The cut included in the 2024 Physician pay rule, which was finalized by the Centers for Medicare & Medicaid Services in November, affects doctors working in nursing homes and other long-term care settings, as well as pay for therapists and other ancillary services. 

In the last few years, Congress has moved to offset similar reductions, which don’t necessarily reflect true costs of physician services but are required if CMS decides to put a greater share of its funding toward other types of care.

The ongoing regular reductions to reimbursement are “an existential threat” to the long-term care sector’s therapists and other providers who bill Medicare Part B, said Cynthia Morton, executive vice president of advocacy group ADVION, earlier this year.

Congress included a 3% offset to conversion factor cuts for 2023 and planned another 1.25% offset for 2024 in the 2023 Consolidated Appropriations Act. But bills that would help make that 2024 change more significant have not moved forward yet this session. 

Morton told McKnight’s Long-Term Care News that the next best opportunity for a fix is  ahead of the government funding expiration on Jan. 19.

“Whatever funding vehicle will be advanced to continue that, we want to have our Physician Fee Schedule patch attached to that,” Morton said. “It’s important that Congress deal with this patient issue in January because the reductions will have already gone into place on Jan. 1.” 

Looking for silver linings

A rate correction could be made retroactive, as has happened in the past.

While ADVION and other provider groups are still advocating for a full 3.7% patch to address the cut, the Senate Finance Committee has so far passed a 1.5% patch and the House Committee on Energy and Commerce passed a 1.25% patch.

Bills that could be a vehicle for the patch are: the Preserving Seniors’ Access to Physicians Act of 2023 (H.R. 6683), which would eliminate the 3.37% conversion factor reduction; and the Strengthening Medicare for Patients and Providers Act (H.R. 2474), which would add a permanent payment update to the Medicare PFS that is tied to inflation, as measured by the Medicare Economic Index.  

There also was a bipartisan letter of almost 200 House members sent to House and Senate leadership asking them to end the 3.37% reduction, Morton noted.

Meanwhile, the American Medical Association, which represents physicians and physician practices, has warned that Congress’ inaction so far could force some providers to cut office hours or forgo treating Medicare patients.

On Monday, the AMA recommended that lawmakers transfer about $1.8 billion from the FY 2024 National Defense Authorization bill to cover the cut. It includes $2.2 billion in money shifted from the Medicare Trust Fund to a Medicare Improvement Fund, which would be more than enough to stop the cuts.

“Facing a nearly 10% reduction in Medicare payments over the past four years and rising practice costs on top of the burdens and burnout of three years of COVID-19, for many physicians, continuing down this road is unsustainable,” said AMA President Jesse M. Ehrenfeld, MD, MPH. 

“These cuts will be felt first and hardest in rural and underserved areas that continue to face significant healthcare access challenges. Medicare physicians do not receive inflationary payment updates, which is why eliminating these cuts is so crucial.”

A series of struggles around assessment began in fall, with the most extensive updates in years to the Minimum Data Set, which captures patients’ clinical needs and also serves as the basis for much of a provider’s state and federal reimbursement.

“It’s not news to anybody that this rollout was not smooth,” said Alicia Cantinieri, senior vice president of Clinical Policy and Education for Zimmet Healthcare Services Group. “There were a lot of technical issues with coding, with skip patterns, with Section GG, with HIPPS code calculation being incorrect.”

Despite the Centers for Medicare & Medicaid Service issuing corrections and technical clarifications in the weeks after the Oct. 1 launch of the updated MDS, some providers still may face long-term consequences of coding errors or delays forced on them by incomplete early guidance from regulators. That was just one of the cautions shared by Cantinieri and two of her Zimmet colleagues during a webinar titled, “Fasten Your Seatbelts: It Might be a Bumpy Ride.”

Cantinieri said the lasting implications of some software and coding issues in the first week of the launch were going to especially affect providers in states that used the Patient Driven Payment Mode to determine a Medicaid case-mix before the changeover.

In the case of providers who needed to code patients receiving respiratory therapy, for example, many found the section blocked out and were unable to capture payment for related services. Some went back and modified submission; others waited to submit until they had clarification on how to correct the problem.

