John R. Bowblis's research while affiliated with Harvard Medical School and other places
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Publications (138)
Recently, the Centers for Medicare & Medicaid Services (CMS) introduced staffing measures related to staffing variability and turnover in the Nursing Home (NH) Care Compare Five-Star Quality Rating System. While the consensus within the literature is that reduced variability and turnover are associated with higher NH quality of care and life, no ex...
Background:
Long-stay nursing home (NH) residents with Alzheimer disease and related dementias (ADRD) are at high risk of hospital transfers. Machine learning might improve risk-adjustment methods for NHs.
Objectives:
The objective of this study was to develop and compare NH risk-adjusted rates of hospitalizations and emergency department (ED) v...
Background and objectives:
Uncovering subgroups of nursing home (NH) residents sharing similar preference patterns is useful for developing systematic approaches to person-centered care. This study aimed to (1) identify preference patterns among long-stay residents, and (2) examine the associations of preference patterns with resident and facility...
Background: The Preferences for Everyday Living Inventory (PELI) is a person-centered care (PCC) tool that uncovers/honors older adults' important preferences. PCC implementation in nursing homes (NHs) often requires additional resources, such as staff time. We explored if PELI implementation is associated with NH staffing levels. Methods: Using NH...
Objectives:
To examine whether facility-reported staff shortages and total staff levels were independently associated with changes in nursing home (NH) outcomes in 2020.
Design:
Longitudinal cohort study.
Setting and participants:
A total of 8466 NHs with staffing and outcome data.
Methods:
This study used NH COVID-19 Public File (2020), Nur...
Objectives:
Ensuring quality of life (QoL) is an important goal of person-centered nursing home care. The provision of person-centered care relies on information captured in the Minimum Data Set 3.0 (MDS). It is unclear to what extent MDS items or QoL-related facility deficiency citations correlate with validated measures of nursing home residents...
Background and Objectives
Person-centered care practices are essential to providing high-quality care for nursing home (NH) residents. A key component of implementing person-centered care is the assessment and fulfillment of residents’ preferences. However, few NHs consistently assess and implement residents’ preferences into care. From 2015 to 201...
To provide context for evaluating proposed nursing home staff regulations, we examined the proportion of facility revenues spent on nursing staff, as well as nursing staff levels in hours worked and paid per resident day, in 2019. Nationally, the median proportion of revenues spent on nursing staff was 33.9 percent, and median nursing staff levels...
Importance:
The Centers for Medicare & Medicaid Services' Five-Star Quality Rating System combines results from nursing home recertification surveys and complaint investigations into a single indicator for health inspections. This combination may mask complaint investigation results.
Objective:
To construct and compare star ratings specific to r...
The number of adults with serious mental illness (SMI) who receive care in nursing homes (NHs) continues to rise. The Preadmission Screening and Resident Review (PASRR) program requires screening for SMI prior to NH placement, in order to avoid inappropriate admission and unnecessary institutional care. We interviewed staff responsible for the proc...
In 2014, 29 of 88 Ohio counties implemented MyCare, which integrated Medicare and Medicaid for dually eligible Ohioans. Using an intent-to-treat, difference-in-difference framework we examined medical expenditures and utilization associated with the implementation of MyCare. Specifically, we compared dually eligible Ohioans in MyCare counties to th...
This study examined the relationship between nursing home (NH) quality using consumer complaints and certified nursing assistant (CNA) annual retention rates among Ohio freestanding NHs with complete data (n = 691). Core variables came from the 2017 Ohio Biennial Survey of Long-term Care Facilities and CMS Automated Survey Processing Environment Co...
Multiple studies have shown an increasing prevalence of adults with serious mental illness (SMI) in nursing homes. As adults with SMI age, the reality of care needs that span physical, medical, and psychosocial services necessitates further consideration of the role of comprehensive, ancillary mental health services in nursing homes (NH). Yet, litt...
The Ohio Department of Medicaid added the PELI as one of five quality incentive points used to determine Medicaid per diem reimbursement rates with the goal of improving person-centered care among Ohio’s nursing homes (NHs). The purpose of this study was to explore if the degree of PELI implementation had an impact on quality as defined by deficien...
