State Medicaid nursing home reimbursement rates: adjusting for ancillaries

Availability of Adult Vaccination Services by Provider Type and Setting

INTRODUCTION

Knowledge regarding the benefits for adult vaccination services under Medicaid's fee-for-service arrangement is dated; little is known regarding the availability of vaccination services for adult Medicaid beneficiaries in MCO arrangements. This study evaluates the availability of provider reimbursement benefits for adult vaccination services under fee-for-service and MCO arrangements for different types of healthcare providers and settings.

METHODS

A total of 43 Medicaid directors across the 50 U.S. states and the District of Columbia participated in a semistructured survey conducted from June 2018 to June 2019 (43/51). The frequency of Medicaid fee-for-service and MCO arrangements reporting reimbursement for adult vaccination services by various provider types and settings were assessed in 2019. Elements of vaccination services examined in this study were vaccine purchase, vaccine administration, and vaccination-related counseling.

RESULTS

Under fee-for-service, 41 Medicaid programs reimburse primary care providers for adult vaccine purchase (41/43); fewer programs reimburse vaccine administration and vaccination-related counseling (33/43 and 30/43, respectively). Similar results were observed for obstetricians-gynecologists, nurse practitioners, and pharmacies. Although 24 fee-for-service (24/43) and 23 MCO (23/34) arrangements cover adult vaccination services in most settings, long-term care facilities have the lowest reported reimbursement eligibility.

CONCLUSIONS

In most jurisdictions, vaccination services for adult Medicaid beneficiaries are available for a variety of healthcare provider types and settings under both fee-for-service and MCO arrangements. However, because provider reimbursement benefits remain inconsistent for adult vaccination counseling services and within long-term care facilities, access to adult vaccination services may be reduced for Medicaid beneficiaries who depend on these resources.

Smoke without Fire: Nursing Facility Closures in California, 1997–2001

This paper draws from a rich longitudinal California data set to analyze the scope and nature of nursing home closures between 1997 and 2001, and to present a Cox proportionate hazards model of the risks of closure that arise from a range of facility and market characteristics. When compared with the sample total of 1,482 facilities operating in the baseline year of 1997, only 56 facilities closed through 2001, involving the loss of 3.8% of facilities and 2,915 beds (2.3%). The multivariate Cox model of factors associated with closure reports that: 1) hospital-based facilities are 600% more likely to close than are free-standing homes; 2) reducing bed size by one standard deviation (52 beds) increases the risk of closure by 460%; 3) facilities with losses of 5% or worse are more than twice as likely to close; and 4) a one-standard deviation increase in the spare bed capacity measure of county competition raises the risk of facility closure by 140%.

Medicaid Nursing Facility Utilization

This study uses a longitudinal California data set (1995 to 2000) to address two concerns about Medicaid nursing facility (NF) utilization. First, to consider the impact of national cost-control policies, the authors analyze data trends in Medicaid NF participants, days of care, and expenditures. Second, the authors investigate the percentage of Medicaid days of care (%MDOC) using a panel regression model to consider resident, facility, and county market predictors. The findings show that although statewide Medicaid NF participants, expenditures, and%MDOC remain stable, Medicaid market segmentation persistes, with program participants distributed unevenly among facilities. Factors associated positively with facility%MDOC are the proportion of minority residents, a larger facility size, for-profit status, the percentage of aged Black persons in the county, and market concentration. The factors associated negatively with%MDOC are the percentages of resident men, residents aged 85 or older, residents with Alzheimer’s disease, Medicaid reimbursement rates, and county wealth.

Bureaucratic Policy Making on Trial: Medicaid Nursing Facility Reimbursement, 1988-1998

Few systematically assess the determinants of Medicaid nursing facility reimbursement. Consequently, this article examines what factors influenceprogram administrators’decisions regarding nursing facility cost report data—the basic information states use to establish payment. Whereas elected officials focus primarily on how much is spent on nursing homes, state Medicaid officials assume primary responsibility for the esoteric and highly technical dimensions that help make spending goals a reality. Findings indicate that the federal government influenced state policy by enabling provider litigation under the Boren Amendment. They also indicate that program administrators responded rationally to fiscal and economic concerns, and that states with stronger administrative capacity were better able to overcome obstacles to sustaining desired policies. Although results reveal that states with more powerful nursing home lobbies tended to implement more generous systems, they fail to reveal significant associations between cost report year and lobbying activity on behalf of the elderly.

