David Barton Smith’s research while affiliated with Drexel University and other places
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This chapter will review several important themes concerning long term care availability, quality of care, and market changes, with special reference to frail aging Hispanics. This review will be based on work performed by Brown University researchers under the aegis of an NIA Program Project, “Shaping Long Term Care in America” (1PO1 AG027296-01A1). Our review will include a brief historical overview of patterns in nursing home use, more recent analyses on racial/ethnic disparities in care access, and current trends in the composition of nursing home residents. We will also examine differences in nursing home performance for homes with different proportions of Hispanic and black residents. Finally, we will review results from a recent study of nursing home closure, which clearly shows differences in closure rates correlated with larger proportions of Hispanic and black residents. Implications of these trends will be discussed for the future of long term care availability and the needs of frail Hispanic elderly.
During the past century, long-term care in the United States has evolved through five cycles of development, each lasting approximately twenty years. Each, focusing on distinct concerns, produced unintended consequences. Each also added a layer to an accumulation of contradictory approaches--a patchwork system now pushed to the breaking point by increasing needs and financial pressures. Future policies must achieve a better synthesis of approaches inherited from the past, while addressing their unintended consequences. Foremost must be assuring access to essential care, delivery of high-quality services in an increasingly deinstitutionalized system, and a reduction in social and economic disparities.
The current long term care system in the United States, similar to an archeological site, is composed of past layers now jerry-rigged together and on the verge of collapse. The bulk of the nation's nursing home bed stock is reaching the end of its useful life and the boom in private assisted living that began in the last decade now face a wave of bankruptcies in the current financial crisis. This paper explores the lessons from the history of past efforts to design a long term care system and the opportunities they provide for restructuring. The U.S. long term care system was constructed in five phases, in roughly twenty year intervals. Efforts in each of these phases focused on often contradictory organizing principles: (1) indoor welfare relief (1910-1930), (2) outdoor income security (1930-1950), (3) indoor health care support (1950-1970), (4) regulatory control (1970-1990) and (5) market control (1990-2010). The resulting long term care system combines many of the contradictory organizing principles and structures of all five phases, frustrating families, the frail elderly and their providers. The past lessons suggest a restructuring that would synthesize the best of each of these previous periods: (1) support for the family informal care system, (2) an emphasis on outdoor relief through income supports, (3) financing that supports a one class system of care within a fully integrated health system, (4) adequate regulatory oversight and (5) responsiveness to the consumers permitting them, as much as possible, to age in place in their own homes.
The real estate and investment banking driven financial crisis and resulting federal bailout was foreshadowed by similar death spirals of so-called market driven health care reforms. Five historical case studies involving: (1) market driven solutions to organ procurement, (2) publicly traded Independent Practice Associations (IPAs), (3) concierge medicine, (4) physician-owned specialty hospitals and (5) publicly traded assisted living corporations will be presented. They failed to live up to their promotional hype, not just in terms of the cream skimming/social justice critique often made of such entrepreneurial profit driven ventures but in terms of profitability. The combination of a public backlash and the unanticipated practical complexities of organizing and financing medical services doomed most of the ventures under each of these headings to failure. Publicly financed regional organ procurements services and donor-ship rather private organization and sale prevailed and are now widely accepted. A backlash against IPAs has eliminated most of the financial incentives providers had to deny services and has blurred any differences between them and traditional insurance products. Many concierge practices were victimized by the inevitable adverse risk selections that attended their higher priced quasi insurance product. Most physician-owned specialty hospitals have failed over concerns of surgeons over the safety and potential malpractice risks and the failure to attract sufficient volume. The largest publicly traded assisted living corporations now teeter on the edge of bankruptcy. The market has spoken and more universal publicly controlled models for the organization and financing of care are indeed the wave of the future.
In 1996 Pennsylvania became one of what are now 14 states to terminate CON requirements. The Philadelphia area healthcare market was dramatically reshaped as the financial decisions of hospitals were now unrestrained by the CON barrier. The number of hospitals doing coronary artery by pass graphs increased from 11 to 21 with only five currently doing more than the 450 procedures per year that CONs previously required as for quality assurance and cost effectiveness purposes. Heart transplant programs have expanded from three to seven with only two currently doing more than the ten per year now required by the Medicare program as a condition of participation. During this same period seven hospitals, most serving predominantly low income communities and most relying on the cross subsidies that a CON franchises provided have closed. Six other hospitals have closed their obstetrical services contributing to a crisis in access for low income families. Two new hospitals in affluent suburban areas that duplicate existing services are in the process of being planned and two for profit exclusively private pay partially physician owned specialty hospitals have opened. On equity, efficiency and effectiveness grounds, the free market that critics of CON advocate, has poorly served the residents of the Philadelphia metropolitan area. The damage in terms of poorer quality, higher cost care has been borne by affluent suburban and indigent inner city residents alike. In the light of the current economic crisis, a variety of alternatives are explored.