Racial/ethnic composition of nursing home (NH) plays a particularly important role in NH quality. A key methodological issue is defining when an NH serves a low versus high proportion of racially/ethnically diverse residents. Using the Minimum Data Set from 2015 merged with Certification and Survey Provider Enhanced Reports, we calculated the racia...
Objectives
The purpose of this study is to expand on previous work testing the relationship between person-centered care (PCC) and quality outcomes in the nursing home (NH) setting. We explore if the Preferences for Everyday Living Inventory (PELI) implementation is a predictor of NH quality, as defined by deficiencies.
Design
Secondary data analy...
Background and Objectives
This study examined the relationship between nursing home (NH) quality using consumer complaints and certified nursing assistant (CNA) annual retention rates among Ohio freestanding NHs (n = 691).
Research Design and Methods
Core variables came from the 2017 Ohio Biennial Survey of Long-term Care Facilities and CMS Automa...
Background
Nursing homes (NHs) are required to provide person-centered care, efforts often folded into broader culture change initiatives. Despite the known benefits of culture change, it is difficult to measure. This study aims to assess the criterion validity of the Preferences for Everyday Living Inventory (PELI) Implementation Indicator with ot...
The federal Preadmission Screening and Resident Review (PASRR) program was enacted in the 1980s amid concerns surrounding the quality of nursing home (NH) care. This program is meant to serve as a tool to assist with level of care determinations for NH applicants with serious mental illness (SMI) and was intended to limit the growth in the number o...
Background and Objectives
Abundant evidence documents racial/ethnic disparities in access, quality of care, and quality of life (QoL) among nursing home (NH) residents who are Black, Indigenous and people of color (BIPOC) compared to White residents. BIPOC residents are more likely to be admitted to lower quality NHs and to experience worse outcome...
Nursing homes (NH) and other institutional-based long-term care settings are not considered an appropriate place for the care of those with serious mental illness, absent other medical conditions or functional impairment that warrants skilled care. Despite policy and regulatory efforts intended to curb the unnecessary placement of people with serio...
Compared to the fee‐for‐service (FFS) model, the managed care delivery system has the potential to improve health care management, increase provider accountability, and support better monitoring of health care quality. However, managed care organizations may attempt to control costs by curbing utilization among Medicaid beneficiaries or reducing re...
Background and Objectives
Despite concerns about the adequacy of nursing home (NH) staffing, the federal agency responsible for NH certification and regulation has never adopted an explicit quantitative nursing staff standard. Harrington and colleagues (2020) have proposed a benchmark for this purpose based on the 1995/97 Staff Time Measurement (ST...
Background and Objectives: Nursing homes (NH) are serving a large number of residents with serious mental illness (SMI). We analyze the highest (“High-SMI”) quartile of NHs based on the proportion of residents with SMI and compare NHs on health deficiencies and the incidence of deficiencies given for resident abuse, neglect, and involuntary seclusi...
Quality of life (QoL) is important to nursing home (NH) residents, yet QoL is only publicly reported in a few states, in part because of concerns regarding measure stability. This study used QoL data from Minnesota, one of the few states that collects the measures, to test the stability of QoL over time. To do so, we assessed responses from two res...
The majority of nursing home (NH) residents have Alzheimer’s Disease or Related Dementias (ADRD). However, the association of ADRD prevalence and NH quality is unclear. The objective of the current study is to understand the association of NH characteristics, including the proportion of ADRD residents, with the prevalence of NH complaints as an ind...
The Omnibus Budget Reconciliation Act (OBRA) of 1987 included provisions for the Preadmission Screening and Resident Review (PASRR) program, which requires states to create and maintain systems to assess persons with serious mental illness (SMI) seeking NH care. The prevalence of SMI in NHs is increasing, and little is known about the effectiveness...
Objective
Quality of life (QoL) is a multidimensional construct that assesses the quality of lived experience in nursing homes (NHs). QoL is directly important to NH residents. However, QoL is only publicly reported in a few states, partly because of concerns regarding measure stability. To address these concerns, we tested the stability of Minneso...
Implemented through five health plans, Ohio’s MyCare demonstration began in 2014 and was designed to coordinate primary, acute care, behavioral health and long-term services in the major urban areas of the state. Individuals who are dually eligible for both Medicaid and Medicare and who reside in specified geographic regions must enroll into a mana...
