Biden Pledges Better Nursing Home Care, but He Likely Won’t Fast-Track It

Yves here. It’s hard to find decent nursing home care in the US to begin with, but the standard of care in predominately Medicaid-supported facilities is very poor. And staffing is a big part of the problem. We pointed out before the vaccine mandates for nursing homes were about to kick in that they were already understaffed industry-wide, IIRC at 93% levels. Several factors have conspired to make that worse:

Far more opportunities to work as home health care aides at comparable pay and with much better work conditions. Families that had options stopped putting relatives in nursing homes with the onset of Covid and some even pulled them out. The shift to more elderly needing care in non-institutional settings greatly increased the overall need for aides, since serving someone in their own house is more labor-intensive than in a facility. We had quite a few aides who had worked in nursing homes and told tales of how abusive the management was.

And if an aide can get private clients and cut out the home health care agency middle-man, they can earn much more than in a nursing home.

Strong preference of some health care workers to avoid a high Covid risk setting. Of our many aides, we had one that quit nursing home work to reduce Covid exposure, and another who quit a nursing job at a hospital when her floor was turned into a Covid floor.

Some quitting to escape vaccine mandates. This issue does not appear to be a significant factor, but from what I can tell, it wasn’t the nothingburger that the officialdom wanted you to think it was. Recall that nursing homes were already short staffed, so any further losses would hurt. Health care organizations tried to depict the vaccine mandates as having no impact, pointing to low levels of firings on the date the mandate kicked in. But that’s not a good measure. To preserve continuity of employment and not have a termination in your record, most would quit before the vaccination deadline. And nurses and CNAs/orderly level staff, as indicated, could easily get hired by a home health agency as a stopgap or a lasting option.

In other words, the already difficult staffing situation has gotten worse, meaning more pay is needed to compensate for having to do the work of 1.2 staffers (at least) in the meantime, plus the inherent difficulty of the job getting worse due to Covid. Yet the industry whinges that since paying more didn’t solve their staffing problem, why should they be expected to hire more people, which presumably will require even better hourly wages? Key howler from the KHN story:

A February study in JAMA Health Forum found that, compared with other parts of the health sector, nursing homes experienced the greatest relative wage growth during the pandemic yet saw the biggest drops in employment….

“By singling out nursing home care for attack, President Biden is only further demoralizing struggling providers and their workers,” Brendan Williams, CEO of the New Hampshire Health Care Association, which lobbies for long-term care facilities, said in a statement. Mark Parkinson, CEO of the American Health Care Association in Washington, D.C., said in a statement that “we cannot meet additional staffing requirements when we can’t find people to fill the open positions nor when we don’t have the resources to compete against other employers.”

What about, “Yes, you need to pay more” don’t you understand? And it’s been endemic across the health care industry that organizations used Covid as an excuse to increase executive pay a lot while only increasing nurse and other low-level worker pay a smidge. I’d like to see theses companies’ top level pay and profits before I believe their poor-mouthing.

By Rachana Pradhan, a Kaiser Health News correspondent who previously worked for Politico, and Harris Meyer. Originally published at Kaiser Health News

President Joe Biden’s top Medicare official suggested Wednesday that forthcoming rules to bolster nursing home staffing won’t be issued under a mechanism, known as interim final rules, that would allow regulations to take effect more or less immediately.

“While we want to move swiftly, we want to get comments from stakeholders,” Chiquita Brooks-LaSure, administrator of the U.S. Centers for Medicare & Medicaid Services, said in an interview about the overhaul Biden promised during his State of the Union address.

“Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and that they expect,” Biden said.

But Brooks-LaSure suggested the administration’s sought-after nursing home changes are not considered urgent even as nursing homes and other long-term care facilities register shocking numbers of covid deaths. A KFF analysis estimated that more than 200,000 residents and staff members of long-term care facilities had died from covid as of Jan. 30, amounting to at least 23% of all U.S. deaths.

“When we do interim final rules, those tend to be things that are absolute emergencies,” Brooks-LaSure said when asked whether they would be considered for nursing home staffing levels, “or tight timelines.”

The White House this week said CMS will first study the issue and then propose minimum staffing standards “within one year,” but officials have been otherwise vague about timing. When issuing regulations, federal agencies generally release a proposal and then seek public feedback before finalizing it. The entire process can take months or even years. But there’s an exception that allows newly issued regulations to kick in much faster even if the agency allows for public comment — a move that Biden officials have exercised recently when issuing a covid vaccine mandate for health workers and implementing a ban on surprise medical bills that took effect this year.

Marjorie Moore, executive director of Voyce, a St. Louis nonprofit that advocates for long-term care residents, said “the speed of this is a little frustrating.” She said she’s seen situations where residents hadn’t had their diapers changed for days because staffing shortages are so dire.

“That’s not what we expect for our most vulnerable,” she said.

Still, she said, “I think one year, knowing that this is government stuff, may be the best we can hope for. That’s not going to be an overnight thing. We just knew there was no way.”

