The 2020 NIC Fall Conference, though held on a virtual platform, presented all the relevance, insight, and expert analysis that attendees have come to expect from the industry’s premier event. Always a staple, sessions focusing on valuations this year were, for some, of particular interest. Amidst a historic global pandemic, which has driven sharp declines in occupancy rates, increased costs, drawn unprecedented media attention, and hastened operational disruption, NIC hosted two discussions on how all of this is impacting valuations across both seniors housing and skilled nursing property types.

Some themes ran through both sessions. Chief among these was the sense that there is plenty of opportunity for investors and operators. While some capital providers appear to be sitting on the sidelines, others are seeing long-term value, along with market fundamentals that will remain long after the pandemic is behind us.

“Valuations in Seniors Housing: How Have Trends Changed and Why?” began with a calming assessment of the realities of a market that, despite major setbacks, is still seeing deals get across the finish line. Moderator Manisha Bathija, former senior investment officer, independent consultant, kicked off the discussion by asking “What’s happened in the acquisitions market since COVID began?” In his response, Ryan Maconachy, vice chairman, healthcare & alternative assets, Newmark Knight Frank, observed that he’s seen, “new deals, and different types of deals, than we’ve ever had to bring to market.” He continued, “There is a lot of volatility. The market is moving on a daily and weekly basis. The one thing we all have going for us is that there’s never been more capital looking at the seniors housing industry to invest in.”

Maconachy also observed that, “We’re seeing folks get very creative, which again, shows you the resiliency of our industry, that we’re not so in a box that we can’t pivot when necessary, and I think folks are getting more comfortable with that by the day.”

For his part, Ben Firestone, executive managing director & co-founder, Blueprint Healthcare Real Estate Advisors, agreed with his co-panelist, but added that, while capital is available, investors are looking for operators who are able to adapt and survive during this time of disruption. He said, “There’s all sorts of capital – tourists and mainstay investors – but the scarce commodity remains the operator that’s going to get it right.”

In agreeing with that point, Maconachy underlined just how important operators are, saying, “Never before has the operator impacted valuation more than today…the operator premium today is as big as it’s ever been. That’s a huge factor in our opinion, on valuation of a deal with operator A and operator B.”

While pricing is being depressed by drops in occupancy, uncertainty, and higher costs associated with COVID-19, both experts indicated that they are looking at a more positive long-term value in the market. Firestone summarized his outlook, saying, “While pricing might be down a little bit, driven largely by NOI, I think we’ll see a rebound. We’ll see rent growth prevail, we’ll see cash flows continue to grow, and we’ll see absorption. Ultimately, I think we’ll get back to where we were, and then some, in the next 12-18 months.”

In “Valuations in Skilled Nursing: How Have Trends Changed and Why?” Moderator Zach Bowyer, managing director/ head of alternatives, JLL Valuation Advisory, discussing the complexity of skilled nursing, reminded the panel, “There’s an old adage in the space: if you’ve seen one skilled nursing facility, you’ve seen one skilled nursing facility.”

When asked who’s buying and who’s selling in the space, Josh Kochek, CIO, Hana2.0, indicated that activity is far from grinding to a halt, “There are still tremendous amounts of opportunity in the marketplace. We have a fairly robust pipeline today.” He explained, “Some of the traditional buyers in terms of public owners of real estate have pulled back a little, either working through maybe some owned assets they’re having difficulty with, and figuring out how to reposition, transition, and recapitalize. Paired with a little bit of depression in the stock prices that has put some of those traditional buyers on the sidelines, for what will probably be the near term, I would expect that at some point before long they’ll be back in the market.”

Panelist Aaron Becker, senior managing director, Lument (formerly Lancaster Pollard), agreed that activity continues. On valuations, he observed that they appear to be holding up better than expected. He said, “Valuations are remaining relatively stable…We’re not seeing as much distressed property as I think some people would expect…”

Not everyone, however, is making capital available at pre-COVID prices, or at all. According to Kochek, “What we’ve seen are lenders that don’t necessarily convey that they’re out of market, but have changed their terms so substantially vs what they were six to twelve months ago, either with LIBOR floors that were either non-existent or 25 basis points, historically, now starting to get into the 50 to 100 basis point range on the LIBOR floor, which in effect is driving up your cost of borrowing.”

Cap rates have been much discussed in recent months. Becker indicated they aren’t the major problem some may have feared, “on the cap rate side, they haven’t risen as much as we feared early on. The cap rates haven’t been much of an issue on the valuation side. The challenge for lenders is focusing on the cash flows.”

