Improving the Quality of Nursing Home Outcomes Are Adequacy- or Incentive-Oriented Policies More Effective?

Division of Health Services Research and Policy, School of Public Health, University of Minnesota, Minneapolis 55455.
Medical Care (Impact Factor: 3.23). 01/1989; 26(12):1158-71. DOI: 10.1097/00005650-198812000-00006
Source: PubMed


Recent debates over health policy have tended to be between procompetitive solutions and proregulatory ones. This dichotomy, however, seems to be less descriptive of the policy debate over ways to improve nursing home quality. This article argues that a more useful distinction may be between adequacy- and incentive-oriented policies. The nursing home industry and others have argued that the financial and physical resources at the disposal of nursing homes have been inadequate to produce acceptable quality levels. Whether quality requires more resources is tested using the 1983 Iowa Outcome Oriented Survey, but none of the quality measures constructed from these data were significantly associated with higher average costs. On the other hand, nonprofit nursing homes, nursing homes with more professional workers (nurses), and nursing homes that cater to private patients have incentives that may motivate them to provide better quality. These factors were often significantly associated with a variety of the quality measures, suggesting that policies based on incentives may be more effective than adequacy-oriented policies.

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    • "The use of outcome measures in this literature is scant. Nyman (1988c) revealed no Medicaid-quality relationship with respect to resident care or quality-of-life measures. In related work however, Nyman (1988b) did find that regulatory violations occur with greater frequency in high Medicaid homes. "
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    ABSTRACT: A long-standing assumption among economists is that nursing home quality is common across Medicaid and private-pay patients within a shared facility. However, there has been only limited empirical work addressing this issue. Using a unique individual level panel of residents of nursing homes from seven states, we exploit both within-facility and within-person variation in payer source and quality to examine this issue. We also test the robustness of these results across states with different Medicaid and private-pay rate differentials. Across various identification strategies, our results are consistent with the assumption of common quality across Medicaid and private-paying patients within facilities.
    Preview · Article · Nov 2008 · Review of Economics and Statistics
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    • "Nursing facility bed supply should be related to state enforcement activities . Where bed supply is low, less competition may occur and facilities may not be as concerned about quality (Nyman 1988). This could result in the need for states to give more deficiencies to nursing facilities. "
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    ABSTRACT: This study presents interview and statistical data from a telephone and fax survey of state agency officials and statistical data from the Centers for Medicare & Medicaid Services' Online Survey Certification and Reporting (OSCAR) system. State survey activities for nursing facilities were reviewed and the number and types of intermediate sanctions issued by states in 1999 were reported, along with barriers to the use of such sanctions. Using five selected enforcement measures to create a summary score, states were classified by quartiles based on the stringency of their nursing facility enforcement activities. Controlling for the number of complaints as a proxy for quality, the predictors of a summary of state enforcement actions were: percentage of population at age eighty-five and above. Democratic governors, higher percentages of chain facilities, and lower facility occupancy rates. Regional differences in enforcement patterns also were shown. Many federal policies and resource constraints were identitied as barriers to effective regulation. The findings identified nursing facility survey and enforcement issues that need to be addressed by policy makers.
    Full-text · Article · Feb 2004 · Journal of Health Politics Policy and Law
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    • "First, the relationship between reimbursement levels and quality of care is not simple, and it is not clear that higher reimbursement rates will improve quality of care. Although research in this area is limited and rather old, some studies have found that higher reimbursement is associated with more staffing, but failed to find a significant relationship to other measures of quality (Cohen & Spector, 1996; Nyman, 1988). Second, higher Medicare and Medicaid reimbursement levels obviously add to public costs. "
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    ABSTRACT: Despite substantial regulatory oversight, quality of care in nursing homes remains problematic. This article assesses strategies for improving quality of care in these facilities. This article reviews the research literature on eight strategies: strengthening the regulatory process, improving information systems for quality monitoring, strengthening the caregiving workforce, providing consumers with more information, strengthening consumer advocacy, increasing Medicare and Medicaid reimbursement, developing and implementing practice guidelines, and changing the culture of nursing facilities. Although individual approaches vary, several themes emerge. First, several strategies require substantially more resources and will increase costs. Second, the research literature does not provide much guidance as to the effectiveness of these options. Third, several strategies assume a degree of data sophistication on the part of nursing homes that may not exist. Fourth, regulation is likely to continue to be the main strategy of quality assurance. Finally, the political saliency of nursing home quality issues is uneven. Quality of care in nursing homes is a major issue for which there is no simple solution.
    Full-text · Article · May 2003 · The Gerontologist
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