North Dakota
North Dakota long-term care providers call federal rule an 'impossible staffing mandate'
BISMARCK — North Dakota health care providers are scrambling to meet new federal standards set for long-term care facilities. Put in motion by a 2023
executive order,
the series of mandates go into effect Aug. 8 despite nationwide concerns — including a lawsuit filed in June by the American Health Care Association against the Department of Health and Human Services and Centers for Medicare and Medicaid Services.
The rule comes in response to high death rates during the COVID-19 pandemic, citing a Centers for Medicare and Medicaid Services, or CMS,
study
that links fatality rates to high turnover and chronic under-staffing in nursing homes.
Medicare- and Medicaid-certified facilities will be required to have a registered nurse on site 24/7 and increase the number of nurse aids available daily. Rural communities have a year longer to implement the standards than urban communities. Proposed last September and finalized in April, the rule received over 46,000 comments during the 60-day national comment period that closed in November.
“This rule does not only impact nursing facilities, it will impact all sectors of health care and the cost of care in our state,” Nikki Wegner, president of the North Dakota Long Term Care Association, testified in a state Health and Human Services committee meeting on Thursday, July 11.
The association is affiliated with two plaintiffs involved in the CMS lawsuit.
“This, for us and for the rest of the nation, is really an impossible staffing mandate. There are simply not enough RNs to fulfill this requirement. While the intent behind the rule is to improve care quality, it presents really significant challenges,” Wegner said.
Rep. Kathy Frelich, R-Devils Lake, responded to Wegner’s testimony, referencing her professional experience with long-term care as an outreach specialist at the
North Dakota School for the Deaf and Resource Center for Deaf and Hard of Hearing.
“I would say that quality of care generally isn’t related to your RN. It’s usually related to your CNA (Certified Nursing Assistant) on that level. So, I’m concerned that this is just adding a cost,” Frelich said. “Ultimately, that goes back to the residents.”
Long-term care residents pay an average of $403.19 per day — over
$12,000 monthly
— a rate Frelich said would “drastically” increase.
Since the height of the COVID-19 pandemic, the number of nursing homes across the state has been in decline. Six facilities closed in just under three years.
According to the
Bureau of Labor Statistics,
North Dakota would need to add 1,313 nursing home workers to return to pre-pandemic levels.
Data
from the Payroll Based Journal indicates 79% of the state’s facilities would not comply with the registered nurse mandate and only 17% would meet nursing requirements.
The same data shows rural communities in the state would be disproportionately impacted, where 86% wouldn’t meet requirements compared to 65% in urban areas. North Dakota would have to spend a minimum of $4.5 million per year to comply.
Individuals 65 and older make up over 16% of the state population with approximately
8,220 people
receiving care every day, according to the Long Term Care Association.
Some facilities could be considered exempt from the mandates. The
final ruling
states facilities would have to prove the local workforce is 20% or more below the national average and that administrators made “good faith” efforts to hire and retain staff.
Tanya Schnabel, administrator for the Wishek Living Center, said most rural facilities would have to apply for an exemption, including hers. She said the process would add to her already full plate of managing the already “concerning” worker deficit.
“We have housing issues here. So, even if somebody wants to move to town to come work for us, there’s no place for them to live that’s affordable. We wouldn’t be able to do it without contract companies right now, because they’re moving here and giving their time to help care for our residents,” Schnabel told Forum News Service.
“This will just probably be the straw that broke the camel’s back,” she said.
Rep. Kelly Armstrong, R-N.D., and 33 other Republicans cosponsored a joint resolution of congressional disapproval introduced by Rep. Michelle Fischbach, R-Minn., in May. Additionally, Sen. Kevin Cramer, R-N.D., sought to delay the rulings by introducing the VA Report on Proposed CMS Staffing Ratios Act, which would require the Veterans Association to study the risks to elderly veterans posed by the new requirements.
North Dakota’s Long Term Care Association is affiliated with the American Health Care Association and Leading Age. Last May, both entities joined four other plaintiffs in filing a
lawsuit
against the Secretary of the United States Department of Health and Human Services and CMS. According to the filing, CMS exceeded its authority by overriding congressional directives and employing “sweeping” new mandates.
“Hopefully they realize that this will probably kill off some rural facilities. If they close, then people would have to drive to Bismarck or Fargo or Jamestown to see their loved ones. That would be devastating,” Schnabel said.
North Dakota
European potato company plans first U.S. production plant in North Dakota
Agristo, a leading European producer of frozen potato products, is making big moves in North America. The company, founded in 1986, has chosen Grand Forks, North Dakota, as the site for its first U.S. production facility.
Agristo has been testing potato farming across the U.S. for years and found North Dakota to be the perfect fit. The state offers high-quality potato crops and a strong agricultural community.
In a statement, Agristo said it believes those factors make it an ideal location for producing the company’s high-quality frozen potato products, including fries, hash browns, and more.
“Seeing strong potential in both potato supply and market growth in North America, Agristo is now ready to invest in its first production facility in the United States, focusing on high-quality products, innovation, and state-of-the-art technology.”
Agristo plans to invest up to $450 million to build a cutting-edge facility in Grand Forks. This project will create 300 to 350 direct jobs, giving a boost to the local economy.
Agristo is working closely with North Dakota officials to finalize the details of the project.
Negotiations for the plant are expected to wrap up by mid-2025.
For more information about Agristo and its products, visit www.agristo.com.
Agristo’s headquarters are located in Belgium.
North Dakota
Audit of North Dakota state auditor finds no issues; review could cost up to $285K • North Dakota Monitor
A long-anticipated performance audit of the North Dakota State Auditor’s Office found no significant issues, consultants told a panel of lawmakers Thursday afternoon.