The study compared the nation as a whole and fourteen regions selected for participation in the RWJF Aligning Forces for Quality initiative (Cincinnati, Cleveland, Detroit, Humboldt County, Kansas City, Maine, Memphis, Minnesota, Seattle, Willamette Valley, Western Michigan, Western New York, Wisconsin, and York County, PA). We compiled regional statistical profiles from a systematic review of all major public data sources (AHRQ, CMS, AHA, AHRQ, NCHS, HRSA, JCAHO and US Census Bureau). The CMS MEDPAR was used to develop racial comparisons of hospital outcomes (medical and surgical death rates, incidents rates of safety problems).We used the CMS/JCHO HospitalCompare consensus process indicators (AMI, Heart Failure, Pneumonia, and Surgical Infection Prevention) and computed structural disparity indicators by region weighting a summary process indicator for each hospital in a region by the proportion of white and black discharges in the region as identified in the MEDPAR. The principal findings were: (1) While there were substantial variations between AF4Q regions on demographic, disease and health care measures, on the average these areas had somewhat lower poverty rates, more health care resources, lower age adjusted death rates and less racial disparities in death rates than the nation as a whole. (2) The degree of racial segregation in terms of hospital use by blacks and whites varied but was relatively low. The Overall Index of Dissimilarity was .333, and the most segregated regions were Wisconsin (.637), Minnesota (.543) and Detroit (.540). (3) There was no difference in the HospitalCompare process summary measure adjusted for where blacks and whites received care in the 14 regions (black/white ratio .99). (4) While black medical admission death rates were lower than whites (.70), surgical death rates were higher (1.21) as were incidents of safety problems (1.39).
We conclude that: (1) The moderate degree of segregation among hospital providers and the lack of variation between hospitals on HospitalCompare indicators contributed to the lack of regional racial disparity on these measures of hospital quality. (2) While there were significant differences between blacks and whites on the MEDPAR indicators, the low incidence rates make it impossible to compare the performance of individual hospitals and the complex factors contributing to these differences don't lend themselves easily to corrective action. (3) Hospitals are in the early stages of developing the internal capacity to analyze performance by race and ethnicity and the HospitalCompare process and MEDPAR outcome indicators have limited usefulness in comparing individual hospital performance.
While nursing homes were insulated from civil-rights enforcement at the time of the implementation of the Medicare program and lagged behind other parts of the health sector in providing comparable access to minorities, they are the only providers for which current reporting requirements make it possible to fully assess racial disparities in use and quality of care. We find that African Americans' use of nursing homes in 2000 in the United States was 14 percent higher than Caucasians' use. The largest relative African American use of nursing homes in 2000 took place in the South and West. Average nursing-home case-mix acuity for African Americans and Caucasians were essentially identical, suggesting that shifts in payment incentives have eliminated the selective admission of easy-care private-pay (predominantly Caucasian) patients and helped fuel the growth of private pay home care and assisted living for this segment of the population. While these shifts in incentives helped increase the use of nursing homes by African Americans, a high degree of segregation and disparity in the quality of the nursing homes used by African Americans persists. Parity in use is an illusive benchmark for measuring progress in assuring equity in treatment.
We describe the racial segregation in U.S. nursing homes and its relationship to racial disparities in the quality of care. Nursing homes remain relatively segregated, roughly mirroring the residential segregation within metropolitan areas. As a result, blacks are much more likely than whites to be located in nursing homes that have serious deficiencies, lower staffing ratios, and greater financial vulnerability. Changing health care providers' behavior will not be sufficient to eliminate disparities in medical treatment in nursing homes. Persistent segregation among homes poses a substantial barrier to progress.
... [13,14] Demographic factors also have a significant impact, as population distribution and ethnic differences pose challenges to balanced development. [15][16][17][18] The care needs and preferences of older persons have both active and passive impacts on the distribution of ECIs. [19][20][21][22] These factors require further examination regarding their influence on Chinese development. ...
