CMS issued its fiscal year (FY) 2023 Skilled Nursing Facilities Prospective Payment System (SNF PPS) proposed rule, which includes asking for public feedback on how staffing in nursing homes and health equity improvements could lead to better health outcomes.

The proposed rule builds upon the Biden-Harris Administration’s commitment to advance health equity, drive high-quality person-centered care, and promote sustainability of its programs. The rule is an important step in fulfilling its goal to protect Medicare skilled nursing facility (SNF) residents and staff by improving the safety and quality of care of the nation’s SNFs (commonly referred to as nursing homes). The SNF PPS provides Medicare payments to over 15,000 nursing homes, serving more than 1.5 million people. Medicare spending to nursing homes is projected to be approximately $35 billion in FY 2022. Through the SNF PPS proposed rule, CMS is continuing its work to transform the SNF payment system to a more patient-centered model by making payments based on the needs of the whole patient, rather than focusing on the volume of certain services the patient receives.

“Everyone deserves to receive safe, dignified, and high-quality care, no matter where they live,” said HHS Secretary Xavier Becerra. “Today we are starting the necessary work to ensure our loved ones living in nursing homes receive the best care at the staffing levels they need. We are working hard to deliver on President Biden’s commitment to protecting seniors and improving the quality of our nation’s nursing homes.”

The SNF PPS proposed rule aims to realize the President’s vision for the nation’s nursing homes as outlined in his State of the Union Address, with a focus on providing safe, dignified, and appropriate care for residents. As part of this vision, the Biden-Harris Administration recently set a goal to improve the quality of nursing homes so that seniors, people with disabilities, and others living in nursing homes get the reliable, high-quality care they deserve. A key part of reaching this goal is addressing staffing levels in nursing homes, which have a substantial impact on the quality of care and outcomes residents experience.

“The COVID-19 pandemic has highlighted serious problems at some of the nation’s nursing homes that have persisted for too long. And we have seen the tragic impact that inadequate staff resources can have on residents and staff,” said CMS Administrator Chiquita Brooks-LaSure. “The Biden-Harris Administration has promised that we will work with all stakeholders to do better for nursing home residents, and today’s proposed rule includes important steps toward our goal to promote safety and quality of care for all residents and staff.”

In the SNF PPS proposed rule, CMS is soliciting input to help the agency establish minimum staffing requirements that nursing homes will need to meet to ensure all residents are provided safe, high-quality care, and nursing home workers have the support they need. This input will be used in conjunction with a new research study being conducted by CMS to determine the optimal level and type of nursing home staffing needs. The agency intends to issue proposed rules on a minimum staffing level requirement for nursing homes within one year.

CMS is also requesting stakeholder input on a measure that would examine staff turnover levels in nursing homes for possible inclusion in CMS’ SNF Value-Based Purchasing (VBP) Program, which rewards facilities with incentive payments based on the quality of care they provide to people with Medicare. Looking at the relationship between staff turnover and quality of care, preliminary analysis by CMS has shown that as the average staff turnover decreases, a facility’s overall rating on CMS’ Nursing Home Five Star Quality Rating System increases, which suggests that lower turnover is associated with higher overall quality. CMS will use the stakeholder feedback to inform a proposal of this measure to include in the SNF VBP Program in the future.

In January, CMS began posting nursing home staff turnover rates (as well as weekend staff levels) on the Medicare.gov Care Compare website, and CMS will be including this information in the star rating system starting in July 2022. This information helps consumers better understand each nursing home facility’s staffing environment and also helps providers to improve the quality of care and services they deliver to residents.

The proposed rule also proposes the adoption of 3 new measures into the SNF VBP Program:

• The Skilled Nursing Facility Healthcare Associated Infections Requiring Hospitalization (SNF HAI) is an outcome measure that assesses SNF performance on infection prevention and management.
• The Total Nursing Hours per Resident Day is a structural measure that uses auditable electronic data to calculate total nursing hours per resident each day.
• The Adoption of the Discharge to Community – Post Acute Care Measure for SNFs (DTC) is an outcome measure that assesses the rate of successful discharges to community from a SNF setting.

To advance health equity and address the health disparities that underlie the U.S. health care system, CMS is requesting stakeholder feedback on the role health equity plays in improving health outcomes and the quality of care in nursing homes. Specifically, CMS is seeking comment on how to arrange or classify measures in nursing home quality reporting programs by indicators of social risk to better identify and reduce disparities.

