A statement from the Center for Medicare Advocacy
In a March 8, 2022 letter, the American Health Care Association (AHCA), the largest nursing home trade association, asked HHS Secretary Xavier Becerra for a meeting with the White House, Secretary Becerra, and the Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure, to describe “the quality efforts that are already taking place, the successes that SNFs have achieved, and our bold plans for the future.”[1] AHCA criticized “the rhetoric” around the White House’s announcement of the nursing home reform agenda, which it claimed “demoralized an already beaten down sector.” AHCA CEO Mark Parkinson has now increased his rhetoric further, calling the reform plan “offensive” and telling nursing homes to “‘fight on’” and to say “‘It’s not our fault, that we are committed to quality, that more fines and regulations won’t do anything but make matters worse.’”[2]
What is most shocking about the March letter and more recent statements by Parkinson is that many of the specific recommendations made by President Biden in his reform agenda are so similar to recommendations put forward just a year ago by AHCA, along with LeadingAge, the trade association of not-for-profit providers, in their own legislative proposal, which they called the Care For Our Seniors Act.[3] The associations wrote then, in an introduction to their legislative proposal, “The COVID-19 pandemic has exposed and exacerbated long-standing challenges impacting the long term care profession. The American Health Care Association (AHCA) and LeadingAge are dedicated to learning from this experience, renewing our commitment to our seniors, and offering solutions that will improve the quality of care in our nation’s nursing homes.”[4] What happened to that rhetoric?
To be sure, AHCA’s and LeadingAge’s proposed Act included an opening section about the COVID-19 pandemic and its devastating toll on residents, “How Did This Happen?” that identifies four factors (demographic data, public health directives, independent research finding geography determines COVID-19 infection rates, and failure to make long-term care facilities a priority) that were all intended to shift blame away from facilities for resident and staff cases and deaths. And the trade associations called for additional reimbursement for any changes that might be made in the future.
Nevertheless, a comparison of the industry proposal and President Biden nursing home reform agenda finds a significant number of similarities. In many areas of common concern, the Biden reform agenda identifies multiple methods and proposals to address the complex issues.
| Issue | AHCA/Leading Age, Care For Our Seniors Act | Biden Nursing Home Reform Agenda |
| Nurse staffing | 24-hour registered nurse coverage. “Research shows a positive association between RN hours and overall quality. We support a new federal requirement that each nursing home have a RN on-staff 24 hours a day and will provide recommendations on how to effectively implement this requirement.” | “Establish a Minimum Nursing Home Staffing Requirement” includes conducting a research study within one year; then proposing and establishing a minimum staffing level to ensure that “all nursing home residents are provided safe, quality care, and that workers have the support they need to provide high-quality services. Nursing homes will be held accountable if they fail to meet this standard.” |
| Direct care workforce | “Recruit and Retain a Long Term Care Workforce Strategy.” “We support implementing a multi-phase tiered approach to supply, attract, and retain the long term care workforce, leveraging federal, state, and academic entities. This includes loan forgiveness for new graduates who work in LTC, tax credits for licensed LTC professionals, programs for affordable housing and childcare assistance, and increased subsidies to professionals’ schools whose graduates work in nursing homes for at least five years.” | 1.“Launch National Nursing Home Career Pathways Campaign.” In collaboration with the Department of Labor, the reform agenda calls for working with “external entities – including training intermediaries, registered apprenticeship programs, labor-management training programs, and labor unions – to conduct a robust nationwide campaign to recruit, train, retain, and transition workers into long term care careers.” 2. “Ensure Nurse Aide Training is Affordable” includes lowering financial barriers for training and certification of aides. 3.“Support State Efforts to Improve Staffing and Workforce Sustainability” includes developing “a template to assist and encourage States requesting to tie Medicaid payments to clinical staff wages and benefits, including additional pay for experience and specialization.” |
