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COVID-19 has resulted in heightened awareness of the inadequacies of our long-term care system in Pennsylvania. The Department of Health has begun their attempt to respond by issuing the first of what will be five sets of proposed regulations to update the commonwealth’s rules for long-term care nursing facilities.
The initial proposal was published in the Pennsylvania Bulletin on July 31 and gives interested parties 30 days to comment. The key change would increase the minimum number of hours of direct care each resident of a nursing facility must receive from 2.7 hours each day to 4.1 hours. As the Department of Health notes in its narrative, which accompanies the proposed regulations, the Centers for Medicare and Medicaid Services (CMS) recommends 4.1 hours as the minimum daily number of hours of care for each resident. The Department further notes that numerous studies have found “a direct correlation between the quality of resident care, quality of resident life and the number of direct care hours that the resident receives.”
The Department determined 603 of the total 689 licensed facilities in the commonwealth do not currently meet the proposed 4.1 minimum daily hours of direct care. The practical result of such a change would be a need for most skilled nursing facilities in Pennsylvania to hire more direct care workers.
The proposed regulations cite numerous costs resulting from an increase in staffing. The Federal Government covers slightly over half of the Medicaid budget for skilled nursing care for Pennsylvanians who have exhausted their assets, but the estimated impact of these new regulations on the Commonwealth’s share of the Medicaid program is $182.5 million.
This staffing increase will also impact care not covered by Medicaid, as not all residents of skilled nursing facilities are Medicaid-eligible. The proposed regulations note there is not “sufficient data to determine who will bear the burden of the remaining costs,” but “at least some of this amount will have to be borne by the regulated community.”
The narrative concludes by noting “the Department believes the increase in quality of life and safety for the approximately 67,500 residents in the impacted long-term care nursing facilities outweighs any additional cost to the regulated community,” while also stating “There are expected to be no additional costs to the general public.”
At first glance, such a change in policy should be celebrated. More care should equal better care and studies of states that have instituted a higher minimum number of hours of care seem to show better outcomes. But a real-world examination of the Department’s proposal reveals two major concerns.
First is the true cost. The reality for skilled nursing facilities today is Medicaid payments are not sufficient for the care of residents. Both for-profit and nonprofit facilities have urged increases in the Medicaid budget to cover the current costs of care, but the message has fallen on deaf ears in both the Administration and in the General Assembly.
Some of the cries for help from operators may be exaggerated, particularly by the large corporate owners in the for-profit sector. But the struggles of many skilled nursing facilities, and the increasing costs of healthcare, are not fiction. And the idea that “some of the amount will have to be borne by the regulated community,” means two things – higher costs for private-pay residents and the likely closure of some facilities.
But the other concern may be even more critical. How, in an environment where most facilities are having trouble attracting staff to cover their needs today, will enough direct care workers be found to allow residents to receive the additional number of hours of care?
Some say this will force facilities to increase salaries to attract workers. But with funding from Medicaid already limited, how can salaries actually be increased without more resources? And even with higher salaries, the pool of potential direct care workers is limited.
These jobs require not only education and knowledge, they require individuals with an aptitude for the physical and emotional demands of this type of work. The demographic challenges we face in the Commonwealth add to difficulties of finding more direct care workers to fill these positions.
In the end, we are again faced with the dilemma we constantly encounter in Pennsylvania – the desire to improve care for our rapidly aging population and the unwillingness to admit that achieving this desire requires a commitment by the entire population to absorb the costs.
The controversy surrounding these proposed regulations will be dramatic within the state government and the long-term care community. But with the Department of Health boldly stating they will not result in any increased costs to the general public (i.e. taxpayers), these regulations are unlikely to serve as the impetus to the funding increases necessary to produce true improvement in the future of long-term care in the commonwealth.
Opinion contributor Ray E. Landis writes about the issues important to older Pennsylvanians. His work appears biweekly on the Capital-Star’s Commentary Page. Readers may follow him on Twitter @RELandis.
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