Medicare prospective payment and quality of care for long-stay nursing facility residents

Medicare Advantage growth and skilled nursing facility finances

OBJECTIVE

To examine the relationship between growth in Medicare Advantage (MA) enrollment and changes in finances at skilled nursing facilities (SNFs).

DATA SOURCES

Medicare SNF cost reports, LTCFocus.org data, and county MA penetration rates.

STUDY DESIGN

We used ordinary least squares regression with SNF and year fixed effects. Our primary outcomes were SNF revenues, expenses, profits, and occupancy. Our primary independent variable was the yearly county Medicare Advantage penetration.

DATA COLLECTION/EXTRACTION

We linked facility-year data from 2012 to 2019 obtained from cost reports and LTCFocus.org to county-year MA penetration.

PRINCIPAL FINDINGS

A 10 percentage point increase in county MA enrollment was associated with a $213,883.89 (95% Confidence Interval [CI]: -296,869.08, -130,898.71) decrease in revenue, a $132,456.19 (95% CI: -203,852.28, -61,060.10) decrease in expenses, and a 0.59 percentage point (95% CI: -0.97, -0.21) decrease in profit margin. A 10 percentage point increase in county MA enrollment was associated with a decline (-318.93; 95% CI: -468.84, -169.02) in the number of resident-days (a measure of occupancy) as well as a decline in the revenue per resident day ($4.50; 95% CI: -6.81, -2.20), potentially because of lower prices in MA. There was also a decline in expenses per patient day (-2.35; 95% CI: -4.76, 0.05), though this was only statistically significant at the 10% level. While increased MA enrollment was associated with a substantial decline in the number of Medicare resident days (487.53; 95% CI: -588.70, -386.37), this was partially offset by an increase in other payer (e.g., private pay) resident days (285.91; 95% CI: 128.18, 443.63). Increased MA enrollment was not associated with changes in the number of Medicaid resident days or a decrease in staffing per resident day.

CONCLUSION

SNFs in counties with more MA growth had substantially greater relative declines in revenue, expenses, and profit margins. The continued growth of MA may result in significant changes in the SNF industry.

Market Competition and Anemia Management in the United States Following Dialysis Payment Reform

BACKGROUND

Whether market competition influences health care provider responses to national reimbursement reforms is unknown.

OBJECTIVES

We examined whether changes in anemia management after the expansion of Medicare's dialysis payment bundle varied with market competition.

RESEARCH DESIGN

With data from the US dialysis registry, we used a difference-in-differences (DID) design to estimate the independent associations of market competition with changes in anemia management after dialysis reimbursement reform.

SUBJECTS

A total of 326,150 patients underwent in-center hemodialysis in 2009 and 2012, representing periods before and after reimbursement reform.

MEASURES

Outcomes were erythropoiesis-stimulating agent (ESA) and intravenous iron dosage, the probability of hemoglobin <9 g/dL, hospitalizations, and mortality. We also examined serum ferritin concentration, an indicator of body iron stores. We used a dichotomous market competition index, with less competitive areas defined as effectively having <2 competing dialysis providers.

RESULTS

Compared with areas with more competition, patients in less competitive areas had slightly more pronounced declines in ESA dose (60% vs. 57%) following reimbursement reform (DID estimate: -3%; 95% CI, -5% to -1%) and less pronounced declines in intravenous iron dose (-14% vs. -19%; DID estimate: 5%; 95% CI, 1%-9%). The likelihoods of hemoglobin <9 g/dL, hospitalization, and mortality did not vary with market competition. Serum ferritin concentrations in 2012 were 4% (95% CI, 3%-6%) higher in less competitive areas.

CONCLUSIONS

After the expansion of Medicare's dialysis payment bundle, ESA use declined by more, and intravenous iron use declined by less in concentrated markets. More aggressive cost-reduction strategies may be implemented in less competitive markets.

Association of Pay-for-Performance Reimbursement With Clinical Quality for Minnesota Nursing Homes Residents

In 2016, Minnesota implemented a new pay-for-performance reimbursement scheme for Medicaid residents in nursing homes, known as Value-Based Reimbursement (VBR). This study seeks to understand whether there is an association between VBR and quality improvement. We use data from 2013 to 2019 including Centers for Medicare and Medicaid Services, Nursing Home Compare, and Long-term care Facts in the US. Using multivariate regression with commuting zone fixed effects, we compare five long-stay and two short-stay clinical quality metrics in Minnesota nursing homes to nursing homes bordering states, before and after VBR was implemented. We find minimal significant changes in quality in Minnesota nursing homes after VBR. Minnesota should reconsider its pay-for-performance efforts.

Prediction of rehospitalization and mortality risks for skilled nursing facilities using a dimension reduction approach

BACKGROUND

Hospitals are incentivized to reduce rehospitalization rates, creating an emphasis on skilled nursing facilities (SNFs) for post-hospital discharge. How rehospitalization rates vary depending on patient and SNF characteristics is not well understood, in part because these characteristics are high-dimensional. We sought to estimate rehospitalization and mortality risks by patient and skilled nursing facility (SNF) leveraging high-dimensional characteristics.

METHODS

Using 1,060,337 discharges from 13,708 SNFs of Medicare patients residing or visiting a provider in Wisconsin, Iowa, and Illinois, factor analysis was performed to reduce the number of patient and SNF characteristics. K-means clustering was applied to SNF factors to categorize SNFs into groups. Rehospitalization and mortality risks within 60 days of discharge was estimated by SNF group for various values of patient factors.

