Senior Care Academy - A Helperly Podcast

Senior Care in Crisis: How Government Regulations Impact Quality of Life with Allison Spangler

• Helperly, Caleb Richardson • Season 4 • Episode 3

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The crisis in senior care isn't coming—it's already here. With Utah nursing homes forced to deny 1,200 admissions in 2023 and the state's senior population projected to grow 18% by 2027, we're facing critical questions about how to care for our aging loved ones.

Allison Spangler, President and CEO of the Utah Healthcare Association, takes us behind the curtain of healthcare policy and advocacy. Her journey from hands-on caregiver to policy champion offers a unique perspective on the challenges facing senior care today. "I fell in love with helping older adults, being their family," she explains, describing her early days as a CNA that sparked a lifelong mission to serve this often-forgotten population.

The conversation reveals startling truths about the regulatory and financial pressures squeezing senior care providers. Nursing homes operate with a staggering $100 per patient per day shortfall in Medicaid reimbursement, while navigating what Spangler describes as "the most regulated industry in the nation outside of NASA." This combination creates an unsustainable model threatening access to care precisely when demographic shifts demand expansion.

We explore the crucial distinctions between skilled nursing facilities and assisted living communities, the special challenges facing rural providers, and innovative approaches like Utah's quality improvement incentive program. Spangler also shares her exciting "Stories of Caring" initiative designed to change public perceptions of long-term care by showcasing the dedication of caregivers who make these communities home.

For anyone concerned about the future of elder care, this conversation offers both sobering realities and hopeful pathways forward. Whether you're a healthcare professional, have aging loved ones, or simply care about this growing societal challenge, you'll gain valuable insights into the complex world of senior care advocacy.

Ready to make your voice heard? Connect with the Utah Healthcare Association at www.uthca.org or reach out to Allison at allie@uthca.org and join the movement to ensure quality care for our seniors.

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Speaker 1:

Joining me is a true leader in the space Allison Spangler, president and CEO of the Utah Healthcare Association. With years of experience in healthcare policy and advocacy, allison is at the forefront of efforts to improve care for seniors across Utah. Today, we're going to explore the impact of government regulations, the biggest challenges facing the industry and what we can do to advocate for better policies. So, allison, thank you so much for jumping on.

Speaker 2:

Absolutely. Thank you so much for having me.

Speaker 1:

Yeah, Jumping into it. I always like to learn more about you. So what inspired you to work in healthcare? And then specifically kind of your story that got you into advocating for seniors?

Speaker 2:

I started out as a CNA in high school. I thought I was going to be a nurse. So I did the CNA course and I worked actually in a long-term care facility here in Utah and I fell in love with it. And I still thought, okay, I'm going to go to college, I'm going to be a nurse. I get to college and I hated chemistry. I absolutely hated it and I was like, okay, abandon ship, we're not doing the nursing thing. But I was still working as a CNA and I I just I fell in love with helping older adults, um, being their family, getting opportunity to care for them every single day, help them get ready for meals, for their day, to see their family.

Speaker 2:

You really do become, become their family and you get that chance to see them at really vulnerable places but then also see them grow. And I knew that was a space that I wanted to be in. And so I changed my my route in college and decided to go the business route and I was trying to figure out you know, what can I do with that? And so I thought, well, let's run nursing homes. And so I went to college out of state, came back to Utah, got my MBA in healthcare management and then found my way into a nursing home to do my administrator and training, got my license license and I ran nursing homes for about five years here in the state of Utah and again it just renewed my love and my passion for older adults.

Speaker 2:

I really think that they're a forgotten population in not just Utah but in the nation, and I wanted to dedicate my life to serving them and to serving the people that work with older adults and that are doing this work and caring for these people day in and day out. And so after about five years of working on the administrative side of things, I then moved to Utah Healthcare Association, so I celebrated my 10 years with Utah Healthcare Association this year. It has been amazing. I really love the opportunity to make changes more on that global scale here with UHCA and know that what I'm doing impacts residents, it impacts workforce and really anyone in the long-term care space in the entire state, where before I was working just in an individual facility. Now I have that chance to really make meaningful change and know that my main goal is to ensure that those living in long-term care facilities have resources and the opportunity to have the best quality of care, at whatever setting they're in.

