Federal officials vowed Tuesday night to issue a nursing home staffing requirement “soon,” despite the premature publication of a federal study that appears to support skilled providers’ objections regarding the feasibility of such a measure.
The accidental online posting Tuesday afternoon of the study, conducted by Abt Associates on behalf of the Centers for Medicare & Medicaid Services, at first seemed to undercut a 18-month-old White House plan to institute an hourly direct care minimum at 15,000-plus nursing homes nationwide.
The report has since been removed from the web by CMS, but it is still available through KFF Health News, which broke news of the study Tuesday afternoon. Researchers made no recommendations in the report but said there was “no single staffing level that would guarantee quality care.”
Jonathan Blum, principal deputy administrator and chief operating officer at CMS confirmed to McKnight’s in an email Tuesday night that a “draft” of the study was posted in error. But he added that, despite immediate reaction to the study results, CMS remains committed to “holding nursing homes accountable for protecting the health and safety of all residents, and adequate staffing is critical to this effort.”
“CMS’s bold actions over the past year and a half are already improving care, increasing transparency, and strengthening accountability, especially for poor-performing facilities,” Blum added. “CMS’s proposal is being developed using a rigorous process that draws on a wide range of source information, including extensive input from residents and their families, workers, administrators, experts, and other stakeholders. We look forward to releasing our proposals, as well as the Nursing Home Staffing Study, soon.”
The study modeled potential staffing rules using four hourly sample standards below a widely expected 4.1 hour per patient day minimum. The fact that none was linked to major quality improvements raised concerns similar to those voiced when CMS ultimately decided against instituting a national staffing rule under consideration in 2016.
It also raised new questions from sector stakeholders about how the results have shaped the Biden administration’s proposal, which has been under formal review by the Office of Management and Budget since May 30.
“In February 2022, the President wisely determined to base any staffing ratios on research. The report he commissioned said there is no single staffing level that would guarantee quality care,” said Ruth Katz (pictured), senior vice president, policy for LeadingAge. “Policy should be based on evidence. We’re interested to see how this inconclusive research could be translated into a proposed rule that would mandate an effective staffing ratio that will improve care for residents and their families.”
Accidental revelations
The study’s online presence was first reported exclusively Tuesday by KFF Health News. Nowhere in the 478-page report was it described as a draft.
Research for it was conducted between May and December of 2022, and the publication was dated June 2023. It was the first public glimpse into how the federal government might have been influenced in what it promised would be a yearlong undertaking to shape a proposed rule.
Researchers examined only staffing levels below the 4.1 hours per resident day that a previous CMS study had recommended more than 20 years ago. That led to swift outrage from consumer groups with whom KFF shared the study early. But providers embraced what they learned of the study Tuesday.
“The CMS staffing study posted today reinforces what we’ve known all along — a one-size-fits-all approach for staffing is shortsighted and out-of-touch with reality,” said Nate Schema, president and CEO of the Good Samaritan Society. “Now more than ever, we urge CMS to reconsider a proposed minimum staffing rule and instead focus on investing in and strengthening programs to attract, retain and grow the long-term care workforce. We owe it to our nation’s seniors and their loved ones to protect access to care close to home.”
Schema has warned repeatedly that a strictly interpreted, uniform standard would be devastating to rural providers, who often have high Medicaid populations and fewer options for recruitment than their suburban and urban peers.
He urged CMS to take nursing experience, training and adequate Medicaid funding into account when considering how to drive quality improvements.
Leaders at the American Health Care Association said that they, too, were hoping the evidence in the study and ongoing stakeholder engagement would make clear the need for more meaningful workforce strategies.
“This report confirms what we’ve been saying for more than a year — that an arbitrary staffing mandate is not feasible and will not equate to higher quality care,” President and CEO Mark Parkinson said Tuesday as the organization continued to review the study.
“There needs to be a comprehensive approach to staffing beyond numbers, acknowledging that each resident and facility is unique,” he added. “We all want to increase the nursing home workforce, but instead of blanket requirements, we need resources and policies that will help recruit and retain more caregivers. We hope this means the Administration is considering a more thoughtful and supportive solution to address the long-term care workforce crisis.”
What’s being considered, what’s not
The four minimum standards presented ranged from 3.3 hours per patient day to 3.88 hours per patient day.
With current rules in place regarding only the presence of RNs and sufficient staff to provide care, Abt reported that 49% of nursing homes performed above median quality levels. With the four new options, the share performing above the median would stay flat or increase to 50%, 54% or 56%.
Likewise, on safety metrics, the rate performing above the median was projected to increase slightly from 50% now to 51% or 53%.
But the report did acknowledge that varying mandated staffing levels would lead to fewer hospitalizations and emergency room visits, and better, faster care. At the highest (3.88 hours) standard, an estimated 0.6% of residents would get delayed care and 0.002% would not get needed care, according to the leaked report. That would also lower emergency room visits by an estimated 14,800 annually and hospitalizations of Medicare patients by 12,100 each year.
The authors also considered options for requiring two types of nurse coverage (RNs and CNAs) or four (total nurse hours, RN, LPN and CNA). Even so, they acknowledged that RNs remain hard to come by in the sector.
“While the regression model results suggest that RN staffing among staff types has the strongest relationship with care quality and safety metrics, simulations imply licensed nurse staffing needs exceed current RN staffing even among many higher-staffed nursing homes,” the authors wrote. “Similarly, nurse aides provide more-direct support to residents, and respondents reported this ADL support is often delayed or missed when staffing is short.”
Differing estimates
Notably, the hourly calculations for staffing options include only nurses, though many providers had asked for options to also include therapists, activity directors and others interacting directly with patients during a given day.
Providers had hoped that flexibility, and other employee titles, could cushion the blow as they continue to face significant workforce shortages.
“Given the historic workforce shortages, funding inequities, and access to care crises across the country, the timing for a national nursing home staffing minimum could not be worse,” Zach Shamberg, president and CEO of the Pennsylvania Health Care Association, told McKnight’s Tuesday. “We continue to urge CMS and the Biden administration to help our providers address these challenges, rather than exacerbate them.”
More than 50% of nursing homes would have to add staffing to meet the 3.3 hour level, at an estimated cost of $1.5 billion more each year.
At the highest level, more than 11,000 of the nation’s 15,200 nursing homes would need to hire more staff — at an annual cost of $5.3 billion each year — to comply.
The cost estimates paled in comparison to projections by non-government analysts. A recently updated CliftonLarsonAllen analysis put the cost of a 4.1-hour standard at $11.7 billion annually.
The sector would also need to hire almost 200,000 new workers, in addition to about 190,000 positions lost since the start of the pandemic, according to estimates.