“Facilities have been left with questions about when to modify, when to resubmit,” she added. “And we haven’t heard any guidance from CMS that they would waive or forgive the submission timing requirement, so there’s the potential that facility could be cited.”

Chief Innovation Officer Steven Littlehale said that regardless of the complication or system error, it is critical that providers keep related records for a few years “so that ultimately you’re not left holding the bag for this sort of failed launch.”

Duplication of efforts

The removal of Section G to measure a patient’s functional status also continues to wreak havoc on payment, especially at the state level. Many states used G to determine payments, and without it, complications have continued to crop up, said Melanie Tribe-Scott, vice president of Quality and Regulatory Compliance.

For providers in many states not using the PDPM yet, the workload has increased significantly, with many requiring that MDS coordinators record information in the replacement Section GG and capture details for all patients on an optional state assessment, too.

The advent of MDS also has led to frozen pay in some states, while upcoming quality measure changes will lead to freezing quality measures as well, the speakers noted. That may discourage providers from being diligent in some areas, thinking they are temporarily less important.

But that couldn’t be farther from the truth for payment, Tribe-Scott added. She said some states would undoubtedly be using codes captured in the frozen period to see how provider behavior and patient needs would shape spending under a system more aligned with PDPM.

And those frozen metrics, which lock in April to give regulators more time to collect full data before publishing new calculations, also could come back to haunt if not given enough attention. Most are connected to new quality measures, which will be used later to inform quality measure ratings on the Care Compare website.

“Eventually, it will be thawed and you’ll see those new measures,” Littlehale said. “It’s important to not turn your back, for quality improvement reasons, on those very outcomes. You need to get a little old school with how you’ve tracking performance in those areas.”

Stay ahead of problems, and no blanking out

Another critical change is coming Jan. 1: Providers will need to submit a higher percentage of MDS data than in years past to remain eligible for a value-based purchasing payment bump. It’s critical they not leave boxes blank, especially new ones, simply because staff don’t understand how or when to complete them, Cantinieri said.

Providers can stay ahead of some of the challenges by taking a few steps as 2024 gets underway, the presenters said.

Cantinieri recommended auditing MDS forms to make sure information is being collected and submitted correctly; a standard size nursing home could make it a quality improvement goal to review 10 charts per month and include charts from a variety of patients involving a range of interdisciplinary staff. An external audit also could benefit providers who want to ensure they’re capturing everything possible in line with the Oct. 1 changes.

The team also suggested reaching out to any MDS-involved software vendors to ensure updates have been made and that any incorrect data caused by early adoption kinks has been retroactively corrected, if appropriate.

The case revolves around National Fire & Marine Insurance’s attempt to have individual COVID claims considered separate healthcare events for legal purposes. A late 2022 interpretation by the US District Court for the Eastern District of Pennsylvania would have forced Genesis to pay $3 million in self-insurance fees in each case related to COVID before getting any relief from its insurer. 

Genesis, which court records described as having aout 400 nursing homes and assisted living facilities in the US, quickly escalated that decision to the US Court of Appeals for the Third Circuit.

On Monday, a three-judge panel ruled that the lower court had erred in even considering National’s request for a quick, summary judgment, saying the full extent of possible payouts by Genesis hadn’t become clear yet.

In legal terms, that made the case “not ripe” for review.

“That is because Genesis is far short of meeting its $3 million threshold on a single SIR [self-insured retention] — let alone on multiple SIRs,” write judges Kent A.Jordan, Stephanos Bibas and David J. Porter.

In late 2022, Genesis said it had paid $1.3 million in covered expenses and anticipated an additional $300,000 over the ensuing five months for all COVID claims against the company. In an update requested by the appeals panel, Genesis put its to-date costs at just over $2 million, which the judges noted was still “far short” of the $3 million threshold.

“At this stage of the case, we fail to see how there is any ‘real and substantial threat’ of harm if a declaratory judgment is not entered,” the judges wrote. “Many COVID-related claims against Genesis already are barred by the statute of limitations in many states. So the likelihood of Genesis’ costs exceeding $3 million any time soon — if ever — does not constitute a substantial threat of real harm.”

