Elder Law Prof Blog

COVID Vaccine and Elders

The articles about the rollout are varied, but many of them focus on the issues getting elders vaccinated. So fwiw, here's a round up of some recent ones. Draw what conclusions that you will.

Some states could vaccinate their seniors twice as fast as others, CNN analysis finds (scroll down for article).

Tampa Bay’s homebound seniors struggle to get coronavirus vaccinations

COVID-19 Vaccine Resources: What Partners Need to Know Now

As COVID-19 Vaccines Become More Widely Available, New Research Emerges on Messaging Best Practices

Most nursing home workers don’t want the vaccine. Here’s what facilities are doing about it.

DeSantis to feds: Florida wants more COVID-19 vaccine doses

 

ABA BIFOCAL Latest Issue Released

The ABA Commission on Law and Aging has published vol. 42, Issue 3 (Jan.-Feb.2021),  its current issue of BIOFOCAL. The issue contains several articles, including a couple on Social Security Rep Payees, with the lead article, How Does Social Security Select Representative Payees for Adults? Results of an Independent Research Study

Almost four million older adults and adults with disabilities have representative payees appointed by the Social Security Administration (SSA) to manage their Social Security or SSI payments. How does SSA determine if a payee is needed? How do SSA staff select a payee? How do they choose an individual versus an organizational payee?  What are the considerations in long-term care residential facilities serving as the payee?  What about guardians serving as payee? How and to what extent does SSA maintain consistency in payee determinations?

In 2018, the Social Security Advisory Board (SSAB) charged researchers at Virginia Tech and the ABA Commission on Law and Aging to conduct an independent study focusing on these compelling questions.  The study team addressed SSA processes for selection of payees for adults. The underlying assumption was that a better understanding of selection practices ultimately could lead to process improvements, as well as a reduction in the potential for misuse and abuse of beneficiary funds while maintaining beneficiary rights.

A pdf of the full issue is available here.

GAO Report on State Reporting of Elder Abuse

A new GAO report was released last week. ELDER JUSTICE: HHS Could Do More to Encourage State Reporting on the Costs of Financial Exploitation offers fast facts, highlights and the report, all available for download or access via the links.  Here are the fast facts:

Financial exploitation of elders—illegal use of their funds or property—affects the victims, their families, and society. Estimated financial costs to victims are in the billions.

Most state-run adult protective services agencies have provided some data on financial exploitation of elders to the Department of Health and Human Services. But it's hard to collect the data because

not all incidents of exploitation are reported to state agencies

victims can be reluctant to implicate family members or caregivers

HHS and state data systems may not align

We recommended that HHS work with state agencies to improve the data on financial exploitation.

The highlights, fast facts, and recommendations are all accessible from here.  The full report is available here.

Consider this from the report:

Studies estimate some of the costs of financial exploitation to be in the billions,
but comprehensive data on total costs do not exist and NAMRS [National Adult Mistreatment Reporting System]  does not currently collect cost data from APS agencies. The Consumer Financial Protection Bureau found actual losses and attempts at elder financial exploitation
reported by financial institutions nationwide were $1.7 billion in 2017. Also, studies published from 2016 to 2020 from three states—New York, Pennsylvania, and Virginia—estimated the costs of financial exploitation could be more than $1 billion in each state alone. HHS does not currently ask states to submit cost data from APS casefiles to NAMRS, though officials said they have begun to reevaluate NAMRS with state APS agencies and other interested parties, including researchers, and may consider asking states to submit cost
data moving forward. Adding cost data to NAMRS could make a valuable contribution to the national picture of the cost of financial exploitation. Recognizing the importance of these data, some APS officials GAO interviewed said their states have developed new data fields or other tools to help caseworkers collect and track cost data more systematically. HHS officials said they plan to share this information with other states to make them aware of practices that could help them collect cost data, but they have not established a timeframe for doing so.