Becker seemed in agreement on that point, and offered his outlook, which echoed the optimism expressed in the seniors housing session. “We will get back to a period where its more “normal,” where things will look better on an income statement, the balance sheet, etc., so just navigating this difficult time right now is really just a function of the passage of time.”

The Labor Department reported that nonfarm payrolls rose by 638,000 in October and that the unemployment rate fell to 6.9% from 7.9% in September. This suggests that the employment recovery from the COVID-related drop in March and April continues. Moreover, the increase is stronger than it seems on the surface because it includes a 147,000 decline in temporary Census workers. The consensus estimates for October had been for a gain of 580,000.

Roughly 12.1 million jobs have been recovered during the May to October period. This is a little more than half the 22.2 million jobs lost since the pandemic began. The pace of improvement is slowing, however. In July, the economy added almost 1.8 million jobs and another 1.5 million in August. Gains slowed to 672,000 in September and 638,000 in October

Health care added 58,000 jobs in October, with the largest gains occurring in hospitals, offices of physicians and dentists and outpatient care centers. These increases were partially offset by a decline of 9,000 workers in nursing and residential care facilities.

The 1.0 percentage point drop in the October unemployment rate to 6.9% was good news and marked the sixth consecutive month of improvement. It still is above the pre-pandemic level of 3.5% seen in February, however, but well below the 14.7% peak seen in April. This jobless rate fell for adult women (6.5%), adult men (6.7%), teenagers (13.9%), Whites (6.0%) and Asians (7.6%), Hispanics (8.8%) and Blacks (10.8%). The number of unemployed persons fell by 1.5 million to 11.1 million.

The number of long-term unemployed (those jobless for 27 weeks or more) increased by 1.2 million to 3.6 million, a figure that suggests that is continues to be a very challenging time for many Americans. Long-term unemployed persons account for 32.5% of the total number of unemployed persons. The number of permanent job losers fell 72,000 to 3.7 million. Moreover, a separate report issued yesterday on unemployment insurance claims showed that more than 21 million workers remain on government assistance in the week ended October 17.

The underemployment rate or the U-6 jobless rate fell to 12.1% in October from 12.8% in September. This figure includes those who have quit looking for a job because they are discouraged about their prospects and people working part-time but desiring a full work week.

Average hourly earnings for all employees on private nonfarm payrolls rose by $0.04 in October to $29.50, a gain of 4.5% from a year earlier. The large employment fluctuations over the past several months, especially in industries with lower-paid workers—complicate the analysis of recent trends in average hourly earnings.
The labor force participation rate, which is a measure of the share of working age people who are employed or looking for work increased by 0.3 percentage point in October to 61.7% and is 1.7 percentage points lower than in February. The employment-population ratio increased by 0.8 percentage point to 57.4% in October but is 3.7 percentage points lower than in February.

The change in total nonfarm payroll employment for August was revised up by 4,000 from 1,489,000 to 1,493,000 and the change for September was revised up by 11,000 from 661,000 to 672,000. Combined, 15,000 jobs were added to the original estimates. Monthly revisions result from additional reports received from businesses and government agencies since the last published estimates and from the recalculation of seasonal factors.

While the October gain in jobs is welcome news, the labor market continues to be strained and the recent spike in the virus across many states could hamper further gains. Indeed, many states are backtracking plans to reopen as coronavirus infections are rising again. As a result, many economists continue to urge Congress and the White House to implement further fiscal stimulus to keep the recovery on track. Some anticipate that without a fiscal stimulus package the recession will deepen further. Moreover, uncertainty about the path of the COVID-19 virus as we enter the fall and winter months as well as the lack of a vaccine continue to weigh on business owners hiring decisions.

Telehealth, telemedicine, virtual care, eConsult, store-and-forward…what does this all mean? More importantly, how do you better serve your resident populations — in a global pandemic and onward? Telehealth is a broad term that seems to get caught in a tangled web of policy, compliance, and reimbursement. However, telehealth brings incredible promise to our highest risk populations in this pandemic, and has transformational implications for the way healthcare will be delivered even once the pandemic is behind us.

