Are nursing homes really in tough shape?

Full transparency needed before any more taxpayer bailouts

THE HEADLINE  for a recent story iminously noted, “Massachusetts nursing home job vacancies hold at historic highs.” That isn’t news to anyone in government, the nursing home industry, or the job placement industry.  Worker shortages in nearly every aspect of life are a fact of life in most job fields, but in professions like education or health care – jobs that deal with people, it is a serious concern.

Imagine being bedridden in a Massachusetts nursing home and urgently needing to get help to the toilet, and no matter how much you press the call button at your bedside, staff don’t arrive in time, or at all for long periods of time.  In such all-to-often cases, that’s a real crisis!  However, in the larger picture, it means that safe, quality care for older adults and people with disabilities doesn’t exist.  Residents of nursing homes, many whose care is largely paid by taxpayers, deserve dignity and respect, but inadequate numbers of nurses and aides, who are generally overworked and underpaid, cannot provide good care, despite their best intentions.

Massachusetts regulations governing nursing home staff require: “sufficient nursing personnel to meet resident nursing care needs, based on acuity, resident assessments, care plans, census, and other relevant factors.”  Those same regulations define sufficient staffing as a “minimum number of hours of care per resident per day of 3.58 hours, of which 0.508 hours must be care provided to each resident by a registered nurse.”

The minimum staffing required by Massachusetts is, itself, below what most health care research suggests is needed, which is agreed by experts as 4.1 hours of care per resident per day. Studies haves defined nursing home quality, measured by structural variables “such as (1) inputs such as the level and mix of staffing; (2) characteristics of facilities such as ownership, size, accreditation, and teaching status, and (3) characteristics of the facility’s residents, such as demographics and payer mix.” Payer status is relevant because the rate for private pay residents is higher than Medicaid residents, and, therefore, the competition to enroll private pay residents often means efforts to provide better quality care, which benefits all residents.

An article published in Health Service Insights on June 29 notes that “state minimum standards are generally below the levels recommended by researchers and experts to consistently meet the needs of each resident.”

“While a number of organizations have endorsed the minimum of 4.1 hours of care per resident per day and have suggested that at least 20 percent of hours should be provided by RNs and LPNs, and facilities should have 24-hour RN care, some experts have recommended even higher staffing standards (a total of 4.55 hours per resident per day ) to improve the quality of nursing home care, with higher adjustments for higher resident acuity.

When the Massachusetts Department of Public Health established the state minimum of 3.55 hours of nursing per resident per day, advocates such as Dignity Alliance Massachusetts submitted testimony urging adoption of the 4.1 hours of nursing per resident as the minimum standard of care.  However, the lobbying of nursing industry representatives resulted in the setting of 3.55 hours of nursing per resident as the state’s standard.

To recount, the appropriate level of nursing care for Massachusetts nursing home residents by regulation must be not less than 3.55 hours of nursing care per resident per day, the recommended level is not less than 4.1 hours of nursing care per resident per day, and the level suggested by many experts on safe, quality care is actually 4.55 hours per resident per day.

The nurse staffing shortage identified by the Massachusetts Senior Care Association, the nursing home industry’s trade organization, as approximately 6,900 vacancies in registered nurse, licensed practical nurse, and certified nurse assistant positions. Nearly half of that number are in certified nurse assistants – the staff who are usually called upon to help a resident to the toilet or clean up the mess if the resident can’t wait.  The question to ask is: Have state regulators determined if all nursing homes are meeting the minimum state standard for nursing care?

To be fair, we know that the overall census of residents in nursing homes has dropped dramatically since the beginning of COVID-19.  However, so have the number of staff.  In addition to the shortage of nursing staff, the industry has reported vacancies in nutrition, housecleaning (which is important to infection control), and other support staff totaling another 1,700 vacancies.  These positions also have an impact on quality of care and safety of the residents.  Many facilities have also restricted admissions to their facilities, hopefully to maintain the required nursing care ratios.

The recently enacted economic development bill, which includes funding for nursing home staff, will offer some relief, according to the industry, assuming that nursing homes offer a living wage to their staff sufficient to attract workers to fill the vacancies.  But where is the evidence that the hundreds of millions of taxpayer dollars already sent to nursing homes, and the hundreds of millions of additional dollars now headed their way in the economic development bill will make a difference?  Even more to the point, how does the Commonwealth know that the money is really needed and being spent for the Legislature’s intended purpose, without an audit of these funds?

If anyone audits these funds, and maybe this should be a priority for the next governor, auditor, or attorney general, they need to look beyond the books of each nursing home. “State regulators and legislators should be able to consider the congruence between return on investment (shareholder interests) and the quality of care provided to patients.  State officials should consider consolidated financial statements of parent corporations in conjunction with financial data reported to state agencies.  The importance of this cannot be underestimated.”

Claims by industry representatives that the industry cannot survive and provide quality care without additional state bailouts or higher Medicaid reimbursement rates are based on cost reports submitted by each facility to state agencies – not on the financial metrics of parent corporations, e.g., income statement, balance sheet, and cash flow statement.  The focus needs to be in the combined payouts to their own ancillary businesses such as real estate, insurance, management services, etc. that are expensed on cost reports which affect each facility’s net income but funnels cash to investors.

“The nursing home industry has a political narrative based on a false impression that the industry is comprised of struggling businesses barely avoiding bankruptcy.  Industry media such as Skilled Nursing News and McKnight’s Senior Living reinforce this narrative, which is based on the pervasively faulty and misleading cost reports – not consolidated financial statements.”  Furthermore, there’s little support for sustaining the nursing home model.  Aging in Place: A State Survey of Livability Policies and Practices, written by the National Conference of State Legislatures with the AARP Public Policy Institute, reported that nearly 90 percent of people over age 65 want to stay in their home for as long as possible, and 80 percent believe their current residence is where they will always live.  It’s time for real transparency and full disclosure to justify any more taxpayer bailouts for an industry that older adults, and others believe has failed them.

Richard Moore is a former Massachusetts state senator who chaired the Committee on Health Care Financing.  He is currently serving as legislative chair for Dignity Alliance Massachusetts, a non-profit statewide coalition of advocates for older adults, people with disabilities and their caregivers. His views in this article do not, necessarily, reflect the views of the coalition.