Analyses predict high cost of staffing mandate

Oct 10, 2023 | Minimum Staffing

News Digest: Billions needed to comply with minimim staffing mandate

Competing estimates of the cost to get all skilled nursing facilities to a minimum staffing level all come in with multi-billion dollar price tags. From CMS’ estimate of over $4B to AHCA and CliftonLarsonAllen’s $6.8B topped by Leading Age’s $7.1B analysis.


RN wages projected to grow more rapidly than wages for other professions, study finds

Registered nurse salaries are projected to increase over the next decade at a rate that surpasses the rate of increases for some other healthcare professions, according to the results of a recent study from

The website evaluated the future hourly earnings of 16 professions using the annual mean hourly earnings for each job from 2013 to 2022 from the Bureau of Labor Statistics. Using these historical data, the site forecast what people in each job would make every year from 2023 until 2033 using an Excel function.

Among the healthcare professions that were examined for potential wage changes over the next decade — such as RN, physician and dentist — when adjusted for the estimated inflation rate, RN was the only one expected to see growth by $12.82 per hour. Dentists’ wages, by comparison, are projected to decline by $13.72 by 2033.


Gaivin, Kathleen Steele. “RN Wages Projected to Grow More Rapidly Than Wages for Other Professions, Study Finds.” McKnight’s Senior Living, 23 Oct. 2023,


Staffing mandate could shift big costs to states — but they may not know it yet

A federal staffing mandate would likely leave states struggling with how to afford increased costs among their operators, a threat that could force wide scale changes in how state Medicaid systems pay providers for skilled nursing care.

It might also convert some state budget officials into opponents of the mandate, once they see more clearly the financial implications.

So warned Martin Allen, senior vice president of reimbursement policy for the American Health Care Association, last week at the AHCA Convention & Expo in Denver.

State leaders can’t wait to make changes until the proposed regulations kick in at least two years from now, depending on when the rule is finalized, Allen added. They need some way to “ramp up” so that providers have some funding in their pockets as mandated nurse hiring begins happening in earnest.


Marselas, Kimberly. “Staffing Mandate Could Shift Big Costs to States — but They May Not Know It Yet.” McKnight’s Long-Term Care News, 10 Oct. 2023,


LeadingAge staffing mandate cost estimate outpaces AHCA’s; Exec urges Congress to act

The proposed federal staffing rule would cost $7.1 billion in the first year alone, according to an analysis from LeadingAge, which sharply criticized the government’s “highly fragmented approach to long-term care financing” in a letter to congressional leaders.

The group issued its analysis Thursday morning, laying out three reasons why the proposed mandate, which was released Sept. 1, will be “impossible to implement”: lack of funding, lack of workers, and increasingly, a lack of access to care for seniors.


Towhey, Jessica R. “LeadingAge Staffing Mandate Cost Estimate Outpaces AHCA’s; Exec Urges Congress to Act.” McKnight’s Long-Term Care News, 1 Oct. 2023,


Responding to staffing agency profit misconceptions

In response to the article published in McKnight’s on September 11, 2023, titled “Profiteering by Nursing Agencies Predicted as Providers Weigh Staffing Mandate,” I feel compelled to provide an alternative point of view and defend nursing agencies, who were portrayed as profiteering hostage takers, akin to modern day pirates. This is simply inaccurate and misleading.

As a representative of a nursing agency, we resonate with the growing apprehensions regarding the potentially adverse impacts of the proposed staffing mandate for nursing home operators. We are acutely aware that our partners are already struggling to stay afloat. And we understand that if our customers go out of business, we go out of business, too.

Nevertheless, it is critical to delineate a distinction between nursing agencies, which predominantly function as vital allies in healthcare operations, from tech-driven staffing platforms that have engaged in price inflation and monopolistic behaviors.