Medically Vulnerable and in Prison

There have been some stories about the impact COVID is having on the prison population.  A news station in Denver, CO ran this story a while back, Broncos players join campaign to release medically-vulnerable inmates during pandemic. The ACLU in Colorado has an effort underway to get the Colorado governor to grant clemency to low-risk prisoners.  The sidebar on the ACLU page gives examples of folks in prison who are medically-compromised but likely low risk if released.  The Marshall Project has a state by state list of COVID in prisons, concluding about 20% of prisoners have COVID. The Federal Bureau of Prisons also has information covering COVID in prisons, which includes their modified operations plans. Although in person visits were suspended, a November update indicated those would be resumed, with safeguards. With the latest surges, I expect those will again be suspended. 

And although prisons are "COVID hotspots," prisoners may not be high in priority for the COVID vaccine per a recent article in the Washington Post, Prisons are covid hot spots. But few countries are prioritizing vaccines for inmates.

Since this is the elderlawprof blog, are you wondering what this has to do with Elder Law? Just google "elderly prisoners and covid" and look at the results. Here are a few:

• Supreme Court denies request from geriatric prisoners seeking Covid relief
• COVID-19 and the Compassionate Release of the Elderly, Infirm or High Risk
• Sick, elderly prisoners are at risk for covid-19. A new D.C. law makes it easier for them to seek early release.
• Pandemic underscores need to release more elderly prisoners | COMMENTARY

SNFS and Vaccination for COVID

Since it's been a few weeks since the vaccine rollout, and with residents of SNFs in the top priority for vaccination, how successful has it been? I have posted a few articles previously, and I wanted to pass on a few more.

In my geographic area, The Tampa Bay Times reported, Tampa Bay nursing homes have all offered coronavirus vaccines to residents and staff. Note here in the headline "offered."  Some folks may refuse to get the vaccine, whether residents or staff. Which brings me to two more articles.

Inside a Nursing Home as Vaccine Arrives: ‘I Hope Everybody Takes It’ is an interesting look at a day inside a SNF when folks from Walgreens were onsite to vaccinate folks.

The approval of Pfizer’s novel coronavirus vaccine in December brought hope to the residents and staff members at Staten Island’s Clove Lakes Health Care and Rehabilitation Center. The facility was hit hard: It lost more than 40 residents to the virus last year and struggled financially as the number of new residents plummeted, along with their income.

The employees and residents had counted on the vaccine to help them return to some semblance of their old routine — including family visits — and were determined not to waste any time. Weeks before a single person got the vaccine staff had been preparing for the rollout, contacting residents and families by mail, email, robocalls and social service workers to reassure everyone about its safety and effectiveness.

And although the Tampa Bay Times reported the successes of vaccine availability in our area, that is not the case elsewhere.  The New York Times also reported a few days ago, Frustrations Boil at Pace of Vaccinations at Long-Term Care Facilities

CVS and Walgreens, which are largely responsible for vaccinating residents and workers in long-term care facilities, are on track to make at least initial vaccination visits to nearly all nursing homes they are working with by Jan. 25. The two pharmacy chains have already given out more than 1.7 million vaccine doses at long-term care facilities.

But the progress is uneven across the country and not nearly as comprehensive for different types of long-term care. For example, thousands of assisted living facilities — for older people who need less care than those in nursing homes — do not yet even have an appointment for their first visit from the pharmacy teams, in large part because states have given such facilities lower priority in their vaccine-distribution plans.

The length of time it is taking is causing some states to come up with alternate plans. The article stresses the critical nature of the situation. 

[T]he rapidly spreading virus continues to decimate nursing homes and similar facilities. The virus’s surge since November has killed about 30,000 long-term care staff and residents, raising the total of virus-related deaths in these facilities to at least 136,000, according to a New York Times tracker. Since the pandemic began, long-term care facilities have accounted for just 5 percent of coronavirus cases but 36 percent of virus-related deaths.

Also noted in the Times article, there are "other things are slowing the campaign. A significant number of long-term care workers have balked at receiving the vaccine. The virus’s spread is also delaying the process. People should not be vaccinated while they still have Covid-19 symptoms or are isolating, according to the C.D.C."