RESULTS

Patient and SNF characteristics (616 in total) were reduced to 12 patient factors and 4 SNF groups. Patient factors reflected broad conditions. SNF groups differed in beds and staff capacity, off-site services, and physical and occupational therapy capacity; and in mortality and rehospitalization rates for some patients. Patients with cardiac, orthopedic, and neuropsychiatric conditions are associated with better outcomes when assigned to SNFs with greater on-site capacity (i.e. beds, staff, physical and occupational therapy), whereas patients with conditions related to cancer or chronic renal failure are associated with better outcomes when assigned to SNFs with less on-site capacity.

CONCLUSIONS

Risks of rehospitalization and mortality appear to vary significantly by patient and SNF, with certain SNFs being better suited for some patient conditions over others.

Does prospective payment influence quality of care? A systematic review of the literature

In the light of rising health expenditures, the cost-efficient provision of high-quality inpatient care is on the agenda of policy-makers worldwide. In the last decades, prospective payment systems (PPS) for inpatient care were used as an instrument to contain costs and increase transparency of provided services. It is well documented in the literature that prospective payment has an impact on structure and processes of inpatient care. However, less is known about its effect on key outcome indicators of quality of care. In this systematic review, we synthesize evidence from studies investigating how financial incentives induced by PPS affect indicators of outcome quality domains of care, i.e. health status and user evaluation outcomes. We conduct a review of evidence published in English, German, French, Portuguese and Spanish language produced since 1983 and synthesize results of the studies narratively by comparing direction of effects and statistical significance of different PPS interventions. We included 64 studies, where 10 are of high, 18 of moderate and 36 of low quality. The most commonly observed PPS intervention is the introduction of per-case payment with prospectively set reimbursement rates. Abstracting evidence on mortality, readmission, complications, discharge disposition and discharge destination, we find the evidence to be inconclusive. Thus, claims that PPS either cause great harm or significantly improve the quality of care are not supported by our findings. Further, the results suggest that reductions of length of stay and shifting treatment to post-acute care facilities may occur in the course of PPS implementations. Accordingly, decision-makers should avoid low capacity in this area.

A Rising Tide Lifts "Related" Boats-Post-Acute Care Quality Improvement is Associated with Improvement in Long-Term Care Quality in Nursing Homes

OBJECTIVES

To examine the relationship between post-acute care (PAC) quality improvement and long-term care (LTC) quality changes.

DESIGN

Observational study using national nursing home data from Nursing Home Compare linked to Brown University's LTCFocus data.

SETTING AND PARTICIPANTS

Free-standing nursing homes serving PAC and LTC residents in the United States.

METHODS

This study used pooled cross-sectional analysis with nursing home-level data from 2005 to 2010 (12,150 unique nursing homes). We used fixed effects models to examine the association between a 1-year change in PAC quality and a 1-year change in LTC quality, with a specific focus on related care domains.

RESULTS

Strong and positive associations were found between related PAC and LTC care domains, particularly between the PAC and LTC influenza vaccination care domains (β = 0.30, P < .001) and the PAC and LTC pneumococcal vaccination care domains (β = 0.55, P < .001). Meanwhile, model results showed PAC quality changes essentially had no associations with unrelated LTC care domains.

CONCLUSIONS AND IMPLICATIONS

This is the first study that examines the association of changes in quality between 2 overlapping but different care domains (ie, PAC and LTC) using multiple quality measures. Our findings indicate that nursing homes can manage concurrent quality improvement in PAC and LTC, particularly on care domains that are related. More research is needed to examine the mechanism that enables such concurrent quality improvement.

Do financial incentives matter? Effects of Medicare price shocks on skilled nursing facility care

Skilled nursing facility (SNF) spending has been one of the fastest growing categories of Medicare spending over the past few decades, and reductions in SNF payments are often recommended as part of Medicare cost containment efforts. Using a quasi-experiment resulting from a policy-driven and facility-specific Medicare payment change, we provide new evidence on how Medicare payment changes affect the amount of SNF care provided to Medicare patients. Specifically, we examine a one-time, plausibly exogenous change in the hospital wage index, an area-level adjustment to SNF payments that affected the majority of SNFs nationwide. Using a panel dataset of SNFs, we model the effects of these payment changes on more than 12,000 SNFs across the United States. We find that increases in Medicare payment rates to SNFs increased the total number of Medicare resident days at SNFs. Specifically, a 5% payment increase raised Medicare resident days by 2.33% at facilities with a 10% Medicare share relative to 0%. Further, the effects were asymmetric: Although Medicare payment increases affected Medicare days, payment decreases did not. Our results have important implications for policies that alter the Medicare base payment rates to SNFs and other health care providers.

