Parkinson: CARES Act Will Keep Nursing Homes ‘Above Water’ In 2020, But Closures Loom In 2021

October 12, 2020, Maggie Flynn, Skilled Nursing News - As skilled nursing operators gather themselves together to prepare for their new era in the wake of a pandemic that has upended their sector in particular and society more broadly, there are significant lessons to be learned from the COVID-19 era, according to the leader of the largest trade organization for nursing homes in the U.S.

Though more resources on the governmental level are necessary for operators to continue in the midst of the pandemic, there are some bright spots, Mark Parkinson, the president and CEO of the American Health Care Association (AHCA), told Skilled Nursing News on October 8.

Those include better access to testing and personal protective equipment (PPE) and improved knowledge on how to care for COVID-19 patients in the event of an outbreak. 

But the lessons from the hard first months of COVID-19 extend beyond the immediate; for Parkinson, the industry will have to reflect on a range of reforms for the years to come, not just the months.

SNN caught up with Parkinson before AHCA’s virtual convention and expo to talk about some of those lessons and areas of reform, and how long operators can sustain themselves during the pandemic.  The conversation, edited for length and clarity, is below.

You’ve described operators as better prepared for “phase two” of COVID-19.  What makes them better prepared now to deal with whatever the next front of the pandemic is?

We’re better prepared now, for three reasons.  First, we have much better access to PPE.  That problem isn’t completely solved, but it’s much better than it was back in March and April.  So you don’t have people that are literally making masks out of towels and gowns out of trash bags.  We have generally good access to PPE.

Second, testing is much better.  Back in March, and April, for all practical purposes, testing just didn’t even exist, because if you could get a test kit, oftentimes results were five to 10 days out — at which point, it just became irrelevant.  It’s much better now, and particularly the Abbott tests that are being sent out by the government on a weekly basis have really been helpful.

And thirdly, the clinicians know a lot more about how to treat COVID than they did seven months ago.  There are better practices in terms of taking care of folks.  There are better drugs available.  And so you add those three things together, and I believe that statistics will show that we’ve got a much lower incidence of COVID in buildings, and much higher incidence of recovery when we do.

Anecdotally, things do seem to be calming from the spring.  I did want to ask, there is another issue you’ve spoken about: the issue of infection control.  What has the pandemic revealed how the approach to it needs to change, in both skilled nursing and the regulatory side?

The major reason that we ended up with COVID in so many long-term care facilities across the country is that COVID can be spread by people who have no symptoms.  Up until COVID, all of our infection control protocols assumed symptoms.  And so we would take people’s temperatures, and if they had a temperature, if they were a worker, we’d send them home; if they were a resident, we would cohort them.

But we never assumed that people that were asymptomatic were sick.  Prior infection control didn’t require, for example, you to wear a mask every single time that you transferred a resident, or bathed them, or hugged them or interacted with them in a close way.

Going forward, we’re really going to have to think about infection control protocols, and do we now need to make some assumptions about asymptomatic carriers of various viruses?  So that’s one issue.

In terms of the regulations, there are regulations that relate to infection control, but the problem is there are hundreds — if not thousands — of regulations that relate to a whole bunch of other things.  So what we encouraged the government before the pandemic, and what we will certainly now be encouraging after the pandemic, is to really focus the regulations on the things that matter the most to resident safety and quality of life. It’s obvious that infection control is one of those things.

We will be supporting enhanced efforts to improve infection control.  But that’s only going to be possible if we shed off some of the hundreds of other regulations that deal with things that just don’t matter.

I think a major theme of what we’ll be pushing next year, when the regulatory analysis is done, is for there to be a renewed focus on infection control, and really spending the time and the resources of both the providers and the regulators on the things that really matter, like infection control.

Would that include something like a broader role for an infection preventionist, or rethinking that role in the skilled nursing setting?

It absolutely could.  Clearly, there will be proposals out there to require an infection control preventionist in every building.  That’s been discussed in the past, and I think it’ll be a major topic for discussion next year.  The AHCA board right now is analyzing that issue.  So I won’t prejudge where the board will come out on that, but I will say that I think providers in general are broadly embracing the idea of wide use of infection control preventionists.  I wouldn’t be surprised if the sector came out with a position that was in that direction.