A request for comment from a Genesis spokeswoman was not immediately returned Tuesday.

The judges ruled that the District Court lacked subject-matter jurisdiction over the controversy and erred in its earlier ruling for National. It vacated that judgment and returned the case to the lower court for further proceedings.

Genesis faced at least 46 COVID-related claims, according to court documents. It took out its additional policy with National Fire & Marine in the fall of 2020, with a coverage period that was supposed to be retroactive to December 2019. While Genesis agreed to pay the first $3 million in defense costs, settlements or judgments for each healthcare event up to $160 million total, it viewed COVID as a single event.

Had National been victorious, it would have covered none of the costs associated with claims against Genesis during the policy period.

As it is, the insurer may remain virtually unaffected by Monday’s ruling.

Before the 2022 ruling, Genesis was subject to 41 unsettled lawsuits and would have to incur about $41,000 in costs each to cross the $3 million total at the heart of the case. But National conceded that only 17 of those 41 lawsuits were currently in litigation.

A call seeking comment from the National Indemnity Company, which owns National Fire & Marine Insurance Company, was not returned Tuesday.

The jury’s finding came after five weeks of testimony in the complicated case involving Brighton Rehabilitation and Wellness Center and Mt. Lebanon Rehabilitation and Wellness Center. The US Attorney’s Office for the Western District of Pennsylvania also prosecuted five company and facility leaders for their roles in a scheme that led to overbilling; the jury found all five not guilty.

Brighton Rehab itself was found guilty of healthcare fraud and five counts of falsification of records in a federal investigation, while Mt. Lebanon was found guilty of one count of falsification of records related to healthcare matters and three counts of falsification of records in a federal investigation. The nursing home defendants are scheduled to be sentenced in May before US District Judge Robert J. Colville.

Neither prosecutors nor defense attorneys offered a solid explanation as to why the jury reserved its convictions for the corporate defendants. But US Attorney Eric Olshan told McKnight’s Long-Term Care News in an email Monday night that his office would pursue similar cases in the future, if warranted.

“Our legal system entrusts the jury with making determinations of guilt, and as in all cases, we respect the jury’s verdict,” he said. “Today, the jury held the two corporate defendants criminally liable for a total of 10 counts of making false statements and obstructing CMS’s critically important work of ensuring that nursing facilities comply with the law.  This office and our law enforcement partners will continue to seek accountability for any individual or business that pursues profit through deceit and does so at the expense of vulnerable members of our community.”

Several counts in the indictment that precipitated this fall’s trial carried up to $250,000 in fines, or jail times in the case of individuals. In a press release issued by the US Attorney’s Office Monday evening, prosecutors said the companies faced a maximum of five years probation, $500,000 in fines, or both, on the counts for which they were convicted.

A message from McKnight’s Long-Term Care News left with a nursing leader at Brighton Rehabilitation for Comprehensive Healthcare Management Services was not returned Monday.

Prosecutors had alleged two different schemes to enrich the nursing homes’ operations. In the first, leaders were accused of falsifying payroll documents to make it appear the nursing homes were meeting required staffing levels, including having non-working direct care staff clock in for shifts they never intended to work. In the second, administrators were accused of changing assessments to make it appear patients were clinically depressed or needed more therapy as a means of delaying discharge and driving Medicare or Medicaid reimbursements.

But in court, attorneys for the individual defendants framed the case as one of sloppy record keeping and government malfeasance, rather than intentional fraud, TribLive reported.

They also hit at the credibility of 20 former nursing home employees as having an ax to grind. Some were fired, others quit and some were offered immunity in exchange for their testimony, the Pittsburgh Tribune-Review noted in its coverage of last week’s closing arguments.

Kirk Ogrosky represented Sam Halper, Brighton’s CEO and 12% owner and an officer at Mt. Lebanon. Orgosky argued there was no evidence Halper was involved in ordering or completing incorrect staffing records but instead told the jury that a handful of staff members came up with a scheme to cheat the buildings’ corporate owners.

“Throughout this case, all defendants cooperated with the US Department of Justice in every way possible. Yet, DOJ pursued individuals without regard for the truth,” Halper said in a statement shared with TribLive. “Thankfully, the jurors were able to hear the evidence and find that the facts did not support DOJ’s claims.”