Examination of the New Short-Stay Nursing Home Quality Measures: Rehospitalizations, Emergency Department Visits, and Successful Returns to the Community

In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced 3 new quality measures (QMs) to its report card, Nursing Home Compare (NHC). These measures—rehospitalizations, emergency department visits, and successful discharges to the community—focus on short-stay residents. We offer a first analysis of nursing homes’ performance in terms of these new measures. We examined their properties and distribution across nursing homes using descriptive statistics and regression models. We found that, similar to other QMs, performance varies across the country, and that there is very minimal correlation between these 3 new QMs as well as between these QMs and other NHC QMs. Regression models reveal that better performance on these QMs tends to be associated with fewer deficiencies, higher staffing and more skilled staffing, nonprofit ownership, and lower proportion of Medicaid residents. Other characteristics are associated with better performance for some but not all 3 QMs. We also found improvement in all 3 QMs in the second year of publication. This study contributes to the validity of these measures by demonstrating their relationship to these structural QMs. It also suggests that these QMs are important by demonstrating their large variation across the country, suggesting substantial room for improvement, and finding that nursing homes are already responding to the incentives created by publication of these QMs.

Long-Term Nursing Home Entry: A Prognostic Model for Older Adults with a Family or Unpaid Caregiver

OBJECTIVES

To comprehensively examine factors associated with long-term nursing home (NH) entry from 6 domains of older adult and family caregiver risk from nationally representative surveys and develop a prognostic model and a simple scoring system for use in risk stratification.

DESIGN

Retrospective observational study.

SETTING

National Long-Term Care Surveys 1999 and 2004 and National Health and Aging Trends Study 2011 and linked caregiver surveys.

PARTICIPANTS

Community-living older adults receiving help with self-care disability and their primary family or unpaid caregiver (N=2,676).

MEASUREMENTS

Prediction of long-term NH entry (>100 days or ending in death) by 24 months follow up, ascertained from Minimum Data Set assessments and dates of death from Medicare enrollment files. Risk factors were measured from survey responses.

RESULTS

In total, 16.1% of older adults entered a NH. Our final model and risk scoring system includes 7 independent risk factors: older adult age (1 point/5 years), living alone (5 points), dementia (3 points), 3 or more of 6 self-care activities (2 points), caregiver age (45-64: 1 point, 65-74: 2 points, ≥75: 4 points), caregiver help with money management (2 points), and caregiver report of moderate (2 points) or high (4 points) strain. Using this model, participants were assigned to risk quintiles. Long-term NH entry was 7.0% in the lowest quintile (0-6 points), 20.4% in the middle 3 quintiles (7-14 points), and 30.9% in the highest quintile (15-22 points). The model was well calibrated and demonstrated moderate discrimination (c-statistic=0.670 in the original data, c-statistic=0.647 in bootstrapped samples, c-statistic=0.652 using the point-scoring system).

CONCLUSION

We developed a prognostic model and simple scoring system that may be used to stratify risk of long-term NH entry of community-living older adults. Our model may be useful for population health and policy applications.

Financial performance, employee well-being, and client well-being in for-profit and not-for-profit nursing homes: A systematic review

BACKGROUND

Expanding the opportunities for for-profit nursing home care is a central theme in the debate on the sustainable organization of the growing nursing home sector in Western countries.

PURPOSES

We conducted a systematic review of the literature over the last 10 years in order to determine the broad impact of nursing home ownership in the United States. Our review has two main goals: (a) to find out which topics have been studied with regard to financial performance, employee well-being, and client well-being in relation to nursing home ownership and (b) to assess the conclusions related to these topics. The review results in two propositions on the interactions between financial performance, employee well-being, and client well-being as they relate to nursing home ownership.

METHODOLOGY/APPROACH

Five search strategies plus inclusion and quality assessment criteria were applied to identify and select eligible studies. As a result, 50 studies were included in the review. Relevant findings were categorized as related to financial performance (profit margins, efficiency), employee well-being (staffing levels, turnover rates, job satisfaction, job benefits), or client well-being (care quality, hospitalization rates, lawsuits/complaints) and then analyzed based on common characteristics.

FINDINGS

For-profit nursing homes tend to have better financial performance, but worse results with regard to employee well-being and client well-being, compared to not-for-profit sector homes. We argue that the better financial performance of for-profit nursing homes seems to be associated with worse employee and client well-being.

PRACTICAL IMPLICATIONS

For policy makers considering the expansion of the for-profit sector in the nursing home industry, our findings suggest the need for a broad perspective, simultaneously weighing the potential benefits and drawbacks for the organization, its employees, and its clients.

Do hospital-owned skilled nursing facilities provide better post-acute care quality?

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission.

The Impact of Green House Adoption on Medicare Spending and Utilization

OBJECTIVE

To evaluate the impact of the Green House (GH) model of nursing home care on Medicare acute hospital, other hospital, skilled nursing facility, and hospice spending and utilization.

DATA SOURCES/STUDY SETTING

Medicare claims and enrollment data from 2005 through 2010 merged with resident-level minimum data set (MDS) assessments.

STUDY DESIGN

Using a difference-in-differences framework, we compared Medicare Part A and hospice expenditures and utilization in 15 nursing homes that adopted the GH model relative to changes over the same time period in 223 matched nonadopting nursing homes. We applied the same method for residents of GH homes and for residents of "legacy" homes, the original nursing homes that stay open alongside the GH home(s).

PRINCIPAL FINDINGS

The adoption of GH had no detectable impact on Medicare Part A (plus hospice) spending and utilization across all residents living in the nursing home. When we analyzed residents living in GH homes and legacy units separately, however, we found that the adoption of the GH model reduced overall annual Medicare Part A spending by $7,746 per resident, although this appeared to be partially offset by an increase in spending in legacy homes.

