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March 1, 2022

Inside the Biden administration's plan to improve nursing homes

Daily Briefing

    The Biden administration on Monday announced plans to improve the quality of nursing homes in the United States, claiming that nursing homes are currently failing to follow federal guidelines.

    The post-acute leader's HR guide

    'Failure … is widespread'

    In a fact sheet, the White House noted that, "[d]espite the tens of billions of federal taxpayer dollars flowing to nursing homes each year, too many continue to provide poor, sub-standard care that leads to avoidable resident harm. In fact, failure to comply with [f]ederal guidelines at nursing homes is widespread."

    The White House cited a report from the Government Accountability Office which found that 82% of all nursing homes inspected from 2013 to 2017 through Medicare and Medicaid surveys had a deficiency in infection prevention and control, "including a lack of regular handwashing."

    "Without decisive action now, these unacceptable conditions may get worse," the White House said.

    The administration also noted that "[p]rivate equity firms have been buying up struggling nursing homes, and research shows that private equity-owned nursing homes tend to have significantly worse outcomes for residents."

    According to the fact sheet, investment in nursing homes by private equity firms has increased from $5 billion in 2000 to over $100 billion in 2018. The fact sheet also cited a study that found private equity-owned nursing homes were 11.1% more likely to have a preventable ED visit and 8.7% more likely to experience a preventable hospitalization than for-profit nursing homes not owned by private equity firms.

    How the Biden administration plans to improve nursing homes

    In the fact sheet, the Biden administration outlined four main reforms it plans to implement to improve nursing homes.

    1. Establish a minimum nursing home staffing requirement.

    CMS will "propose minimum standards for staffing adequacy that nursing homes must meet." The fact sheet cited a study that found every 20-minute increase in nurse staffing was associated with a 22% drop in confirmed Covid-19 cases and a 26% drop in Covid-19 deaths. 

    CMS will also "conduct a new research study to determine the level and type of staffing needed to ensure safe and quality care and will issue proposed rules within one year," according to the fact sheet, and the facilities "will be held accountable if they fail to meet this standard."

    2. Reduce resident room crowding.

    The administration plans to reduce resident room crowding, noting that multi-occupancy rooms "increase residents' risk of contracting infectious diseases, including Covid-19." To do this, CMS "will explore ways to accelerate phasing out rooms with three or more residents, and to promote single-occupancy rooms."

    3. Adjust the Skilled Nursing Facility Value-Based Purchasing Program.

    The program provides financial incentives to nursing homes to meet certain quality standards, and, according to the fact sheet, CMS will "propose new payment changes based on staffing adequacy [and] the resident experience, as well as how well facilities retain staff."

    4. Prevent unnecessary treatment and medication.

    According to the fact sheet, the use of antipsychotic drugs in nursing homes has dropped significantly in recent years, however "inappropriate diagnoses and prescribing still occur at too many nursing homes."

    To combat this, CMS "will launch a new effort to identify problematic diagnoses and refocus efforts to continue to bring down the inappropriate use of antipsychotic medications."

    The fact sheet also included other actions CMS will take, including the creation of a database of nursing home owners and operators, the collection and reporting of "more robust" corporate ownership and operations data, improvements to the Nursing Home Care Compare website, and a closer examination at the role private equity firms play in nursing homes.

    President Biden also intends to call on Congress to take more action to improve nursing homes in his State of the Union address, including the allocation of $500 million to CMS "to support health and safety inspections at nursing homes." (Frieden, MedPage Today, 2/28; Brown, McKnights, 2/28)


    Advisory Board's take

    CMS staffing proposal lacks support in execution. Here’s why that matters.

    By Blake Zissman and Monica Westhead

    There is no question that providing the best quality care for patients requires more staff and less staff turnover. Staffing requirements for nursing homes, and linking those requirements to value-based payments, has been a long time coming for the industry. But the requirements being proposed by the Biden administration and CMS raise the question of where nursing homes and long-term care facilities will find those staff—or the funding to pay them sufficiently.

    In a recent report by the Washington Post, roughly 420,000 employees in nursing homes and long-term care have already left the industry across the last two years. And in addition, a Health Affairs study found that nursing homes were the only site of care to not recover staffing levels from April 2020 to June 2021.

    While we agree that these requirements will make care for seniors safer in the long-term, we're curious as to whether the proposals will include support to retain and recruit staff in the immediate, especially amidst a severe staffing shortage. Initial coverage of the proposals indicates additional funding for nursing home surveys but doesn't speak to any potential reimbursement changes that could facilitate higher staffing levels, or higher pay to retain staff.

    There is a possibility that these changes will force poor-performing nursing homes to close their doors, resulting in an influx of staff who need jobs at other facilities. The promise of higher staffing level requirements may also bring back staff that have left due to concerns about understaffing.

    What nursing home leaders need to do now is continue to sharpen their focus on retention efforts and improvements to clinical quality. These proposals by the Biden administration and CMS indicate that there will be increased attention put on post-acute care in the coming years, especially regarding quality of care—a goal the entire industry shares.

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