 

Loneliness is Still A Factor

Despite the existence of the COVID vaccine, it will be some time before life returns to the 2021 version of "normal."  Loneliness is still a factor for many. I blogged a little over a week ago about my sister's cat and mentioned how pets can help combat loneliness. The New York Times ran a story about loneliness (not about my sister's cat) a couple of weeks ago. Combating an Epidemic of Loneliness opens with some interesting statistics. "Humans can survive three minutes without air, three days without water, three weeks without food and — according to survival lore — three months without companionship. Whether true or not, what’s clear is that people need people. And pandemics, many of us are learning, can be lonely times."  The article explains what loneliness means-it's more than being by oneself. "A useful way to think about loneliness, she said, is as the difference between how much social connection people want and how much they are getting" one expert noted in the article.  The article even mentions the brain science and studies undertaken on the topic. The article offers several suggestions to combat loneliness: 

(1) Friend-but not just anyone you call "friend." "

When seeking out connections, focus on your most unconditionally supportive friends and family. Some research shows that people feel more stressed and disconnected when their friendship networks include people who have betrayed them, weren’t there for them during tough times, frequently argue with them or otherwise cause negative feelings. A call with a close friend, in other words, will probably help more than a college reunion over Zoom.

(2) Be helpful to others.  Remember random acts of kindness? Those can be done even if you are staying home. (3) Start a hobby. (4)Reach out to others-lots of folks are lonely, and the article suggests younger people may need this connection.  

And I'll add this to the list. If you have a pet, give it a hug.

COVID Shortens Life Expectancy Projections?

A few days ago, CNN ran this story: Coronavirus will knock more than a year off average US life expectancy, study finds.

A new study published in the Proceedings of the National Academy of Sciences projects that Covid-19 will reduce US life expectancy in 2020 by 1.13 years, with a disproportionate number of deaths occurring among Black and Latino populations. When combined with provisional estimates of US death rates for the first half of the year, the data show a clear rise in the mortality rate as the pandemic took hold of the nation.

The  "study used Census Bureau data and data on actual and projected deaths from the pandemic of the University of Washington's Institute for Health Metrics and Evaluation and the National Center for Health Statistics [as well as] various models and estimates for mortality rates."  Based on their findings, the researchers concluded "a reduction in US life expectancy at birth of 1.13 years to 77.48 years."

 

Improving Neighborhoods Key for Aging in Place

AARP has released a new, free handbook, A Handbook for Improved Neighborhoods. The focus here is on land use and zoning regulations, many of which are not conducive to aging in place. "In some communities, the lack of walkability, opportunity and livability stems from zoning and development decisions that intentionally separated people by race, faith, ethnicity or income." It discusses "options for communities to consider as they identify and select small-scale, incremental policy changes that can be made without overhauling entire zoning codes and land use policies." I'm going to use it in my class, having students examine zoning and land use ordinances in their cities and how they would rewrite them to make their cities more conducive to aging in place.  Thanks to my colleague, friend and expert in new urbanism, Professor Mark Bauer, for sending me this.

 

The Future of Caregiving

PHI has released a new report, Caring for the Future: The Power and Potential of America’s Direct Care Workforce. Here are the key takeaways from the report

• Caring for the Future' describes the many profound challenges that have long faced this country’s direct care workforce.
• To our collective detriment, direct care workers remain undervalued and underutilized in the long-term care sector.
• Improving direct care jobs requires a comprehensive, national strategy that guides leaders across the public and private sectors.

The executive summary, available for download here, explains

Every day around the country, direct care workers leave their homes to ensure that older adults and people with disabilities have the care and support they need. These 4.6 million workers are the paid frontline of support for consumers and their families, growing as a workforce annually as people live longer and demand surges. They work in private homes, nursing homes, and residential care settings. They are unquestionably essential, as the COVID-19 pandemic has tragically underscored. They are predominantly women, people of color, and immigrants—diverse workers disproportionately impacted by structural racism and gender inequality. These workers are not valued, compensated, or supported at the level they deserve. Caring for the Future: The Power and Potential of America’s Direct Care Workforce explains these and other challenges and offers a clear and achievable path toward achieving quality jobs for this critical workforce.

The executive summary covers f0ur sections and lists eight recommendations.  The entire 126 page report is available here.

DOJ Announces Charges vs. Home Health Aide

A DOJ press released announced that a Home Health Aide [has been] Charged in Twenty-Two Count Indictment for Stealing Elderly Clients’ Identity, Banking, and Credit Card Information and Using it to Commit Financial Fraud.

According to allegations contained in the indictment and previously filed criminal complaint, for over a year starting in January 2019, Cofer worked as a home health aide servicing senior citizens in the South Florida community. During that time, Cofer gained access to her elderly clients’ social security numbers, dates of birth, bank accounts, credit cards, and other information.  Without the knowledge or consent of these elderly clients, Cofer allegedly used the information to steal money from bank accounts, open unauthorized credit card accounts, deposit unauthorized checks, make herself an authorized user on credit accounts, make unauthorized purchases of items such as a mannequin head and wig stand, pay her mobile phone, insurance, and other bills, and send money to a prison inmate, among other things.

The press release notes that additional information, including "court documents and information" here www.flsd.uscourts.gov.  Use case #s 20-MJ-8273 and 21-CR-80003-Middlebrooks.  

COVID, Vaccination Confusion & More

There are so many stories being published about COVID and the impact on elders, I'm just going to include a few in this post.

I had mentioned a few weeks back that some states were circumventing the CDC recommendation on the second priority tier for vaccination. Florida is among those states, choosing to vaccinate those 65 and older. In case you weren't aware, Florida has a lot of folks 65 and older. And not enough vaccine doses for everyone. When the second batch of vaccines arrived, stories appeared regarding confusion and inefficiencies regarding signing up to receive the vaccine. (I and several of my friends can tell you first-hand accounts of this). As the New York Times described it,  ‘It Became Sort of Lawless’: Florida Vaccine Rollout Turns Into a Free-for-All.  It's not just Florida having this problem, as noted in  Online Sign-Ups Complicate COVID-19 Vaccine Rollout For Older People.

We need to remember that not everyone has access to a computer or reliable internet-so are we leaving out an entire group in that 65 and over category eligible for the vaccine?  With states left to administer the programs,  Vaccination Disarray Leaves Seniors Confused About When They Can Get a Shot.

It seems to me that COVID news has been pushed off the news as the #1 story, replaced by the insurgency (rightfully so) but we shouldn't lose focus on the increasing spread of the pandemic. So we know things are going to get worse, before they get better---we haven't seen the surge from the Christmas holidays, but it's coming and very soon.  Just look at what happened at Thanksgiving:  COVID Kills Over 12,000 Nursing Home Residents in Weeks Surrounding Thanksgiving.

Finally, if you don't read any of these articles, read this one. COVID-19 And Congress Have Left The Senior Citizen Safety Net In Tatters explains the impact the pandemic and the economy is having on senior centers.

Whew.

A Tribute to a Cat

Yes, this post is about a cat. If that doesn't interest you, stop now. I promise the next blog post will be back to the news items I usually discuss.

My sister's 18 year old cat has died.  He was an old cat by any way you calculate it, but he was so much more.  This cat, like all cats, had a unique personality.  He was the king of the neighborhood (in his mind) and split his time equally inside and outside. He took no interest in birds, squirrels, or other outdoor creatures but he did take a great interest in inanimate objects.  I don't know whether he fancied himself a one-cat beautification committee, or he viewed this as bringing "gifts" to his people, but anything left in anyone's yard was fair game for him to bring home.

He most frequently-to the point of close to daily-would bring my sister a newspaper-whether from her driveway, or a neighbor's. He got so adept at bringing the papers, he could hop a fence and maneuver through the dog door without dropping the paper. Although the paper seemed to be his favorite trophy, he had previously brought in gardening gloves, small stuffed animals, and most recently a toy sword (I have no clue how he got that through the doggy door). 

Why is his passing newsworthy in my opinion? This pandemic has shown us the importance of connections, whether with each other or our pets.  Pets bring great joy to the lives of people and help stem the impact of our isolation. The antics of my sister's cat delighted her, and me.  This cat loved her and was loved by her in turn.  He had a good life. He had a purpose. He had worth. He never complained in his old age about doing his self-appointed job. He kept doing his job up to a couple of days before he died.  Isn't it wonderful to be loved , to bring joy to others, to have a purpose and be able to fulfill your purpose long through your life. I hope this story brought a smile to you.

Medicare Drug Out of Pocket Costs

Kaiser Health News ran an article (before Congress recessed), Seniors Face Crushing Drug Costs as Congress Stalls on Capping Medicare Out-Of-Pockets.

Many Americans with cancer or other serious medical conditions face ...  prescription drug ordeals. It’s often worse, however, for Medicare patients. Unlike private health insurance, Part D drug plans have no cap on patients’ 5% coinsurance costs once they hit $6,550 in drug spending this year (rising from $6,350 in 2020), except for very low-income beneficiaries.

President-elect Joe Biden favors a cap, and Democrats and Republicans in Congress have proposed annual limits ranging from $2,000 to $3,100. But there’s disagreement about how to pay for that cost cap. Drug companies and insurers, which support the concept, want someone else to bear the financial burden.

That forces patients to rely on the financial assistance programs. These arrangements, however, do nothing to reduce prices. In fact, they help drive up America’s uniquely high drug spending by encouraging doctors and patients to use the priciest medications when cheaper alternatives may be available.

The article examines the cost of specialty drugs and reviews the results of a 2019 Kaiser survey on the issue.  The high cost of such drugs may impede a person's ability to retire, the article noted. The article reviews the situation of some folks who have had to make treatment decisions based on costs and some choose to not have a prescription filled due to the costs. 

There is help from some non-profits, but beneficiaries may not know about them. "The high drug prices and coverage gaps have forced many patients to rely on complicated financial assistance programs offered by drug companies and foundations. Under federal rules, the foundations can help Medicare patients as long as they pay for drugs made by all manufacturers, not just by the company funding the foundation."

Stay tuned to see if Congress takes up the issue when it reconvenes. 

2020 Summary of Guardianship Legislation

The American Bar Association Commission on Law & Aging has released its 2020 summary of guardianship legislation.  The summary, Directions of Reform: 2020 Adult Guardianship Legislation Summary, American Bar Association Commission on Law and Aging is available .here.

The summary is divided into the following: pre-adjudication issues,  multi-jurisdictional issues, guardian selection, guardian actions, fees, rights of the individual, capacity matters, guardian & fiduciary misconduct, and post-adjudication/monitoring matters. The summary includes a chart at the end for a quick reference. The link  to the archives for prior year summaries is available here.

KFF Web Briefing on COVID Vaccine and LTC Facilities

Mark your calendars for a free briefing on January 14 at noon eastern for a free webinar from the Kaiser Family Foundation.  A Shot in the Arm For Long-Term Care Facilities? Early Lessons from the COVID-19 Vaccine Rollout to High Priority Populations:

KFF will hold an interactive web event at Noon Eastern time on Thursday, January 14 that will provide the latest data on COVID-19 cases and deaths in long-term care facilities and examine how the effort to vaccinate residents and staff in long-term care settings is going, challenges experienced so far, and opportunities for improvement.

The event will be co-moderated by Tricia Neuman, a Senior Vice President of KFF and Executive Director of the Program on Medicare Policy, and Rachel Garfield, a Vice President at KFF and Co-Director of the Program on Medicaid and the Uninsured. Priya Chidambaram, a Senior Policy Analyst at KFF, will provide the latest data on cases and deaths in long-term care facilities. A panel discussion on COVID-19 vaccination efforts will follow featuring a range of perspectives, including those of patients, nursing home officials, and pharmacy providers who are performing the vaccinations.

Click here to register for the webinar.

The COVID Vaccine Priority List?

Earlier this week the Washington Post published this article, Wealthy donors received vaccines through Florida nursing home. According to the article, the  "chief executive of MorseLife Health System, a high-end nursing home and assisted-living facility in West Palm Beach, Fla., [contacted] members of the board and major donors" and offered them the opportunity to get the COVID vaccine.  This also  "includ[ed] members of the Palm Beach Country Club, according to multiple people who were offered access, some of whom accepted it. The precise number of invitations, and how many may have also gone to non-donors, could not be learned."  The article notes the confusion in Florida regarding the vaccination protocols that basically "highlights how the country’s patchwork approach to immunization against the coronavirus — leaving decisions about eligibility to state and local authorities as well as to individual providers —[and]  is creating opportunities for facilities to provide access to well-connected people while thousands of others wait in line."  The article also notes that those in charge took the position that they stayed within the protocols.  The article mentions that a number of those offered the opportunity fell within the age group, but did not reside at the facility and  concludes with information about the two views of what happened. 

