For-Profit Care and Quality: An
Oxymoron?
Joel Lexchin
School of Health Policy and
Management
York University
Points to Cover
• Measures of quality of care and long-term
care facility status
• Explanation for differences
– Payment mechanisms
– Staffing
Post-Acute Care Residents
Antipsychotic Prescribing
• Manitoba
– Odds of being dispensed antipsychotic medications were
1.7 times greater for residents of for-profit homes in the
Winnipeg Regional Health Authority versus not-for-profit
and public homes in Manitoba
• Minnesota
– Medicare and Medicaid certified for-profit facilities had
higher antipsychotic use rates than did not-for-profit
facilities
• United States
– All 14,631 Medicare and Medicaid certified homes
– Antipsychotic use was higher in those operated on a forprofit basis versus those on a not-for-profit basis
Outside North America (Israel)
Scores adjusted for daily paid rate, institutional size & staffing
level
Overall Level of Care
• British Columbia (Canada) for-profit versus not-for-profit facilities
– Higher adjusted hospitalization rates for pneumonia, anemia, and
dehydration
– No difference for falls, urinary tract infections, or decubitus
ulcers/gangrene
– No difference in mortality rates
• Two meta-analyses (American data)
– “systematic differences exist between for-profit and not-for-profit
nursing homes. For profit nursing homes appear to provide lower
quality of care in many important areas of process and outcome”
– Not-for-profit facilities delivered higher quality care than did for-profit
facilities for two of the four most frequently reported quality
measures” and for the two others there were non-significant results
favouring not-for-profit homes
Newly Admitted Residents
Residents admitted to for-profit, independently owned facilities were
younger, took fewer medications and had fewer falls in the 30 day
prior to admission
For-Profit Status or Other Factors?
• US study looking at pressure ulcers
– May not be profit status but the extent to which practice
environment supports staff nurses
• Poorer performance among US for-profit homes may
relate to them having lower occupancy, higher
Medicaid census, and operating in US states with lower
Medicaid payments compared to not-for-profit homes
– Higher percent Medicaid residents and lower payments
put fiscal pressures on both for-profit and not-for profit
homes
– Restraint use increased and nursing levels decreased in
both types of homes
Amount of Care By Type of Ownership
Residents requiring more complex care – Types 2 and 3 – reside predominantly in
government-owned facilities in four of five Canadian regions. On the other hand, in four of
five regions, residents needing Type 1 Care reside in Not-For-Profit facilities where we
generally observe the highest unregulated staffing levels.
Can Other Factors Explain Staffing
Levels?
• Residents requiring more complex care – Types 2
and 3 – reside predominantly in governmentowned facilities in four of five Canadian regions
• In four of five regions, residents needing Type 1
Care reside in Not-For-Profit facilities where we
generally observe the highest unregulated
staffing levels
• Public payment levels differ by province but are
the same to all types of homes in each province
Conclusions
• Better quality of care by multiple measures in
not-for profit facilities
• Better staffing in not-for profit facilities
• Staffing not explained by type of patient, size
of facility or payment
Bibliography
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