Marissa Bergh

America’s nursing homes are in crisis, and the government has been complicit. In the past 2 and a half years, COVID-19 has killed more than 158,000 nursing home residents. These facilities, filled with the nation’s most medically frail, have been understaffed, poorly managed and ignored for decades, creating the perfect storm allowing the pandemic to wreak devastating casualties. 

The residents were not the only victims. Due to low pay, lack of professional advancement and abysmal working conditions, more than 400,000 nursing home staff have left the field— exacerbating the already existing shortage of the long-term care workers who provide critical support to these aging adults. 

Perhaps the only silver lining of this tragedy is the newfound political will to rebuild the nursing home infrastructure to ensure high-quality care for America’s aging population. 

In August, with hopes to “achieve better healthcare outcomes and address longstanding inequities for Medicaid Beneficiaries,” the Biden administration and Centers for Medicare & Medicaid Services issued a joint bulletin encouraging states to tie Medicaid payment for nursing home services to quality measures that would improve the safety and quality of care, with a strong emphasis on efforts that improve working conditions and retention of direct care staff (e.g., wages and benefits). 

On the surface, incentivizing nursing homes to foster better working conditions for their staff seems like a robust solution to improve quality of care — particularly given the fact that 70% of nursing homes are classified as for-profit. However, performance-driven, market mediated measures are known to be flawed drivers of quality improvement. 

Fifteen years ago, eight states tied nursing home Medicaid payments to performance indicators, including staffing ratios, and the results generated pessimism about the effectiveness of this approach. Despite the incentives, most nursing homes did not address staffing conditions, and in many cases, deficiencies were worse than before.

Analysts found that states were unable to offer incentives large enough to offset the costs of meeting the quality metrics, making it more compelling for nursing home corporations to continue exploiting staff to save money. Pay-for-performance or value-based payment models are often well intentioned; unfortunately, in practice they are not strong enough to combat the profit-focused motivation of some nursing home operators, because they do not threaten penalties to facilities that continue to deliver substandard care.

Bigger and bolder steps are urgently needed. Updating regulatory and oversight rules at the federal and state levels would be more effective to ensure better staffing conditions and quality improvement. An important first step is the imminent federal minimum staffing requirement that CMS is expected to announce next year. 

However, the work cannot stop here as minimum staffing requirements only address one aspect of working conditions. Regulations, along with commensurate funding, should also ensure wage and benefit enhancements to ensure these workers’ right to a livable wage, which in turn will help attract and retain these critical staff.  And furthermore, measures that promote financial transparency, such as medical loss ratios and mandated financial audits, would help ensure that funds are appropriately used to support staff and residents instead of cushioning a nursing home’s bottom line. 

Until long-term care is no longer the forgotten stepchild of the healthcare industry, with investment an afterthought rather than a strategy to advance quality, person-centered care for the disabled and aging population, we will continue to see staffing shortages and an inability to respond adequately in times of crisis. Access to quality long-term care for everyone who needs it should be a reality. This will only be possible if regulations are rewritten to be meaningful in today’s environment and adequate dollars are invested to ensure a workforce that is able to meet the needs of an increasingly complex and vulnerable population.

Marissa Bergh, BSN, RN, is a graduate student at NYU Rory Meyers College of Nursing. Her research, affiliated with the Hartford Institute for Geriatric Nursing, focuses on improving health delivery and health outcomes for aging adults in long-term care settings. She has worked clinically with aging adults in both inpatient hospitals and the community.