Biden’s proposal would amount to the biggest increase in federal nursing home regulation in nearly four decades. CMS could pursue several elements under the agency’s existing authority, such as investigating the role of private equity in the sector, increasing its scrutiny of the poorest-performing facilities, and making public more information about facilities’ finances and operators.

Some ideas would require congressional action. They include allowing CMS to ban from the Medicare and Medicaid programs those facilities owned by people or corporations with subpar track records and to increase penalties on poor-performing facilities from $21,000 to $1 million.

Most states have standards for nursing home staffing levels, but the minimums vary widely. Some states have been criticized for granting exemptions so facilities can provide less care for each resident.

Forthcoming federal rules on staffing must be designed to avoid “unintended consequences,” said David Grabowski, a professor of health care policy at Harvard Medical School, who is supportive of the effort. “Figuring out the right kind of threshold for facilities is going to be challenging.”

He said unintended consequences might come from boosting staffing levels by disproportionately hiring nursing assistants, who earn less and have limited responsibilities, at the expense of positions for licensed practical nurses and registered nurses, or depleting resources in other important areas like housekeeping.

Brooks-LaSure declined to say whether CMS would allow nursing homes to seek exemptions, instead arguing that minimum staffing rules will “help with retention.”

“We’re hearing from staff over and over about the strain that staffing is placing on them personally and on residents. And we have got to address the quality of care for people who are enrolled in our programs,” she said. “We want to work with industry, absolutely, to get there, but everything we hear is about what kind of strain the insufficient staffing is putting on residents and on the workers themselves.”

The industry, for its part, hasn’t minced words in criticizing Biden’s plan, especially after the pandemic exacerbated existing workforce retention problems. A February study in JAMA Health Forum found that, compared with other parts of the health sector, nursing homes experienced the greatest relative wage growth during the pandemic yet saw the biggest drops in employment.

“By singling out nursing home care for attack, President Biden is only further demoralizing struggling providers and their workers,” Brendan Williams, CEO of the New Hampshire Health Care Association, which lobbies for long-term care facilities, said in a statement. Mark Parkinson, CEO of the American Health Care Association in Washington, D.C., said in a statement that “we cannot meet additional staffing requirements when we can’t find people to fill the open positions nor when we don’t have the resources to compete against other employers.”

Central to Biden’s plan is getting facilities to open their books to make public information about their opaque finances and operating structures. Among other moves, CMS plans to create a database to identify nursing home owners and operators.

There is an international movement to more closely monitor and improve nursing home staffing levels, staff pay, and quality of care.

To achieve that, 106 investor groups and labor unions in the U.S., Canada, and Europe that manage more than $3 trillion in assets have published staffing, pay, and quality goals for nursing homes. They are pressing large companies and real estate investment trusts that operate nursing homes to publicly disclose whether they are complying with those targets. They seek greater financial transparency in nursing home operations.

Some of the investor groups have told nursing home operators that if they fail to meet the expectations, they may take shareholder actions against management and ultimately divest from the companies.

But those investors and unions are facing tough challenges in getting the information they seek, said Adrian Durtschi, head of the health care section at UNI Global Union, which spearheaded the international effort.

He noted greater cooperation from nursing home operators in European countries with more heavily regulated national health care systems and stronger unions. It’s been slower in the U.S., he said, where there are so many private nursing home companies.

“Transparency is key for investors to make good investments, and unions need it for good negotiations,” Durtschi said. “But it’s generally not easy to access the information. Some companies are willing to disclose it, while others are more resistant.”

Biden’s plan could inspire others to enact similar disclosure laws and regulations, he added.

For instance, French authorities are under pressure to toughen nursing home oversight following revelations of severe quality-of-care problems at nursing homes run by Orpea, a large publicly traded operator of high-end facilities. As a result, some investment funds have reduced their nursing home holdings.

“Demands for higher standards, more transparency, and more union rights,” Durtschi said, are “great to see.”

In the U.S., Brooks-LaSure said CMS can use its leverage. “As part of our requirements to participate in the Medicare and Medicaid program, we have authority to require entities to report information to us,” she said. However, Grabowski, noting the industry’s skill at staying steps ahead of the government and weak agency enforcement, said that “it sounds like a great objective, but it’s going to be really challenging.”

“I’m a little skeptical they’ll make the necessary investment,” he said of CMS.

One advocate for vulnerable older adults, who’ve especially suffered during the pandemic, saw hope in Biden’s statement.

“Nursing homes getting literally three lines in the State of the Union is profound,” said Dr. Michael Wasserman, a geriatrician in California. “Let us stop and realize that the White House has recognized improving quality in nursing homes as a priority.”