Tall, Jaime. “Responding to Staffing Agency Profit Misconceptions.” McKnight’s Long-Term Care News, 29 Sept. 2023,


Staffing rule could bring system ‘collapse,’ providers say, but CMS stands firm

Nursing homes’ leading lobbying organization unloaded a full, research-backed attack on the viability of the White House’s proposed staffing mandate Tuesday. But the administration was unmoved, and instead doubled down on its commitment to impose first-ever workforce minimums on the beleaguered industry.

American Health Care Association President and CEO Mark Parkinson warned the “whole” US long-term care system would be at risk of “collapse” if the rule were implemented without modifications.

Without more funding and other changes, operators would have to restrict services and close wings and buildings, setting off a chain reaction that would discharge more than a quarter million patients out of nursing homes, or roughly 26% of the current population, he said.


Berklan, James M. “Staffing Rule Could Bring System ‘Collapse,’ Providers Say, but CMS Stands Firm.” McKnight’s Long-Term Care News, 27 Sept. 2023,


AHCA: Staffing Proposal to Cost $6.8B Per Year, Create Access Issues for Nearly One Quarter of Nursing Home Residents

More than 280,000 residents, or nearly a quarter of all residents, could be impacted by the staffing mandate – if nursing home operators have no choice but to reduce their census in order to meet hourly requirements.

The proposed federal mandate would require an estimated 102,154 additional full-time employees. That’s 80,077 certified nursing assistants (CNAs) and 22,077 registered nurses (RNs), according to an analysis released Tuesday by the American Health Care Association (AHCA) and prepared by professional services firm CliftonLarsonAllen (CLA).

The proposed rule requires 2.45 CNA hours per resident per day (HPRD) and 0.55 RN HPRD, and for facilities to have an RN on site 24 hours per day.


Amy Stulick. “AHCA: Staffing Proposal to Cost $6.8B per Year, Create Access Issues for Nearly One Quarter of Nursing Home Residents.” Skilled Nursing News, 26 Sept. 2023,


BREAKING: Price of nursing home staffing mandate is $6.8B, 100K more workers, analysis finds

Nursing homes would need to spend more than $6.8 billion annually to meet a proposed federal staffing mandate, which also would require them to hire more than 102,000 new workers if enacted as originally introduced, according to an analysis updated Tuesday by accounting and consulting firm CliftonLarsonAllen.

That projected cost is nearly 60% higher than the $4 billion annual cost estimated by the Centers for Medicare & Medicaid Services in a draft rule it issued Sept. 1. The CLA analysis was conducted in conjunction with the American Health Care Association/National Center for Assisted Living.

“What CLA’s analysis confirms is that this proposed rule is deeply flawed, and the Biden Administration has woefully underestimated the feasibility and cost of this unfunded mandate,” AHCA President and CEO Mark Parkinson said in advance of the analysis’ release this morning.

More than 287,000 patients, or about 26% of those currently in nursing homes, would need to be discharged due to lack of available staff If the staffing policy were enacted as proposed, Parkinson added at a late-morning press conference.


Marselas, Kimberly. “[Updated] BREAKING: Price of Nursing Home Staffing Mandate Is $6.8B, 100K More Workers, Analysis Finds.” McKnight’s Long-Term Care News, 26 Sept. 2023,


New Analysis Finds Federal Staffing Mandate Would Require 100,000 Additional Nurses and Nurses’ Aides, Cost $6.8 Billion Per Year

The American Health Care Association (AHCA), representing more than 14,000 nursing homes and other long term care facilities across the country that provide care to approximately five million people each year, released an analysis today by professional services firm CLA (CliftonLarsonAllen LLP), which analyzed the impact of President Biden’s proposed federal staffing mandate on nursing homes. The proposed rule would require specific nursing home staff to spend a minimum number of hours with each resident – 2.45 nurse aide hours per resident per day (HPRD) and 0.55 registered nurse (RN) HPRD – as well as have a RN on site 24 hours a day.