Objectives
Nursing homes (NHs) in micropolitan areas are reported to have different facility and market factors than urban NHs, but how these factors contribute to differences in emergency department (ED) visits remains unknown. This study examined and quantified sources of micropolitan-urban differences in NH risk-adjusted rates of any ED visit, E...
Long-term services and supports (LTSS), including care received at home and in residential settings such as nursing homes, are highly racially segregated; Black, Indigenous, and persons of color (BIPOC) users have less access to quality care and report poorer quality of life compared to their White counterparts. Systemic racism lies at the root of...
Objective
Nursing homes (NHs) are serving an increasing proportion of residents with cognitive issues (e.g. dementia) and mental health conditions. This study aims to: 1) implement unsupervised machine learning to cluster NHs based on residents' dementia and mental health conditions; 2) examine NH staffing related to the clusters; and 3) investigat...
While research tends to find an association of nurse staffing with quality in nursing homes, few studies examine complaints as a quality measure or account for ancillary staff. This study used federal nursing home complaint data to examine how key explanatory variables including nursing and ancillary staffing were associated with numbers of complai...
Objectives
The objective of this study was to examine the relationship between high wages and empowerment practices on certified nursing assistant (CNA) retention, necessary for providing high-quality care for nursing home (NH) residents.
Methods
Measures of provider-level CNA empowerment and wages from the 2015 Ohio Biennial Survey were used to e...
Background and objectives:
Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing...
Objective:
To measure the impact of Medicaid managed long-term services and supports (MLTSS) on nursing home (NH) quality and rebalancing.
Data sources/study setting:
This study analyzes secondary data from annual NH recertification surveys and the minimum dataset (MDS) in three states that implemented MLTSS: Massachusetts (2001-2007), Kansas an...
Consumers play a key role in the U.S. nursing home (NH) oversight through a federally established complaint process. However, past variation by state in complaint numbers and rates raised questions about the uniformity of the process. We examined state variation in numbers of complaints at intake and substantiated complaints, percentages of NHs wit...
6585
Background: Functional impairments affect > 40% of hospitalized patients (pts) with advanced cancer. After hospital discharge, about 20% of pts received rehabilitation (rehab) in nursing homes (NHs) to maintain functional independence. There is evidence from broad pt cohorts that Medicare Prospective Payment (PP) financially incentivizes NHs t...
Background:
Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents.
Objectives:
To determine and quantify sources of rural-urban differences in NH risk-adjuste...
Low retention of certified nursing assistants (CNAs) and direct care workers (DCWs) continues to be an unresolved problem for nursing homes (NH) and assisted living (AL) settings. While numerous studies have examined predictors of CNA retention in NHs, little attention has been paid to differences between settings of long-term care. To inform pract...
Studies suggest that nursing homes (NHs) that predominantly serve residents with serious mental illness (SMI) are of worse quality due to poor resources (i.e., high Medicaid-paying census) and lower staffing. We used national Certification and Survey Provider Enhanced Reports (CASPER) data to examine the deficiencies issued to NHs from 37,800 recer...
Complaints provide important information to consumers about nursing homes (NHs). Complaints that are substantiated often lead to an investigation and potentially a deficiency citation. The purpose of this study is to understand the relationship between substantiated complaints and deficiency citations. Because a complaint may contain multiple alleg...
The Centers for Medicare and Medicaid Services (CMS) publishes a 5-star rating system for nursing homes (NH). Currently, the 5-star rating for health deficiencies weights deficiencies from annual recertification surveys and complaints equally. Complaint deficiencies may contain different information than survey deficiencies because complaint defici...
Nursing homes (NH) are inspected annually, however, residents and others can file complaints any time. Complaints are critical to NH oversight. Another important quality factor is staffing. Our objective was to examine the association of complaints and staffing levels in a 2017 sample of 14,194 freestanding NHs. We used federal data on NH complaint...
The Preferences for Everyday Living Inventory (PELI) was mandated as a pay for performance indicator by the Ohio Department of Medicaid in 2015. This study explored the impacts of PELI implementation on regulatory outcomes in 2017.
The level of PELI implementation from n=551 Ohio nursing home providers between 2015 and 2017 were linked with Centers...
With nursing homes being hit hard by the COVID-19 pandemic, it is important to know whether facilities that have any cases, or those with particularly high caseloads, are different from nursing homes that do not have any reported cases. Our analysis found that through mid-June, just under one-third of nursing homes in Ohio had at least one resident...