... Despite the identification of several adverse occupational and organizational conditions at nursing homes (Almost and Laschinger, 2002, Gruss et al., 2004), research is needed to address potential racial/ethnic differences in their distribution. Although studies have examined racial/ethnic disparities on indicators of service quality for residents at nursing homes (Smith et al., 2007 ), there is less emphasis on racial/ethnic or other sociodemographic differences in the distribution of psychosocial occupational hazards among workers. Examining working conditions at nursing homes is important because regulatory and financial policies, as well as organizational and psychosocial characteristics in these workplaces, may affect the health of direct-care workers and the quality care for the elderly. ...
... Legal segregation in healthcare continued through the mid-1960s until Congress passed the Civil Rights Act of 1964. 51 Shortly thereafter, the Medicaid program forced many hospitals to adhere to the Civil Rights Act and to hire doctors who would treat patients of all races, although unequally. 51 Federal funding supported coerced sterilization, and some African American women were threatened with denial of medical care or termination of welfare benefits if they did not undergo sterilization. ...
... However, we contend that the long-term care system in the United States is misaligned with the needs of the population, a problem that is rooted in their foundations in 19 th century "poorhouses" that emerged as a band-aid solution for unsheltered, marginalized populations. Despite the elimination of poorhouses in the 20 th century following the expansion of social welfare, the emergence of nursing homes in their place has continued their legacy of congregate, depersonalized care, albeit with a greater emphasis on medicalized services (5). ...
... The first evidence according to [25] is that for newly eligible individuals there is an increase in any long-term care use suggesting that before the expansion, there were a high amount of long-term care unmet needs. In general, the literature suggests that historically racial segregation in health care services remains high [26,27] including nursing homes [28]. The findings of [28], obtained by using the Dissimilarity Index between Black and White residents, not only suggest that racial segregation remains high in nursing homes within metropolitan areas but more importantly argue that the quality of care that racial minorities receive is lower. ...
... В международных оценках для этих целей используется валовой внутренний продукт (ВВП) в расчете на душу населения, в региональных исследованиях, соответственно, валовой региональный продукт (ВРП) или среднедушевые денежные доходы [6][7][8][9]. Например, в работах [10,11] показано, что уровень заболеваемости и смертности от ССЗ у населения с более низким уровнем дохода существенно выше. В 1975 г. ...
... These swings tend to be driven by repeated reactive supply and demand alignment interventions as economic and social circumstances change. 13 More critical appraisals of workforce planning suggest a moving away from a quantification of the problem's size and narrow planning aims, 10 towards an appreciation of the interactions and inter-relationships between the health system and its workforce. 11 These critical views have prompted reviews of planning systems, which suggest more robust methodologies for projecting health workforce requirements and linking these to productivity and the system's non-human resources. ...
... 32 Such efforts had a sweeping impact on the nation's health care landscape, and some were optimistic that the progressive social policy reforms to expand access would reduce the nation's stark health disparities. 33 The stakes were particularly high for Black women as the government's elimination of midwives left Black women with fewer options for having a safe birth at home. Compared to the 27 percent of Black babies delivered in hospitals in 1940, by 1960 85 percent of Black births took place in a hospital. ...
... As we learned from the Civil Rights Movement, cultural norms and shifts in interpersonal and social relations often follow policy change, not vice versa. 34 In addition to efforts to create new policies that promote equity, justice, and well-being, investments in efforts to change policy are needed to eliminate policies, practices, programs, and institutions that create and perpetuate inequity in opportunities and outcomes or that do not positively benefit or serve the populations of interest. 35 Although policy efforts to achieve health equity have tended to focus on the need for new policies, focus is also needed on de-implementing or eliminating policies that are ineffective or harmful (eg, the use of race in measuring kidney function, implicit bias training without other policy or institutional change). 1 Policies that are ineffective and harmful waste resources and often obscure, undermine, or underfund efforts that are promising or actually effective. ...
... The explanation for why these disparities continue to exist is often no more comforting. The evidence suggests that racial differences in health care quality are not the result of isolated behaviors of incompetent or bigoted individuals but are rooted in institutional inequities that are entrenched in the health care system (Smith, 2006) and racism (Griffith, Childs, Eng, & Jeffries, 2007;Griffith, Mason, et al., 2007). This compelling evidence logically provokes the question, "How do we address and eliminate health care disparities?" ...
