LACONIA — Gerie Pingol, 53, was trained as mechanical engineer in the Philippines, his native country. But when his degree and experience didn’t translate to a career in the U.S, he tapped an inner talent and an abiding interest: his love of people — especially elders in need of care, empathy and patience.
“As a Filipino, it’s normal for us to take care of older people, and normal for us to take care of our grandparents,” said Pingol, a green card holder who did an about-face from manufacturing.
For the last six years, Pingol has worked as a licensed practical nurse, or LPN, on staff at Belknap County Nursing Home — a job he never envisioned, but has discovered fulfillment in — including during the turbulence of COVID-19.
“At Belknap County Nursing Home, the residents are very nice so it was easy to change my career,” he said. “Working at the nursing home is like my second home.”
To the patients, Pingol is a blessing. To BCNH, he is a godsend — a dependable staff caregiver during unprecedented times: the pandemic never actually passes, but ebbs temporarily, only to return around the corridor with vigor or a variant.
Skills and heart aren’t the only value Pignol and stalwart nurses bring in these times. As the pandemic wears on, burnout and disillusionment run high, along with temptations to travel or work elsewhere for higher pay. Health care facilities in New Hampshire and nationwide are grappling with ways to attract and retain nurses at all levels. Solutions range from boosting wages to work-study agreements, subsidizing education, and improving benefits.
In the simmering emergency that COVID-19 spawned, coupled with an exodus of retiring nurses and others lured by easier jobs or less stress in related careers, traveling nurses have emerged as a lifesaver and last resort for facilities plagued by chronic staff shortages. But the use of exorbitantly paid transients is a double-edged sword, according to health care administrators and staff.
“We love traveling nurses,” said Mike DellaVecchia, now a staff nurse in emergency room at Huggins Hospital in Wolfeboro. Without them, over-worked nurses would endure longer shifts and weeks without a break, he said. But “paying rental doctors and rental nurses is not sustainable. The traveling nurses aren’t making all the money. It’s the big agencies,” said DellaVecchia, who worked as traveling nurse between Florida and New England for 18 years. He said he makes more money now, especially with overtime, because travelers have periods without pay between assignments.
It's a thorny issue. Traveling nurses enable facilities to keep beds open, and occasionally admit new patients. But they can cost two to three times what a staff nurse is paid, and their contracts usually expire after 90 to 180 days, requiring replacements, or an extension of their contract. When staff nurses leave, some return to their original employers for temporary assignments that pay double what they previously earned. Hourly rates become a matter of supply and demand, and they fluctuate. Staffing agencies collect hefty fees and one of the first questions they ask health care administrators whose backs are against the wall: How much are you willing to pay?
The pandemic ushered in bidding wars, not unlike those in real estate – and a whole new level of financial precariousness.
“The cost of travelers is enormous,” said Pam DiNapoli, executive director of the New Hampshire Nurses Association. “And they don’t have to come from out of state. They can come from Catholic Medical Center, going to Elliot Hospital” in Manchester. “We need to incentivize people to stay at their home organizations.”
Traveling LNAs, LPNs and RNs from staffing agencies have always cost much more to hire, but COVID-19 dissolved any invisible, fragile ceiling that may have existed before. The cost of traveling nurses has vaulted 120% since the pandemic started, said DiNapoli. That translates to one traveling nurse for the price of two to three staff nurses — sometimes four. This is bad economics especially for nursing homes that depend on the state’s Medicaid reimbursements, which don’t come close to covering the actual costs of caring for chronically ill and elderly patients, most of whom have run through their life savings. At county-owned nursing homes, the percentage of patients on Medicaid is 75.9% — 80 to 85% at BCNH, when the facility is full.
Hospitals are also hard hit, and strapped to compete with the rates of travelers.
Price gouging in a free market that is not free
DiNapoli said the rationale is, "If I’m going to work this hard, I want to be compensated." Some traveling nurses make $125 an hour compared to staff members who have stayed and are making $50 or less plus benefits, with more experience at the job.
One large out-of-state staffing agency, which books traveling nurses nationally through its website, allows facilities to press a button to automatically outbid what another facility is offering elsewhere in the country.
Nurses who travel are typically not grounded by family commitments, or bound to a facility by health insurance, retirement benefits or workplace culture, or by loyalty to patients or co-workers. Some have their housing and travel expenses paid through tax-free vouchers.
When they arrive on a new turf, sometimes with less training and experience, their presence can dampen morale among loyal staff. They require on-site training, just like any newbie.
Most staff members are happy to do some mentoring, but over the long haul, it can be demoralizing to train someone who is making a lot more money and is less prepared to hit the ground running.
“It can cause a lot of friction where you work,” said Di Napoli. “It’s become a national issue. We have a lot of conversations about what this is doing for quality of care. You have inexperienced nurses coming into a setting they don’t know, taking care of the sickest of the sick.”
Then there’s staff attrition. Some nurses are lured away by what amounts to a gold-rush size paycheck for temporary commitments in the high-stress, high-risk work environment of the pandemic.
Agencies are taking advantage of a free market that is not actually free, but tied to fixed rates of reimbursement, health care experts say.
Ethics vs. economics
“Some people are calling to say it’s an ethical issue because people are charging so much,” said DiNapoli. “It’s a form of price gouging. They’re taking advantage of the times.”