Among CLA’s findings:

  • Nursing homes would need to hire an estimated 102,154 additional full-time employees (80,077 nurse aides and 22,077 RNs).
  • The proposed mandate would cost nursing homes approximately $6.8 billion per year – higher than the $4 billion per year estimate from the Centers for Medicare and Medicaid Services (CMS).
  • Ninety-four percent of nursing homes are currently not meeting at least one of the three proposed staffing requirements: the 2.45 nurse aide HPRD, the 0.55 RN HPRD, and the 24/7 RN.


New Analysis Finds Federal Staffing Mandate Would Require 100,000 Additional Nurses and Nurses’ Aides, Cost $6.8 Billion Per Year. (n.d.).,000-Additional-Nurses-and-Nurses%E2%80%99-Aides,-Cost-$6-8-Billion-Pe.aspx


"Crackdown": Proposed Nursing Home Minimum Staffing Rule to Cost the Industry $4.23 Billion and Would Directly Impact For-Profit Facilities

According to President Biden’s recently published column, the Administration’s proposed rule, published on September 6, 2023, mandating that nursing homes begin to staff facilities so that registered nurses (RNs) and nurse aides (NAs) provide a minimum number of hours per resident day (HPRD) of care is a “crackdown” designed to “[deliver] a clear message to the nursing home industry: no more padding profits on the backs of residents and nurses.” The President’s column clarifies that the Administration is focused on for-profit facility staffing, particularly in those facilities owned by private equity firms, although the rule would apply to both non-profit and for-profit facilities.

The Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) estimate that facilities’ total cost to satisfy the proposed minimum staffing requirement would cost the industry approximately $4.23 billion. Furthermore, CMS and HHS acknowledge that the proposed requirements would require approximately 79 percent of long term care (LTC) facilities to increase their staff levels to ensure full compliance with the proposed requirements.


“‘Crackdown’: Proposed Nursing Home Minimum Staffing Rule to Cost the Industry $4.23 Billion and Would Directly Impact For-Profit Facilities.” JD Supra, 19 Sept. 2023,


Profiteering by nursing agencies predicted as providers weigh staffing mandate

Nearly two years after skilled nursing providers first took their concerns about massive nursing agency price hikes to federal regulators, they’re again warning of overreliance on temporary workers due to a federal staffing mandate that could lower quality and raise costs substantially.

The cause of this new concern is the proposed federal staffing minimum for nursing homes, which calls for 2.45 hours per patient day of certified nurse aide coverage and 0.55 hours per patient day of registered nurse coverage. While providers have typically relied heavily on temporary workers to fill their CNA ranks, a new requirement to have RNs on hand 24 hours a day also could drive more agency use.

“It is not hard to imagine that just as the industry seems to be weaning themselves off of agency, this could very easily force them to reverse course,” Fred Bentley, managing director of consulting firm ATI Advisory, told McKnight’s Long-Term Care News. “How else are nursing home operators going to meet the requirements? I don’t see this massive infusion of more RNs or CNAs coming online.”


Marselas, Kimberly. “Profiteering by Nursing Agencies Predicted as Providers Weigh Staffing Mandate.” McKnight’s Long-Term Care News, 11 Sept. 2023,


Unfunded staffing mandate’s financial requirements a ‘fantasy,’ observers say

Though a costly national nursing home staffing mandate proposed Friday offers no new financial support for operators, it could trigger more reporting requirements as the federal government tries to spur states into increasing their Medicaid outlays.

The Centers for Medicare & Medicaid Services’ rule would require each state to calculate and submit to CMS the share of each nursing home’s Medicaid dollars being spent on direct care worker and support staff wages and benefits. The information gleaned through this “Medicaid Institutional Payments and Payment Transparency” provision would be made public.

CMS said it also is considering adding a requirement to capture and make public an average statewide per diem, or daily, rate paid to providers.


Marselas, Kimberly. “Unfunded Staffing Mandate’s Financial Requirements a ‘Fantasy,’ Observers Say.” McKnight’s Long-Term Care News, 5 Sept. 2023,

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