Reopening Virginia’s nursing homes could hinge on sweeping new testing requirements. No one’s sure who’s picking up the tab.

The key to reopening Virginia’s 287 nursing homes lies in dramatically expanded testing for residents and staff, based on recent recommendations from the federal Centers for Medicare & Medicaid Services. 

The lingering question is who’s on the hook for the cost. In the roughly two weeks since CMS released its guidelines on May 18, the Virginia Department of Health — responsible for adapting the federal recommendations and handing them down to the state’s nursing facilities — is still “working through the guidance and trying to turn it into something more useable” said Sarah Lineberger, director of the agency’s health care-associated infections program.

The CMS memo directs states to begin implementing recommendations “immediately” and Lineberger added that VDH hopes to release Virginia-specific guidance by the end of the week. But while the agency hasn’t finalized all the details, both she and Kim Beazley, the deputy director of VDH’s Office of Licensure and Certification, said it’s likely that its directives will be consistent with those set by CMS. 

“We are expecting to essentially align with their testing recommendations, at least in the initial phase,” Lineberger said. For nursing homes in Virginia to move past the first phase of reopening — lifting many of the current restrictions on outside visitors and group activities — that means VDH will likely adopt guidelines asking every facility to conduct a baseline test of all residents and staff members.

Even more importantly, VDH is likely to retain a recommendation for nursing homes to test staff on a weekly basis, Lineberger added. That becomes especially important as the rest of Virginia begins to lift social distancing restrictions, allowing health care workers to go out in public.

“Nursing homes have been closed to visitation, but obviously staff members are still going in and out,” Lineberger said. “And staff members live in the community, so the idea is that staff can bring COVID-19 into facilities just by going about their day-to-day lives.” 

Some of the country’s worst nursing home infections — including an outbreak at Canterbury Rehabilitation & Healthcare Center in Henrico that led to 51 deaths — are believed to be caused by asymptomatic employees passing the virus onto residents.

Additional details on the state’s guidelines won’t be clear until their final release, including how VDH plans to ensure compliance with the reopening plan (though Beazley said some recommendations would be incorporated into her office’s survey process for nursing facilities). What is clear is that even modified guidelines would require nursing homes to dramatically expand their current testing programs, which in some cases have been almost nonexistent.

In recent weeks, VDH has begun performing broad baseline testing — better known as point prevalence surveys — at nursing homes, largely thanks to funding and assistance from the Virginia National Guard. But of the state’s 287 nursing facilities, only 42 have been tested, though nine surveys are currently in the works, Lineberger said.

State-provided prevalence surveys are free for nursing homes, but it’s unclear how many facilities have independently pursued baseline testing. “I don’t think we’ve even contacted all of them to know that,” Lineberger added.

And while VDH is hoping that the National Guard will eventually test all 287 nursing homes, troops are also conducting point prevalence surveys at other congregate facilities, including state prisons. Gov. Ralph Northam announced last week that the federal government will continue reimbursing the Virginia National Guard through Title 32 status until August 21, but it’s not certain how long troops will remain deployed for COVID-19 response efforts.

“Once the federal government decides to shut off that resource, we’ll have to find other ways to support testing in the long-term, because this is not going away anytime soon,” said Dr. Danny Avula, director of the Richmond and Henrico Health Departments. 

He added that it’s far outside the norm for facilities to pursue widespread testing on their own. Multiple state officials acknowledged that some nursing homes have declined point prevalence surveys from VDH (Avula could think of at least two in his district). Many nursing homes — historically understaffed and low-funded health care settings — are afraid that baseline testing might expose large numbers of asymptomatic employees, who would then be required to isolate for two weeks, exacerbating existing staffing problems. 

In April, the federal government also required nursing homes to begin reporting cases to the Centers for the Disease Control and Prevention, with plans to release facility-specific data later this week, which could further dissuade them from widespread testing, Avula said.

“It’s not the local folks — it’s the corporate leaders who are expressing resistance and not being aggressive about testing asymptomatic individuals,” he added. “Because ultimately it means that they then have to hold folks out and are worried about their ability to sustain an operation.”

