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LeadingAge to CMS: Nursing Home Staffing Mandates Will Fail as Proposed

“The proposal will fail because it does not consider two major issues: The ongoing workforce crisis and the proposal’s astronomical implementation costs,” says aging services leader.

In comments submitted today to the Centers for Medicare and Medicaid Services (CMS) on Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Proposed Rule (CMS-3443-P), LeadingAge, the association of nonprofit providers of aging services, including nursing homes, urged the agency and the Biden administration to demonstrate much-needed leadership in two critical areas: policies impacting payment for long-term care services and staffing in the sector.


Expanding on the written submission, Katie Smith Sloan, president and CEO, LeadingAge, said:

“For the first time in decades, our federal government is committed to meaningful action to ensure America’s older adults and families can receive quality care in nursing homes, and in their homes and communities. We applaud that interest and share that goal. However the administration is not getting this right, yet.

The proposal will fail because it does not consider two major issues: the ongoing workforce crisis and the proposal’s astronomical implementation costs. Should CMS opt to implement it as is, older adults and families’ already limited access to care will only get worse.

We’ve long said that care costs money. Implementation expenses of this proposal–which includes no additional funding support–range from $4.06 billion by CMS’ estimates to $7.1 billion by our estimate, in the first year alone. Reimbursement rates for Medicaid, the primary payer of long-term care, cover on average only 84% of the cost of care. The result is a hefty unfunded mandate that providers must make up. CMS says it “welcomes” states to discuss increasing Medicaid payment rates, but that is unlikely. We urge the administration and CMS to take greater responsibility and demonstrate the federal leadership needed to make positive change.

Workforce shortages across health care and specifically in long-term care are well-documented. By CMS’s own estimates, the proposed minimum staffing standards would require 90,000 additional nursing staff to enter the long-term care workforce. How is this possible when 193,100 openings for registered nurses alone are expected each year over the next decade, but only 177,400 are expected to be added to the workforce by the end of the same time period? Nursing schools turned away over 91,000 qualified applicants for the 2021-2022 academic year due to a lack of nurse educators. In this environment, it will be incredibly difficult for nursing homes to fill these new positions.

What’s more, the challenges of bringing new staff to long-term care must be considered. Right now, fewer than 10% of working RNs select jobs in long-term care. How will more nurses, nurse aides and other needed staff be wooed to our sector? Despite its rhetoric in support of long-term care workers, the administration persists in publicly demonizing nursing homes, repeatedly insisting that all providers are abusing the trust of older adults and their families while “padding profits on the backs of residents and nurses.” Not only are these inflammatory words an inaccurate characterization of an entire sector, but they also demoralize the thousands of honest, dedicated, hard-working men and women employed in it. Given that embrace of nursing-home bashing, as well as the government’s chronic failure to cover the costs of care, is our nonprofit members’ struggle to recruit and retain qualified workers surprising? CMS and the administration must be part of the solution.

Finally, the importance of and need for evidence-based standards on staffing cannot be overemphasized. For CMS to proceed with implementation of these requirements –for which there is no evidence, according to findings from the CMS-hired consulting firm, Abt Associates–is an irresponsible, willful misapplication of existing evidence. Much as the agency would require a nursing home’s operational plan to be evidence-based and data-driven, we require no less from our regulatory process.

The unintended consequences of this rule, if implemented as proposed, will be dire. We urge CMS not to proceed with these proposed staffing standards. We do not support a move forward until CMS can assure enough qualified applicants and adequate funding to meet requirements. Older Americans and their families deserve quality nursing home care they can count on.

The administration needs to get it right.”


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