Ogrosky did not return a message from McKnight’s seeking additional comment Monday.

The app aims to improve the exchange of patient information and better inform the care provided to nursing home patients. It bridges the gap between medical records systems that use different data storage technologies and offers patient information in a format influenced by nursing home workers themselves.

The development stems from a study that started with a team of experienced nursing home nurses identifying key data points and helping shape the way the tool works and its visual format. The process was detailed in the Journal of the American Medical Directors Association.

“The reason that people go to a nursing home after being hospitalized is due to their needs for additional support for medical complexity. Receiving information that is inaccurate or delayed ties the hands of the clinical providers in the nursing home, making it more difficult to provide safe and appropriate care at the time of transition,” co-developer and study author Kathleen Unroe told McKnight’s Long-Term Care News Friday. “Medications for pain or other medical conditions could be delayed due to a lack of up-to-date information.”

Some conditions, especially behavioral health needs, may also be missed by receiving facilities, and those facilities may be unequipped to treat such needs.

 “Not only can this place the patient’s health at risk, it can also put the health and safety of other residents (in the patient’s home or in a SNF), as well as provider staff, at risk,” CMS Director David Wright wrote in a memo to hospitals earlier this year. “These situations can cause avoidable readmissions, complications, and other adverse events.”

Robust info sharing helps staff

Preventing unnecessary readmissions is one of Unroe’s main areas of focus as a research scientist for the Regenstrief Institute at Indiana University.  She’s been bewildered by the lack of consistency or movement toward interoperability between healthcare settings.

“This is an issue we have had the technology to solve for a long time and I and other clinicians are frustrated that the situation varies so much by facility and by discharging hospital,” she said. “I appreciate that CMS is pushing hospitals to take responsibility for transmitting appropriate and timely information to nursing homes to support care transfers.”

The app development project focused on how critical information should be optimally presented and integrated into nursing home workflows. 

“A nursing home admission nurse or admitting physician should not have to sift through a pile of paper or dig through lengthy electronic health records to capture basic pieces of data that we need to know on each admission,” Unroe said.

The app provides “robust” information quickly to support what the research team called a seamless transition of care across settings, regardless of which electronic medical record systems the two facilities use. It addresses residents’ medical needs as well as what supports they might need for activities of daily living, explained co-author Joshua R Vest, PhD, of the Department of Health Policy and Management at Indiana University. 

And the benefits won’t necessarily be limited to patients, Unroe added.

“Costs of staff training are reduced if the time is put into thoughtful, user-centered design, such as the results presented in this study,” she said. “Increasing sophistication of medical record systems and a greater push for interoperability mean it is possible to get widespread solutions in nursing homes into use.”

Unroe now plans to advance the prototype into a fully scaled tool for broad use on computers and handheld devices. The researchers plan to test it in real time with actual transfers to confirm that it will support nursing home nurses “to efficiently and safely admit patients as well as to ensure that there is no disruption in the clinical care plan created by the hospital due to transition to a nursing home,” Regenstrief said in a press release.

Sen. Bob Casey (D-PA), chairman of the Senate Special Committee on Aging, noted that nearly 4 million older adults reported having a substance use disorder in 2022, with 1.8 million of those involving drug use. Mortality from drug overdoses among seniors also more than tripled between 2000 and 2022, he added, citing federal data. 

“Older adults are not immune to these issues, and this a growing and evolving crisis in America,” Casey said in opening the hearing, which focused both on access to opioids and gaps in care. 

“Older adults tend to be overlooked for substance use disorders in typical screenings and prevention efforts, even though they are more susceptible to developing substance use disorders than other age groups and at higher risk of undiagnosed and untreated substance use disorders,” he added. “The people, the problems and the solutions remain largely invisible to our society.”

Nursing homes are increasingly being called on to treat patients with substance use disorders, with both federal regulators and state law enforcement officials reminding facilities that they cannot turn away such patients when they are also in need of skilled care.

Some nursing homes have begun to specialize in providing such care, particularly for opioid-addicted patients requiring administration of suboxone treatments.