CMS is proposing a 3.9%, or $1.4 billion, update to the payment rates for nursing homes, which is based on a 2.8% SNF market basket update plus a 1.5 percentage point market basket forecast error adjustment and less a 0.4 percentage point productivity adjustment. The proposed rule also contains a proposed adjustment to payment rates as the result of the transition to the SNF payment case-mix classification model  ̶  the Patient Driven Payment Model (PDPM) that went into effect on October 1, 2019. When finalizing the PDPM, CMS also stated that the transition to PDPM would not result in an increase or decrease in aggregate SNF spending. Since PDPM implementation, CMS’ data analysis has shown an unintended increase in payments. Therefore, CMS is proposing to adjust SNF payment rates downward by 4.6%, or $1.7 billion, in FY 2023 to achieve budget neutrality with the previous payment system. As a result, the estimated aggregate impact of the payment policies in this proposed rule would be a decrease of approximately $320 million in Medicare Part A payments to SNFs in FY 2023 compared to FY 2022.

More Information:

• Proposed rule
• Fact sheet: President Biden’s remarks during the State of the Union Address on improving nursing home safety and quality
• Fact sheet: FY 2023 SNF PPS proposed rule

The U.S. Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced the availability of $4.5 million for hiring, training, certifying, and compensating community-based doulas in areas with high rates of adverse maternal and infant health outcomes. This announcement builds on the Biden-Harris Administration’s commitment to reduce maternal mortality and morbidity and address the nation’s Black maternal health crisis.

This funding, provided through HRSA’s Healthy Start Initiative, will increase the total number of Healthy Start doula programs from 25 to approximately 50 nationwide.  HRSA’s Healthy Start Initiative works to improve health before, during, and after pregnancy and reduce racial and ethnic disparities in rates of infant deaths and adverse maternal health outcomes.

Read the press release.

U.S. Department of Agriculture (USDA) Rural Development Under Secretary Xochitl Torres Small announced that the department is accepting applications for grants to help start, expand or improve rural cooperatives and other mutually-owned businesses.

USDA is offering priority points to projects that advance key priorities under the Biden-Harris Administration to help communities recover from the COVID-19 pandemic, advance equity and combat climate change. These extra points will increase the likelihood of funding for projects seeking to address these critical challenges in rural America.

USDA is making the grants available under the Rural Cooperative Development Grant (RCDG) program to help improve economic conditions in rural areas through cooperative development. For fiscal year 2022, the maximum award is $200,000. Grants are awarded on a competitive basis through a national competition.

Nonprofit organizations and institutions of higher education are eligible to apply for grants to provide technical and cooperative development assistance to individuals and rural businesses.

Electronic applications must be submitted to grants.gov by 11:59 p.m. Eastern Time on June 6, 2022. Interested applicants are encouraged to contact their local USDA Rural Development State Office well in advance of the application deadline to discuss their project and ask any questions about the RCDG program or the application process. Contact information for state offices can be found at http://www.rd.usda.gov/contactus/state-offices.

Additional information on the required materials and how to apply for the RCDG program are available on page 19842 of the April 6, 2022, Federal Register.

If you’d like to subscribe to USDA Rural Development updates, visit our GovDelivery subscriber page.

From the National Rural Health Association

On March 30, 2022, Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to provide routine updates to the Medicare Hospice payment system for Fiscal Year (FY) 2023.

Total estimated payments to hospices of a 2.7% ($580 million) increase in their payments for FY 2023. Further, the per patient that is made to a hospice annually. The proposed aggregate cap that limits the overall hospice payments for FY 2023 is $32,142.65.

Other key proposals include:

• Establish a permanent, budget neutral, mitigation policy to smooth the impact of year-to-year changes in hospice payments related to changes in the hospice wage index through a permanent cap on decreases greater than 5%.
• Improve data collection to measure and analyze disparities across programs and policies that apply to the Hospice Quality Reporting Program (HQRP) including development of a new HOPE tool, updates to quality measures, CAHPS hospice survey, and advancing HIE.

At this point, NRHA is not planning to submit comments on the proposed changes.  Please share any questions or concerns with NRHA staff before the May 31, 2022 deadline. To submit comments, please do so through the federal register here. CMS’s FY23 Hospice Payment Rate Update NPRM Fact Sheet can be found here.

From the National Rural Health Association

On March 23, 2022, the Occupational Safety and Health Administration (OSHA) reopened the rulemaking record partially and scheduled an informal public hearing to seek comments on specific topics that relate to the development of a final standard to protect healthcare and healthcare support service workers from workplace exposure to the COVID-19 virus.

The original 2021 OSHA Emergency Temporary Standard (ETS) aimed to protect workers in healthcare settings from occupational exposure to COVID-19. The ETS – which also served as a proposed rule – focused on healthcare workers most likely to have contact with people infected with the virus. The healthcare ETS required covered healthcare employers to develop and implement COVID-19 response plans to identify and control COVID-19 hazards in healthcare settings.

