Relationship Between State Medicaid Policies, Nursing Home Racial Composition, and the Risk of Hospitalization for Black and White Residents

Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ON M6A 2E1, Canada.
Health Services Research (Impact Factor: 2.78). 07/2008; 43(3):869-81. DOI: 10.1111/j.1475-6773.2007.00806.x
Source: PubMed


To examine racial differences in the risk of hospitalization for nursing home (NH) residents.
National NH Minimum Data Set, Medicare claims, and Online Survey Certification and Reporting data from 2000 were merged with independently collected Medicaid policy data.
One hundred and fifty day follow-up of 516,082 long-stay residents.
18.5 percent of white and 24.1 percent of black residents were hospitalized. Residents in NHs with high concentrations of blacks had 20 percent higher odds (95 percent confidence interval [CI]=1.15-1.25) of hospitalization than residents in NHs with no blacks. Ten-dollar increments in Medicaid rates reduced the odds of hospitalization by 4 percent (95 percent CI=0.93-1.00) for white residents and 22 percent (95 percent CI=0.69-0.87) for black residents.
Our findings illustrate the effect of contextual forces on racial disparities in NH care.

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Available from: Susan C Miller, Mar 11, 2014
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    • "Using the MDS for research, policy evaluation and planning has the advantage of not requiring the same level of precision as is needed to justify a clinical decision about an individual resident nor even as definitive as should be necessary to publish the relative ranking of one home over another on a given quality measure. Furthermore, there are statistical means of "adjusting" out the idiosyncratic measurement error that can occur in some facilities and not others, still making it possible to examine the effect of states' policies on resident adjusted outcomes such as pain or ADL[51,52]. Evidence of the strong monotonic relationship between the CHESS scale and one year mortality among new NH admissions is clearly at least as strong as the Charlson Index or the Deyo-Elixhauser scale as applied to hospital discharge diagnoses. "
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    ABSTRACT: The Minimum Data Set (MDS) for nursing home resident assessment has been required in all U.S. nursing homes since 1990 and has been universally computerized since 1998. Initially intended to structure clinical care planning, uses of the MDS expanded to include policy applications such as case-mix reimbursement, quality monitoring and research. The purpose of this paper is to summarize a series of analyses examining the internal consistency and predictive validity of the MDS data as used in the "real world" in all U.S. nursing homes between 1999 and 2007. We used person level linked MDS and Medicare denominator and all institutional claim files including inpatient (hospital and skilled nursing facilities) for all Medicare fee-for-service beneficiaries entering U.S. nursing homes during the period 1999 to 2007. We calculated the sensitivity and positive predictive value (PPV) of diagnoses taken from Medicare hospital claims and from the MDS among all new admissions from hospitals to nursing homes and the internal consistency (alpha reliability) of pairs of items within the MDS that logically should be related. We also tested the internal consistency of commonly used MDS based multi-item scales and examined the predictive validity of an MDS based severity measure viz. one year survival. Finally, we examined the correspondence of the MDS discharge record to hospitalizations and deaths seen in Medicare claims, and the completeness of MDS assessments upon skilled nursing facility (SNF) admission. Each year there were some 800,000 new admissions directly from hospital to US nursing homes and some 900,000 uninterrupted SNF stays. Comparing Medicare enrollment records and claims with MDS records revealed reasonably good correspondence that improved over time (by 2006 only 3% of deaths had no MDS discharge record, only 5% of SNF stays had no MDS, but over 20% of MDS discharges indicating hospitalization had no associated Medicare claim). The PPV and sensitivity levels of Medicare hospital diagnoses and MDS based diagnoses were between .6 and .7 for major diagnoses like CHF, hypertension, diabetes. Internal consistency, as measured by PPV, of the MDS ADL items with other MDS items measuring impairments and symptoms exceeded .9. The Activities of Daily Living (ADL) long form summary scale achieved an alpha inter-consistency level exceeding .85 and multi-item scale alpha levels of .65 were achieved for well being and mood, and .55 for behavior, levels that were sustained even after stratification by ADL and cognition. The Changes in Health, End-stage disease and Symptoms and Signs (CHESS) index, a summary measure of frailty was highly predictive of one year survival. The MDS demonstrates a reasonable level of consistency both in terms of how well MDS diagnoses correspond to hospital discharge diagnoses and in terms of the internal consistency of functioning and behavioral items. The level of alpha reliability and validity demonstrated by the scales suggest that the data can be useful for research and policy analysis. However, while improving, the MDS discharge tracking record should still not be used to indicate Medicare hospitalizations or mortality. It will be important to monitor the performance of the MDS 3.0 with respect to consistency, reliability and validity now that it has replaced version 2.0, using these results as a baseline that should be exceeded.
    BMC Health Services Research 04/2011; 11(1):78. DOI:10.1186/1472-6963-11-78 · 1.71 Impact Factor
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    • "Black clients are much more likely to be in nursing homes with serious deficiencies, lower staffing ratios, and greater financial vulnerability—the net result being separate and unequal care (Smith et al. 2007). Troubling racial disparities in care range from inappropriate pharmacologic management and physical therapy to higher rates of hospitalization from nursing homes for black residents (Gruneir et al. 2007). "
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    ABSTRACT: Nursing homes in the United States are a product of American federalism and reflect the complexities and variabilities of that system. Over time, institutional long-term care for frail elders has shifted from local government funding and administration to state-level oversight and support to a shared federal-state concern. The unsystematic American approach produces haphazard results in terms of quality, equity, and efficiency. The graying of the American population will increase the demand for long-term care, resulting in pressure for a more coherent policy response. Copyright 2009, Oxford University Press.
    Publius The Journal of Federalism 12/2009; 39(1):138-163. DOI:10.1093/publius/pjn030 · 0.76 Impact Factor
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