Staffing, a long-standing thorn in the side of skilled nursing operators even before the COVID-19 pandemic, has emerged as one of the most critical elements in how facilities manage an outbreak and navigate the current public health emergency.
But it would be hard to tell that fact by the pay certified nursing assistants (CNAs), who form the backbone of the workforce at many facilities, receive.
In the wake of the ongoing havoc caused by COVID-19, however, there’s an opportunity for major reforms around how CNAs are compensated and treated within SNFs — if stakeholders will act, Sabra Health Care REIT (Nasdaq: SBRA) CEO Rick Matros argued during the virtual CNA Staffing Summit held on October 20 by the National Association of Health Care Assistants (NAHCA).
“I think that we have an ability here now, with the dialogue that’s going on in our country — our country’s at a moment now that we have to take advantage of, where we have to push to have a different kind of culture,” he said. “A culture that pays people well, that pushes people above the poverty line, that creates equal opportunity for everyone in our society.”
The percentage of CNAs who live below the poverty line in the U.S. far outstrips the proportion among the general population; 17% of CNAs are below the poverty line, compared with 9% of Americans, Matros noted, a state of affairs he described as “simply unacceptable.”
A third of CNAs are Black and half are people of color, while 90% of the CNA workforce are female, he added. This necessitates including these concerns in dialogue and lobbying in with policymakers, Matros argued.
“When we lobby, when we put out PR, we have to tie this all together, because I do think that there’s an opportunity to leverage this,” he said. “In terms of in terms of pay and Medicaid, obviously, we are under-reimbursed, and we have always talked a lot about trying to have better pass-throughs and trying to get more pass-through for wages. I think we just need to put specific proposals out there, and I think we should have a minimum standard in every state.”
The difficulty of implementing such a standard, with 50 different Medicaid systems in 50 different states, isn’t lost on Matros, and the minimum standard would have to vary market by market.
But for SNFs and CNAs, the importance of implementing some kind of reform around wages is paramount, especially after the first major COVID-19 outbreak in the U.S. was shown to be driven by staffers working shifts at more than one SNF.
Using a $20-per-hour wage as an example of a minimum, Matros argued that that wage should be “baked into the cost component function of every Medicaid system in every state that we have” for CNAs. But whatever the final number ends up being, the goal should be to eliminate CNAs living below the poverty level, he said.
“They shouldn’t have to work second jobs,” he said. “They’ve got kids to take care of, and lots of other responsibilities like everybody else does. It impedes your ability to effectively take care of those other responsibilities, which has to be heartbreaking, because folks need two jobs, sometimes three jobs.”
He also cautioned that so-called “career ladders,” wherein CNAs are put on a track to advance along the clinical track or eventually migrate to other roles, are not the solution — especially when those pathways are in place only because CNAs cannot make a living in a job that many of them view as a calling.
This means providing specific proposals, with nursing home associations in various states assessing the economic factors and determining a wage level that would keep CNAs from living below the poverty line, which would then be integrated into the Medicaid formula.
“Along with those lines, when you’re looking at the poverty level, at what level do folks need to be reimbursed for their health insurance?” he said as an example of the type of calculation required. “Should the employer be required to pay 70% of the premium? So again, let’s do that same analysis, so instead of going to the Hill and talking about ‘We need more Medicaid dollars,’ let’s come up with all those specific formulas, and then lobby on those formulas.”
The finances of many operators have taken a beating over the course of the COVID-19 pandemic, and operating margins were hardly robust even last year before the coronavirus became the dominating force in the industry.
But with staffing emerging as a critical factor in how well facilities fare during COVID-19 outbreaks, and the issue of worker treatment one that existed well before the pandemic, now is the time to set some kind of standard in the reimbursement infrastructure, Matros argued.
“If we set a standard, that no CNA in the country should fall below the poverty line, that should at least create some standard for a base pay. I also believe that there should be a standard for benefits as well,” he said. “And there should be no difference, by the way, between the benefits an administrator gets, or someone in the corporate office gets and [what] the CNA gets.”