Frequent nursing home closures and an access crisis across the country mean skilled nursing providers and unions must put aside their differences to find common ground in the post-pandemic age.
However, achieving that alignment in the midst of seismic regulatory changes and legal challenges is another story.
“We’re at a crossroads,” said Zach Shamberg, president and CEO of the Pennsylvania Health Care Association (PHCA). “The pandemic exposed many flaws in our long term care system. Prior to the pandemic, this industry was facing a workforce shortage, a funding crisis, burdensome regulations in Pennsylvania Our legal climate was driving good providers away.”
Much like other parts of the country, the past three years of Covid have exacerbated and accelerated these issues in the state – the association has seen nursing homes close, changes of ownership, reorganizations and sales, he said.
These issues are complicated by the fact that the rising demographic in a nursing home is the 85 and older population with higher acuity, he said. This population is expected to double by 2040 in Pennsylvania.
“We are now in the midst of an access to care crisis. And my question is, in terms of the industry coming together, and working together, if not now, when? Now is the time when we have to put our differences aside. Providers and workers and advocacy organizations have to team up to find and achieve support for this industry,” said Shamberg. “If we don’t, we could see a collapse.”
Pandemic circumstances promote more alignment
Some union leaders believe interests more closely overlap now – with alignment more common between these two entities. Skilled Nursing News spoke to a national union representative who preferred to remain anonymous.
This leader agrees that unions and providers are joined in efforts to increase reimbursement rates – under the condition that funds go toward staffing and direct care staff compensation. This wasn’t always the case, with providers in the past wanting increases with no strings attached.
It’s important to remember that the skilled nursing industry isn’t monolithic either. While some players like the Ensign Group (NYSE: ENSG) are run at a very high profit level, a lot of other operators are smaller, region-specific businesses that barely break even.
And improving the public image is another area where both entities could benefit.
The industry is being pushed to be more transparent by regulatory agencies than they have in the past 10 to 20 years, this leader added. Moreover, the industry recognizes its public image was tarnished during the pandemic, and it now seeks to regain public trust.
All of that has made some unlikely partnerships possible that would have been impossible if providers weren’t rebuilding their public image, according to this union leader.
Still, unions tend to think of workforce issues not in terms of a shortage, but as a “good job shortage.” In other words, union leaders believe the workers are out there, but the work isn’t attractive to a lot of people with low pay and that, in many cases, lacks union representation.
And so, both entities share an interest in transforming nursing home jobs into the kind of positions people want to keep and in an industry in which they want to grow.
A national model
While facing such dire circumstances, Pennsylvania became one example of where these two entities came together in late 2021 — when the industry was still at the height of the pandemic and facing an increasingly severe workforce shortage.
“At the end of the day, we were very proud to find real common ground,” said Shamberg. “That common ground includes investments in workers, whether it’s higher wages, better benefits, more incentives, providers and workers.”
Both unions and providers want those things, and they became united last year on recruiting and retaining the workforce, especially as the sector emerged from the Covid-19 pandemic, Shamberg said.
PHCA and SEIU Healthcare PA, along with other stakeholders, including the governor, members of the state legislature and state department of health, worked together to make a historic investment – a 17.5% Medicaid rate increase. It had been nearly a decade since the last Medicaid reimbursement increase in the state, according to Shamberg.
Meanwhile, staffing regulations were updated, with staffing ratios implemented for the first time in Pennsylvania; the outcomes proved to be beneficial for both workers and providers.
“We also implemented first-of-its-kind accountability provisions, which state that new funding has to go to resident and resident-related care costs. At the end of the day, providers benefited workers benefited and most importantly, the residents they serve benefited,” noted Shamberg.
Moreover, unions and the PHCA also took steps to eliminate barriers to a nursing career, cutting through red tape and bureaucracy that “so often” keeps prospective workers away from the SNF industry.
Unions and PHCA were able to find common ground in regulating staffing agencies and introducing more clinical roles, including the certified medication aide (CMA), which allows a certified nurse aide to pass out medications to residents and free up registered nurses for other services.
Shamberg hopes Pennsylvania can serve as a national model for states across the country, by which providers and workers can collaborate to be successful in policy decisions. He said the association looked to Massachusetts, Oregon and Minnesota when planning their collaboration with SEIU Healthcare PA.
Sticking points
While PHCA and local unions are aligned on many staffing issues, the federal staffing mandate is still a point of contention, Shamberg said.
While unions at the state and national level have been very supportive of the nationwide staffing minimum, PHCA is opposed.
“Providers are opposed. That’s especially important in Pennsylvania, because we did this work last year,” said Shamberg. “We worked with the unions, we worked with our governor, we worked with local legislators to find the right staffing minimum to find the right staffing ratio, to achieve commensurate funding to include accountability provisions, and to get this done in a way that will work for Pennsylvania and for older Pennsylvanians.”
A ‘one size fits all’ mandate should not be implemented at the national level, he said.
He believes it could negatively impact the industry not just in Pennsylvania, but nationwide.
“Looking back at the 2001 study, looking at what CMS said in 2015 – where they admitted a one size fits all approach does not work – we hope that there’s some common ground,” said Shamberg. “We hope that just like in Pennsylvania, we can work with CMS and the unions and the Biden administration, and members of Congress to find a middle ground here, because 4.1 could be disastrous.”
Unions, on the other hand, have been publicly supportive of a 4.1 PPD national mandate which includes CNAs, LPNs, and RNs.
Absent national minimums, the union leader said, there is no way sustainable, safe staffing can happen in every state. Union members feel very strongly that the mandate, coupled with state medicaid rebasing tied to staffing numbers as well, is crucial to ensure safe care.
Another point of contention, this union leader said, is respecting workers’ rights to join a union in the first place. Covid data shows unionized facilities had lower mortality rates during the pandemic.
Nursing home workers in southern states specifically find it incredibly hard to organize, the union leader said.
Training programs and complementary policy ties
As unions and providers work to get preferred policies in place at the federal and state level, union leaders say it helps to have connections on both sides of the aisle – through union-provider collaboration.
While unions aren’t partisan, they do lean more to the left with political issues, this union leader said. Providers lean more to the right. Combined, bipartisan legislation is more likely to get introduced and pack more of a punch on the floor.
One such example of this bipartisan policy is out of Illinois. Nursing homes received a $700 million bump in reimbursement, which could not have been possible without such a collaboration, and connections with Democratic and Republican representatives, this union leader said.
Another added boon of collaboration are better workforce initiatives and training. National unions like SEIU have created robust training programs with providers that make it possible for incumbent workers to gain new skills and move into better compensated positions.
Labor management partnerships between the two entities have helped with pipeline efforts and been paid for using collective bargaining funds and sometimes grant money.
Training programs run the gamut – tutoring, mentoring, childcare stipends are all included.
A bigger sign that coming together for the greater good is being embraced as a way forward: A more recent endeavor between SEIU, providers and other stakeholders seeks to establish nursing home standards boards across the country. Each board would have representatives from unions, operators and state agencies.
These boards would collect evidence, testimony and determine what appropriate compensation standards are for this industry, subjective to reimbursement levels.
So far, the idea has come to fruition in Minnesota, where the governor signed legislation to establish such a board.
Companies featured in this article:
CMS, Pennsylvania Health Care Association, SEIU, SEIU Healthcare PA
