State-imposed limits on Medicaid reimbursement for nursing facility care

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.

Medicaid capital reimbursement policy and environmental artifacts of nursing home culture change

PURPOSE OF THE STUDY

To examine how Medicaid capital reimbursement policy is associated with nursing homes (NHs) having high proportions of private rooms and small households.

DESIGN AND METHODS

Through a 2009/2010 NH national survey, we identified NHs having small households and high proportions of private rooms (≥76%). A survey of state Medicaid officials and policy document review provided 2009 policy data. Facility- and county-level covariates were from Online Survey, Certification and Reporting, the Area Resource File, and aggregated resident assessment data (minimum data set). The policy of interest was the presence of traditional versus fair rental capital reimbursement policy. Average Medicaid per diem rates and the presence of NH pay-for-performance (p4p) reimbursement were also examined. A total of 1,665 NHs in 40 states were included. Multivariate logistic regression analyses (with clustering on states) were used.

RESULTS

In multivariate models, Medicaid capital reimbursement policy was not significantly associated with either outcome. However, there was a significantly greater likelihood of NHs having many private rooms when states had higher Medicaid rates (per $10 increment; adjusted odds ratio [AOR] 1.13; 95% CI 1.049, 1.228), and in states with versus without p4p (AOR 1.78; 95% CI 1.045, 3.036). Also, in states with p4p NHs had a greater likelihood of having small households (AOR 1.78; 95% CI 1.045, 3.0636).

IMPLICATIONS

Higher NH Medicaid rates and reimbursement incentives may contribute to a higher presence of 2 important environmental artifacts of culture change-an abundance of private rooms and small households. However, longitudinal research examining policy change is needed to establish the cause and effect of the associations observed.

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.

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.

Quality of care in nursing home organizations: Establishing a health services research agenda

Health services research has led to exciting new findings about the critical importance of the amount and type of nursing staff in nursing homes for improving the processes and outcomes of care. This paper reviews recent theoretical and research issues and outlines areas where research is needed. The nursing home research agenda for the future needs to concentrate on: (1) the relationship between structural measures of nursing (eg, staffing levels, education, turnover rates) and the outcomes and processes of care; (2) adequate processes of care and ways to improve the reliability of clinical outcome measures; (3) better ways to risk-adjust for resident characteristics; (4) the impact of nursing home characteristics (eg, ownership) and public policies (eg, reimbursement) on structural factors, processes, and outcomes; and (5) cost-effectiveness studies of nursing care at the organizational or system level.

Medicaid case-mix nursing home reimbursement in three states

Case-mix nursing facility payment raises issues of access, quality, equity, and cost. Case-mix should better match payment to costs, improve access, and provide incentives to increased staffing and quality of care; but it may also increase costs. This paper reports analysis of Medicaid cost-report data from three case-mix states. Case-mix did not discourage capacity building and was more equitable for providers. Medicaid access declined in one state but increased in another. There were shifts toward greater skilled care in two states, with evidence of greater focus of resources on patient care. Case-mix showed no evidence of cost-constraint and some signs of increased costs. Whether such mixed outcomes are viable in the current era remains to be seen.

Explaining state Medicaid nursing home reimbursement

Medicaid nursing home reimbursement methods and per diem rates affect costs, quality, equity, and access. State rate-setting is a laboratory of policymaking, which can inform state and federal Medicaid reform initiatives. This paper explains state Medicaid nursing facility rates in 1979-1994. Findings suggest that prospective facility-specific methods constrained rates in some but not all periods, particularly when older cost-reports were employed in rate-setting. Analysis failed to show that prospective class rate-setting methods constrained rate increases. Findings suggest that the efficacy of reimbursement methodology to control rates depends upon wider health care policy trends and that future facility-level analyses should consider policy contexts as between states.

Nursing facility staffing in the states: the 1991 to 1995 period

Trends in the average nurse staffing levels are reported for certified nursing facilities in the United States from 1991 through 1995. Data from the federal On-Line Survey Certification and Reporting system show a small overall increase in the staffing levels for registered nurses (RNs), licensed vocational and licensed practical nurses (LVNs/LPNs), and nursing assistants over the 5 years, but there are substantial variations across states and regions. A two-stage least squares panel analysis examined predictors of nurse staff levels in states. States with higher resident case mix levels had higher RN and LVN/LPN hours. States with higher percentages of large facilities had lower RN and LVN/LPN levels and states with higher percentages of for-profit facilities had lower RN staff levels. States with a higher percentage of Medicaid residents had higher LVN/LPN staff levels. These findings indicate the need for more studies of staff variations and public policies that affect staffing.