There was a stark, though not at all unexpected, dichotomy between participants in Monday’s listening session to gather input on coming nursing home staff minimums.

Kimberly Marselas

On the one hand, you had consumer advocates — armed with the Biden administration’s aggressive reform push and 20 years of resentment about perceived understaffing — ready to throw fuel on the fire.

And on the other, there were nursing home leaders from major organizations, mid-sized chains and tiny, independent facilities in rural settings pleading with federal regulators to douse the flames.

Where a resident advocate might see the potential for more staffing rules to help nursing homes rise from the ashes of COVID, providers are legitimately worried that a well-intentioned but under-supported mandate might just burn the sector down for good.

Long ago singed by the current staffing crisis, many of these providers approached the conversation with the Centers for Medicare & Medicaid Services with weariness, maybe even desperation, in their voices. 

Take the comments of Cathy Almon, vice president of operations for six skilled nursing facilities in North Carolina, who has seen agency staffing costs push some local providers out of business and an inability to hire anyone at any rate threaten others.

“I would like to know what CMS is planning on doing in terms of areas of the country where we are truly struggling hard to find staff. Where I’m located at, it is a daily battle to find staff, to find nurses, to find CNAs,” she said. “It’s important that whatever CMS determines through this study, that attention is paid to the fact that certain areas of the country might not be doing as well as others when it comes to available staff to pull from in order to meet a minimum staffing level.”

What happens when providers miss the eventual mark set by CMS has yet to be determined. But knowing the White House wants to increase maximum fines to $1 million and that new staffing metrics already sent thousands of providers’ star ratings plummeting, worst-case scenarios are no doubt looming large in providers’ minds.

Rosemary Simino is with Golden View Healthcare in Meredith, NH, part of a lakeside region where an entire county “boasts” 6,000 residents. The 131-bed facility has a 4-star rating for staffing. But for providers like Simino, a burning question might be how long that could be sustained after the Centers for Medicare & Medicaid Services implements a minimum.

Simino asked CMS to consider regional and local disparities in applicant pools, particularly in rural areas; unemployment rates and how they affect the ability to hire; and the varying abilities of nonprofits, independents, for-profit organizations and large chains to absorb additional staffing costs.

In nearby Maine, administrator Brett Seekins is looking for an add-on for providers who can get above new benchmarks.

“Payments vs. the actual cost of doing business today, especially today, they’re not aligned. Not aligned at all,” he said.

Seekins noted that federal wage indexes and adjustments don’t do enough to address market variability, and that states that have adopted their own minimum staffing rules haven’t necessarily increased their Medicaid costs to cover the costs. That leaves providers to compensate by reducing budgets for other programs and/or borrowing proceeds from other payers.

Those who don’t have the right payer mix to borrow from themselves, well, they’re likely the ones limiting admissions when they can’t find staff, or throwing up the for sale sign when the pressures refuse to lessen.

And yet many of those fired-up consumer advocates showed cold indifference to the plight of providers who argue that stricter rules could put care out of reach for more seniors.

Ahimsa Luthuli, a senior policy analyst at the Service Employees International Union, suggested CMS create both a staff-to-resident ratio and an hourly minimum care provision and force providers to display their current coverages set against those requirements on every shift.

How or where providers will get the workers needed to meet those requirements or how they’ll pay them didn’t make Monday’s slash-and-burn message from the union. Rather, Luthuli seemed to accuse providers, many of whom have given dramatic raises over the last two years, of using that as an excuse as they fight for fair regulations.

“Whether higher wages are the result of collective bargaining, cost-of-living differences or supportive employer practices, potential costs related to higher wages should not be used to justify less-than-safe staffing levels,” Luthuli said.