Impact of Florida Legislative &
Regulatory Innovations on Nursing
Home Turnover, Tenure, Financial
Performance & Quality of Care
Panel Presentation at Academy Health
June 5,2007
2/1/2007
1
Collaboration across Florida Universities
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Kathryn Hyer,PhD, MPP, University of South Florida
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Mishu Popa & Shabnam Mehra, PhD students
Larry Polivka, PhD, Victor Molinari, PhD
Christopher Johnson, Ph.D., Texas A&M University
Health Science Center, Co-Principal Investigator
Jeffrey Harman, PhD, University of Florida
David Macpherson, PhD, Florida State University
William Even, PhD, Miami University of Ohio
Robert Weech-Maldonado, University of Florida
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5/29/2016
Alexandre Laberge, PT, PhD student
Acknowledge Funding Sources
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Administration on Agency research grant
Award # 90AM2750/02
Commonwealth Fund (Hyer, Johnson,
Harman)
Award # 20050582
5/29/2016
Acknowledge Advisors
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Charlene Harrington, PhD, Chair, National
Advisory Board for Commonwealth Fund
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Christine Bishop, PhD
Dana Mukamel, PhD
Vince Mor, PhD
5/29/2016
Goals of presentation
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To examine how nursing home providers in Florida responded
over a six-year period (1999-2004) to both financial incentives
to increase spending on direct care and to new staffing
mandates
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Understand the long term care nursing labor market in Florida
and the US
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Understand top management stability and its impact on
deficiencies and nurse staff turnover
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To examine how quality of care and financial performance
changed in Fl nursing homes after new staffing, regulatory
requirements and reimbursement rates were changed to
improve quality.
5/29/2016
Fl Nurse Staffing Changes 1999-2007
1999-2001
2002
2003
2007
5/29/2016
Appropriate Medicaid
direct care staffing
adjustment (DCSA)
incentives (HB 1971)
Increase CNA and
LPN/RN staffing
standards effective
January 2002
Increase CNA staffing
standards to 2.6
effective January 2003
Daily minimum of 2.7
CNA HPRD effective
January 2007
1.7
0.6
2.3
2.6
1
1
2.9 w eekly
1
Background: Fl. Nursing Home
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Florida has 650 NHs with 70,000 with beds
certified as Medicaid and Medicare
Florida has 2,200 Assisted Livings with
70,000 beds
Late 1990’s Florida was a high litigation state,
insurance coverage was expensive and
difficult to obtain, NHs were filing for
bankruptcy and quality of nursing care was
suspect.
5/29/2016
Staffing Mandates Matter:
Florida Nursing Home Provider
Response to Financial Incentives
to Increase Nurse Staffing
Presentation at Academy Health Annual Research Meeting
Kathryn Hyer, Ph.D.
University of South Florida
Principal Investigator
Christopher Johnson, Ph.D.
Texas A&M University Health Science Center
Co-Principal Investigator
Jeffrey Harman, PhD, Investigator, University of Florida
Shaban Mehra,
University of South Florida PhD Program
2/1/2007
8
Direct Care Staffing Adjustment (DCSA)
Incentive Program 1999 legislation
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5/29/2016
Who: Incentives paid to Medicaid-participating
facilities. 600 of 648 Medicaid providers
volunteered. 594 provided follow-up data
When: Beginning April 1, 2000 and continuing until
mandates were imposed in January 2002.
How: Direct patient care increase in Medicaid per
diem ($31.7 million dollars/annualized and
sustained until mandates began in Jan 2002)
Direct Care Staffing Adjustment Medicaid
Payments
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Baseline study period 1/1/99—6/30/99
Follow-up study period 5/1/00—10/31/00
595 Medicaid providers
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Minimum payment of $0.50/Medicaid patient day of money
spent on minimum ($8 million-25% of total allocated)
Additional money ($23.1 million-75%) inversely allocated to
providers with lowest staffing and highest Medicaid
utilization
NH Medicaid add-on payments
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5/29/2016
$1.96 average Medicaid patient day
$2.81 maximum Medicaid patient day
Direct Care Staffing Adjustment (DCSA)
Incentive Program
Pay “cost of hiring additional
CNA and licensed nurses or
cost of salary or benefit
enhancements to retain
such staff”
5/29/2016
Financial Incentives to Increase
Staffing in Florida Nursing Homes
What are the characteristics of
nursing homes that responded to
Medicaid direct patient care increase
incentive?