OIG keeps focus on needs, treatment access

Thursday’s hearing coincided with the publication of an annual brief from the Health and Human Services Office of Inspector General that examines access to treatment for opioid use disorder and the opioid overdose-reversal drug naloxone.

It found that about 52,000 Medicare enrollees experienced an opioid overdose in 2022. Of the 1.1 million enrollees who have opioid use disorder, just 18% received medication to treat that disorder. In some states, the OIG found far lower access, with Florida the worst with just 6% receiving treatment medication.

While naloxone has been an important tool in addressing the nation’s opioid crisis — one Senate witness credited with “saving countless Americans from death” — it last year became an over-the-counter medication. That could mean less affordable access for some Medicare patients, and the OIG warned CMS to make sure providers know how to educate patients and prepare for additional need.

The OIG report recognized that CMS and the department “had taken a number of actions” to increase access to suboxone and other opioid use disorder treatments. 

“However, the low percentage of enrollees receiving medication to treat their opioid use disorder calls for additional action,” the report said.

David Skoczulek, vice president of business development and communications at Connecticut-based iCare Health Network, said providing access to “patient-centered, specialized substance use treatment and care in the skilled nursing setting is critical.”

“Substance use disorder crosses all social and demographic lines,” he added. “The need for these services is not going away and it’s not even appearing to ebb over time. We will be living with the impacts of the opioid epidemic for a very long time in all aspects of healthcare, and skilled nursing care is not an exception. It’s highly prevalent and we will need increasing supports, access and coverage to provide quality care to these individuals.”

Medicare coverage gaps remain 

Much of the conversation Thursday revolved around the inability of Medicare-covered seniors to access residential treatment and other services under either traditional or managed care plans.

While commercial insurance providers in the US must provide parity in the way they cover physical health needs and behavioral health needs, the Medicare system has not been changed to reflect that standard.

“Older adults and people with disabilities deserve non-discriminatory coverage of substance use disorder and mental health treatment,” said Deborah Steinberg, senior health policy attorney at the Legal Action Center. “We urge you to ensure that Medicare beneficiaries do not continue to be left behind.”

She pointed to the 2018 SUPPORT Act, which first added coverage of opioid use treatment to Medicare, as the start of improved treatment for opioid use disorder. This year, Congress included coverage of addiction counselors (under the umbrella of mental health counselors) and intensive outpatient treatment in its consolidated appropriations bill.

And CMS has also issued regulatory guidance and coding to make sure beneficiaries have more access to peer support specialists and community health workers, Steinberg noted. The agency also increased Medicare reimbursement for psychotherapy and office-based substance use treatment to “address barriers to provider participation,” Steinberg said.

Nursing homes, however, aren’t paid extra by the federal government for substance use disorder care provided to their residents, despite its additional staffing and safety demands and costly counseling services. State Medicaid plans, however, do in some cases help offset the cost of bringing in behavioral health professionals.

Also Thursday, Sen. Mike Braun (R-IN), the committee’s ranking member, issued a new report emphasizing concerns about the illicit opioid trade and the increasing ways seniors may interact with fentanyl-laced drugs.

“Despite [a] dramatic increase in overdoses due to synthetics, prevention messaging for older adults still reflects traditional concerns about prescription opioid misuse but does not focus on synthetics like fentanyl increasingly infecting drugs taken by older Americans,” the report stated.

Using data from the Centers for Disease Control and Prevention, the analysis found that deaths over the four-week period ending Nov. 19 were more than four times higher than those recorded during a four-week period ending June 25.

About 1,000 residents died from the virus in the fall time frame, bringing the year-to-date total to roughly 9,000 residents, AARP reported. Since the start of the pandemic, more than 185,000 nursing home patients have died of COVID.

But vaccinations, at first widely embraced by residents and later mandated for healthcare workers, drove infection and deaths rates down dramatically starting in 2021.

The uptick in deaths last month, accompanied by a quadrupling of infections of both residents and staff compared to this summer, comes as vaccine coverage is way down compared to the last two winters.

