The Centers for Medicare & Medicaid Services (CMS) begins the summer with a new administrator, Chiquita Brooks-LaSure. Soon, the skilled nursing industry will begin to see how this new agency leader — who has a history with CMS and the Department of Health and Human Services (HHS) — will shape nursing home policy and regulation.
The two issues that most urgently demand attention are rules changes, notably related to the three-day stay requirement, and infection control policies, according to Harvard Professor David Grabowski and Avalere Health’s Managing Director Fred Bentley.
Rule changes
In the early days of the pandemic, the federal government issued several waivers to help an overwhelmed health system.
One of those was the three-day stay waiver, which got rid of the requirement that a patient must have a three-day inpatient hospital stay for Medicare to cover the subsequent stay in a skilled nursing facility.
“Our actions allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities,” Seema Verma, then-administrator of CMS, said when the waiver was announced in March 2020.
Those waivers served a purpose for a time, “greasing the skids and getting individuals out of hospitals,” as Grabowski described it. But, with hospitals returning to normal the question becomes whether such rule changes remain necessary.
“With the light at the end of the tunnel for the pandemic, we have to think about what stays, what goes, and what changes as far as rules, regulations and requirements for SNFs,” Bentley told SNN.
He thinks the federal government will return some of the rules, especially the three-day waiver, to the way they were pre-COVID.
“The big question for SNFs is the three-day waiver. Is that going to be permanent or will they revert back to the three-day requirement?,” he said. “My sense is that while some of the flexibilities may stay in place, something like the three-day waiver will probably go away.”
Grabowski agreed and expects the rule changes for SNFs to be temporary.
“I believe many of the temporary rule changes for SNFs and other post-acute care providers will be removed in the coming months,” he explained. “In particular, I do not believe the three-day rule will be continued.”
He felt that the waiver has been popular with SNFs because they can “skill-in-place” their long-stay patients. The waiver also allowed hospitals to keep beds open for COVID patients.
“However, with COVID cases on the decline in hospitals, the rationale for this waiver is no longer present,” he said. “There is also a belief that the three-day waiver has led to an increase in lower-value SNF care.”
In the long-term, he wants
to see alternative payment models that encourage nursing homes to “skill-in-place” for care reasons and not financial ones.
Infection control
One of CMS’ initial efforts coming out of the pandemic is expected to be centered around infection control, and specifically, improving infection control at nursing homes moving forward.
“Following the pandemic, I would be shocked if we don’t continue to see increased regulatory scrutiny on this issue along with increased requirements such as a full-time preventionist,” Grabowski told SNN.
Bentley was of the same mind.
“The big longer-term question that Brooks-LaSure and the new administration will have relative to nursing homes is infection control,” he said. “I think the pandemic really showed the shortcomings there within the industry. I’m not pointing fingers … Certainly, there were some bad actors.”
Coming out of the pandemic, infection control will need to be a top priority for the new administration, he said.
It’s a different world now from the one when the pandemic started, as facilities should b to be investing in protecting their staff now and into the future.
The challenges nursing homes faced in controlling infection through the pandemic was “eye-opening,” Dr. Buffy Loyd-Krejci, founder of infection control consulting firm IPCWell, said during Skilled Nursing News’ Rethink podcast last month.
She worked in nursing homes all over the country throughout the course of the pandemic.
Their lack of readiness was in part because it wasn’t until 2016 that CMS mandated that every certified SNF begin implementing an infection control, she said.
“They weren’t ready because it hasn’t been a priority,” she said.
Bentley doesn’t think the nursing home industry will be caught off guard again and anticipates intensified scrutiny on what nursing facilities are doing as well as infractions related to infection control.
“The new administration is going to crack down on those in a way that we wouldn’t have seen pre-pandemic,” he added.
CMS doesn’t necessarily need to “come down harder” on nursing homes, in the opinion of Janine Finck-Boyle, vice president of regulatory affairs for LeadingAge, which represents more than 5,000 nonprofit aging services providers.
She does think that mandating improvements to the survey process will lead to better resident care and will turn around poor performers, especially as infection control is concerned.
Finck-Boyle would like to see CMS continue to conduct and look at infection control surveys from the past year, with an eye toward how practices can be improved.
“During the pandemic there was a process put into place called the surface infection control survey that was specific to infection control,” she said.
While Finck-Boyle believes there are many functions of the survey process that are “currently broken”, she feels that the industry learned a lot through these infection control surveys, and wants to see those efforts continue.
“I think what was taken out of this was a focus on infection control and looking at ways to collaborate with nursing homes,” she added. “If you look at our Blueprint For A Better Aging Infrastructure you’ll see we really want CMS to look at the outcomes of surveys and at the survey process as a whole.”
Finck-Boyle will also be looking for CMS to follow recommendations made by the National Academies of Sciences, Engineering and Medicine to modify the nursing home regulatory framework in a report that will be released later this year.
She expected Brooks-LaSure to be open to some of these ideas to improve the aging infrastructure and is excited to work with her.
“She comes from inside and we are very excited about that because of the work she’s done … she’s an experienced policy maker,” Finck-Boyle said. “We are very happy to see that she was brought forward and confirmed.”
More on Brooks-LaSure’s Ambitious Agenda
Biden’s pick, Brooks-LaSure was confirmed at the end of May in a 55-44 Senate vote, with five Republicans supporting the confirmation.
She described her agenda as “ambitious” from the get-go.
“The COVID-19 pandemic has illuminated so many of the longstanding health disparities in this country, and CMS has the ability to advance health equity for all Americans through Medicare, Medicaid, and the health insurance marketplace,” she said at her confirmation hearing. “We’re going to build on the Affordable Care Act and continue to bring down health care costs for American families.”
Her confirmation as the first Black woman to head CMS was celebrated by lawmakers and health groups across the country.
She is now one of the gatekeepers in the health care industry, managing roughly $1 trillion of the federal budget and overseeing some of HHS’ most important programs, joining new HHS secretary Xavier Becerra.
Grabowski thinks they both need to look at addressing staffing challenges in nursing homes with federal dollars.
“If I was advising Brooks-LaSure, I would advocate that she focus on strengthening the workforce through minimum staffing standards and wage floors,” Grabowski added. “The nursing home sector is in need of major reform but the workforce can be addressed in the relatively short-term. These workforce reforms would likely require more Medicaid funding.”
Grabowski thinks Medicaid funding should be used for workforce reforms as long as it is paired with increased oversight of nursing home cost reports and ownership data.
“We need to make certain that the new funding is being spent as intended,” he said
Companies featured in this article:
Avalere Health, IPCWell, LeadingAge, National Academies of Sciences