Predictors of emergency commitment for nursing home residents: the role of resident and facility characteristics

OBJECTIVES

The ability of nursing homes to manage the mental health needs of their residents is crucial to providing high quality care. An important element is preventing exacerbations of psychiatric conditions that trigger discharge from the nursing home (NH) because of an emergency commitment (EC) for an involuntary psychiatric examination. The objective of this study was to examine the relationship between resident and facility characteristics and the risk of EC for involuntary psychiatric examination among Medicaid-enrolled NH residents in Florida.

DESIGN

This retrospective cohort study employed 2.5 years (31 December 2002 through 30 June 2005) of Medicaid enrollment and fee-for-service, pharmacy, and involuntary commitment data to examine resident characteristics. NH characteristics were obtained from the Online Survey Certification and Reporting database.

SETTING

Medicaid-certified NHs in Florida (N= 584).

PARTICIPANTS

Medicaid-enrolled NH residents (N= 32,604).

RESULTS

Younger age, male gender, having dementia, having a serious mental illness (SMI), and residing in a for-profit facility were all independently associated with the greater risk of EC. Although most residents with EC were prescribed psychotropic medication, less than half received non-pharmacological behavioral health outpatient services before or after their involuntary psychiatric examination.

CONCLUSION

Our findings highlight the salience of resident and facility characteristics to prevalence rates of EC for involuntary psychiatric examinations among NH residents and underscore a need for increased education, communication, and future research on the predictive factors as well as the consequences of these adverse events.

Improving direct-care compensation in nursing homes: Medicaid wage pass-through adoption, 1999-2004

Because states play such a prominent role in the U.S. health care system, they have long grappled with how to best control health care costs while maintaining high quality of care. There are many policy tools available to address efficiency and quality concerns--from pure state regulation to market-oriented competition designs. Given public discourse and official party platforms, one would assume that states controlled by Democrats would be more likely to adopt regulatory reforms. This study examines whether party control, as well as other economic and political factors, is associated with adopting wage pass-through (WPT) policies, which direct a portion of Medicaid reimbursement or its increase toward nursing home staff in an effort to reduce staff turnover, thereby increasing efficiency and the quality of care provided. Contrary to expectations, results indicate that states with Republican governors were against WPT adoption only when for-profit industry pressure increased; otherwise, they were more likely to favor adoption than their Democratic counterparts. This suggests a more complex relationship between partisanship and state-level policy adoption than is typically assumed. Results also indicate that state officials reacted predictably to prevailing political and economic conditions affecting state fiscal-year decisions but required sufficient governing capacity to successfully integrate WPTs into existing reimbursement system arrangements. This suggests that WPTs represent a hybrid between comprehensive and incremental policy change.

Medicaid nursing facility rates, capacity, and utilization: a structural analysis

This analysis extends earlier work using national data to examine Medicaid nursing facility (NF) utilization (participants per aged population) and its interrelationships with Medicaid per diem NF reimbursement rates and NF bed capacity, using state-level data over 19 years to estimate two-stage structural equations. Findings demonstrate complex relationships among these factors. Reimbursement rates showed no demonstrable impact on utilization but positive effects on beds. Beds, in turn, positively predict utilization and negatively predict rates. Findings suggest that policy makers might focus on constraining Medicaid NF costs through controlling bed stock rather than by keeping rates lower, which can have untoward effects on quality and equity.

The association of individual and facility characteristics with psychiatric hospitalization among nursing home residents

OBJECTIVE

To examine resident and facility characteristics associated with psychiatric hospitalizations (PH) for Medicaid enrolled nursing home (NH) residents.

METHODS

Participants were all Medicaid enrolled NH residents (n = 32,604) from all Medicaid certified nursing homes in Florida (n = 584) with complete data. We used individual demographic and diagnostic characteristics, as well as facility characteristics, to explore risk of psychiatric hospitalization in this dataset.

