On Monday, the U.S. Department of Treasury announced the launch of the Coronavirus State and Local Fiscal Recovery Funds, established by the passing of the American Rescue Plan in March. The recovery funds provide $350 billion in emergency funding for eligible state and local governments and provide substantial flexibility for each jurisdiction to meet local needs—including support for households, small businesses, impacted industries, essential workers, and the communities hardest-hit by the crisis.

This Treasury Department Fact Sheet outlines generalized categories of eligible uses for the funds, including support for public health expenditures, addressing negative economic impacts caused by the public health emergency, and providing premium pay for essential workers. It is also stated that “recipients have broad flexibility to decide how best to use this funding to meet the needs of their communities.”

Suggested uses to support the public health response include vaccination programs, medical expenses, testing, contact tracing, PPE purchases, support for vulnerable populations to access medical or public health services, and ventilation improvements in key settings like healthcare facilities. In a March 2021 letter to the Department of Treasury, Argentum emphasized that “over the past year, senior living providers in the United States have incurred more than $15 million in COVID-related expenses for procuring PPE, infection control supplies, hero pay, and additional staff costs,” while also noting that “more than 85% of these communities in the United States do not receive state or federal funding…This means these communities have not had the same access to federal relief as other providers.”

Argentum President and CEO James Balda said the Association and its state partners have been meeting with governors and state legislators to request prioritized funding. “We are extremely pleased that additional resources may soon be on their way to help these communities – many of whom are still struggling from the steep costs and lost revenue due to COVID-19,” Balda said.

With respect to providing premium pay for essential workers, the announcement highlights that “Since the start of the public health emergency, essential workers have put their physical well-being at risk to meet the daily needs of their communities and to provide care for others. Many of these essential workers have not received compensation for the heightened risks they have faced and continue to face.” Although it is made clear that there is a broad range of essential workers, i.e., anyone who must be physically present at their job, skilled nursing staff are the first group to be listed specifically.

Funding is expected to be distributed beginning this month, and states and entities will have until the end of 2024 to spend the funds.

Key Takeaways. This blog examines the impact COVID-19 deaths through late-April 2021 have had on near-term supply needs for seniors housing. We conclude there are 41,000 fewer units needed at the national level in the near-term than what may have been projected prior to the COVID-19 pandemic. For perspective, 41,000 units is larger than the entire seniors housing inventory in the Philadelphia metropolitan market.

Background. In 2019, NIC published a whitepaper titled, Looking into the Future: How Much Seniors Housing Will Be Needed?. The paper provided supply projections out to the year 2040 for seniors housing at the national level. The paper considered differing scenarios of penetration rates as well as age cohorts (i.e., 75-plus, 80-plus, 85-plus). Based on the 85-plus cohort and the 30% penetration scenario, it concluded that 1,657,868 units of seniors housing would be needed in 2021.

This blog provides an update to these projections using data from the U.S. Census along with provisional death counts to COVID-19 for seniors 85+ from the CDC and National Center for Health Statistics (NCHS).

Findings. The CDC reports weekly updates of provisional COVID-19 death counts by sex and age. As of April 28, 2021, the CDC reported that provisionally 169,545 people aged 85+ in the United States have lost their lives to the COVID-19 pandemic. This staggering number is tragic and reflects the fact that elderly individuals have been the most vulnerable to this insidious virus. These deaths accounted for 30% of all deaths associated with COVID to date. We at NIC express our deepest sympathies to those who lost loved ones and we understand that each one of the 169,545 individuals are more than just numbers and statistics. Importantly, the death counts that the CDC reports are provisional and may be upwardly adjusted as the data is revised. They are based on the death certificates that the National Center for Health Statistics has received and coded at the time of reporting. The CDC notes that the five most recent weeks of reporting are typically less than 90% complete.

As a result of these deaths, NIC Analytics estimates that the revised projected units needed for 2021 using the same methodology as used in the whitepaper for the 85+ cohort and 30% penetration rate is 41,000 fewer units than were projected to be needed in the original 2019 analysis. These 41,000 units represent a 2.5% decrease from the units originally projected for 2021 for the 85+ cohort (1,657,868). For perspective, this volume of units is:

• Larger than the number of open seniors housing units for 29 of the 31 individual metropolitan market inventories that comprise the NIC MAP Primary Markets as of 1Q21.
• Greater than the entire open seniors housing inventory in Philadelphia (40,596 units) as of 1Q21.

Further, if we scale these 41,000 units back to the 99 NIC MAP Primary and Secondary Markets (using the same methodology that we’ve used in the NIC Investment Guide), this scales to 25,300 fewer units needed due to the loss in life from pandemic-related deaths for the NIC MAP Primary and Secondary Markets. For perspective, this value is:

• More than of all the net seniors housing absorption for the NIC MAP Primary and Secondary Markets in 2019 (nearly 24,000 units).
• 96% of the inventory growth that occurred during 2020 for the NIC MAP Primary and Secondary Markets.
• More than all the seniors housing construction starts in the last five quarters (nearly 20,900 units broke ground from 1Q 2020 through 1Q 2021) in the NIC MAP Primary and Secondary Markets.

Methodology and calculation. Considering the tremendous loss of life to COVID-19, we wanted to provide an estimate of what the impact of these deaths is to the supply projections we published in 2019. As stated earlier, the CDC provisionally reported that 169,545 people aged 85+ in the United States had lost their lives to the COVID-19 pandemic from the beginning of the pandemic through April 28^th, 2021.

From the U.S. Census Bureau population projections published in 2017, the population projected to be 85+ on July 1, 2021 was 6,808,852. We aren’t yet at July 1, 2021, which means there are some people who will turn 85 between April 28 and July 1, and there will also sadly continue to be loss of life as well. We chose to use the 2021 population projection and provisional death counts through April 28 instead of using the population projection for 2020 as 2020 would not have captured the full impact of the pandemic thus far. Subtracting the 169,545 COVID-19 related deaths that occurred in 2021 from the population projection yields 6,639,307 people.

For our analysis, we used households as the unit of demand in order to use NIC’s penetration rates which are based on households. In our 2019 whitepaper, we converted population projections from the U.S. Census Bureau by age cohort through 2040 to projections of households using a conversion ratio of 1.23 persons per household for the 85+ cohort. This conversion ratio was based on the U.S. Census 2017 American Communities Survey of households and population. This shifts the population of 6,639,307 individuals 85+ and becomes 5,397,811 households 85+.

Then, we applied the same seniors housing penetration rate for households over 85 of 30% and derived a projection of 1,616,586 as the number of units that would be needed in 2021 (if the same penetration rate from the whitepaper were to be maintained). This value is less than the 1,657,868 originally projected for the 85+ group at 30% penetration for 2021 from the 2019 whitepaper.

Caveats and limitations to this analysis. There are a few caveats to this analysis. First, and as stated above, the death counts used in this analysis will likely be upwardly revised because the death measures are provisional. Sadly, more people will lose their lives to COVID-19. Second, this analysis does not consider the changes in consumer attitudes about the sector that have occurred during the pandemic, nor does it consider any potential pent-up demand bounce that could affect the penetration rates; it assumes the penetration rates remain static. And lastly, this analysis also does not take into account occupancy, it is based on population estimates, provisional death counts, penetration rates (not occupied penetration rates), and the population to households conversion factors.

Conclusions. Our thoughts continue to be with all who have lost a loved one to COVID-19 and with the staff of seniors housing and nursing care properties who continue battling the virus on the front lines. We respect and appreciate all of the hard work and constant care. The results of this analysis show that the projected units needed to service the 85-plus cohort are less than what would have been had COVID not occurred.

The Labor Department reported that nonfarm payrolls rose by 266,000 in April.  This was a sharp slowdown from the downwardly revised gain of 770,000 in March, originally reported as 916,000. The consensus estimates for April had been for a gain of 1,000,000. Despite the April increase, job levels remain 8.2 million below the pre-pandemic levels of February 2020.

Employment in health care changed little in April (-4,000) as a gain in ambulatory health care services (+21,000) was largely offset by a job loss of 19,000 in nursing care facilities. Health care employment is down by 542,000 since February 2020.  

Separately and from a separate survey, the Labor Department reported that the unemployment rate edged up to 6.1% from 6.0% in March. The jobless rate is now 2.6 percentage points above the pre-pandemic level of 3.5% seen in February 2020, but well below the 14.7% peak seen in April.  

The underemployment rate or the U-6 jobless rate was unchanged at 10.4% down from 10.7% in March. 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.  

The number of long-term unemployed (those jobless for 27 weeks or more) was little changed from March at 4.2 million but is 3.1 million higher than February 2020, suggesting that this continues to be a very challenging time for many Americans. Long-term unemployed persons account for 43.0% of the total number of unemployed persons.  

The labor force participation rate, which is a measure of the share of working-age people who are employed or looking for work was steady at 61.7% in April but is 1.6 percentage points lower than in February 2020. Many workers have dropped out of the labor force since the pandemic began to take care of family members or out of fear of working and catching the virus.  

Average hourly earnings for all employees on private nonfarm payrolls rose by $0.21 in April to $30.17, a gain of 0.3% from a year earlier. This was well below the 4.2% annual gain recorded in March. Notably, however, the pandemic has affected the ability to fully interpret the wage data due to the wide swings in employment trends. 

The change in total nonfarm payroll employment for February was revised down up by 68,000 from a gain of 468,000 to 536,000 and the change for March was revised down by 146,000 from 916,000 to 770,000. With these revisions, employment in February and March combined is 78,000 lower than previously reported. Monthly revisions result from additional reports received from businesses and government agencies since the last published estimates and from the recalculation of seasonal factors.

The April data was disappointing after such robust gains in recent prior months. It may reflect ongoing health-related concerns about the pandemic and the need for workers to still take care of family members, especially school-aged children. That said, the ongoing drop in COVID cases, the widespread distribution of vaccines, and a shift in consumer confidence should support a more complete re-opening of the economy and a fuller recovery in jobs in the coming months. The weak April number also suggests that the Fed will continue in its resolve to not alter its stated monetary policy goals and will keep its bond-buying program intact and interest rates low as it pursues its full employment goal.

Over the last month, a series of congressional hearings and confirmations shined a spotlight on the seniors housing and care sector as a whole, as well as a number of areas impacting the industry. The hearings followed a tumultuous year of navigating the COVID-19 public health emergencies and subsequent media scrutiny, and covered a wide range of topics, including staffing necessities, private equity investment, quality metrics, home and community-based services (HCBS) funding, reimbursement pressures, telehealth flexibilities, and dual-eligible care coordination.

Below is a summary of key points from each hearing.

Senate Committee on Finance: A National Tragedy: COVID-19 in the Nation’s Nursing Homes

On March 17, the Senate Committee on Finance, chaired by Sen. Ron Wyden (D-OR), held the hearing “A National Tragedy: COVID-19 in the Nation’s Nursing Homes.” The hearing included testimonies from a nursing care certified nursing assistant (CNA), an AARP Director, a long-term care ombudsman, American Health Care Association’s (AHCA) Chief Medical Officer, Dr. David R. Gifford, and University of Chicago Public Health Sciences professor, Dr. Tamara Konetzka.

AHCA’s Dr. David R. Gifford shared testimony that sought to educate the committee on the needs of nursing home residents, the emotional and physical toll the pandemic had on residents and staff, as well as the multitude of challenges operators faced during the public health emergency. These challenges included the constantly evolving and sometimes conflicting guidance from local, state, and federal governments, the lack of reliable and timely testing, personal protective equipment (PPE) shortages, and the workforce crisis that was exacerbated by the pandemic.

With regards to the existing standard quality metrics, Dr. Konetzka of University of Chicago highlighted that “multiple rigorous studies” have found standard quality metrics do not have a meaningful association with COVID-19 outcomes for nursing homes and that even prior infection control citations were not associated with COVID-19 outcomes. Konetzka’s comments echo a 2019 GAO report that quality measures should better align with CMS’s strategic objectives at improving care quality rather than simply additional obligations of providers.

Gifford’s testimony also emphasized that COVID-19 didn’t cause problems that exist in the sector, but rather exacerbated or brought them to light. This is true on the staffing front as well – staffing challenges predate the pandemic. Thus, when the pandemic hit, tight staffing levels went from a strain to a crisis itself. Adelina Ramos, a Rhode Island Certified Nursing Assistant shared key points on this topic, including the often-low starting wages for skilled nursing workers, the prevalence of skilled nursing workers working multiple jobs, and that the often-low staffing ratios themselves tend to feed into the employee turnover challenge.

Konetzka highlighted that “Though community spread of COVID-19 and facility size have proven to be the top predictors of nursing home outbreaks in multiple studies, staffing does have an effect on how a COVID-19 outbreak plays out. More staff did not reduce the chance of outbreaks, but more staff hours meant fewer deaths and cases once an outbreak occurred.”

Dr. Gifford cited a November 2020 survey of skilled nursing providers that found 70 percent of nursing homes had hired additional staff and 9 out of 10 asked staff to work overtime and provided hero pay. Gifford summarized AHCA/NCAL’s actions relative to staffing through the pandemic – developing free online courses to train temporary caregivers, urging Congress to direct financial aid to long-term care properties, and sharing a strategy roadmap with governors to address the workforce shortage. Gifford summarized the sector’s needs by saying, “We need ongoing staff support as this pandemic continues, but we also need a more long-term solution. … We need a comprehensive strategy to recruit more health care heroes to serve in long term care.”

A National Bureau of Economic Research (NBER) study on private equity investment in healthcare made its way into the hearing multiple times. The study included data on 1,674 nursing homes that were acquired by private equity firms in 128 unique deals between 2000 and 2017. The study cited instances of bad outcomes for nursing homes that were acquired by private equity owners. These include elevated risk of death for short-term Medicare patients, higher rates of antipsychotic drug use, and increased taxpayer spending on episodes of care.

The American Investment Council has pushed back on the NBER findings, saying that “private equity firms make long-term investments in…nursing homes to help rescue, build, or grow businesses, often providing much-needed capital to strengthen struggling companies.” The council also said that the NBER research hasn’t been peer-reviewed and doesn’t include data on Medicaid patients, who comprise most long-term nursing home residents. The paper is “inconsistent with recent peer-reviewed academic research that shows that private equity-backed companies are delivering high-quality care to nursing home residents, particularly during the COVID-19 crisis,” it said.

One subcommittee member spoke in favor of the for-profit healthcare system. Rep. Tom Suozzi (D-NY 3rd District) said “I’m not against making money as long as you are taking care of your patients.”

Senate Special Committee on Aging: COVID-19 One Year Later: Addressing Health Care Needs for At-Risk Americans

On March 18, the Senate Special Committee on Aging, chaired by Sen. Bob Casey (D-PA), held the hearing “COVID-19 One Year Later: Addressing the Health Care Needs for At-Risk Americans.” Much of this hearing focused on the disparities in care during the pandemic. Speakers noted the virus had a disproportionate impact on the elderly, people with disabilities, minorities, and rural Americans. While this hearing was not focused on seniors housing or skilled nursing, private equity investment in long-term care was brought up and questions were posed regarding its suitability for the sector.

Comments highlighted the two different types of patients that are found in skilled nursing, and how they don’t necessarily align with each other. Anthony Jackson, senior vice president and chief operating officer of Roper Saint Francis Healthcare, and a former nursing home administrator said “When you look at the viability of a nursing home, they started to move away from the responsibility for which they exist, which is to take care of patients from a long-term perspective. They moved toward taking care of short-term types of disease which provides for quicker turnover and a better reimbursement.”

On HCBS services, Senator Elizabeth Warren (D-MA) said “…the coronavirus has also highlighted the critical importance of providing care safely in home and communities. Here’s the problem: Millions of Americans can’t access HCBS services at home. … We must make HCBS a mandatory benefit in Medicaid and expand Medicare to cover more at-home, long-term care services.” Following this hearing, the American Jobs Plan was announced, which includes $400 billion to expand access to Medicaid home and community-based services.

House Ways and Means Oversight Subcommittee: Examining Private Equity’s Expanded Role in the U.S. Health Care System

A week later, on March 25, the House Ways and Means Oversight subcommittee, chaired by Rep. Bill Pascrell (D-NJ 9th District) held the hearing “Examining Private Equity’s Expanded Role in the U.S. Health Care System.” Skilled nursing and private equity ownership were the central themes for this hearing, again citing the February 2021 National Bureau of Economic Research (NBER) study. Ernest Tosh, an attorney specializing in nursing home abuse and neglect highlighted what he considers to be a lack of transparency in for-profit skilled nursing chains’ use of taxpayer funds. Tosh said “We really have no idea what the financial position of these facilities is. They can be made to look bankrupt, but, in fact, may be making millions and millions of dollars each.” Tosh proposes requiring skilled nursing operators to file consolidated financial statements for entire chains, not just individual properties.

In anticipation of another congressional hearing scrutinizing the sector, AHCA/NCAL’s CEO and President Mark Parkinson proactively released a statement before the hearing highlighting both the shortcomings of government funding coverage and the limited role of private equity within the ownership of skilled nursing properties. Parkinson said “In the long-term care sector, private equity companies own less than 10 percent of nursing homes, and large investor acquisitions are decreasing. However, the small number of nursing homes that have turned to alternative revenue sources underscore the financial and staffing crisis that nursing homes are facing due to the fact that Medicaid does not cover the cost of care.”

Senate Finance Committee Confirmation Hearings: CMS Administrator Chiquita Brooks-LaSure and HHS Director Andrea Palm

On April 15, the Senate Committee on Finance held a confirmation hearing for both the CMS Administrator and the HHS Director, which covered applicable topics of Medicare and Medicaid funding and reform, telehealth, staffing, oversight, and penalty changes for skilled nursing properties.

Senator Mike Crapo’s (R-ID) opening statement on both Brooks-LaSure and Palm touched on the topic of telehealth. “Patients and providers have benefited from expanded access to telehealth and expedited approval of COVID-19 vaccines, diagnostics, and treatments. Going forward, Medicare and Medicaid patients must have the same access to innovative items and services as those with commercial insurance.” Several other senators highlighted the need to ensure that the telehealth boom that started during the pandemic continued. In response, Brooks-LaSure said that she wants to examine what CMS’s authority is to extend the flexibilities that are set to expire at the end of the public health emergency.

Senator Bill Cassidy (R-LA) also commented that “We both know we spend lots of money on duals, and we get miserable outcomes. … One of the issues is that it is difficult for aligning incentives for both state and federal governments.” Brooks-LaSure responded that there needs to be better coordination between long-term care, nursing homes, and hospitals.

The hearing did not highlight any major opposition to either nomination, and likely signals the confirmation of each to their respective roles at CMS and HHS.

Unprecedented change in healthcare has led to new expectations from payers, providers, and consumers. The latest NIC Leadership Huddle, titled “Telehealth’s Tipping Point: The New Norm in Care and How to Build for Success” brought together telemedicine experts to cut through the hype. Attendees benefitted from a substantive discussion on building the right-sized telehealth program; selecting relevant telehealth services; addressing staffing issues, and picking the right technology and business models, as the industry moves to kickstart or enhance telehealth programs as part of the new normal.

