medicare home health care :: Article CreatorFeds Establish New Rules For Health Care Staffing And Pay
After the COVID-19 pandemic exposed serious problems with the health care workforce and patient care, especially at nursing homes, some major changes are coming.
This week, the federal Centers for Medicare & Medicaid Services established new minimum staffing requirements for nursing homes nationwide and set new worker pay standards for home- and community-based health care services.
The new rules govern long-term care provided to low-income disabled people and the elderly — funded with federal Medicaid dollars and administered by the states.
One goal is to upgrade the pay and services provided by health aides that agencies send into patients' homes to help with bathing, meals, medications and the like. Many are immigrant women earning low wages, according to Jennifer Lav, a senior attorney at the National Health Law Program.
Medicaid will now direct more health care spending into their pockets.
"80% of the rates that are paid by the state to providers have to go directly to the workers, as opposed to administrative overhead," Lav said.
There are also new standards for minimum staffing at nursing homes, covering RNs, nurse's aids and other workers, said Robin Rudowitz, vice president and director of the Program on Medicaid and the Uninsured at health-policy research group KFF.
"Our analysis showed that only one in five nursing facilities would meet the requirements," she said.
Employers will have time to achieve the new staffing levels.
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Biden Administration Unveils New Rule On Nursing Home Staffing Levels
By: Clark Kauffman
Indiana Capital Chronicle
For The Republic
WASHINGTON — The Biden administration has introduced a controversial set of new regulations intended to increase staffing levels and improve patient care in nursing homes.
The new staffing rule from the Centers for Medicare and Medicaid Services (CMS) has faced fierce opposition from the industry and Republicans in Congress. It establishes for the first time national minimum staffing requirements for nursing homes that collect taxpayer money through Medicare- and Medicaid-funded services.
The staffing requirements will be phased in over the next two to five years, and CMS has made provisions to grant exemptions for care facilities in rural areas, such as Indiana, where there's a shortage of available caregivers.
An estimated 25% of facilities will fall under the rural area exemption. Many of Indiana's long-term care facilities spend thousands recruiting foreign-educated nurses because of the state's shortage, according to the Indiana Health Care Association/Indiana Center for Assisted Living (IHCA).
In a statement to the Indiana Capital Chronicle, IHCA President Paul Peaper called the decision "unrealistic" and "unfunded," and said it would jeopardize access to care.
He noted that, unlike some other health care sectors, staffing for long-term facilities hasn't recovered from COVID-19. It's still 7.4% lower than pre-pandemic, according to the Bureau of Labor Statistics.
"Long-term care remains the only health-care sector that has yet to recover to pre-pandemic staffing levels and instead of supportive policies to help with recruiting, retaining and training caregivers, we are given an unreasonable edict. Our members remain committed to ensuring quality outcomes for our residents and are not opposed to staffing ratios if they are accompanied with the right financial and regulatory support. The rule includes neither," Peaper said.
"This flawed and shortsighted policy will not move the needle in the right direction. We look forward to working with our Congressional delegation to support the bipartisan Protecting America's Seniors' Access to Care Act to prevent CMS from enforcing this overreaching mandate," he added.
Indiana's staffing in nursing homes lags behind the national average when it came to hours spent per resident day, according to a 2023 analysis from CMS.
The ideal range for best patient outcomes ranges between 3.8 and 4.6 hours per day across several positions, including registered nurses, licensed practical nurses and nurse aides. The national average sits at 3.76 hours but Indiana reported 3.51 hours, falling short across each of the three professions.
In a written statement, CMS said it believes that by improving working conditions and wages, improvements in the recruitment and retention of direct care workers will follow, enabling nursing staff to provide safer, higher quality care to all residents.
Inadequate staffing has long been considered the single biggest contributor to poor quality care in nursing homes.
Last November, Indiana Gov. Eric Holcomb and 14 other Republican governors sent Biden a letter objecting to the new rule and arguing that the nursing home industry is facing a workforce crisis, particularly in rural areas. The governors predicted that minimum staffing levels would "force over 80% of facilities nationwide to hire more staff" and result in many of them closing.
A map showing the variation in Hours spent Per Resident Day (HPRD) by state. (Map from CMS Nursing Home Staffing Study June 2023 report)
CMS officials said Tuesday they don't expect the new rule to force any facilities to close, noting that some states have imposed even higher staffing level requirements with no resulting shutdowns.
The new rule has been two years in the making, and CMS has fielded more than 46,000 public comments on it from caregivers, residents, industry representatives and resident advocates.
Toby S. Edelman, a senior policy attorney for the Center for Medicare Advocacy and a national expert on long-term care, noted Tuesday that the new rule announced this week establishes only "the minimum permissible staffing levels" care facilities must meet.
"The rule does not end the discussion about staffing levels," she said. "Under federal rules issued earlier, all facilities are also required to conduct, at least annually, a facility assessment. This process requires each facility to determine the actual nursing needs of its own residents and to ensure that it has enough staff and that its staff have the necessary skills to meet its residents' needs. Properly implemented and enforced, the facility assessment process will require many facilities to implement higher staffing levels than the minimums announced today."
Rule mandates 24-hour nurse availability
The specific provisions of the new rule include elements related to staffing, public disclosure and resident assessments:
Nursing care: Residents must receive at least 3.48 hours of nursing care per day, which would include at least 0.55 hours of care from a registered nurse per resident, per day, as well as 2.45 hours of care from a certified nurse aide per resident, per day.
Around-the-clock nurse availability: All homes must have a registered nurse on site 24 hours per day, seven days per week. The nurse must be available to deliver critical care to residents at any time.