But there is some reason for optimism. The AARP analysis reported about 25% of nursing home residents were considered up-to-date on COVID shots, though that figure was based on Nov. 19 reporting. As of Dec. 3, according to Centers for Medicare & Medicaid Services data, the resident up-to-date figure had climbed to 30.7%, with 7.2% of staff covered.

Resident deaths peaked at 338 the week ending Nov. 26, then fell back to about 260 per week for the first two weeks of December, according to a review of CDC data by McKnight’s Long-Term Care News on Thursday. That’s still on pace to record another 1,000 deaths by year’s end, however.

Providers have continued to encourage vaccination, but in many states they reported early challenges with accessing shots, paying for them and getting enough for all of their people. More broadly, aging services providers said they are facing the same challenges public health officials are: a lack of interest in yet another round of vaccines.

“Long-term care providers are making every effort to encourage residents and staff to get vaccinated, and we are confident we will continue to make progress in the face of cold and flu season,” David Gifford, MD, chief medical officer at the American Health Care Association/National Center for Assisted Living told McKnight’s in late November.

“While nursing home residents are more than three times as likely to be up to date on their COVID vaccinations compared to the general public, nursing homes do not operate in a vacuum,” he added. “Unfortunately, we face the same challenges that we’re seeing across the US population at large: vaccine misinformation, hesitancy and fatigue. We need a collective approach to boost vaccine access and uptake, and AHCA/NCAL will continue to seek support of public health officials and the broader health care community.”

In November 2021, AARP reported, almost 90% of residents were vaccinated and roughly 40% had received a booster shot. Staff vaccinations had also hit the 80% mark just ahead of the Supreme Court approving a federal mandate. That mandate was ended along with the expiration of the public health emergency earlier this year.

More than 75% of nursing homes would not meet the proposed hourly requirements for registered nurses and certified nurse aides or 24/7 RN coverage if it were enacted now, according to the Centers for Medicare & Medicaid Services’ own rule. A KFF research brief issued weeks after the rule’s September proposal put that share even higher, at 81%.

That leaves somewhere between 19% and 25% of nursing homes that are already capable of meeting all three new standards. In addition, U.S. News & World Report last month published a list of 700 nursing homes (or about 4.6% of all those in the US) that meet both current requirements for eight hours of RN coverage five days a week, and proposed requirements for round-the-clock care.

McKnight’s Long Term Care News spoke with leaders of three facilities achieving the mark to explore how and why their operating conditions allow them to exceed national norms. Their experiences demonstrate how critical certain types of partnerships and reimbursement models could be in making higher staffing goals achievable nationwide.

Permian Residential Care Center, Texas

This 5-star, 90-bed nursing home is in the midst of oil country. When local seniors need care, they typically turn to Permian; there are no other skilled nursing facilities within a 25-mile radius.

That lack of local competition for the area’s few nurses, paired with the backing of a well-regarded, nonprofit community hospital have helped Permian maintain high levels of CNA and RN staffing. It staffs at 5 hours and 30 minutes of total direct care per day, according to CMS data, far surpassing the national average of 3 hours and 47 minutes. Permian beats national averages in the CNA, LPN and RN categories, too.

Being under the same umbrella and top-level leadership as the hospital makes it easier for Permian to operate fully staffed versus peers in a corporate structure with layers of regional overhead, Administrator Cydney Fulks told McKnight’s. 

“I think one of the things that helps us afford our nursing is we don’t pay a landlord fee. We don’t pay any operators’ cost because we are able to operate individually. We’re not paying a management company,” she said. “And if we need to make decisions here [about staffing], we’re able to have a discussion and go to our hospital CEO for the support that we need.”

Another major benefit that helps Permian recruit? The Andrews County Hospital District, the health system with which it’s aligned, has established level pay rates across settings.

“We don’t compete with the clinic for rates. We don’t compete with the hospice for rates,” Fulks said. “We have the same rates across the board, and I do find that to be very helpful whenever people are making decisions on where they’re going to work.”

Though Permian has a CMS-reported turnover rate of just 31%, it still dedicates resources to ensure leaders can more easily recruit when that’s needed.

Two local colleges offer clinical training at Permian, and Fulks said leaders aim to make those rotations educational and fun to expose students to the kind of activities regularly happening in nursing homes. The facility also runs a CNA training program, which it relied upon as it was staffing up a new 22-bed memory unit. 