Speaker 1:

Yeah, yeah, it's really cool thinking about when you were an administrator, like you said, you were making an impact on all of the residents within your facility, but then you were running into the barriers with policy and like everything that you had to deal with and so being able to, a decade on the other side, actually make those changes and those impacts that more broadly affect the tens of thousands of seniors that are living in long-term care in Utah. So that's really cool, um on that. So what? Over 10 years now that now you're the president and CEO, which is super cool, um, really running the show on how Utah looks at long-term care and the policies. But what does your typical day look like? What are you doing day-to-day as the president of UHCA?

Speaker 2:

So I mean we are a trade association. A large part of my role is supporting our members. Our members are long-term care and senior living facilities, so our job is to support those workers within these communities and within these facilities so that they can do their job, which is providing great quality care. In communities, every day looks really different A lot of meetings, putting out a lot of fires but the large part of my job really is on the advocacy side.

Speaker 2:

I spend a lot of time lobbying. We large part of my job really is on the advocacy side. I spend a lot of time lobbying. We've got fantastic contract lobbyists that we work with. I myself am also a lobbyist. We meet with a lot of legislators. We do a lot of work during the session. A lot of work outside of the session but really trying to gather stories from our members of what's going on in their communities so that we can share those with legislators. So working with our members on in their communities so that we can share those with legislators. So working with our members touring facilities and really that advocacy piece is huge. The grassroots efforts, as well as just the efforts on our own as an association to change policy, gain favor of legislators, trying to help them really understand and get a clear picture of the sector. Another huge piece of the job is working on the regulatory side here locally and federally.

Speaker 2:

We work very closely with DHHS here in Utah as they're changing rules or as they're providing surveys in the facilities just to better educate ourselves so that we can better educate our members. So it really just is advocacy on many different sides, whether it's legislatively or advocating on the policy regulatory side. We're also working very closely on the reimbursement side. We work a lot with the Medicaid department here in Utah and also Medicare and Medicaid federally at the national level Medicare and Medicaid federally at the national level. But it's really a great opportunity for us as Utah Healthcare Association to be able to be the ones who are sharing the voice of the people that are providing the care in facilities. We have a lot of really great caregivers who deserve their stories to be heard and again, I think that this industry oftentimes gets a bad rap, and so my job is to change that and to change that in the community, to change that federally, to change that with our legislators, and so that's really what we do here.

Speaker 2:

Utah Health Association.

Speaker 1:

Yeah, on the policy change side, what would you say are some of the biggest policy challenges that senior care are facing today?

Speaker 2:

Yeah, I think senior care and nursing homes specifically. So there's two aspects. Maybe it'd be helpful if I back up here, so senior care can be kind of broken down in a couple of different aspects. There's the nursing home side, which is extremely regulated and has a lot of oversight. You're typically getting patients that are a lot sicker. Some come in just for rehab for a couple of weeks and go home, some that nursing home or that nursing facility is going to be their long-term home, whether that's indefinitely or until death.

Speaker 1:

That's typically like a skilled nursing facility.

Speaker 2:

Correct. Yeah, so you may hear skilled nursing facility, nursing home nursing facility, long-term care facility.

Speaker 2:

We kind of use all those terms synonymously and the majority of residents living in a nursing facility are paying for their care through Medicaid. There are some private insurances, you know short-term patients typically are using Medicare, but in Utah over 60% of people residing in a nursing home are on Medicaid. Now you move into senior living side, which is more on the assisted living care. The majority of people living in those homes are on private pay. Medicare doesn't pay for that stay. There are some waiver programs in the state of Utah for Medicaid, but the majority are paying privately.

Speaker 2:

Now assisted living communities also are a lot less regulated. They aren't federally regulated, they're only regulated on the state level and those patients don't typically residing in those communities don't need as much care. They aren't needing that round-the-clock RN coverage. They don't need quite as much extensive direct care staff for their activities of daily living. So there's really a huge difference between those two sectors of the senior living or long-term care industry.

Speaker 2:

And that's really what we focus on when we're talking to legislators is what's the difference? Because that really makes a difference when we are trying to change policy or enact new policies, because something that may be a good change for a nursing facility might not be the same for an assisted living facility or vice versa. So it's really important for us, as we're working with policymakers, to distinguish the difference between the two, so that they both don't get lumped in together with a new rule or a new policy, because that could be really damaging to a particular industry. We don't want a lot of regulations in assisted living facilities, for a reason they just don't. They don't need it. They need certain parameters, they need standards. But nursing facilities they're taking care of really sick patients, so we understand that there's a lot more policy that goes into that.

