When she started working as a certified nursing assistant 22 years ago, Victoria Mitchell was assigned about eight patients during her morning shifts.
Now, Mitchell says, she and her co-workers are told to care for up to 11 patients per shift. They hurry, but patients are left waiting for basic care, as CNAs bathe, dress and feed each one in turn.
“This job is getting heavier and with less pay, and the patients are feeling it, too,” said the 43-year-old mother and grandmother, who works at Hopkins Manor in North Providence.
Still, UnitedHealth Foundation ranked Rhode Island’s nursing home quality second in the nation this year, saying that 65.8% of the state’s nursing home beds are in four- or five-star facilities.
At the same time, the nursing home industry has contracted, according to the R.I. Department of Health. In 2009 there were 92 nursing homes with 9,276 beds. Currently 85 licensed nursing homes with a total of 9,177 beds operate in the Ocean State.
Of the current numbers, 339 nursing home beds are private, while in 2009, that number was 421. All other beds accept Medicare and Medicaid patients.
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NURSING HOME REPRESENTATIVE: Scott Fraser is the CEO and president of the Rhode Island Health Care Association, which represents 67 for-profit nursing homes and related facilities throughout the state.
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Although no closures have taken place recently, Scott Fraser, CEO and president of the Rhode Island Health Care Association, says that some homes fear they may be pushed over the brink by consistently low reimbursement rates even as an aging baby-boom population promises an influx of people needing nursing home care.
“There is a very serious concern … that you’re going to see more homes going out of business at a time when you’re seeing our population going in the other direction,” he said. “Our capacity in the state is just about 90%, and that’s a good thing as you look around at a lot of other states … but that only leaves [about] 11% of beds to fill, and there’s a greater need coming in the next decade.”
Not being able to pay overworked staff more remains a significant barrier to growth in the industry locally, with much of the problem caused by the reimbursement rates Fraser points to.
Many nursing homes in Rhode Island say they are unable to afford significant wage increases for their staff because of low Medicaid reimbursement rates and delayed payments caused by lingering backlogs from the state’s Unified Health Infrastructure Project.
UHIP was meant to simplify the application and approval process for public-assistance programs throughout the state, including Medicaid, Supplemental Nutrition Assistance Program, cash assistance and subsidized child care. Almost immediately after its 2016 launch, the system was beset by glitches, leading to delays in approval and reimbursement.
Now, despite a 2.5% reimbursement rate increase in the state’s fiscal 2019 budget, and a 1% increase in the 2020 budget, many nursing homes throughout the state say the increases aren’t enough.
“Utilities, food, medication and insurance costs for our employees all continue to grow at a rate greater than 2%,” said Kathleen Gerber, executive director of Cherry Hill Manor Nursing and Rehabilitation Center in Johnston. “Because we must finance these increases, it leaves us unable to provide raises for our staff, who already work in a demanding, exacting and stressful industry. The challenge we face is to recruit, train and retain staff in an understaffed, underpaid industry. The cost of turnover to patients is immeasurable.”
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STAFFING STANDARDS: Raise the Bar on Resident Care members rally outside the Bannister Center in Providence on July 25. The group demands starting wages of $15 per hour for certified nursing assistants and a minimum staffing standard that would require nurses and assistants to spend a total of about four hours daily with nursing home residents.
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UHIP’S LINGERING EFFECTS
Although Rhode Island nursing homes say reimbursement rates have been low for decades, they point to UHIP and its disastrous rollout as a financial millstone that continues to weigh heavily on their budgets.
“The reimbursement levels are nothing new, we’ve had to deal with those for a long, long time,” said Mark Loiselle, Saint Elizabeth Community’s chief financial officer. “We weren’t reimbursed a lot, but we were paid in 45 days. Now we aren’t reimbursed a lot but we’re paid in a lot longer time period.”
State officials have promised fixes, but approvals for Medicaid applications are backlogged, and payments to nursing homes are still delayed as UHIP glitches persist.
Sen. Louis P. DiPalma, D-Middletown, the state Senate’s Finance Committee health and human services finance subcommittee chair, says the troubled system is steadily improving as work on it continues.
“It’s a complex and complicated system. It takes time to get done,” he said. “Did UHIP go live too soon? Absolutely … but it’s getting there. Are we completely there? … With regards to meeting the timetables of both efficiency and quality, we’re not there yet.”