Imagine an 87-year-old woman living in a senior living community. She falls on her way to the bathroom, hurting her hip and hitting her head. She is able to call for help and the night staff comes to her room. The young man on duty helps her back in bed, but knows she needs medical attention. He types her name into the iPad on the wall and is immediately connected with an ER doctor. The physician introduces herself, asks a few basic questions, and directs the night staff employee through a physical examination. She then directs the night staff employee to take a photo of the resident’s eyes to include in a neurology consult. The physician reassures the woman that everything is fine for now, but that she will need to get an x-ray in the coming days. The physician also explains that she will deliver the news from the neurologist in the morning, but there is nothing to worry about now. The woman is able to fall asleep and wakes up to a message from her ER doctor and a neurologist providing her detailed instructions around her care plan and the next steps — reassuring her she will be alright. She shares the videos with her senior living facility staff, children, and grandchildren.

How was this possible? First, the senior living community had synchronous primary and urgent care telehealth services. The operator of the property had already gathered key health data, emergency contacts, and consent, all of which was integrated into their in-room tablet and HIPAA compliant telehealth portal. The telehealth ER doctor was able to immediately access the key information and pair it with the incident requiring medical attention. Second, the operator and telehealth provider had asynchronous telehealth services for specialty care and video communication. This enabled the ER doctor to access specialists and receive care plan guidance within hours while also communicating key information to the resident in a shareable, repeatable, and personalized video message. This solution is what enabled the woman to have a neurology consult without leaving her room and receive a summary of her experience and next steps to re-watch, show her staff nurses, and share with concerned family.

Effective use of telehealth can result in reductions in ER visits, readmissions, and unnecessary COVID-19 exposures, while empowering front-line staff and improving the resident and family experience altogether. Telehealth has the potential to drive immense value for residents and providers alike within seniors housing. It may feel like this vision is a long way off, but the solutions are ready and available — operators need only understand what their options are and thus what best fits with their priorities.

A Brief History

The history of telehealth goes back several decades. Telehealth was first authorized in Medicare in 1997. Shortly thereafter, the internet boom democratized access to information, accelerating innovation across industries and instigating the rise of consumer choice (“consumerism”). The Affordable Care Act initiated a healthcare course correction toward value-based care, all while consumers were starting to expect the same kind of options, service, and convenience with their healthcare that they were experiencing when buying groceries, booking a plane ticket, or customizing a pair of shoes.

By the beginning of 2020, the majority of healthcare providers and hospital systems had started offering telehealth or at least had it on their strategic roadmap for the coming years, as it demonstrated the potential to not only please healthcare consumers, but also address rising healthcare costs and quality care access inequities. As such, telehealth has been on an upward trajectory for decades, albeit a slow one, until now.

When COVID-19 hit the U.S., cities, counties, and numerous states went under shelter in place policies. For millions of Americans, and thousands of healthcare providers, the need for telehealth options became urgent. CMS used emergency rulemaking to provide Medicare telehealth flexibilities for the duration of the pandemic. This expanded telehealth-eligible services, provided tech mode flexibilities, and expanded the types of practitioners eligible to provide telehealth services. Adoption skyrocketed, both by physicians and their patients, primarily older adults.

COVID-19 has significantly accelerated the proliferation of telehealth as a key element in care delivery. Now, telehealth is in the toolkit of nearly all providers and is an option for nearly all patients, including millions of seniors housing and care residents. According to a study done by McKinsey & Co, by May 2020, 76% of consumers said they are now interested in using telehealth going forward. User adoption coupled with telehealth’s impact potential on triage, coordination, productivity and convenience will ensure its continued presence in healthcare — and seniors housing — as we know it.

Telehealth Today

Telehealth can simply be defined as care delivered via virtual communication between patients and healthcare providers or providers to other providers.

There are many vendors offering a variety of telehealth solutions in today’s market. it is important to understand the defining variables that sit behind the vast array of options.

