Clif Porter

Scott‍

Hi, welcome to VERSED Podcast powered by VIUM Capital. We'll be hearing from leaders all across the long-term care sector who are shaping the future of our profession. Through these discussions, it's our hope that you'll be even more well-versed as you tackle your day in seniors' housing and healthcare. I'm your host, Scott Tittle, and this is VERSED.

Clif Porter of AHCA/NCAL, Senior Vice President, Government Relations. Hey, Clif, welcome to our podcast.

Clif

Scott. Good to be here. Good to see you.

Scott

Man, it is an honor to have you. We've been friends for a long time. We've fought a lot of battles together, both at the state level and also in DC, and had the opportunity to work together at AHCA/NCAL for my six years there. So it's an honor to have you here for all kinds of reasons. We could talk about a ton of topics today, but I really want to get your perspective on some hot topics, both at CMS and Capitol Hill and then kind of a look ahead to 2024 and your perspective. And so I know our listeners are really going to enjoy this. Before we get started, I just want to say congrats on all the awards you've received recently. For those listeners who don't know, man, Clif is just being acknowledged and recognized for all his hard work during Covid and post-Covid, but recognized as one of the Hill's top lobbyists of 2023, and McKnight's Pinnacle, industry Ally Award winner for '23, so incredibly well deserved Clif, and congratulations on all your success recently.

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Clif

Thank you, Scott. Appreciate it.

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Scott

Yeah, a lot of people know you in your current role, but you've been in the industry for a long time, probably your whole career, really. Maybe give us a little bit of background of where you have been before AHCA/NCAL, and really how you got in the business initially.

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Clif

Scott, I appreciate you asking me that because frankly, that is really where my roots are. Believe it or not, this year is my 35th year in the business. I was in undergrad, majored in Healthcare Management, and basically became a licensed nursing home administrator. I took my exam about a month before I graduated. I am a lifer. I've been doing this since 1989. Started in a 34-bed nursing home in Stafford, Virginia. First real project was to get Medicare certification that was, they were an all-Medicaid building and private pay, and they needed to get Medicare certified and start doing rehab and that kind of thing. And we converted a little wing. And for the first 15 years of my work life, I was in facility operation. So I've run facilities as small as 34 beds.

I've opened facilities. My last building I ran was a 218-bed facility outside of Washington, DC. Yeah, so as you could tell, I'm an operator at heart. Became a Regional Vice President for ManorCare and ran the Washington, DC market for them for about six years, and then got into government affairs, started ad hoc. And then ultimately my boss, who was the chief operating officer of ManorCare saw what we were doing ad hoc and decided that he wanted to build a GR function within the company. And ManorCare was a very big multi-state chain as folks remember, and didn't have a GR department. So they sort of asked me to set that up, which I did then came to AHCA. So that's that's my career in a nutshell.

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Scott

Thanks for going through that Clif. And I think I wanted people to understand your background because I think that's what's made you such an effective advocate on the front lines because you've done it. You've been at every perspective and every point of the buildings, run the buildings, know what the residents are like, know what the staff's like, know what those pressure points are like, and you can speak in real-time to members of Congress and staff of what it's like. And I think that makes you an incredible advocate, so thanks for walking through all that. We met back, I think in 2010 when I started at Indiana Healthcare Association, you were at ManorCare and part of our senior team there. So thanks for being so kind to me all those years back then. Boy, the sector really pushed back last year on President Biden's mandatory SNF staffing ratio proposal, over 40,000 formal comments, which just blows the doors off any record in any prior formal comment period for a CMS rule. Maybe just tell our listeners where things stand now and what some next steps could be with the rule.

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Clif

Honestly, I think every year there's some existential threat that we're always faced with, but you know, we never in our, imagination would've experienced something like that. And we not only got through it, but I think we survived and are now thriving and are better because of it. But, you know, once you get that behind you, you kind of say, okay, ah, whew we can, we can get on with rebuilding. And then the Biden administration makes this proposal, which was for me a big bucket of cold water thrown right on our faces as we are still in the process of recovery. In this business, we used to always joke and say that, memories are short and memories are really short when it comes to policymakers in DC and this is just one of these policies that makes no sense.

Particularly, considering the timing of what we're coming out of the facts around the fact that we have a structural deficit of clinicians in this country. It's not just a nursing home, a long-term care problem, it's throughout the entire healthcare system. What we've decided for some crazy reason is that we need to mandate more staff in one specific sector of healthcare. To your point, our members have just been phenomenal in the response we had over 18,100 or so comments. And we've had a tremendous amount of coalition partners as well that work with us on articulating why this doesn't make sense. Namely the American Hospital Association many nonprofit and faith-based organizations. The nice thing is that there's just a significant diversity of voices that are speaking against this particular proposal. And at this point, we're waiting on the finalization of the rule due to the voluminous comments that were submitted.

