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Kang Y, David SV, Bowblis JR, Intrator O, Downer B, Li CY, Goodwin JS, Xu H. Financial Performance is Associated With PPE Shortages in Chain-Affiliated Nursing Homes During the COVID-19 Pandemic: A Longitudinal Study. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2023; 60:469580231219443. [PMID: 38102846 PMCID: PMC10725134 DOI: 10.1177/00469580231219443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 11/02/2023] [Accepted: 11/20/2023] [Indexed: 12/17/2023]
Abstract
Many nursing homes operated at thin profit margins prior to the COVID-19 pandemic. This study examines the role of nursing homes' financial performance and chain affiliation in shortages of personal protection equipment (PPE) during the first year of the COVID-19 pandemic. We constructed a longitudinal file of 79 868 nursing home-week observations from 10 872 unique facilities. We found that a positive profit margin was associated with a 21.0% lower probability of reporting PPE shortages in chain-affiliated nursing homes, but not in non-chain nursing homes. Having adequate financial resources may help nursing homes address future emergencies, especially those affiliated with a multi-facility chain.
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Affiliation(s)
- Yejin Kang
- University of Texas Medical Branch, Galveston, TX, USA
| | | | | | - Orna Intrator
- University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Canandaigua VA Medical Center, Canandaigua, NY, USA
| | - Brian Downer
- University of Texas Medical Branch, Galveston, TX, USA
| | - Chih-Ying Li
- University of Texas Medical Branch, Galveston, TX, USA
| | | | - Huiwen Xu
- University of Texas Medical Branch, Galveston, TX, USA
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2
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Morantz A, Ross L. Intermediate Care Facilities for Individuals With Intellectual Disabilities: Does Ownership Type Affect Quality of Care? INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2022; 60:212-225. [PMID: 35640607 DOI: 10.1352/1934-9556-60.3.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/06/2021] [Indexed: 06/15/2023]
Abstract
Because many large, state-owned Intermediate Care Facilities for Individuals With Intellectual Disabilities (ICF/IIDs) have closed or downsized, their average size has fallen markedly, as has the number that are publicly owned. We probe the relationship between ownership type and four measures of care quality in ICF/IIDs. Data on deficiency citations suggest that for-profits underperform other ownership types, although data on complaints show no clear pattern. Meanwhile, data on staffing ratios and restrictive behavior management practices, based mostly on facility self-reports, generally tell the opposite story. Our results lend some credence to concerns regarding inadequate care in for-profit ICF/IIDs, while underscoring the importance of requiring ICF/IID operators to report more comprehensive, longitudinal data that are less prone to error and reporting bias.
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Affiliation(s)
| | - Leslie Ross
- Leslie Ross, University of California, San Francisco
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Sharma H, Xu L. Association between wages and nursing staff turnover in Iowa nursing homes. Innov Aging 2022; 6:igac004. [PMID: 35770065 PMCID: PMC9233199 DOI: 10.1093/geroni/igac004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background and Objectives
Nursing staff turnover is a substantial concern for nursing homes that care for millions of older individuals, especially during the COVID-19 pandemic. Low pay is considered as one of the key reasons for high turnover. However, we do not know whether increasing wages can lead to lower turnover. In this study, we fill this gap in our understanding by analyzing the relationship between wages and nursing staff turnover.
Research Design and Methods
We obtained data on hourly wages (Medicare Cost Reports), turnover (Iowa Department of Human Services), and nursing home and resident characteristics (Nursing Home Compare and LTCFocus) from 2013 to 2017. We summarized the characteristics of nursing homes as well as turnover trends over time. Next, we used pooled OLS and facility fixed effects regressions to examine the relationship between wages and turnover adjusting for nursing home and resident characteristics.
Results
Among the 396 nursing homes in Iowa, average hourly wage was $27.0 for registered nurse (RNs), $21.6 for licensed practical nurses (LPNs), and $14.1 for certified nurse aides (CNAs) during 2013 to 2017. Average turnover rates were increasing over time for all staff types and in 2017, turnover rates were 46.0% for RNs, 44.4% for LPNs, and 64.7% for CNAs. In both pooled OLS and facility fixed effects regressions, higher wages were associated with lower turnover of CNAs but not LPNs or RNs. The magnitude of the effect of wages on turnover for CNAs was lower in facility fixed effects regressions.
Discussion and Implications
We found significant relationship between hourly wages and turnover for CNAs but not for LPNs or RNs. Focusing on higher wages alone may not lead to lower turnover of all types of nursing staff in nursing homes. We should also focus on non-wage factors related to turnover.
