The majority of skilled nursing chief financial officers are more optimistic than last year about their ability to compete. But Medicare Advantage — and a few other factors — are dark spots in their sunny skies.

That’s according to new insights released by investment firm Ziegler last week. Over the summer, the company polled 134 CFOs and other financial professionals in this space to figure out what’s keeping them up at night. One key change: About 80% said they are somewhat to very optimistic about their organization’s ability to compete, an 11% uptick from the 72% cited in the last two surveys.

About 42% of those polled said short-stay skilled nursing occupancy was lower than 2017, a six-percentage-point decline from the last survey. Meanwhile, 36% said short-stay occupancy was flat, year over year, and 22% saw an increase.

On the long-stay side, 29% of providers said occupancy is lower than a year ago; about 46% said it stayed flat, and 25% said it is higher than the previous years.

Some of the most common pain points for CFOs in 2018 included decreased lengths of stay (82%) and individuals with more acute needs than in the past (80%). More than half of those surveyed by Ziegler said they are experiencing a narrowing of networks from hospitals and other providers, with more treatment plans completely avoiding skilled care.

One of the reasons for that may be the increasing proliferation of Medicare Advantage plans. Ziegler added a new question this year to gauge MA activity and found that about 49% of providers said they have experienced a moderate, negative impact from such plans. More than 10% said the impact was moderate, positive, while almost 27% said they experienced little impact.

“Medicare Advantage plans are making it much more difficult to get paid a fair price for the services provided. They continue to add cumbersome processes making it more difficult for people needing services to receive those services,” which have added “additional costs and huge amounts of frustration,” one CFO noted in the survey.You can read Ziegler’s entire CFO Hotline report here.