Higher death rates in LTC homes tied to for-profit ownership, analysis shows
Data suggests disparity cannot be fully explained by other factors, experts say
Ontario’s for-profit long-term-care homes have reported far more COVID-19 deaths on average than nonprofit and municipal facilities, even accounting for factors the industry has repeatedly claimed explain the long-standing disparity, a Star investigation finds.
For months, the industry has insisted that the reason for-profit homes have consistently reported worse outcomes than non-profit and municipal homes has nothing to do with ownership but is the result of other factors, such as the rate of COVID-19 infections in the surrounding community and the fact that for-profits own more older facilities.
A new Star investigation shows that even after accounting for those factors — and several others — for-profit homes have still seen many more deaths per capita.
Older homes and those located in areas with higher infection rates have clearly seen elevated death tolls. The Star’s analysis does not dispute this claim. What it does show is that for-profit status has also been undeniably associated with worse outcomes throughout Ontario’s COVID-19 pandemic.
Several experts who have seen the Star’s analysis say the findings suggest the for-profit sector’s higher death rates cannot be fully explained by other factors.
The Star analysis compares Ontario’s detailed home-byhome records of COVID-19 outbreaks across several different factors, from the age of a home, to local infection rates, to the size of the facility, among others. Whether looking at those factors in isolation or in dozens of combinations, forprofit homes reported the highest rate of deaths per registered bed in virtually every case.
For-profit homes had the worst outcomes in both hardhit cities where the virus raged and in communities left relatively unscathed; worst, whether run by sole operators or by large chains; worst among facilities with a handful of beds and those with hundreds. For-profits also reported more deaths in older homes, in which dated design standards have been blamed for some of Ontario’s worst outbreaks, and in homes built to newer, stricter regulations.
The pattern is consistent in the data from the entire pandemic and is even clearer in Ontario’s second wave, during which there was an even larger gap between the poorer outcomes at the for-profits relative to non-profit and municipal facilities.
The analysis reached the same result even when the Star excluded the 10 homes that saw Ontario’s highest death rates — including Roberta Place in Barrie, Tendercare in Scarborough and Pinecrest in Bobcaygeon. Again, compared to non-profits and municipal homes, the for-profit sector reported the worst death rate in the vast majority of comparisons.
The Star shared its methodology and findings with several researchers, including Ashleigh Tuite, an infectious disease epidemiologist and a mathematical modeller at the Dalla Lana School of Public Health.
“It’s very clear that there is an association with for-profit status and the mortality rates that we’re seeing in the context of these outbreaks,” Tuite said, noting that it’s not entirely clear exactly why this association exists. “But it’s clear that you can slice this different ways and you continually see this difference between for-profit status and outcome.”
Tuite said it may be time to “shift the conversation” away from design standards and toward “a more fulsome conversation about what we need to do in the short term as well as the long term to make sure that these for-profit homes are safer for residents.”
Donna Duncan, CEO of the Ontario Long Term Care Association — which represents 70 per cent of the province’s nursing homes, including most forprofit homes — declined an interview request for this story.
In a written response to questions, she said the OLTCA refutes the Star’s findings, “as they lack important context and do not account for a range of factors that experts agree increase the likelihood and magnitude of a COVID-19 outbreak.”
She did not respond to followup questions asking to specify those factors and any flaws in the Star’s methodology.
Instead, a spokesperson referred back to Duncan’s original statement, in which she reiterated the OLTCA’s position that the most important risk factor was the daily incidence of COVID-19 infections in the surrounding community. She also pointed to the age of buildings and number of beds per room as major factors contributing to the magnitude of the virus’s impact in a home. (The Star’s analysis does take community prevalence and the age of homes into account. The analysis does not include the number of beds per room, as that data is not publicly disclosed.)
“Simplifying complex issues based on political ideology hinders our ability to bring about real change that is long overdue,” Duncan wrote. “This is not appropriate or acceptable.”
The Star first reported that Ontario’s for-profit long-termcare homes had a higher average rate of COVID-19 deaths last May. The publicly available data showed that the coronavirus entered long-term-care homes at roughly the same rate, regardless of ownership type. Once an outbreak occurred, however, they were far deadlier, on average, in for-profit homes.
This is still the case. From last March until this week, for-profit homes with at least one COVID-19 outbreak have reported 7.3 deaths for every 100 registered beds, nearly double the 3.8 reported by non-profits and nearly five times the 1.5 deaths for every 100 municipal beds.
Last summer, a study published in the Canadian Medical Association Journal examining the effect of COVID-19 in longterm care during Ontario’s first wave found, in general, that forprofit homes with bigger and deadlier outbreaks had older building design standards and a higher proportion of chain ownership.
That study’s lead author, Nathan Stall, a physician specializing in geriatrics at Mount Sinai Hospital, said the Star’s findings suggest the poorer outcomes in for-profit homes cannot be explained away by older design standards or chain ownership.
“From your analysis, there’s clearly something else that’s contributing. Is it leadership? Is it staffing? Is it deficiency in infection prevention and control? We’re not always going to know that, but we need to try to figure out what those factors are so that we can save the lives of those people,” he said.
“Staffing cannot be understated. We know that they have lower levels and lower quality of staffing within the for-profit sector and we know that they’re paid less, too.”