Objectives:
Hospitalizations are common among long-stay nursing home (NH) residents, but the role of rurality in hospitalization is understudied. This study examines the relationships between rurality, NH, and market characteristics and NH quarterly risk-adjusted hospitalization rates of long-stay residents over 10 quarters (2011 Q2-2013 Q3).
Des...
Background and objectives:
Low retention of direct care workers (DCWs), either certified nursing assistants in nursing homes (NH) or personal care assistants in assisted living (AL), continues to be an unresolved problem. While numerous studies have examined predictors of DCW retention in NHs, little attention has been paid to differences between...
Objective
To examine the impact of commercial dental insurer and provider concentration on dentist reimbursement.
Data Sources
We utilized provider data from the American Dental Association, reimbursement data from IBM Watson MarketScan® Commercial Research Databases, submitted billed charges from FAIR Health®, dental insurance market concentratio...
This study examines the racial/ethnic disparity among nursing home (NH) residents using a self-reported, validated measure of quality of life (QoL) among long-stay residents in Minnesota. Blinder–Oaxaca decomposition techniques determine which resident and facility factors are the potential sources of the racial/ethnic disparities in QoL. Black, In...
(300 words)
Objectives
During the COVID-19 pandemic, U.S. nursing homes (NHs) have been under pressure to maintain staff levels with limited access to personal protection equipment (PPE). This study examines the prevalence and factors associated with shortages of NH staff during COVID-19 pandemic.
Design
We obtained self-reported information on s...
Background and objectives:
Certified nursing assistant (CNA) turnover and retention are critical aspects of facilities' ability to provide cost-effective, high quality person-centered care. Previous studies and industry practice often treat turnover and retention as similar concepts, assuming that low turnover and high retention are synonymous. Th...
Objectives: To investigate trends in racial/ethnic differences in nursing home (NH) residents’ quality of life (QoL) and assess these patterns within and between facilities. Method: Data include resident-reported QoL surveys ( n = 60,093), the Minimum Data Set, and facility-level characteristics ( n = 376 facilities) for Minnesota. Hierarchical lin...
![Distribution of HHI (All primary care physician [PCP] practices, N =...](publication/342737998/figure/fig2/AS:11431281174420658@1689225901629/Distribution-of-HHI-All-primary-care-physician-PCP-practices-N-212-018_Q320.jpg)
In this paper, we explore the effects of primary care physician (PCP) practice competition on five distinct quality metrics directly tied to screening, follow‐up care, and prescribing behavior under Medicare Part B and D. Controlling for physician, practice, and area characteristics as well as zip code fixed effects, we find strong evidence that PC...
Objectives
Medicaid nursing home (NH) reimbursement rates and bed-hold policies have been shown to be associated with hospitalization of urban NH residents, but their relationships with emergency department (ED) visits, especially in rural NHs, remain unknown. This study explores the relationships of Medicaid NH policies with three NH quarterly ris...
Objectives
The Preferences Assessment Tool (PAT) in the Minimum Data Set (MDS) 3.0 assesses 16 resident preferences for daily routines and activities. Although integrating important preferences into care planning is essential to provide person-centered care in nursing homes (NHs), preferences rated as important but unmet or unimportant may not rece...
We examine the effect of commercial dental insurance concentration on the size of dental practices, the decision of dentists to own a practice, and the choice of dentists to work at a dental management service organization—a type of corporate group practice that has become more prevalent in the United States in recent years. Using 2013–2015 dentist...
Background and Objectives: Nursing homes (NHs) are serving greater proportions of residents with serious mental illness (SMI), and it is unclear whether this affects NH quality. We analyze the highest and lowest quartiles of NHs based on the proportion of residents with SMI and compare these NHs on facility characteristics, staffing, and quality st...
What services are available and where racial and ethnic minorities receive long-term services and supports (LTSS) have resulted in a lower quality of care and life for racial/ethnic minority users. These disparities are only likely to worsen during the COVID-19 pandemic, as the pandemic has disproportionately affected racial and ethnic minority com...
Background and Objectives
The proportion of racial/ethnic minority older adults in nursing homes (NHs) has increased dramatically and will surpass the proportion of white adults by 2030.Yet, little is known about minority groups’ experiences related to the quality of life (QOL). QOL is a person-centered measure, capturing multiple aspects of well-b...
