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Response to CMS RFI on Revising the Requirements for Long-Term Care Facilities to Establish Mandatory Minimum Staffing Levels

In a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure responding to a request for information on revising requirements for long-term care facilities to establish mandatory minimum staffing levels, MACPAC explored policies to ensure adequate staffing in nursing facilities while encouraging CMS to apply a health equity lens in its analyses of staffing standards. Medicaid is the primary payer for most nursing facility residents. The Commission plans to examine how Medicaid payments can be structured to better assure adequate staffing for the care of Medicaid-covered nursing facility residents and discuss the results at a future MACPAC public meeting.

MACPAC recently conducted a review of pre-pandemic staffing data and found that nursing facilities that serve a higher share of Medicaid-covered residents were much more likely to have lower staffing rates compared to other facilities. Facilities with a high share of Medicaid-covered residents also serve more racial and ethnic minorities, and so worse staffing levels at these facilities may exacerbate health disparities. MACPAC also found considerable variation in nursing facility staffing at the state level. For example, in three states (Alaska, Hawaii, and North Dakota) and the District of Columbia, fewer than 10 percent of freestanding nursing facilities had 1- or 2- star staffing ratings in 2019, while in three other states (Georgia, Louisiana, and Texas) more than 70 percent of facilities had these low ratings.

To better understand state policy levers, MACPAC compiled information on current state staffing policies, including state minimum staffing standards and Medicaid payment methods. States can establish minimum staffing standards that exceed current federal minimum staffing standards of 0.3 hours per resident day (HPRD) for a 100-bed facility. MACPAC found that 38 states and the District of Columbia had minimum staffing standards that exceeded the minimum federal requirements as of October 2021. However, only 11 states and the District of Columbia had standards that were greater than 3.0 HPRD, and only the District of Columbia had a minimum staffing standard of 4.1 HPRD, the level recommended by CMS’s 2001 staffing study.

MACPAC also examined how states can develop Medicaid payment methods to incentivize facilities to spend more of their revenue on staff. Some examples of state Medicaid payment policies that are intended to promote adequate staffing include wage pass-through payment policies that require facilities to spend a specified portion of the Medicaid rate on staff wages and cost-based payment policies for direct care staff that pay facilities more if they spend more on staffing.

In the coming year, MACPAC will continue to look at principles that states should consider when setting Medicaid nursing facility payment policies to promote access to adequate staffing, promote an efficient use of resources, and reduce health disparities.