President Joe Biden’s top Medicare official suggested on Wednesday that upcoming rules to bolster nursing home staffing would not be released as part of a mechanism, known as interim final rules, that would allow regulations to come into force more or less immediately.
“While we want to move quickly, we want feedback from stakeholders,” Chiquita Brooks-LaSure, administrator of the U.S. Centers for Medicare & Medicaid Services, said in an interview about the overhaul promised by Biden during his speech. State of the Union speech.
“Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and expect,” Biden said.
But Brooks-LaSure suggested the changes the administration is seeking in nursing homes are not seen as urgent, even as nursing homes and other long-term care facilities see shocking numbers of covid deaths. A KFF Analysis estimated that more than 200,000 long-term care facility residents and staff had died of covid as of January 30, representing at least 23% of all deaths in the United States.
“When we come up with interim final rules, it’s usually about things that are absolute emergencies,” Brooks-LaSure said when asked if they would be considered for home staffing levels. care, “or tight deadlines”.
The White House said this week that CMS would first study the issue and then come up with minimum staffing standards “within a year,” but officials have otherwise been vague on the timeline. When issuing regulations, federal agencies typically publish a proposal and then seek public comment before finalizing it. The whole process can take months or even years. But there is an exception that allows newly released regulations to take effect much more quickly even if the agency allows public comment — a decision Biden officials exercised recently when issuing a warrant. covid vaccine for health workers and the implementation of a ban on surprise medical bills which took effect this year.
Marjorie Moore, executive director of Voyce, a St. Louis nonprofit that advocates for residents of long-term care facilities, said “the speed at which this is a bit frustrating.” She said she’s seen situations where residents haven’t changed their diapers for days because staffing shortages are so severe.
“This is not what we expect for our most vulnerable,” she said.
Still, she said: ‘I think a year, knowing this is government business, is perhaps the best we can hope for. This will not happen overnight. We just knew there was no way.
Biden’s proposal would represent the largest increase in federal regulation of nursing homes in nearly four decades. CMS could pursue several things under the agency’s existing authority, such as investigating the role of private equity in the sector, increasing its scrutiny of underperforming facilities, and making more information public about finances and facility operators.
Some ideas would require congressional action. They include allowing CMS to ban facilities owned by individuals or companies with poor track records from Medicare and Medicaid programs and increasing penalties on poorly 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 grant exemptions so that facilities can provide less care to each resident.
Upcoming federal staffing rules must be designed to avoid “unintended consequences,” said David Grabowski, professor of health care policy at Harvard Medical School, who supports the effort. “Determining the right type of threshold for installations is going to be difficult.”
He said unintended consequences could come from increasing the workforce by disproportionately hiring practical nurses, who earn less and have limited responsibilities, at the expense of licensed practical nurse and registered nurse positions, or by draining resources in other important areas like housekeeping.
Brooks-LaSure declined to say whether CMS would allow care homes to apply for exemptions, arguing instead that minimum staffing rules will “help with retention.”
“We keep hearing from staff about the strain staffing puts on them personally and on the residents. And we have to take care of the quality of care for people enrolled in our programs,” she said. “We definitely want to work with industry to make this happen, but all we hear is about the kind of pressure that understaffing is putting on residents and on the workers themselves.”
The industry, for its part, has been outspoken in criticizing Biden’s plan, especially after the pandemic exacerbated existing labor retention issues. A February study in JAMA Health Forum found that, compared to other parts of the healthcare industry, nursing homes experienced the largest relative wage growth during the pandemic, but experienced the largest declines in employment .
“By attacking home care nursing, President Biden is only further demoralizing struggling providers and their workers,” said Brendan Williams, CEO of the New Hampshire Health Care Association, which lobbies for long-term care facilities. duration, in a press release. Mark ParkinsonCEO of the American Health Care Association in Washington, DC, said in a statement that “we cannot meet additional staffing needs when we cannot find people to fill vacancies or when we do not have the resources to compete with other employers.”
Central to Biden’s plan is to get institutions to open their books to make public information about their opaque finances and operating structures. Among other measures, CMS plans to create a database to identify owners and operators of nursing homes.
There is a international movement to more closely monitor and improve care home staffing levels, staff compensation and quality of care.
To achieve this, 106 investor groups and unions in the United States, Canada and Europe that manage more than $3 trillion in assets have published staffing, compensation and quality targets for retirement homes. . They are lobbying big companies and real estate investment trusts that operate retirement homes to publicly disclose whether they are meeting those targets. They seek greater financial transparency in nursing home operations.
Some of the investor groups have told care home operators that if they fail to meet expectations, they may take legal action against management and ultimately divest themselves of the businesses.
But these investors and unions face tough challenges getting the information they seek, said Adrian Durtschi, head of UNI Global Union’s healthcare section, which led the international effort.
He noted greater cooperation from care home operators in European countries with more heavily regulated national healthcare systems and stronger unions. It’s been slower in the United States, he said, where there are so many private retirement home companies.
“Transparency is essential for investors to make good investments, and unions need it for good negotiations,” Durtschi said. “But it’s usually not easy to access information. Some companies are willing to disclose it, while others are more reluctant.
Biden’s plan could inspire others to enact similar disclosure laws and regulations, he added.
For example, the French authorities are under pressure to reinforce the surveillance of retirement homes following revelations of serious quality of care issues in the EHPADs of Orpea, a major listed operator of high-end establishments. As a result, some investment funds have reduced their holdings in nursing homes.
“Demands for higher standards, more transparency and more union rights,” Durtschi said, are “great to see.”
In the US, Brooks-LaSure said CMS can use its leverage. “As part of our requirements to participate in Medicare and Medicaid, we have the authority to require entities to provide information to us,” she said. However, Grabowski, noting industry’s ability to stay ahead of government and weak agency enforcement, said “it sounds like a great goal, but it’s going to be really tough.”
“I’m a bit skeptical about the investment needed,” he said of CMS.
An advocate for vulnerable seniors, who have suffered particularly hard during the pandemic, saw hope in Biden’s statement.
“Nursing homes literally getting three lines in the State of the Union is deep,” said California geriatrician Dr. Michael Wasserman. “Let’s stop and realize that the White House has recognized improving quality in nursing homes as a priority.
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