For nearly two decades, the Virginia General Assembly has failed to find a legislative solution for the lack of personnel in retirement homes. According to a new report presented to lawmakers this week.
The move would pit lawmakers against the nursing home industry, which has long lobbied against minimum staffing standards. But analysts with the State Joint Commission on Health Care found that Virginia ranks below the national average when it comes to providing adequate care.
Nationally, 31 percent of nursing homes have a one or two star staffing rating – the lowest possible score – from the US Centers for Medicare & Medicaid Services. Assessments are based on the expected number of direct hours needed to care for patients living in the facility, who often have varying levels of acuity.
“Virginia has more low-staffed facilities than other states,” Kyu Kang, commission analyst, said at a meeting Tuesday. Statewide, 43% of nursing homes have a one or two star score. It’s a matter of patient care, and also of inequity, according to the report. Facilities with inadequate staff are more likely to score lower on quality and health inspection ratings. And understaffing is worse in nursing homes with high proportions of low-income, black residents, who are disproportionately likely to be enrolled in Medicaid.
“There is significant overlap in the populations that we are studying,” Kang said. “Facilities with a higher percentage of Medicaid residents also serve a higher percentage of black residents. “
Solving the problem through politics, however, has often been a challenge in the General Assembly. Laws setting minimum staffing requirements have been introduced every year for nearly two decades with growing bipartisan support, notably from Del. Vivian Watts, D-Fairfax, and Senator Jennifer Kiggans, R-Virginia Beach, a geriatric nurse practitioner.
So far nothing has happened. Advocates, lawmakers, and the industry widely recognize that the state’s Medicaid reimbursement rates for nursing homes – the largest source of payment for most facilities – do not cover the true cost of care. Due to Virginia’s stricter requirements for approving admission to nursing homes through Medicaid, residents often need more assistance with daily living than in other states.. And the commission’s most recent report found that a growing number of residents have behavioral health needs that are not factored into reimbursement rates.
“The pricing methodology really focuses on physical health needs and does not focus on mental health,” said Steve Ford, senior vice president of policy and reimbursement for the Virginia Health Care Association-Virginia Association of Assisted Living – an industry group representing state nursing homes. .
With reimbursement rates already low, forcing institutions to hire more guards would also force the state to increase spending on Medicaid. The report estimated that minimum staffing standards could cost Virginia an additional $ 14.1 million per year – a figure that would be matched by federal funds.
“There is a significant tax impact,” said Senator George Barker, D-Fairfax, deputy chairman of the commission. “So that makes it a bit difficult. “
Lawmakers, however, say the urgency has increased over the past year and a half. “I think the dynamics have changed in large part because of COVID,” Del said. Patrick Hope, D-Arlington, Chairman of the Commission. To date, long-term care facilities have accounted for just over a third of total coronavirus deaths in Virginia, according to the data of the State Department of Health.
In many cases, staffing levels have played a crucial role in how institutions have responded to an outbreak. Skyview Springs, a nursing home in Luray, was repeatedly cited by state regulators last May when an inspection found more than 60% of its residents had tested positive for the coronavirus (24 eventually died from the virus). Employees did not isolate COVID-19 positive patients from negative patients, with one worker blaming “staff limitations” that made it difficult to separate patients.
“I think this really highlighted the disparities that we have within our collective care facilities – especially nursing homes – in their understaffing,” Hope said. “So this is a great opportunity to take advantage of it. “
Industry representatives say Medicaid reimbursement rates have always been the number one issue for nursing homes in Virginia. Keith Hare, CEO of VHCA-VCAL, said tariffs should be increased without establishing new and potentially difficult requirements for facilities, which are struggling – like most most of the healthcare industry – hire and retain staff.
But while there is a broad consensus among lawmakers that increasing payments should go hand in hand with staffing requirements, analysts have found that increasing reimbursements alone is less effective than fixing minimum ratios. “In states that have tried to start by simply increasing Medicaid reimbursements rather than implementing an endowment mandate, this has helped, but not as much as the mandates in terms of increasing those numbers,” Kang said. .
The majority of states already have requirements in place, either through minimum staff-to-patient ratios, minimum hours of direct care, or a combination of the two. Hope said the latest report – unlike previous studies – offered solid options on how to both structure the mandate and fund it.
Lawmakers could implement general staffing requirements for nursing homes or an “acuity-based” formula determined by patient needs – one option, Barker said, would better serve patients with higher care demands. intensive. The study also listed various options for increasing Medicaid funding, including reinstating a Virginia estate tax or an annual nursing home fee.
Virginia is one of six states without an industry rating, but there is a precedent. The state funded the expansion of its Medicaid program in 2018 by implementing a new hospital levy, which before the law was passed often absorbed the cost of caring for low-income and uninsured patients.
“I think we have a lot of options on the table and it could be a combination of funding mechanisms,” Hope said. It is less certain that Medicaid reimbursements will be increased to incentivize higher wages for nursing home staff, who often earn only between $ 14 and $ 15 an hour, according to a recent report by a other state working group.
Recruiting and retaining employees has long been a challenge for the industry, which has often blamed labor shortages on the inability of many nursing homes to provide adequate staff – and as an argument against them. minimum personnel requirements.
Of the. Mark Sickles, D-Fairfax, member of the Joint Commission on Healthcare, said Virginia could do more to promote geriatric care and attract more professionals to the field. He also promoted incentives for nursing homes that do more to increase staff – including language in the latest budget which orders the State Department of Medical Assistance Services to develop a program that would grant higher reimbursement rates to facilities with better performance scores.
Analysts were skeptical that defining staffing requirements would be an insurmountable hurdle for the industry.
“There was a consensus” – among nursing home leaders and staff – “that labor shortages are at the heart of the problem,” the report reads. “But facility-level data indicates that most nursing homes in Virginia are able to overcome shortages and meet minimum staffing levels based on CMS expectations.”