Nursingg Homes response
p
to
publication of the Nursing
Home Compare report card: The
“T h
“Teaching
to the
h Test”
T ” strategy
Dana B. Mukamel, William D. Spector, Jacqueline Zinn,
David L. Weimer, Richard Ahn
The University of California, Irvine
We gratefully acknowledge funding by NIA grant # AG023077
 Nursing
Home Compare published
clinical QMs for the first time on
11/12/2002

Information:
 General facility information
 Quality:
Q lit



Health deficiencies
Staffing
“Clinical”
Clinical quality measures
Nursingg homes provide
p
manyy services:


Hotel services
Clinical services
H t l services
Hotel
i
Cli i l services
Clinical
i
High
g
Low
Consumer’s ability to assess quality
Empirical
p
evidence about nursingg home
choice prior to Nursing Home Compare era:

1998 survey of residents in PA and NJ: Most
important factors – cleanliness, friendliness, and
qqualityy of life (Castle
(
NG,, 2003))

2001 revealed
l d preference
f
study
d in 4 states:
Probability of admission significantly increased
with hotel quality but not with clinical quality
(Pesis-Katz
(Pesis
Katz et al., 2007)
 Nursing
N i
Home
H
C
Compare revealed
l d the
h
quality of clinical services:


The elasticity of demand with respect to
clinical quality increased
Main hypothesis:
Following publication of Nursing Home
p , nursing
g homes changed
g the relative
Compare,
allocation of resources from activities related to
hotel services to clinical activities.
Sub-hypothesis:
yp





Nursing homes identified in the report card as having low
clinical quality were more likely to reallocate resources
than those that were not.
Low occupancy nursing homes were more likely to
reallocate resources than high occupancy nursing homes.
N rsing homes in more competitive markets were
Nursing
ere more
likely to reallocate resources than nursing homes in less
competitive markets.
markets
For-profit nursing homes were more likely to reallocate
resources than non
non-profit
profit nursing homes.
homes
Chain-owned nursing homes were more likely to
reallocate resources than non
non-chain
chain nursing homes
homes.
Sample:
p

10,002
0,00 free
ee standing
sta d g nursing
u s g homes
o es
nationally

2001-2006

2 years pre, 4 years post

About 54,000 observations
Data sources:

HCRIS: expenditures by cost center

OSCAR: nursing home characteristics

MDS case mi
MDS:
mix and
nd competition
mp titi n

NHC: QMs on first publication
Estimated model:
ClinicExp
HotelExp
i ,t
    RUG i ,t   MC i ,t   RC t 
i ,t
N
I
i 1
i

Inference based on robust standard errors

Stratified analyses by:





Ownership
Occupancy
Chain
Quality
Competition
  i ,t
CLINICAL EXPENDITURES
Central Pharmacy Services
Pharmacy
Medical Records and Library
Social Service
Intern and Residents
Other General Service Cost
Skilled Nursing Facility
Nursing Facility
Intermediate Care Facility
Other Long Term Care
Radiology
Laboratory
Intravenous Therapy
Oxygen (Inhalation) Therapy
Physical Therapy
Occupational Therapy
Speech Pathology
El t
Electrocardiology
di l
Medical Supplies Charged to Patients
Drugs Charged to Patients
Dental Care – Title XIX Only
S
Support
S
Surfaces
f
Other Ancillary Service Cost Center
Clinic
Rural Health Clinic
Other Outpatient Service Costs
Hospice
HOTEL EXPENDITURES
Capital Related Costs – Building and Fixture
Capital Related Costs – Movable Equipment
Plant Operation, Maintenance, and Repairs
Laundry and Linen Service
Housekeeping
Dietary
Interest Expense
MEAN
1.78
3,108,772
1,980,867
0.925
0 124
0.124
STANDARD
DEVIATION*
6.04
2,460,345
1,860,652
0.094
0 010
0.010
Ownership:
For-Profit (%)
Private Non-Profit
Non Profit (%)
Government (%)
71.6
24 7
24.7
3.7
─
─
─
Chain (%)
Non Chain ($)
Non-Chain
58.7
41 3
41.3
─
─
Occupancy (%):
69.9
45.9
Market
M
k t competition:
titi
% of Markets with HHI < 0.11
% of Markets with HHI > 0.18
7.5
67.1
─
─
VARIABLE
Clinical / Hotel Expenditures
Annual Clinical Expenditures ($)
Annual Hotel Expenditures ($)
RUGs Case Mix Index
Proportion of Medicare Patients
% off nursing
i
homes
h
designated
d i
d as llow quality
li (at
( the
h 20th percentile
il off their
h i state):
)
Pain
21.9
─
Pressure Ulcers
23.7
─
Decline in ADLs
23.2
─
Infections
23.1
─
Physical Restraints
21.7
─
Urinary Incontinence
21.8
─
Change in Clinical to Hotel Expenditures Ratio
Changee in Ratiio
0.123***
0.126***
0.119***
0 112*
0.112*
0.093***
0.088***
0.063
0.070*
0.026
Overall
FP
NFP
Yes No
Chain
Low High
Occupancy
High Low
Competition
Quality
0.109***
0 115***
0.115***
0.118***
0.112***
0.098***
0.075*
Pain
0.076*
0.073*
Pressure
Ulcer
Decline in
ADLs
Low
High
0.073*
Infection
0.079*
Physical
Restraints
 Impact

on the average facility:
Ratio increased from
1.78 to 1.87

5%
Equivalent to
17% increase in RUGs case mix
29% in proportion of MC patients
Conclusions:
 “Teaching
Teaching
 Not
 Is
to the Test
Test”
unexpected
it desirable?
Hotel expenditures per day stable at $49-$50
 Clinical expenditures per day increased from
$71 to $76

 Why
Wh
no adverse
d
iimpact on h
hotell
q
quality?
y
Sufficient reimbursement
 Counterbalancing
C
b l i regulation
l i
 “Fuzzy”
y incentives

 Need
 Need
N d
to continue monitoring
to perform
f
micro
i
studies
di off
ote quality
qua ty
hotel