We don't anticipate that that finalization can even practically happen at the earliest until the summertime, just because they have to go through every comment by law. And then from there, the rule will be finalized and we're hopeful that our voices have been heard and that it will be moderated. But we've had, you know, a tremendous amount of congressional support. That's kind of where we are, and our goal this year is really going to be to push, to advance that legislation, and continue to put pressure on the administration to do what we consider to be the right thing, moderate this proposal in a manner that's gonna make it practical and implementable.

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Scott

We've talked with some prior guests specifically from certain states about what certain states have done with respect to staffing levels at the state level. And some of those have been very workable. And, again, I think we want to highlight and emphasize, you know, the sector's not against staffing mandates. It just must be reasonable, workable, funded. And you know what, boy, there's just gotta be some funding there. I mean, just to ask the sector this time to step up and, and pay for additional staff when the funding is just not there. And Medicaid still is chronically underfunded, right? So, are those some of the ways you're talking about?

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Clif

Yeah, no question. All those points are appropriate points. The real key is, again, just making sure that we've got the staff available to hire. We're just ignoring what the obvious is and a cataclysm from a staffing perspective, registered nurse and caregiver staffing supply perspective based just purely on demand and the demographics in our country. So we're going to see a continued explosion of the 85-plus population, and that population is the greatest consumer of healthcare. And so the need for nurses in every setting, not just nursing homes, but in every setting, is going to explode. And if we don't do something now, and I mean now to address wholesale supply from immigration to education, technical schools, to training programs, to regulatory, it's just so many things that we have to do to prepare for that tsunami because if we don't, by the time that I need those services, I might not be in a position to get them.

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Scott

And Clif just give, for our listeners a contextual point, AHCA/NCAL has put out some data that we're about 150,000 employees short still of pre-pandemic employment levels. So, we're in a huge hole now and then the President comes out with this proposal to hire more staff and not provide any funding. And by the way, the staff isn't there to hire anyway. So let's talk about immigration a little bit. And I've heard you use this great phrase, "Let's focus on something really comprehensive, almost like a new deal approach to workforce solutions in healthcare." You, I think you hit some of those prongs there a little bit, but a lot of people say, "Hey, immigration is the answer." What are your thoughts about that? Can it be the answer and what can really meaningful immigration reform look like?

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Clif

Is it the answer alone? No, but as a part of the answer, yes. We have an immigration system now that is unfortunately overly influenced by politics and not based on what our economy needs in the moment. And I think that there are some very common sense approaches that can be undertaken that would help us improve the supply of caregivers in our country. One of them is we're not in any way saying that there should be illegal immigration, but we can, we have jobs for people today. And if we could position ourselves to bring in particularly registered nurses in certain key clinical categories similar to what we do with Ph.D. engineers for software, we do it now. And we allow special considerations for allowing folks to come to the country to do that. We ought to be doing the same thing for healthcare.

It has to be like a big new deal kind of approach. Regulatory relief is a big solution. We've got regulatory construct, particularly in long-term care, where we spend way too much time on paper and compliance. And if we simply resolved and revise some of that and alleviated some of the duplicative aspects of the regulatory construct that we had, that would alleviate and allow nurses, registered nurses, licensed nurses to actually spend more time at the bedside, which would help solve the problem. How can we get regulatory relief to have our own training programs? We've got a couple of pieces of legislation that address that, that would allow us to better train and be able to develop CNA programs and keep those programs alive in markets where they're woefully needed. Temporary nursing assistance. You know, I use that term, that was something that was used during the pandemic. The reality is those kinds of programs that you sort of have an entry-level category that can ultimately progress through a career path all make good sense. Loan forgiveness, I mean a variety of things. So student faculty for nurses, how do we better fund faculty, RN faculty at nursing schools around the country to ensure that we have more supply of nurses?

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Scott

And for our listeners who are trying to feverishly keep up right now and take some notes I just want to let everybody know, we're going to put out a follow-up piece called VIUM Voice and an advocacy piece for the year to let people know what they can do, how they can follow up with their members of Congress, both the House and Senate side to support the key pieces of legislation that you're talking about, not only with Immigration reform but also to help push back on the minimum staffing ratio bill. So we're going to be putting that out very soon. We're getting a little short on time, but I do want to get to Covid because I know we're not through and done with Covid yet and we're certainly getting better with it. But maybe give an update on where we are with Covid cases, where we are in terms of hospitalization rates, mortality rates, and then I did see more recently you just met with the senior folks at HHS about trying to get vaccination rates back up again. So maybe say a little about where we are with Covid.

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Clif

As much as we want to put Covid behind us, it's still with us, and I think it will forever be with us. The reality right now is that we are seeing increased cases of Covid in facilities and in the community at large. The good news is obviously that Covid is not what it was as it relates to the severity of the disease, but in an immunocompromised population, an 85-plus population it's still a very, very real risk for patients and something that I think that we have to be vigilant about. So you touched on a meeting that Mark Parkinson and Dave Gifford had, our Chief Medical Officer, with the Secretary. And basically, the call was designed to collaborate on, one, ways to better harness data so we can have a real-time perspective on what's going on with Covid, particularly in the community and in our facilities.