“Based on the work that we performed, there weren’t any red flags,” Chris Ricchiuto, representing consulting firm Forvis Mazars, said.
The review was commissioned by the 2023 Legislature following complaints from local governments about the cost of the agency’s services.
The firm found that the State Auditor’s Office is following industry standards and laws, and is completing audits in a reasonable amount of time, said Charles Johnson, a director with the firm’s risk advisory services.
“The answer about the audit up front is that we identified four areas where things are working exactly as you expect the state auditor to do,” Johnson told the committee.
The report also found that the agency has implemented some policies to address concerns raised during the 2023 session.
For example, the Auditor’s Office now provides cost estimates to clients before they hire the office for services, Johnson said. The proposals include not-to-exceed clauses, so clients have to agree to any proposed changes.
The State Auditor’s Office also now includes more details on its invoices, so clients have more comprehensive information about what they’re being charged for.
The audit originally was intended to focus on fiscal years 2020 through 2023. However, the firm extended the scope of its analysis to reflect policy changes that the Auditor’s Office implemented after the 2023 fiscal year ended.
State Auditor Josh Gallion told lawmakers the period the audit covers was an unusual time for his agency. The coronavirus pandemic made timely work more difficult for his staff. Moreover, because of the influx of pandemic-related assistance to local governments from the federal government, the State Auditor’s Office’s workload increased significantly.
Gallion said that, other than confirming that the changes the agency has made were worthwhile, he didn’t glean anything significant from the audit.
“The changes had already been implemented,” he said.
Gallion has previously called the audit redundant and unnecessary. When asked Thursday if he thought the audit was a worthwhile use of taxpayer money, Gallion said, “Every audit has value, at the end of the day.”
The report has not been finalized, though the Legislative Audit and Fiscal Review Committee voted to accept it.
Audit of state auditor delayed; Gallion calls it ‘redundant, unnecessary’
“There was no shenanigans, there were no red flags,” Sen. Jerry Klein, R-Fessenden, said at the close of the hearing.
Forvis representatives told lawmakers they plan to finish the report sometime this month.
The contract for the audit is for $285,000.
Johnson said as far as he is aware Forvis has sent bills for a little over $150,000 so far. That doesn’t include the last two months of the company’s work, he said.
The consulting firm sent out surveys to local governments that use the agency’s services.
The top five suggestions for improvements were:
- Communication with clients
- Timeliness
- Helping clients complete forms
- Asking for same information more than once
- Providing more detailed invoices
The top five things respondents thought the agency does well were:
- Understanding of the audit process
- Professionalism
- Willingness to improve
- Attention to detail
- Helpfulness
Johnson said that some of the survey findings should be taken with a “grain of salt.”
“In our work as auditors, we don’t always make people happy doing what we’re supposed to do,” he said.
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North Dakota
'False promise' or lifesaver? Insulin spending cap returns to North Dakota Legislature
BISMARCK — A bill introduced in the North Dakota House of Representatives could cap out-of-pocket insulin costs for some North Dakotans at $25 per month.
The bill also includes a monthly cap for insulin-related medical supplies of $25.
With insulin costing North Dakota residents billions of dollars each year,
House Bill 1114
would provide relief for people on fully insured plans provided by individual, small and large group employers. People on self-funded plans would not be affected.
“I call insulin liquid gold,” Nina Kritzberger, a 16-year-old Type 1 diabetic from Hillsboro, told lawmakers. “My future depends on this bill.”
HB 1114 builds on
legislation
proposed during the 2023 session that similarly sought to establish spending caps on insulin products.
Before any health insurance mandate is enacted,
state law
requires the proposed changes first be tested on state employee health plans.
As such, the legislation was altered to order the state Public Employees Retirement System, or PERS, to introduce an updated bill based on the implementation of a $25 monthly cap on a smaller scale.
The updated bill — House Bill 1114 — would bring the cap out of PERS oversight and into the North Dakota Insurance Department, which regulates the fully insured market but not the self-insured market.
Employers that provide self-insured health programs use profits to cover claims and fees, acting as their own insurers.
Fully insured plans refer to employers that pay a third-party insurance carrier a fixed premium to cover claims and fees.
“It (the mandate) doesn’t impact the entire insurance market within North Dakota,” PERS Executive Director Rebecca Fricke testified during a Government and Veterans Affairs Committee meeting on Thursday, Jan. 9.
Blue Cross Blue Shield Vice President Megan Hruby told the committee that two-thirds of the provider’s members would not be eligible for the monthly cap, calling the bill a “false promise.”
“We do not make health insurance more affordable by passing coverage mandates, as insurance companies don’t pay for mandates. Policy holders pay for mandates in the form of increased premiums,” Hruby said.
She touted the insurance provider having already placed similar caps on insulin products and said companies should be making those decisions, not the state government.
Sanford Health and the Greater North Dakota Chamber also had representatives testify against the bill.
Advocates for the spending cap said higher premiums are worth lowering the cost of insulin drugs and supplies.
“One of the first things that people ask me about is, ‘Why should I pay for your insulin?’ And my response is, ‘Why should I have to pay for your premiums?’” Danelle Johnson, of Horace, said in her testimony.
If adopted and as written, the spending caps brought by
House Bill 1114
would apply to the North Dakota commercial insurance market and cost the state around $834,000 over the 2025-27 biennium.
According to the 2024 North Dakota diabetes report,
medical fees associated with the condition cost North Dakotans over $306 billion in 2022.
The state has more than 57,200 adults diagnosed with diabetes, and a staggering 38% have prediabetes — a condition where blood sugar levels are high but not high enough to cause Type 2 diabetes.
Nearly half of those people are adults 65 years old or older.
North Dakotan tribal members were also found to be twice as likely to have diabetes compared to their white counterparts.
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