CMS leaders speak with Maryland nursing home leaders
Picture here are (L-R): CMS Administrator Chiquita Brooks-LaSure; CMS Special Assistant Kristiana Yao (back to camera); Edwina Bell, Director of Nursing, St. Elizabeth’s; Lee Fleisher, M.D., CMS Chief Medical Officer. Credit: Will Harris/CMS

Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure has visited nursing homes numerous times, but on Wednesday she did so for the first time in her current capacity as their top federal overseer. 

A two-hour tour and roundtable discussion with various LeadingAge Maryland providers underscored the federal agency’s focus on quality outcomes and state-level efforts to tie funding to performance.

President Biden’s sweeping nursing home reform plans and CMS’ proposed fiscal 2023 Medicare payment cuts were key focal points.

“What we’re really committed to is looking at this in a holistic way,” Brooks-LaSure said during her visit to St. Elizabeth Rehabilitation and Nursing in Baltimore.

“Those are two important pieces – the staffing and certainly thinking about payments. We are really focused on both being a partner at CMS with our colleagues across the administration, as well as states, in trying to think about how to make sure we are paying appropriately and really thinking about how to implement staffing requirements in a way that’s going to make sense.”

Even though CMS personnel cannot comment on proposed rules, the administrator emphasized that she and her colleagues are very interested in providers’ viewpoints. 

“Part of this discussion today is really hearing directly from providers the issues they’re facing, and we certainly intend to include that in our decision-making,” Brooks La-Sure said.

CMS Chief Operating Officer Jonathan Blum expanded on that theme.

“Two pieces we’re watching carefully,” he explained. “The comment period for Medicare (the proposed payment rule) and how we help support states with a new payment framework.

“We are very encouraged by some states that have tied reimbursement increases with quality of care increases, staffing increases,” he added. “CMS has direct authority regarding Medicare payment rates (but) we’re in a comment period (and can’t comment). But we’re also very interested to better understand how CMS can support state efforts that really want to raise reimbursement but tie it to some key, shared quality goals.”

Illinois and New York are among the states pushing ahead with increased provider payments tied to performance.

Agency frustrations

St. Elizabeth Administrator Zachary Richards said the CMS group, which included Chief Medical Officer Lee Fleisher, asked a wide-range of questions during their private roundtable discussion with providers. The impact of staffing agencies, how COVID management processes have evolved, surveys and the regulatory process all received significant attention, he noted.

“I don’t think anything we said was news to them. They were definitely well-informed,” noted Richards, who is director of senior care at Catholic Charities of Baltimore, which operates St. Elizabeth.

But staffing agency practices definitely seemed to pique interest, he noted. LeadingAge officials will be sharing information with CMS about pricing caps in places that they exist.

“I think that just hearing the impact of agency staffing and what our agency partners are responsible for, or better yet, what they’re not responsible for, as far as training their staff or educating their staff or holding their staff accountable — that definitely was a big topic of conversation,” Richards said. “Are the staffing agencies doing their competencies, and what does that involve?

“That’s one of our frustrations,” he continued. “If someone messes up and they’re our staff, we can counsel and guide, and that person has buy-in. They’ve built a relationship with their residents, as opposed to the amount of hours our clinical staff have to spend documenting if somebody at the agency doesn’t do their documentation or has medication errors. … We all know it affects resident care and quality.”

He said the sincerity of his visitors’ approach was greatly appreciated by the providers in attendance.

“Every element of conversation was so encouraging,” he said. “It was refreshing to know that CMS is listening to providers and they are absorbing comments and trying to figure out practical ways to move forward with regulations and industry in whatever form that may take. Over the years, we’ve all had experiences with people just paying lip service and it did not feel like that.”

Other LeadingAge Maryland members in attendance included Steve Coetzee, president and CEO of Fahrney Keedy, in Boonsboro, MD; Regina Figueroa, COO of National Lutheran Communities & Services, in Frederick, MD; and St. Elizabeth Director of Nursing Edwina Bell.

Bell reiterated negative effects of overreliance on agency staffing. St. Elizabeth’s regular, full-time staff has dropped from 230 before the pandemic to 157 today. As a result, operators have been “inundated with clinicians who, in many cases, are simply chasing the dollar.”

“The result, and the real issue I feel is really important, is we end up with breaks in continuity in care,” Bell explained. “We also have our own staff feeling undervalued and unappreciated, which leads to low morale and that’s a huge problem.”

From a management point of view, it’s also very difficult to handle agency staff, she added.

Criticism and connection

LeadingAge Maryland President and CEO Allison Ciborowski sat next to Brooks-LaSure and didn’t hold back criticism of the White House’s proposed reforms.

“… The only additional funding called for in the Administration’s nursing home initiative is for more survey resources,” she noted. “Finding more deficiencies and taking money out of nursing homes is not going to get us what we want. If this model worked, and if today’s reimbursement was sufficient, we wouldn’t be experiencing the crisis in access to care.”

“A staffing ratio mandate will not amount to more than words – and more fines for noncompliance – without meaningful changes to increase the supply of qualified workers, for example, in immigration policy,” she added.

Yet Ciborowski also emphasized that she felt the CMS in-person visit was promising.

“Clearly, they are wanting to understand how they can operationalize some of the things President Biden has announced, and they really want to do that well, so I was encouraged and heartened,” she said.

In addition to providing more information about where staffing agency pricing caps are in play, she said CMS also wants to know more about potentially positive effects of the three-day stay waiver.

“They seemed certainly open to discussing it and seeing more data and where it’s been useful and what that data looks like,” she noted.

She said busy note-taking by the CMS visitors was a good sign.

“I hope it kind of lifted the veil and closed the gap between the perspective they might have of nursing homes from a national perspective to the reality on the ground and getting to see some of the incredible work that happens,” she explained. 

“There maybe were not huge ‘light bulb’ moments, but there were things our provider members were saying that really resonated with CMS staff, and maybe things were put in a way they hadn’t thought of before.”