Nursing homes encountered a further layer of complication in 2017, when the R.I. Executive Office of Health and Human Services issued $132 million in emergency advance payments to cover Medicaid costs backlogged by UHIP. The money helped rescue some nursing homes teetering on the brink of bankruptcy, but facilities still must repay the state.
Earlier this year, state officials released a list of dozens of nursing homes who they said owed the state $84.3 million in interim payments.
Paying the state back, some homes say, is nearly impossible when they are still owed money for up to a year or more of Medicaid services for patients.
“The delay in payment from the implementation of UHIP is unforgivable. Currently the nursing homes continue to waste time resubmitting information, being paid incorrectly, being accused of receiving more money than we are owed and [receiving] demands that it be paid back immediately,” Gerber said. “It is erroneous that any nursing home owes the state when the state is, on average, nine months to a year delayed in approving Medicaid applications. In reality, what the state owes any nursing home far exceeds any rate overpayment a nursing home may have received.”
Increases in fiscal 2019 and this fiscal year to Medicaid reimbursements aren’t enough, industry leaders say, because of a series of funding cuts dating back to 2012. Prior to 2012, base rates were updated automatically every three years in the state budget, said James Nyberg, director of LeadingAgeRI, which represents 15 nonprofit facilities that offer care for older people. In 2012, the updates stopped, and reimbursements were upped on the basis of inflation index rates.
Then, in the fiscal 2016 budget, EOHHS instituted a 2% cut to Medicaid payments to nursing homes. Taking effect in July 2015 as part of Gov. Gina M. Raimondo’s Reinvention of Medicaid initiative, it was initially interpreted by many in the industry as a one-time decrease spanning 12 months.
But the cut was not restored, prompting 59 nursing homes to sue for $8 million per year that it was in effect.
In April 2018, an R.I. Superior Court judge ruled in favor of the nursing homes in a decision that threatened to put the state on the line for up to $24 million.
A missed appeal deadline by the attorney handling the case for the state made payback appear possible, but as the Raimondo administration was pushing for an emergency extension, state lawmakers proposed an 8.5% cut in Medicaid reimbursements to the fiscal 2019 budget to compensate for the nursing homes’ lawsuit victory.
Uproar over the move quieted the next day when lawmakers reached an agreement with nursing homes. In exchange for dropping the $24 million suit, the 8.5% cut was nixed as well.
Instead, nursing homes got a 1.5% increase in Medicaid reimbursement payments in July 2018 and another 1% increase several months later. An additional 1% increase is included in the fiscal 2020 budget.
The increases are based on the rates that were cut 2% in 2015, nursing home representatives point out.
A nursing home inflation index that took effect in 2012 was not applied in 2013, 2014, 2017 or 2018.
This year’s 1% reimbursement increase is based on the inflation index, although it doesn’t reflect the more than 3% growth of the index, Nyberg said.
“This means [nursing homes] have to make tough decisions about staffing, first and foremost. If you only get a 1% rate increase, how can you recruit and retain staff?” he said.
It’s not clear if, or how soon, more money could be coming from the state, and lawmakers say it’s too early for speculation.
“The governor will submit her budget to the legislature in January and the House Finance Committee will hold public hearings on all budget items, including state funding for nursing homes. It is too soon to project any budget items for next year,” Larry Berman, a spokesman for House Speaker Nicholas A. Mattiello, D-Cranston, wrote in an email to Providence Business News.
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BOOMERS ARE COMING
Several factors are at play when it comes to the industry’s readiness for a groundswell of baby boomers, said Matt Trimble, chief operating officer of Saint Elizabeth Community.
He worries that the difficulty homes face now in attracting quality caretakers will become urgent in coming years. Low pay and a shrinking amount of younger people are to blame, he says.
“With the baby boomers aging and the supply of people to take care of them declining, we’re facing a significant crisis that doesn’t seem to be on anyone’s radar right now,” Trimble said.
On top of that, he added, a state moratorium on new nursing home facilities and beds will quash improvements to care.
For Fraser, whose organization represents 67 for-profit nursing homes and related facilities, the inflation index represents a possible fix for nursing homes’ money woes.
“I would start to just fund that Medicaid inflation index. If they would just fully fund that, that would go a long way,” he said. “Our facilities are doing more with less, it’s just harder and harder for the homes to meet their bills on a timely basis. They’re still continuing to provide quality care.”
Keeping a lid on the ever-growing inflation rate, though, has helped lawmakers balance the overall budget, Berman said.
