How do dental practices respond to changes in scope of practice regulations?

Regulations that restrict the tasks that credentialed workers are allowed to perform may affect a firm's input choices, output, and which part of the market the firm serves. Using dental practice survey data from 1989 to 2014 and a stacked difference-in-differences design, this paper examines the effects of state-level scope of practice regulations on the behavior of dental practices. Results suggest that scope of practice deregulation in regards to dental hygienists' ability to administer nitrous oxide or local anesthesia is associated with fewer dentist visits per week in the short-term, lower patient wait times, and an increased likelihood of treating lower revenue generating publicly insured patients. There is weak evidence that scope of practice deregulation alters a practice's labor inputs.

Can Implementing Person-Centered Care Tools Reduce Complaints? Evidence from the Implementation of PELI in Ohio Nursing Homes.

Nursing homes receive complaints when actual care provided to residents misaligns with desired care, suggesting that person-centered care (PCC) and honoring resident preferences in care delivery may help prevent complaints from arising. We explore whether nursing home implementation of a PCC tool, the Preferences for Everyday Living Inventory (PELI), is related to measures of complaints. Publicly available data on Ohio nursing homes was used to examine 1,339 nursing home-year observations. Regression techniques were used to evaluate the relationship between the extent of PELI implementation and four complaint outcomes: any complaint, number of complaints, any substantiated complaint, and number of substantiated complaints. Nursing homes with complete PELI implementation were less likely to have any complaints by 4.7% points (P < .05) and any substantiated complaints by 11.5% points (P < .001) as compared to partial PELI implementers. When complete PELI implementers did have complaints, they were fewer than partial PELI implementers. Complete PELI implementers were not immune from receiving complaints; however, the complaints they did receive were fewer in number and less likely to be substantiated as compared to communities who only partially implemented a PCC tool.

Consumer Complaints in Nursing Homes: Analyzing Substantiated Single-Allegation Complaints to Deficiency Citations.

Complaints provide important information to consumers about nursing homes (NHs), but how substantiated complaints map onto deficiency citations is unknown. The purpose of this study is to understand the relationship between substantiated complaints and deficiency citations. Federally collected NH complaint and inspection records were obtained to identify all single allegation, substantiated complaints for NHs across the U.S. in 2017. Overall, the 369 complaint allegations in our sample resulted in a total of 585 deficiencies at the inspection stage; however, 35.2% of the allegations led to no deficiencies. Nearly two-thirds of the 369 substantiated single allegation complaints were categorized at the intake stage as quality of care (31.7%), resident abuse (17.3%), or resident neglect (14.1%). Further, 18% of the inspection deficiencies originated with complaint allegations that were prioritized as immediate jeopardy at intake, but of these, 71.4% were determined upon inspection to constitute "no actual harm with potential for more than minimal harm." These results provide evidence that complaints have the potential to provide unique valuable information on NH quality of care and draw regulatory attention to consumers' concerns. Future studies should include qualitative research concerning complaint processes by conducting interviews/surveys of complainants, NH staff/administrators, long-term care ombudsmen, and state officials.

Developing a Machine Learning Risk-adjustment Method for Hospitalizations and Emergency Department Visits of Nursing Home Residents With Dementia.

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) visits among long-stay residents with ADRD using Extreme Gradient Boosting (XGBoost) and logistic regression. RESEARCH DESIGN: Secondary analysis of national Medicare claims and NH assessment data in 2012 Q3. Data were equally split into the training and test sets. Both XGBoost and logistic regression predicted any hospitalization and ED visit using 58 predictors. NH-level risk-adjusted rates from XGBoost and logistic regression were constructed and compared. Multivariate regressions examined NH and market factors associated with rates of hospitalization and ED visits. SUBJECTS: Long-stay Medicare residents with ADRD (N=413,557) from 14,057 NHs. RESULTS: A total of 8.1% and 8.9% residents experienced any hospitalization and ED visit in a quarter, respectively. XGBoost slightly outperformed logistic regression in area under the curve (0.88 vs. 0.86 for hospitalization; 0.85 vs. 0.83 for ED visit). NH-level risk-adjusted rates from XGBoost were slightly lower than logistic regression (hospitalization=8.3% and 8.4%; ED=8.9% and 9.0%, respectively), but were highly correlated. Facility and market factors associated with the XGBoost and logistic regression-adjusted hospitalization and ED rates were similar. NHs serving more residents with ADRD and having a higher registered nurse-to-total nursing staff ratio had lower rates. CONCLUSIONS: XGBoost and logistic regression provide comparable estimates of risk-adjusted hospitalization and ED rates.

