The day to day work crap has been falling heavier upon my soul than usual the last few days. I’m not sure why. Probably because I can see the light at the end of the tunnel and I’m in the psychological process of beginning to detach myself from the craziness that marks my professional life. And it all appears to be getting crazier at an exponential rate due to the combination of demographic changes and fall out from political impacts on the missions of academic health centers. Eight and a half months before the first phase of retirement kicks in and, if all goes as plans, twelve and a half months until it’s over and out. In the meantime, keep on trudging. The notes will get written. The hands will get held. The referrals will get sent. The refills will get to the pharmacy. They always do no matter how removed I may be feeling.
I’ve been fielding a lot of complaints from friends, acquaintances, patients, learners, and random people on the street on the state of institutional elder care these days. I agree that, at least locally, it’s a bit of a mess. There are a lot of dedicated people in the field but they’re fighting an uphill battle against very strong forces over which we have minimal control and the end result is declining quality, unhappy residents, frustrated families, and a lack of better options. Why is this happening? The usual reason…. money. It’s all about who is getting paid how much for what sort of service.
I’ve gone into excruciating detail in these writings before about the various types of senior living available and how they differ from each other and what sort of services are required. I am not going to write that all out again. If you really want to read it, let me know and I’ll link to all of that in the comments. What’s important in terms of current trends is that the industries (homecare, hospice, senior living, skilled nursing) are subject to the same sorts of market forces as all else in late stage capitalism. Most of these entities began as small businesses, often family run or started by not-for-profit entities such as religious groups for specific social mission. Over the last fifty years, as costs and regulations have increased, it has become more and more difficult for a small operator to exist. This has led to consolidation and larger companies buying up smaller ones to take advantage of economies of scale and centralized management.
If you go up the corporate chain of ownership, there’s been a move over the last three or four decades for the companies at the top of the food chain to be bought or controlled by large investment firms for the purpose of extracting wealth. Amedisys is owned by United Health. Aveanna by Bain Capital. Encompass’s major shareholders are Blackrock and Vanguard. And on it goes. The need to preserve profit plus the centralized management systems means there is very little wiggle room at any individual facility to staff outside of centrally set models, to do things in a different way or to set budgets around community needs rather than corporate needs. Room and board in a reasonable senior facility now runs about $3000 a month with other services added on through an a la carte pricing menu. Need help with medications? You can get those packaged and passed for a modest fee. Need someone to provide actual assistance? That will be $25 an hour four hours minimum daily. (That unskilled sitter isn’t being paid $25 an hour. Going salary is $12-13 an hour. The rest is going up the corporate food chain).
As demographics change, there’s going to be issues moving forward. The owners of facilities understand this which is why the building of new senior facilities has slowed just as the Baby Boom is entering its 80s and the time in the life cycle when they may have need of such places. The owners know that the aging Boomers aren’t interested in the current model and that many of them will not have the resources nor will their family systems have the resources for the hefty price tags associated with senior living. The earlier generations who have taken advantage of them are the last generations who had defined benefit pensions and were able to take advantage of the post war economy to increase their assets in ways that are not currently possible. I haven’t a clue as to what’s going to happen to the Boom as they enter the dementia belt and they and their families will not opt for institutional care and their family systems won’t be intact enough to allow for care at home. Probably a huge spike in elder homelessness, especially if the current administration starts taking an axe to Social Security, Medicare and Medicaid as they are threatening. I’ve had four decades of creative solutions to unsolvable problems. I’m leaving these unsolvable problems for the next generation of geriatricians. We have some bright young things coming up the ranks. They need not worry about unemployment.
I think I have puzzled together my cast for the Tempest. I’m going to sleep on it one more night to make sure I don’t have a stroke of genius in the night and then get a cast list and script out to everyone tomorrow so people will have plenty of time to look things over before we dive into rehearsal in ten days or so. I still have a lot of things to work on and solve. The one I’m trying to get a handle on at the moment is sound, music and songs. There’s a bunch of singing in The Tempest but, of course, no official music. Sir Arthur Sullivan wrote music for all of the songs in the 19th century but it’s way too art song for our concept. I need something much lighter. Perhaps someone in the cast will want to run with doing some composing and arranging. That’s what I did with Midsummer a few years ago and it worked out really well.
I could comment on national politics such as Schrodinger’s cease fire in Iran, the maltreatment of visitors for the World Cup, the attempt to use the post office to circumvent the constitution regarding state responsibility for elections, and the turning of the national mall into a scene out of Spielberg’s AI but I don’t have the inclination or the energy at the moment. Going to watch Law and Order instead.
Life, The Universe, and Everything 