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The siren is blaring for New Hampshire’s long-term care crisis


The siren is blaring for New Hampshire’s long-term care crisis

Mar 28, 2023 | 4:50 am ET
By Brendan Williams
The siren is blaring for New Hampshire’s long-term care crisis
Any inability of nursing homes to admit new residents backs up hospitals. (Getty Images)

If you have ever heard a tornado siren, you know what a frightening sound that is. Given the plight of our state’s nursing homes, such a siren should be sounding in Concord.

Consider: Our state has one of the nation’s five-worst nursing home staffing shortages. There are county facilities with wait lists of over 100 prospective residents that they cannot serve. One informed me that half of its nursing positions are open, or, more granularly, 65 percent of its licensed nursing assistant positions – the frontline caregivers in any nursing home. As a result, one-third of the facility’s beds are effectively offline.

Massachusetts has only one-sixth as many nursing homes experiencing staffing shortages, in part because, by raising Medicaid rates 33 percent since the COVID-19 pandemic began, Massachusetts has done such a great job of importing New Hampshire caregivers.

Here, with a shortage of homegrown licensed staff looking for work, nursing homes are stuck using out-of-state staffing agencies and competing with hospitals and other desperate health care providers in doing so. While such utilization is necessary to serve residents, it’s disruptive to the continuity of care – imagine a stranger at your bedside – and demoralizing to permanent staff who know these agencies, through price-gouging, can pay more. Thus, it becomes possible for a longtime caregiver to switch teams and effectively be leased back to you on an exploitative contract basis as a “traveling nurse,” even if the only real travel is a few blocks. This is untenable.

Further, any inability of nursing homes to admit new residents backs up hospitals, which have no choice but to admit patients thanks to one of history’s biggest unfunded mandates: the Emergency Medical Treatment and Active Labor Act signed into law by no less a free-market champion than President Ronald Reagan.

You often hear comparisons of the costs of in-home care versus nursing home care, but those are meaningless. Broken out, the average Medicaid payment for New Hampshire nursing home care is $9.33 an hour per resident for care, housing, laundry, meals, and other services. And that is far short of costs. It is another reason why nursing homes want in-home care to survive and thrive, because nursing home reimbursement is acuity-based using a complicated coding system.

In other words, if nursing homes took in those who can efficiently be cared for at home it would be a recipe for bankruptcy. Far from coveting those who can be cared for at home, nursing homes regularly discharge into home and community-based settings (HCBS). In the same fashion that our hospitals do not want to be jammed up with those ready for discharge to nursing homes, nursing homes must find safe HCBS discharges. Accordingly, the nursing home sector fully supports improving home care and assisted-living facility reimbursement. People must recognize that interdependency is at work, not social Darwinism pitting vulnerable populations against one another.

Other states support their entire long-term care continuums. Oregon values a nursing home resident over twice as much as does New Hampshire through its Medicaid rates, and yet also has been the nation’s foremost HCBS leader, with home care workers making no less than $16.67 an hour through Medicaid.

And many states have stepped up to help nursing home care specifically, even a poor state like Alabama – which so far has given $140 million of its American Rescue Plan Act funds to assist its nursing homes. While such funds here would be a critical bridge to any rate increase that cannot occur until July 1, and help alleviate disastrous circumstances, nursing home providers must also see a double-digit Medicaid rate increase of a magnitude like those recently adopted by other states.

Gov. Chris Sununu’s proposed across-the-board annual 3.1 percent Medicaid rate increases started the budget conversation off right in Concord and look to be improved upon in the House, by perhaps a couple percentage points each year, depending on the final math. While this is appreciated, much more must be done to keep a long-term care crisis from rapidly spinning into catastrophe.