At the end of the day, experts say it comes down to cost. VDH estimates there are roughly 30,000 nursing home residents in Virginia and 30,000 employees, with a per-test cost of $100 to $175. Based on those estimates, it would cost between $6 million and $10.5 million to test every resident and staff member in the state.

Dr. Jim Wright, the medical director at Canterbury Rehab, said most nursing homes are more worried about the staff testing requirement. According to Beazley, Medicare will reimburse up to $100 per test for residents. The agency doesn’t currently compensate facilities for the staff time it takes to administer the test, but some nursing homes — like Canterbury —  have been entirely reimbursed, depending on how much they pay per test.

However, when it comes to staff testing, most nursing homes are on their own. Wright said that Canterbury, which implemented a rigorous testing program as it worked to contain its own COVID-19 outbreak, began proactively testing 25 percent of its 117 staff members every week after the new CMS recommendations first came out. 

“In lieu of any established requirements, the thought was that we would go ahead and start testing anyway, in hopes that VDH would issue guidance on what percentage of your staff to test and it wouldn’t be 100 percent,” Wright said. The facility currently pays $50 a test from a private lab, and Wright said it would cost nearly $6,000 a week to test all 117 employees. 

He’s exploring whether his employees’ insurance plans will help cover testing, but Canterbury’s corporate owner, Marquis Health Services, is currently absorbing the full cost. Wright said the facility is committed to paying for testing if an employee’s individual health plan won’t  — “at least for right now” — but “it’s not ideal.”

“We are part of a large corporation that owns a lot of facilities and does have financial resources,” he continued, “but it can’t go on forever without it affecting operations. You can’t continuously spend that much money and not have it affect staffing or your environment or something. Margins are very thin, usually, in long-term care facilities.”

“I think what would be ideal is for the state to absorb the costs,” he added. “Have the state provide equipment, provide the cost of administering the tests, and, if needed, provide the manpower. Those are the things we really need.”

A question of cost

Virginia Finance Secretary Aubrey Layne said the price tag attached to expanded testing has become the main sticking point as VDH works to draft and release the guidelines. 

Cost concerns are nothing new for long-term care facilities, he added, but the current COVID-19 pandemic at the facilities — which as of Wednesday accounted for 10 percent of the state’s total cases and close to 60 percent of its deaths, according to VDH’s public surveillance dashboard — has exacerbated long-held tensions over funding. Many nursing homes say their operation costs are skyrocketing as they work to contain or prevent the virus. CEO Melissa Andrews of LeadingAge Virginia, an association of nonprofit senior living centers, previously reported one member that spent $180,000 on personal protective equipment in a single week.

So far, there’s been little direct aid to nursing homes themselves. Layne said the state has allocated $42.3 million of its roughly $3.1 billion in federal CARES Act funding — the national coronavirus relief package — to testing efforts, which has benefited nursing homes through increased point prevalence surveys.

In early April, Northam also dedicated an additional $20 per patient per day to nursing homes through the Virginia Department of Medical Assistance Services. The added reimbursement came from the state budget, but Layne said it didn’t require additional spending because the state was able to redirect Medicaid reimbursements that ordinarily went to hospitals for elective procedures.

From March 25 to the end of April, hospitals were banned from performing those operations to conserve space for COVID-19 patients. Layne said the savings will continue to go to nursing homes through the end of June. But moving forward, the state will need to look at its budget to see if the additional reimbursement can continue, and — if so — how they’ll be funded.

“We’ll have to do a reforecast to determine if, in fact, those rates have to change or we have to put more money in, depending on the utilization,” he added.

As an added frustration, nursing homes haven’t been able to regain money through federal or state assistance. Layne said while Virginia’s hospitals received roughly $170 million in direct federal aid, nursing homes didn’t get anything. Some of the state’s largest senior care associations asked for a share of CARES Act funding to recoup some of those costs, but Layne said Virginia, like all states, is forbidden from directing coronavirus relief dollars to replace lost revenues.

Recently, industry leaders modified their request, asking the state to allocate some of its federal funding toward higher Medicaid reimbursement rates for nursing homes, Layne added. But there’s concern among some state officials over sending more money to facilities that, in some cases, are owned by for-profit companies with poor records of care. 