RESULTS

Using generalized estimating equations, we found that younger age, male gender, poor physical health, serious mental illness, dementia, and drug use disorder were associated with risk of psychiatric hospitalization. Most notably, residents under 65 were more than three times more likely to undergo psychiatric hospitalization and dementia was associated with a three-fold increase in the risk of psychiatric hospitalization. Predictors of PH differed somewhat for younger and older residents. Among facility characteristics, greater facility size, low proportion of those paying via Medicare and high proportion of residents with serious mental illness were associated with increased risk of psychiatric hospitalization, whereas, low proportion of residents paying via Medicaid, high proportion of residents paying via Medicare, and low proportion of resident with serious mental illness were associated with reduced risk.

CONCLUSIONS

Both resident and facility characteristics impact risk for psychiatric hospitalization. Attention to identified predictors may reduce risk and improve outcomes for nursing home residents.

Operating environment and USA nursing homes' participation in the subacute care market: a longitudinal analysis

We examined the impact of environmental factors on USA nursing homes' participation in the subacute care market. Findings suggest that the Balanced Budget Act of 1997 did not have a significant impact in the participation of nursing homes in the subacute care market from 1998 to 2000. However, there was a declining trend in the participation of nursing homes in the subacute care market after the implementation of Medicare prospective payment system (PPS). Furthermore, nursing homes with a higher proportion of Medicare residents were more likely to exit the subacute care market after PPS. Results also suggest that nursing homes have responded strategically to the environmental demand for subacute care services. Nursing homes located in markets with higher Medicare managed care penetration were more likely to offer subacute care services. Environmental munificence was also an important predictor of nursing home innovation into subacute care. Nursing homes in states with higher Medicaid reimbursement and those in less competitive markets were more likely to participate in the subacute care market.

The devil's in the details: trading policy goals for complexity in medicaid nursing home reimbursement

There is great variability in how much nursing home providers are paid for a day of care for a Medicaid recipient, how the payment level is set, and what mechanisms are used to reimburse facilities. Given the absence of recent, comprehensive in-depth analyses of state reimbursement systems, this article undertakes a comparative case analysis of Medicaid nursing facility reimbursement in Alabama, California, Minnesota, Texas, Washington, and Wisconsin. Findings indicate that states design their methods of reimbursement to achieve desired policy outcomes related to facility cost and quality, access to care, payment equity, service capacity, and budgetary control. The result, however, has been the development of enormously complex and demanding rate-setting methodologies, the adverse consequences of which can outweigh and overwhelm the discrete policy objectives contained in the reimbursement formula. This complexity highlights the potential trade-off between achieving desired goals and costly administrative burdens, opportunities for appeal and disagreement, difficulties understanding the ramifications of system changes, reliance on simplified decision-making rules, and exclusion of otherwise interested parties from the policy process.

California nursing facility quality and union environments

OBJECTIVE

Many studies have examined quality effects of nursing facility (NF) staffing, but few have examined effects of unionization. Concerned with possible effects of unionization on quality, we analyzed unionization and local market climate of unionization, predicting both complaints (reflecting either quality problems or better monitoring and advocacy) and the substantiation of serious complaints (indicating major quality problems).

METHOD

Data were analyzed on California freestanding NFs in 1999 (N = 1,155). OLS regression was employed to predict both quality complaints and serious violations, the latter both controlling and not controlling for numbers of complaints.

RESULTS

Unionized NFs showed more complaints than did non-unionized NFs. Non-unionized NFs had more serious violations, particularly when the proportion of other county facilities unionized was higher.

DISCUSSION

These findings suggest that unionization enhances problem reporting while, especially in stronger union environments, reducing the incidence of serious quality violations.

State health policy making determinants, theory, and methods: A synthesis

The American states exhibit considerable differences in health policy and market characteristics. Not only do they display substantial variation in spending, but they also display substantial variation in the strategies chosen to control costs, improve access, and ensure quality care. This article synthesizes studies that use 50-state statistical techniques to model policy adoption in the health sector. The purpose is to assess the strengths and weaknesses of this literature, to place it in the context of comparative state policy research generally, and to identify factors that best predict 17 health policy outcomes at the state level. A database was assembled containing 245 equations abstracted from 63 studies published between 1975 and 2002. Some predictors (such as income, aged population, public opinion, and nursing home beds) were studied much more frequently than others (e.g., education, divided government, federal Medicaid mandates, other states' adoptions). Results show that 43 of the 87 policy making determinants examined consistently predict two or more state-level outcomes, including four that predict five outcomes (non-white, urban, income, unemployment), two that predict six (tax capacity/effort, hospital beds), and two that predict seven (nursing home beds, liberal public opinion). Gaps are shown to exist in our understanding of the policy making effects of political system and intergovernmental characteristics.

