Providers Push Back on CMS’s Move to Zero in on Nursing Roles in Minimum Staffing Study

Nursing home providers and industry leaders renewed their pleas this week to federal government officials to consider non-nursing positions in its proposed minimum staffing requirements, perhaps to no avail.

An upcoming study to help determine an appropriate staffing level will squarely focus on nursing staff, specifically registered nurses (RNs), licensed practical nurses (LPNs), licensed vocational nurses (LVNs) and certified nursing assistants (CNAs), according to Abt Associates Principal Alan White, the research firm contracted by CMS to study the issue.

The Centers for Medicare & Medicaid Services (CMS) hosted a virtual stakeholder listening session on Monday to provide additional information on its plans to establish a proposed minimum staffing level, in addition to opening the floor for overall feedback on the topic.

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White reminded listeners on the call that the study will include four parts: a literature review, nursing home site visits, quantitative analyses and cost analyses. The ultimate goal is to “build on and not replace” past research, he said.

Both Dr. David Gifford, chief medical officer for the American Health Care Association (AHCA) and Janine Finck-Boyle, vice president of health policy for aging services organization LeadingAge, expressed concern over a seemingly one-size-fits-all approach when nursing home care has changed so dramatically, and continues to do so, based on acuity levels.

“We know that here we’re looking and talking about nurses, but there are nursing homes throughout the country that have changed some of their models …. As we’re looking towards the future for minimum staffing, we need to make sure that all the interdisciplinary team is taken into account,” Finck-Boyle said on the call.

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CMS should also be factoring in therapists, psychologists and social workers, podiatric specialties, culinary staff and other team members who provide daily care to residents, according to Luke Neumann, vice president of service and relationship development at Florida-based Palm Garden Healthcare.

And they weren’t the only ones with such requests. Other leaders across the health care continuum sounded off on the issue as well.

“We recognize that the nursing categories are essential roles to the care that’s delivered at the nursing homes, but would appreciate CMS recognizing the roles and care that are provided by these non-nursing titles,” said Scott Gaffney, assistant vice president, health economics and finance at the Greater New York Hospital Association.

As the industry’s ongoing workforce shortage continues, and costs remain elevated due to inflation, operators continue to wonder how they will be able to comply with such regulations — and who is ultimately going to pay for it.

“Given the failure to invest in incentivized nursing infrastructure, and to meet the crisis level demand, if there were a minimum staffing requirement as an unfunded mandate today we would be hard pressed to be able to hire enough nurses, CNAs or caregivers to be able to meet current demand, let alone a higher demand,” Neumann added.

Setting the stage

The staffing study is being completed on a very expedited timeline, White said. Dr. Lee Fleisher, CMS chief medical officer and director of the Center for Clinical Standards and Quality (CCSQ) reiterated on the call that the proposed minimum will be published sometime in Spring 2023.

The original study that wrapped up in 2001, in which White was also involved, took eight or nine years to complete.

Officials now have access to “newer and better data”, he said, referring to Payroll Based Journal (PBJ) staffing measures and other CMS quality measures that have been developed since the first study.

In addition to the quantitative analyses, CMS will review cost analyses using Medicare cost reports and average hourly wages paid to RNs, LPNs and nurse aides, as well as fringe benefit costs.

The study will also consider payer mix differences, mix of agency staff versus full-time employees, size of the facility, its geographic location, to better determine the cost.

Using that information in conjunction with PBJ staffing data will allow officials to simulate and potentially estimate what the costs would be for different nursing homes to be in compliance, White said.

“Bringing in the cost analysis kind of allows us to balance those benefits or understand how those benefits are balanced against the costs that a nursing home would incur to increase staffing up to whatever level CMS might specify,” White said.

The nursing home site visits will also help paint a more complete picture. CMS is expected to visit 75 total nursing homes across 15 states. Officials will first visit 50 facilities to conduct on-site interviews with nursing leadership, direct care staff, residents and family.

The remaining 25 nursing homes will be visited shortly thereafter to “validate the initial findings,” White said.

While the data CMS is using may be new, the issue of staffing shortages in the nursing home industry is not, according to worker and resident advocates who were on the call.

“Care will not improve until all facilities have enough well trained staff. Facilities also need to pay them well, pay them appropriate benefits and treat them well,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy. My final comment is no more excuses and no more delays. We don’t want to have another store study 20 years from now.”

No more sticks, more strategic collaboration needed

Sarah Dobson, senior director of public policy and advocacy at Lutheran Services in America, implored CMS officials to consider geographical differences in costs as well as hiring and retaining staff when undergoing site visits, and in turn, a facility’s ability to meet a minimum based on those challenges.

The nursing home sector has lost nearly 229,000 caregivers nationally since February 2020, according to Bureau of Labor Statistics (BLS) data.

“Unfortunately, the new proposals with no additional funding will exacerbate the current crisis and make it more difficult to hire needed staff. This will lead to fewer older adults able to receive skilled nursing care and more closures in rural areas with already limited health care options,” she said on the call.

Dobson pointed to opportunities for CMS to help bolster the workforce including easing the path to securing work visas for international workers and refugees and allowing greater flexibility for SNFs to provide on-site training for new hires and existing employees, especially CNAs.

Immigration does fall outside of CMS’s jurisdiction, which means immigration policy as a long-term solution to staffing shortages would have to be a cross-agency initiative.

Reier Thompson, president and CEO of North Dakota-based Missouri Slope, is starting to believe there is no adequate wage that will attract and retain employees, further highlighting the need for various government agencies to work together to develop creative solutions to increase the supply of CNAs and nurses into the health care industry.

“There are other solutions out there but just having the president say this is the way we’re going to do it and initiate with a stick, we need more collaboration, we need more strategic collaboration across multiple departments of the government to increase supply so that we can have a fighting chance at having this all be very successful because it should be,” he said on the call.

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