Earlier this summer, it seemed things were improving within the nation's convalescent long-term care (LTC) facilities. Severe COVID cases and deaths dropped sharply following the federal government's push to vaccinate residents and staff in what has been the pandemic's most deadly setting: the nursing home.
But as the Delta variant surges across the country, cases and deaths are rising again. CMS data indicates that weekly cases in nursing homes have surged over 11-fold since the week ending June 27, and weekly deaths have surged more than 5-fold. While the numbers are still far below the pandemic's devastating stretch last winter, the trend is not heading in the right direction.
To combat the latest threat, President Biden announced that, for all long-term care organizations that accept Medicare funds, staff must be vaccinated against COVID-19 – or risk losing their Medicare funding.
If LTC companies lose Medicare revenue, their business models would collapse. As of May 2021, the National Investment Center for Seniors Housing & Care (NIC) reported that over 80% of nursing home revenue comes from Medicaid and Medicare, including managed Medicare plans.
Many long-term care residents and their families would welcome a vaccine mandate for people who work in their facilities. But LTC facility operators have expressed concern that vaccine mandates for staff who are hesitant or outright against vaccination will leave their jobs, with some expecting the loss of 20% or more of their workforce. The worry is understandable; the LTC industry has a deep understaffing problem, which has accelerated during the pandemic. Given that many nursing home residents need around-the-clock care, a further shortage of nurses and personal care aides will all but certainly make matters worse.
Mark Parkinson, the president and CEO of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) – which represents more than 14,000 LTC facilities nationwide – says a mandate applied to all health care workers would prevent LTC workers from leaving to work in other health care settings.
But is such a threat from staff serious, or is it overblown? An early look at healthcare providers that have implemented their own staff vaccine mandates sheds some light on this question.
Currently, about 39% of health systems have employee vaccination mandates in place. Houston Methodist hospital was the first to implement a mandate, and later became the target of an unsuccessful lawsuit by employees to overturn it. Houston Methodist pressed forward with a deadline of June 7 for its 25,000+ employees to complete vaccination. The result: only 153 either resigned or were terminated for refusal to take the vaccine, despite nearby options to work at facilities without a mandate.
Genesis Healthcare, one of the largest LTC operators with nearly 250 nursing and assisted living facilities in 23 states, announced a vaccine mandate in early August, requiring all staff at minimum to receive the single-dose Johnson & Johnson vaccine or the first of two mRNA shots by Aug. 23. While data through that deadline is due to be released by CMS later this week, preliminary data shows several Genesis-owned facilities have experienced sharp increases in staff vaccination rates while still avoiding shortages among clinical, nursing, and personal aide staff. (While the company is reporting that 100% of staff have received at least the first dose, the company has not released information on how many employees have resigned or how many the company has or plans to terminate for noncompliance to achieve 100% vaccination.)
There are several potential reasons why an exodus of vaccine-refusing staff – including those in nursing homes – hasn't materialized, even though public polling indicates many healthcare workers would walk if vaccines were required.
For some, the prospect of termination or having to resign may be acceptable in pursuit of a worthy cause, at least in theory. But in reality, a job change can be disruptive and difficult for workers and their families. Besides the usual transitions associated with a job change, vaccine-hesitant healthcare workers have to consider whether they have a realistic chance of securing work within the healthcare field since they will have to explain to potential employers why they quit or were fired for refusing the vaccine. In addition, the evidence of the vaccine's efficacy and safety, coupled with the FDA granting full approval for the Pfizer-BioNTech version, continues to assuage concerns from some staff, who are hesitant out of a sincere desire to have more information before proceeding. Finally, many healthcare providers are minimizing staff turnover by combining mandates with personal outreach to educate staff.
It is also worth noting that any loss of staff objecting to vaccination must be balanced, at least in part, by the potential for staff to miss work if they test positive for COVID. The nursing home industry nationwide is seeing this already, with staff cases increasing from 496 for the week ending June 20 to 5,855 for the week ending Aug. 15 – an increase of nearly 12-fold.
In drafting the interim final rule on COVID vaccine mandates in LTC facilities, the Biden administration will have to consider what percentage of staff vaccinated is acceptable to meet its requirement, the severity of penalties for noncompliance, and what exemptions, if any, are permissible. One thing Biden should not worry too much about, however, is whether staff will quit over it. Evidence suggests the threat is exaggerated.