Requiring nursing homes to spend a specific share of revenues on direct care alone won’t guarantee that facilities are “adequately” staffed, a new study finds.

Rather, researchers who reviewed spending and staffing data from more than 12,000 nursing homes found that a minimum hourly staffing requirement is more likely to increase direct care.

Still, because of different state Medicaid rates that drive wide variations in staff spending, the Centers for Medicare & Medicaid Services may be hard-pressed to develop a minimum staffing rule that is both effective and widely accepted without providing additional federal funding.

“The only way to do it, if you’re going to try to lift all boats, is to either provide funding or create mechanisms that incentivize some of these lower-staffed states to increase their staffing requirements,” said John R. Bowblis, PhD, professor of economics and research fellow at the Scripps Gerontology Center of Miami University.

“The only way to assure there’s enough staff is to implement a minimum staffing level requirement. But if you implement the minimum staffing level requirement that’s too high, and the states don’t want to fund it, then you have those legal challenges. That’s the push and the pull that’s going on here.”

Bowblis is lead author of a Health Affairs study published Monday that looks at both share of revenue spent on direct nursing care by nursing homes and their current levels of nurse staffing. The study found that nationally, nursing homes spent a median revenue share of 33.9% on nursing staff, including administrative nurses such as DONs and MDS nurses. It also found that median nursing staff hours worked, using Bowblis’ expanded definition, totaled 3.67 hours per patient day.

Traditionally, many consumer advocates have called for a per patient day rate that includes only direct, hands-on care.

The new study found that staffing levels would not necessarily rise with a mandated spending threshold because costs could go up for higher wages or other needs, without adding more individual workers or hours to a facilities payroll. Early last year, the National Academies of Sciences, Engineering, and Medicine had recommended that nursing homes designate a specific portion of their revenues for direct care of residents, a move already being implemented by at least three states.

But Bowblis’ study found that increased spending did not necessarily equate to more staff.   

The study also found that high-Medicaid facilities had the lowest share of facilities meeting certain thresholds. For instance, 79.1% of high-Medicaid facilities were staffed at 3.0 hours per patient day or better vs. 91.5% across the US. Just 9.1% were staffed above 4.1 hours worked vs. 26.2% across the US.

Other authors are David Grabowski, PhD, or Harvard Medical School; Hulwen Xu of the University of Texas Medical Branch; and Christopher S. Brunt of Georgia Southern University.

They urged CMS to consider its ultimate staffing proposal in a broad context, particularly when trying to affect change in states with historically low nursing staff levels of lower-than average Medicaid rates.

“If CMS comes out and says, ‘We want you to hit a specific minimum number,’ and they apply that number evenly across states, it is not going to have an equal effect across states,” Bowblis told McKnight’s Long-Term Care News. “If they have to hire so many more [nurses] that it causes the state to increase its Medicaid reimbursement rate, they may not do so and that could either cause nursing homes to close or be in violation of the federal regulations.”

Bowblis warned some states could take CMS to court over an “unfunded mandate,” or providers might choose to meet the nursing minimum at the cost of other quality-of-life services, such as lower-quality dining, less social workers or fewer activities aides to help with behavioral interventions.

“And any time you implement any type of regulation, what you’re doing is tying the hands of the nursing home from being able to pick the type of staff that they think is best given the residents who are in their facility,” Bowblis said. “People want to think of it as a simple situation, which is more people are better. But it’s not just more people. It’s the type of people that we’re looking at.”