Nursing Home Clinicians Need a Seat at the Policy Table to Address ‘Chronic Underfunding’ and Workforce Shortages

At a time when healthcare policy changes and potential Medicaid cuts create uncertainty for nursing homes, Signature HealthCARE is forging ahead with initiatives that will result in certain wins for providers.

According to Kathy Gallin, vice president of legislative affairs and health policy at Signature HealthCARE, key legislative priorities for the organization include workforce solutions and CNA training to address an unresolved matter. 

Signature’s other priorities include defeating the federal minimum staffing mandate. Gallin argued that CMS lacks the authority to enforce such a rule, citing a $22 billion cost and the difficulty of attracting staff in an increasingly competitive labor market.

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In an interview with Skilled Nursing News, Gallin also expressed concerns about potential Medicaid cuts and regulatory changes, particularly CMS’ push for transparency. While transparency is important, Gallin believes focusing on private equity ownership is a distraction, and efforts should focus on addressing funding and workforce shortages.

More nursing home provider representation in policymaking is vital for shaping policies that ensure quality care in nursing homes, she said, as providers battle low reimbursement rates, with the current funding failing to cover the rising costs of care.

Headquartered in Kentucky, Signature is a provider of long-term care, offering services across the health care continuum, including skilled nursing, home health, assisted living, and in-home care, with more than 60 locations across Indiana, North Carolina, Virginia, Kentucky, and Tennessee.

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The conservation below is edited for length and clarity.

Are there any legislative or policy issues that are particularly important for Signature going into 2025?

Gallin: We must continue to focus on workforce solutions and advocate for CNA/TNA training, immigration reforms, increasing nurse aid training and faculty and of course the staffing mandate.

The CNA lockout bill would really help address the shortage of CNAs by ensuring that nurses aides have the access to the quality training they need to provide the care to our residents. We really need to continue to build a pipeline of caregivers as you know, CNAs provide the necessary daily care for nearly 1.3 million frail and elderly Americans in a skilled nursing facility, and they they really play an integral role in many communities, particularly in rural and small communities, where skilled nursing facilities are often the major employer.

The Healthcare Workforce Investment Act, which was just recently introduced, would direct the Secretary of HHS to award grants to states to establish and increase the availability of and improve access to qualified health care programs to really increase and strengthen the health care workforce, which we know is suffering right now. The bill addresses both funding and collaboration and boosting the pipeline of health care workers, as I previously mentioned, and subsequent to that, the observation status, which has been an ongoing problem for years. We’ve been talking about this for the last two decades. It’s an ongoing problem. It’s so archaic, and it really just needs to be solved.

And finally, of course, the minimum staffing mandate. If we didn’t speak of the minimum staffing mandate, we’d be remiss, and I know you have seen that 22 other states have joined, you know, this effort, and we hope that we can make some progress. I know that Texas will be handling the lawsuit, and we’ll see what happens.

How will some of President’ Trump’s initial executive orders and potential cuts to Medicaid impact nursing home operators like Signature?

While Trump’s various executive orders include freezing all regulations for 90 days … there is still so much unknown at this point in time.

We must continue to advocate for protecting Medicaid and addressing regulatory environment improvements that will be very critical to our success [and] staying focused on quality measures. It is also important to protect beneficiaries’ access to care and services while ensuring provider sustainability.

SNN: Can you offer us a behind the scenes look on how the effort to defeat the staffing is going?

Gallin: We’re cautiously optimistic that it will be defeated.

SNN: There have been a lot of legislative hurdles to increasing the rolls of immigrant nurses. Do we have any sense for how open our lawmakers might be now facilitating immigrant visas for

Gallin: As far as from what I have seen, no. They stopped the visa process [in 2024], and that’s so ridiculous right now, when we are in such need of health care workers and the international nurses really can play a huge part for the rising demand that we are seeing, and it’s just odd that that they would have paused the immigration visa process for us to hire international nurses and bring them over to deliver that exceptional care that they provide.

SNN: On the topic of additional regulation compliance, CMS began a push for transparency during the Biden Administration, the latest effort being the requirement related to revalidation paperwork that asks facilities to detail ownership. Would this really improve outcomes for your organization?

Gallin: They need to slow that down. And, I don’t believe it would improve outcomes. While we support transparency to help families make those informed decisions about their loved ones, focusing on ownership and private equity … is a red herring. Less than 5% of facilities are owned by private equity. About 12% are owned by a REIT, which typically has no influence over daily operations. Policymakers need to focus on the chronic underfunding of the health care sector and workforce shortages if we’re really going to make a difference.

SNN: And then what do you make of CMS’ 2025, Medicare payment update?

Gallin: We appreciate the increase, but we’re still not stabilized, and the figures do not incorporate the SNF value-based purchasing reduction for certain SNFs that are subject to the net reduction in payments under the SNF VBP. Those adjustments are estimated to total something like $196.5 million in fiscal year 2025. And given the expansion of CMS’ authority to impose per instance CMPs, in conjunction with per day CMPs really exceeds CMS’ delegated authority. It conflicts with congressional intent, and would result in the use of CMPs that would have a more attenuated influence over quality of care than other available remedies, such as directed plans of correction, or directed in service training and programs like that.

SNN: How concerned are you about the federal staffing mandate and its potential impact on Signature?

Gallin: Frankly, I don’t believe that CMS has the authority to impose a staffing mandate. CBO [Congressional Budget Office] scored the minimum staffing rule to exceed $22 billion. And, the industry has to continue to attract and retain employees to the nursing home sector and contend with increased competition from other health care providers for the same labor pool. This requires nursing homes to continue increasing wages and benefits to recruit and retain staff, and these salary expenses will really exceed increased revenue from Medicare and other payers. The staffing mandate is just too much. It’s just not doable right now.

SNN: Are you looking to downsize in 2025, or have downsized in any state in the past year, given the litigious environment and all the other challenges?

Gallin: To the best of my knowledge, we’re not looking to downsize at this time. Our goal is really to continue to support all of our Signature facilities so that the administrator, director of nursing [DON] and department heads at those facilities can really remain focused on providing quality care to their resident population.

SNN: In what area of health care policy making would having the voice of the nursing home providers be really beneficial?

Gallin: There used to be a Long Term Care Commission a couple of years ago, and one of our nurses was on that commission. She said that they were able to have great round table discussions. And I think if they brought in clinicians like our chief nursing officer, Barbara Revelette, to be just in front of the policymakers all across the country that are making decisions about the care that’s provided, that would be very helpful. We should be included in those conversations.

SNN: New studies show discrepancies in the cost of nursing home care versus what is reimbursed. For every dollar that nursing homes put in, they’re only getting back 86 cents. Any thoughts on reimbursements?

Gallin: There is quite a discrepancy there. And the cost of care is rising. Our policymakers really need to keep that in mind when they are passing laws that impact the care that we’re able to provide. They have to understand that it is critical that we have the funding that we need to be able to provide the quality that we want to give to our residents.

SNN: Any final thoughts on what changes you’d like to see?

Gallin: I would like to see more post acute, long-term care providers to have a seat at the table with our policy makers. After all, we’re the experts at what we do, and that’s to provide meaningful solutions that really strengthen deliverance of quality care for our beloved seniors. And I really think they need to bring us to the table more.

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