Webinar on Elder Abuse: Prevention, Intervention, and Remediation

Mark your calendars for January 21, 2021 at 2 p.m. eastern for a webinar on Elder Abuse Prevention, Intervention, and Remediation from the National Center on Law and Elder Rights.

Everyone who works with older adults has a role to play in prevention, intervention, and remediation of abuse, neglect, and exploitation. Helping starts with understanding the landscape of elder abuse and the service providers and systems involved in addressing abuse. This legal basics training will provide an overview of the fundamentals of abuse, neglect, and exploitation and the signs and signals of abuse that attendees can reference in their daily lives and work.

At the end of this training, participants will be able to:

• Describe the three stages of responses to abuse
• Apply basic definitions of abuse, neglect, and exploitation
• Identify risk factors or signs of abuse, neglect, or exploitation
• Identify the differences between undue influence, exploitation, and fraud
• Describe added risks in a time of COVID-19

To register, click here.

Enduring the Pandemic: Crisis Competence

The New York Times recently ran an article that focused on how elders are persevering during the pandemic.  How the Oldest Old Can Endure Even This introduces us to the concept of crisis competence. That is, "[n]o visitors. No friends at the dining table. Neighbors dying without notice. But many older adults have proved resilient during the pandemic, a phenomenon known as 'crisis competence.'" For those older adults who live in long term care facilities, they have had to give up more autonomy in return for being kept safe. 

Maybe it's their perspective, having a history of years on which to face their present and their future.

A surprise of the pandemic has been how well many older adults have adapted to the restrictions. “There’s crisis competence,” said Mark Brennan-Ing, a senior research scientist at Hunter College’s Brookdale Center for Healthy Aging. “As we get older, we get the sense that we’re going to be able to handle it, because we’ve been able to handle challenges in the past. You know you get past it. These things happen, but there’s an end to it, and there’s a life after that.”

While people of all ages have struggled this year, those 65 and up are still more likely to rate their mental health as excellent compared with people under 50.

The article focuses on several residents of a ltc facility, which provides us with important insights. The article wraps up and offers this advice "A motto to take into the new year: Horrible stuff happens, and people rebound from it."

Will COVID Change the Future of Long Term Care?

The Wall Street Journal published this piece back in December. Covid Spurs Families to Shun Nursing Homes, a Shift That Appears Long Lasting explains the trend

The pandemic is reshaping the way Americans care for their elderly, prompting family decisions to avoid nursing homes and keep loved ones in their own homes for rehabilitation and other care.

. . .

The drop-off has persisted since spring, including at times when the virus’s spread was subdued. In the summer, when many hospitals were performing near-normal levels of the kinds of procedures that often result in nursing-home stays, referrals to nursing homes remained down.

Occupancy in U.S. nursing homes is down by 15%, or more than 195,000 residents, since the end of 2019, driven both by deaths and by the fall in admissions, a Wall Street Journal analysis of federal data shows.

The decline in nursing-home patients covered by Medicare, which provides payments vital to the homes’ business model, is even steeper. That has left the industry in precarious financial shape. The biggest U.S. nursing-home company said in August it might not have enough money to pay its obligations.

I always ask my students two questions when we cover the topic of nursing homes: 1.  do they believe nursing homes are important to our society for the provision of long term care? (they answer yes). 2.  How many of them want to  reside in a SNF at some point in their lives? (they answer no). 

Surveys have long shown many patients don’t want to go to nursing homes. The pandemic has made them even less popular, according to a September survey of adults 40 and older by AARP. Just 7% said they would prefer a nursing home for family members needing long-term care, and 6% said they would choose one for themselves. Nearly three in 10 respondents said the pandemic had made them less likely to choose institutional care.