CONCLUSIONS

To the extent that the GH model reduces Medicare spending, adopting nursing homes do not receive any of the related Medicare savings under traditional payment mechanisms. New approaches that are currently being developed and piloted, which better align financial incentives for providers and payers, could incentivize greater adoption of the GH model.

Does the Volume of Post-Acute Care Affect Quality of Life in Nursing Homes?

Although short-stay, post-acute nursing home stays are increasing, little is known about the impact of volume of post-acute care on quality of life (QOL) within nursing homes. We analyzed data from the 2010 Minnesota QOL and Consumer Satisfaction survey ( N = 13,433 residents within 377 facilities) and federal Minimum Data Set to determine the influence of living in a facility with an above-average proportion of post-acute care residents on six domains of resident QOL. In bivariate analyses, an above-average proportion of Medicare-funded post-acute care had a significant negative influence on four domains (mood, environment, food, engagement) and overall facility QOL. However, when resident and facility covariates were added to the model, only the food domain remained significant. Although the challenges of caring for residents with a diverse set of treatment and caregiving goals may negatively affect overall facility QOL, negative impacts are moderated by individual resident and nursing home characteristics.

Medicare skilled nursing facility reimbursement and upcoding

Post-acute care provided by skilled nursing facilities (SNFs) is reimbursed by Medicare under a prospective payment system using resource utilization groups (RUGs) that adjust payment intensity on the basis of predefined ranges of weekly therapy minutes provided and the functionality of the patient. Individual RUGs account for differences in the intensity of care provided, but there exists significant regional variation in the payments SNFs receive from Medicare due to the use of geographic adjustment factors. This paper is the first to use this geographic variation in the generosity of Medicare reimbursement to empirically test if SNFs respond to payment differences between RUG categories. The results are highly suggestive that SNFs upcode patients by providing additional therapy minutes to increase revenue, whereas we find no evidence of upcoding related to patient functionality scores. Simulating how different payment differentials affect RUG selection, we predict that reducing the financial incentive to upcode could result in significant savings to Medicare.

Medicare home health care patient case-mix before and after the Balanced Budget Act of 1997: effect on dual eligible beneficiaries

The Balanced Budget Act (BBA) of 1997 changed the payment system for Medicare home health care (HHC) from cost-based to prospective reimbursement. We used Medical Expenditure Panel Survey data to assess the impact of the BBA on Medicare HHC patient case-mix measured by the Centers for Medicare and Medicaid Services Hierarchical Condition Categories (CMS-HCC) model. There was a significant increase in Medicare HHC patient case-mix between the pre-BBA and Prospective Payment System (PPS) periods. The increase in the standardized-predicted risk score from the Interim Payment System period to PPS was nearly 4 times greater for the dual eligibles (Medicare-Medicaid) than for the Medicare-only population. This significantly greater rise in the HHC resources required by dual eligibles as compared to nonduals could be due to a shift in HHC payers from Medicare only to Medicaid rather than be an actual increase in case-mix per se.

Malpractice litigation and nursing home quality of care

OBJECTIVE

To assess the potential deterrent effect of nursing home litigation threat on nursing home quality.

DATA SOURCES/STUDY SETTING

We use a panel dataset of litigation claims and Nursing Home Online Survey Certification and Reporting (OSCAR) data from 1995 to 2005 in six states: Florida, Illinois, Wisconsin, New Jersey, Missouri, and Delaware, for a total of 2,245 facilities. Claims data are from Westlaw's Adverse Filings database, a proprietary legal database, on all malpractice, negligence, and personal injury/wrongful death claims filed against nursing facilities.

STUDY DESIGN

A lagged 2-year moving average of the county-level number of malpractice claims is used to represent the threat of litigation. We use facility fixed-effects models to examine the relationship between the threat of litigation and nursing home quality.

PRINCIPAL FINDINGS

We find significant increases in registered nurse-to-total staffing ratios in response to rising malpractice threat, and a reduction in pressure sores among highly staffed facilities. However, the magnitude of the deterrence effect is small.

CONCLUSIONS

Deterrence in response to the threat of malpractice litigation is unlikely to lead to widespread improvements in nursing home quality. This should be weighed against other benefits and costs of litigation to assess the net benefit of tort reform.

Serious mental illness and nursing home quality of care

OBJECTIVE

To estimate the effect of a nursing home's share of residents with a serious mental illness (SMI) on the quality of care.

DATA SOURCES

Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims.

STUDY DESIGN

We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects.

PRINCIPAL FINDINGS

An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non-SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents.

CONCLUSIONS

Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight.

Ownership conversion and closure in the nursing home industry

Ownership conversions and closures in the nursing home literature have largely been treated as separate issues. This paper studies the predictors of nursing home ownership conversions and closure in a common framework after the implementation of the Prospective Payment System in Medicare skilled nursing facilities. The switch in reimbursement regimes impacted facilities with greater exposure to Medicare and lower efficiency. Facilities that faced greater financial difficulty were more likely to be involved in an ownership conversion or closure, but after controlling for other factors the effect of exposure to Medicare is small. Further, factors that predict conversion were found to vary between not-for-profit and for-profit facilities, while factors that predict closure were the same for each ownership type.

