United States' Nursing Home Finances: Spending, Profitability, and Capital Structure.

Little is known about nursing home (NH) financial status in the United States even though most NH care is publicly funded. To address this gap, this descriptive study used 2019 Medicare cost reports to examine NH revenues, expenditures, net income, related-party expenses, expense categories, and capital structure. After a cleaning process for all free-standing NHs, a study population of 11,752 NHs was examined. NHs had total net revenues of US$126 billion and a profit of US$730 million (0.58%) in 2019. When US$6.4 billion in disallowed costs and US$3.9 billion in non-cash depreciation expenses were excluded, the profit margin was 8.84 percent. About 77 percent of NHs reported US$11 billion in payments to related-party organizations (9.54% of net revenues). Overall spending for direct care was 66 percent of net revenues, including 27 percent on nursing, in contrast to 34 percent spent on administration, capital, other, and profits. Finally, NHs had long-term debts that outweighed their total available financing. The study shows the value of analyzing cost reports. It indicates the need to ensure greater accuracy and completeness of cost reports, financial transparency, and accountability for government funding, with implications for policy changes to improve rate setting and spending limits.

Examining California nursing home profitability and related factors before and during the COVID-19 pandemic.

BACKGROUND: The financial status of nursing homes (NHs) is a policy concern, especially during a pandemic, because of the higher costs associated with infection prevention and resident care. METHODS: This exploratory study was designed to assess the impact of the federal and state COVID-19 funding support on California NHs profitability during 2020, the first year of the pandemic, compared with 2019, the last pre-pandemic year. The study examined the association of Medicare and Medicaid days, related-party transactions, as well as other facility characteristics on net income profit margins, using cross-sectional regression analysis of data from state NH cost reports and federal NH provider data for 2019 and 2020. RESULTS: California skilled NHs had average reported net income profit margins of 2.26% in 2019 and 7.0% in 2020 with wide variations (from a loss of about 48% to a gain of 74% in 2020). Regression analysis found that the number of beds, occupancy rates, high-quality rating scores, and medium and high proportions of Medicare resident days were positively associated with net income margins in 2019 and 2020. Chains in 2020 (but not 2019), related-party expenditures in 2019 and 2020, median Medicaid days (in 2019), high Medicaid resident days (71%-73% or higher) in 2019 and 2020, and medium and high managed care resident days were negatively associated with net income margins in both years. CONCLUSIONS: Although NH admissions and occupancy rates declined substantially between 2019 and 2020, some (but not all) California NHs had a substantial increase in profit margins in 2020 over 2019. More studies of nursing home financial patterns and profitability are needed to examine trends over time and variations across states.

Variation in the use of federal and state civil money penalties for nursing homes.

PURPOSE: The study examined factors associated with state variations in the use of federal and state civil money penalties (CMPs) for nursing homes. DESIGN AND METHODS: We collected federal and state CMP data from state survey and certification agencies for 2004. We also used federal CMP data from the federal enforcement action database for 2000-2004. Logistic regressions examined factors related to whether states issued CMPs, and ordinary least squares regressions examined the number and amount of federal CMPs (2000-2004) and the total federal and state CMPs (2004). RESULTS: In 2004, 3,159 federal and state CMPs were collected, for a total of $21.6 million, but CMPs were given for only 2% of deficiencies issued. The number of federal CMPs collected was positively related to average facility occupancy rates, the percentage of facilities with deficiencies for harm or jeopardy, and state survey and certification budgets but was negatively related to the number of facility complaints per nursing home bed. Total federal and state CMPs were positively related to state senators' liberal voting records, having a democratic governor, and the percentage of Medicaid nursing home residents and were negatively related to the population aged 65 and older, complaints per nursing home bed, percentage of hospital-based facilities, and home- and community-based expenditures. IMPLICATIONS: The Centers for Medicare & Medicaid Services should address the state variations in CMPs by providing states and federal regional offices with guidelines on the use of federal CMPs. It should also improve accuracy and completeness by including federal and state CMPs in its enforcement database.

The collection and use of funds from civil money penalties and fines from nursing homes.

PURPOSE: This study examined federal and state civil money penalties and fines collected from nursing homes and how states used the collected funds. DESIGN AND METHODS: We used a telephone survey of state officials, Freedom of Information Act requests, state Web site searches, and stakeholder interviews to describe the funds collected, the availability and the use of funds, public information about penalties and fines, and the state allocation process and policies. RESULTS: In 2004, 43 states collected a total of $21 million from more than 3,000 federal and state penalties and fines. Forty-two states had $60.5 million in fund accounts from penalties and fines available in 2005, and 32 states spent $28 million on a wide range of projects. Fifteen states spent $17.9 million on survey and certification activities, 19 states spent $5.6 million on provider projects, 6 states spent $1.3 million on advocacy projects, and 12 states spent $2.7 million for other projects. Most states did not provide information to the public about issuing penalties and fines, have formal procedures to inform stakeholders and allocate funds, or involve stakeholder groups in the decision-making process. IMPLICATIONS: Funds from federal and state penalties and fines vary widely across states. These funds are a resource for improving the quality of nursing home care that needs more attention from policy makers and stakeholder groups.