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  1. BurntOutNA

    I have worked in both home health and facilities as a nurse’s aide and I have some serious safety concerns about both. One good thing about a facility is the presence of RNs(when they are there) to advocate for nurses aide safety when it comes to repetitive stress injuries and environmental upkeep. I have come within a hair’s breadth of impaling myself on a syringe at a home because it was tossed on a chair rather than safely disposed of and I have gotten repetitive stress injuries helping overzealous home care patients with physical therapy without proper relief due to lack of other workers. Home care they push you real hard because they feel like they are paying a lot which causes tension. I will not do home care again because of these reasons. The downside to facilities is that the rules to protect staff and residents break down as shortages of staff and supplies dissipate. I saw this summer 2020 to spring 2021. Even understaffed, it is nice to have some backup. Also, a facility will have workers comp and regular inspections, something that is often missing in home care. I am taking a breather from healthcare but when I go back it will be to a facility because I swear to God the last two home health people I was working for were happy to grind me into paste and spit me out they had so little regard for my health.

    1. Yves Smith Post author

      How was a syringe even out? The home health care agencies here won’t even let them give clients dietary supplements (in pill form) or aspirin, much the less meds of any sort.

      I don’t understand the comment about home health care. On a 7 hour shift, our aides had at the very outside 2 hours of active work and typically only and hour and 15 mins: wiping down the kitchen and bathroom counters (no toilets), sinks, and faucets, meal prep, transfer to and from a bathroom for toileting, 2X a week a sponge bath, meal prep and cleanup (no cooking beyond heating up frozen pancakes or toasting a muffin; we’d often get carryout), unloading the dishwasher, doing a laundry and folding clothes, changing sheets 1x a week, occasionally sweeping the kitchen floor, maybe washing it once a week.

      You ask for too much as a client, word gets out among the aides and you don’t get staffed.

      1. BurntOutNA

        Syringe was out because the patient’s Mom was overwhelmed and just leaving them everywhere. You ran a tight ship, but most homes are scary places to work. I am in a rural area and every house feels like a sinking ship and I’m afraid to go to work. Not good.

        1. BurntOutNA

          I also should add I wish a job at your place was available! I was dealing mostly with people with complex behavioral issues the agencies wouldn’t put up with, so I chose to work in a high stress environment. But geez, the things I’ve seen and had to do as services collapsed with the pandemic.

  2. KLG

    I have been in and out of medical clinics for the past three months, daily for the past five weeks. This week in the elevator one of the CMA’s who does intake (Good morning, how do you feel?, weight, BP, prescription refills?) was talking on her phone about a new job at a nearby MallWart distribution center, starting at $20-24 an hour. That is undoubtedly $5-9 per hour more than she makes currently. The many things wrong with this picture are absurd!

    Rumor is that the previous hospital administrator (oops, CEO) was given an $18M platinum parachute after a well earned defenestration. If that is off by a factor of 10, it is still absurd.

    1. .human

      I have zero respect for management that are paid more than about ten times average company salaries.

      The story about William McQuire and his $1.6B (yes, that’s a B) golden parachute when he was ejected from United Healthcare still gets my goat.

  3. Skunk

    I don’t know anyone in a nursing home and am not well-versed in the subject. However, what struck me during the initial phase of the pandemic was that the gig economy seemed to play a role in nursing home outbreaks. If a worker is giving individual care to a number of private patients, then going back and forth to one or more nursing homes, this seems like a recipe for transferring infections between clusters of vulnerable people. Perhaps nursing homes should be legally required to use only full-time staff. Cutting costs by using gig workers seems like a betrayal of any responsibility to protect the vulnerable residents.

  4. jackiebass63

    Where I live in rural upstate NY, pay is a problem for getting good nursing home workers.I’m not sure what nurses are paid but most nursing homes don’t employ many RNS or LPNS.In a facility with 500 patients there is usually one nurse on duty.A doctor is employed on a part time bases. Aids make $15 – $18 an hour. This isn’t easy work.It is tough both mentally and physically. I don’t believe I could do their job even if the pay was better. I’ve fortunately never been a patient in a nursing home. My wife and mother have been patients in a nursing home. I have seen 6 different nursing homes operate with my mother and wife. The care at each was about the same. I hope I never have to be in a nursing home. From being a visitor , to me it would be very depressing. People who have never visited a nursing home don’t realize what they are like.

  5. sharonsj

    This discussion has been going on for years but I doubt Congress will do a damn thing because of too much medical money sloshing through politicians’ fingers. I have two friends with unsolvable problems: an elderly husband with dementia and a father with dementia who won’t take his medications. With the former, my friend has the money to hire some extra help (and to put cameras throughout the house because he falls down a lot). But it’s not enough. The other friend (who doesn’t live at home) has his elderly mother attempting to care for his elderly father but she can’t really handle it; they don’t have money but still can’t get help.

    All my relatives live too far away and I won’t have the money for an old age home anyway. I’ve decided my eventual course of action will be saving up my pain pills and taking them with a few bottles of my favorite alcoholic eggnog.

  6. TBellT

    I felt like an underemphasized piece of Bernie’s M4A proposal was the Long Term Care Coverage. So many people I meet are shocked when they realize its not actually part of Medicare already and that to get on it they will have to spend all the way down to Medicaid limits. Know many of my friend’s parents who are dealing with this issue when caring for their own parents. It causes a lot of unnecessary pain and interfamily drama.

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