More than 280,000 residents, or nearly a quarter of all residents, could be impacted by the staffing mandate – if nursing home operators have no choice but to reduce their census in order to meet hourly requirements.
The proposed federal mandate would require an estimated 102,154 additional full-time employees. That’s 80,077 certified nursing assistants (CNAs) and 22,077 registered nurses (RNs), according to an analysis released Tuesday by the American Health Care Association (AHCA) and prepared by professional services firm CliftonLarsonAllen (CLA).
The proposed rule requires 2.45 CNA hours per resident per day (HPRD) and 0.55 RN HPRD, and for facilities to have an RN on site 24 hours per day.
“There are two ways to meet the staffing mandate. One is to increase staff, the other is to decrease the number of residents in the facility. Those are the only two levers that can be pulled,” said Cory Rutledge, chief assurance officer at CLA, speaking at a press conference held by AHCA following the analysis’ release.
If operators can’t find additional staff, he continued, the only thing to do is discharge residents that are currently in SNFs.
“Logic would tell us that those individuals don’t have any better options in terms of places to go, particularly those that are on Medicaid,” said Rutledge.
Mark Parkinson, president and CEO of AHCA, said during the press conference that the Biden administration is well intentioned with its minimum staffing proposal, but unfortunately the proposal, if mandated, will have “disastrous results.” It won’t improve quality, he said, but will decrease access for the people the administration is trying to help.
“The administration’s own study concluded that this would not work or that the policy was not justified. Its own study indicated that there was no specific threshold of hours, where all of a sudden quality improves or quality declines,” said Parkinson. He also noted that if the proposal were to go into effect today, nearly every nursing home in the country would be considered out of compliance.
One positive, however, inherent in the government’s bid to improve staffing is that the Biden administration issued this as a proposed rule and not an interim final rule. That gives associations like AHCA the opportunity to talk with administration officials, and for members to talk with officials to ideally stop the policy or significantly shape it before it’s finalized, noted Parkinson.
“That’s priority number one. In addition to that, we’re talking with members of Congress because organically there are members of Congress that have asked what they can do to help try to change or stop this policy. That’s our complete effort,” said Parkinson.
It appears that litigation is not a main focus for the organization as of right now.
Disproportionate impact on Medicaid recipients
Nursing homes that didn’t meet at least one of the mandate’s hourly requirements were more likely to have a majority of their residents relying on Medicaid, according to the report.
About 94% of all SNFs are currently not meeting at least one of the three proposed staffing requirements, the report found – 36% of facilities aren’t meeting any of the requirements, 34% fail to meet two of the requirements, and 24% are not meeting at least one of the hourly requirements.
CLA also anticipates cost to be approximately $6.8 billion per year to nursing homes, higher than the $4 billion per year estimate from the Centers for Medicare & Medicaid Services (CMS).
The only way to meet this enormous cost is through the Medicaid system, Parkinson added. Either Congress would need to fund the increased costs, or CMS could force states to pay an adequate Medicaid rate before the agency approves the state’s Medicaid plans.
“The [legal] question is, can CMS force states to pay additional amounts to providers in order to meet this requirement? That’s the only way that we really see that this can work is through the Medicaid system,” said Parkinson.
Meanwhile, 60% of nursing homes are currently operating at a loss, Parkinson said. Those that do have a gain say it’s a minor margin.
“If all of a sudden we had to lose roughly 25% of our population, the whole thing would collapse,” said Parkinson. “It’s not just the 287,000 folks that are at risk of displacement. It’s really everybody that lives in a nursing home.”
One exception, he added, are high-end nursing homes that principally take Medicare beneficiaries and private pay residents.
“Those folks would be fine. That’s a pretty small number of people, though,” said Parkinson. “The vast majority of people, so people that are impoverished that I really think the administration wants to help the most, the people that live principally in Medicaid facilities, they are the most at risk because of this proposal.”
Real world impact
Marie Costa, vice president of clinical services with Revive Health Senior Care Management in Nevada, said Revive had to make the hard decision to not reopen a dual-certified wing, which served those eligible for both full Medicaid and Medicare with a capacity for 60 residents, due to the labor shortage.
Revive serves primarily Medicaid recipients, she said.
In Northern Nevada, Revive has been facing an “eye opening” amount of competition for staffing from area factories and retail distribution centers. Moreover, local hospitals also started hiring licensed practical nurses (LPNs) during the pandemic.
“We’re trying to be as innovative as possible in attracting and retaining workers, but with increased competition from local factories, distribution centers, and other health care providers, we are stuck,” said Costa.
Nevada is one of the top five worst states facing the nurse staffing shortage, she said. It’s yet another example of how a one-size-fits-all staffing mandate doesn’t acknowledge the vast differences in the labor market, she said, in different parts of the country.
Costa also touched on the lack of LPN coverage as part of the proposed mandate. This position, she said, is a “lifeline” for Revive’s facilities.
“It is incomprehensible that the Washington bureaucrats do not recognize the necessary role [LPNs] play as part of the care team. LPNs matter. Nursing homes thrive because of the LPNs. If LPN hours do not count, then we really have no recourse,” said Costa, referring to a reduction in census.
Companies featured in this article:
