“The Omicron variant has challenged the skilled nursing recovery given the staffing shortages around the country as skilled nursing properties are unable to hire enough staff to admit more residents.”

– Bill Kauffman

NIC MAP^® data, powered by NIC MAP Vision, released its latest Skilled Nursing Monthly Report on March 3, 2022. The report includes key monthly data points from January 2012 through December 2021.

Here are some key takeaways from the report:

Occupancy

Skilled nursing property occupancy increased 24 basis points in the month of December, ending the month at 76.0%. This was the highest occupancy level since May 2020. After not changing from October to November, occupancy continued its slow recovery, which was challenged by the Delta variant and, more recently, the Omicron COVID-19 variant. Occupancy has increased 411 basis points from the low of 71.8% set in January 2021. The fact that occupancy held steady through the Delta variant and the early stage of Omicron suggests that the demand for skilled nursing properties remains, but a significant challenge for many skilled nursing operators around the country has been the staffing shortages that limit the ability to admit new residents. The already difficult labor shortage has grown increasingly worse as staff infected with Omicron have been forced to quarantine.

Managed Medicare

Managed Medicare revenue mix increased 20 basis points from November to end December at 9.9%, reversing the 20-basis point decline that occurred from October to November. It remains well below its 2021 high of 10.8% seen in February 2021 but was up by 204 basis points from the pandemic low set in May 2020 of 7.9%. The increase from the pandemic low is likely due to growth in elective surgeries from 2020, which typically creates additional referrals to skilled nursing properties. Meanwhile, Managed Medicare revenue per patient day (RPPD) decreased again, albeit slightly, ending December at $451. In addition, it is down 3.4% from December 2020. It has decreased $107 (19.2%) from January 2012 when the data series began to be reported as managed Medicare enrollment continues to grow across the country.

Medicare

Medicare revenue per patient day (RPPD) increased slightly from November to end December 2021 at $580. It has decreased 1.0% from $585 in June 2020 when severe cases in skilled nursing properties were increasing significantly during the early stages of the pandemic. The federal government implemented many initiatives to aid properties for cases of COVID-19, including increases in Medicare fee-for-service reimbursements to help care for COVID-19 positive patients requiring isolation. Meanwhile, Medicare revenue mix also trended higher in December, increasing 57 basis points ending December at 20.7%. However, it has been falling since January 2021 when it was 24.5%.

Medicaid

Medicaid revenue per patient day (RPPD) was relatively flat from November to end December 2021 at $248. Medicaid RPPD declined 1.1% from February of 2021 to September 2021 but has since increased 1.6% from September to December. This increase is likely due to some states adjusting their Medicaid budgets and increasing reimbursement for the 2022-2023 fiscal year. Medicaid RPPD increased 0.90% from a year ago in December 2020 and has increased 5.0% from pre-pandemic levels of February 2020 ($236). Medicaid reimbursement has increased more than usual as many states embraced measures to increase reimbursement related to the number of COVID-19 cases to support skilled nursing properties.

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 to provide data at localized levels in the future. Operators who are interested in participating can complete a participation form. NIC maintains strict confidentiality of all data it receives.

Relationships are the heart of the senior housing and care industry and are key to future success. Expertly designed to foster collaboration, the NIC Spring Conference features a myriad of innovative networking opportunities throughout the three-day event. In addition to scheduled events like our networking lounges and receptions, the popular Braindate™ platform is also returning this year, which offers intimate, curated discussions tailored to attendees’ interests. 

Beginning March 1, attendees can post topics they’re interested in discussing on the Braindate platform’s Topic Market. In these one-on-one or group discussions, participants can tap into the experiences and expertise of operators, capital providers, and other care partners through deep, knowledge sharing conversations.  

One-on-one Braindates are 30-minute conversations that you book with another attendee. You can either post a topic or request a meeting with a topic author and meet in the Braindate Lounge onsite at the conference.  

Group Braindates are 45-minute collaborative conversations with up to five people. The group will meet at the Braindate Lounge and the topic author will serve as the moderator to ensure that all participants can share their unique perspectives.  

All attendees have insights and experiences that can benefit others and anyone can post a topic or join a Braindate. We highly recommend taking advantage of this opportunity to engage in meaningful conversation (not sales pitches) while making connections and building new relationships. 

For more information about Braindates, visit the 2022 NIC Spring Conference website. 

The 2022 NIC Spring Conference will be held March 23-25 in Dallas, TX, at the Omni Dallas. Register today.

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Curious about what happened with asking rates and actual rate discounting in 2021 or how move-in patterns differed by care segment? Then read on for key takeaways from the recently released 4Q2021 NIC MAP^® Seniors Housing Actual Rates Report, available to NIC MAP^® subscribers.

In the recently released report, national monthly data through December 2021 of actual rates and leasing velocity is presented, including data on rate discounting and move-in/move-out trends. NIC MAP subscribers have access to the full report, which includes national data and additional key takeaways as well as data for the Atlanta, Philadelphia, and Phoenix metropolitan markets. 

Select takeaways from the 4Q2021 NIC MAP^® Seniors Housing Actual Rates Report are listed below. These key takeaways are pulled from the Segment Type report. Care segments refer to the levels of care and services provided to a resident living in an assisted living, memory care, or independent living unit.

Key Takeaways

• All three senior housing segment types—independent living, assisted living, and memory care—experienced the highest growth in year-over-year asking rates in the fourth quarter of 2021 since NIC MAP began reporting the data in 2017. Assisted living (6.6%) had the highest increase of the three levels of care, followed by independent living (6.0%), then memory care (3.5%). These gains continue the trend of growth in asking rates that started earlier in 2021 following the immense pandemic-related pressures of 2020.

• For the third quarter in a row, move-ins outpaced move-outs for all three care segments (independent living, assisted living, memory care) in fourth quarter 2021. This marks ten consecutive months of move-ins outpacing move-outs from March 2021 through December 2021. Move-ins for assisted living segments were at 3.4% in October and December of 2021, down from the recorded high of 3.9% in June 2021.
• Average initial rates for residents moving in were discounted below asking rates for all three care segments. Initial rate discounts were slightly greater in the fourth quarter of 2021 than in the third quarter for independent living segments and memory care segments. Of the three segments, memory care had the largest initial rate discounting of 10.2% ($719) in December 2021. On an annualized basis, this discount is equivalent to 1.2 months. This discounting is comparable to the discounting one year earlier in December 2020 of 10.3% ($702 or 1.2 months.) The least discounting in the year 2021 for memory care segments was still high at 7.9% ($547) in August.

• Of the three metropolitan markets that are currently reported, the largest discounting in initial rates from asking rates for residents moving into senior housing was Atlanta’s assisted living segment (December 2021) and Phoenix’s independent living segment (November 2021) which were both at 17.1% (or 2.1 months on an annualized basis).
  

NIC MAP Vision CEO Explains the Importance of Actual Rates Data Initiative

Arick Morton, CEO of NIC MAP Vision, discusses the importance of the actual rates data initiative for the company and the senior housing industry at large. Operators can learn more about actual rates by visiting the NIC MAP Vision actual rates page.

Our Software Partners Support this Initiative

At the 2021 NIC Fall Conference in Houston, Texas, Glennis Solutions and Eldermark were proudly announced as certified Actual Rates Software Partners. Glennis Solutions and Eldermark now offer their senior housing operator customers the ability to share their data more efficiently in the official NIC Actual Rates format. To receive certification, a software provider works with the NIC MAP Vision team to develop reports that meet the NIC Actual Rates standard format. They are then required to provide six months of actual rates data for two or more operators using those reports.

NIC and NIC MAP Vision appreciate the time, effort, and commitment from our software partners and thank them for their partnerships .

The Actual Rates Data Initiative is driven by the need to continually increase transparency in the senior housing sector and achieve greater parity to data that is available in other real estate asset types. Now, more than ever, having access to accurate data on the actual monthly rates that a senior housing resident pays as compared to property level asking rates helps the sector achieve this goal.

About the Report

The NIC MAP^® Seniors Housing Actual Rates Report provides aggregate national data from approximately 300,000 units within more than 2,600 properties across the U.S. operated by 25 to 30 senior housing providers. The operators included in the current sample tend to be larger, professionally managed, and investment-grade operators as we currently require participating operators to manage 5 or more properties. Note that this monthly time series is comprised of end-of-month data for each respective month.

While these trends are certainly interesting aggregated across the states, actual rates data are even more useful at the metro level. NIC MAP Vision is continuing to work towards reporting more markets.

Interested in Participating?

The Actual Rates Data Initiative is an effort to expand senior housing data and we are looking for operators who have five or more properties to participate. We have expertise in extracting data from industry leading software systems, such as Yardi, PointClickCare, Alis, MatrixCare, Glennis Solutions, and Eldermark and can facilitate the process for you.

Operators contributing data to the NIC MAP^® Actual Rates report receive a complimentary report which allows them to compare their own data against national, and metropolitan market benchmarks.

In addition to receiving a complimentary report, your organization benefits through:

• More informed benchmarking, strategic planning, and day-to-day business operations,
• Increased transparency, aligning with other commercial real estate assets in terms of data availability,
• Saved time, Actual Rates data is collected electronically directly from operators’ corporate           offices, removing the need for telephone calls to individual properties, and
• Enhanced investment and efficiency across the sector.

Learn more.

Introduction

This blog presents an abbreviated portion of the recently released white paper by NIC Analytics. Understanding the population demographics and prevalence of chronic kidney disease (CKD) by market can provide insights about potentially targeting select metropolitan areas in which to develop communities with specialized offerings for senior housing residents with CKD. Due to the differing levels of Medicare beneficiaries (MB) with CKD by metropolitan area, operators may be able target specific markets where they can gain increased resident interest as well as potential additional income by offering services tailored to residents with CKD such as in-home dialysis and specialized dietary support.

Serving the kidney health needs of residents is an opportunity for senior housing operators. About 37 million Americans are estimated to have chronic kidney disease, but many people do not know they have it and are undiagnosed. The CDC estimates that as many as 90% of people who have CKD do not know, and as many as 40% of people with severe CKD do not know. Chronic kidney disease is more common among seniors, with an estimated 38% of people aged 65 and older having CKD.

Most people who have CKD do not reach the point of needing dialysis, but nearly 800,000 Americans do have End Stage Renal Disease (ESRD) with 71% of them requiring dialysis and the remaining 29% receiving a transplant. Older Americans with ESRD comprise ~1% of Medicare patients, but account for ~7% of Medicare spending. In-home dialysis improves patient comfort and flexibility in care plan scheduling, as they have greater ability to adjust the hours and frequency of their treatment.

Dialysis within senior housing properties. Could dialyzing at home in senior housing present a “win-win” for all parties involved? Residents may be more satisfied with their dialysis care and operators can capture Medicare reimbursement. In addition to offering in-home dialysis, operators could distinguish a focus on treatment for CKD by offering additional features like specialized dining, as high protein diets are often recommended. Operators with their own Medicare Advantage or I-SNP plan may be able to capture increased Medicare reimbursement for in-home dialysis done at their properties. Additionally, considering the high rates of underdiagnosis of CKD, operators choosing to specialize care in this area could test residents for CKD to determine unmet needs for kidney health.

The recently released white paper and this blog illustrate how NIC MAP Vision data can help operators understand the local dynamics of a market. In addition to industry-leading senior housing supply and occupancy data, NIC MAP Vision offers subscribers different counts of Medicare beneficiaries (MB) with different types of diagnoses that can be drilled down to local geographies.

For this analysis, we use Medicare beneficiaries (MB) with chronic kidney disease to demonstrate how NIC MAP Vision can support an evaluation of potential demand for this niche specialization. We investigate trends in chronic kidney disease in potential senior housing residents, existing supply of senior housing (inventory), and usage of senior housing (occupancy). A full description of the methodology and limitations and caveats to the analysis can be found here. A similar analysis of the incidence in dementia was recently published by NIC Analytics.

The Medicare beneficiary data do not specify the level of severity of CKD and ESRD is not broken out (that level of detail is not available to NIC MAP Vision from Medicare). As a result, the number of Medicare beneficiaries with CKD included in this analysis is not directly equivalent to the number of people who will need dialysis and at the same time these data also understate the incidence of CKD due to underdiagnosis. These data are still useful in understanding incidence of CKD and market evaluation for operators who may be considering a focused offering for residents with CKD.

Key Findings

Certain metropolitan markets have higher shares of Medicare beneficiaries with chronic kidney disease, but even markets with lower shares may still hold opportunity. As the chart below demonstrates, the markets with the highest shares of Medicare beneficiaries with chronic kidney disease include:

• • Tampa (35.5%, 200,351 total MB with CKD)
  • Orlando (35.3%, 118,241 total MB with CKD)
  • Detroit (34.2%, 223,545 total MB with CKD)
  • Miami (34.0%, 352,802 total MB with CKD)
  • St. Louis (32.7%, 139,738 total MB with CKD)
  • San Antonio (32.4%, 94,801 total MB with CKD)

Markets with the lowest shares of Medicare beneficiaries with chronic kidney disease in the Primary Markets include:

• • Portland (21.6%, 69,870 total MB with CKD)
  • Minneapolis (23.1%, 103,658 total MB with CKD)
  • Pittsburgh (23.7%, 104,159 total MB with CKD)
  • Seattle (24.1%, 112,675 total MB with CKD)
  • San Diego (24.4%, 103,680 total MB with CKD)

Interestingly, Portland, Minneapolis, and Seattle are metros with higher penetration rates of senior housing more generally. Penetration rates are a way to measure use or availability of senior housing and can be calculated in several different ways. NIC has traditionally defined penetration as the sum of senior housing inventory divided by the number of households aged 75+. Some people also think of penetration rates as a proxy for consumer familiarity (higher penetration rates meaning higher levels of familiarity with senior housing as a product). It is interesting that three metros where senior housing is a well-known and established concept are areas where there are lower amounts of Medicare beneficiaries with CKD.

It’s also valuable to note the total numbers of seniors on Medicare with CKD per metro area. Although San Diego has a smaller share of Medicare beneficiaries with CKD than San Antonio, San Diego has a larger total number of Medicare beneficiaries with CKD by nearly 9,000 people.

As previously mentioned, Minneapolis (32.7%), Portland (30.5%), and Seattle (22.4%) are all markets with higher rates of senior housing penetration and have higher levels of senior housing as a share of MB with CKD. Senior housing is a well-established concept in these three metro markets. Interestingly, Kansas City (20.4%) and Denver (20.0%) are also markets with higher levels of senior housing as a share of MB with CKD. Las Vegas (4.9%), New York (5.5%), Los Angeles (7.1%), Riverside (7.3%), and Miami (7.3%) are the five metro markets in the Primary Markets with the lowest shares of senior housing over MB with CKD. The three Florida metros (Tampa, Orlando, and Miami) that are in the top 5 metros of the 31 Primary Markets that have high shares of total MBs with CKD are all under 12% for senior housing as a share of MB with CKD. New York (824,213) and Los Angeles (515,152) are unsurprisingly the two metro markets with the highest total number of MB with CKD.

This demonstrates that in addition to differing incidence of chronic kidney disease among the Medicare beneficiaries, there are also varying levels of senior housing inventory, with some markets like Miami having a high share of MB with CKD, high total numbers, and lower levels of senior housing inventory. However, Miami is a market that was still facing notable occupancy challenges in the fourth quarter of 2021.

The white paper presents additional data findings. Selected metrics provide a baseline for evaluating potential demand, current supply, and current utilization rates of available supply when considering a senior housing product offering tailored to serving the population of seniors with CKD or ESRD. NIC MAP Vision offers these data at more localized levels along with additional data that would be useful to planning a product offering including data on income levels and locations and drive times for hospitals.

