As several states across the country have extended or made permanent nursing home Medicaid rate bumps tied to the pandemic, at least in part to stem the tide of high staffing costs and inflationary pressures, Texas operators are anxiously awaiting their fate ahead of next year’s legislative session.
Focused Post Acute Care Partners CEO Mark McKenzie remains hopeful and believes state officials are more aware and have a much deeper knowledge of the challenges the nursing home industry faces than they did before.
Texas operators receive $154.98 per patient day even though the state’s methodology says they should be making about $275 per patient day.
The Texas Health Care Association, and its members, are asking for the $19 increase that was put in place with the public health emergency (PHE) to become permanent, as well as an additional $19 — which would put the Medicaid reimbursement range closer to $200.
“Really bringing up to that $38 per patient day add-on … would be not only a breath of fresh air, but it would certainly be a significant step in the right direction,” McKenzie said on an episode of the Rethink podcast.
Highlights of the podcast, edited for length and clarity, are below. Subscribe to Rethink via Apple Podcasts, Google Podcasts, or SoundCloud.
On whether Texas will join the number of other states that have made Medicaid rate bumps tied to the PHE permanent, and what would be adequate reimbursement:
Well, first I’m very hopeful — I think it pays to be a little positive in these types of settings.
I know that our past history in Texas has not been one that has embraced fully funding the Medicaid system for the skilled nursing environment … The average Medicaid recipient in Texas, if you separate our QUIP [quality incentive payment] program, is receiving about $154.98 per Medicaid patient day — against the methodology that says that we should be making about $275 per patient day and that’s through Texas’ methodology.
I think that, as we have learned through the pandemic, the state and the senior leadership has really developed an awareness and a much deeper knowledge of the challenges that we have than they did in the past.
As you know, Texas is a relatively conservative state regardless of the side of the aisle and so both try to be extraordinarily responsible. What the association is looking at is obviously we would like to see the $19.63 from the public health piece, in some form, stay in play after the public health emergency [PHE] is removed. Our hope is that we see that $19 stay in place as well as an additional $19 which would bring us to a $38 a day add-on to that base number of $154 which would put us in that $200-plus Medicaid reimbursement range.
Really bringing up to that $38 per patient day add-on … would be not only a breath of fresh air, but it would certainly be a significant step in the right direction.
I believe that the leadership, regardless of side of the aisle, has a willingness and responsibility to help. I think their big challenge is trying to figure out what that number is, and so we’ve tried to be pragmatic when we talk to them and my hope is that we continue to go down that line and that they live up to what they’ve insinuated or suggested … They recognize the need and that something has to be done.
On what place there is for heavily rural operators in the skilled nursing industry:
When we talk about the rural markets, I think we touch in two places really; we grew a vibrant piece of the economy in those markets and in the areas that we’re able to continue to operate we continue to be a vital piece of the economy.
I think the big challenge for us in the rural market as we look at it going forward is from a staffing standpoint and from our ability to operate and bring the systems into the rural communities that our urban communities enjoy much more abundantly or much more readily.
You look across the spectrum we see a lot of emphasis in rural hospitals and the need to keep those rural hospitals open and the need to become creative with what we do from a legislative standpoint and a reimbursement standpoint on how to make sure that that remains so that there’s access in those areas. It’s much the same need that we need to see for the post-acute care industry in those rural markets.
It starts with recognizing that the skilled nursing side is just as impacted and as affected as the rural access hospitals are because in many ways, we are the exact same person competing for the exact same people to deliver the exact same care Though one is for an acute period of time and the other is for a long period of time, many of the patients that we have or the team members that we have — they are two people on the same side of the coin. Our team members float between the rural access hospital and then they also work over the skilled nursing center.
We are often either the largest or the second largest employer in those communities, and so just from an economic position for those communities it’s imperative that the thought process is put together so that our operators that are in the rural settings have an opportunity to be successful because not only is it an access to care issue for for from a long-term care perspective, but it’s an economic viability issue for the communities that we serve.
On some of the biggest successes and challenges McKenzie faced has faced thus far:
I would have to say the needs, the patients themselves have changed. As I look at what I would call our lightest or most easy patients to tend to or care for were patients in 1990 and 1991 that we would have been mortified to take out of the hospital and bring into our communities. I was fortunate to have one two-year degree RN in the building, whereas now I have BSN’s and I have master level RNs. I have the type of skill sets and they have the ability to provide care for a litany of comorbidities that allow us to be a very complex center for those patients that need our type of care model.
Then I would say technology. Long-term care in Texas, and I would probably say generally across the system, is slow to adopt technology or we were early on. Now we seem to be embracing it much better than what we did in the early 90s or three decades ago. We’re always looking for that new toy that will help us become much more effective and be able to provide that consistent care and have a better knowledge of what’s going on with our residents.
Then finally the regulatory environment in general has changed. Obviously it needed to change with the increased expectation of the types of patients that we care for and what we needed to be able to do is that our regulatory cadence has definitely been leveled. I would say 10 fold, but I’m not sure that that would be correct. Now the criteria of patients that our industry sees as a whole, and again we see the same residents in the rural markets that we see as they do in urban markets, it stands to reason that the expectations of the regulatory oversight would be significantly increased.
On Focused Post Acute Care Partners’ wins and challenges related to staffing:
We’re starting to see some of the people that left come back, we’ve got a handful of team members. Now they haven’t come back to the senior leadership role, they would come back into a charge nurse role or or maybe the assistant director of nursing or MDS or something like that, where they’re not having to be the full leader.
But that said, getting that type of knowledge back to our communities is very, very helpful. When you look at it from the nurse aide level and some of our more direct line levels, it is still a challenge because of the staffing agencies that have been created and reset the market for some of the wages or how our team members want to work. The one thing Covid did for all of our industries is it’s going to force us to have to think about how we staff going forward and be thoughtful to the work life balance that those team members want so that they don’t burn out.
