Opinion: Relief is needed for NH nursing homes


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Published: 02-25-2024 7:30 AM

Brendan Williams is the president and CEO of the New Hampshire Health Care Association.

New Hampshire’s nursing home providers were very grateful to legislators and Governor Sununu for including them in a historic investment in Medicaid rates in the current two-year state budget. The help could not have been timelier.

A December report found nursing homes led all healthcare sectors with wage increases of 24.9% between February 2020 and September 2023. Yet, despite wage inflation and runaway inflation in other costs providers must incur, no help has come from the federal government.

The American Rescue Plan Act passed in 2021 has provided roughly $37 billion to home and community-based settings, but only allotted $500 million for nursing homes – for infection control, not care. And the Biden Administration has proposed an unfunded nursing home staffing mandate estimated to cost $6.8 billion a year. This has drawn criticism from rural state congressional Democrats, including ours, and even the president’s own Small Business Administration.

Awaiting their fate under this federal sword of Damocles, nursing home providers face another problem. They’re not the only ones competing in a red-hot job market. The New Hampshire Department of Health and Human Services (DHHS) is too. That has left unfilled vacancies at DHHS, most critically, from the provider perspective, in processing Medicaid applications. Unhelpful to both DHHS and providers is the fact that family members are often uncooperative in providing documentation necessary to qualify a nursing home resident for Medicaid.

Most are on Medicaid, and no one argues it covers their full care costs. But it gets worse: If a Medicaid application is not yet approved a provider does not get paid anything. Of course, that does not stop the provider from incurring care costs while awaiting payment. And it becomes awfully difficult to pay some of those costs, such as bills from vendors, if you’re in arrears.

Just take one example: A Manchester facility resident with an outstanding balance of $25,000 while their Medicaid application is not yet complete or approved. Every day of their Medicaid pending status costs the facility $400 per day. It was already going to lose a substantial portion of that care cost even if paid, but now must somehow come up with the cash flow to keep caring for somebody for whom it’s already owed $25,000. Then multiply this one resident by twenty.

There is no margin to play this waiting game. According to a federal government presentation, the all-payer margin for freestanding nursing homes fell in 2022 to negative 1.4 percent.

And the scale of our workforce crisis is revealed by the fact that the state itself recently raised the value of its temporary staff contractsat the New Hampshire Hospital and Glencliff Home from $3,770,000 to $11,500,000. Of the sixteen staffing agencies contracted with, only two are based in New Hampshire. If the state is paying a per diem rate of no less than $80 an hour to an agency for the services of a registered nurse, that rate, were it for a full-time equivalent employee of the facility, would be $166,400 a year.

It’s not as if the state does not pay its own direct care employees generously; indeed, far more than what private facilities can afford. There simply are not enough homegrown licensed workers to go around. That even the state must use staffing agencies is a canary in a coal mine.

Given all these pressures, New Hampshire must consider providing extra financial relief to nursing home care as a bridge to what we can all hope is greater normalcy and financial stability. The risk otherwise is facility closures or forced sales.