Leaders from across the sector – nurses and policy experts – are urging lawmakers to more carefully consider some of the stipulations of the nursing home staffing proposal, including the ratios of direct care staff, timing and even financial factors that may ultimately prevent the industry from complying with its conditions.
The Centers for Medicare & Medicaid Services’ (CMS) staffing proposal calls for Medicare- and Medicaid-certified nursing homes to provide a minimum of 0.55 hours per resident per day of care from registered nurses (RNs) and 2.45 hours of care from certified nursing assistants (CNAs), with non-rural nursing homes having 3 years and rural nursing homes have 5 years to meet these standards.
“It’s a little bit of a strange rule,” said David Graboswki, a health policy expert from Harvard University, who has testified before Congress on many legislative issues related to the nursing home sector. “[Of] the three direct care staff types in a nursing home, two of them now have a number that [federal authorities] say that nursing homes have to step up to the other one, which was completely ignored in the legislation.”
Grabowski was referring to the exclusion of licensed practical nurses (LPNs), his comments made during a webinar discussion that was moderated by Lori Porter, co-founder and CEO of the National Association of Health Care Assistants (NAHCA).
Graboswki emphasized the importance of analyzing more operational data and financial figures to arrive at more conclusive answers to the puzzle of the most adequate staffing levels at nursing homes. Two primary objections raised by providers, namely a documented shortage of direct care labor and concerns about timing, must be further explored, he said.
“It takes all three staff types to really produce high quality care,” Grabowski said. “I’m not just worried about the number of CNAs, which I agree are too low, but I’m also really worried about LPNs and RNs here.”
Grabowski acknowledged that nursing homes have faced criticism during the pandemic, some of which was justified, but he also pointed out the challenging circumstances the industry was dealing with.
While CMS estimates an annual cost of $4 billion to meet the staffing requirements outlined in the proposed rule, a previous study conducted by CliftonLarsonAllen, based on a higher hourly standard, suggests that the cost could reach approximately $11 billion annually. Given the backdrop of increased Covid-related expenses and declining Medicaid rates, this cost has raised significant apprehensions among nursing home operators and owners.
Grabowski stressed the need for federal officials to closely monitor cost data and investigate the extent to which funding might be dissipating from the system through questionable business transactions. He argued that without this critical data, nursing homes can claim that compliance will bankrupt them, leading to a repetitive discussion.
Acuity levels at SNFs must be a consideration
Provider representatives shared many of Grabowski’s concerns. Nonprofit providers said that despite often having better staffing and quality metrics, they are anxious about the potential cost of the rule. Others mentioned state Medicaid underpayments and the challenge of rebuilding the workforce, even with increased wages for certain positions.
Moreover, representatives from a physicians’ association said that the existing stipulations may not address the needs of skilled nursing facilities (SNFs) with more medically complex residents.
Geriatrician Michael Wasserman, chairman of the California Association of Long Term Care Medicine’s (CALTCM) public policy committee, said that the industry needs to make staffing level decisions that take into account the complexity and acuity of the facilities’ population and functional level of residents and the services they require.
“We want to make sure that we don’t just focus on a number per se, because we don’t believe that minimum levels should become maximum levels,” he said. “We’ve all seen that in states where there are minimums, that they become the de facto maximum. And that we really need to look at the issues of acuity and the needs of the residents.”
Wasserman said that it was important to note that today’s nursing homes were not the same as the ones 20 years ago – a time when CMS first suggested that minimum staffing levels should be set at 4.1 PPRD.
“We actually have younger people with very complex medical and social needs,” he said. “We have older adults with very complex medical and social needs. And we really need to make staffing level decisions, considering the complexity and acuity of the facilities population.”
A compromise needed
Sherry Perry, the board chair of NAHCA, called on nursing home operators to show compassion and be willing to sacrifice some profit for the greater good of caring for the elderly. She urged the government and owners to come to the table and find a compromise.
“It’s sad for the residents,” Perry said. “And it’s sad for the people who care about those residents and who want to take care of them and give them a good quality of life when they’ve given so much to everyone else.”
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