Stall emphasized that, despite the overall trend, many forprofit homes he has visited have “performed admirably” throughout the pandemic. “I’ve been inside them. They care deeply about their residents,” he said.
The majority of Ontario longterm-care homes did not report any fatal cases during the pandemic, regardless of ownership type. Still, of the 20 worst-hit homes in Ontario’s second wave, 17 are for-profit facilities; as a group, these homes have few other similarities.
They range from large, older facilities with shared rooms, to tiny, newer ones, like King City Lodge, which reported 11 fatal cases in just 36 beds, all conforming to more recent building regulations.
They are homes located in hard-hit communities and facilities in health units that were relatively unscathed, such as Caressant Care Listowel in the Huron-Perth health unit, or Extendicare Kapuskasing in northeastern Ontario’s Porcupine Health Unit.
Nine of these 17 for-profit homes are owned by chains; the other eight are independently run. Six have contracts with outside management firms. Seven have fewer than 100 beds, another seven have up to 200, while the remaining three are larger.
The Star’s findings are bolstered, in part, by a recent Ministry of Health analysis that finds ownership status, along with older design standards, were associated with higher mortality in Wave 2, although not in Wave 1. The ministry’s analysis uses different methods from the Star’s, but compares many of the same factors.
The Star used a technique called “stratified analysis” to compare homes’ death rates by ownership across dozens of combinations of characteristics — 81 separate tests in all. This process reveals a consistent pattern in outcomes, but doesn’t seek to answer the question of why for-profits saw the most deaths in virtually every case.
The ministry’s study attempts to apply more complex modelling methods to the raw data to tease out which factors have had the strongest effect. Although the ministry found that ownership type had an effect for Wave 2, it says it did not when using data for the full pandemic. This difference “indicates that the effect changes over time and depends highly on the selected time period,” the researchers said. “The experiences of specific homes in Wave 2 may be driving the overall effect.”
Nearly 60 per cent of Ontario’s more than 600 long-term-care homes are privately owned and run for-profit. The remainder are run by non-profits or municipalities. Every home in the province is funded according to the same government formula, regardless of ownership type, at a total cost of $4.3 billion a year.
Homes are not allowed to profit from funding for resident care, services or food, but they can keep money for profit from a fourth funding category for things like housekeeping and administration, and from premiums charged to residents for private rooms.
Research from both the U.S. and Canada has found that forprofit long-term-care homes, on average, have lower staffing levels compared to non-profits.
Charlene Harrington, a professor emeritus at the University of California, San Francisco, who has studied nursing homes in both Canada and the U.S., said staffing tends to be the biggest difference between forprofit and non-profit operators.
In a commentary published in CMAJ last August alongside Stall’s research, Harrington and Dr. Margaret McGregor highlighted pre-pandemic research on lower staffing levels in forprofit nursing homes and recent U.S. studies linking lower nursing staff levels with worse COVID-19 outcomes.
“This evidence clearly shows that ownership matters when it comes to staffing, and staffing matters when it comes to managing outbreaks of COVID-19 in LTC facilities,” she wrote.
In an interview, Harrington said that although having adequate nursing staff is the most important factor for controlling an outbreak, auxiliary staff, such as housekeeping, is also important; so is having less staff turnover. “If they don’t have as much total staffing it makes a difference.”
A report by the Office of the Seniors Advocate in British Columbia, published last year based on pre-pandemic data, found that the for-profit longterm-care sector in B.C. did not deliver 207,000 hours of direct resident care for which it was funded in 2017-18, while the
not-for-profit sector provided 80,000 extra, unfunded hours. The same report found that wages paid to care staff in the for-profit sector can be as low as 28 per cent below the industry standard.
A Star analysis of pre-pandemic union staffing data published last year found for-profit homes in Ontario employed 17 per cent fewer full- and parttime workers than non-profit and municipal homes.
Ontario’s minister of longterm care, Merrilee Fullerton, declined an interview request for this story. In a written response to questions, a ministry spokesperson said that the province is investing $1.75 billion over the next 10 years to develop and upgrade longterm-care homes, including building 30,000 new spaces. The province has also introduced a new funding model to “incentivize the development and upgrading of long-termcare homes in the province.”
Pat Armstrong, a York University sociology professor who is leading a global study on standards in long-term care, said the growing body of evidence from the COVID-19 pandemic showing worse outcomes in for-profit homes should raise questions about whether private owners should be allowed to continue in the sector.
“I don’t think we could get rid of them overnight, that’s for sure,” Armstrong said. “But we could certainly start moving in that direction.”
Ontario’s NDP has pledged that, if elected, it would stop issuing new licences to forprofit long-term-care owners and phase out existing for-profit operators within eight years.
Dr. Bob Bell, a former deputy health minister and former CEO of the University Health Network, has said that would be a mistake.
“We need to redevelop a whole lot of homes and doing that without private capital involved, I think, is going to be more difficult than doing it with private capital involved,” he told the Star in an interview.
Bell, who last year chaired an advisory panel for Revera, one of the largest long-term-care corporations in North America, said he would like to see more conclusive evidence that the higher death rate in for-profit homes is statistically significant. “It’s hard to see how there would be a clinically relevant reason for having more mortality,” he said. “Certainly if there is, based on your analysis, that’s something that needs to be explained.”