Changing Economic Incentives in Long-Term Care

Just as managed care has changed utilization and incentives in other parts of health care, there is a whole set of incentives built around long-term care that really matter. For example, if nursing homes have a financial incentive to hospitalize people with certain health conditions, then in the long run they are not going to develop the programs and invest in the resources to treat those people in the facility. Instead they're going to use those resources to stay in business or to provide other types of care. And while we can assume that policymakers do not create regulations that they expect will lead to poor quality, efforts to increase access or efficiency sometimes have the unintended consequence of reducing quality. Health care sectors in which spending is rising particularly rapidly or in which access seems to be problematic may be prone to regulations that fail to take into account potential effects on quality. There's a lot of money spent on nursing homes; there's certainly a lot of interest from public funders in nursing homes; and nursing homes have a long history of quality-of-care problems. Not surprisingly, then, some of the most interesting sets of bad incentives for quality can be found in nursing homes.nursing home, Medicare, Medicaid, long-term care, elderly, social welfare.

Changing Economic Incentives in Long-Term Care

Just as managed care has changed utilization and incentives in other parts of health care, there is a whole set of incentives built around long-term care that really matter. For example, if nursing homes have a financial incentive to hospitalize people with certain health conditions, then in the long run they are not going to develop the programs and invest in the resources to treat those people in the facility. Instead they\u27re going to use those resources to stay in business or to provide other types of care. And while we can assume that policymakers do not create regulations that they expect will lead to poor quality, efforts to increase access or efficiency sometimes have the unintended consequence of reducing quality. Health care sectors in which spending is rising particularly rapidly or in which access seems to be problematic may be prone to regulations that fail to take into account potential effects on quality. There\u27s a lot of money spent on nursing homes; there\u27s certainly a lot of interest from public funders in nursing homes; and nursing homes have a long history of quality-of-care problems. Not surprisingly, then, some of the most interesting sets of bad incentives for quality can be found in nursing homes

The Pay-Off on Nursing Home Report Cards

For the past decade, policymakers have used public reporting of quality measures as a strategy to improve quality in nursing homes. In theory, public reporting might improve overall quality in two ways: first, if consumers choose nursing homes with better performance, and second, if public reporting encourages nursing homes to improve their performance. Has public reporting had its intended effects? Does improving quality give nursing homes a competitive advantage in the marketplace, thereby improving their bottom line? This Issue Brief summarizes a series of studies that assess the impact of public reporting on nursing home quality and on the financial performance of these facilities

Changes in Consumer Demand Following Public Reporting of Summary Quality Ratings: An Evaluation in Nursing Homes

A nursing home report card that converted 12 measures of quality into a simple 5-star system significantly affected consumer demand for low- and high-scoring facilities. One-star facilities typically lost 8 percent of their market share and 5-star facilities gained more than 6 percent of their market share. These results support the use of summary measures in report cards

The Effect of Integration of Hospitals and Post-Acute Care Providers on Medicare Payment and Patient Outcomes

Vertical integration between hospitals and skilled nursing facilities (SNFs) increases Medicare payments for the first 60 days of care by $2,424 (17%), compared to hospital-SNF pairs that are not vertically integrated. These integrated hospital–SNF pairs also experience a decline in 30-day rates of rehospitalization or death of 5 percentage points on a base rate of 31.3%. Vertical integration between hospitals and home health agencies (HHAs) has little effect on Medicare payments and patient outcomes, nor does informal integration in either setting

The relationship between Medicaid policy and realized access to home- and community-based services

Medicaid funding for home- and community-based services (HCBS) has increased substantially in recent decades. Prior research has investigated the effects of this expansion on outcomes for individuals as well as costs to Medicaid, often using state policy as a proxy for access to HCBS or implicitly assuming that more generous policies affect outcomes through access, an assumption that may not hold. In this study, using survey data linked to Medicaid claims, we assess the extent to which common measures of state Medicaid HCBS generosity correspond to increased individual use of HCBS among older adults with potential needs. We find several measures to have strong predictive power, but only with relatively large changes in policy generosity. Our findings imply that increased funding of HCBS is not sufficient to ensure access to services and that researchers should be careful when using state policy generosity as a proxy for access

Accuracy of infection reporting in US nursing home ratings

Objective: To assess the accuracy of nursing home-reported data on urinary tract infections (UTIs), which are publicly reported on Nursing Home Care Compare, and pneumonia, which are not publicly reported. Data sources and study setting: We used secondary data for 100% of Medicare fee-for-service beneficiaries in the United States between 2011 and 2017. Study design: We identified Medicare fee-for-service beneficiaries who were nursing home residents between 2011 and 2017 and admitted to a hospital with a primary diagnosis of UTI or pneumonia. After linking these hospital claims to resident-level nursing home-reported assessment data in the Minimum Data Set, we calculated the percentages of infections that were appropriately reported and assessed variation by resident- and nursing home-level characteristics. We developed a claims-based nursing home-level measure of hospitalized infections and estimated correlations between this and publicly reported ratings. Data extraction methods: Medicare fee-for-service beneficiaries who were nursing home residents and hospitalized for UTI or pneumonia during the study period were included. Principal findings: Reporting rates were low for both infections (UTI: short-stay residents 29.1% and long-stay residents 19.2%; pneumonia: short-stay residents 66.0% and long-stay residents 70.6%). UTI reporting rates increased when counting additional assessments, but it is unclear whether these reports are for the same versus a newly developed UTI. Black residents had slightly lower reporting rates, as did nursing homes with more Black residents. Correlations between our claims-based measure and publicly reported ratings were poor. Conclusions: UTI and pneumonia were substantially underreported in data used for national public reporting. Alternative approaches are needed to improve surveillance of nursing home quality.</p

Family Structure and Long-Term Care Insurance Purchase

While it has long been assumed that family structure and potential sources of informal care play a large role in the purchase decisions for long-term care insurance (LTCI), current empirical evidence is inconclusive. Our study examines the relationship between family structure and LTCI purchase and addresses several major limitations of the prior literature by using a long panel of data and considering modern family relationships, such as the presence of stepchildren. We find that family structure characteristics from one\u27s own generation, particularly about one\u27s spouse, are associated with purchase, but that few family structure attributes from the younger generation have an influence. Family factors that may indicate future caregiver supply are negatively associated with purchase: having a coresidential child, signaling close proximity, and having a currently working spouse, signaling a healthy and able spouse, that long-term care planning has not occurred yet or that there is less need for asset protection afforded by LTCI. Dynamic factors, such as increasing wealth or turning 65, are associated with higher likelihood of LTCI purchase

Patient Outcomes After Hospital Discharge to Home with Home Health Care vs to a Skilled Nursing Facility

In this study of more than 17 million Medicare hospitalizations between 2010 and 2016, patients discharged to home health care had a 5.6 percent higher 30-day readmission rate than similar patients discharged to a skilled nursing facility (SNF). There was no difference in mortality or functional outcomes between the two groups, but home health care was associated with an average savings of $4,514 in total Medicare payments in the 60 days after the first hospital admission

The Staffing-Outcomes Relationship in Nursing Homes: The Staffing-Outcomes Relationship

To assess longitudinally whether a change in registered nurse (RN) staffing and skill mix leads to a change in nursing home resident outcomes while controlling for the potential endogeneity of staffing