Discussion

This analysis demonstrates differing levels in incidence of diagnosed chronic kidney disease among potential residents of senior housing in the Primary Markets and differing levels of senior housing supply and utilization. Improving diagnosis of CKD would also enhance the health of residents and provide additional opportunities for income for operators. The number of people who have CKD is projected to grow in the coming years, meaning that product offerings focused on serving the needs of seniors with chronic kidney disease may have added future demand as well.

With the trends toward increasing dialysis at home, senior housing operators could consider adding opportunities for residents to receive dialysis at home in senior housing to offer additional convenience and potentially create an additional revenue stream. The Medicare beneficiary data as well as the supply and occupancy data sourced from NIC MAP Vision can help support analyses evaluating potential local demand for at home dialysis or other product offerings focused on serving seniors with CKD or ESRD.

For further information on CKD, a case study of an operator serving this market, additional findings from our analysis, well as the full caveats and limitations, please download our white paper. 

Sources

ⁱ CDC – Chronic Kidney Disease in the US 2021 – https://www.cdc.gov/kidneydisease/publications-resources/CKD-national-facts.html
ⁱⁱ United States Renal Data System, 2020 Annual Report; Transplantation (https://adr.usrds.org/2020/end-stage-renal-disease/6-transplantation)
ⁱⁱⁱ Medicare, VisionLTC data, powered by NIC MAP Vision – https://visionltc.nicmapvision.com/

Omicron within skilled nursing facilities accounted for about seven percent of U.S. fatalities, higher than the Delta but far below the Fall 2020 spike.

While COVID-19 cases in the country and within skilled nursing facilities (SNFs) were very high during the Omicron surge in January 2022, data shows that fatalities among SNF residents remained significantly below the fall 2020 spike prior to the vaccine rollout.

The high caseload recorded in January 2022 exacerbated staffing shortages due to sickness-related absenteeism among SNF workers. However, SNF occupancy (based on CMS data) remained relatively stable compared with the sharp downturn during the fall 2020 spike prior to the vaccine rollout. This is mainly due to the fast retreat of Omicron, the reduced level of severe illness and fatalities, and pandemic preparedness among operators acquired from prior waves.

In this analysis, we provide a summary of the COVID-19 situation within SNFs and assess the impact of the Omicron spike on occupancy for skilled nursing facilities compared with the Delta and fall 2020 COVID-19 spikes. The analysis also showcases the noteworthy contribution and essential role of vaccines in mitigating the risk of severe illness and limiting fatalities among SNF residents.

Weekly COVID-19 cases in the country and within SNFs are currently dropping fast and at the same pace in which they peaked.

NIC’s Skilled Nursing COVID-19 Tracker, featuring CDC data as of February 13, 2022 (U.S. cases data) and CMS data as February 6, 2022 (SNF cases data), shows that COVID-19 cases in the country and within SNFs are falling fast and at the same pace in which they peaked. Weekly COVID-19 cases in the country fell by 80% from their January 16 peak of 5.58 million cases to 1.13 million cases on February 13 and are now near pre-Omicron levels.

Similarly, case counts within SNFs are falling sharply and following the same trajectory as weekly tallies in the country. New cases among SNF workers have fallen by 63% from their January 16 peak of nearly 68,000 to less than 23,000 cases on February 6. Over the same period, newly confirmed cases among residents have fallen by 55%, from about 48,000 cases on January 16 to less than 22,000 on February 6.

For the week ending February 6, 2022, per-resident rate of new COVID-19 infections dropped to 2% (about 200 in 10,000 residents tested positive), down 2.3 percentage points (pps) from its record high in mid-January 2022 of 4.3%.

Regionally, SNFs in the South region reported the highest per-resident rate of new COVID-19 infections at 2.75% (down 1.85pps from January 16), followed by the Midwest (1.71% – down 1.67pps from January 16), the West (1.53% – down 2.56pps from January 16), then the Northeast (1.35% – down 3.45pps from January 16).

