The Biden administration recently took a step forward in its efforts to improve staffing levels and the quality of care in nursing homes, but its plans are meeting harsh criticism from industry advocates.
On September 1, the federal government’s Center for Medicare & Medicaid Services (CMS) proposed new rules that would require long-term care (LTC) facilities to keep more nurses on-site and conduct more robust assessments of their ability to meet resident needs. However, while facility owners have acknowledged a need for more nurses, they generally disagree that a minimum staffing mandate is the right solution. In fact, the American Health Care Association (AHCA), the leading nursing home trade association, has called the CMS mandate “unfounded, unfunded and unrealistic.”
“Nursing home and other long-term care operators believe these new rules would put their businesses at risk and ultimately restrict access for people who need this care,” said Jessica Johnson, senior director of healthcare banking for BOK Financial®.
Rules designed to improve patient care—but compliance expensive
According to CMS, the mandate is designed to address chronic understaffing problems and hold nursing homes accountable for providing safe and high-quality care for over 1.2 million residents at Medicare and Medicaid-certified LTC facilities. CMS issued the proposal partly in response to the COVID-19 pandemic, which the agency said highlighted and exacerbated existing problems related to staffing and insufficient care.
Specifically, the proposed CMS mandate would require LTC facilities to:
- Maintain a minimum nurse staffing standard of 0.55 hours per resident day (HPRD) for registered nurses (RNs) and 2.45 HPRD for nurse aides (NAs);
- Have an RN onsite 24 hours a day, seven days a week; and
- Conduct “enhanced facility assessments” (beyond what most providers already do) to determine appropriate staffing levels above the proposed minimums.
Johnson said there are two critical flaws with the proposal that undermine nursing homes.
“First, facility owners are going to have trouble meeting these requirements due to a shortage of skilled nurses in the workforce,” she said. “They can’t increase staffing if there are no nurses to be found.”
To that point, health care organizations such as the American Hospital Association, American Nurses Association and the American Association of Colleges of Nursing concur that the nationwide nursing shortage has only intensified since the pandemic and is expected to get worse.
“Secondly, even if facilities can find the nurses they need, the extra labor costs will pose a problem,” said Johnson. “They’re being asked to staff more people, but they’re not receiving any additional funding or higher reimbursement rates from Medicare and Medicaid.”
A June 2023 research report prepared for CMS concluded that increased staffing requirements would likely cost LTC facilities between $1.5 and $5.3 billion per year, depending on the stringency of the rules.
What comes next
The staffing mandate is still in proposal form, and CMS is currently soliciting comments on alternative policy options.
LTC industry advocates will likely argue there are better solutions to be found, which could include increasing sources of government funding to LTC facilities so they can address staffing shortages and improve quality of care on their own terms.
Concurrently, health care experts are unanimous in their assertion that more must be done to increase the labor pool of skilled nurses, making it easier for nursing homes and other providers to find the help they need.
Among other recommendations to stem the nursing shortage, various health care organizations have urged Congress to invest in nursing schools, support salary increases, develop training and apprenticeship programs, and make it easier for foreign-trained nurses to get U.S. work visas.
The way things are now, the proposed staffing mandate could drive LTC facilities to admit fewer residents (rather than hiring more nurses) to stay in compliance, or even exit the business altogether, Johnson said.
“The ‘silver tsunami’ of aging baby boomers is bearing down on America’s healthcare system,” she said. “The CMS mandate could inadvertently create a scarcity of quality long-term care for seniors just as demand for these services is exploding.”
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