David G. Stevenson

Ownership Conversions and Nursing Home Performance

OBJECTIVEnTo examine the effects of ownership conversions on nursing home performance.nnnDATA SOURCEnOnline Survey, Certification, and Reporting system data from 1993 to 2004, and the Minimum Data Set (MDS) facility reports from 1998 to 2004.nnnSTUDY DESIGNnRegression specification incorporating facility fixed effects, with terms to identify trends in the pre- and postconversion periods.nnnPRINCIPAL FINDINGSnThe annual rate of nursing home conversions almost tripled between 1994 and 2004. Our regression results indicate converting facilities are generally different throughout the pre/postconversion years, suggesting little causal effect of ownership conversions on nursing home performance. Before and after conversion, nursing homes converting from nonprofit to for-profit status generally exhibit deterioration in their performance, while nursing homes converting from for-profit to nonprofit status generally exhibit improvement.nnnCONCLUSIONSnPolicy makers have expressed concern regarding the implications of ownership conversions for nursing home performance. Our results imply that regulators and policy makers should not only monitor the outcomes of nursing home conversions, but also the targets of these conversions.

Hospice care in the nursing home setting: a review of the literature.

The U.S. Medicare hospice benefit has expanded considerably into the nursing home (NH) setting in recent years. This literature review focuses on the provision of NH hospice, exploring its growth and the impact of such care on NH residents, cost and efficiency implications for NHs and government, and policy challenges and important areas for future research. Although hospice utilization is relatively modest among NH residents, its increased availability holds great promise. As an alternative to traditional NH care, hospice has been shown to provide high-quality end-of-life care and offer benefits, such as reduced hospitalizations and improved pain management. The provision of NH hospice also has been shown to have positive effects on nonhospice residents, suggesting indirect benefits on NH clinical practices. Importantly, the expansion of hospice in NHs brings challenges, on both clinical and policy dimensions. Research has shown that NH-hospice collaborations require effective communication around residents changing care needs and that a range of barriers can impede the integration of hospice and NH care. Moreover, the changing case mix of hospice patients, including increased hospice use by individuals with conditions such as dementia, presents challenges to Medicares hospice payment and eligibility policies. To date, there has been little research comparing hospice costs, service intensity, and quality of care across settings, reflecting the fact that few comparative data have been available to researchers. The Centers for Medicare & Medicaid Services have taken steps toward collecting these data, and further research is needed to shed light on what refinements, if any, are necessary for the Medicare hospice program.

Private Equity Investment And Nursing Home Care: Is It A Big Deal?

Private equity investors have recently targeted nursing home chains as investment opportunities. Media attention has raised quality-of-care concerns, but little has been published in the research literature on the topic. Using a multivariate framework, we assessed how private equity purchases of nursing homes affected a range of outcomes. Although some transactions are quite recent, we found little evidence to suggest that nursing home quality worsens significantly following purchase by private equity companies. Nonetheless, recent nursing home ownership trends raise important questions about oversight and accountability, whose answers extend beyond private equity ownership.

Nursing home consumer complaints and their potential role in assessing quality of care.

Background:State survey agencies collect and investigate consumer complaints for care in nursing homes and other health care settings. Complaint investigations play a key role in quality assurance, because they can respond to concerns of consumers and families. Objective:This study uses 5 years of nursing home complaints data from Massachusetts (1998–2002) to investigate whether complaints might be used to assess nursing home quality of care. Research Design:The investigator matches facility-level complaints data with On-Line Survey Certification and Reporting (OSCAR) data and Minimum Data Set Quality Indicator (MDS QI) data to evaluate the association between consumer complaints, facility and resident characteristics, and other nursing home quality measures. Results:Consumer complaints varied across facility characteristics in ways consistent with the nursing home quality literature. Complaints were consistently and significantly associated with survey deficiencies, the presence of a serious survey deficiency, and nurse aide staffing. Complaints were not significantly associated with nurse staffing, and associations with 6 MDS QIs were mixed. The number of complaints was significantly predictive of survey deficiencies identified at the subsequent inspection. Conclusion:Nursing home consumer complaints provide a supplemental tool with which to differentiate nursing homes on quality. Despite limitations, complaints data have potential strengths when used in combination with other quality measures. The potential of using consumer complaints to assess nursing home quality of care should be evaluated in states beyond Massachusetts. Evaluating consumer complaints also might be a productive area of inquiry for other health care settings such as hospitals and home health agencies.