Since the 2000s, private equity (PE) firms have been actively acquiring nursing homes (NH). This has sparked concerns that with stronger profit motive and aggressive use of debt financing, PE ownership may tradeoff quality for higher profits. To empirically address this policy concern, we construct a panel dataset of all for-profit NHs in Ohio from...
Background and objectives:
To examine whether nursing homes (NHs) provide better quality when unemployment rates rise (countercyclical) and explore mechanisms contributing to the relationship between quality and unemployment rates.
Research design and methods:
The study uses the data on privately owned, freestanding NHs in the continental United...
Since the mid-2000s, skilled nursing facilities (SNFs) face an increasing percentage of post-acute care patients enrolled in Medicare Advantage (MA), yet our understanding the of how this affects SNFs is limited. Managed care may provide better coordination and continuous care that enhances SNF quality, but MA plans can also negotiate lower payment...
Stabilizing certified nursing assistant (CNA) employment is necessary for maintaining care networks and providing high quality of care for nursing home (NH) residents. This study’s objective was to examine the relationship of high wages and empowerment practices on CNA retention. We used the 2015 Ohio Biennial Survey to construct a facility-level d...
The proportion of racial/ethnic minorities in nursing homes (NHs) has increased steadily in recent years. This study longitudinally examines minority NH residents’ quality of life (QoL); a key measure of overall well-being. We used unique data from Minnesota annual QoL interviews (2011-2015), merged with resident and facility characteristics to mod...
Background: Social service staff may play a key role in helping post-acute care patients in skilled nursing facilities return home, yet few studies quantify how social service staff contribute to better patient outcomes. Method: A quasi-experimental statistical approach, regression discontinuity, was used among newly-admitted, Medicare post-acute c...
Antipsychotics (APMs) are commonly used off-label to control behavioral symptoms of dementia in nursing home (NH) residents despite FDA warnings. As part of the Centers for Medicare and Medicaid Services’ (CMS) partnership to reduce the use of APMs in long-stay NH residents with dementia, CMS began publicly reporting an APM quality measure on the N...
The proportion of nursing home (NH) residents that have serious mental illness (SMI) has increased over the least two decades. Residents with SMI tend be younger and have different medical needs than traditional residents. To better understand this population, our study examined the facility, staffing, and resident characteristics of NHs that were...
From its name to the type and setting of care provided, the world of long-term services and supports has changed dramatically in the last two decades. Using 26 years of longitudinal data from the state of Ohio this presentation describes how the long-term services system is different from the one that existed in the early 1990’s. Data come from 13...
Background:
Long-stay nursing home (NH) residents are at high risk of having emergency department (ED) visits, but current knowledge regarding risk-adjusted ED rates is limited.
Objectives:
To construct and validate 3 quarterly risk-adjusted rates of long-stay residents' ED use: any ED visit, ED visits without hospitalization or observation stay...
Objectives:
Each year states are required to survey nursing homes (NHs), including issuing deficiency citations when regulatory standards are not met. These deficiency citations can have substantial consequences for NHs. Because it is imperative that the survey process is conducted consistently across facilities, this study aims to determine wheth...
Objectives:
An increasing number of post-acute care patients are admitted to skilled nursing facilities (SNFs) with behavioral symptoms such as wandering and rejecting care, which can interfere with care and place a patient at risk of social isolation or injury. This study examines whether increasing the qualifications of social service staff thro...
Occupational licensing has grown dramatically in recent years, with more than 25% of the US workforce having a license as of 2008, up from 5% in 1950. Has licensing improved quality or is it simply rent-seeking behavior by incumbent workers? To estimate the impact of increased licensure of social workers in skilled nursing facilities (SNFs) on serv...
This study examines how the professionalization of social service staff with qualified social workers (QSWs) is related to the psychosocial functioning (e.g., depressive symptoms and cognitive functioning) of short-term, post-acute care nursing home residents. Utilizing the Minimum Data Set and facility-level data from the Certification and Survey...
Nursing facility (NF) resident case-mix is changing nationally to include more minority residents. Minority residents are younger, have higher rates of mental illness, and better function than White residents. Racial segregation in NFs also means that minorities tend to live in different NFs from White residents. We investigated the interplay betwe...