The agency is reopening the rulemaking record to allow for new data and comments on topics, including the following:

• Alignment with the Centers for Disease Control and Prevention’s recommendations for healthcare infection control procedures.
• Additional flexibility for employers.
• Removal of scope exemptions.
• Tailoring controls to address interactions with people with suspected or confirmed COVID-19.
• Employer support for employees who wish to be vaccinated.
• Limited coverage of construction activities in healthcare settings.
• COVID-19 recordkeeping and reporting provisions.
• Triggering requirements based on community transmission levels.
• The potential evolution of SARS-CoV-2 into a second novel strain.
• The health effects and risk of COVID-19 since the ETS was issued.

Comments on OSHA’s limited reopening of the COVID-19 healthcare ETS are due by April 22, 2022, and the informal public hearing will begin on April 27, 2022. Individuals interested in testifying at the online public hearing must submit a notice of intention to appear by April 6, 2022. View OSHA’s Federal Register Notice on govinfo.gov. View OSHA’s press release on the Notice on osha.gov.

NRHA plans to submit comments on the limited reopening reflective consistent with the intent of our 2021 comments. Please reach out if there are specific issues or concerns you’d like NRHA to reflect in our comment letter.  For more information, please contact ccochran@ruralhealth.us.

Even after she’s clocked out, Sarah Lewin keeps a Ford Explorer outfitted with medical gear parked outside her house. As one of just four paramedics covering five counties across vast, sprawling eastern Montana, she knows a call that someone had a heart attack, was in a serious car crash, or needs life support and is 100-plus miles away from the nearest hospital can come at any time.

“I’ve had as much as 100 hours of overtime in a two-week period,” said Lewin, the battalion chief for the Miles City Fire and Rescue department. “Other people have had more.”

Paramedics are often the most highly skilled medical providers on emergency response crews, and their presence can make a lifesaving difference in rural areas where health services are scarce. Paramedics are trained to administer specialized care from the field, such as placing a breathing tube in a blocked airway or decompressing a collapsed lung. Such procedures are beyond the training of emergency medical technicians.

But paramedics are hard to come by, and a long-standing workforce shortage has been exacerbated by turnover and resignations related to pandemic burnout.

Larger departments are trying to attract paramedics by boosting pay and offering hefty signing bonuses. But small teams in underserved counties across the U.S. don’t have the budgets to compete. Instead, some rural crews are trying to train existing emergency responders for the roles, with mixed results.

Miles City is among the few communities in rural eastern Montana to have paramedic-level services, but the department doesn’t have enough paramedics to offer that care 24/7, which is why medics like Lewin take calls on their time off. The team received a federal grant so four staffers could become paramedics, but it could fill only two slots. Some prospects turned down the training because they couldn’t balance the intense program with their day jobs. Others didn’t want the added workload that comes with being a paramedic.

If you’re the only paramedic on, you end up taking more calls,” Lewin said.

What’s happening in Miles City is also happening nationwide. People who work in emergency medical care have long had a name for the problem: the paramedic paradox.

“The patients who need the paramedics the most are in the more rural areas,” said Dia Gainor, executive director of the National Association of State EMS Officials. But paramedics tend to gravitate to dense urban areas where response times are faster, the drives to hospitals are shorter, and the health systems are more advanced.

“Nationally, throw a dart at the map, the odds are that any rural area is struggling with staffing, with revenue, with access to training and education,” Gainor said. “The list goes on.”

The Michigan Association of Ambulance Services has dubbed the paramedic and EMT shortage “a full-blown emergency” and called on the state legislature this year to spend $20 million to cover the costs of recruiting and training 1,000 new paramedics and EMTs.

At the beginning of this year, Colorado reactivated its crisis standard of care for short-staffed emergency medical service crews experiencing mounting demand for ambulances during a surge in COVID cases. The shortage is such a problem that in Denver a medical center and high school teamed up to offer courses through a paramedic school to pique students’ interest.

In Montana, 691 licensed paramedics treat patients in emergency settings, said Jon Ebelt, a spokesperson for the Montana Department of Public Health and Human Services. More than half are in the state’s five most-populous counties — Yellowstone, Gallatin, Missoula, Flathead, and Cascade — covering a combined 11% of the state’s 147,000 square miles. Meanwhile, 21 of Montana’s 56 counties don’t have a single licensed EMS paramedic.

Andy Gienapp, deputy executive director of the National Association of State EMS Officials, said a major problem is funding. The federal Medicaid and Medicare reimbursements for emergency care often fall short of the cost of operating an ambulance service. Most local teams rely on a patchwork of volunteers and staffers, and the most isolated places often survive on volunteers alone, without the funding to hire a highly skilled paramedic.

If those rural groups do find or train paramedics in-house, they’re often poached by larger stations. “Paramedics get siphoned off because as soon as they have those skills, they’re marketable,” Gienapp said.