During those in-house exposures, students experience a high nurse-to-patient environment.

“On my first day here, I thought they were having a staff meeting. There were so many people working,” Fulks recalled. “I didn’t know because it was my first day, but that was actually the staffing pattern. It alleviates a lot of burnout for there to be that many people.”

On a recent Wednesday afternoon, the building had 55 residents being cared for by six nurse aides, two shower aides and two restorative aides.

“They know that they can come to work and do a good job with their residents, and they’re not going to be stretched too thin,” Fulks said. “They can feel comfortable providing care because they know they’re not going to be one nurse providing for 50 people.”

And should Permian receive a sudden rush of patients, it only has to reach out to the hospital next door to find an RN quickly or get overnight coverage. Leaders work together on the ground to come up with long-term approaches and new strategies as needed.

“If we were in a different situation, like some of the communities around us, [the mandate] is going to be very difficult,” said Paul Slaughter, Permian’s certified medical director. “One, they don’t make their own decisions. Two, they’re going to say they don’t have the money. Three, if they have the money, it’s going to be somebody in Dallas or Houston making these decisions.”

While Slaughter has empathy for other facilities that may soon find themselves struggling to recruit and to afford anyone they can hire, he also believes a mandate may be necessary — especially for buildings without local control.

“In seeing the way these other places operate, if they don’t get given some direction on regulatory issues, they’re not going to do it. They’re masters at how to get around it anyway.”

Lorien Health Services Bulle Rock and Mt. Airy, Maryland

Lorien, with eight skilled nursing facilities across Northern Maryland, launched in 1977. Each  building has been built and continuously owned by the same family, and they are led by long-time CEO and President Lou Grimmel.

Two Lorien facilities made the U.S. News & World Report list of nursing homes that meet both the current RN daily coverage standards and the round-the-clock coverage proposed by CMS.

While both buildings have ventilator care units that require the presence of an RN or respiratory therapist at all times, Grimmel told McKnight’s that’s not the only reason its buildings have so many caregivers.

Higher staffing levels are part of the culture at Lorien, Grimmel said, although that comes with a steep cost that must be offset in some way. For now, it’s being borne by the owners’ tolerance to fund losses.

“We can’t make it work on the reimbursement itself,” he said. “We have ownership that cares and funds it, but how sustainable is that?”

Until COVID and its trailing inflationary pressures, the Lorien model worked because most campuses compensated for lower paying nursing home residents with a larger number of  Assisted Living units charging adjustable market rates.

Bulle Rock, which opened in 2018, was supposed to share its campus with a hospital that was never built and an assisted living component that was paused due to COVID. Instead, Lorien added a ventilator care unit there to help drive up reimbursements and support higher staffing levels.

“We can’t make it without it. We have to add something,” Grimmel said, adding that he’d like to work with the state on some kind of grant funding for behavioral health or other services that would help keep operations affordable.

He’s not surprised that so many newcomers to the sector cut staff to manage costs.

“What are you expected to do when your reimbursement stays basically consistent and because of the pandemic, your operating expenses, mainly labor, have skyrocketed?” Grimmel asked. “We don’t have a choice like the airlines to cancel flights. We don’t have a choice like the restaurants to close down tables. We have to get staff, regardless of what it costs us.”

But often, money isn’t enough to stem the tide. Sometimes, the right workers, especially RNs, simply aren’t available. Lorien is looking far and wide, but the federal government has stalled its efforts to bring in 31 new contracted RNs from the Philippines.

“We staff what we can get. It’s really that simple,” Grimmel said. “If we could get the RNs, we would staff all our buildings like Bulle Rock.”

But, Grimmel warned, not all owners will fund ongoing losses due to staffing, and none can do it without end. Even those driven by mission will need more financial support to survive, Grimmel said.

Government policies are too reactive, Grimmel said, noting the lack of funding for initiatives for senior care amid a rush of regulatory activity.

“Six of our eight facilities just won US News & World Report recognition. How are they doing it?” he asked. “It’s not because of the regulations. It’s because of our core principles.”