Fewer Bonuses, More Penalties At Skilled Nursing Facilities Serving Vulnerable Populations

Performance and Penalties in Year 1 of the Skilled Nursing Facility Value‐Based Purchasing Program

“…Interestingly, we did not find that SNFs with a high proportion of racial or ethnic minorities, dually enrolled beneficiaries, or beneficiaries with disabilities performed more poorly under SNF VBP after accounting for structural characteristics and frailty, although we did note that facilities in low‐income neighborhoods were more likely to receive penalties. This is in contrast to one prior study of SNF VBP; our findings may differ from theirs because of the additional structural and patient population covariates we included in our models or because their cutoffs for patient population were based on the overall population at each SNF while ours were based off the short‐stay population (those eligible for the readmission measure). Our findings of the lack of relationship between social risk and readmission also differ from studies in other care settings, where patient population characteristics are consistently linked with worse performance and higher penalties .…”

“…[19][20][21][22] As the SNF VBP program is new, there are no prior studies, to our knowledge, quantifying relationships between these structural characteristics and performance under the program, though one recent publication noted that facilities with a high proportion of racial and ethnic minorities or individuals living in poverty were more likely to be penalized. 23 However, prior work has suggested that structural and patient case mix characteristics are significant predictors of provider performance in VBP programs in other care settings. For example, associations between VBP performance and patient income, race, ethnicity, and/or disability have been found in similar programs in the hospital, outpatient, and dialysis settings.…”

Addressing Systemic Racism in Nursing Homes: A Time for Action

“…Not surprisingly, the result was that majority-Black homes had a 14% lower chance of receiving a bonus and a 6% higher chance of being fined than those that were majority White; a clear example of structural racism because the policy advantaged majority-White homes and disadvantaged majority-Black homes, thereby exacerbating the underlying differences in resources. 25,27,68 Provisions of the Coronavirus Aid, Relief, and Economic Security (CARES) act followed a similar pattern of structural racism by allocating incentive payments to nursing homes that were successful in countering COVID-19 rather than targeting resources to struggling homes that disproportionately serve people of color. 69,70 Another impact of centuries-long systemic racism has been the increased prevalence of chronic illness and functional impairment in older Black individuals compared with White individuals.…”

“…Comparing nursing homes with the lowest (1 star) quality rating from the US Centers for Medicare & Medicaid Services (CMS) to those with the highest (5 star) rating, low-quality homes are more than twice as likely (13% vs 27%) to house 50% or more Black residents and much more likely to have more than half of their residents paid for by Medicaid (43% vs 5%). 27 One key factor leading to concentrations of Black individuals in low-quality nursing homes is the payment system. Medicare and most private insurance contracts pay only for post-acute, rehabilitative episodes as opposed to longer-term care, and uptake of private longterm care insurance policies is low, such that there is no systematic coverage of long-term care in the United States.…”

Research Needed: Better Quantitative Studies to Identify Causes of COVID-19 Nursing Home Disparities

“…Studies show that NHs serving higher proportions of older adults who are AA/Black or Latinx tend to deliver lower-quality care and perform worse under the new payment incentive model. 2 Worse COVID-19 outcomes seen among minority-serving NHs are an example of the types of disparities that result from systemic racism. Patterns in lower quality of care experienced by NH residents who are AA/Black or Latinx often stem from receiving care in lower-quality NHs, as opposed to being cared for differently within the same NH.…”