Exploring the relationship between private equity ownership and nursing home performance: a review

Private equity has acquired multiple large nursing home chains within the past few years; by 2007, it owned 6 of the 10 largest chains. Despite widespread public and policy interest, evidence on the purported impact of private equity on nursing home performance is limited. In our review, we begin by briefly reviewing the organizational and environmental changes in the nursing home industry that facilitated private equity investments. We offer a conceptual framework to hypothesize the relationship between private equity ownership and nursing home performance. Finally, we offer a research agenda focused on the important parameters of nursing home performance: financial performance, and quality of care.

Medicaid bed-hold policy and Medicare skilled nursing facility rehospitalizations

OBJECTIVE

To analyze the effect of states' Medicaid bed-hold policies on the 30-day rehospitalization of Medicare postacute skilled nursing facility (SNF) residents.

DATA SOURCES

Minimum data set assessments were merged with Medicare claims and eligibility files for all first-time SNF admissions (N = 3,322,088) over the period 2000 through 2005; states' Medicaid bed-hold policies were obtained via survey.

STUDY DESIGN

Regression specification incorporating facility fixed effects to examine changes in Medicaid bed-hold policies on the likelihood of a 30-day SNF rehospitalization.

PRINCIPAL FINDINGS

Using a continuous measure of bed-hold generosity, state Medicaid bed-hold was positively related to Medicare SNF rehospitalization. Specifically, the introduction of a bed-hold policy with average generosity increases Medicare rehospitalizations by 1.8 percent, representing roughly 12,000 SNF rehospitalizations at a cost to Medicare of approximately U.S.$100 million over our study period.

CONCLUSIONS

Although facilities do not receive a Medicaid bed-hold payment for Medicare SNF stays, we found that the adoption of more generous policies led to greater SNF rehospitalizations. This type of spillover is largely ignored in current discussions of Medicare payment reforms such as bundled payment. Neither Medicare nor Medicaid has an incentive to internalize the risks and benefits of its actions as they affect the other.

Performing well on nursing home report cards: does it pay off?

OBJECTIVE

To examine whether high performance or improvement on quality measures leads to economic rewards for nursing homes in the presence of public reporting.

DATA SOURCES

Data from 6,286 freestanding Medicare-certified nursing homes between 1999 and 2005 were identified in Medicare Cost Reports, Minimum Data Set, and Online Survey and Certification Reporting System.

STUDY DESIGN

Using a facility-level fixed-effects model, the effect of public reporting on financial performance was measured by comparing each of four financial outcomes (revenues, expenses, operating, and total profit margins) before (1999-2002) to after (2003-2005) public reporting was initiated. The effects were estimated separately by level of performance and improvement over time.

PRINCIPAL FINDINGS

Facilities that improved on publicly reported performance had increased revenues and higher profit margins after public reporting, mainly through increased Medicare admissions. High-scoring facilities showed similar patterns, though differences were not statistically significant.

CONCLUSIONS

Providers that improve their performance under public reporting may receive a return on their investment in quality improvement. This supports the business case for public reporting.

The revolving door of rehospitalization from skilled nursing facilities

Almost one-fourth of Medicare beneficiaries discharged from the hospital to a skilled nursing facility were readmitted to the hospital within thirty days; this cost Medicare $4.34 billion in 2006. Especially in an elderly population, cycling into and out of hospitals can be emotionally upsetting and can increase the likelihood of medical errors related to care coordination. Payment incentives in Medicare do not encourage providers to coordinate beneficiaries' care. Revising these incentives could achieve major savings for providers and improved quality of life for beneficiaries.

Organizational characteristics and cancer care for nursing home residents

OBJECTIVE

We evaluate whether organization, market, policy, and resident characteristics are related to cancer care processes and outcomes for dually eligible residents of Michigan nursing homes who entered facilities without a cancer diagnosis but subsequently developed the disease. DATA SOURCES/STUDY DESIGN/DATA COLLECTION: Using data from the Michigan Tumor Registry (1997-2000), Medicare claims, Medicaid cost reports, and the Area Resource File, we estimate logistic regression models of diagnosis at or during the month of death and receipt of pain medication during the month of or month after diagnosis.

PRINCIPAL FINDINGS

Approximately 25 percent of the residents were diagnosed at or near death. Only 61 percent of residents diagnosed with late or unstaged cancer received pain medication during the diagnosis month or the following month. Residents in nursing homes with lower staffing and in counties with fewer hospital beds were more likely to be diagnosed at death. After the Balanced Budget Act (BBA), residents were more likely to be diagnosed at death.

CONCLUSIONS

Nursing home characteristics and community resources are significantly related to the cancer care residents receive. The BBA was associated with an increased likelihood of later diagnosis of cancer.

Games policy makers and providers play: introducing case-mix-based payment to hospital chronic care units in Japan

Case-mix-based payment was developed for hospital chronic care units in Japan to replace the flat per diem rate and encourage the admission of patients with higher medical acuity and was part of a policy initiative to make the tariff more evidence based. However, although the criteria for grouping patients were developed from a statistical analysis of resource use, the tariff was subsequently set below costs, particularly for the groups with the lowest medical acuity, both because of the prime minister's decision to decrease total health expenditures and because of the health ministry's decision to target the reductions on chronic care units. Providers quickly adapted to the new payment system mainly by reclassifying their patients to higher medical acuity groups. Some hospitals reported high prevalence rates of urinary tract infections and pressure ulcers. The government responded by issuing directives to providers to calculate the prevalence rates and document the care that has been mandated for the patients at risk. However, in order to monitor compliance and to evaluate whether the patient is being billed for the appropriate case-mix group, the government must invest in developing a comprehensive patient-level database and in training staff for making on-site inspections.