Gienapp wants to see more states deem emergency care an essential service so its existence is guaranteed and tax dollars chip in. So far, only about a dozen states have done so.

But action at the state level doesn’t always guarantee the budgets EMS workers say they need. Last year, Utah lawmakers passed a law requiring municipalities and counties to ensure at least a “minimum level” of ambulance services. But legislators didn’t appropriate any money to go with the law, leaving the added cost — estimated to be up to $41 per resident each year — for local governments to figure out.

Andy Smith, a paramedic and executive director of the Grand County Emergency Medical Services in Moab, Utah, said at least one town that his crew serves doesn’t contribute to the department’s costs. The team’s territory includes 6,000 miles of roads and trails, and Smith said it’s a constant struggle to find and retain the staffers to cover that ground.

Smith said his team is lucky — it has several paramedics, in part because the nearby national park draws interest and the ambulance service has helped staffers pay for paramedic certification. But even those perks haven’t attracted enough candidates, and he knows some of those who do come will be lured away. He recently saw a paramedic job in nearby Colorado starting at $70,000, a salary he said he can’t match.

“The public has this expectation that if something happens, we always have an ambulance available, we’re there in a couple of minutes, and we have the highest-trained people,” Smith said. “The reality is that’s not always the case when the money is rare and it’s hard to find and retain people.”

Despite the staffing and budget crunches, state leaders often believe emergency crews can fill gaps in basic healthcare in rural areas. Montana is among the states trying to expand EMS work to nonemergency and preventive care, such as having medical technicians meet patients in their homes for wound treatment.

A private ambulance provider in Montana’s Powder River County agreed to provide those community services in 2019. But the owner has since retired, and the company closed. The county picked up emergency services last year, and County Commissioner Lee Randall said that providing basic healthcare is on the back burner. The top priority is hiring a paramedic.

Advancing the care that EMT crews can do without paramedics is possible. Montana’s EMS system manager, Shari Graham, said the state has created certifications for basic EMTs to provide some higher levels of care, such as starting an IV line. The state has also increased training in rural communities so volunteers can avoid traveling for it. But those steps still leave gaps in advanced life support.

“Realistically, you’re just not going to have paramedics in those rural areas where there’s no income available,” Graham said.

Back in Miles City, Lewin said her department may get an extension to train additional paramedics next year. But she’s not sure she’ll be able to fill the spots. She has a few new EMT hires, but they won’t be ready for paramedic certification by then.

“I don’t have any people interested,” Lewin said. For now, she’ll keep that emergency care rig in her driveway, ready to go.

Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

The U.S. Department of Health & Human Services (HHS), through the Health Resources and Services Administration (HRSA), released a Request for Information (RFI) seeking input on ways to strengthen and improve the Organ Procurement and Transplantation Network (OPTN) through the upcoming Fiscal Year 2023 Request for Proposal (RFP).

The National Organ Transplant Act of 1984 established the OPTN to coordinate and improve the effectiveness of the nation’s organ procurement, distribution and transplantation systems and to increase the availability of, and access to, donor organs for patients with end-stage organ failure.  The law specifies that the OPTN be operated under federal contract.  In the coming months, HRSA will be issuing a Request for Proposal (RFP) for the next OPTN contract.

The RFI will support HRSA’s efforts to increase accountability in OPTN operations, modernize performance of the OPTN IT system and related tools, and improve engagement with donors and patients.  It specifically focuses on opportunities to strengthen equity, access, and transparency in the organ donation, allocation, procurement, and transplantation process in the contract arrangement that results from the forthcoming RFP.

“HRSA is committed to making organ procurement and transplantation more equitable, accessible, and transparent,” said HRSA Administrator Carole Johnson. “The Request for Information released today is an important step in advancing these goals and we look forward to receiving robust feedback on ways to increase organ donation, improve patient and donor engagement, strengthen accountability throughout the system, and best leverage modern technology to support this life-saving work.”

In addition to seeking feedback on the governance, finance, IT, data collection, policy, and operational components of the OPTN contract more broadly, this RFI specifically solicits feedback on ways to incorporate the findings and recommendations of the February 2022 National Academies of Science, Engineering, and Medicine (NASEM) report titled Realizing the Promise of Equity in the Organ Transplantation System, as well as the lessons learned from HRSA’s 2019 market research, conducted in partnership with the U.S. Digital Service, on ways the OPTN IT system should leverage modern IT architecture.

Interested parties may access information regarding the RFI here: https://sam.gov/opp/df25032b76b1467eabae79a2ba222ead/view.   The RFI is open for a 30-day period beginning April 8, 2022. Responses to the RFI are due to HRSA by May 9, 2022 at 1 p.m. ET.

To learn more about HRSA’s organ transplantation activities, please visit www.organdonor.gov.