| Infection preventionist | “Enhanced Infection Control Preventionist” includes helping establish “an updated guideline for staffing infection preventionists in each nursing home based on proven, successful strategies.” | “Strengthen Requirements for On-site Infection Preventionists” includes clarifying and increasing the standards for infection preventionists. |
| Chronically poor performing facilities | “Chronic Poor Performing Nursing Facilities and Change of Ownership.” “Chronic poor performing nursing homes often do not meet the needs of their residents. The survey system needs a process to help turn these facilities around or close the facility.” The trade associations propose a five-step process to identify and address poor performers: “(1) Identify chronic poor performing facilities via calculated score; (2) Conduct an analysis to determine the reason for chronic poor performance; (3) Develop a turn-around plan; (4) Monitor progress; and (5) Determine if the plan of correction goals have been met or the need for plan revisions.” | 1.“Beef up Scrutiny on More of the Poorest Performers” includes overhauling the Special Focus Facility program “to more quickly improve care for the affected residents, including changes that will make its requirements tougher and more impactful.” 2. “Increase Accountability for Chain Owners of Substandard Facilities” includes seeking “new [legislative] authority to require minimum corporate competency to participate in Medicare and Medicaid programs” so that CMS can “prohibit an individual or entity from obtaining a Medicare or Medicaid provider agreement for a nursing home (new or existing) based on the Medicare compliance history of their other owned or operated facilities (previous or existing) . . . [and] expand CMS enforcement authority at the ownership level.” 3. “Expand Financial Penalties and Other Enforcement Sanctions” includes using “data, predictive analytics and other information processing tools to improve enforcement.” 4. “Provide Technical Assistance [through Quality Improvement Organizations] to Nursing Homes to Help them Improve.” |
| Personal protective equipment | “Minimum Personal Protective Equipment (PPE)” includes supporting requirements for a minimum 30-day supply of PPE | “Ensuring Pandemic and Emergency Preparedness in Nursing Homes,” one of five overriding themes in the agenda, includes “Continued COVID-19 testing in long term care facilities,” “Continued COVID-19 vaccinations and boosters,” “Enhancing Requirements for Pandemic and Emergency Preparedness,” and “Integrate Pandemic Lessons into Nursing Home Requirements.” |
| Private rooms | “Shift to Private Rooms” includes supporting “development of a national study producing data on conversion costs and a recommended approach” to make the shift to private rooms. | “Reduce Resident Room Crowding” includes exploring ways “to accelerate phasing out rooms with three or more residents and to promote single-occupancy rooms.” |
What AHCA objects to in President Biden’s nursing home reform agenda is enforcement – being held accountable for actually meeting federal standards of care for residents. AHCA supports reimbursement for facilities, but it opposes fines or other financial consequences when facilities fail to meet federal care standards.
In their joint legislative proposal last year, AHCA and LeadingAge called for “Improving America’s Nursing Homes By Learning From Tragedy & Implementing Bold Solutions For the Future.”[5] The Center for Medicare Advocacy agrees with this statement. President Biden’s nursing home reform agenda addresses many of the longstanding problems raised by the two trade associations, but it goes further in proposing meaningful and workable solutions. AHCA should support the President’s nursing home reform agenda.
March 23, 2022
Contact: Ms. Toby S. Edelman, tedelman@medicareadvocacy.org
The Center for Medicare Advocacy (https://www.medicareadvocacy.org) is a national, non-profit, law organization that works to advance access to comprehensive Medicare coverage, health equity, and quality health care for older people and people with disabilities. Founded in 1986, the Center focuses on the needs of people with longer-term and chronic conditions. The organization’s work includes legal assistance, advocacy, education, analysis, policy initiatives, and litigation of importance to Medicare beneficiaries nationwide. Our systemic advocacy is based on the experiences of the real people who contact the Center every day. Headquartered in Connecticut and Washington, DC, the Center also has attorneys in CA, MA, and NJ.
[1] Letter is available at https://www.ahcancal.org/News-and-Communications/Fact-Sheets/Letters/AHCA-Letter-HHS-NursingHomeReformPlan.pdf
[2] James M. Berklan, “Parkinson calls on providers to fight Biden’s ‘offensive’ reform plan,” McKnight’s Long-Term Care News (Mar. 21, 2022), https://www.mcknights.com/news/parkinson-calls-on-providers-to-fight-bidens-offensive-reform-plans/
[3] Care for Our Seniors Act, https://www.ahcancal.org/Advocacy/Documents/Care%20for%20Our%20Seniors%20Act%20-%20Overview.pdf
[4] Id.
[5] Id.