Cost analysis will be “an important part” of a final report on federal minimum staffing standards, the head of a national study assured nursing home stakeholders Monday.
“I think these cost analyses are really important,“ said Alan White, PhD, principal at Abt Associates, the firm contracted by the Centers for Medicare & Medicaid Services to research the agency’s possible staffing mandate.
“We’ll know from the other analyses … what the benefits of increased staffing are in terms of better quality and better resident outcomes, that sort of thing. Bringing in the cost analysis kind of allows us to understand how those benefits are balanced against the costs that nursing homes would incur to increase staffing to whatever level CMS might specify.”
And potential costs of a mandate expected next year are weighing heavily on providers’ minds, as evidenced by comments during a listening session hosted by CMS. They pleaded with Abt and CMS to be mindful of the true costs of an unfunded — or underfunded — new staffing rule.
Sarah Dobson, senior director of public policy and advocacy for Lutheran Services in America, said her large nonprofit aging services organization is concerned about the impact a mandatory minimum staffing could have on access to care.
“This issue is already a crisis with providers reducing occupancy and not meeting existing community needs,” she said. “Even before COVID and continuing today, providers were in a critical workforce shortage that led to long waiting lists, older adults languishing in hospitals due to a lack of SNF beds and vulnerable older adults without access to quality care options. Unfortunately, the new proposals with no additional funding would exacerbate the current crisis and make it more difficult to hire needed staff.”
Dobson urged CMS to increase reimbursement rates for nursing home care, and said providers wanted to work with the agency on expanding the workforce and improving training and retention efforts.
Reier Thompson, representing Missouri Slope nursing home in Bismarck, ND, said the mandate would be a true threat as even much higher wages haven’t been enough to create a steady supply of job candidates.
“This needs to have more strategic collaboration from other departments of the government outside of CMS in order to develop creative solutions that will increase the supply, specifically of nurses and CNAs into the healthcare industry,” Thompson said, suggesting longer-range plans such as immigration reform. “Just having the president say, ‘This is the way we’re going to do it,’ and initiate with a stick, we need more collaboration to increase supply so we can all be successful, because we should be. Our residents, our tenants deserve the very best.”
‘Failure to invest’ creates shortages
Abt’s White shared again much of what was made public in a CMS blog last week, but he also distributed more details on how his team would evaluate costs. Abt will use salary, hourly wage and benefits information from cost reports, as well as Payroll Based Journal staffing data and economic indicators to measure incremental adjustments and their impacts.
White was a researcher on the landmark nurse staffing study that recommended a 4.1-hour per patient, per day measure in 2001. It was never adopted, but its methodology and other staffing studies that have built on it remain the basis for his firm’s latest research, he made clear Monday.
He also announced site visits needed to gather qualitative data and observe and measure time spent on specific tasks will begin within the “next week or two.” He emphasized the accelerated timeline of the ongoing work.
That 2001 staffing study took “eight or nine years,” but this time around investigators are tasked with completing their report in less than 12 months.
“We’re trying to do all this work on a fast timeline,” White said. “This is research that is needed quickly.”
Providers seemed to bristle at the fast pace, given that the push comes amid the unabating one-two combination of COVID-19 and a workforce crisis.
“Given the failure to invest and incentivize nursing infrastructure and to meet the crisis-level demand, if there were a minimum staffing requirement as an unfunded mandate today, we would be hard-pressed to be able to hire enough nurses, CNAs or caregivers to be able to meet current demand let along a higher demand,” said Luke Neuman, vice president of Palm Garden Healthcare, an owner-operator of 14 Florida rehabilitation centers.
Include more than nurses
He asked that facilities be able to include therapists, psychiatrists, podiatrists and other specialists in whatever calculation CMS creates.
It was a plea echoed by Jeanine Finck-Boyle of LeadingAge, who asked the agency to consider on its site visits how the pandemic had changed care delivery, whether through the use of telehealth or interdisciplinary care teams.
Finck-Boyle and David Gifford, MD, chief medical officer for the American Health Care Association, also said any recommended rule should also take into account the increased complexity of modern nursing home patients, and how a building’s needs can change over time.
“It would be interesting to know, given the past studies Dr. White has described, the relationship of staffing levels and how it changes over time and how it changes with acuity. Are there going to be efforts to do a one-shoe-fits-all minimum staffing ratio?” Gifford asked. “Or is there some way that takes into consideration some nursing homes do a lot of high-acuity care, some nursing cares do low acuity care, some have a mix of care?”
Worker and patient advocates also joined Monday’s call.
Toby Edelman, an attorney with the Center for Medicare Advocacy, noted that though there is urgency in the current CMS effort, the sector has been here before.
“Most facilities do not have enough staff. This problem is not new,” Edelman said. “Care will not improve until all facilities have enough well-trained staff. Facilities also need to pay them well, pay them appropriate benefits and treat them well… . No more excuses and no more delay. We don’t want to have another study 20 years from now.”