact that reimbursements rates don't vary based on quality of care.
The Centers for Medicare and Medicaid Services did not return a requests for comment by press time.
The American Health Care Association and National Center for Assisted Living, a trade group, said in a statement that these new studies expose chronic underfunding. The group said it’s so bad that most nursing homes barely break even, hence the low wages and the drive to cut costs.
But Gupta and Grabowski have some tips when looking for a place to send a family member. They said not to rely solely on the government’s star rating system and its nursing home compare website.
“I would definitely do my research on the quality of the facility or its history,” Gupta said. “Has it changed hands recently? If so, who's the new buyer?”
“Talk to the staff," Grabowski recommended. "How long have you worked here? How long have other staff been there?”
And they both said not to be be swayed by glossy ads or glass chandeliers.