Now the challenge will be how to pay for it. It’s one thing to mandate a requirement; it’s another thing is to figure out a way to actually implement it.  In addition to the board taking a look at various proposals, including a mandatory infection control person, we’re also looking at Medicaid reform, and bringing ideas to Congress to pay for some of these clinical ideas that people are going to have.  You can’t just mandate this stuff without figuring out a way to pay for it.  Otherwise, it will just never happen.

Something that you have mentioned is the need for operators to reflect on ways that things can improve.  What are some of the necessary internal changes that have been highlighted by COVID, whether it’s how the operating business is structured or how things like sick leave are handled?  How is AHCA thinking about addressing those issues?

The operators have done a really good job in a very challenging situation.  So I really want to start out by saying: Hats off to the fact that they have just never quit, and have really worked non-stop since early March to try to fight the pandemic that is really, really hard to fight.  This virus spreads in ways that just make it very difficult to stop.  Even the very best providers that are out there doing what appears to be the best possible infection control practices are still coming up with COVID.

Having said that, there are some things that we are going to have to look at moving forward in the future, that we have figured that if we can afford the change, if we can come up with the resources, can make a difference.

Those include what we just talked about, which is an enhanced role for an infection control preventionist.  It probably also includes some employment policies relating to workers that are working in multiple buildings and creating the possibility when viruses do occur of enhancing the spread.

It probably also involves some things about pay itself, and making sure that when people are sick, they can go home and continue to get paid and can continue to work.

Another thing that we need to look at — and again, very expensive, not clear how it could be paid for — is the idea of creating more private rooms in the skilled nursing setting.  Most of the nursing homes that are out there were built 50 years ago, and there were a basic model that people followed.  Almost all of them have two people to a room, and what we learned during the pandemic is that that made it really hard to stop.  If you look at the incidence of COVID in assisted living buildings, that are primarily a private-room set up, it’s obvious that the incidence is much lower.

So there are four or five things that we need to look at.  Again, we need the resources [from] the government to make these changes.  But we absolutely need to figure out if these are things that should be done in the future.

Speaking of the future, AHCA had a survey this year that found at their current operating costs, as many as 40% of nursing homes could end up closing operations.  Obviously, those costs can fluctuate, but is there a sense of what the fallout is going to be, particularly since SNF occupancy continues to struggle?

The data that demonstrates how challenging it is financially for buildings has been useful in us convincing the government that we need continued aid.  And the CARES Act funds that we’ve received so far on the skilled nursing side have been really helpful.

It varies company by company, but in the aggregate, I think the CARES Act funding that we’ve been able to achieve so far, when you add in the four monthly payments that are going to be going out on the value-based purchasing program that’s in effect right now, I think that they get most operators to the end of 2020 with their heads above water.

If we don’t get assistance beyond that point, beyond the end of 2020 into 2021, that’s when you’re going to see that large percentage of buildings that say that they’re operating at a loss, that’s where you’re going to see potential closures.

Our job now is to convince the government to continue to provide that funding help until we get to a vaccine and until census recovers.  Because as you pointed out, in addition to the loss in revenue and the increase in expenses, the continued problem that we have on the business side is that census is not improving.  It dropped very quickly about 10%, a couple months into the pandemic, and it stayed there.  But it hasn’t gotten better.

Until census starts getting better, if we don’t have a continual flow of funds from the government to these facilities, we’re going to have closures.

Obviously it’s hard to think past COVID-19 right now, but what are some of the issues outside that that AHCA is focusing on?

I mean, COVID has been such an overwhelming issue in buildings and in D.C. that it’s covered up a lot of other issues.  It’s hard to remember this, but the biggest issue coming into 2020 was PDPM [the Patient-Driven Payment Model], and how was PDPM working, and what was going to end up happening with PDPM.

As we come out of the pandemic — hopefully in the first part of next year, we get a vaccine and we start to get things back more to normal — I think there’s going to be a renewed analysis of PDPM and how it’s functioning.

In our discussions with operators, it appears to be functioning really well.  We’re pleased that CMS did not make any changes to PDPM with the 2021 payment rule, and we’re really anxious to get back to a normal time, where we can do a deep dive and figure out if PDPM is the answer that it appears to be.