With a presidential election less than a week away and a pandemic still raging out of control in many parts of this country, the post-acute and long-term health care landscape finds itself on the brink of what could be both a brutal and potentially transformative winter.
A shift in power in Washington could bring new rules, investigations, and oversight. COVID-19 spikes could stress regional health care systems to the breaking point yet again. And seniors and frontline caregivers remain at the center of the danger.
During SNN’s virtual Rethink conference earlier this month, we asked a wide swath of leaders from the space how they would change the operational landscape if given carte blanche. The answers were diverse, touching on topics from payments to enforcement to wages, and any actual reforms will likely look significantly different from these suggestions.
But starting today and continuing into next month, SNN will present the answers to a simple but bedeviling question: If you could change the state of post-acute and long-term care in the United States, how would you do it?
First up, a pair of operators — Cascadia Healthcare CEO Owen Hammond and Genesis HealthCare (NYSE: GEN) CEO George Hager — and Sabra Health Care REIT (Nasdaq: SBRA) CEO Rick Matros.
Owen Hammond, CEO, Cascadia Healthcare
I think there’s some some good, thought-provoking conversations that are continuing to happen in the industry now, but for me, I think it comes back to the heart of what we do. I think we need to have a better dialogue with CMS and stakeholders in this industry, and we need to band together and talk about how we can get nurses to actually do nursing care, instead of regulatory compliance. Most of the nurses nowadays are spending most of their time documenting, and managing policies and procedures — and especially now, with all the different infection control surveys coming in there during this.
They’re in this quandary, because they’re trying to manage all of the patient aspects, and then all the outside influences trying to maintain some compliance. I think we need to go a little bit further away from the policing state that it feels [like] in our industry, and really start to come to the table and have a dialogue about what we’re really doing in this industry — and allow our people to do what they do best, and that’s patient care.
Sitting down with them and figuring out how we can loosen the burdens to let our nurses, specifically, and CNAs, actually give that care and find a way where we can build that trust up with the community at large, so they are not going to be looking at our industry in a poor light. I feel like as an industry, we’ve got to all get off the sidelines and stand up and start advocating for the great people that work in it, and the residents that we care for.
This is a vulnerable population. I feel like the dialogue might be different if this adversely affected young children as opposed to the elderly, and I think that there might be different policies put in place and different urgency set aside for this.
I just want to remind everybody how important these elderly residents are. They are the ones that have helped build this nation. They’re the ones that have paid into the the social contract that we [built] in the ’50s. They are active members of the community, even if they’re inside of our walls. We need to make sure that we are building a continuum of networks that are out there that really view them as people and not objects.
I’ll get off my soapbox on that. But I think as we continue to have that dialogue and go further ahead, we need to get away from the rhetoric and we need to sit down with CMS. We need to sit down with the other providers in the communities and figure out that gap. Right now, we spend more time documenting and figuring out how we’re going to be in compliance — children at a playground are more free to do things than elders in our facilities. I think that’s just backward, and I think that we need to have a real dialogue about that, and I hope that people will speak up and start joining … myself and others within the industry to really bring that conversation to life.
As we continue to look at the needs of the future generations that will be using our services in this industry, I think we need to take a hard look at the CON, the certificate of need regulations within different states. And I know that’s a touchy subject, but if we are having barriers to being able to open new facilities with different types of rooms and settings, we’re going to run into a real issue. Most of the buildings are 50, 60 years old; they were built for a specific population at the time, more of a convalescent home.
That has changed: The acuity has risen, and we continue to be more acuity-focused in most of our facilities, and the needs of the people that are coming to use these services are higher and different. If we are restricted from being able to build these facilities across the nation, we’re going to find ourselves in a real pinch when the tsunami comes across.
We continue to look to build — we built two [facilities], we’re going to be building two more — and we look for new and innovative ways to adapt our footprint. But we run in, continually, to the cost barriers and regulatory issues with CON states, and I think that needs to be addressed as well.
George Hager, CEO, Genesis HealthCare
I think one of the things this pandemic has done is it’s validated that the skilled nursing industry is a critical component of the health care delivery system. It’s so necessary as patients are triaged and required to transition from the acute care setting, ultimately into the community safely, which is our objective for the most part. But we also serve a chronically ill population that is typically funded by the state Medicaid programs, and for the most part, the state budgets have not allowed the state Medicaid systems to adequately fund the needs of the long-term care industry.
From a long-term structural perspective, what has resulted is: We have an infrastructure today that was built principally in the ’80s and the ’90s, when the skilled nursing industry was principally an industry that served a long-term care patient that could not fulfill a certain level of activities of daily living. But it wasn’t the sub-acute or severely chronically ill population in skilled nursing.
The infrastructure, when it was developed, was built for a very different purpose. Now we find ourselves serving a very, very different population, a population suffering from severe chronic illness, from dementia — a sub-acute population that is vulnerable to issues like COVID-19.
I agree we need to try to change the dialogue from the current penalty-oriented, financial penalty-oriented, aggressive-oversight type of system we have today to a more constructive and collaborative approach to how we’re going to attract capital and invest in this industry, so this industry is better able and capable to deal with things like the pandemic, but not only the pandemic.
We have a tidal wave coming at us with respect to the aging population, and as the life expectancy continues to increase, and the incidence of chronic illness and dementia continues to grow, this industry needs more. It needs more investment. It needs more capital, it needs more programming, it needs more clinical skill.
And we need to access capital to do that, and we need support from the regulatory environment — clearly from the administration, from the federal level, the state level, from the investment community, from the clinical community, our peers above us on the acute care side and below us on the home care side — to really collaborate around how we can make this industry really more sustainable and more effective in serving the need that we clearly, clearly have demonstrated through this pandemic that we need to be able to provide.
Rick Matros, CEO, Sabra HealthCare REIT
Wage support for staff, that would be number one. We have to be able to pay them more than they’re getting paid.
That’s going to have to go to Medicaid reform. Maybe in the absence of Medicaid reform, systems at least need to change so that you’ve got larger pass-throughs when it comes to wages. So this is we’re going to do: All these states [would] increase Medicaid rates, but this rate increases is all going to be focused on better wages and benefits for the employees. Certainly that’s not reform. But that’s at least a way of getting there.
There are already plenty of states that have those mechanisms in place for their Medicaid systems; they may need to change the ceiling on that. But some of the mechanisms are already [in place]; we’ve already got cost-reimbursed Medicaid programs all over the place.
From an enforcement perspective, I think to truly have enforcement on things that most affect outcomes. So forget about tags because you’ve got some dust-in-the-hallway type of thing, and let’s focus on helping operators get to where they need to get to on infection control, disaster preparedness. Get away from some of the paper stuff and have it truly be outcome-focused.
It’s been talked about a lot, but it’s still very inconsistent across the country. I think adding regulations is not the answer. I think shifting the focus of regulations so that it really, truly is an outcome-oriented process, and have it be a little bit more collaborative than it’s been, along with the wage issues. Those would be my top priorities.
These responses have been condensed and edited for clarity.