All nursing home residents deserve high quality care, regardless of where they live. Despite the obvious point that geography is not relevant to the care that residents actually need, a January 20, 2023 letter to CMS Administrator Chiquita Brooks-LaSure, expresses concern about the Administration’s plan to mandate nurse staffing levels for nursing facilities. The letter’s two key points– rural nursing facilities need more flexibility in identifying how much staff they need and “meeting staffing mandates will place nursing homes in financial jeopardy” – repeat claims made by nursing home owners, operators, and trade associations for many years. Both arguments can be disputed and should be rejected.
First, residents’ needs for nursing care do not differ depending on whether residents live in rural or urban areas. There is no evidence or reason to believe that residents in rural nursing facilities have lesser nursing needs than residents in urban areas. A resident who needs assistance in transferring from her bed to her wheelchair needs sufficient staff assistance for transfers; a resident who needs help in bathing needs sufficient assistance for bathing. Registered nurses are required to assess residents’ conditions and to administer medications, among other critical functions. In some states, licensed practical nurses may also administer some medications. What is key is that “local workforce conditions” are not relevant in identifying a resident’s actual need for care. The Biden-Harris Administration is conducting a staffing study in order to determine what residents’ nursing needs are. When decades of research document that more nursing time means better quality of care and quality of life for residents, as well as lower rates of COVID-19 infections and deaths, equity demands that standards of care, including nurse staffing levels, not be lowered for rural communities.
Adequate staffing levels are critical for staff as well as for residents. Nursing facilities that have sufficient numbers of well-trained nursing staff have fewer worker injuries and more success in retaining staff and reducing turnover.
A 2011 study, “Staffing Levels in Rural Nursing Homes,” looked at nurse staffing at 171 nursing facilities in Colorado, Idaho, Nevada, Utah, and Wyoming. Administrators and directors of nursing in rural facilities that had high nurse staffing levels “attributed their success to having a good reputation, being flexible, and offering individual growth opportunities (e.g., school reimbursement).” Rural facilities successfully recruited and retained qualified staff when they increased wages or offered wages that were comparable to other facilities, offered educational opportunities (including on-site), and enhanced the work environment (offering flexible work schedules and having a “positive workplace that appreciated employees”).
In short, the recommendations for rural facilities are similar to the recommendations for all facilities for improving nurse staffing levels. Staff need “better wages, better health insurance, and better pensions, as well as improved training, supervision, and mentoring.”
The letter’s second argument is equally unavailing. There is money available in the reimbursement that facilities already receive from Medicare and Medicaid to pay for increases in nurse staffing levels.
Medicare rates are high. In its March 2022 report, the Medicare Payment Advisory Commission (MedPAC) reported that Medicare margins for freestanding facilities exceeded 10% for 22 consecutive years. In 2020, the Medicare margin was 16.5% (and 19.2%, if federal COVID-19 relief funds were included). MedPAC also reported that in 2020, the “all-payer total margin” (including managed care, Medicare, Medicaid, and private insurance) was 3%, an increase from 2019.
Medicaid rates vary across the country. In a January 2023 Issue Brief, the Medicaid and CHIP Payment and Access Commission (MACPAC) reported that it could not determine whether Medicaid payments were adequate until there was increased transparency in how nursing facilities spend their Medicaid reimbursement. MACPAC identified significant variations in states’ base Medicaid payment rates (which, it noted, do not reflect states’ full Medicaid payments to nursing facilities) and reported that 19% of facilities have more than 100% of their costs met just by base Medicaid payment rates.
Moreover, as the Empire Center in New York, the New York Attorney General in a series of lawsuits, The New York Times, the Naples Daily News in Florida, and others have repeatedly documented, nursing facilities divert billions of dollars of public reimbursement to private profit, often through related party payments they make to businesses they own. Under the Nursing Home Reform Law, 42 U.S.C. §§1395i-3(f)(1), 1396r(f)(1), it is the “general responsibility” of the Secretary of the Department of Health and Human Services “to promote the effective and efficient use of public moneys.” Redirecting public reimbursement to care and requiring facilities to spend their reimbursement on staff will not place facilities in financial jeopardy. It is the law.
February 2, 2023 – T. Edelman