Registered nurse staffing mix and quality of care in nursing homes: a longitudinal analysis

PURPOSE

To examine the relationship between registered nurse (RN) staffing mix and quality of nursing home care measured by regulatory violations.

DESIGN AND METHODS

A retrospective panel data study (1999-2003) of 2 groups of California freestanding nursing homes. One group was 201 nursing homes that consistently met the state's minimum standard for total nurse staffing level over the 5-year period. The other was 210 nursing homes that consistently failed to meet the standard over the period. All facility and market variables were drawn from California's cost report data and state licensing and certification data, as well as 3 other databases.

RESULTS

The RN to total nurse staffing ratio was negatively related to serious deficiencies in nursing homes that consistently met the staffing standard, whereas the ratio was negatively associated with total deficiencies in nursing homes that consistently failed to meet the standard over the 5-year period. As the RN to licensed vocational nurse ratios increased, total deficiencies and serious deficiencies decreased in both groups of nursing homes.

IMPLICATIONS

A higher RN mix is positively related to quality of care, but the relationship is affected by overall nurse staffing levels in nursing homes. Further studies are necessary for a better understanding of RNs' unique contributions to the quality of care in nursing homes.

Annual expenditures for nursing home care: private and public payer price growth, 1977 to 2004

BACKGROUND

Long-term nursing home care is primarily funded by out-of-pocket payments and public Medicaid programs. Few studies have explored price growth in nursing home care, particularly trends in the real cost of a year spent in a nursing home.

OBJECTIVES

To evaluate changes in private and public prices for annual nursing home care from 1977 to 2004, and to compare nursing home price growth to overall price growth and growth in the price of medical care.

RESEARCH DESIGN

We estimated annual private prices for nursing home care between 1977 and 2004 using data from the National Nursing Home Survey. We compared private nursing home price growth to public prices obtained from surveys of state Medicaid offices, and evaluated the Bureau of Labor Statistics Consumer Price Indexes to compare prices for nursing homes, medical care, and general goods and services over time.

RESULTS

Annual private pay nursing homes prices grew by 7.5% annually from $8645 in 1977 to $60,249 in 2004. Medicaid prices grew by 6.7% annually from $9491 in 1979 to $48,056 in 2004. Annual price growth for private pay nursing home care outpaced medical care and other goods and services (7.5% vs. 6.6% and 4.4%, respectively) between 1977 and 2004.

CONCLUSIONS

The recent rapid growth in nursing home prices is likely to persist, because of an aging population and greater disability among the near-elderly. The result will place increasing financial pressure on Medicaid programs. Better data on nursing prices are critical for policy-makers and researchers.

Determinants of performance failure in the nursing home industry

This study investigates the determinants of performance failure in U.S. nursing homes. The sample consisted of 91,168 surveys from 10,901 facilities included in the Online Survey Certification and Reporting system from 1996 to 2005. Failed performance was defined as termination from the Medicare and Medicaid programs. Determinants of performance failure were identified as core structural change (ownership change), peripheral change (related diversification), prior financial and quality of care performance, size and environmental shock (Medicaid case mix reimbursement and prospective payment system introduction). Additional control variables that could contribute to the likelihood of performance failure were included in a cross-sectional time series generalized estimating equation logistic regression model. Our results support the contention, derived from structural inertia theory, that where in an organization's structure change occurs determines whether it is adaptive or disruptive. In addition, while poor prior financial and quality performance and the introduction of case mix reimbursement increases the risk of failure, larger size is protective, decreasing the likelihood of performance failure.

Nursing home performance in resident care in the United States: is it only a matter of for-profit versus not-for-profit?

Poorer resident care in US for-profit relative to not-for-profit nursing homes is usually blamed on the profit motive. But US nursing home performance may relate to Medicaid public financing in a manner qualifying the relationship between ownership and quality. We investigated effects of Medicaid resident census, Medicaid payment, and occupancy on performance. Resource dependence theory implies these predictors may affect discretion in resources invested in resident care across for-profit and not-for-profit facilities. Models on physical restraint use and registered nurse (RN) staffing were studied using generalized estimating equations with panel data derived from certification inspections of nursing homes. Restraint use increased and RN staffing levels decreased among for-profit and not-for-profit facilities when the Medicaid census increased and Medicaid payment decreased. Interaction effects supported a theory that performance relates to available discretion in resource allocation. Effects of occupancy appear contingent on the dependence on Medicaid. Poorer performance among US for-profit nursing homes may relate to for-profit homes having lower occupancy, higher Medicaid census, and operating in US states with lower Medicaid payments compared to not-for-profit homes. Understanding the complexity of factors affecting resources expended on resident care may further our understanding of the production of quality in nursing homes, whether in the US or elsewhere.

The staffing-outcomes relationship in nursing homes

OBJECTIVE

To assess longitudinally whether a change in registered nurse (RN) staffing and skill mix leads to a change in nursing home resident outcomes while controlling for the potential endogeneity of staffing.

DATA SOURCES

Minimum Data Set (MDS) nursing home resident assessment data from five states merged with Online Survey Certification and Reporting (OSCAR) data from 1996 through 2000.