Speaker 1:

Yeah, and a lot of times I think you can see like too much policy. We had Adam Benton on the podcast from Stellar about a year ago and he was trying to I think it was a Colorado facility or something, but he was trying to put in a ice cream parlor that was ran by adults with different disabilities or different abilities and he said something along the lines of like if they want to stop us, they could go to hell or something like that. Like when you get so much regulation, sometimes it can hinder doing good in one of those things. So it is an interesting kind of balance of like which regulations are needed, which ones help the facility, which ones hurt the facility, like just add more administrative overload to an already administratively heavy industry. I'm curious on how government regulations on that line impact the quality of care that the residents are getting in the facility. Like do you see what? I guess, what government regulation have you seen have the biggest positive impact within the facilities?

Speaker 2:

Yeah, you know, you just summarized policy and burdensome regulations really well. There's this joke out there. I think there is some merit to it. But we joke in the industry that nursing homes are the most regulated industry in the nation outside of, like NASA. And you know, nuclear, not nuclear. But you know, like space exploration and you know those type of you know big scientific industries and I really actually believe that to be true.

Speaker 2:

I think there is a lot of extensive oversight and major burdensome policies and regulations that are just excessive, major burdensome policies and regulations that are just excessive. And I think for decades federal bureaucrats really have doubled down on these excessive and really punitive systems that I think fail to produce real change. You know, they just continue to pile on regulations, guidance, penalties. It just ends up being this hamster wheel effect and then they're also administering enforcement really disproportionate. It ends up being very subjective instead of objective, which to begin with the policies are supposed to be everyone following the same thing. But when you get different people coming in to provide surveys or people interpreting rules different ways, again it just becomes really burdensome and it becomes difficult and I think the system right now as it is is very inconsistent and ineffective and in my mind, the way the system is, it's not driving quality improvement among these nursing facilities or senior living facilities to enhance the quality of care, and I think that's a real problem and a huge opportunity for change. We've been really excited about the change of administration and some of the things that it's brought. Cms has put out some requests for information to the many associations throughout the country and we're excited about what that means because it gives us the opportunity to respond and say here's how much oversight's happening. Here's why we think that it's burdensome and why there needs to be a change with these long-term care facilities so that we can focus on quality of care. You know, you find a nurse becomes a nurse because they want to help people, but then a nurse gets promoted to be a nurse manager and then what little do they know that they're going to be burdened with a lot of paperwork and a lot of rules and policies that they have to follow. That may seem at first glance like a really good idea, but the more you dig into it, sometimes I think we're wasting resources when those nurses could be providing the care that they need or coming up with innovative solutions for quality of care or for ways to improve the industry. So I think you know Utah has done some really good things with changing a policy or adding things to promote quality of care. We've got a really great quality improvement incentive program that really, like the title says, incentivizes facilities to look at quality and to have quality improvement and to make innovative changes. They get a little bit of extra money to do this, but they have a lot of stipulations that they have to follow, and I think that is a good trade-off. Value-based payments and value-based care is really popular right now. We're giving you this funding and what are you going to do with it and how are you changing? And I think people respond really well to that. They really do. The caregivers and the people that are running these facilities really want to do what's best for the people living in their facilities.

Speaker 2:

But when you're burdened down by hefty rules and policies and then to add on top of that the enforcement, the civil money, penalties, it can be really discouraging.

Speaker 2:

And because of that there have been a significant amount of closures throughout the country of nursing homes because they just following the rules are really expensive, or they have infractions and they can't pay the fines, or just, you know, lack of reimbursement there's.

Speaker 2:

You know, there's a lot of things that go into it. So I think overall there needs to be an overhaul of changing federally and then I think states then can continue to follow suit and making things, you know, easing those regulations and those policies. I think another thing that Utah has done policy-wise has been implementing home and community-based waiver programs. That has been really beneficial for a lot of seniors in Utah because they can't care for themselves at home anymore or they need a little bit more care in the home. So there's a waiver program that allows them to do a couple of things, to have some additional care at home under a Medicaid waiver program, so that they can afford it or reside in an assisted living community under that Medicaid waiver program which helps supplement that care to where they can afford it, and I think that's where it's really needed most.

Speaker 2:

There are a lot of low-income seniors out there and, as you know, the amount of older adults aging into the system is growing exponentially. In Utah by 2027, it's going to grow by 18%. That's a huge number. We're also going to see in Utah a decline in caregivers, which you know is historically in Utah we take care of our own, but we're seeing now the cost of living. People can't afford to have two parents stay at home anymore, two people in the home, or one person stay in the home and one person work. They need two people working. So we're going to see a decline in caregivers, an increase in older adults. So having programs like these Medicaid waiver programs or Medicaid program in general for seniors to live in a nursing facility long-term are really beneficial for people that are going to need this care. Moving forward.