The article notes that the SNF industry has already begun to pivot, and home health care agencies are expanding their services.  Medicare's changes to allow for more services in homes also help as some of the Advantage plans have already moved in that direction. The article provides some interesting anecdotes about some of the services available. It's past time for us to rethink how we provide long term care in this country.  Long past time....

A subscription is needed to access the full article.

Thanks to Professor Dick Kaplan for sending me this article.

Starting 2021 with Looking at Operation of SNFs

Happy 2021. Several articles have been published examining the pandemic's longer-term impact on SNFs. I wanted to point out two.  First, consider the Washington Post article about how SNFs are structured, Profit and pain: How California’s largest nursing home chain amassed millions as scrutiny mounted.

Instead of relying upon outside vendors, Brius pursued a business practice long used by a majority of for-profit nursing homes nationwide: paying related companies for goods, services and rent.

More than 70 percent of the country’s nursing home providers use operating funds to pay themselves through so-called related parties — companies they or their family members partially or wholly own. In 2018, Brius nursing homes paid related parties $13 million for supplies, $10 million for administrative services and financial consulting, and $16 million for workers’ compensation insurance, state records show. The homes also sent a total of $64 million in rent to dozens of related land companies.

The practice is legal and widely supported by the industry, which argues that related parties help control costs and limit financial liability. Watchdog groups counter that nursing home owners can reap excessive profits from public funds by overpaying their own companies. Related parties generally do not have to disclose profits, leaving regulators with little way to assess the financial gains of owners.

Covid has changed the "business as usual" model, it would seem, as the article notes that "scrutiny has mounted in recent months as the federal government delivered about $54 million to Brius homes in coronavirus relief aid, meant as a lifeline for providers struggling to protect residents amid an unprecedented health crisis that has killed more than 92,000 nursing home residents nationwide."  The Washington Post did an in-depth look at this SNF chain. The article details what the reporters discovered regarding finances and taxes. There are California groups that have called for the California legislature to revise the oversight of SNFs.  The article indicates that efforts may also be made at a federal level. This detailed article is well worth reading and I plan to assign it to my students, so they can have a better understanding of the structure of SNFs.

Next consider this opinion from the New York Times,, This Is Why Nursing Homes Failed So Badly.

The first coronavirus outbreak in the United States occurred in a nursing home near Seattle, in late February. Since then, the country has endlessly revised its hot spot map. Yet the situation in nursing homes and assisted-living facilities has only gotten worse: More than 120,000 workers and residents have died, and residents are now dying at three times the rate they did in July.

Long-term care continues to be understaffed, poorly regulated and vulnerable to predation by for-profit conglomerates and private-equity firms. The nursing aides who provide the bulk of bedside assistance still earn poverty wages, and lockdown policies have forced patients into dangerous solitude.

Fortunately... and maybe hopefully...., with the COVID vaccine and priority given to those who work and reside in SNFs, this won't be a story that continues in the same vein. But the author of this piece aren't telling us we will return to the prior way of things. "When the pandemic is finally history, we’ll need to deal with all of this: the staffing shortages, low pay and lack of accountability — the many ways we have failed residents, family members and staffers. The awful truth is that long-term care was designed to fail years before Covid-19."  Why is this? Various stressors combined push the need for change in how long term care is provided.  "Over the past few decades, the popularity of “aging in place,” combined with new medical technologies and longer life spans, has changed the nature of care for seniors and people with disabilities. Residents of the nation’s 15,400 C.M.S.-certified nursing homes are much older, sicker and poorer than they used to be."  The article mentions the health of the residents, low pay for employees, employees working jobs at different facilities as contributing to the crisis.

The author makes a number of suggestions for changing long-term care in the U.S.  and concludes with a call for action from the incoming administration

Most important, we must transform the way we think about long-term care — treating it not as human warehousing or the duty of underpaid women, but as an integral part of our medical system.

All of these changes are possible — and modest, really, given the magnitude of the emergency. By 2050, 19 million people will be 85 or older, and many will require help to live with comfort and a modicum of dignity. What we really need, for all Americans, is single-payer health insurance that covers quality long-term care. But short of that, Mr. Biden and Kamala Harris have a chance to make amends for the deadly failures of the current administration.