Without the funds and the resources needed to meet COVID-19 testing recommendations, the federal government’s guidance on reopening nursing homes could create more confusion for skilled nursing facilities — and more challenges on top of the considerable strain they already face in combating the spread of the illness.
“At a high level, I really think this is a bit of a hollow requirement,” David Grabowski, a professor of health care policy at Harvard Medical School and a member of the Medicare Payment Advisory Commission (MedPAC), told Skilled Nursing News on May 20. “You’re telling nursing homes and states to test all staff and residents regularly, yet not actually the providing the tests to them, and I think that’s a real mistake.”
The Centers for Medicare & Medicaid Services (CMS) released guidance on reopening nursing homes on May 18.
While allowing states flexibility in how the criteria in the guidelines should be implemented, the agency emphasized that SNFs should be among the last institutions to reopen as communities try to move out of their various stay-at-home phases.
The guidelines detail several parameters for testing and COVID-19 community infection status that SNFs ideally should meet before moving toward reopening, including the requirement to have baseline testing for all residents and staff — and the capacity to subsequently test staff once a week.
But states have the ability to choose how they measure their SNFs’ readiness to emerge from visitation lockdown, and some of them, such as New York, have adopted even stricter measures for testing than those in the CMS guidelines.
The CMS guidance is helpful in the flexibility it offers, Christopher Laxton, the executive director of AMDA — The Society for Post-Acute and Long-Term Care Medicine, told SNN on May 20. That’s important, given that COVID-19 testing strategies should be tailored to the clinical situation, according to AMDA’s policy statement on testing, released the same day — though before — CMS put out the reopening guidelines.
“However, it doesn’t go very far in terms of the considerations of what a testing strategy should look like,” Laxton said.
This omission is striking because in New York and elsewhere, SNFs have reported serious hurdles to securing enough tests. Though CMS administrator Seema Verma has emphasized that states have sufficient testing capacity, this doesn’t always match what Grabowski has heard and what other reports seem to suggest: Namely, that some states have the capacity to test or provide testing while others do not.
“Saying states should be doing regular testing at nursing homes, I don’t think that this is going to move the needle in a major way, just because most states don’t have testing,” Grabowski told SNN, adding that a testing requirement like New York’s is being set without actually providing the tests to SNFs. “I don’t know how any of these actors, at a state or federal level, believe this is actually going to meaningfully change testing unless they actually go in and make those tests available.”
There are ways states can do this, he added. Some states have made use of the National Guard to perform tests at nursing homes, while others, such as Massachusetts, provided SNFs with the tests directly — though Grabowski acknowledged that the latter effort didn’t quite turn out as the Bay State would have hoped.
But his point was that there are ways to provide the tests to nursing homes, and that leaving it to the states or even facilities to secure testing would not do much to increase tests to the needed level.
Even if that testing is provided, the capacity of states to process the tests is another matter entirely. Many nursing facilities have existing relationships with commercial labs, but those relationships are based on normal test volumes, Laxton told SNN. It’s not certain that a given lab could process a sudden surge of polymerase chain reaction (PCR) tests from a SNF, he told SNN.
The importance of timely results is also a factor — so much so that when provider PruittHealth was looking for private labs to bolster its COVID-19 testing, chief clinical officer Fran Rainer told SNN in April that turnaround time was a major consideration in their choice of lab. That’s because PruittHealth found that COVID-19 symptoms tended to only show five to seven days after exposure.
That raises another complicating factor: Labs can typically process PCR results in 24 to 48 hours, Laxton noted.
“In terms of being able to use the test results in a productive way, they need to be back in the clinician’s hands within that timeframe,” he explained. “Anything beyond 48 hours — in essence, the test results become useless. What we’ve heard is that some of the processing labs, when they’re placed with high volume, those get delayed a week or even two weeks, which essentially makes it a pointless exercise.”
Laxton also pointed out that the language of the guidance memo is ambiguous; even though CMS says access to adequate testing includes the capacity to give all SNF residents and staff a baseline COVID-19 test and then re-test all staff weekly, it also notes that state and local leaders could adjust the requirement for weekly staff testing based on virus circulation in the community.
“Is the survey team going to tag you if you don’t test?” Laxton asked rhetorically. “These are all very much open questions, and we know that our members, nursing homes, are risk-averse.”
The issue of testing is “hugely consequential,” he told SNN, given the fact that AMDA’s data show that nationally, around 20% of staff test positive with universal testing and have to be quarantined for two weeks, putting already short-staffed SNFs into an even greater workforce pincer.
In addition, as AMDA noted in its policy statement, the idea of “universal testing” is not as clear as it might sound. One definition might involve testing all residents and staff regardless of symptoms, while another might involve keeping facility-wide testing only to sites with outbreaks.
To be on the safe side, many of AMDA’s nursing home members are going to act as though the new guidelines are mandates to test everyone on a weekly basis, Laxton told SNN.
But that raises another major challenge: the cost of testing. PCR tests can cost anywhere from $100 to $175 each, he told SNN, and when it comes to testing thousands of staff, that will add up. Though some states are requiring private insurance companies to cover this testing, not all of them are doing so — and even with that coverage, staff could have to pay a deductible or a copay. And that’s assuming the staff have access to insurance, which is not always a given, Laxton noted.
On a national level, the American Health Care Association (AHCA) estimated that testing each nursing home resident and staff member just once would cost $440 million, and argued that it shows the need for additional funding from the Department of Health and Human Services (HHS).
Grabowski agreed, arguing that most SNFs want to supply their workers with personal protective equipment (PPE) and universal testing — but they’re just one part of a bigger ecosystem that’s already pushed to the brink.
“That’s only going to happen if somebody purchases those for them and actually provides them,” he told SNN. “I don’t think nursing homes … are going to be able to bid against other actors in the system and get tests and PPE to their buildings unless we help provide it to them.”