Driven to Tiers: Socioeconomic and Racial Disparities in the Quality of Nursing Home Care

Abstract

Nursing home care is currently a two-tiered system. The lower tier consists of facilities housing mainly Medicaid residents and, as a result, has very limited resources. The nearly 15 percent of U.S. nonhospital-based nursing homes that serve predominantly Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies. They are more likely to be terminated from the Medicaid/Medicare program, are disproportionately located in the poorest counties, and are more likely to serve African-American residents than are other facilities. The public reporting of quality indicators, intended to improve quality through market mechanisms, may result in driving poor homes out of business and will disproportionately affect nonwhite residents living in poor communities. This article recommends a proactive policy stance to mitigate these consequences of quality competition.T hose writing on the quality of nursing home care have, for the most part, framed the discussion in terms of its uniformly poor quality and have largely ignored the prospects and implications of a two-tiered system differentiated by quality. In contrast, our article provides evidence of a two-tiered system of nursing home care. The lower tier consists of facilities with high proportions of Medicaid residents and, as a result, very limited resources. Thus, stratification affects the number, type, and quality of services provided to residents of lower-tier facilities, who are disproportionately poor and from minority

Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes

“…4 A tiered system of nursing home care that concentrates blacks in marginal-quality nursing homes also appears to exist. 5 n Historical background. Historically, segregation and discrimination in access to higher-quality nursing homes in the United States have never been systematically addressed.…”

Medicaid Reimbursement and the Quality of Nursing Home Care: A Case Study of Medi-Cal Long-Term Care Reimbursement Act of 2004 in California

“…Facilities with higher percentages of Medicaid residents have been found to be associated with more deficiencies [38][39], higher odds of hospitalization [40][41], more complaints [42], higher likelihood of voluntary or involuntary terminations [39,43], higher rates of antipsychotic medication prescription [39,44], and higher rates of physical restraint use and pressure ulcers [39]. Nursing homes with higher proportions of black residents and rural nursing homes also exhibited worse processes and outcomes [45][46][47].…”

“…The level of resources available has substantial influence on quality of care. Studies have found that nursing homes with high concentrations of Medicaid patients were more like to have quality of care problems due to very limited resources compared to nursing homes with low concentrations of Medicaid patients [39,[188][189]. In addition, public reporting may increase the divide between providers that are more or less able to improve quality [190].…”

“…The public reporting of quality may steer prospective residents away from poor quality nursing homes as report cards increase the likelihood that patients select higher-quality providers. In turn, this will reduce admissions and revenues and make it even harder for these facilities to achieve quality improvement [39].…”

Utilization of Acute Care among Patients with ESRD Discharged Home from Skilled Nursing Facilities

“…Race as recorded in the Medicare denominator file was aggregated into three categories (white, black, and other) because ,1% of the parent study's cohort had race besides white or black (1). We also included number of hospitalizations within 90 days before SNF admission, comorbid conditions and Charlson comorbidity score based on International Classification of Diseases-Ninth Revision (ICD-9) codes in inpatient Medicare claims (19) From NH Compare, we obtained information on the following SNF characteristics: facility bed count, ownership status (unknown, for-profit, government, or nonprofit), registered nurse hours per resident day, and licensed practical nurse hours per resident day (20).…”