Nursing Homes

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Why don’t patients care about quality?

October 10, 2011 in Nursing Homes, Quality | 6 comments

For nursing homes at least, patients do not seem to have much choice.  According to an article by Grabowski and Town:

The introduction of the NHQI was generally unrelated to facility quality and consumer demand. However, nursing homes facing greater competition improved their quality more than facilities in less competitive markets…The lack of competition in many nursing home markets may help to explain why the NHQI report card effort had a minimal effect on nursing home quality. With the introduction of market-based reforms such as report cards, this result suggests policy makers must also consider market structure in efforts to improve nursing home performance.

In general, there are many reasons why patients do not respond to provider report cards.  It could be the case that the provider is a monopoly, and thus the patient has little choice of providers.  Alternatively, patients may not be aware of the quality metrics.  One would thing that high quality providers, however, would spend money advertising their high quality ratings to make patients aware of their services.  In other cases, the patients may not be the ones directing care choices.  Providers may be the ones who are the de facto selectors of care.

Patients could also not believe that the CMS quality ratings are very useful.  They may prefer other sources of information on medical quality such as their friends, relatives, or physicians.  Thus, it may be the physician who actually chooses to which nursing home the patient will go.  If the physician has incentives to sent the beneficiary to nursing homes in the network or simply does not wish to spend the time analyzing nursing home quality, then patients may be less likely to be allocated to high quality nursing home.

 

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State Adoption of Nursing Home Pay-for-Performance

January 31, 2011 in Nursing Homes, P4P | No comments

On the importance of Nursing homes:

“More than 1.5 million people reside in U.S. nursing homes at a cost of more than $120 billion per year (Kaiser Family Foundation, 2007). Medicaid is the majority payer of nursing home services, giving indigent people access to nursing home care by directly reimbursing facilities for the care of Medicaid-eligible residents…State Medicaid programs are responsible for approximately half of all nursing home spending, and Medicaid residents constitute 65% of all bed-days.”

As nursing home expenditures have taken up a larger and larger share of expenditures, a number of State Medicaid Agencies have instituted pay-for-performance requirements (P4P).  A paper by Werner, Konetzka and Liang (2007) evaluate some of these P4P efforts.  A total of 15 states had planned or existing nursing home P4P programs when this article was published.

Here is a map of all the states who have initiated P4P programs for Nursing Homes.

“Financial rewards in nursing home P4P are based on a variety of different quality measures , including traditional measures such as staffing, regulatory deficiencies, resident satisfaction, and clinical quality and less traditional measures such as occupancy, efficiency, Medicaid use, and culture change. Most use at least 4 different categories of measures, and none uses less than 3.”

The following table summarizes the types of quality measures used in state nursing home P4P programs.  This table lists specific clinical measures used for P4P.

High performing nursing homes generally receive a financial reward for their status.  Most states use a per-diem add on as a reward for high performance.  One state, Vermont, gave flat-rate bonuses to up to 5 facilities that met predetermined quality thresholds.  This table summarizes the level of payment in selected state nursing home P4P programs.

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Value-Based Purchasing in Nursing Homes

December 13, 2010 in Medicaid, Medicare, Nursing Homes, P4P | 1 comment

More than 3 million frail and disabled individuals rely on nursing home services in any given year.  About half of these individuals consider the nursing home to be their primary place of residence.  Nursing home quality, however, has often been called into question.

Some experts believe pay-for-performance schemes will improve nursing home quality.  Today, I will review previous efforts to improve nursing home quality though P4P.

Briesacher et al. (2009)

A paper by Briesacher, Field, Baril and Gurwitz review P4P in nursing homes in a variety of states.   The authors note that “Approximately one-half of all Medicaid Programs currently operate some type of pay-for-performance program, and 85 percent have plans to do so within 5 years.”  This report consider nursing home P4P programs in: California, Colorado, Florida, Georgia, Illinois, Iowa, Kansas, Massachusetts, Minnesota, Ohio, Oklahoma, Texas and Utah.

Measures considered include:

  • Clinical Measures (e.g., pressure sores, use of physical restraints, pain management, quality of life, MDS indicators, state-developed CAHPS measures, care plans)
  • Satisfaction Levels (e.g., patient, family, employees)
  • Structural Measures (e.g., nursing retention, staff turnover, occupancy rates, special licensure, state survey compliance, staffing hours/ratios)
  • Cost (e.g., Medicaid utilization, administrative costs, efficiency)
  • Pressure sores,
  • Use of physical restraints,
  • Pain

Bonuses were paid depending on whether the nursing homes surpassed some threshold of these quality measures.  Some of the bonuses were paid as a flat rate ($3/day in Ohio and $0.50-$0.0 in Utah) and other used a percentage increase (up to 2.4% in Minnesota, 1%-3% increase in Iowa).  The highest bonus paid was 5% of per diem reimbursement where the lowest bonuses were $0.25.

“We found little empirical evidence that pay-for-performance programs increase the quality of care of residents or the efficiency of that care in nursing homes. However, the program set in San Diego did find benefits, and it used the strongest of all evaluation designs, a randomized control design.” The San Diego RCT randomized nursing homes into treatment and control groups and gave the treatment groups incentive payments for: (i) accepting patients needing the most functional assistance, (ii) improving patient functional status, and (iii) prompt discharges of patients who remained out of the facility for at least 90 days.

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