 How did nurse staffing change?
 What was the impact on quality?
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5/29/2016
Data
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CMS OSCAR data was used for deficiencies
and structural characteristics.
Florida’s Agency for Health Care
Administration Cost Data provided following
data for baseline and follow-up periods
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5/29/2016
amounts of incentive provided to nursing homes
nursing hours per patient day by nurse level
overtime hours and agency hours
Methods
Baseline statistics
 T-tests on facility characteristics
 Minimum incentive dollars (N=145)
 Maximum incentive dollars (N=146)
Two-way ANOVA
 Changes in nurse staffing hours by nurse level
 Changes in use of agency by nurse level
Difference in difference by incentive payment amount
 Quality indicators
 Deficiencies
5/29/2016
Methods
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Compare:
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Baseline period (Jan-June 99) with
follow-up (May-Oct 2000)
Quartiles of providers receiving money
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Minimum incentive $
Maximum incentive $
Changes in nurse staffing hours
Employee hours, overtime hours
Changes in use of agency
Changes in quality of resident care
(Quarter 1 2000 vs 4th Quarter 2001)
5/29/2016
Baseline characteristics of NH receiving
Minimum and Maximum Incentive dollars
Variables
Avg add-on/
patient day
Avg total addon facility
5/29/2016
Minimum Incentive
Quartile N=146
sd
mean
Maximum Incentive
Quartile N=145
sd
mean
T-tests
$1.33
$0.40
$2.44
$0.15
***
$34,163
$25,332
$68,117
$31,974
***
Baseline characteristics of NH receiving
Minimum and Maximum Incentive dollars
Minimum Incentive
Quartile (N=146)
Variables
Number of
beds
Medicaid
Ratio
Medicare
Ratio
Acuity Index
5/29/2016
Maximum Incentive
Quartile (N=145)
mean
sd
mean
sd
T-Tests
131
60
119
40
*
0.57
0.23
0.7
0.17
***
0.14
10.71
0.12
1.38
0.11
10.37
0.07
1.09
***
*
Characteristics of NH responding by Minimum
and Maximum add-on quartiles 1999
Minimum Incentive
Quartile (N=146)
Variables
% For Profit
% Chain
% Urban
Number of
beds
5/29/2016
Maximum Incentive
Quartile (N=145)
mean
71
65
96
sd
45
48
20
mean
91
83
88
sd
29
38
33
T-Tests
***
***
***
131
60
119
40
*
CNA Percent Change in Hours/ prpd
80
60
40
20
Minimum
Maximum
0
Mean Total Nurse
Staffing Hours
-20
-40
-60
5/29/2016
Mean Agency Nurse
Staffing Hours
Mean Total
Overtime Hours
Mean Employed
Nurse Staffing
Hours
Percent Change in LPN Hours/ prpd
120
100
80
60
Minimum
40
Maximum
20
0
Mean Total Nurse
Staffing Hours
-20
-40
5/29/2016
Mean Agency Nurse
Staffing Hours
Mean Total Overtime
Hours
Mean Employed Nurse
Staffing Hours
Percent Change in RN Hours/ prpd
250
200
150
Minimum
100
Maximum
50
0
Mean Total Nurse
Staffing Hours
-50
5/29/2016
Mean Agency
Nurse Staffing
Hours
Mean Total
Overtime Hours
Mean Employed
Nurse Staffing
Hours
Changes in total nurse staffing hours/prpd
Means in nurse staffing
hours/ prpd
Minimum Incentive Maximum Incentive
Mean
SD
Mean
SD
p
CNA total hours baseline
2.60
1.09
1.77
0.25 ***
CNA total hours after $
2.32
0.44
2.08
0.69 ***
Within group change(p) **
***
LPN total hours baseline
1.01
0.45
0.67
0.17 ***
LPN total hours after $
0.90
0.29
0.76
0.20 ***
Within group change(p) *
***
RN total hours baseline
0.56
0.32
0.29
0.13 ***
RN total hours after $
Within group change(p)
