Nursing home workers face a higher risk for COVID-19 than most Americans, providing essential care in hazardous conditions and at lower pay than they deserve, says David Grabowski, a professor of health care policy at Harvard Medical School. Giving them a living wage, decent benefits and adequate personal protective equipment is not only the right thing to do, it would help keep long-term care residents safer amid the pandemic, too, he says.
Grabowski, whose “day job” is doing research on the U.S. long-term care system, says it’s time to rethink the underlying structure of nursing home reimbursement.
Since the pandemic began, Grabowski has taken on a slew of new roles: serving on a Centers for Medicare & Medicaid Services task force called the Coronavirus Commission on Safety and Quality in Nursing Homes, testifying twice before Congress and writing op-eds aimed at advancing the cause of nursing home workers and residents alike.
Thanks to COVID-19, nursing home workers now have the most dangerous job in America, Grabowski and co-authors declared in a July 28 opinion piece in the Washington Post. Using CMS nursing home data, they determined that more than 200 COVID-19 related fatalities will occur per 100,000 nursing home workers if overall deaths continue at their current pace over a full year.
For their brave and selfless response in continuing to work in an already physically and emotionally demanding job – now with the added danger of coronavirus exposure – nursing home workers like nurses, certified nursing assistants and support staff should receive national hazard pay, Grabowski and co-authors argued.
Direct care staff at nursing homes also need access to good-quality personal protective equipment to prevent virus transmission, free access to coronavirus testing and the ability to make choices about when to stay home when they’re sick without fear of income loss, they added.
Grabowski’s career direction was shaped almost serendipitously when he was a Duke University undergrad in the early 1990s. “I had an adviser who said, ‘We should think about this as a project for your senior thesis,’” he recalls. “To be honest, I really knew nothing about long-term care or nursing homes. I ended up doing the project and it was everything that interested me about economics and public policy – only more so.”
The challenges faced by long-term care facilities, residents and caregivers soon captured Grabowski’s attention. “I ended up doing my dissertation on Medicaid payment and nursing home quality,” he says, Since then, he adds, “Basically, I’ve been doing this research on this area without realizing we would ever have this kind of pandemic and this kind of situation.”
Location – of the nursing home itself and where workers live in the surrounding area – plays an important role in the COVID-19 outbreaks, according to studies conducted nationwide. That includes findings on Cleveland, Detroit and New York City from Grabowski and colleagues, published June 24 in JAMA.
In June, Grabowski was named to the CMS task force to help provide a road map for policymakers on how to assist nursing homes during the pandemic. In advising CMS, Grabowski drew on his research that evaluated how well the Nursing Home Compare star-ranking system correlated with the extent of COVID-19 outcomes. “We found with regards to the pandemic that it’s really hit nursing homes of all quality ratings,” he says. “It’s been much more about where the facility is located than the prior quality.”
All that is not to say that facilities that have more staff haven’t been better at preventing huge outbreaks, Grabowski notes. However, he adds, “This much is true: If you’re in a nursing home where your staff live in a neighborhood where there’s a big outbreak, they’re going to, unfortunately, unbeknownst to them, bring the virus asymptomatically into the nursing home.”
Staying out sick is a fraught decision for many long-term care workers who develop COVID-19 symptoms like coughing. “We see a lot of pressures on the caregivers,” Grabowski says. “One is to come in when they’re not feeling well, because many of these buildings, because of the low pay, are understaffed. Many of the direct caregivers lack sick leave. They lack benefits. So they really have to keep working through this.”
Cross-contamination among facilities makes it even harder to contain COVID-19. “There’s also pressure, oftentimes, to try to fill in across multiple facilities to make ends meet,” Grabowski says. “Not any fault of the caregivers – they didn’t have PPE, they didn’t have testing. But it’s also, unfortunately, contributed to further spread of the virus and further nursing home deaths. So it’s really sad. A nursing-home workforce that was in better standing in terms of their pay and their benefits would have actually protected residents. And we really failed in that regard.”
On June 25, Grabowski testified on these dire facts at a House Ways and Means subcommittee hearing on the COVID-19 nursing home crisis. “It didn’t have to be this way,” he began. Now, he continued, “It is time for the federal government to make the necessary investment to mitigate the spread of COVID across all U.S. nursing homes. We owe it to our parents and grandparents and the individuals that care for them.”
Grabowski was struck by the testimony of a fellow participant, licensed practical nurse Melinda Haschak, who described stressful pandemic work conditions, extremely inadequate supplies and resulting financial hardship after she contracted COVID-19. “While I appreciate the donations of food and the occasional pizza party we receive, my co-workers and I don’t need a pizza party – we need PPE,” she told Congress.
Economics can no longer be ignored. “It really comes down to the reimbursement model,” Grabowski explains. “Unlike other parts of the health care system – where it’s predominantly private insurance, or it’s predominantly the Medicare program, which tend to be more generous – most long-term care is paid for by state Medicaid programs. And state Medicaid programs reimburse at a much lower rate relative to other payers.”
Nursing homes rest “on this precarious model where the majority of bed-days are Medicaid,” Grabowski continues. That’s where they’re breaking even or even losing money, he says. “But they also do some short-stay, post-acute care following an individual coming from the hospital to a nursing home for rehab before they go home. That’s very lucrative.”
Subsidizing the long-stay Medicaid patients this way isn’t working, Grabowski says: “This is not a model that has led to nursing home and other long-term care providers really being able to pay those caregivers a living wage.”
As an alternative, polices like wage pass-throughs (additional fund allocations to increase compensation) and wage floors could actually tie reimbursement dollars to the wages of the direct caregiver, Grabowski says. “I really think that makes a lot of sense here,” he says. “If we pay more, we don’t want to see those dollars go to the CEO salaries, or private equity groups or other entities. We really want those to go into the pockets of those direct caregivers.”
The roots of pay inequities among long-term care workers go deep. “Many of the CNAs, for example, are making close to minimum wage,” Grabowski notes. “It has been, in many ways, this forgotten group of workers. I don’t know if that’s some classism, or racism or sexism. A lot of the workforce there is predominantly women, a lot of minorities and recent immigrants to the U.S. So it is a vulnerable group of caregivers, and one I don’t think we’ve supported in a way that really is necessary.”
Nursing home workers help residents stay as active as possible, make sure they take medications safely and provide hands-on care like toileting, feeding and bathing for residents who can no longer perform these functions themselves.
When residents are sick with COVID-19, their care needs increase just as isolation requirements make providing that care much more difficult. The emotional toll is heavy on nursing home workers when residents they’ve come to know pass away from COVID-19.
Now, the pandemic has put nursing homes front and center in the public eye and for policymakers. “It’s been an opportunity to really educate a lot of people about who works in the nursing home, who receives services and what their needs are,” he says.
“There are a lot of things that could be done – from testing to PPE, to, obviously, better pay and benefits for the workforce – that could help protect what I would consider the true heroes in the nursing home space,” Grabowski says.