But two, what tools can we use to improve vaccination rates amongst our patients and amongst our staff? And what we're finding is, is that generally speaking, the vaccination rates in skilled nursing for the 65-plus population is a little bit lower than it is in the community. Right around 36% community's about 37%. You know, our goal is obviously to drive that number up, but there is a lot of hesitancy and resistance where folks are like, you know, do I really want to do this and why? The key is education and obviously for our patient population, you can have a 65-plus population at a certain percentage, but most of our patients are over 80. So would they benefit from having a vaccine? Absolutely. I'm confident that our operators will be vigilant in ensuring that we get more vaccines in arms and ultimately protect our patients from this scourge that we're still dealing with.

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Scott

Tell us about where we are with the 3-Day Stay rule right now. I thought I saw a headline recently that AHCA/NCAL is doing a big push again to try and eliminate the 3-Day Stay rule. And there's a bill out there to honor observation stays to count towards the 3-Day Stay rule. What are the chances that we finally get rid of that requirement and or that that bill passes that at least there's some relief?

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Clif

I hope one day that they'll say, "Clif was around to help kill the 3-Day Stay rule." Maybe it is, it's just one of these career goals that I have to hopefully get accomplished before I bronze my cleats and hang them up. This issue is obviously sort of a legacy issue from the very beginning of the Medicare program. I always say when you speak about the fact that the Congressional Budget Office says it costs billions of dollars if we repeal it yet, I always say, insurance companies don't have a three-day stay. And it's not because it's expensive it's because it's not. And if private markets don't have a three-day stay, it's for one reason, and one reason only it's because it's less expensive and more efficient. So it's just one of these areas where we have this huge disconnect between what I call reality in the marketplace and sort of structural political math and process.

And what we're trying to do is we've done some analysis to provide some data now that we actually have real data around what the world looks like without a three-day stay. Because if you recall, during the pandemic, we didn't have, we had a waiver of that three-day stay requirement. So we now have real data that we're actually able to show about the three-day stay. I think one thing that was constantly a concern in the CBO scoring process was abuse, right? People were going to abuse the three-day stay and run it up. Well, that didn't happen during Covid. Not at all. It didn't happen at all. Frankly, it was used very sparingly. So I think, again, in practice, it just makes all the sense in the world to get rid of this.

I'm confident that we will, there was a recent regulatory announcement around observation stays where there's gonna be a new appeal process that's gonna help consumers be able to appeal those decisions around observation stays that were unbeknownst to them. And that's a real positive development and I think will help beneficiaries in particular. So, long story short, legislatively I doubt anything in the near term at least, but I think over the next five years we have a real shot and we're really planning strategically on how to accomplish that in a little bit more longer range window than it being resolved immediately.

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Scott

Thanks for that update Clif. I know I get a lot of questions from our clients about it and just wanted to give a quick update because I saw those headlines and thought at least maybe there's some movement, some momentum towards a final decision on it eventually. Hey, before we go, just one quick question before I ask all of our listeners. What's on your nightstand? What are you reading right now? Or is there a book that you'd like to recommend to folks?

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Clif

Yeah, you know what? It's funny, I just started The Fourth Turning is Here. I'm a big nonfiction guy, but it's a little bit scary. It just talks about sort of population trends, trends in values, there was a saying years ago, someone said, that I always liked bad times, made good men. Good men made great times. Great times make bad men. Bad men make bad times. And, we go through the cycle every 80 years or so, this is what this book's based on where you see the turning of those dials and we're entering into this dark time if you will, or I know I'm not my granddaddy and our great-grandparents generation they were a different kind of people and they built a different country. So this book kind of gets into some of the data, information, the economy. And so it's an interesting read. It's a little dark, you know, doesn't mean it has to happen, but it is kind of cool.

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Scott

That's an interesting book. I'm sure listeners love to check it out. You gave me a book a while ago called Win the Day and I think it was from your pastor there, right? Yeah, that was a great book. I really appreciate that. I'm going to conclude, I'm going to disagree with you for the first time our whole interview. You are a great man and we're so blessed that you were on the front lines of Washington DC. Please say hi to Debbie and all your kids. You're an incredible husband, incredible father, just so thankful for all you're doing for the entire sector to get us through these really difficult times. So thanks so much and would love to have you back on about a year from now.

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Clif

Appreciate you guys and thanks to VIUM for doing this. And as always, if there's anything that we do to be helpful let us know and to all your listeners, we're here for you and we're going to continue to fight. So thanks again.

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Scott

Hey Clif, thanks so much. Hey, for our listeners, thanks for tuning in. This is VERSED.