Layne said it’s been exacerbated by the fact that some facilities have declined point prevalence surveys out of fear of losing employees.

“That’s the debate,” Layne said. “It gets back to the whole decision of how much should be left to them and how much should be the public’s expense. We’re concerned about making sure that from a public health standpoint, from a public dollar standpoint, we are there to help the residents. We want to make sure the money goes to benefit the residents and it actually changes things.”

Stretching already strained facilities

Joani Latimer, who advocates for nursing home residents as the state’s long-term care ombudsman, said there are legitimate concerns over bad actors, even in a traditionally strained industry. “I think some providers do a much better job of maximizing resources to meet resident needs than others, and the results really show,” she said.

One of Latimer’s recent, and gripping, complaints came from a family whose relative began showing symptoms of COVID-19 in a nursing facility. “They were able to ‘see,’ through their conversations, that the resident was having these symptoms, but they were running into significant challenges to get any kind of testing, or really, any attention at all,” she said.

Finally, the family drove down to the facility to take their relative to the hospital. The resident later died of coronavirus, Latimer said. But she also pointed out that nursing facilities, in Virginia and across the country, are often limited by reimbursement rates that don’t always meet the cost of providing care, affecting everything from facility maintenance to staffing ratios.

“I know we’ve heard of situations where, especially on a night shift, there might have been two [certified nursing assistants] to 60 residents, which is concerning, obviously,” Latimer said. 

She, along with Wright and Avula, also said the expanded testing requirements were likely to significantly impact nursing home operations, from personal protective equipment to staffing to expenditures. Wright, who’s coordinated multiple rounds of testing at Canterbury, says it requires training workers to administer the swabs and giving them the appropriate gear to shield against the virus. 

For facility-wide testing, it generally takes at least two staff members anywhere from two to three hours, he added. CMS recommendations also call for nursing homes with existing COVID-19 outbreaks to regularly test everyone in the facility until there are no new positive tests — which could represent a significant staff and resource investment for the 217 nursing homes in Virginia with outbreaks of the virus.

In many cases, state assistance already hasn’t been as extensive as expected. Wright said it’s been clear that the state’s six regional health care coalitions — run through a partnership between VDH and the Virginia Hospital and Healthcare Association — don’t have enough personal protective equipment to fully meet the needs of nursing homes. Last month, VHHA’s director of emergency preparedness reminded facilities that state-ordered equipment would be distributed based on “urgent need” — a supply of seven days or fewer or an unplanned shortage.

At the same time, normal supply chains have been severely disrupted by the pandemic, with many suppliers prioritizing hospitals or large health systems, said Keith Hare, president of the Virginia Health Care Association-Virginia Center for Assisted Living. That’s made it especially challenging for nursing homes to procure protective equipment on their own.

“I’ve heard of some of my colleagues turning to Amazon, trying to get masks and gowns at exorbitant prices,” Wright added. Canterbury has largely been shielded from the shortage by its large parent company, making it one of the rare nursing homes in Virginia that’s not forced to reuse supplies.

“I’d hate to be an independent facility trying to get PPE now,” he said. “I don’t know where you’d go.”

Latimer said the state’s Medical Reserve Corps, a group of volunteers that Northam has said could help relieve staffing issues at nursing homes, has also been less helpful than expected. “For one thing, you can’t immediately call them and have them come the next day,” she added. “And they’re only short-term. But those care needs, and the dedicated staffing needs, if a person tests positive — those go on for a long time.”

“The Medical Reserve Corps isn’t close to meeting the need,” Avula added, especially given that prevalence testing is likely to pick up anywhere from five to 20 health care workers with asymptomatic cases of COVID-19. Those issues — particularly the concerns over personal protective equipment, funding and staffing — are something the state will have to address to move forward with reopening nursing homes, he said.

“There’s a lot of people who would probably be amenable to doing much more active testing if we can figure out the staffing and reimbursement,” Avula continued. “If there was a really clear pathway to getting reimbursed for the tests, covering the staff time of people doing the test, and then to have the staff, period, then I think a good percentage of our facilities would be onboard.”