First off, nobody knew/knows how many assisted living beds are needed in the Seacoast. When I opened Bellamy in 2006, it was the first new resource in several years and it was a hybrid model.

The assisted living field splits out into several distinct markets:

Medicaid- low income, low service, small, usually renovations of old homes and a social model, “bed and breakfast” approach. Very good if you’re old, on Medicaid, and not too ill.

Big Box, Bling- three or four stories, apartments, amenities, expensive, private pay with a mix of independent apartments, light assisted living, and a memory care unit in the basement. Usually, national chain-owned contracted management, now often an asset in a REIT portfolio. Excellent geriatric country club living but don’t get sick!

Medical/psychiatric model assisted living with an emphasis on dementia, Parkinson’s, variants of dementia, requiring highly trained staff with behavioral, psycho-social, and psycho-pharmacologic skills. Growing business, private pay, expensive (labor costs greater than 50% of expenses- ask the management) now morphing into unproven therapeutic approaches in lieu of training staff the old-fashioned, hard way.

Continuing Care Retirement Communities- hybrid license with a large up-front entry fee that is returnable in part, plus monthly fees. Offers all levels of care and in the effort to be all things to all people, may fall short in some areas and exceed in others. Very large campus using public money and a non-for-profit (501c3) operating status.

So, how many are too many? Portsmouth has 30,000 restaurant seats. Is that too many? Too many pharmacies, gas stations, bagel stores, coffee shops…

Licensed health care facilities like mine and up the food chain to acute care hospitals used to be regulated artificially by state agencies who tinkered with supply and demand. Hospitals and nursing homes that take federal and state money (Medicare/Medicaid) must work with their payors not to add supply on a whim.

Political clout killed (bad pun) the acute care supply and demand relationship and consolidation of hospitals (Boston, Exeter, Dover BED’s R Us) is a free-for-all.

There are Medicaid nursing home beds available to be built in the Seacoast but who will finance a guaranteed money loser

So, high demand=high prices; low demand=low prices

The new facilities have some big debt but luckily at low-interest rates. Are there enough high payors for their markets or will they cut costs and offer deals, as the housing and apartment markets typically do when supply exceeds demand.

The new players will squeeze the existing market- who can go how low to attract the customers

And what will the customers get for their money?

Some words to the wise: read the contract carefully, then read it again.

Is there a clause requiring your family to provide private duty if your loved one needs more support? If so, by whom and how much in hours and dollars? Can the facility discharge your loved one for problematic behavior? What kind of behavior?

Health care, especially geriatrics, has become the ultimate hybrid of supply and demand, cost, outcomes, efficiencies, and definitions of quality.

In hospice geriatrics, a peaceful, painless death is a good outcome. Keep that in mind when you’re considering assisted living for someone who doesn’t know your name anymore.