The Effect of State Policies on Nursing Home Resident Outcomes

Authors

  • Vincent Mor PhD,

    1. From the *Center for Gerontology and Health Care Research and Department of Community Health, Alpert Medical School, Brown University, Providence, Rhode Island; Women's College Research Institute, Women's College Hospital, Toronto, Ontario; Department of Health Care Policy, Harvard University Medical School, Harvard, Massachusetts; and §Fox School of Business and Management, Temple University, Philadelphia, Pennsylvania.
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  • Andrea Gruneir PhD,

    1. From the *Center for Gerontology and Health Care Research and Department of Community Health, Alpert Medical School, Brown University, Providence, Rhode Island; Women's College Research Institute, Women's College Hospital, Toronto, Ontario; Department of Health Care Policy, Harvard University Medical School, Harvard, Massachusetts; and §Fox School of Business and Management, Temple University, Philadelphia, Pennsylvania.
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  • Zhanlian Feng PhD,

    1. From the *Center for Gerontology and Health Care Research and Department of Community Health, Alpert Medical School, Brown University, Providence, Rhode Island; Women's College Research Institute, Women's College Hospital, Toronto, Ontario; Department of Health Care Policy, Harvard University Medical School, Harvard, Massachusetts; and §Fox School of Business and Management, Temple University, Philadelphia, Pennsylvania.
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  • David C. Grabowski PhD,

    1. From the *Center for Gerontology and Health Care Research and Department of Community Health, Alpert Medical School, Brown University, Providence, Rhode Island; Women's College Research Institute, Women's College Hospital, Toronto, Ontario; Department of Health Care Policy, Harvard University Medical School, Harvard, Massachusetts; and §Fox School of Business and Management, Temple University, Philadelphia, Pennsylvania.
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  • Orna Intrator PhD,

    1. From the *Center for Gerontology and Health Care Research and Department of Community Health, Alpert Medical School, Brown University, Providence, Rhode Island; Women's College Research Institute, Women's College Hospital, Toronto, Ontario; Department of Health Care Policy, Harvard University Medical School, Harvard, Massachusetts; and §Fox School of Business and Management, Temple University, Philadelphia, Pennsylvania.
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  • Jacqueline Zinn PhD

    1. From the *Center for Gerontology and Health Care Research and Department of Community Health, Alpert Medical School, Brown University, Providence, Rhode Island; Women's College Research Institute, Women's College Hospital, Toronto, Ontario; Department of Health Care Policy, Harvard University Medical School, Harvard, Massachusetts; and §Fox School of Business and Management, Temple University, Philadelphia, Pennsylvania.
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Address correspondence to Vincent Mor, Brown University, Community Health, Box G-S121, Providence, RI 02912. E-mail: vincent_mor@brown.edu

Abstract

OBJECTIVES: To test the effect of changes in Medicaid reimbursement on clinical outcomes of long-stay nursing home (NH) residents.

DESIGN: Longitudinal, retrospective study of NHs, merging aggregated resident-level quality measures with facility characteristics and state policy survey data.

SETTING: All free-standing NHs in urban counties with at least 20 long-stay residents per quarter (length of stay>90 days) in the continental United States between 1999 and 2005.

PARTICIPANTS: Long-stay NH residents

INTERVENTIONS: Annual state Medicaid average per diem reimbursement and the presence of case-mix reimbursement in each year.

MEASUREMENTS: Quarterly facility-aggregated, risk-adjusted quality-of-care measures surpassing a threshold for functional (activity of daily living) decline, physical restraint use, pressure ulcer incidence or worsening, and persistent pain.

RESULTS: All outcomes showed an improvement trend over the study period, particularly physical restraint use. Facility fixed-effect regressions revealed that a $10 increase in Medicaid payment increased the likelihood of a NH meeting quality thresholds by 9% for functional decline, 5% for pain control, and 2% for pressure ulcers but not reduced use of physical restraints. Facilities in states that increased Medicaid payment most showed the greatest improvement in outcomes. The introduction of case-mix reimbursement was unrelated to quality improvement.

CONCLUSION: Improvements in the clinical quality of NH care have been achieved, particularly where Medicaid payment has increased, generally from a lower baseline. Although this is a positive finding, challenges to implementing efficient reimbursement policies remain.

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