Helen Carrillo

Does investor ownership of nursing homes compromise the quality of care

OBJECTIVES Two thirds of nursing homes are investor owned. This study examined whether investor ownership affects quality. METHODS We analyzed 1998 data from state inspections of 13,693 nursing facilities. We used a multivariate model and controlled for case mix, facility characteristics, and location. RESULTS Investor-owned facilities averaged 5.89 deficiencies per home, 46.5% higher than nonprofit facilities and 43.0% higher than public facilities. In multivariate analysis, investor ownership predicted 0.679 additional deficiencies per home; chain ownership predicted an additional 0.633 deficiencies. Nurse staffing was lower at investor-owned nursing homes. CONCLUSIONS Investor-owned nursing homes provide worse care and less nursing care than do not-for-profit or public homes.

The Regulation and Enforcement of Federal Nursing Home Standards, 1991-1997

This article reports historical trend data on resident characteristics and conditions, problems, and deficiency patterns for nursing facilities from 1991 through 1997 from Health Care Financing Administration (HCFA) administrative records from the On-Line Survey, Certification, and Reporting System (OSCAR). Over this period, residents show some increases in dependency and conditions, although there was a decline in the use of restraints. The deficiencies reveal continued quality problems in some nursing homes, although the average number of deficiencies given to facilities declined by 44 percent between 1991 and 1997. The discussion considers possible explanations for the decline in deficiencies, including whether the quality of care in nursing homes has improved or whether the enforcement process has gradually been weakened.

Nurse Staffing and Deficiencies in the Largest For-Profit Nursing Home Chains and Chains Owned by Private Equity Companies

OBJECTIVE To compare staffing levels and deficiencies of the 10 largest U.S. for-profit nursing home chains with five other ownership groups and chain staffing and deficiencies before and after purchase by four private equity (PE) companies. DATA SOURCES Facilities for the largest for-profit chains were identified through Internet searches and company reports and matched with federal secondary data for 2003-2008 for each ownership group. STUDY DESIGN Descriptive statistics and generalized estimation equation panel regression models examined staffing and deficiencies by ownership groups in the 2003-2008 period, controlling for facility characteristics, resident acuity, and market factors with state fixed effects. PRINCIPAL FINDINGS The top 10 for-profit chains had lower registered nurse and total nurse staffing hours than government facilities, controlling for other factors. The top 10 chains received 36 percent higher deficiencies and 41 percent higher serious deficiencies than government facilities. Other for-profit facilities also had lower staffing and higher deficiencies than government facilities. The chains purchased by PE companies showed little change in staffing levels, but the number of deficiencies and serious deficiencies increased in some postpurchase years compared with the prepurchase period. CONCLUSIONS There is a need for greater study of large for-profit chains as well as those chains purchased by PE companies.

Medicaid Community-Based Programs: A Longitudinal Analysis of State Variation in Expenditures and Utilization

As states face challenges posed by budget crises and pressures to develop Medicaid home and community-based services (HCBS), this paper provides a longitudinal analysis of state variation in expenditures and utilization for three HCBS programs (waivers, home health and personal care), and for total Medicaid HCBS. The first part of the analysis describes the nature and scope of state variation for each program in 1999, using such measures as participants per 1,000 population and expenditures per capita. The second part of the analysis presents time-series regression models that estimate sociodemographic, state policy, and market factors associated with intra-state variation in waiver participants and expenditures, and home health, personal care and total HCBS expenditures for the period 1992–99. Among the results, positive state-level factors related to HCBS participants and expenditures include: higher percentages of aged people, greater incomes per capita, and a larger supply of home health agencies.

The effect of certificate of need and moratoria policy on change in nursing home beds in the United States.

OBJECTIVES This study examined the effects of state certificate of need and/or moratorium requirements on the change in nursing home bed growth in states over a 13-year period. METHODS Data were collected from five telephone surveys of state officials about state certificate of need and moratorium policies, state Medicaid nursing home reimbursement rates, and the licensed nursing home beds in each state for the 1979 through 1993 period. Two-stage least squares regression analysis treated certificate of need and/or moratorium and Medicaid reimbursement rates as endogenous variables in predicting the change in nursing home beds per aged population in states. RESULTS States that had a certificate of need and/or moratorium did have significant reductions in the growth in nursing home beds but Medicaid nursing home reimbursement rates were not related to change in bed stock. The percentage of the population living in a metropolitan area, the personal income per 1,000 population, the percent unemployed, a states tax effort, and time were positively associated with change in nursing home beds. The ratio of nursing home beds per 1,000 aged population in the previous year was a negative predictor of change in bed stock in a given year. CONCLUSIONS State regulatory policies have an effect on bed growth in contrast to reimbursement policies.

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.

Does Investor-Ownership of Nursing Homes Compromise the Quality of Care?

Quality problems have long plagued the nursing home industry. While two-thirds of U.S. nursing homes are investor-owned, few studies have examined the impact of investor-ownership on the quality of care. The authors analyzed 1998 data from inspections of 13,693 nursing facilities representing virtually all U.S. nursing homes. They grouped deficiency citations issued by inspectors into three categories (“quality of care,” “quality of life,” and “other”) and compared deficiency rates in investor-owned, nonprofit, and public nursing homes. A multivariate model was used to control for case mix, percentage of residents covered by Medicaid, whether the facility was hospital-based, whether it was a skilled nursing facility for Medicare only, chain ownership, and location by state. The study also assessed nurse staffing. The authors found that investor-owned nursing homes provide worse care and less nursing care than nonprofit or public homes. Investor-owned facilities averaged 5.89 deficiencies per home, 46.5 percent higher than nonprofit and 43.0 percent higher than public facilities, and also had more of each category of deficiency. In the multivariate analysis, investor-ownership predicted 0.679 additional deficiencies per home; chain-ownership predicted an additional 0.633 deficiencies per home. Nurse staffing ratios were markedly lower at investor-owned homes.

State regulation of the supply of long term care providers

After the removal of the federal reguirements for certificate of need (CON) in 1986, the majority of states (40) and the District of Columbia retained their CON and/or added a moratorium on new nursing facilities and beds. Some states were also regulating the growth of other types of long term care (LTC) facilities and home health agencies. States with a CON and/or moratoria were more likely to have a greater non- White population, to have liberal politicians, and to have a lower capacity to raise taxes. When state financial budgets are limited, policymakers are likely to continue to regulate the supply of LTC providers.

Developing personal care programs: national trends and interstate variation, 1992-2002.

This paper examines the development of programs delivering personal care to the elderly and disabled. First, we report the latest national participant and expenditure trend data for the three main personal care programs: the Medicaid Personal Care Services (PCS) benefit, Medicaid 1915(c) waivers, and the Older Americans Act Title III. Second, to examine interstate variation revealed in the trend analysis, we present three time-series regression models of personal care development (expenditures, participants, and existence of PCS benefit) that control for state socioeconomic, political, policy, and provider characteristics. Positive predictors of personal care development include: percentages of population aged 85 and older, and nonwhite; per capita income; and liberal state politics. Negative predictors of personal care development include rates of Medicare home health users and hospital beds.