Socioeconomic and Geographic Disparities in Accessing Nursing Homes With High Star Ratings.

OBJECTIVES: The Centers for Medicare & Medicaid Services Nursing Home Compare (NHC) serves as the most comprehensive repository of Medicaid- and/or Medicare-certified nursing homes providing services to approximately 1.4 million US residents. A gap in the literature exists in understanding on the national level whether residents from socioeconomically disadvantaged counties experience disparities in the access to nursing homes with higher NHC star ratings. The study aimed to examine nursing home quality variations with regard to county-level socioeconomic, geographic, and metropolitan status, while adjusting for nursing home facility-level characteristics. DESIGN: Cross-sectional ecological study. SETTING AND PARTICIPANTS: 15,090 Medicaid/Medicare-certified nursing homes with nonmissing star ratings. MEASURES: Study outcomes were NHC overall, health inspection survey, nurse staffing, and quality measure star ratings. County-level measures included SES index, geographic regions, and metropolitan status. Facility-level characteristics included ownership, chain affiliation, type and length of Medicaid/Medicare certification, hospital affiliation, continuing care retirement community status, number of certified beds, and occupancy. RESULTS: Counties with average adjusted overall, nurse staffing, and quality measure star ratings below 3 stars appeared to be clustered in the South. Nursing homes located in counties with lower SES were associated with lower overall star ratings [adjusted mean stars: 3.66 to 3.84, 95% confidence interval (CI): (3.54, 3.79) to (3.73, 3.95)]. A similar pattern was observed in staffing [adjusted mean stars: 3.75 to 4.23, 95% CI: (3.54, 3.97) to (4.10, 4.35)] and quality ratings [adjusted mean stars: 3.29 to 3.52, 95% CI: (3.12, 3.47) to (3.35, 3.69)]. CONCLUSIONS: Residents in socioeconomically disadvantaged counties experience disparities in accessing nursing homes with higher star ratings. These areas may lack sufficient resources to adequately staff the facility and deliver care that meets industry quality standards. These issues are likely to persist and possibly even worsen for the lower- and middle-class geriatric population given the current uncertainty around healthcare reform.

Supporting Transformation through Delivery System Reform Incentive Payment Programs: Lessons from New York State.

The New York Delivery System Reform Incentive Payment (DSRIP) waiver was viewed as a prototype for Medicaid and safety net redesign waivers in the Affordable Care Act (ACA) era. After the insurance expansions of the ACA were implemented, it was apparent that accountability, value, and quality improvement would be priorities in future waivers in many states. Despite New York's distinct provider relationships, previous coverage expansions, and local and state politics, it is important to understand the key characteristics of the waiver so that other states can learn how to better incorporate value-based arrangements into future waivers or attempts to limit spending under proposed Medicaid per-capita caps or block grants. In this article, we examine the New York DSRIP waiver by drawing on its design, early experiences, and evolution to inform recommendations for the future renewal, implementation, and expansion of redesigned or transformational Medicaid waivers.