unfortunately there are a lot of ppl in a situation where they did not declare that in time and we can't assume they would.
Over prescription of antipsychotics is still common in US psychiatric facilities, and even if not there are alternatives, like very high dosages of SSRIs or other specific medications with complacency as a side effect.
But it is really difficult staying enthusiastic about treating someone, long term, who is never going to repay any extra efforts. Caring for the elderly/infirm is a really gruelling experience.
It seems quite likely that there physically are not enough doctors who have the mental stamina to do that. The options the average person faces if they can't care for themselves are going to be doctors who don't really care, or nothing.
I can see that in the facility where my parents live. Overall the place is fine but it's constantly understaffed and people aren't paid well. This is a way harder job than my much better paid tech job. I can slack off for days when I feel like it whereas the care personnel never can escape the grind.
It's sad that these people get paid so little considering how psychologically strenuous their work is and how much human benefit comes out of it.
This article strikes a chord with me. After a long hospital stay, I sent my father to inpatient rehab (aka "nursing home") for two weeks. Before he went, they told me I could do daily visits outside his window. After he was there, they made me schedule visits ahead of time with their "activities coordinator" who told me I was lucky to get twice a week. They didn't bother to make him do any of his therapy, rather they just let him lay in bed the whole time. They put him on a bunch of new meds to make their job easier, double dosed his biannual medication, etc. It was of course impossible to get anybody on the phone to talk about any of the details of his care (and not for a lack of trying). I only discovered the meds after the fact when I requested the records (which was also its own ordeal, and they're not even complete).
Administratively though, they were on the ball. The intake paperwork pushed me to sign him up for a long term stay (complete with "sign here" highlights on patently unnecessary forms; I rejected them), and they wasted no time switching his insurance billing address to their own address. His stay ended abruptly one (early) morning, when they punted him back to the hospital with a dubious story. I believe it was because they knew his Covid test was coming back positive but didn't officially "know" yet, and this way they could keep their numbers down.
After the second hospital stint, I just took him home despite the extreme burden. I hired some private helpers and between them and myself being extremely involved with the visiting nurses/rehab, he did much better. I would have paid for more bona fide sessions of rehab if I could have, but that's our inflexible system.
If you have a good relationship with your family and one of them is in the position of "needing" a nursing home, it behooves you to save them from these horrible institutions that are mainly geared to milk their insurance. Even at decent hospitals and not during Covid, if someone else is not there and continually advocating, their care will be overlooked.
I don't believe that it affected his care. There were a fixed number of hospitals, inpatient rehabs, and visiting nurse associations, and they all took his plan. And I can't possibly see their behavior being different for a different payer - the incompetence was intrinsic to their deliberate bureaucracies. The only way to rise above would have been to find providers that didn't take "insurance" at all, such that the actual customer was the patient rather than another bureaucracy.
The Medicare rules were limiting by fixing the amount of rehab sessions he got per week. The length of his care would have been limited too (discharge rules), but I advocated to extend him within the system. But any bureaucracy is going to be similar, and thus the only way to fix that would be neutering the whole "insurance" cartel and forcing the industry into radical price transparency. Which is basically the line I was straddling with the private pay helpers.
What Medicare really helped with is making his copays sane and giving me solid footing to push back on billing fraud. For instance, one equipment supplier sent me a bill for 50% more than it should have been, and then shamelessly stood by their story on the phone ("you owe us this amount, so you need to pay"). I presume they successfully defraud many people that way.
I agree with the principle behind your other points though, in an ideal world we would not prescribe these medications to the elderly to ‘aid in management’