STUDY DESIGN

Resident-level longitudinal analysis with facility fixed effects and instrumental variables. Outcomes studied are incidence of pressure sores and urinary tract infections. RN staffing was measured as the care hours per resident-day and skill mix was measured as RN staffing hours as a proportion of total staffing hours.

DATA EXTRACTION METHOD

We use all quarterly MDS assessments that fall within 120 days of an annual OSCAR data point, resulting in 399,206 resident-level observations.

PRINCIPAL FINDINGS

Controlling for endogeneity of staffing increases the estimated impact of staffing on outcomes in nursing homes. Greater RN staffing significantly decreases the likelihood of both adverse outcomes. Increasing skill mix only reduces the incidence of urinary tract infections.

CONCLUSIONS

Research that fails to account for endogeneity of the staffing-outcomes relationship may underestimate the benefit from increased RN staffing. Increases in RN staffing are likely to reduce adverse outcomes in some nursing homes. More research using a broader array of instruments and a national sample would be beneficial.

The market for long-term care services

Although a large literature has established the importance of market and regulatory forces within the long-term care sector, current research in this field is limited by a series of data, measurement, and methodological issues. This paper provides a comprehensive review of these issues with an emphasis on identifying initiatives that will increase the volume and quality of long-term care research. Recommendations include: the construction of standard measures of long-term care market boundaries, the broader dissemination of market and regulatory data, the linkage of survey-based data with market measures, the encouragement of further market-based studies of noninstitutional long-term care settings, and the standardization of Medicaid cost data.

Medicare expenditures for nursing home residents triaged to nursing home or hospital for acute infection

OBJECTIVES

To compare Medicare payments of nursing home residents triaged to nursing home with those of nursing home residents triaged to the hospital for acute infection care.

DESIGN

Observational study with propensity score matching.

SETTING

Fifty-nine nursing homes in Maryland.

PARTICIPANTS

Two thousand two hundred eighty-five individuals admitted to the 59 nursing homes and followed between 1992 and 1997.

MEASUREMENTS

Demographic and clinical data were obtained from interviews and medical record review and linked to Medicare payment records. Incident infection was ascertained according to medical record review for new infectious diagnoses or prescription of antibiotics. Hospital triage was defined as hospital transfer within 3 days of infection onset. Hospital triage patients were paired with similar nursing home triage patients using propensity score matching. Medicare expenditures for triage groups were compared in 1997 dollars.

RESULTS

Of 3,618 infection cases, 28% were genitourinary infections, 20% skin, 14% upper respiratory, 12% lower respiratory, 4% gastrointestinal, and 2% bloodstream. Two hundred fifty-six pairs of hospital and nursing home triage cases fulfilled matching criteria. Mean Medicare payments+/-standard deviation were $5,202+/-7,310 and $996+/-2,475 per case in the hospital and nursing home triage groups, respectively, for a mean difference of $4,206 (95% confidence interval=$3,260-5,151). Mean payments per case in the hospital triage group were $3,628 higher in inpatient expenditures, $482 higher in physician visit expenditures, $161 higher in emergency department expenditures, and $147 higher in skilled nursing day expenditures.

CONCLUSION

Per-case Medicare expenditures are higher with hospital triage than for nursing home triage for nursing home residents with acute infection. This result may be used to estimate cost savings to Medicare of interventions designed to reduce hospital use by nursing home residents.

Restructuring in response to case mix reimbursement in nursing homes: a contingency approach

BACKGROUND

Resident-based case mix reimbursement has become the dominant mechanism for publicly funded nursing home care. In 1998 skilled nursing facility reimbursement changed from cost-based to case mix adjusted payments under the Medicare Prospective Payment System for the costs of all skilled nursing facility care provided to Medicare recipients. In addition, as of 2004, 35 state Medicaid programs had implemented some form of case mix reimbursement.

PURPOSE

The purpose of the study is to determine if the implementation of Medicare and Medicaid case mix reimbursement increased the administrative burden on nursing homes, as evidenced by increased levels of nurses in administrative functions.

METHODOLOGY/APPROACH

The primary data for this study come from the Centers for Medicare and Medicaid Services Online Survey Certification and Reporting database from 1997 through 2004, a national nursing home database containing aggregated facility-level information, including staffing, organizational characteristics and resident conditions, on all Medicare/Medicaid certified nursing facilities in the country. We conducted multivariate regression analyses using a facility fixed-effects model to examine the effects of the implementation of Medicaid case mix reimbursement and Medicare Prospective Payment System on changes in the level of total administrative nurse staffing in nursing homes.

FINDINGS

Both Medicaid case mix reimbursement and Medicare Prospective Payment System increased the level of administrative nurse staffing, on average by 5.5% and 4.0% respectively. However, lack of evidence for a substitution effect suggests that any decline in direct care staffing after the introduction of case mix reimbursement is not attributable to a shift from clinical nursing resources to administrative functions.

PRACTICE IMPLICATIONS

Our findings indicate that the administrative burden posed by case mix reimbursement has resource implications for all freestanding facilities. At the margin, the increased administrative burden imposed by case mix may become a factor influencing a range of decisions, including resident admission and staff hiring.

