Despite the federal government’s likely decision to keep the public health emergency (PHE) in place past January, the nursing home industry continues to prepare for operations without the safety net of certain waivers.
Leaders in the space say any continuation of PHE waivers – temporary or permanent – should be dependent on cost and patient quality evaluations.
The trouble is, while such evaluations of the waivers and Covid-related programs exist, that information hasn’t been made publicly available by the Centers for Medicare & Medicaid Services (CMS), according to former CMS Administrator Seema Verma. The only exception being surveys tied to the temporary nurse aide (TNA) program, she told Skilled Nursing News.
SNN reached out to CMS to see if there were any other waiver-specific evaluations released, but didn’t hear back from the entity as of press time.
In the meantime, operators would benefit from investing in ways to continue using certain waivers. Verma used the three-day stay waiver as an example, which is still allowed beyond the PHE through value-based care programs.
CMS still seeks to incentivize operators to participate more in Medicare Advantage (MA) and other value-based care options, she said.
“I think CMS would be more open to that as long as it’s inside a value-based arrangement,” added Verma.
The Department of Health & Human Services (HHS) is expected to keep the PHE in place past the January expiration date, according to a Reuters report, as concerns of a tripledemic looms over all health care settings during winter months.
The PHE was originally put in place in March 2020 and has been renewed every quarter since.
“It’s incumbent on CMS to be able to say, it’s not just a light switch here and we’re going to turn all these off,” said Verma. “I think it’s worth a discussion with the industry about what’s actually needed. I hope that’s the approach, as opposed to just saying we’re going to turn these off.”
In an October interview, before the Reuters report was released, David Chess, founder and chief medical officer of primary care practice Tapestry Health, told SNN that an extension would likely be given as facilities braced for a winter surge in illnesses. Verma, on the other hand, said it should have been continued months ago.
“COVID is going to be hitting the homes again pretty hard. It’s not going to be ruthless like it was before … but it’s going to be rampant. Plus it’s going to be a very difficult flu season. They’re not going to want to take down those barriers,” added Chess.
Waivers that CMS sunset in May include:
- restricting in-person resident groups
- physician delegation of tasks to other clinical positions
- physician visits made by other clinical positions
- suspending quality assurance and performance improvement (QAPI) efforts
- waiving utilization of certain resources to help residents choose a post-acute care provider
- suspending the requirement to provide residents with a copy of their records within two working days
Waivers that ended June 7 include:
- allowing non-certified nurse aides to work for longer than four months as they prepare for their exams (with the exception of approved extensions per state)
- using non-SNF-certified buildings or rooms for isolation purposes
- waiving maintenance of dialysis machines and ancillary dialysis equipment
“They’ve already pulled back on a ton of items that have made getting access harder. That’s coupled with the increased regulatory vigilance,” said Chess of the discontinued waivers and reform initiatives outlined by the Biden administration in February.
Evaluations will inform CMS’ next moves
Verma said evaluations were a “really big part” of instituting the waivers in the first place when she was at the helm of the government agency.
“The three-day [stay waiver] rule in particular was one where we started to look at that to say, ‘is this going to get abused? Are we going to see increased costs,’” said Verma. “Two years is enough time to be able to say, we saw some problems in this particular area or, we didn’t really see problems in this area and so maybe we can continue it.”
Suspension of the three-day stay requirement allows Medicare patients to be discharged to a skilled nursing facility without having to stay at a hospital for at least three days.
Without the waiver, patients transferred from a hospital to a SNF in fewer than three days would have incurred out-of-pocket costs. The federal agency initially waived the requirement to free up hospital beds at the onset of the pandemic.
The only waiver that had any sort of evaluation made publicly available, according to Verma, was the TNA program. The federal agency linked the waiver to resident weight loss, depression and pressure ulcers, with a “lack of certain minimum standards” at its core using long-term care surveys.
“This gives a little bit of flexibility, but at the same time, it’s a conundrum for the agency because you want to make sure that you are assuring quality. If you don’t have well-trained staff inside a nursing home, there could be an issue with quality of care,” said Verma.
Associations appear to be split on the TNA program. The American Health Care Association (AHCA) has called on CMS multiple times to reinstate the waiver, arguing that such frontline workers provide much-needed care.
The National Association of Health Care Assistants (NAHCA), which represents more than 26,000 CNAs across the country, has formally supported discontinuation of the waiver, raising concerns of bringing aides to the bedside without appropriate training.