“The Medicaid budget represents a huge share of state spending, with much of that for long-term care services. Every year, the governor and the legislature must balance those costs against all needs,” he said. “Curtailing growth in the payment rates has been one way to do that.”
DiPalma, who is also first vice chair of the Senate’s Finance Committee, said budget savings from capping this year’s inflation index increase at 1% totaled $3.5 million.
An alternative approach may be to include the full amount during initial budget deliberations to measure its potential drain on other costs, he said.
“If we start with the budget that has it in; it’s a great way to start,” DiPalma said, adding that Raimondo proposed the 1% at the start of budget talks.
“Every year we’re faced with structural budget deficiencies that we need to close. … At the same time we’re needing to invest in things [such as] education, and roads and bridges,” he said. “How do we do a similar multiyear plan for health and human services, which nursing homes are a part of? We need to look at things holistically as well. Money will certainly go a ways to address that, but it’s not the only thing.”
In fiscal 2019, Rhode Island’s nursing homes received $134.9 million in reimbursement funds from the state, as well as $145.3 million in federal money, DiPalma said.
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DELAYED APPLICATIONS: Kathleen Gerber, executive director at Cherry Hill Manor Nursing and Rehabilitation Center in Johnston, speaks with Louie Spina. Gerber said, “It is erroneous that any nursing home owes the state when the state is, on average, nine months to a year delayed in approving Medicaid applications.”
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WEATHERED THE STORM?
Although it is more financially secure now than it was three years ago, Mount St. Rita Health Centre in Cumberland relentlessly tracks expenses in order to stay comfortably afloat.
“A big piece of it is labor. We work very carefully on how we staff the facility. We avoid overtime and try to avoid agency staff,” or nurses for hire, said administrator Bill Fleming.
Cuts to the 98-bed center’s staff, which numbers 115, aren’t likely, though.
“That’s as low as we can probably go, we can’t do it with less than that,” Fleming said.
But while times are lean, the facility, where about 82% of patients are on Medicaid, isn’t facing financial difficulty, he added.
Meticulous attention to finances has allowed Mount St. Rita to pay back its advanced UHIP payments and endure delayed Medicaid reimbursements.
“You’ve got to manage it very, very closely,” Fleming said.
But when it comes to money, the recently formed union-backed group Raise the Bar on Resident Care is pushing to increase caretaker wages.
The group, made up of District 1199 SEIU New England members and others, held a public rally earlier this year to demand starting wages of $15 per hour for CNAs and a minimum staffing standard that would require nurses and assistants to spend a total of about four hours daily with nursing home residents.
Members are also pushing state lawmakers to create legislation requiring staffing minimums.
While nursing homes say low Medicaid reimbursements prevent wage increases for caretakers, Raise the Bar suggests that reprioritizing spending may be the answer.
“I think they are right to a certain extent,” said Emmanuel Falck, elected organizer of District 1199 SEIU New England. “We obviously need to resource nursing homes at appropriate levels so we can pay nursing home workers a living wage. But I also think there’s a lot of money in the system that should be going directly to the bedside and bedside care that doesn’t always get there.”
Fraser, of the Rhode Island Health Care Association, counters that funding is essential to address staffing concerns. When rate increases don’t match up with the inflation index, nursing homes are hard-pressed to offer raises, he said.
“Our members would love to be able to pay increased wages. … The folks that do the work at our homes are just incredible, but the money has to come from somewhere,” he said. “When the majority of your residents are on Medicaid and you’re only getting a 1% increase a year, that’s tough to make up.”
Fraser, citing a Centers for Medicare and Medicaid Services study released in early July, added that Rhode Island nursing homes currently average nearly 3.6 hours of daily care for residents.
Long-term care state ombudsman Kathy Heren, of the Rhode Island Alliance for Better Long Term Care, said she has not seen significant staffing cuts at nursing homes across the state or received complaints about short-staffing.
“They’ve really weathered the storm and I’ve really not seen services cut,” she said. “However they’re doing it, they’re doing it.”
Perhaps Victoria Mitchell, the CNA at Hopkins Manor, which did not return a phone call seeking comment, identifies the issue best. She says that she sticks with the job out of a love of being a caretaker, but predicts that young people entering the health care industry will shy away from nursing homes.
“The job doesn’t pay, young kids don’t want to do that job,” she said.
Elizabeth Graham is a PBN staff writer. Contact her at Graham@PBN.com.