Purpose: Family satisfaction, while recognized as important, is frequently missing from validated measures of long-term care quality. This paper uses validated measures from two states and identifies organizational and structural factors associated with higher family satisfaction with nursing home care. Methods: Data sources are family satisfaction...
Understanding the predictors of direct-care worker turnover rates in nursing homes has received considerable attention. Yet, much less is known about retention rates for direct care workers. Turnover and retention are critical aspects of facilities’ ability to provide cost-effective, high quality, person-centered care. Facilities operate in an envi...
CMS initiated its “National Partnership” (March 2012), implemented public reporting an antipsychotic (APM) quality measure (July 2012), and revised nursing home (NH) guidelines to reduce unnecessary APM (May 2013). We determine NH response to these CMS strategies by examining change in APM, physical restraint and psychoactive polypharmacy rates and...
Owner-managers are administrators that hold significant equity interests in the facility they operate. We examine how the presence of owner-managers is related to the workforce outcomes of retention and wages in nursing homes (NHs). Using a sample of for-profit NHs in Ohio from 2005 to 2015, multivariate regression analysis compares workforce outco...
Family satisfaction, while recognized as important, is frequently missing from validated measures of long-term care quality. This is the first study to compare family satisfaction across two states using validated measures and to compare the organizational and structural factors associated with higher family satisfaction with nursing home care. Dat...
The literature on provider ownership has primarily focused broadly on for‐profits compared with nonprofits and chains versus nonchains. However, the understanding of more nuanced ownership arrangements within individual facilities is limited. Utilizing the principal–agent and managerial control frameworks, we study the role of managerial ownership...
Health care providers face fixed reimbursement rates from government sources and need to carefully adjust staffing to achieve the highest quality within a given cost structure. With data from the Certification and Survey Provider Enhanced Reports (1999-2015), this study holistically examined how staffing levels affect two publicly reported measures...
Within the United States, a growing debate about special tax treatment and community benefits provided by not-for-profits (NFPs) has been occurring. While the nondistribution constraint of NFPs is often thought to incentivize higher quality and more charitable care, NFPs may also be used by contractors for personal gain. This study explores whether...
We estimate the causal effect of nurse turnover on mortality and the quality of nursing home care with a fixed-effect instrumental variable estimation that uses the unemployment rate as an instrument for nursing turnover. We find that ignoring endogeneity leads to a systematic underestimation of the effect of nursing turnover on mortality and quali...
The Centers for Medicare and Medicaid Services initiated three strategies (in March and July 2012 and in May 2013) to reduce the use of unnecessary antipsychotic medications in nursing homes, especially their widespread use to control behavioral symptoms of dementia. We examined 86,163 state recertification surveys conducted at 15,055 facilities in...
Purpose of the study:
Ownership of nursing homes (NHs) has primarily focused broadly on differences between for-profit (FP), nonprofit (NFP), and government-operated facilities. Yet, among FPs, the understanding of detailed ownership structures at individual NHs is rather limited. Particularly, NH administrators may hold significant equity interes...
The regulation of nursing homes in the U.S. often includes mandates that require a minimum nurse staffing level. In this paper, we exploit new minimum nurse staffing regulations by the states of New Mexico and Vermont that were implemented in the early 2000s to determine how nursing homes responded in terms of staffing, quality, and the decision to...
Purpose of the study:
Social service departments in nursing homes (NHs) are staffed by qualified social workers (QSWs) and paraprofessionals. Due to greater workforce challenges in rural areas, this article aims to describe the staffing levels and composition of these departments by rurality.
Design and methods:
Certification and Survey Provider...
Although nurse staffing has been extensively studied within nursing homes (NHs), social services has received less attention. The study describes how social service departments are organized in NHs and examines the structural characteristics of NHs and other macro-focused contextual factors that explain differences in social service staffing patter...
This article explores the differentiated effects of health insurer market concentration on net compensation of employees across distinct firm sizes. Consistent with the existing literature evaluating insurer market concentration and the theory of compensating differentials, we find evidence of higher premiums and reduced net compensation for employ...
Objective:
In 2006, Ohio changed its Medicaid reimbursement methodology for nursing homes (NHs) to promote more efficient staffing levels. This study examines the impacts of this policy change on quality.
Research design and subjects:
Ohio NHs were categorized based on their anticipated change in reimbursement under a new reimbursement system in...