At our lowest point, 25% of our shifts would be uncovered … Pre-pandemic we would run between 8 and 10% uncovered of their shifts and that’s a metric that we’ve continued to follow throughout. Obviously we’ve addressed compensation, we’ve addressed education, trying to put systems in place. At any given day we’ll run about 9% of our projected shifts still not being covered, which kind of mirrors what we started in pre-Covid times.
The opportunity to use, I’ll call them universal workers, hospitality workers in multi kind of locations or multi roles within the time when staffing was at its most critical was helpful … I think it’s demonstrated that not everything has to be done by a CNA … About 70% of the duties that the nurse aide would be doing fall under those that anybody can do if they’re just there to do it. The win for us has been getting creative with identifying what roles we can pull off the CNA so that … So how can we minimize the duties that they do and bring them to an alternative profession to come in and do.
Our hope is that as we move forward and we look at some of the staffing requirements coming down the line from CMS that appear to be headed our way that they too will be creative and allow creativity at bedside and creativity of communities to look at what type of team member or what kind of type of license or certification is needed for certain pieces of the job … But it does a couple of things for us.
First it creates the ability to bring people in and they think they want to be in nursing or think they want to be in the health care field, they can do certain things and get a flavor for it and see if that’s really for them. But it also creates kind of a track of, hey if I come in as a hospitality aide, I can become a certified nursing assistant and then on through, now you have a true difference in job function as well as ability from a compensation standpoint so that we can do some pretty unique things.
On the Biden administration’s recently announced changes to CMS’s special focus facility (SFF) program, and whether it could deter operators from purchasing struggling facilities to turn them around:
I’ve read it and, like every provider, we’re kind of taken aback. I’m not sure that I believe continuing to throw stones or make the stones larger … Make it more aggressive is the way to go.
They want to broad brush that particular provider as a bad provider [because they have an SFF facility] as opposed to looking at it as a one off within a system that appears to be doing really good things across the system in general. And so as CMS often does, there’s really no collaboration. Especially in the special focus communities … We need to be able to sit down there and have a conversation about what is going well and what is not going well both ways because the same surveyors survey the other buildings that those providers have and don’t have those challenges. Additional fines isn’t going to make me try to get the community off the special focus list any harder than I was trying to get it off the special focus list anyway because it doesn’t do me, from a very biased position, any good to have a building perceived to be very ineffective and not providing a standard of care that is expected both internally with myself as well as the community in which we serve.
I think it’s going to create a problem that if there truly is a bad operator, it’s going to be very difficult to get an organization to assume that building to try to fix it because if you make the hurdle higher, you’re asking me as a provider to come in and take what we already know to be a problematic building — and now I’m under the gun to solve that problem.
So I think the biggest challenge is that from a future standpoint, if there’s a provider that says,’ hey, I’ll come in and try to fix this building’ I think people will really take a second look at that because it puts them in a very precarious position if they’re not successful.
I know from my perspective, I took a special focus facility just before the pandemic hit from an outgoing provider, and we did it as a favor, and it ended up taking us a bit of time to get that facility off the list. But we did get it off the list.
But as we talk about what goes on today and their suggestions on the special focus facility, I’m not sure I would take that risk again. It’s just a risk that if you’re not successful, you end up in that broad brush stroke of you were a poor provider, we had to close your building down — and to me this would fall into that no good deed goes unpunished.
So from that standpoint, I think you have a problem getting someone that everyone agrees is an exceptional operator to take them. Otherwise, it will sit there and languish until it either gets closed down or the provider can solve the problem.
On McKenzie’s vision of the skilled nursing facility of the future:
I thought about that question and tried to think about it, but I think I’m just going to take a step back and say we’re at a point in time that is ever evolving.
I think that until all of the stakeholders get on the same page — and that’s CMS, that’s the operators, that’s the payors, as well as the residents and the advocacy groups for the residents — that we can all agree what is going forward, this is what we expect out of the skilled nursing center, this is what we think it should look similarly like and then we can start putting that into practice.
I think if we have to look at the future, if you’re asking me under the assumption that it’s under the same environment in which we’ve had to work the last 30 years I’ve been in — though I’m an optimistic person — I just don’t see material change system-wide.
I think you will see everybody, every operator and every smaller organization looking at it through their own lens. I’d probably be remiss if I said anything more than you’ll see subtle improvements, more single occupancy rooms, but that’s kind of a standard answer that we all give.
Until we have a true system that we’re all agreeing on that this is the environment that we have to make work, it’s very difficult and that’s just one small guy’s opinion.
On one thing that providers should ‘Rethink’ about skilled nursing:
I’m going to go back to staffing. I will speak for myself as a leader of this organization, but also in our organization, we’ve been so married to whether it was 6-2, 2-6, 10-6, Monday through Friday … We’ve been so married to that within our industry that we were unable to effectively attack the staffing crisis that we had as we came through. Instead of looking at all the other ways you could get your staffing metric accomplished, we kept trying to put that square peg in a round hole and people want flexibility.
We knew it pre-pandemic … But we as an industry as a whole stuck to our rigid staffing patterns of it’s always been this way. The one thing that we’ve done is we’ve developed our own scheduling system that mirrors that of an agency or a ShiftKey type function. We have rolled it out in seven of our buildings, we’re working through the final bugs of it, it will be rolled out to all of our buildings at the end of this year. In those buildings using it, we’ve seen a greater satisfaction in our team members, we’ve incrementally seen better shift coverages. I’m not saying it’s the end all be all, but we’ve seen improvement.
Companies featured in this article:
Centers for Medicare & Medicaid Services, CMS, Focused Post Acute Care Partners
