The Canadian narrative of the COVID-19 pandemic has quickly become focused on the country’s failure to protect its older adult population.
With an overwhelming 81 per cent of COVID-19-related deaths occurring in long-term care homes (LTCH) during the first wave, Canada had the highest proportion of deaths in LTCH of all of the members of the Organization for Economic Co-operation and Development (OECD) with such deaths in those countries averaging 38 per cent. Within Canada, the differences between jurisdictions was even greater; some regions reported no COVID-19 deaths in LTCH, while others reported sky-high rates of 80 and even 97 per cent.
“A national tragedy” is the only term to express what happened to the residents of long-term care facilities.
Many organizations and campaigns are pointing at for-profit long-term care providers to explain what happened, and are demanding the end of for-profit ownership and management in the LTCH sector.
Studies to explain what happened in Canada’s long-term care facilities during COVID-19 have highlighted several factors, including the type of ownership. And the devil is always in the details.
On average, the for-profit facilities have been found to be more likely to have lower service quality. A recent study in the Journal of Post- Acute and Long-Term Care Medicine found that the likelihood of an outbreak happening in a specific home was not related to its for-profit status, but for-profit status is related to the high rate of infections and deaths once an outbreak happens.
Canada has a relatively low percentage of for-profit LTCHs compared to other OECD countries, so why the discrepancies between Canada and its OECD colleagues in the number of COVID-19 deaths in LTCHs?
Some researchers suggest while a lot of effort went into preparing the hospital sector in order to prevent overload, not much was done to prepare the continuing-care sector. And, when faced with the consequences of some of the devastating confounding factors of COVID-19 — such as asymptomatic patients, latency period, lack of personal protective equipment, untrained personnel, casual workers working in various locations, shoddy oversight and regulation and obsolete facility design — the measures taken were too little too late.
It’s clear factors other than the type of ownership influenced COVID-19 in long-term care, but it’s still important to note documented differences in the quality of service and care between for-profit and not-for-profit LTCHs. For example, a 2015 study found that after one year, residents in for-profit facilities had 10 per cent higher risk of mortality and 25 per cent higher risk of hospitalization.
In another study, a systematic review of more than 8,800 studies was done. From there, 82 studies that compared the quality of care in for-profit and not-for-profit LTCHs between 1965 and 2003 were selected for meta-analysis. (Meta-analysis allows researchers to combine and compare data from previous research studies and derive conclusions from that research.)
In this meta-analysis, four frequently reported quality indicators were assessed, and included the level and quality of staffing, pressure ulcer or bed-sore prevalence, physical restraint use and deficiencies reported during government assessments of facilities.
Results of the meta-analysis demonstrate there’s more to quality of care than simply for-profit or not-for-profit status. In 40 of the 82 studies analyzed, not-for-profit LTCHs came out on top: Those studies found that not-for-profit LTCHs delivered higher quality care as measured by two of the four most frequently reported quality measures, namely staffing and pressure ulcer or bed-sore prevalence. And of these 40 studies, not-for-profit facilities had a slight (though statistically non-significant) edge on the two other most frequently used indicators, specifically, physical restraint use and number of deficiencies found during government regulatory assessments.
Three studies found for-profit LTCHs delivered better outcomes. But the remaining 39 studies that were part of the meta-analysis had less consistent findings and no clear conclusions could be made on whether not-for-profit or for-profit LTCHs deliver better outcomes.
What’s wrong with for-profit’s model?
Every study comparing for-profit and not-for-profit outcomes points towards the same factors that lead to poorer outcomes: obsolete facility designs, lower levels of staffing per resident, less care time per resident, poor working conditions and very low wages, fewer regulated staff, more casual staff working at different locations, more usage of staffing agencies, fewer specialists per facility and more residents per facility. On average, for-profit facilities tend to exhibit at least some of these characteristics, but they show up in not-for-profit facilities, too.
What can be done?
Calls are increasing to “de-privatize” the long-term care sector, but the mechanisms by which that could be done aren't clear. Should Canada nationalize the sector and transfer the ownership and management of LTCHs to government agencies or to not-for-profit groups? What legislative or policy tool would the government use to force for-profit owners out of the sector? What legal challenges could or would be brought forward by the for-profit owners? Assuming success, how exactly would these transfers of ownership help to mitigate all the aforementioned factors?
Legislation and regulation in the sector, with serious penalties and ways of tying funding and accreditation to a set of national criteria and regular inspections are more likely to have faster, as well as longer and lasting beneficial effects on the whole sector, rather than just transferring the ownership from for-profit to not-for-profit entities. While the LTCH sector falls under provincial jurisdiction, there may be room for the federal government to adjust the Canada Health Act so it includes long-term care delivery. Federal transfers for LTCH could then be tied to provincial legislation and regulation of the sector.
The desire to force for-profit entities out of the sector seems to be mostly based on a set of ideological values, namely that one should not make profits out of social services provided to the most vulnerable people of our society.
While a legitimate stand, it might not be the best or only way forward to achieve safe long-term care. Creating robust regulations and penalties for the sector across the country would ensure providers are held to account for the services they offer and the outcomes their residents experience. If for-profit owners can respect these requirements while still making profits, it is not clear why, in a free market society, they should be forced out. On the other hand, if respecting these requirements affects operators’ profitability, then the operators who were in it purely for profit will see themselves out.
The sticking points will be the political will to implement and enforce the standards, and regulate the sector with the rigour it so clearly needs.