Relationship between Quality of Care and Negligence Litigation in Nursing Homes

BACKGROUNDnIt is unclear whether high-quality health care institutions are less likely to be sued for negligence than their low-performing counterparts.nnnMETHODSnWe linked information on tort claims brought against 1465 nursing homes between 1998 and 2006 to 10 indicators of nursing home quality drawn from two U.S. national data sets: the Online Survey, Certification, and Reporting system and the Minimum Data Set Quality Measure/Indicator Report. We tested for associations between the incidence of claims and the quality measures at the facility calendar-quarter level, correcting for facility clustering and adjusting for case mix, ownership, occupancy, year, and state. Odds ratios were calculated for the effect of a change of 1 SD in each quality measure on the odds of one or more claims in each facility calendar-quarter.nnnRESULTSnNursing homes with more deficiencies (odds ratio, 1.09; 95% confidence interval [CI], 1.05 to 1.13) and those with more serious deficiencies (odds ratio, 1.04; 95% CI, 1.00 to 1.08) had higher odds of being sued; this was also true for nursing homes that had more residents with weight loss (odds ratio, 1.05; 95% CI, 1.01 to 1.10) and with pressure ulcers (odds ratio, 1.09; 95% CI, 1.05 to 1.14). The odds of being sued were lower in nursing homes with more nurses aide-hours per resident-day (odds ratio, 0.95; 95% CI, 0.91 to 0.99). However, all these effects were relatively small. For example, nursing homes with the best deficiency records (10th percentile) had a 40% annual risk of being sued, as compared with a 47% risk among nursing homes with the worst deficiency records (90th percentile).nnnCONCLUSIONSnThe best-performing nursing homes are sued only marginally less than the worst-performing ones. Such weak discrimination may subvert the capacity of litigation to provide incentives to deliver safer care.

Planning for the Future — Long-Term Care and the 2008 Election

Long-term care affects a large portion of the population, it is expensive, and it requires a unique partnership between government and citizens. David Stevenson writes that, nonetheless, the candidates in the 2008 presidential race have been virtually silent about long-term care policy.

Ownership Status and Home Health Care Performance

Few studies have analyzed for-profit and nonprofit differences in the home health care sector. Using data from the National Home and Hospice Care Survey, we found that patients in nonprofit agencies were more likely to be discharged within 30 days under Medicare cost-based payment compared to patients in for-profit agencies. However, this difference in length of enrollment did not translate into meaningful differences in discharge outcomes between nonprofit and for-profit patients, suggesting that—under a cost-based payment system—nonprofits may behave more efficiently relative to for-profits. These results highlight the importance of organizational and payment factors in the delivery of home health care services.

Medicare Part D and Nursing Home Residents

The objective of this study was to analyze national Part D formulary data to assess adequacy of coverage across seven drug classes commonly used by nursing home residents and older people, focusing on individuals dually eligible for Medicare and Medicaid and plans in which they enroll. Focusing at the molecule level, reasonably broad coverage across drug classes and minimal prior authorization overall was found. Of nonprotected classes, 69% of plans cover at least four of five Alzheimers medications, 76% cover at least three of four bisphosphonates, 86% cover at least three of five proton pump inhibitors, and 61% cover at least four of six 3‐hydroxy‐3‐methylglutaryl coenzyme A reductase inhibitors (statins). Nevertheless, a minority of plans are less generous, and some drug formulations important to nursing home residents are covered less well. For example, 11% of plans cover only one or two of the six statins. Of protected drug classes, plans generally cover all molecules, as expected. The majority of plans require no prior authorization for covered medications in six of seven classes reviewed (excepting bisphosphonates). A minority of plans once again are more stringent. For example, 22% and 9% of Part D Plans nationally require prior authorization for all covered Alzheimers drugs and proton pump inhibitors, respectively. Random assignment of dually eligible patients to below‐benchmark plans means that some residents initially will be enrolled in these more‐restrictive plans. Part D allows nursing home residents to switch plans at any time, but there are important barriers to residents self‐advocacy. Finally, it is unclear how well nursing homes and the pharmacies they work with will work across Part D plans, and vigilance will be required as the benefit proceeds.

The influence of Medicare home health payment incentives: does payer source matter?

During the late 1990s, the U.S. government instituted an interim payment system (IPS) to constrain Medicare home health care expenditures. Previous research has focused largely on the implications of the IPS for Medicare patients; this study broadens the analysis to consider patients with other payer sources. Using the National Home and Hospice Care Survey, we found similar effects of the IPS across payer types. Specifically, the IPS was associated with a decrease in care for the sickest patients, less agency assistance with activities of daily living, and shorter length of use. However, these changes did not translate into worse discharge outcomes.

Targeting Nursing Homes Under the Quality Improvement Organization Program’s 9th Statement of Work

In the Quality Improvement Organization (QIO) programs latest Statement of Work, the Centers for Medicare and Medicaid Services (CMS) is targeting its nursing home activities toward facilities that perform poorly on two quality measures—pressure ulcers and restraint use. The designation of target facilities is a shift in strategy for CMS and a direct response to criticism that QIO program resources were not being targeted effectively to facilities or clinical areas that most needed improvement. Using administrative data, this article analyzes implications of using narrowly defined criteria to identify facilities that need improvement, particularly in light of considerable evidence showing that nursing home quality is multidimensional and may change over time. The analyses show that one in four facilities is targeted for improvement nationally but that approximately half of some states facilities are targeted while other states have almost none targeted. The analyses also convey deeper limitations to using threshold values on individual measures to identify poorly performing homes. Target facilities can be among the top performers on a range of other quality measures, and their performance on targeted measures themselves may change over time. The implication of these features is that a very different group of facilities would have been chosen had the QIO program targeted other measures or examined performance at a different point in time. Ultimately, CMS has chosen a blunt instrument to identify poorly performing nursing homes, and supplemental strategies—such as soliciting input from state survey agencies and more closely aligning quality improvement and quality assurance efforts—should be considered to address potential limitations.