Speaker 1:

Yeah, you touched on one of the points, but I'm curious what you think the biggest gaps are currently in the healthcare system when it comes to senior care. I think there is a huge gap, one of my biggest pet peeves, and I wish that there was a solution. But like a sliding scale. It's like Medicaid pays for it but if you make $10 more, you have to come up with $3,000 to cover or $10,000 to cover your own bills. Anyway, we've seen that a lot with people that need, even like caregivers, where they need money, but they're like I only can work this many hours or else I lose all my benefits, and it's like. It's like so tricky, and so I'm curious that's, of course, one, but what other big gaps do you see in the health care system when it comes to supporting seniors?

Speaker 2:

I would say the largest gap is reimbursement for the facilities, for the assisted living side on the waiver or for the nursing home side, just on their Medicaid rate. And the reason I think that's a big gap for senior care is because currently both assisted living and nursing facilities are operating in a significant shortfall for Medicaid. So, for example, nursing facilities operate about $100 per patient per day in a shortfall. So if they're receiving I'm just going to throw out some numbers out there around $230 per patient per day, and sorry, I'm like totally getting into the weeds on this.

Speaker 2:

It's okay, I'm all about math, but I think it's important for people to understand why this is an access to care issue. Because if nursing homes are not receiving the reimbursement that they need to care for a patient, so if it's $100 a day shortfall, then that is $100 a day that they have to make up somewhere and that means that that's money that they have to cut because they're not receiving the full amount of reimbursement from the state for their Medicaid patients. And when 60% of patients in the state are on Medicaid, that is a large chunk of people residing in our facilities that we are not being wholly funded for is a large chunk of people residing in our facilities that we are not being wholly funded for and costs keep rising. Their supplies, their workforce, potentially their rent, their mortgage, whatever it is. All their overhead is significantly increasing and their Medicaid rate increases maybe at a very slow amount. If we're lucky, the legislature has been very generous in the last few years that we have gotten some rate increases. Very grateful for that, but we still have a long way to go to be whole.

Speaker 2:

And that gap, that shortfall, then becomes an access to care issue, because if you are not receiving the full reimbursement that you need, that means that you can't increase wages as much as you want to, so you can't be competitive.

Speaker 2:

It's a very difficult-finding workforce. A lot of your money is having to go to expensive supplies and DME and things to support the people in your facility. But if you're having to pay for those things, you're going to have to consider well, I've got these very subacute patients. Can we afford to take more with the limited staff that we have? Because we all know we're still in a significant workforce shortage? So it's just all these things that stack up, and what that means is can these senior living communities, can these nursing facilities, really remain viable at a time that seniors are going to need them the most and that will become an access to care issue In 2023, nursing homes in Utah had to deny around 1,200 admissions because they didn't have the workforce or because they just simply couldn't take these patients because of cost constraints or workforce constraints. That's a significant number that I would anticipate. That will only grow if we don't find some way to make changes.

Speaker 1:

Yeah, if we're growing by 18%, then that 18% of 1200 is another 40, 30, 40 people that just don't get care after an injury, an injury, yeah, when you go to lobby for these improvements and these increases, how, I'm super curious on the backside, like where are you saying you know this? Funds, like? One example I could say is like maybe if Medicare or Medicaid pays the actual amount instead of having that lower amount, then we're able to help more people. They live longer, like where, I guess, what levers are you trying to pull as an organization to say like we need the funding and here's our ideas of where we can potentially get it from to help seniors?

Speaker 2:

Yeah, I mean I think it's really easy to go up there and highlight rural facilities. We have a lot of rural communities throughout the state of Utah and if you think about a person who grew up in a very small rural community they worked there, their family is there they come to a point in their life where they need long-term care, whatever that means, but the local long-term care facility just closed because they weren't getting enough funding or because of burdensome regulations or fines. Where does that person go? Then they end up going somewhere two, three, four, 500 miles away, getting completely dispersed from where they grew up, from where their family is, where their community is. I think that's a really easy selling point for us to the legislature. We have a lot of amazing rural legislators in our great state that are sympathetic to that and understand that. So that's one really strong selling point that we have.

