On March 1, 2022, President Joseph R. Biden delivered the traditional annual State of the Union address. What was less traditional was the short statement on nursing home quality during his hour-long speech. “Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and that they expect,” said President Biden.
Those 30 seconds on nursing home reform were pointing to a set of more detailed proposals, which may have the greatest impact on nursing home quality since the Omnibus Budget and Reconciliation Act of 1987 (OBRA 87).
The reforms are divided into five broad categories:
Ensuring Taxpayer Dollars Support Nursing Homes That Provide Safe, Adequate, and Dignified Care
Enhancing Accountability and Oversight
Creating Pathways to Good-paying Jobs With the Free and Fair Choice to Join a Union
Ensuring Pandemic and Emergency Preparedness in Nursing Homes
Each category has its own set of even more detailed proposals that outline where the Biden-Harris Administration will focus its efforts. According to the officials of the Centers for Medicare & Medicaid Services (CMS) who have spoken in various open-door forums, CMS will be fast tracking many of these proposals.
The first iteration of implementation arrived via the Skilled Nursing Facility Prospective Payment System (SNF PPS) Proposed Rule, which was issued on April 7, 2022. The rule outlined proposals to add quality measures around infection prevention and staff turnover, and it included a request for information about addressing the staffing shortage crisis.
The Society Response
Shortly after the State of the Union address, AMDA – The Society for Post-Acute and Long-Term Care Medicine issued a response urging the Biden-Harris Administration to be “broad, innovative, and practical” in its thinking on reforming PALTC (see the March 4, 2022, press release at https://bit.ly/3bhlU08
). The Society stated its strong support for some proposals, such as single-occupancy rooms, ownership transparency, and a full-time infection preventionist.
However, the Society expressed concern about the lack of proposals for improvements in health information technology and urged the Administration to “change the way we look at care providers in PALTC,” noting that “policies that demoralize and demonize nursing homes and their staff have led many caring professionals to leave PALTC.”
This is a time for bold proposals that take the nursing home sector into the 21st century and do not leave it behind by increasing the gap in care between care settings.
The Society called on the administration to address the staffing crisis by addressing the various aspects of the problem, including “ensuring a safe work environment for direct care staff that provides adequate compensation and benefits, plentiful training and career advancement opportunities, and engaged and competent clinical leadership.”
Likewise, the Society urged the administration to address the shortage of trained physicians in this field. Over the course of the pandemic, the Society has heard anecdotes of more physicians leaving PALTC and of severe shortages in hands-on care in parts of the country. This problem has mainly been hidden because physicians who practice in PALTC do not have a specialty or subspecialty designation.
Medical Director Transparency
The Society strongly urged the administration to improve transparency around the medical director role. “The facility medical director, required by the OBRA 1987 law, is responsible for coordination and oversight of the overall clinical care in the facility. And yet, after the more than 30 years since that law passed, this vital position remains a sadly underutilized and invisible role to most patients, families, and even others in the healthcare field. The Administration can easily change this, for a start by compiling and disseminating a public listing of medical directors of every Medicare/Medicaid certified nursing facility in this country, as we have advocated for the last several years.”
The Society has requested such action be taken in several of its comment letters and has reiterated this request in its response to the SNF PPS proposed rule. Further, at the June 2022 meeting of the House of Delegates, the American Medical Association (AMA) adopted a Society proposed policy to “advocate for the Centers for Medicare & Medicaid Services to promote health care transparency and consumer access to quality health care by hosting a public listing of medical directors of all nursing facilities in the country” (https://bit.ly/39CFIKX
The Society plans to continue to work with Congress and CMS to ensure implementation of this important initiative.
Shortly after the release of the Biden-Harris Administration proposals, the National Academies of Sciences, Engineering, and Medicine (NASEM) issued its own report on nursing home reform. The report, “The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, Staff” (https://bit.ly/3Oa6kBQ
), outlined a broad range of recommendations, including many that touched on the administration’s proposals. This report could prove to be a pivotal moment for enacting nursing home reform. In a similar fashion, an Institute of Medicine (IOM) — predecessor to NASEM — report led to the passage of the OBRA ‘87 nursing home reform law. In its response to the report (https://bit.ly/3bfVyeH
), the Society urged Congress and the administration to take immediate action to implement the report’s recommendations.
Given the broad stakeholder group that helped develop the report, this could serve as the one set of recommendations endorsed by the broadest set of stakeholders in the PALTC sector. Among the many proposals was support for the Society’s proposals to address the staffing crisis as well as transparency for medical directors.
The Society looks forward to continuing its advocacy work to advance its priorities for the PALTC sector. If you are interested in helping with our efforts or have thoughts about any of our proposals please email us at [email protected]
Mr. Bardakh is director of public policy and advocacy for AMDA – The Society for Post-Acute and Long-Term Care Medicine.