Total hours baseline
Total hours after $
Within group change(p)
0.46
0.29
0.31
0.17 ***
2.73
3.14
0.32 ***
0.83 ***
5/29/2016
**
ns
4.17
3.66
***
1.54
0.75
***
Changes in Mean Hourly Wage
Means in hourly wages
Minimum Incentive
Mean
SD
$8.40
1.18
$9.39
1.32
CNA hourly wage baseline
CNA hourly wage after $
***
LPN hourly wage baseline
LPN hourly wage after $
1.73
1.55
***
5/29/2016
$14.54
$15.42
1.85
1.5
**
ns
$18.08
$18.98
2.65
2.23
ns
***
***
$18.67
$19.97
***
p
*
*
***
$13.93
$15.49
RN hourly wage baseline
RN hourly wage after $
Maximum Incentive
Mean
SD
$8.86
1.4
$9.66
1.23
2.99
2.51
**
Difference in difference
Quality Indicator
ADL decline 4 points
Bladder worsening
Coefficient
P-value
(Compared to middle
incentive group)
P-value
(High vs. Low
incentive)
Min group
-0.006
0.417
0.437
Max group
0.001
0.921
Min group
0.001
0.874
Max group
0.021
0.014
Incentive
quartile
0.056
Log Linear transformations
Bowel worsening
Pressure sore_low
Restraints
5/29/2016
Min group
-0.006
0.914
Max group
0.140
0.010
Min group
0.124
0.180
Max group
-0.019
0.833
Min group
-0.047
0.596
Max group
-0.042
0.627
0.024
0.186
0.962
Results-Incentive Program
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Expected to see increase in mean hours/prpd at all
facilities receiving new monies
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Significant between-group differences at baseline
Significant increases in employed nurse hours for CNAs,
LPNs, RN increases only in group receiving maximum
incentive dollars
Even after new money group receiving maximum $
is still not at minimum HPRD
LPNs appear to substitute for RN HPRD
Wages increased for CNAs, LPNs, mixed RNs
5/29/2016
Discussion
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How was the direct care staffing money
spent?
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5/29/2016
Spent according to legislative intent
Differences between minimum and maximum
incentive groups.
Incentives allow discretion which does not
translate to staffing increases per resident day
Low amounts of money spent on RNs despite
increasing acuity
Discussion
Incentives did not improve the quality of
care
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5/29/2016
Was money sufficient?
Total Nursing HPRD
Total Nursing Hours Per Resident Day Florida
versus Nation*
5
4.5
Florida
4
US
3.5
3
1999 2000 2001 2002 2003 2004
Year
* From Slack, A., Hyer, K. & Johnson, C.E.. “Reviewing Florida’s Efforts to Improve Nursing Home Quality Through Nurse
Staffing Mandates, Regulation and Medicaid Reimbursement” (Figure 1, Working paper, 2006.)
5/29/2016
Staffing Mandates Matter
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Incentives change organizational behavior in
nurse staffing but do not necessarily increase
hours per resident per day
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Florida staffing changes are natural
experiment with mandates following
incentives
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Can’t address how staff are deployed
5/29/2016
Next Steps
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Difference in difference models over
mandates
Examine the changes in quality at facilities
when mandates are imposed
Track total salary within departments with Dr.
Weech-Maldonado
Identify characteristics of facilities with
variation in quality by staffing (high quality
and low quality)
5/29/2016
More information

Kathryn Hyer khyer@cas.usf.edu
5/29/2016