Implementation of the resident assessment instrument/minimum data set in the nursing home as organization: implications for quality improvement in RN clinical assessment

The Resident Assessment Instrument/Minimum Data Set (RAI/MDS) used in nursing homes (NHs) participating in the Federal Medicare and Medicaid programs is a state-of-the-art, computerized clinical assessment instrument. RAI/MDS-derived data are essential, used for NH reimbursement, quality measurement, regulatory quality monitoring activities, and clinical care planning. Completing or coordinating the RAI/MDS, which may be conceived of as implementation, is a federally mandated responsibility of the RN involving clinical assessment, a core professional competency of any RN. How the RAI/MDS is implemented in each NH provides evidence of how each NH as an organization understands both the RAI/MDS process and its organizational level responsibility for promotion of RN competence in clinical assessment. Research literature related to RAI/MDS development, testing, and accuracy is used to identify what is known about organizational level implementation of the RAI/MDS. Evidence-based suggestions to enhance RN competence in RAI/MDS clinical assessments, given existing organizational barriers, are provided.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Medicare and Medicaid: conflicting incentives for long-term care

The structure of Medicare and Medicaid creates conflicting incentives regarding dually eligible beneficiaries without coordinating their care. Both Medicare and Medicaid have an interest in limiting their costs, and neither has an incentive to take responsibility for the management or quality of care. Examples of misaligned incentives are Medicare's cost-sharing rules, cost shifting within home health care and nursing homes, and cost shifting across chronic and acute care settings. Several policy initiatives--capitation, pay-for-performance, and the shift of the dually eligible population's Medicaid costs to the federal government--may address these conflicting incentives, but all have strengths and weaknesses. With the aging baby boom generation and projected federal and state budget shortfalls, this issue will be a continuing focus of policymakers in the coming decades.

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies

OBJECTIVE

Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations.

DATA SOURCES/STUDY SETTING

Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently.

STUDY DESIGN

Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics.

PRINCIPAL FINDINGS

Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63).

CONCLUSIONS

State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

Hospitalization of nursing home residents: the effects of states' Medicaid payment and bed-hold policies

OBJECTIVE

Hospitalizations of nursing home residents are costly and expose residents to iatrogenic disease and social and psychological harm. Economic constraints imposed by payers of care, predominantly Medicaid policies, are hypothesized to impact hospitalizations.

DATA SOURCES/STUDY SETTING

Federally mandated resident assessments were merged with Medicare claims and eligibility files to determine hospitalizations and death within 150 days of baseline assessment. Nursing home and market characteristics were obtained from the Online Survey Certification and Reporting, and the Area Resource File, respectively. States' average daily Medicaid nursing home payments and bed-hold policies were obtained independently.

STUDY DESIGN

Prospective cohort study of 570,614 older (> or =65-year-old), non-MCO (Medicare Managed Care), long-stay (> or =90 days) residents in 8,997 urban, freestanding nursing homes assessed between April and June 2000, using multilevel models to test the impact of state policies on hospitalizations controlling for resident, nursing home, and market characteristics.

PRINCIPAL FINDINGS

Overall, 99,379 (17.4 percent) residents were hospitalized with rates varying from 8.4 percent in Utah to 24.9 percent in Louisiana. Higher Medicaid per diem was associated with lower odds of hospitalizations (5 percent lower for each $10 above average $103.5, confidence intervals [CI] 0.91-0.99). Hospitalization odds were higher by 36 percent in states with bed-hold policies (CI: 1.12-1.63).

CONCLUSIONS

State Medicaid bed-hold policy and per-diem payment have important implications for nursing home hospitalizations, which are predominantly financed by Medicare. This study emphasizes the importance of properly aligning state Medicaid and federal Medicare policies in regards to the subsidy of acute, maintenance, and preventive care in the nursing home setting.

Does Organisational Culture Influence Prescribing in Care Homes for Older People?

Prescribing in care homes for older people has been the focus of much research and debate because of inappropriate drug choice and poor monitoring practices. In the US, this has led to the implementation of punitive and adversarial regulation that has sought to improve the quality of prescribing in this healthcare setting. This approach is unique to the US and has not been replicated elsewhere. The literature has revealed that there are limitations as to how much can be achieved with regulation that is externally imposed (an 'external factor'). Other influences, which may be categorised as 'internal factors' operating within the care home (e.g. patient, physician and care-home characteristics), also affect prescribing. However, these internal and external factors do not appear to affect prescribing uniformly, and poor prescribing practices in care homes continue to be observed. One intangible factor that has received little attention in this area of healthcare is that of organisational culture. This factor has been linked to quality and performance within other health organisations. Consideration of organisational culture within care-home settings may help to understand what drives prescribing decisions in this particularly vulnerable patient group and thus provide new directions for future strategies to promote quality care.

Medicare payment changes and nursing home quality: effects on long-stay residents

The Balanced Budget Act of 1997 dramatically changed the way that Medicare pays skilled nursing facilities, providing a natural experiment in nursing home behavior. Medicare payment policy (directed at short-stay residents) may have affected outcomes for long-stay, chronic-care residents if services for these residents were subsidized through cost-shifting prior to implementation of Medicare prospective payment for nursing homes. We link changes in both the form and level of Medicare payment at the facility level with changes in resident-level quality, as represented by pressure sores and urinary tract infections in Minimum Data Set (MDS) assessments. Results show that long-stay residents experienced increased adverse outcomes with the elimination of Medicare cost reimbursement.