Why states’ success in tying Medicaid to endowment could propel CMS policy

While setting higher staffing standards for nursing homes continues to be a top priority in the minds of federal leaders, few in the industry see it as a viable or sustainable path.

Given the current staffing climate, with an approximately 15% decline in the long-term care workforce since the start of the pandemic, any newly developed standard would have to come with an infusion of funds. That’s why several states have tied Medicaid reimbursement incentives to staff quality in recent months.

Unable to sustain unfunded mandates, seniors advocate and policy expert Brian Perry thinks tying increased reimbursement at the state-by-state level is a great “first step,” but it’s also necessary to solve the problem at the macro level.

“I think the state comes up with incentive ratios, things of that nature, that’s probably where it lands, but fixing [the workforce] pipeline needs to be part of that conversation as well,” Perry told Skilled Nursing News.

Yet leaders of the Centers of Medicare & Medicaid Services (CMS) have indicated on more than one occasion that they want to explore a change in the way Medicaid dollars are spent, with more direct ties to staff and community. quality of care.

“We want to make sure the dollars get to the direct care staff to ensure high-quality care,” Daniel Tsai, deputy administrator and center director for Medicaid and CHIP services, previously told Kaiser Health News.

CMS officials also announced the possibility of a Medicaid requirement during an April nursing home roundtable hosted by the agency in Chicago. State officials, nursing home workers, residents and their families participated in discussions with CMS Administrator Chiquita Brooks-LaSure and CMS Deputy Chief Administrator and Chief Operating Officer Jonathan Blum , as well as Tsai.

During the roundtable, Tsai told reporters at the event, including SNN, that CMS “is considering and is eager to discuss how we can create either transparency or standards for a minimum amount of reimbursement is actually paid to direct care staff versus all sorts of other things.”

The agency is also adding new requirements for investigators to incorporate payroll-based log (PBJ) staffing data for inspections to help identify insufficient staffing levels.

Reimbursement incentives are the only way for some industry gurus like Robert Applebaum, director of the Ohio Long-Term Care Research Project at the University of Miami, to see minimum staffing standards achievable.

“Medicaid runs the show in nursing homes, and every state is grappling with Medicaid spending,” he told Skilled Nursing News. “At the end of the day, we can all say we want better staffing, but until we’re willing to pay, it’s not going to happen.”

Some states, including Michigan and North Carolina, are seeking new measures to allocate additional cash injections to direct care workers. Michigan previously enacted a temporary one-year hourly wage increase for direct care staff and North Carolina approved $1 million in one-time bonuses.

In Washington, D.C., about 80-85% of care for nursing home residents is paid for using Medicaid funds, making it “the wage-setting beast,” according to Forest CEO DC Hills, Tina Sandri.

In Illinois, newly signed legislation, Illinois House Bill 246, went into effect this month and aims to increase funding for nursing homes in the state by $700 million directly related to staffing. personal.

“There are very few losers in the new Illinois methodology and it doesn’t lock you into the norm either. As you get older, you will see increases in your rate,” Illinois Health Care Association executive director Matt Hartman told Skilled Nursing News. “I consider that an incitement.”

He said it’s not a silver bullet to ongoing staffing issues, but it’s a “stepping stone” for Illinois facilities to get a head start.

“The 4.1 number you’ve been hearing about for years is just a number, it doesn’t focus on resident care or needs and doesn’t focus on today’s market,” he said. declared.

CMS makes staffing a top priority

Changing how Medicaid dollars are spent is part of White House reforms introduced in February and remains central to CMS’s plans moving forward.

“As we see that states are really thinking about how they can make sure they’re paying for value…that’s something we really want to work with states on the Medicaid side,” Brooks-LaSure said. to members of the press following a round table on retirement homes. held in April.

The agency recently sought stakeholder feedback on a measure that would examine staff turnover levels in nursing homes to be included in the SNF’s Value Based Purchasing (VBP) program and remains committed to creating minimum spending standards for nursing home owners. Medicaid Reimbursement Fund for Direct Care.

Hartman felt that Illinois’ approach to the staffing crisis could serve as something of a “blueprint” or “roadmap” that other states and the federal government could use.

“We fully agree with the government here,” he added. “Each study shows that the main drivers of quality and resident satisfaction are linked to exceptional levels of staff.”

Still, he felt there needed to be “concomitant funding” to go along with any proposed minimum staffing.

CMS is expected to study the issue and introduce proposed rules on a minimum staffing level requirement within a year of President Biden’s State of the Union address in February.

A national staffing standard could lead the industry to failure

Sandri wants to see more resources put forward at the state and national level to help nursing homes staff.

“Just because you create a rule that you have to have staffing levels doesn’t make that curve magically go up. There must be resources that push that curve back for us to even get back to pre-COVID staffing levels,” she said.

Forest Hills currently has a vacancy rate of 22% in June.

Although DC has a minimum staffing requirement in place, Sandri says a temporary waiver is in place so she doesn’t get “stunned.” However, she worries about the long-term implications of this because when Covid goes away, the staff shortage will not go away with it.

She fears a national staffing standard could spell massive failure for nursing homes in a significant and well-reported extent, further eroding public confidence in the sector.

“If we go to this national staffing standard, the fear I have is that it puts us in a place of failure, at least initially, and it could initially take a long time,” she added.

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