David C. Grabowski

High Body Mass Index Does Not Predict Mortality in Older People: Analysis of the Longitudinal Study of Aging

OBJECTIVE: To determine the excess mortality associated with obesity (defined by body mass index (BMI)) in older people, with and without adjustment for other risk factors associated with mortality and for demographic factors.

Interventions to Reduce Hospitalizations from Nursing Homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project

A substantial proportion of hospitalizations of nursing home (NH) residents may be avoidable. Medicare payment reforms, such as bundled payments for episodes of care and value‐based purchasing, will change incentives that favor hospitalization but could result in care quality problems if NHs lack the resources and training to identify and manage acute conditions proactively. Interventions to Reduce Acute Care Transfers (INTERACT) II is a quality improvement intervention that includes a set of tools and strategies designed to assist NH staff in early identification, assessment, communication, and documentation about changes in resident status. INTERACT II was evaluated in 25 NHs in three states in a 6‐month quality improvement initiative that provided tools, on‐site education, and teleconferences every 2 weeks facilitated by an experienced nurse practitioner. There was a 17% reduction in self‐reported hospital admissions in these 25 NHs from the same 6‐month period in the previous year. The group of 17 NHs rated as engaged in the initiative had a 24% reduction, compared with 6% in the group of eight NHs rated as not engaged and 3% in a comparison group of 11 NHs. The average cost of the 6‐month implementation was

Medicaid reimbursement and the quality of nursing home care

7,700 per NH. The projected savings to Medicare in a 100‐bed NH were approximately

Competitive spillovers across non-profit and for-profit nursing homes

125,000 per year. Despite challenges in implementation and caveats about the accuracy of self‐reported hospitalization rates and the characteristics of the participating NHs, the trends in these results suggest that INTERACT II should be further evaluated in randomized controlled trials to determine its effect on avoidable hospitalizations and their related morbidity and cost.

The cost-effectiveness of noninstitutional long-term care services: review and synthesis of the most recent evidence.

An influential series of papers have found that an increase in Medicaid reimbursement decreases the level of nursing home quality in the presence of certificate-of-need (CON) and construction moratorium regulations. Using more recent national data, an outcome-oriented measure of quality, and an alternative methodology, this study finds a positive, albeit small, effect of reimbursement on quality. Although this paper does find some evidence of excess demand within the market for nursing home care, this new finding is attributed to a decline in nursing home utilization over the last two decades.

Medicare’s Bundled Payment Pilot for Acute and Postacute Care: Analysis and Recommendations on Where to Begin

The importance of non-profit institutions in the health care sector has generated a vast empirical literature examining quality differences between non-profit and for-profit nursing homes. Recent theoretical work has emphasized that much of this empirical literature is flawed in that previous studies rely solely on dummy variables to capture the effects of ownership rather than accounting for the share of non-profit nursing homes in the market. This analysis considers whether competitive spillovers from non-profits lead to higher quality in for-profit nursing homes. Using instrumental variables to account for the potential endogeneity of non-profit market share, this study finds that an increase in non-profit market share improves for-profit and overall nursing home quality. These findings are consistent with the hypothesis that non-profits serve as a quality signal for uninformed nursing home consumers.

Sizing Up The Market For Assisted Living

There has been significant expansion and change in the financing, coverage, and delivery of home-and community-based services during the past decade. This article reviews the cost-effectiveness of Medicaid waiver programs, consumer-directed care, capitated models that blend acute and long-term care services, and case management and subsidized community services for individuals with dementia. Generally, these new care models were found to be associated with increased costs, but greater client and caregiver welfare. Depending on the specific features of the program, capitated care models and consumerdirected care were identified as potential mechanisms toward providing services more efficiently. Importantly, however, most recent evaluations have relied on potentially confounded research designs, which leaves open the question of whether the findings relate to the programs or biased selection across the treatment and comparison groups.

Antipsychotic and Benzodiazepine Use Among Nursing Home Residents: Findings From the 2004 National Nursing Home Survey

In the National Pilot Program on Payment Bundling, a subset of Medicare providers will receive a single payment for an episode of acute care in a hospital, followed by postacute care in a skilled nursing or rehabilitation facility, the patients home, or other appropriate setting. This article examines the promises and pitfalls of bundled payments and addresses two important design decisions for the pilot: which conditions to include, and how long an episode should be. Our analysis of Medicare data found that hip fracture and joint replacement are good conditions to include in the pilot because they exhibit strong potential for cost savings. In addition, these conditions pose less financial risk for providers than other common ones do, so including them would make participation in the program more appealing to providers. We also found that longer episode lengths captured a higher percentage of costs and hospital readmissions while adding little financial risk. We recommend that the Medicare pilot program test alternative design features to help foster payment innovation throughout the health system.

A Longitudinal Study of Medicaid Payment, Private-Pay Price and Nursing Home Quality

Assisted living has emerged as an important housing and long-term care option for older Americans. To date, development of this sector has occurred largely without government financing or regulation. In this study we used primary data that we collected on county-level assisted living supply to gain a fuller understanding of this sector nationally. Reflecting their reliance on private resources, assisted living facilities are located disproportionately in areas with higher educational attainment, income, and housing wealth. As this sector evolves, policymakers will have to contend with issues related to access to services, public financing, quality of care, and regulatory oversight.

Use Of Telemedicine Can Reduce Hospitalizations Of Nursing Home Residents And Generate Savings For Medicare

OBJECTIVES To document the extent and appropriateness of use of antipsychotics and benzodiazepines among nursing home residents using a nationally representative survey. METHODS Cross-sectional analysis of the 2004 National Nursing Home Survey. Bivariate and multivariate analyses examined relationships between resident and facility characteristics and antipsychotic and benzodiazepine use by appropriateness classification among residents aged 60 years and older (N = 12,090). Resident diagnoses and information about behavioral problems were used to categorize antipsychotic and benzodiazepine use as appropriate, potentially appropriate, or having no appropriate indication. RESULTS More than one quarter (26%) of nursing home residents used an antipsychotic medication, 40% of whom had no appropriate indication for such use. Among the 13% of residents who took benzodiazepines, 42% had no appropriate indication. In adjusted analyses, the odds of residents taking an antipsychotic without an appropriate indication were highest for residents with diagnoses of depression (odds ratio [OR] = 1.31; 95% confidence interval [CI]: 1.12-1.53), dementia (OR = 1.82; 95% CI: 1.52-2.18), and with behavioral symptoms (OR = 1.97, 95% CI: 1.56-2.50). The odds of potentially inappropriate antipsychotic use increased as the percentage of Medicaid residents in a facility increased (OR = 1.08, 95% CI: 1.02-1.15) and decreased as the percentage of Medicare residents increased (OR = 0.46, 95% CI: 0.25-0.83). The odds of taking a benzodiazepine without an appropriate indication were highest among residents who were female (OR = 1.44; 95% CI: 1.18-1.75), white (OR = 1.95; 95% CI: 1.47-2.60), and had behavioral symptoms (OR = 1.69; 95% CI: 1.41-2.01). CONCLUSION Antipsychotics and benzodiazepines seem to be commonly prescribed to residents lacking an appropriate indication for their use.