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Affiliation(s)
- Hari Sharma
- Department of Health Management and Policy, College of Public Health, The University of Iowa, Iowa City, Iowa, USA
| | - Lili Xu
- Department of Health Management and Policy, College of Public Health, The University of Iowa, Iowa City, Iowa, USA
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4
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Kummet C, Schneider K, Wang C, Longinaker N, Joseph-King M, Anderson K, Brecher A, Vitolo S. Medicare Beneficiary Factors Associated with Skilled Nursing Facility Lengths of Stay. J Appl Gerontol 2022; 41:1365-1375. [PMID: 35085044 DOI: 10.1177/07334648211062875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The objectives of this study are (1) to identify beneficiary-level characteristics associated with skilled nursing facility (SNF) length of stay (LOS), and (2) to determine if significant differences in LOS exist for vulnerable populations at the individual level or among nursing homes that serve a disproportionate share of vulnerable populations. This study employed 2014-2015 Medicare Long-Term Care Minimum Data Set (MDS v3.0) assessment, fee-for-service claims and enrollment, and 2014 Nursing Home Compare data to examine SNF LOS in Medicare beneficiaries. We used a hierarchical linear model to identify which beneficiary-level characteristics are associated with SNF LOS, while controlling for facility-level characteristics. After controlling for beneficiary-and facility-level characteristics, we found dual eligibility, racial or ethnic minority, depression, and Alzheimer's disease to be associated with longer Medicare covered SNF stays. We found that facilities that served higher proportions of dually eligible individuals tended to have higher average LOS compared to other facilities.
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Affiliation(s)
- Colleen Kummet
- Federal Health Division, General Dynamics Information Technology (GDIT), West Des Moines, IA, USA
| | | | - Chong Wang
- Federal Health Division, General Dynamics Information Technology (GDIT), West Des Moines, IA, USA
| | - Nyaradzo Longinaker
- Federal Health Division, General Dynamics Information Technology (GDIT), West Des Moines, IA, USA
| | - Maria Joseph-King
- Federal Health Division, General Dynamics Information Technology (GDIT), West Des Moines, IA, USA
| | - Karyn Anderson
- Medicare-Medicaid Coordination Office Centers for Medicare & Medicaid Services, Baltimore, MD, USA
| | - Andrew Brecher
- Medicare-Medicaid Coordination Office Centers for Medicare & Medicaid Services, Baltimore, MD, USA
| | - Sara Vitolo
- Medicare-Medicaid Coordination Office Centers for Medicare & Medicaid Services, Baltimore, MD, USA
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5
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Sharma H, Hefele JG, Xu L, Conkling B, Wang XJ. First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance. Med Care 2021; 59:1099-1106. [PMID: 34593708 DOI: 10.1097/mlr.0000000000001648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions. OBJECTIVE The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP. RESEARCH DESIGN We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis. RESULTS The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312. CONCLUSIONS SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.
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Affiliation(s)
- Hari Sharma
- Department of Health Management and Policy, The University of Iowa, Iowa City, IA
| | | | - Lili Xu
- Department of Health Management and Policy, The University of Iowa, Iowa City, IA
| | | | - Xiao Joyce Wang
- McCormack Graduate School of Policy and Global Studies, University of Massachusetts, Boston, MA
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6
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Nursing Home Profit Margins and Citations for Infection Prevention and Control. J Am Med Dir Assoc 2021; 22:2378-2383.e2. [PMID: 33930318 PMCID: PMC8079226 DOI: 10.1016/j.jamda.2021.03.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 03/18/2021] [Accepted: 03/21/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Recent rampant spread of COVID-19 cases in nursing homes has highlighted the concerns around nursing homes' ability to contain the spread of infections. The ability of nursing homes to invest in quality improvement initiatives may depend on resource availability. In this study, we sought to examine whether lower profit margins, as a proxy for lack of resources, are associated with persistent infection control citations. DESIGN We conducted a retrospective study. SETTING AND PARTICIPANTS Medicare-certified nursing homes in the US with financial and facility characteristics data (n = 12,194). METHODS We combined facility-level data on nursing home profit margins from Medicare Cost Reports with deficiency citation data from Nursing Home Compare (2017-2019) and facility characteristics data from LTCFocus.org. We descriptively analyzed infection control citations by profit margins quintiles. We used logistic regressions to examine the relationship between profit margin quintiles and citations for infection prevention and control, adjusting for facility and market characteristics. RESULTS About three-fourths of all facilities received deficiency citations for infection prevention and control during 1 or more years from 2017 to 2019 with about 10% of facilities cited in all 3 years. Facilities in the highest profit margin quintile had 7.6% of facilities with citations for infection prevention and control in each of the 3 years compared with 8.1%, 10.0%, 10.7%, and 13.7% for facilities in the fourth, third, second, and first quintiles of profit margins, respectively. Multivariable regressions showed that facilities with the lowest profit margins (first quintile) had 54.3% higher odds of being cited in at least 1 year and 87.6% higher odds of being cited in each of the 3 years compared with facilities with the highest profit margins (fifth quintile). CONCLUSIONS AND IMPLICATIONS Our findings indicate that nursing homes may need more resources to prevent citations for infection prevention and control.