Chain Reaction

This paper reports on an exploratory study of nursing home bankruptcy. From state and industry data regarding nearly 1,000 California facilities, it was possible to identify 155 homes in five chains (multi-facility organizations) that were operating in bankruptcy in 2000. When compared with facilities in non-bankrupt chains, while the bankrupt chain facilities had significantly worse financial liquidity, higher administrative costs, and higher payables to related parties, they also had more Medicare residents, fewer Medicaid residents, better solvency, and were located in less competitive county markets and in areas with higher Medicaid reimbursement rates. These findings indicate that, rather than facility characteristics and local market factors, strategic decisions taken at the corporate (chain) level are the major determinants of nursing facility bankruptcy status.

Medicaid nursing facility reimbursement in flux: effects of federal regulatory changes and prevailing fiscal conditions, 1978-1998

Basic concepts and trends are examined in Medicaid nursing facility reimbursements between 1978 and 1998, because Medicaid payment reform is a common budget reduction strategy pursued by state officials. Non-incremental changes in state rate-setting methods, as well as incremental changes in per diem rates and expenditures per recipient, are analyzed. In addition to substantial cross-state variation, results reveal clear trends in reimbursement policy characteristics over time. Not only do these track closely with changes in the federal regulatory environment, but they also track closely with prevailing fiscal and economic conditions. Given the serious ramifications reimbursement policy changes can have for nursing home residents and providers, it is imperative that the impact of federal disengagement from this policy area be understood.

Effect of State Medicaid Reimbursement Rates on Hospitalizations from Nursing Homes

OBJECTIVES

To estimate the effect of state Medicaid nursing home reimbursement rates on hospitalizations of nursing home residents.

DESIGN

Cross-sectional sample of nongovernment-owned nursing homes with 25 beds or more in one Metropolitan Statistical Area in each of 10 states in 1993, with 6 months follow-up on mortality and hospitalizations.

SETTING

Two hundred fifty-three nursing homes.

PARTICIPANTS

Eight to 16 randomly selected residents from each facility, totaling 2,080.

MEASUREMENTS

Minimum Data Set assessments conducted by research nurses at baseline. A three-category 6-month outcome was defined as (1) any hospitalization; for those not hospitalized, (2) death versus (3) alive in the facility.

RESULTS

Using multinomial logistic regression, adjusted to survey design, controlling for resident and facility characteristics, a 10 dollar increase in 1993 Medicaid reimbursement rate above the mean rate of approximately 75 dollars resulted in a 9% reduction in a resident's risk of hospitalization (P<.05).

CONCLUSION

State Medicaid reimbursement rates appear to affect clinical decisions regarding the need for hospital admission and thresholds for nursing home use. The findings from this study reemphasize the importance of properly aligning state Medicaid and federal Medicare long-term care policies because, currently, states have no incentive to increase reimbursement rates to avoid hospitalization.

Nursing home staffing, turnover, and case mix

This study examined the predictors of total nurse and registered nurse (RN) staffing hours per resident day separately in all free-standing California nursing homes (1,555), using staffing data from state cost reports in 1999. This study used a two-stage least squares model, taking into account nursing turnover rates, resident case mix levels, and other factors. As expected, total nurse and RN staffing hours were negatively associated with nurse staff turnover rates and positively associated with resident case mix. Facilities were resource dependent in that a high proportion of Medicare residents predicted higher staffing hours, and a higher proportion of Medicaid residents predicted lower staffing hours and higher turnover rates. Nursing assistant wages were positively associated with total nurse staffing hours. For-profit facilities and high-occupancy rate facilities had lower total nurse and RN staffing hours. Medicaid reimbursement rates and multifacility organizations were positively associated with RN staffing hours.