Brendan Williams, president of the New Hampshire Health Care Association, which represents 58 nursing homes, nine assisted living facilities and five continuing care retirement communities, said traveling nurses have become the solution du jour where there a few if any alternatives. In long term care, “It’s absolutely essential because we don’t have other options. Even though facilities have raised wages, none of that matters if you can’t find licensed professionals in your community. In order to cover your shift, you have to go with staffing agencies. It’s predatory pricing. They play a lot of games,” he said.
County nursing homes in the southern tier of the state were quoted $50 an hour for a traveling nurse assistant, or LNA, whose rate in New Hampshire typically varies between $14 and $18 an hour. “You tack on $20 if you have COVID in the facility,” said Williams.
Some agencies book nurses with more than one provider, which prompts a last-minute price war with hospitals and nursing homes bidding against each other, said Williams. "It’s really a marketplace of desperation at this point. And it’s unsustainable.”
“Staff leave and return to your building as a traveler for an out of state staffing agency. It’s like we’re swirling down the drain and there’s no end in sight. Medicaid doesn’t cover normal nursing costs, let alone traveling nurses,” said Williams. “You have no choice other than utilizing pirates. You’ve got to cover your shifts.”
The cost of travelers leaves little or no money to expand total nursing staff, which would enable long term care facilities to admit new residents. Occupancy at New Hampshire’s 13 county nursing homes hovers at roughly 75% – about 65% in Belknap County.
“There’s enough beds,” said Williams. “There’s just not enough staff.” That reverberates for hospitals, which cannot release eligible patients to long term care. “Hospitals get jammed up,” said Williams. To health care facilities squeezed at both ends, “It feels like an extinction event.”
Traveling nurses have been hired for public health assignments, too, manning COVID vaccination sites and working as members of strike teams to provide emergency health care coverage around the state.
Is intervention required to staunch the climbing costs?
Regulating costs in a free market
The state of Massachusetts currently regulates what health care staffing agencies can charge, much like utilities. Texas also has controls that limit what traveling nurses can be paid. Minnesota is currently looking at price ceilings. In the meantime, the American Healthcare Association has filed a complaint with the Federal Trade Commission. Williams said he hopes the New Hampshire’s consumer protection laws will enable the NH Attorney General’s office to take up the cause also.
In terms of changing the landscape, the pandemic has functioned as a rapidly moving glacier, the stuff of science fiction, exaggerating and accelerating staffing and cost problems that had been brewing long before. In some cases, hospitals can pass along costs to consumers in the form of larger bills, but that’s not possible for nursing homes. Medicare and private-pay consumers already help subsidize the cost of caring for otherwise uninsured Medicaid patients, many of whom are indigent.
“We’ve all become vulnerable during this pandemic,” said Williams. “And then the vultures descended. And now we can’t shoo them away.” New Hampshire is one of the best states in the country in terms of vaccination rates for nursing home staff and residents, he said. “The staffing crisis is the second wave of the pandemic. We just can’t find people. It’s like eBay. Instead of bidding on an object, you’re bidding on a person.”
Ground zero at nursing homes
It’s difficult to estimate how many traveling nurses are working in New Hampshire – or even their uppermost rate of pay. Or what percentage of health care facility staff they comprise at the present time.
The Belknap County Nursing Home currently employs four traveling nurses. Administrator Shelley Richardson said talking freely about how much they cost only serves to discourage loyal full-time workers.
“In order to keep the building viable, we have to hire from outside agencies,” said Richardson. “We’ve always had traveling nurses. We have four travel nurses now or we would have to close.” The nursing home licensed for 98 beds is hovering at two-thirds full, unable to accept more.
Richardson hopes the county delegation will approve a jump in funding that will enable BCNH to bring wages in line with competitors, including other county homes. American Rescue Plan funds boosted pay with short-term stipends. Starting wages for LNAs are now $15 an hour, up from just shy of $13. Pay for LPNS begins at $24 an hour. “If we didn’t do something, we’d have a mass exodus,” Richardson said. She hopes a compensation study will pinpoint a sweet spot for wages that are realistic — and doable.
“When you call agencies now they ask, ‘What are you willing to pay?’ Unless you’ve got someone in your building and they like it,” the sky’s the limit. “I have (agencies) every day trying to recruit our staff,” Richardson said.
A Connecticut agency is currently charging $154 an hour for a transient RN, while a Nebraska agency wants $178 for a registered nurse. RNs at BCNH currently earn $32 an hour — $50 if they’re mandated to stay because someone calls in sick. It’s not unusual for nursing homes to pay double or triple for a traveler with an identical license. With the ongoing stress of the pandemic, some staff leave for three- to six-month contracts without benefits, a retirement plan or health insurance.
Williams hopes the bubble will burst and rates will drop back down to realistic levels — without a recession to cool things down.
“I believe in the free market,” said Williams. “But there are limitations. It’s not supposed to rise to such excess. Health care is not really part of the free market when you have government payers.”
“We need to pay people so we can open up our building more, take more staff and make more money,” said Richardson.
“We are very affected by the lack of nurses,” said Pingol, who, like others on BCNH’s staff, stays late when a replacement doesn’t show. “We are concerned about the safety of residents.” RNs and LPNs have many of the same responsibilities, he said, including dispensing medications.
“Still, we are so happy to have traveling nurses work for us. They help lessen the stress is someone is out,” said Pingol, who hopes someday to become an RN.
When traveling nurses haven’t worked at BCNH before, “you need to train them first and some are arrogant and disrespectful to staff. If you are going to a new facility, you need to be more respectful,” he said. “From the first day, you need to be part of the flow.”