Self-assessments: Aside from meeting the new minimum standards, all facilities will be required to perform annual assessments to determine the actual level of staffing needed to meet all residents' needs. Those assessments, which will be more detailed than those currently required, are intended to address the fact that many care facilities already meet the new minimum standards but are still failing to meet residents' needs due to heightened levels of acuity or the need for one-on-one supervision.
Staff retention: Each facility will be required to at least develop a formalized plan to maximize their workforce recruitment and retention efforts. To help ensure compliance, CMS will also be requiring states, to which much of the enforcement efforts are delegated, to collect and report on the percentage of Medicaid payments spent on compensation for direct care workers and support staff.
The new rule also requires that providers allocate at least 80% of home- and community-based payments to direct care worker pay, targeting concerns about for-profit players in health care spaces. In Indiana, many nursing home facilities are owned by government entities to leverage more federal funds — but local units aren't required to invest those dollars back into their centers.
CMS has promised to publicly report the spending data collected by the states, and the states themselves will also be required to report facility-specific data on publicly accessible websites.
The federal agency has also pledged $75 million to be spent on a national nursing home staffing campaign aimed at increasing the number of nurses working in long-term care facilities. As part of that effort, CMS will be providing financial incentives for nurses to work in nursing homes.
In announcing the new requirements, CMS acknowledged that some facilities are "experiencing challenges in hiring and retaining certain nursing staff because of local workforce unavailability." To address that, the agency will offer waivers for the rule requiring a nurse to be on site 24-hours per day, and will also offer "financial hardship exemptions" to the staffing requirement.
The facilities that seek such an exemption will first have to show they're in an area where the supply of nurses at least 20% below the national average as calculated by the U.S. Bureau of Labor Statistics and U.S. Census Bureau.
They'll also have to provide documentation of good faith efforts to hire and retain staff, including the payment of competitive wages, and they'll have to disclose the amount of money spent on nurse staffing relative to the home's total revenue.
Facilities that are granted an exemption will then have to post a notice of its exemption status in a prominent, publicly accessible location inside the facility, and will have to provide any prospective residents with written notice of the exemption status.
Some homes will not be considered for exemption, including those on CMS' list of special-focus facilities that have history of repeat, serious violations, and those recently cited for a pattern of insufficient staffing that has resulted in harm to residents.
For most facilities, the new staffing requirements will be phased in over the next two years, but that timeline has been extended to accommodate the needs of rural facilities where the workforce shortage is particularly acute.
Rural facilities will have 90 days to meet the new rule on facility assessments. They'll have three years to meet the requirements on 3.48 hours of total nurse staffing and a 24-hour nurse, and five years to meet the more specific requirements of 0.55 registered-nurse hours per day, per resident.
Senior Reporter Whitney Downard contributed to this story.
— The Indiana Capital Chronicle covers state government and the state legislature. For more, visit indianacapitalchronicle.Com.
As I See It: A Promising Way To Solve Health Care Problems?
An opinion published by Bloomberg News, "If US inflation reflected rising home insurance costs, it'd be even higher," reproduced in the April 11 paper, suggested that, as a way to control health care costs and broaden access to affordable choices, lawmakers should reconsider introducing a public option — a government-run plan that would compete alongside private insurance companies.
It cited efforts from states such as Colorado and Washington that used legislative tools including premium-reduction targets, or price negotiations for reimbursement rates for hospitals and clinical providers, and concluded that it is "perhaps the most promising way" to solve our current health care problems.
While early results from Washington showed the public option plans can have a moderate positive impact on health care costs, the experiment is in its infancy, and challenges remain: Many individuals reported confusion navigating the different networks, and narrower choices of providers, and, after two years, the voluntary participation in the public option is still low (11%).
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In Colorado, which started its reform in 2019, only 15% of option plans met the premium reduction target by 2023. These findings are reported in a health forum published in the Journal of the American Medical Association (March 28) and offer cautionary tales about the overall effectiveness of public option plans in changing the current chaotic, fragmented system.
Health care reform is complicated and politically challenging because it requires tradeoffs that may be unacceptable to specific interest groups: private insurance corporations mostly driven by profit; providers concerned about reimbursements; patients are now consumers in a less-than-transparent market.
The practice of medicine seems no longer an art or a science, but is now defined as a business, especially predatory now that equity firms are stepping in to buy out financially failing clinical practices.
In this Land of the Free, we pride ourselves that Americans are able to make choices in health care, just as we would shop for goodies at a supermarket. The reality: choices, very limited; confusion, widely spread.
Introducing a public option plan to compete with other health insurance plans may sound good, but it may not have a fighting chance: There is no guarantee that our politicians will continue to support it when the private health industry is the top lobbying spenders, and when its competitors can cherry-pick healthier members and put obstacles to medical services to minimize their own costs.
Simply put, I'd much rather go with a single-payer system: Everybody is covered with basic essential benefits, and with equal dignity. If the term "single-payer" puzzles you, think of Medicare benefits funded by fair taxes and offered not just to seniors but to everyone.
If you hear Medicare will go bankrupt in X number of years, don't panic. Any program, public or private, is always a work in progress, and we can adjust revenues and expenses, benefits and resources to make the program stay cost-effective and sustainable.
Most of all, a Medicare-for-All will be simpler and less expensive to deliver than current health insurance plans that spend up to 15% of their revenues on administrative and advertising costs.
It will also be more equitable — not a Cadillac treat for the rich and powerful but leaving no one behind without preventive or essential medical services either. Some may call this socialist medicine, but with the majority of Americans believing that providing health care coverage for all is a government responsibility (according to a 2020 Pew Research Center survey), I call it democracy at its core.
Although implementing a single-payer program faces many challenges, let's keep our eyes on the prize, for we cannot achieve the American pursuit of happiness without good and equitable health services for all.
Chinh Le is a retired physician and a former Corvallis resident. He now lives in Happy Valley.
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