1. Modality: Telehealth can be delivered through a variety of media — audio, video, or text. It is critical to consider the richness of the media. Video and other virtual media are the closest to in-person, while text may feel impersonal or automated.
2. Timing: Telehealth can be delivered both synchronously and asynchronously. Synchronous refers to live communication such as a phone call. Asynchronous refers to communication that is delivered and then stored until the recipient reviews it — think of a voicemail (this is also referred to as store and forward). The value of synchronous telehealth is that it most closely resembles an in-person appointment. Asynchronous telehealth can also provide significant value to both patients and providers, as it eliminates the need for scheduling and can be referred back to, shared, or re-consumed.
3. Participants: The most common use for telehealth is between patient and healthcare provider. Telehealth also empowers senior living care workers to take an active role in their residents’ care journeys, through three-way visits. The ability to include family or caregivers in the care process leads to better communication and decision-making for the resident. Telehealth also extends to virtual communication for care delivery purposes between two healthcare providers — think of a second opinion, or a consult. This mode of telehealth can collapse the care cycle by empowering frontline providers with specialist expertise — reducing wait times, coordinating care, and reducing medical costs.
4. Provider integration: Many telehealth companies offer hardware or software to facilitate care. Others offer integration with provider networks, and occasionally operate as their own health system. Doctor On Demand, for example, has a network of board-certified primary care physicians, psychiatrists, therapists, and physician-led care teams. Similarly, Sitka is supported by a vast network of specialty providers such as dermatologists, cardiologists, neurologists, etc.

There are a myriad of options, and there is a lot to consider, but this should help set structure around the landscape of offerings.

Telehealth and Senior Care

Senior housing and care providers are uniquely positioned to reap value from telehealth for residents, families, staff, and the senior living communities themselves. Seniors housing has a captive user base around the clock and immediate economies of scale upon adopting a new solution. These communities largely have the power to control access and devices, while the expertise needed for physical examinations is usually available on site, oftentimes eliminating the need for in-person visits to your community. By employing telehealth solutions, operators can significantly decrease the need for in-person trips to the doctor’s office, or the emergency department, which families and residents now prefer to avoid.

The seniors housing population itself has greater need and greater reward for telehealth. The senior population accounts for the highest proportion of medical costs in the US, driven by ER visits and inpatient stays. Many times, conditions are worsened by travel and unnecessary exposures — avoidable with telehealth. Also, the senior population is eligible for value-based care (e.g., capitated Medicare Advantage Plans), which eliminates the incentive for excessive doctor visits or procedures and instead encourages timely and preventive care.

Seniors housing and care communities are home to over three million older adults, most of whom have multiple chronic conditions. The pandemic has brought with it heightened fear by these seniors and their adult children of traditional healthcare delivery settings, such as the hospital, the emergency department, and even the waiting room of the doctor’s office. Seniors increasingly both want and need to have healthcare services brought to their residential communities.

A clear opportunity exists for every type of senior living property, but telehealth is not one size fits all. Each senior living type, brand, and property should be assessed to identify how telehealth can be implemented to solve its most pressing needs.

First, structural elements must be assessed: skilled nursing availability, staff coverage, resident health plan membership mix, technological infrastructure (e.g., wifi, device access). Each of these factors will be key considerations as you balance budgetary constraints and feasibility of the different telehealth offerings.

It’s also important to factor in the intangibles: brand, culture, family involvement, resident investment in community decisions, staff / management relationship. Think about the goals of your proposed telehealth solutions and how they fit into your organization’s identity. While telehealth poses significant value, does the solution you are considering align with your organizational strategy and mission? Consider making small adjustments to better fit with competing priorities.

As you set off on this journey, it will be important to remember the fundamental rule of change management: key stakeholders must be included in the conversation and bought-in at each step. Such stakeholders may change depending on the operator or property type, but consider leadership, staff, residents, and families. Inclusion may entail conducting a pilot with specific residents and staff that have high likelihood to champion the chance, or hosting a marketing event with families early on to communicate the goal for the new telehealth solution. Buy-in will be critical to early stage implementation and to long-term success of telehealth in your organization.

Telehealth is Here to Stay

Change management may be daunting, but telehealth is here to stay. The sooner your telehealth solution is up and running, the better your communities and your residents will be in the long run. Telehealth is a powerful way to offer your residents safe and timely care, and will only become more essential in the future.

In his recent “NIC Talk,” given at the 2020 NIC Fall Conference, Dr. Tim Ferris, CEO of the Mass General Physicians Organization, said that when it comes to the utilization of telehealth to bring services to seniors with chronic conditions, “We are not going back.” Indeed, telehealth offers senior housing providers opportunity for onsite triage and proactive management of residents’ chronic conditions, allowing this high-risk population to stay at home. Pandemic necessitated telehealth will hopefully diminish soon, but continued investment and change management will ensure improved healthcare services, outcomes, and comfort for seniors in years to come.

Sources: McKinsey report — Telehealth: A quarter-trillion-dollar post-COVID-19 reality?

This article was originally posted on Medium by Sitka, Inc.

