Nursing homes’ leading lobbying organization unloaded a full, research-backed attack on the viability of the White House’s proposed staffing mandate Tuesday. But the administration was unmoved, and instead doubled down on its commitment to impose first-ever workforce minimums on the beleaguered industry.

American Health Care Association President and CEO Mark Parkinson warned the “whole” US long-term care system would be at risk of “collapse” if the rule were implemented without modifications. 

Without more funding and other changes, operators would have to restrict services and close wings and buildings, setting off a chain reaction that would discharge more than a quarter million patients out of nursing homes, or roughly 26% of the current population, he said.

“We can’t implement this policy now. And we probably can’t implement it ever,” Parkinson said at a Tuesday morning press conference. 

He said more than 100,000 workers who left the profession during the pandemic haven’t returned, making it historically difficult to meet current demand — before factoring in the rising wave of seniors needing future services, and also before factoring in additional demands for the staffing mandate.

A second “inherent flaw,” he said, is that the mandate is unfunded. New research from CliftonLarsonAllen released Tuesday projected costs at $6.8 billion annually — 60% higher than the Centers for Medicare & Medicaid Services announced when it released the proposed rule Sept. 1.

An additional 80,000 nurse aides and 22,000 registered nurses would need to be hired to comply with the staffing proposal’s requirements, said Cory Rutledge, chief assurance officer at CLA, during the press conference.

The $6.8 million per year estimate is not adjusted for inflation, he noted, meaning the amount would be expected to increase annually. While unsure of how CMS calculated its cost estimates, Rutledge said he was confident in CLA’s numbers are “thorough and more up-to-date” because they took into account more recent wage indexes and various outlier information. 

There are two ways to meet the staffing mandate, he explained: Increase staff or decrease the number of residents in the facility.

“Those are the only two levers that can be pulled,” he said. “So if we can’t find the additional staff, the only thing to do is discharge residents that are currently in skilled nursing facilities. Logic would tell us that those individuals don’t have any better options in terms of places to go, particularly those that are Medicaid (residents).”

About 26% of the 1.1 million residents currently in facilities that don’t meet the staffing criteria would have to be discharged in order to meet the mandate’s requirements, he said. 

Parkinson blamed the administration’s “completely backwards” process of announcing plans without proper prior research for placing providers, and ultimately residents, in a no-win situation.

Regulators stand firm on rule

CMS, however, remains “unwavering” in its commitment to the staffing mandate, an agency spokeswoman told McKnight’s Long-Term Care News Tuesday.

“Our focus is on advancing implementable solutions that promote safe, high-quality care for residents and consider the challenging circumstances some LTC facilities face,” CMS Press Secretary Sara Lonardo said in an emailed statement. “We believe the proposed requirements are achievable and necessary.”

She lauded the proposed rule for a staggered implementation over five years for facility types based on geographic location, as well as exemptions for facilities that are “facing a significant staffing hardship despite their best efforts to hire.”

She cited President Biden’s comprehensive February 2022 “Action Plan for Nursing Home Reform” as a catalyst to a system that plans to deliver dignified care and creates a “pipeline of direct care workers” with “good-paying jobs.”

“It is imperative that LTC facilities are adequately staffed based on resident acuity and need, and this proposed rule is a first step toward that goal,” Lonardo said. 

“Establishing a minimum staffing level ensures that all nursing home residents, including residents in rural communities, are provided safe, high-quality care and that workers have the support they need to provide high-quality care,” she added.

Lonardo observed that CMS, in partnership with the Health Resources and Services Administration (HRSA), will launch a nationwide campaign “to help bolster the pipeline of nurses coming to work in nursing homes.” The campaign will include more than $75 million in incentives for nurses to work in nursing homes, such as scholarships and tuition reimbursement, and “a multi-media marketing initiative to raise awareness of rewarding opportunities to work in nursing homes.”

Pointing the pandemic finger

Parkinson added that the COVID-19 pandemic “highlighted and exacerbated existing problems at the nation’s nursing homes. And we know that adequate staffing is the metric most directly linked to safety and high-quality care for nursing home residents.”

Hours earlier, however, that previously known position was jabbed at by Parkinson, who noted that near the beginning of the pandemic, asymptomatic staff were unknowingly carrying COVID into buildings and spreading infections from site to site.

“We want to have a constructive dialogue with the administration but it’s hard to do that when there are continuing implications that 200,000 people that died in nursing homes with COVID were because of the nursing homes. That statement fails to understand the basics,” Parkinson said. Larger buildings were getting COVID the most because they had the most workers bringing in COVID from the outside, he explained.

 “Really, one of the ironies of this policy is we’re being blamed for COVID and yet if, in fact, there had been more workers in the first year of COVID, there would have been more COVID itself in buildings. That’s not a reason to not have more staff, and we’re not suggesting that,” he continued. “But it’s certainly a reason to stop blaming nursing homes for the 200,000 people that died in them. Thousands of lives were saved because of the heroic acts of people continuing to work in a very dangerous situation.”

‘Ignoring facts,’ proposing solutions

He continued on to rebut other administration critiques of the sector, including those about involvement of outside investors and private equity groups.

“Wall Street is basically not involved in our sector any more,” Parkinson said. “Publicly traded companies tried in the late 1990s and early 2000s and it simply didn’t work. As we sit here today, there are only two publicly traded companies that own facilities, and combined, they own less than 400 of the 15,000-plus nursing homes that are out there.

“When the administration blames private equity for problems in nursing homes, it’s ignoring the facts,” he added. “The government’s own statistics indicate that private equity owns less than 5% of nursing homes.”

The administration is generating false stereotypes of the typical nursing home operator, Parkinson, a former facility owner, added. 

“We are not this big, greedy conglomerate of companies that are trying to provide terrible care just to make money. Really, the absolute opposite is true,” he said. “Providers, for the most part, are compassionate people who are mission-driven and called to this work and that’s the reason that they take care of folks, frankly, who not a lot of others are willing to take care of.”

Parkinson said his group is working with both Congress and the administration to “stop the policy or significantly reshape it.” He did not directly answer a question as to whether AHCA would, in fact, sue to stop the rule, as it had threatened before the proposal’s release. If the administration is unwilling to “scrap” the policy, he said, changes need to be made.

First, licensed practicing nurses (LPNs), who were not mentioned in the proposal’s hourly calculations, need to be factored in, as either a part of registered nurse or nurse-aide hours.

Next, the phase-in period should be lengthened to five years “for all of the requirements, so that perhaps we can have some recovery of our workforce.” 

“Then we need to come up with some funding mechanism so that if we can actually somehow end up finding these workers, they can actually be paid for,” he concluded.

The 60-day comment period for the proposed rule is open until Nov. 6, 2023.