The federal minimum staffing proposal was rushed through and is “inherently flawed” to a degree that makes it possible to defeat, according to the chief of the nation’s largest nursing home association.
In a wide ranging conversation at the Skilled Nursing News (SNN) RETHINK conference in Chicago last week, Mark Parkinson, president and CEO of the American Health Care Association (AHCA), said problems with the staffing proposal stem from lack of funding and the federal government ignoring the regional differences in staffing, census and reimbursement, among other issues.
“The quality of the process usually defines the quality of the product. And this rule was the result of a very poor process … If they had followed a process, they wouldn’t be stuck with where they are right now,” Parkinson told SNN. “Every administration that has studied it has decided to not do it. And that’s because they’ve had a good process in which they talked to stakeholders, they talked to providers, they [did] studies before they announced the policy.”
Any minimum staffing mandate is best addressed at the state level, Parkinson said, because for starters there are “dramatic” differences between Medicaid rates, with some states still reimbursing with Medicaid rates of around $170 with others at over $400. Moreover, there are facilities in states like New York with over 600 beds while facilities in Kansas or Washington might more commonly have 40 beds. In addition, there are differences of licensure across the country. Also, some states might not have enough registered nurses (RNs) to fulfill the rather difficult 24/7 RN requirement, while in others there may not be a sufficient number of qualified candidates.
“It doesn’t make sense to have the same requirement in every state … there are all sorts of workforce differences,” Parkinson said.
The proposal calls for Medicare- and Medicaid-certified nursing home to provide a minimum of 0.55 hours of care from registered nurse per resident per day and 2.45 hours of care from a nurse aide per resident per day, with non-rural nursing homes having 3 years and rural nursing homes have 5 years to meet these standards.
“What we’re really hoping is that the [Biden] administration just won’t issue the rule, that they will come to understand that a one-size-fits-all just doesn’t work across the whole country,” Parkinson said.
Regional differences demand nuances
Moreover, about six states already have their own staffing mandates, sometimes in conflict with the federal proposal.
As the federal minimum staffing proposal continues to receive criticism over its proposed stipulations and awaits feedback from providers during the 60-day comment period, Parkinson said it is important for providers to lodge their concerns with the Centers for Medicare & Medicaid Services (CMS). AHCA’s goal is to get at least 10,000 complaints filed.
Parkinson said any staffing mandate would necessitate a pool of workers to draw from and enough funding to allow the workers to be paid.
“This rule is impossible to implement, first of all, because the workers aren’t there,” he said. “And secondly, because the funding wasn’t there. You know, I’ve talked about the states where the average Medicaid rates are $170. [Here], they just can’t staff at this level and keep their doors open.”
Moreover, inadequate funding will mean huge ramifications for the most vulnerable facilities, he said. CMS has by its own estimates shared that it will cost between $4 billion to $5 billion a year to fund the staffing proposal as it stands, which is an average of about $300,000 per building, Parkinson estimated.
“So the unintended consequence of this rule is the complete opposite of what President Biden believes in and what Secretary Becerra believes in … folks that are the poorest in our society are going to be impacted by this policy the most. So in my view, the policy is inherently flawed,” he said.
Parkinson said he’s afraid too that the rule will lead to a lot of citations for nursing homes. “Almost every building in the country at some point will be noncompliant,” he said, especially in regards to the RN rule.
Licensed practical nurses (LPNs) are not counted in the proposed staffing rule, and their exclusion will cause problems as well, said Parkinson. But pushing for their inclusion must be done in a thoughtful manner, lest adding LPNs also drive up total hours per resident day requirements.
“It’s a real head scratcher as to why there’s a complete disrespect of LPNs in this policy,” he said. “So we’re having a much more nuanced ask [to the federal government], which is to count more LPNs, but count them either in the RN category or the other categories, depending upon where the provider needs them to be.”
Addressing a room full of providers, Parkinson said that submitting comments in the next 60 days is crucial.
“What’s important is that [federal authorities] understand how much this impacts every single building … go to our website [and] just talk about your experiences, challenges in getting staff and your concerns about the impact that this would have on the industry,” he said.
At the end of the comment period, with intense advocacy efforts underway, Parkinson said he hopes that the proposed rule will not be implemented at all.
Advice for workforce retention
And while the staffing proposal dominated the conversation, Parkinson also spoke about what providers can do to strengthen their workforces.
“I really think [what] providers need to focus on the most right now is employee satisfaction and engagement,” Parkinson said. Even as AHCA is pushing legislators to increase the workers through passing a “reasonable” immigration policy, he said nursing home operators have to pursue workforce initiatives that have succeeded.
Turnover rates vary dramatically among AHCA members. Some providers have turnover rates of less than 50%, while others have over 200%.
“As we do a deep dive on how is it that these companies have very low turnover … [they] just have great leaders that are mission driven, who get the mission of the organization permeated through the entire employee group. The employees understand the mission and are all about it. They’re all fighting together,” Parkinson said.
Employee retention can also be helped by providing employees with good mentors and programs for education, especially those that offer training and education that facilitate a career path from CNA to LPN or even RN, he said.
Medicare advantage, I-SNPs and population management strategy
In the midst of the burdens created by the growth of Medicare Advantage plans – with more burdens on the way if the staffing proposal is approved – Parkinson said nursing homes can avail themselves of opportunities for profits through value-based purchasing (VBP) incentives, the creation of institutional special needs programs (I-SNPs) where possible, and population health management.
“That’s really what population health management is all about,” he said. “It’s saying, ‘Okay, if we can’t beat the managed care companies, let’s kind of become one ourselves through an I-SNP, or let’s become sort of like one.’”
Many providers have gone the route of either having their own I-SNPs, or they participate with partnerships.
“That’s a way for Medicaid-only buildings to have a cash flow stream to maybe survive even though Medicaid is generally such a poor payer. So I’m super excited about it. And I would just encourage everybody here to have a population health management strategy,” Parkinson said.
Parkinson said that AHCA is trying to get its members to develop ways to increase their leverage against managed care companies. The issue is especially pressing given the preponderance of small providers throughout the sector.
“Most of them have 10 or fewer buildings, so they can’t have any leverage to negotiate. So AHCA started to build networks across the country,” he said.
Currently, five such networks exist and AHCA is looking to add additional networks in three more states by the end of 2023. Being part of these networks for smaller providers seems like a good strategy based on results so far, he said.
And as for the staffing proposal, defeating it remains the main goal for AHCA in the latter half of 2023.
“If there is a groundswell of providers across the country talking to the reps, talking to their senators, we’re hopeful that if CMS doesn’t do the right thing here that Congress will step in and force them to,” he said.
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