Speaker 2:

I think also it's easy to tie it back to workforce because no matter what the legislators do, what their profession is, they all are seeing the workforce shortage. I mean you can go everywhere and see that there are not enough workers. You go to Jersey Mike's and the line is an hour long because they don't have enough workforce. You go to the grocery store, the lines are long, your food costs more. I mean, it's so easy to show that the cost of workforce is a lot more, there's a shortage of workforce the cost of care, but really framing that in a way that they understand, trying to get personal helping them, helping them understand like what if this was your loved one, you know, we, we want them to have good care, we want them to have access to care. Access to care is really important to legislators, and so I would say those are, you know, a lot of the, the, the main points that we make when trying to advocate to, to policymakers.

Speaker 1:

Yeah, and to your point on the rural communities. It's one thing if the community shuts down, but it's also another thing when you have a population of 2,500 and everybody's like oh, you don't want to work at the nursing home because you don't get paid, like it's really quickly to go around, and then all of a sudden you're cycling back through of like oh yeah, I worked here four years ago.

Speaker 1:

We just need some money, so I'll be here for the next three months and then they're cycling through the same 2,500 people trying to keep it staffed. So it's-.

Speaker 2:

Yeah, 100% correct. They have such a small pool of workforce in that small community it is it's a double-edged sword access to care, but also the staff to care for them.

Speaker 1:

Yeah, Going back to something you said earlier of like a lot of your time is spent on trying to kind of change the stigmas around long-term care. What does that look like? Like? What are you guys actively doing to try to make it so people don't think of nursing homes as the nursing homes of the seventies? That are like where they've said their mom, that's like terrible.

Speaker 2:

Oh my gosh, I know I it's. It's so wild that people still think of the nursing homes from the 70s and the 80s because things have changed so much. I mean you'll see the person centered care, focus. They've completely remodeled and refocused how they look. I mean listen it's still.

Speaker 2:

It's still a long-term care setting and I understand that nobody wants to live there, but we are making some strides and I think we just encourage the public to come and tour, we encourage legislators to tour. But one of the things that I'm really excited that we're working on is our Stories of Caring series. We have not debuted it yet, but we are going into our communities, into our member facilities and interviewing caregivers.

Speaker 2:

We are trying to understand why they work in long-term care, what they feel in their day-to-day work makes a difference or gives them meaning. And so, because of that, we're taking all these videos and we're putting them together to have 20-second clips or a minute clips or, you know, whatever it is for us to share with legislators, for us to share with our members and to use, just in marketing in the general, to try to, you know, bring more positive light to the industry. And this is going to take a long time. It's going to take a long time to change people's mind. Covid gave us a really bad rap. You know that we're going to continually work to grow our way out or to claw our way out of that hole, but I'm really excited about our stories of caring. I think that that's going to be a really good marketing tool for us to spread some goodness in the community. And it really is that feel good of, you know, getting to see these caregivers and how meaningful the work in long-term care is for them.

Speaker 1:

Yeah, no, I love that. I think that'll be awesome and that's really the biggest lever. I think that a lot. I think, just in general, that the senior care space, long-term care and in-home care, like it's yet we've yet to see them fully come into the digital era of using video and content and brand and all of that to actually showcase, like, what is happening. Um, and so it's cool that you guys are working on that. I love that. Um, we're already at time, which is crazy. Um, what message would you give to someone who wants to make a difference in senior care advocacy, a difference in senior care advocacy, I would say let your voice be heard.

Speaker 2:

There are so many amazing caregivers and supporters of long-term care, especially in our great state of Utah, and it is so much easier for me to do my job when I can understand the passion that is from these caregivers, the passion that these caregivers have and the stories that they have. There are so many good things happening in our communities throughout the state and we want to be able to share them. So my advice to people working in long-term care or that have a passion in long-term care is to let your voice be heard. Reach out to places like Utah Healthcare Association or wherever you can, so that we can share your story or help us understand your concerns. Where do you feel that there needs to be changes? You guys are the ones in the front lines working every single day. Let us be your big voice, but share that with us so that we can try to enact change.

Speaker 1:

Yeah, I love that. Who should reach out to Utah Healthcare Association if we have administrators or people listening? Who do you want to work with?

Speaker 2:

I mean you're always welcome to reach out to me. My email is super easy. I mean you're always welcome to reach out to me. My email is super easy Allie A-L-L-I-E at U-T-H-C-A dot org. You can always go to our website, wwwuthcaorg. We have a great staff here. We want to help you. We want to be a resource for you.

Speaker 1:

Please let us do that. Awesome. This has been so awesome, allie, really great insights, and I love what you guys are doing to help seniors across Utah. So thank you for giving some time.

Speaker 2:

Yes, thank you so much. I just appreciate the opportunity. Anytime I can talk about this industry, I'm here for it. So thank you.