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Konetzka RT, Davila H, Brauner DJ, Cursio JF, Sharma H, Werner RM, Park YS, Shippee TP. The Quality Measures Domain in Nursing Home Compare: Is High Performance Meaningful or Misleading? THE GERONTOLOGIST 2021; 62:293-303. [PMID: 33903898 DOI: 10.1093/geront/gnab054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The reported percent of nursing home residents suffering adverse outcomes decreased dramatically since Nursing Home Compare began reporting them, but the validity of scores is questionable for nursing homes that score well on measures using facility-reported data but poorly on inspections. Our objective is to assess whether nursing homes with these "discordant" scores are meaningfully better than nursing homes that score poorly across domains. RESEARCH DESIGN AND METHODS We used a convergent mixed-methods design, starting with quantitative analyses of 2012-2016 national data. We conducted in-depth interviews and observations in 12 nursing homes in 2017-2018, focusing on how facilities achieved their Nursing Home Compare ratings. Additional quantitative analyses were conducted in parallel to study performance trajectories over time. Quantitative and qualitative results were interpreted together. RESULTS Discordant facilities engage in more quality improvement strategies than poor performers, but do not seem to invest in quality improvement in resource-intensive, broad-based ways that would spill over into other domains of quality and change their trajectory of improvement. Instead, they focus on lower-resource improvements related to data quality, staff training, leadership, and communication. In contrast, poor-performing facilities seemed to lack the leadership and continuity of staff required for even these low-resource interventions. DISCUSSION AND IMPLICATIONS High performance on the quality measures using facility-reported data is mostly meaningful rather than misleading to consumers who care about those outcomes, although discordant facilities still have quality deficits. The quality measures domain should continue to have a role in Nursing Home Compare.
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Affiliation(s)
- R Tamara Konetzka
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, Illinois, USA.,Department of Medicine, Biological Sciences Division, University of Chicago, Chicago, Illinois, USA
| | - Heather Davila
- VA Boston Healthcare System, Boston, Massachusetts, USA.,Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Daniel J Brauner
- Department of Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA.,Department of Family and Community Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, Michigan, USA
| | - John F Cursio
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, Illinois, USA
| | - Hari Sharma
- Department of Health Management and Policy, University of Iowa, Iowa City, Iowa, USA
| | - Rachel M Werner
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Young Shin Park
- School of Nursing, University of Minnesota, Minneapolis, Minnesota, USA
| | - Tetyana P Shippee
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
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Tamara Konetzka R, Yan K, Werner RM. Two Decades of Nursing Home Compare: What Have We Learned? Med Care Res Rev 2020; 78:295-310. [PMID: 32538264 DOI: 10.1177/1077558720931652] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Approximately two decades ago, federally mandated public reporting began for U.S. nursing homes through a system now known as Nursing Home Compare. The goals were to provide information to enable consumers to choose higher quality nursing homes and to incent providers to improve the quality of care delivered. We conduct a systematic review of the literature on responses to Nursing Home Compare and its effectiveness in meeting these goals. We find evidence of modest but meaningful response by both consumers and providers. However, we also find evidence that some improvement in scores does not reflect true quality improvement, that disparities by race and income have increased, that risk-adjustment of the measures is likely inadequate, and that several key domains of quality are not represented. Our results support moderate success of Nursing Home Compare in achieving intended goals but also reveal the need for continued refinement.
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Affiliation(s)
| | - Kevin Yan
- The University of Chicago, Chicago, IL, USA
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Sharma H, Perraillon MC, Werner RM, Grabowski DC, Konetzka RT. Medicaid and Nursing Home Choice: Why Do Duals End Up in Low-Quality Facilities? J Appl Gerontol 2019; 39:981-990. [PMID: 30957619 DOI: 10.1177/0733464819838447] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We provide empirical evidence on the relative importance of specific observable factors that can explain why individuals enrolled in both Medicare and Medicaid (duals) are concentrated in lower quality nursing homes, relative to those not on Medicaid. Descriptive results show that duals are 9.7 percentage points more likely than nonduals to be admitted to a low-quality (1-2 stars) nursing home. Using the Blinder-Oaxaca decomposition approach in a multivariate framework, we find that 35.4% of the difference in admission to low-quality nursing homes can be explained by differences in the distribution of observable characteristics. Differences in education and distance to high-quality nursing homes are important drivers, as are health status and race. Our findings highlight the need for creative policy solutions targeting the modifiable factors to reduce the disparity.
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10
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Bowblis JR, Roberts AR. Cost-Effective Adjustments to Nursing Home Staffing to Improve Quality. Med Care Res Rev 2018; 77:274-284. [DOI: 10.1177/1077558718778081] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Health care providers face fixed reimbursement rates from government sources and need to carefully adjust staffing to achieve the highest quality within a given cost structure. With data from the Certification and Survey Provider Enhanced Reports (1999-2015), this study holistically examined how staffing levels affect two publicly reported measures of quality in the nursing home industry, the number of deficiency citations and the deficiency score. While higher staffing consistently yielded better quality, the largest quality improvements resulted from increasing administrative registered nurses and social service staffing. After adjusting for wages, the most cost-effective investment for improving overall deficiency outcomes was increasing social services. Deficiencies related to quality of care were improved most by increasing administrative nursing and social service staff. Quality of life deficiencies were improved most by increasing social service and activities staff. Approaches to improve quality through staffing adjustments should target specific types of staff to maximize return on investment.
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