Budgeting for capital expenditures has taken on a new complexity. Not only are investors changing their assumptions in the COVID-19 era, but the seniors housing stock is aging. A growing number of older properties need costly updates to stay competitive.

Two sessions at the 2020 NIC Fall Conference addressed the best approaches to capital expenditures, or CapEx, in a quickly changing environment.

 “Regaining occupancy is critical,” said speaker Colleen Blumenthal, COO & managing partner at HealthTrust. “Any investment that helps occupancy will be revenue enhancing.”

Blumenthal was joined in the educational session and a separate peer-to-peer exchange by Lukas Hartwich, senior analyst, Green Street Advisors.

Expenses related to COVID-19 are not expected to have a long-term impact on CapEx allocations or underwriting assumptions. according to the panelists. Aging buildings will be a bigger concern going forward.

But investors question whether some COVID-related costs can be classified as capital expenditures vs. unbudgeted expenses. High-cost items might be considered capital expenditures, according to Blumenthal. These might include new technology platforms and HVAC systems. Rooms converted to spaces for employees to change into personal protective gear might qualify as well.

Rising expenses related to the pandemic have caused investors to defer some capital spending. The replacement of carpeting can wait. Resources are being devoted to keeping residents safe.

Building obsolescence is a big issue. The first wave of seniors housing properties is reaching the 25-year-age mark. “Assets need more capital expenditures as they age,” said Hartwich. Boilers break down. Roofs need to be replaced. 

Capital expenditures can fix some age-related problems, but not others. For example, many assisted living buildings from the 1990s include an ice cream parlor, an amenity out of fashion. That space can be repurposed for another use, according to Blumenthal. But units with eight-foot ceilings, or a property with a lot of studio apartments can’t be fixed.

Even newer properties may need an upgrade.

“Assets need more capital expenditures as they age, boilers break down. Roofs need to be replaced.”  -said Hartwich. 

“Competition is a huge factor in spending,” said Blumenthal. Five-year-old buildings may require a complete interior refresh to compete with a new community that opens nearby. She said the competition is especially intense at the high-end of the market which accelerates capital expenditures.

On average, operators spend about 26% of net operating income (NOI) annually on capital expenditures, according to the 2020 State of Seniors Housing report, compiled by HealthTrust.

The State of Seniors Housing report is based on a sample size of 1,748 properties. Among properties built since the year 2000, spending on CapEx totals about $2,500 to $2,600 per unit. Spending on older properties tends to be higher than for newer properties. Older buildings need more repairs and updates.

Other data sources confirm those numbers, according to Greenstreet’s Hartwich. NCREIF, the industry organization that aggregates commercial real estate data for institutional investors, pegs CapEx in the 20-25% range in recent years.

CapEx Factors

Spending varies based on property type and location.

For example, life plan communities tend to spend the most on CapEx, about $7,000 annually per unit. Life plan or continuing care communities rank as among the oldest of senior living properties. These communities often charge entrance fees and tend to have upscale amenities, such as multiple dining venues, that may require regular capital expenditures. “The more the amenities, the higher the expectations of the residents,” said Blumenthal. “High-end communities are fast to replace carpeting and other items.”  

Owners of properties in tertiary markets are slow to reinvest. Consumers often don’t have a lot of choice of where to live. Competition is scarce, so there’s less incentive to invest in properties.

Another major factor driving capital expenditures is a change in ownership. Spending peaks just before or right after a sale. Those are the times when owners are most likely to spend on big ticket items to help boost occupancy.  

In general, capital expenditures are increasing. “We really see an uptick,” said Hartwich. Much of the increase can be attributed to the age of the buildings.

Over the last decade, capital expenditures have increased at a 9% rate compounded annually. In 2011, spending was about $2,500 a unit and now it’s $5,000 a unit. Communities built prior to 1980 spend about 40% of NOI on capital expenditures. Properties built in the 1980s and 1990s spend about 30% on CapEx.

Interestingly, owners say they are spending less on CapEx in 2020 than they did in 2019. Some of the decline could be due to the disruption caused by the COVID-19 outbreak. Workers have not had access to buildings to conduct renovations. Spending is being allocated for items to improve resident safety, such as touchless light switches.

Historical data and comparisons to other asset classes should be used with caution when figuring CapEx reserves. Seniors housing has more amenities than apartments. Hotels get more wear and tear than seniors housing.

