An unrelenting virus will shape the year ahead, but staffing shortages, state and federal legislation and technology also could lead to much-needed new opportunities for the skilled nursing sector.
As U.S. skilled nursing providers approach the two-year anniversary of COVID-19’s deadly beginnings, they’re looking for a fresh start. But will they be able to find it in a year during which any major opportunities will almost certainly still be influenced by the pandemic itself?
When taking stock of what lies ahead, 2022 could prove to be a rebound year should omicron recede and healthcare start to normalize nationwide. It also will be a year filled with new and ongoing obstacles, be they related to staffing, occupancy, technology, regulation, compliance or reimbursement.
“Occupancy is your most worrisome pain point right now,” said Cynthia Morton, executive vice president of the National Association for the Support of Long Term Care, noting inextricable ties between census and lack of staff. “In the nursing home sector, we are very low in terms of our workforce. It’s not a good picture.”
Staffing’s impact on access to care makes it one area ripe for change. Clifton Porter II, senior vice president for government affairs at the American Health Care Association, said he expects to lobby aggressively for workforce solutions in 2022.
“We’ve got to be mindful of stimulative type legislation that will help increase supply of clinical staff, be that increasing nurse faculty to funding for training programs to regulatory relief around nurse aide training programs,” Porter told McKnight’s Long-Term Care News. “I see a lot of opportunity on that front.”
Staffing and several areas of focus for nursing homes in 2022 will be shaped by any further extensions — or the cancellation — of the public health emergency. Although it was officially set to expire Jan. 16, it was widely expected to be extended for an additional 90 days at press time.
Ongoing waivers of the three-day stay rule, expanded use of telehealth and other temporary fixes enabled by the PHE will be critical for nursing home operators seeking to create revenue and capitalize on efficiencies. Additional extensions would need to be granted in spring and summer to ensure operational flexibilities through 2022.
“There are a lot of conjoined relief elements at both the state and federal level that are important to our members, so extending that PHE is going to be key,” Porter said. “We’re hopeful and cautiously optimistic, but the real question gets down to the March/April decision and the June/July decision.”
Payment and regulatory
While the industry is getting an extra $410 million in Medicare Part A funding this year, or a 1.2% pay increase, regulatory experts say providers must remain cautious as the Centers for Medicare & Medicaid Services weighs a clawback provision.
“The big headline for the Part A rule for SNFs was a delayed consideration of recalibrating the parity adjustment,” Morton said, noting an unexpected increase in payments following the 2019 adoption of the Patient-Driven Payment Model. “We’ve got a 5% cut that CMS has to impose on us, but they have some flexibility. … That is the $10,000 question: How is CMS going to do that?”
Porter said providers must remain prepared to convince CMS that now is not the time.
“We recognize that PDPM was designed to be budget-neutral, but we contend that we are still in the midst of a very serious crisis,’’ he said. “Frankly, getting out of this crisis is not a light-switch event. We can’t hit the switch and everything’s back.”
This year, providers also will be looking for additional assistance from states, many of which are reckoning with challenges resulting from years of low Medicaid funding. Operators argue those payment rates have stymied their efforts to offer wages and benefits that attract and retain staff.
With agency staff pricing through the roof, several states boosted Medicaid rates temporarily. Only time will tell if there’s interest in converting temporary patches into permanent funding solutions — or if states will follow the lead of New York, and tie additional Medicaid to spending rules.
Late in the year, providers could learn of another hit: Federal officials are expected to add at least one new measure to the value-based payment program, which currently only penalizes providers who fail to meet hospital readmission targets. New VBP requirements would follow a year in which CMS took 2% from all providers nationwide, but only doled out 60% of that to providers citing pandemic restrictions — resulting in a 0.8% cut.
Legislative lifelines
The Build Back Better package could offer additional support for nurse-training grants and infection control improvements in long-term care. It passed the House but then stalled in the Senate late last year. Party leaders tabled negotiations in January in favor of competing issues such as the voting rights and a new spending measure to keep the government operating.
“The longer the delay between getting back to the table and getting it resolved, does that create headwinds?” Porter asked.
Even as Build Back floundered, lawmakers stepped up in December to ensure providers struggling with extraordinary pandemic and staffing costs wouldn’t have to bear nearly 10% in scheduled Medicare cuts. Instead, Congress passed a bill that cancelled some of those cuts for 2022 and more slowly phased in others.
A 2% sequester cut is now expected to begin in April, while a 4% budget-balancing cut known as PAYGO has been pushed off until 2023. While Porter said more delays are possible,” he didn’t see “any appetite for a long-term solution.”
“The most important thing is getting this pandemic behind us, and the faster that happens … that’s better for everybody,” he said. “But it’s not necessarily realistic to think that measures of relief will continue absent a pandemic.
“If we end up where omicron continues or there’s some new variant that creates new and additional spread, then I would say the likelihood of getting some form of extension increases.”
Likewise, Porter expects Provider Relief “as we’ve become accustomed to it” will end in 2022. AHCA, however, will continue to advocate for disbursal of funds remaining from an initial $17.5 billion allotment.
Technology twists
One bright spot for providers over the last two years has been the expansion of and innovation in technology that addresses residents’ clinical and social needs. It will pay to stay abreast of expected changes in rules and regulations.
There are many telehealth bills in Congress dictating what it will look like after the PHE, but without passage of some, the American Telehealth Association predicts a “cliff” ahead.
“It will be a very tough job by Congress to start to consider what legislation they want to pass,” Morton explained on a December webinar.
Bills that enable telehealth permanently could also seek to better control it. While the government in the past sharply criticized telehealth over quality and overpayment concerns, attention now may turn to ensuring services are delivered securely. The Health and Human Services Office of Inspector General is evaluating the use of Medicare telehealth services during the pandemic and is expected to report its findings and recommendations this year. Investigators could key in to concerns about Information privacy as data sharing has increased exponentially.
“In general, there’s been an increase in cyber attacks in all sectors, but healthcare has been particularly hit hard,” said Beth Pitman, a healthcare privacy and IT attorney at Nashville-based Waller. “Data security is going to be a big focus. The other thing that’s more exciting, though, is there are more telehealth remote monitoring devices and other types of technology in place and being developed that can improve services.”
Providers must meet their obligations to secure information for both patients and staff members.
“HIPAA is just the tip of the iceberg,” Pitman said. ”There are other federal and state regulations that impact privacy and data security.”
Donna Doneski, NASL’s director of policy and membership, also noted several technical issues will impact providers. CMS has upgraded its platforms to take advantage of new data reporting and tracking capabilities. There also will be “a rebranding” of the common clinical data set used by federal agencies, as a long-awaited interoperability framework goes live.
In addition, changes to e-prescribing standards should make it easier for third-party providers, including nursing homes, to receive medication information for their residents.
From the January/February 2022 Issue of McKnight's Long-Term Care News