Moderator Ryan Brooks, Senior Principal, Healthcare, NIC, pointed out the timeliness of the discussion, saying, “The timing of this conversation really couldn’t be more appropriate. As we speak, the House Ways and Means Health Subcommittee is beginning their hearing, titled, ‘Charting the Path Forward for Telehealth,’ where they will be examining what needs to be done from the regulatory and legislative perspectives to sustain the current momentum of telehealth.”

Michael Kurliand, Director, Telehealth and Process Improvement, West Health, provided some context for the rise of telehealth in a brief presentation. He pointed to projected shortages of primary care physicians and specialists, as well as uncertainty on the numbers of nurses that will be available to serve the needs of what is already a quickly expanding population of seniors. In addition to these shortages, the numbers of unpaid caregivers is decreasing rapidly.

Kurliand also pointed to the extremely high cost of healthcare. Given the realities of COVID-19, telehealth, according to Kurliand, enables access to care for lower-acuity patients, who might otherwise defer care, and get sicker, out of fear of infection. Meanwhile, the technology is enabling physicians to use their medical offices to see only the higher-acuity, and more profitable, patients. Overall, he expects CMS to continue to support the technology, as it helps to deliver care while lowering costs and improving outcomes.

Before COVID, Kurliand, who has been in the telehealth industry for 25 years, pitched the many benefits of the technology, including access to care, timeliness of care, care coordination, and resident satisfaction. Post-COVID, however, according to Kurliand, the main driver of the growth of telehealth is safety.

Kurliand also highlighted the speed and intensity of the technology’s growth, going from 0.1% of Medicare beneficiaries using telehealth prior to the pandemic to 39% by November of 2020. Additionally, investment in health technology companies is on the rise, further fueling the development and improvement of the offerings that the technology is making possible.

Josh Hofmeyer, Senior Care Officer, Avera eCARE, provided some insight on how telehealth actually works. He emphasized that the technology offers many use-cases and should be matched to the gaps in care that occur within your organization, such as during transitions, which he said are a common area in which telehealth implementation can make a big difference in outcomes. Not every organization will have the same needs. “If you’re strictly doing psychiatry, that’ll only be video-to-video conversations, you don’t need the same type of setup as someone who’s looking for clinical support, that urgent care component,” he said.

Once you have selected your platform, according to Hofmeyer, its about looking at outcomes. He looks for improved transfer rates, reduced emergency room visits, rehospitalization rates, and increased ability to treat in place. He also pointed to increased length of stay and higher occupancy rates in nursing homes.

On that point, he said, “When I was managing assisted living, I cannot even count the number of times we didn’t have access to the clinical care we needed, so we’d transfer our resident to the hospital and the next thing we knew, they were going across town to a skilled nursing facility and we never saw them again. That’s very common because that’s the path of care that those people take. That’s not needed if we have the right access and the right things in place. We’re able to help stop some of that.”

Pam Ferris, President, and CEO, Seacrest Village offered an operator’s point of view. She provided her organization’s practical experience with new telehealth technologies implemented over the pandemic. While helpful, in Ferris’ experience, telehealth does not always eliminate the need for in-person visits with providers. It also required additional staff.

Overall, however, the experience was positive. “Right now, we’re just trying to get back to a sense of normalcy. We really do believe in telehealth and the benefits that will come from it. We just want to go back and really evaluate how it worked in various operations, and what would be the best way to go forward. It’s not a one-size-fits-all, as other panelists have mentioned, and it appears for us, at least, to have worked differently in different settings.”

Going forward, Ferris said she is likely to partner with a hospital system, which she believes already has the infrastructure and resources in place for the right telehealth program. She also expressed the hope that CMS and her state’s health department will continue to relax restrictions on telehealth, even as COVID becomes a thing of the past. For the moment, she said, “This is a great way to start, on one of the biggest game-changers in the way medicine is practiced, and how seniors will be served, in the years ahead.”

You can register to attend upcoming NIC Leadership Huddles, including both the live webinars as well as the optional, first come, first served participation in peer-to-peer discussions, within the Events tab on nic.org. Registrants are provided with a recording of the event, compliments of NIC and our generous sponsors and partners.