Weekly COVID-19 fatalities among SNF residents falling and remained relatively low compared with the highest level seen during the fall 2020 spike.

At the height of the Omicron surge in January 2022, weekly COVID-19 cases among SNF residents set a new record at about 48,000 new cases, 45% above the peak recorded in December 2020 of about 33,000 new cases. However, weekly COVID-19 fatalities remained relatively low and far below the highest level seen back in fall 2020 prior to the vaccine rollout. In fact, weekly COVID-19 fatalities among residents during the Omicron surge peaked at about 1,500 on January 23, 2022, 75% less than the peak recorded on December 20, 2020 of nearly 6,000 new fatalities.

Per-resident rate of COVID-19 fatalities stood at 0.10% on February 6, down 3 basis points from its peak during the Omicron surge on January 23, 2022 and is now 44 basis points below the fall 2020 peak of 0.54% on December 20, 2020.

SNF Occupancy held its ground despite high caseload and severe staffing challenges.

The high COVID-19 caseload exacerbated staffing shortages among SNF workers in January 2022. The exhibit below shows that the declining case tallies within SNFs started to alleviate staffing shortages caused by sickness-related absenteeism among workers. Notably, the share of SNFs reporting staffing shortages among nursing staff, aides, and other staff took a downward trend following the sharp decline in case counts. For the week ending February 6, 2022, about 28.6% of SNFs reported shortages of aides, 26.7% reported shortages of nursing staff, and 17% reported shortages of other staff.

Interestingly, occupancy for SNFs (based on CMS data) held its ground and remained somewhat stable during both the Omicron and Delta spikes compared with the fall 2020 spike. During the Omicron spike, SNF occupancy fell by 0.7pps, from 72.4% on December 19, 2021 to 71.7% on January 23, 2022, then inched up 0.2pps to 71.9% on February 6, 2022. Similarly, SNF occupancy during the Delta spike fell by 0.3pps, from 71.9% on August 1, 2021 to 71.6% on September 12, 2021.

The fall 2020 spike weighed heavily on SNF occupancy. The exhibit below shows that occupancy dropped by 3.7pps, from 71% on October 11, 2020 to 67.3% on January 10, 2021 (the lowest level of occupancy since the onset of the pandemic). This was mainly due to a relatively long-lasting fall 2020 spike and the high level of fatalities in the early days of the pandemic prior to the vaccine rollout.

COVID-19 vaccines made an extraordinary contribution to mitigate the risk of severe illness and limit fatalities among SNF residents.

The analysis below shows that during the fall 2020 spike prior to widespread vaccinations among SNF residents, COVID-19 fatalities among SNF residents accounted for 30% of total fatalities in the country. over 52,000 SNF residents died over the period from the week ending October 11, 2020 to the week ending January 10, 2021.

During the Delta spike. As vaccines have been administered for most residents of skilled nursing facilities (as of August 1, 2021, 83% of residents had been fully vaccinated before the Delta took hold), fatalities among SNF residents as a share of total fatalities in the U.S. dropped to 4.7%, down over 25pps from the share recorded during the fall 2020 spike.

During the Omicron spike. At 7%, fatalities among SNF residents as a share of total fatalities in the country remained far below the share recorded during fall 2020 spike (30%), but 2.3pps higher than the share during the Delta spike (4.7%).

The COVID-19 stats below show that the Omicron spike has caused more fatalities among SNF residents than the Delta spike. This is partly due to the relatively high case counts and the lagging booster shots. As the Omicron variant took hold in December 2022, only 52% of fully vaccinated residents had received a booster, and only21% of staff.

Booster rates are increasing but still lagging. As of February 6, 2022, 60% of residents within SNFs had received a COVID-19 vaccine booster and roughly 30% of staff.

To gain in-depth insights and track vaccination coverage, U.S. weekly cases, and the week-over-week change rate for new resident cases and fatalities of COVID-19 within skilled nursing facilities at the state and county levels, visit NIC.org.