The Nursing Home Crisis: Prognosis Guarded

On February 28, 2022, the White House released a detailed “Fact Sheet” replete with plans to “improve the safety and quality of nursing home care, hold nursing homes accountable for the care they provide, and make the quality of care and facility ownership more transparent.” The proposed reforms were further highlighted during the State of the Union Address, wherein President Biden noted that “Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and expect.” The hoped-for reforms are intent on ensuring that “every nursing home provides a sufficient number of staff who are adequately trained to provide high-quality care.” The new paradigm will also seek to ensure that “poorly performing nursing homes are held accountable for improper and unsafe care and immediately improve their services or are cut off from taxpayer dollars.” Concurrent efforts will be undertaken to ensure that “the public has better information about nursing home conditions so that they can find the best available options.” In this Commentary, we review the newly released nursing home reform proposal and discuss the likelihood of the consummation thereof.

At the time of this writing, in excess of 1.5 million seniors reside in >15,500 Medicare- and Medicaid-certified nursing homes across the nation. Most of these facilities are accredited to function as short-term skilled nursing facilities and as long-term nursing homes for the aged. Over 69% are deemed to be for profit, that is, owned by corporations or private equity. It took the coronavirus disease 2019 (COVID-19) pandemic to bring the nursing home crisis into sharper focus. In what many view as a glaring distress signal, over a quarter of the national COVID-19 death toll (201,000 men and women) was ascribable to nursing home residents and staff. It is in wake of this grievous outcome that the Administration announced a series of reforms intent on “Improving Safety and Quality of Care in the Nation’s Nursing Homes.”

Leading the nursing home reform toward “safe, adequate, and dignified care” are several new initiatives. Paving the way is the conception of “minimum nursing home staffing requirement,” which requires the Centers for Medicare & Medicaid Services (CMS) to “propose minimum standards for staffing adequacy that nursing homes must meet.” Yet another initiative seeks to “reduce resident room crowding,” with an eye toward advancing privacy and dignity as well as reducing the “risk of contracting infectious diseases, including COVID-19.” A related initiative aims to “strengthen the skilled nursing facility value-based purchasing program” by linking payment for quality care to “staffing adequacy, the resident experience, as well as how well facilities retain staff.” Additional efforts will seek to “reinforce safeguards against unnecessary medications and treatments” such as antipsychotic drugs.

With enhanced “accountability and oversight” in mind, the Administration intends to call on Congress to add $500 million to the CMS budget “to support health and safety inspections at nursing homes.” Concurrently, the Administration will seek to “beef up scrutiny on more of the poorest performers.” In addition, plans will be drawn to “expand financial penalties” against “poor-performing facilities.” President Biden will also be calling on Congress to “raise the dollar limit on per-instance financial penalties levied on poor-performing facilities, from $21,000 to $1,000,000.” To complement the aforementioned initiatives, the Administration will seek to “increase accountability for chain owners of substandard facilities” while providing “technical assistance to nursing homes to help them improve.”