There is some overlap between seniors housing and hospitality in terms of the owner-operator dynamic. But historical data for lodging goes back further. “When you are looking at newer assets, CapEx may seem lower which can cause investors to overestimate returns,” said Hartwich. “The sector is aging.”

CapEx tends to be “lumpy,” according to Blumenthal, uneven from year to year. Spending may be high one year and then low the next. The timing of renovations often depends on broader market conditions.

Allocations for CapEx may also depend on how long the investor intends to hold a property, according to Greenstreet’s Hartwich. Short-term investors with a hold period of say five years may set aside less for CapEx compared to investors that plan to hold the property for a longer period.  

Looking ahead, it’s likely that COVID-19 will not have a long-term impact on capital expenditures. Most costs will be allocated to one-time operating expenses. “Investors will adjust,” said Hartwich.

Managed Medicare revenue mix at 8.2%

NIC MAP^® Data Service released its latest Skilled Nursing Monthly Report on October 29, 2020, which includes key monthly data points from January 2012 through August 2020.

Here are some key takeaways from the report:

1. The trend of declining occupancy rates for skilled nursing continued in the month of August due to the on-going impacts of COVID-19. The downward pressure on occupancy has been significant since the pandemic, with another 81 basis point drop from July to August to a new low of 73.8%. This represents a 9.6 percentage points drop in just the five months since March (83.4%) and a 10.9 percentage point decline since February. On a year-over-year basis, the occupancy rate is down 10.5 percentage points from August 2019. The occupancy trend was consistent across geographies as both urban and rural areas decreased from July to August ending at 73.7% and 75.1%, respectively.
2. Patient day mix across all four payor types, i.e., Medicare, managed Medicare, Medicaid and Private, trended differently as Medicare and managed Medicare increased from July to April but Medicaid and Private decreased. This suggests the weakness in occupancy from July to August may be due to Medicaid admissions and/or patient days.
3. Medicare patient day mix increased 40 basis points from 12.1% in July to 12.5% in August. Since March, it is up 114 basis points and since last year, it is up 125 basis points from 11.2%. In addition, Medicare revenue mix increased 87 basis points from July to August, increasing from 20.8% to 21.6%. The combination of the overall decline in occupancy and the increase in Medicare patient day mix and revenue mix suggests that the waiver of the 3-Day Rule imposed by the Centers for Medicare and Medicaid Services (CMS) is having a positive impact on Medicare days. Meanwhile, Medicare revenue per patient day (RPPD) declined 0.3% from July to August, ending at $549. It has now decreased 1.1% from June after an initial increase during the earlier periods of the pandemic as skilled nursing properties were likely receiving more Medicare RPPD because of additional reimbursement due to COVID-19 positive patients requiring isolation.
4. Managed Medicare admissions have seemingly stabilized after decreasing significantly during the pandemic. Its patient day mix increased 14 basis points from July ending August at 5.9% and up 40 basis points since April. In addition, managed Medicare revenue mix is up 21 basis points from July ending August at 8.2% and up 34 basis points since April. The current stabilization in patient day and revenue mix is at the same time managed Medicare revenue per patient day (RPPD) is decreasing. RPPD decreased from $449 in July to $447 in August and is down 1.1% since February. The latest decrease in August suggests the downtrend in RPPD may be continuing after initial reimbursement stability from insurance companies during the earlier pandemic days. Although some stabilization occurred in August, managed Medicare revenue mix is down 168 basis points since March and down 246 basis points since February when it was 10.7%.
5. Medicaid revenue mix declined 46 basis points from 48.8% in July to 48.4% in August. Medicaid revenue mix has declined 222 basis points since March when the mix was 50.6%. Furthermore, it has decreased 324 basis points from August 2019. Medicaid patient days likely decreased as well, due to lower overall admissions during the pandemic thus far and some Medicaid patients converted to Medicare because of the waiver of the 3-Day Rule. Meanwhile, the increases in Medicaid RPPD seen at the onset of the pandemic have slowed. Medicaid RPPD is up 0.4% since April but has increased 2.5% since March when initial increases in reimbursement from states helped skilled nursing properties related to the number of COVD-19 cases at properties. RPPD was flat from July to August at $233.

   To get more trends from the latest data you can download the Skilled Nursing Monthly Report. There is no charge for this report.

   The report provides aggregate data at the national level from a sampling of skilled nursing operators with multiple properties in the United States. NIC continues to grow its database of participating operators in order to provide data at localized levels in the future. Operators who are interested in participating can complete a participation form here.