Changes in patient sorting to nursing homes under public reporting: improved patient matching or provider gaming?

Center for Health Equity Research and Promotion, Philadelphia VAMC, Division of General Internal Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
Health Services Research (Impact Factor: 2.49). 11/2010; 46(2):555-71. DOI: 10.1111/j.1475-6773.2010.01205.x
Source: PubMed

ABSTRACT To test whether public reporting in the setting of postacute care in nursing homes results in changes in patient sorting.
All postacute care admissions from 2001 to 2003 in the nursing home Minimum Data Set.
We test changes in patient sorting (or the changes in the illness severity of patients going to high- versus low-scoring facilities) when public reporting was initiated in nursing homes in 2002. We test for changes in sorting with respect to pain, delirium, and walking and then examine the potential roles of cream skimming and downcoding in changes in patient sorting. We use a difference-in-differences framework, taking advantage of the variation in the launch of public reporting in pilot and nonpilot states, to control for underlying trends in patient sorting.
There was a significant change in patient sorting with respect to pain after public reporting was initiated, with high-risk patients being more likely to go to high-scoring facilities and low-risk patients more likely to go to low-scoring facilities. There was also an overall decrease in patient risk of pain with the launch of public reporting, which may be consistent with changes in documentation of pain levels (or downcoding). There was no significant change in sorting for delirium or walking.
Public reporting of nursing home quality improves matching of high-risk patients to high-quality facilities. However, efforts should be made to reduce the incentives for downcoding by nursing facilities.

  • [Show abstract] [Hide abstract]
    ABSTRACT: : Changes in resident outcomes may be driven by many factors, including changes in nursing home care processes. Understanding what processes, if any, lead to successful improvements in resident outcomes could create a stronger case for the continued use of these outcome measures in nursing home report cards. : To test the extent to which improvements in outcomes of care are explained by changes in nursing home processes, a setting where, to our knowledge, this link has not been previously studied. RESEARCH DESIGN/MEASURES:: We describe facility-level changes in resident processes and outcomes before and after outcomes were publicly reported. We then assess the extent to which the changes in outcomes are associated with changes in nursing home processes of care, using the public release of information on nursing home outcomes as a source of variation in nursing home outcomes to identify the process-outcome relationship. : All 16,623 US nursing homes included in public reporting from 2000 to 2009 in Online Survey, Certification and Reporting and the nursing home Minimum Data Set. : Of the 5 outcome measures examined, only improvements in the percentage of nursing home residents in moderate or severe pain were associated with changes in nursing home processes of care. Furthermore, these changes in the measured process of care explained only a small part of the overall improvement in pain prevalence. : A large portion of the improvements in nursing home outcomes were not associated with changes in measured processes of care suggesting that processes of care typically measured in nursing homes do little to improve nursing home performance on outcome measures. Developing quality measures that are related improved patient outcomes would likely benefit quality improvement. Understanding the mechanism behind improvements in nursing home outcomes is key to successfully achieving broad quality improvements across nursing homes.
    Medical care 07/2013; 51(7):582-8. DOI:10.1097/MLR.0b013e31828dbae4 · 2.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The high cost of the US health care system does not buy uniformly high quality of care. Concern about low quality has prompted two major types of public policy responses: regulation, a top-down approach, and report cards, a bottom-up approach. Each can result in either functional provider responses, which increase quality, or dysfunctional responses, which may lower quality. What do we know about the impacts of these two policy approaches to quality? To answer this question, we review the extant literature on regulation and report cards. We find evidence of both functional and dysfunctional effects. In addition, we identify the areas in which additional research would most likely be valuable. Expected final online publication date for the Annual Review of Public Health Volume 35 is March 18, 2014. Please see for revised estimates.
    Annual Review of Public Health 10/2013; DOI:10.1146/annurev-publhealth-082313-115826 · 3.27 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Information on the quality of healthcare gives providers an incentive to improve care, and this incentive should be stronger in more competitive markets. We examine this hypothesis by studying Pennsylvanian hospitals during the years 1995-2004 to see whether those hospitals located in more competitive markets increased the quality of the care provided to Medicare patients after report cards rating the quality of their Coronary Artery Bypass Graft programs went online in 1998. We find that after the report cards went online, hospitals in more competitive markets used more resources per patient, and achieved lower mortality among more severely ill patients.
    Journal of Health Economics 01/2014; 34C:42-58. DOI:10.1016/j.jhealeco.2013.12.004 · 2.25 Impact Factor