NASHVILLE, TN — After characterizing business conditions as “never worse,” the skilled nursing sector’s top advocate said stakeholders need more help from both the federal and state governments to forge a viable path forward.
The solution could lie in the Centers for Medicare & Medicaid Services universally demanding that states prop up Medicaid payments, said Mark Parkinson, the president and CEO of the American Health Care Association/National Center for Assisted Living, during a media briefing Tuesday at the group’s annual meeting.
“CMS has talked about really putting some teeth into its authority to require states to pay an adequate amount of Medicaid — for all healthcare providers, not just skilled nursing facilities. In far too many states right now, the reimbursement for Medicaid is dramatically less than the actual cost of taking care of people in nursing facilities,” he said.
“CMS has the power and we urge them to enforce it. Secondly, we’re going to need some help from the states. A number of states have stepped up during the pandemic and used some of the hundreds of millions of dollars that they’ve received from the federal government for providers, but unfortunately, some have not.”
Parkinson said CMS, as usual, seems to hold the key when it comes to potentially ensuring adequate Medicaid funding, which is “really what it’s all about.”
“Some pretty high level officials at CMS have started to talk about this (Medicaid adequacy rule) as a possibility in some public meetings,” Parkinson said in follow-up questioning. “The law says states have to pay an adequate Medicaid payment rate. The states’ argument has always been, as long as we have vacancies, it proves that our Medicaid rate is enough to provide access, because there are places for people to go.
“What we’re saying and what the CMS folks have been saying, there is a difference between having access to care and having access to quality care. Quality care may be more expensive than just any care, and the statute says ‘access to quality care.’ And so they’re hinting that they’re thinking about doing something that would require states to not just show that they have empty Medicaid beds but show that people actually have access to quality care. It would be sort of like an administrative Boren Amendment. It was a statute that required states to cover the cost [of quality care]. This would be very significant if it occurred. We encourage CMS to put pressure on states to pay an adequate rate.”
CMS officials acknowledged at several public meetings this year that they were very intrigued with various models where states assume more responsibility for reimbursement.
Congress likely to help?
Parkinson and AHCA/NCAL Vice President of Government Relations Clifton Porter II addressed a wide range of issues at the media briefing, identifying — to no one’s surprise — staffing and census as top concerns. Congressional action has “ground to a halt,” Porter noted, expressing hope that a lame-duck session of Congress could give some indication by mid-December whether any helpful legislation might be in play.
In particular, he is hopeful about S4381 and HR8805, the “Ensuring Seniors’ Access to Quality Care Act,” which would essentially allow nursing centers to expand their own aide training programs.
“(We) feel good about that,” Porter said.
That sentiment was 180 degrees from his outlook on any kind of “significant” movement on immigration reform to help ease industry staffing shortages. There are “hundreds of thousands” of would-be immigrants who could help offset the loss of at least 200,000 skilled nursing employees since the start of the pandemic, Parkinson said.
But only if they can get safely to the US, and with an approved job track. Don’t count on it any time soon, Porter said Tuesday.
“I’m not optimistic at all that there’s going to be any significant movement at all on immigration in the near term,” he said. “But we’re doing everything we can to try to impact workforce issues and challenges, bit by bit and bite by bite.”
How a minimum staffing rule could play out
Eventually, that will include a grassroots campaign to pressure CMS to issue a reasonable minimum staffing rule, which the administration has said should be expected by April.
Despite some indications of sensitivity to providers’ financial plight and bankruptcy filings with the issuance of a surprisingly generous 2023 pay rule in July, Parkinson said that it is clear the minimum staffing rule will be forthcoming and not be sidetracked by any protestations from operators, Parkinson said.
AHCA has estimated it could cost providers $10 billion annually to comply with a minimum staffing mandate of 4.1 nurse staffing hours per resident day. It also would require the recruitment of at least 100,000 more nurses — beyond the 200,000 employees skilled nursing would first need to resupply to get back up to pre-pandemic levels.
“We are hopeful when they issue the rule it will demonstrate they’ve listened to us and they’ve heard the reality. I don’t think they’re just going to back away from doing a rule. The president can’t come out and back off,” Parkinson told McKnight’s.
However, he also expressed some optimism when pointing out a handful of scenarios that could ease providers and others into new standards.
“They can issue a rule that’s paid for and/or didn’t kick in until the workforce has recovered. Maybe they’d tie it into some (Bureau of Labor Statistics) data,” Parkinson explained.
CMS also could issue a rule “in a broad way so that the number is more achievable,” Parkinson added. This could mean widening the list of job titles that could count toward accruing direct care hours per day.
“Then the final thing that they could do is they could demo this,” he said, referring to the implementation of a demonstration project. “Maybe try a state that does have a good Medicaid rate and see what the effect is.
“They are listening to us. We talk to them frequently,” Parkinson continued. “We will have a grassroots campaign before the rule comes out. Our members are going to help them understand what the realities on the ground are.”