“That one makes me a little bit nervous, although I also understand that we’re in an acute staffing shortage,” Verma said. It’s all about finding a balance between adequate staffing and quality, she added.
CMS originally announced back in April that it had planned to phase out the waiver, among others tied to the PHE. Anyone hired prior to June 7 would have until Oct. 7 to meet testing requirements, CMS had said.
But in August CMS issued updated guidance that provided opportunities for individual facility and statewide or county waivers to get additional time to certify TNAs when testing and training barriers were apparent.
A more permanent fix lies in the Building America’s Health Care Workforce Act. The bill would allow TNAs to stay in their roles an additional 24 months following the end of the Covid-19 public health emergency; these extra hours would count toward 75-hour, state-approved training and competency evaluation programs.
Telehealth allowances, with parameters
While CMS officials will likely want to put parameters in place to deter overbilling and ensure utilization is appropriate, Verma said a continuation of telehealth waivers will help operators increase quality and access to care in the years ahead.
Like so many other flexibilities tied to the PHE, examining telehealth waivers in the skilled nursing space, evaluating its effectiveness and defining telehealth in the sector will better inform CMS’ stance on allowances.
Telemedicine visits in a nursing home need to have additional equipment available to monitor different parts of the body – meaning remote patient monitoring will need to become more normalized in facilities and at the core of a SNF telehealth visit definition.
“If you don’t have at least those basics, you’re not doing a real visit with a patient in a nursing home. You’re having a chat,” added Chess.
Using waiver evaluations to better define telehealth, Chess said, will help the agency and operators tackle access issues. The definition of telehealth is “all over the place” currently, said Chess.
“After two years, we know that it’s worked well,” added Verma, especially as the sector continues to face provider shortages across the country. “We have to acknowledge that nursing homes are struggling and that the provision of more medical care could lead to better outcomes and higher quality.”
Physician visits tied to care transitions should revert back to in-person appointments, she added, while behavioral health assessments or visits with specialists could still be a telehealth visit moving ahead.
This would help with transfer trauma or general discomfort with moving an elderly, frail patient outside of the nursing home for a specialist or general physician visit, she added.
“We have a problem with readmissions … having more access to better medical care across different specialties could answer a lot of the issues around quality,” noted Verma.
States replace PHE safety net
Looking ahead, some states have baked aspects of the PHE waivers into their budgets moving forward, mostly through making temporary Federal Medical Assistance Percentage (FMAP) funding permanent.
It’s a move CMS advocates as PHE waivers are likely sunset in the near future.
Illinois, for one, approved a $700 million increase to nursing home funding in the state as of July 1.
The funding pool devotes $290 million to $350 million toward staffing incentives; $70 million toward a new quality program; $83 million for CNA compensation and support workforce retention, tenure, promotion and training; $34 million to end rural reimbursement rate disparities; $52 million to transition from Resource Utilization Groups (RUG-IV) to Patient Driven Payment Model (PDPM); and $170 million to boost base Medicaid reimbursement.
Florida’s rate increase included $293 million for nursing center care, or $419,000 per care center, and requires all nursing home employees be paid at least $15 per hour as a condition of the additional funding.
Pennsylvania’s Medicaid reimbursement rate increase was 17.5% higher for nursing homes in 2023, an increase of $35 per resident per day.
A big priority for AHCA in 2023 will be to get all 50 states to revisit and ultimately adjust their Medicaid rates, with rate increases tied to staff pay, minimum staffing ratios and other measures tied to care quality.
The federal government could also step in and issue a Medicaid adequacy rule, AHCA President and CEO Mark Parkinson said in an October interview. Such a rule would require states to pay an adequate amount of Medicaid to not just nursing homes but all government providers.
A data-informed future
From the day CMS waivers were implemented, and every quarter thereafter, CMS has been running parallel evaluations and updating the possibility of more permanent solutions, according to Verma.
CMS must go through the list of waivers “over and over again” to determine which ones the agency will keep regardless of the PHE, and keep a close eye on others that required a conversation, required evaluation and data:
“These should be data-driven decisions,” she told Skilled Nursing News.
She hopes CMS uses that data, along with dialoguing between the agency and industry leaders, to figure out what’s needed moving forward. At the same time, she recognizes that the extension of some of these waivers is not a permanent solution to larger nursing home issues.
“It’s not a solution to say, well, we’re not going to require as much training as we’ve had in the past or give you a little bit more time. The goal is to improve quality. We’ve just got to figure out a better strategy of how to get there,” she said.
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