The effect on dental care utilization from transitioning pediatric Medicaid beneficiaries to managed care.

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 reimbursement for Medicaid services. It is an empirical question whether managed care increases or decreases utilization of services. Using detailed pediatric public insurance dental claims data from 2016 through 2018, we examined whether the transition from FFS to managed care affects rates of dental care utilization. Between 2016 and 2018, Indiana, Missouri and Nebraska transitioned pediatric Medicaid beneficiaries from public dental fee-for-service programs to private managed care entities. Using an extended two-way fixed-effects estimation framework, we found that dental managed care leads to a decline in dental care utilization, especially when compared to states that maintain FFS provision of Medicaid dental services.

Quality of Life Scores for Nursing Home Residents are Stable Over Time: Evidence from Minnesota.

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 resident cohorts who were surveyed in subsequent years (2012-2013 and 2014-2015). Stability was measured using intra-class correlation (ICC) obtained from hierarchical linear models. Overall QoL had ICCs of 0.604 and 0.614, respectively. Our findings show that person-reported QoL has adequate stability over a period of one year. Findings have implications for higher adoption of person-reported QoL measure in long-term care.

The Relationship Between Staffing Levels and Consumer Complaints in Nursing Homes.

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 complaints and the likelihood of receiving a complaint. Results support that nursing home staffing is associated with quality. While direct care staffing was associated with fewer complaints, larger effects were found for social service and activities staffing. Increasing ancillary staffing may be a cost-effective way to reduce complaints.

Serious Mental Illness in Nursing Homes: Stakeholder Perspectives on the Federal Preadmission Screening Program.

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 of NH residents with SMI. Despite this policy effort, the prevalence of SMI in NHs has continued to increase, and little is known about the mechanisms driving the heterogeneous and suboptimal administration of the PASRR program, absent routine evaluative efforts. We conducted 20 semi-structured interviews with state and national stakeholders to identify factors affecting PASRR program administration and NH care for residents with SMI. Stakeholders expressed concern regarding fragmentation, specifically lack of clarity in the value of assessments beyond a regulatory requirement. Additionally, they cited variable program administration as contributing to fragmented communication patterns and inconsistent training across jurisdictions. Given the number of people with SMI currently residing in NHs, policy and practice should take a person-centered approach to assess how PASRR can be better used to support resident needs.

Rural-Urban Differences in Nursing Home Risk-adjusted Rates of Emergency Department Visits: A Decomposition Analysis.

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-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents. RESEARCH DESIGN: We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors. SUBJECTS: Privately owned, free-standing NHs in the United States (N=13,260). RESULTS: Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (ß=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED. CONCLUSIONS: Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.

Construction and Validation of Risk-adjusted Rates of Emergency Department Visits for Long-stay Nursing Home Residents.

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 (outpatient ED), and potentially avoidable ED visits (PAED). RESEARCH DESIGN: The authors calculated quarterly NH risk-adjusted ED rates from 2011 Q2 to 2013 Q3 national Medicare claims and Minimum Data Set data. Using random-effect linear regressions, the authors validated these rates against Nursing Home Compare overall 5-star quality ratings and examined their associations with hospitalization rates to provide a quality context. SUBJECTS: Resident-quarter observations (7.3 million) from 15,235 unique NHs. RESULTS: Risk-adjusted rates of any ED, outpatient ED, and PAED averaged 9.7%, 3.4%, and 3.2%, respectively. Compared with NHs with 1 or 2 stars overall rating, NHs with ≥3 stars were significantly associated with lower rates of any ED visit, outpatient ED, and PAED (ß, -0.23%, -0.16%, and -0.11%, respectively; all P<0.01). Pearson Correlation coefficients between hospitalization rates and rates of any ED visit, outpatient ED, and PAED were 0.74, 0.31, and 0.46, respectively. CONCLUSIONS: The moderately negative associations of 5-star ratings with ED rates provide supportive evidence to their validity. Outpatient ED and PAED were moderately correlated to hospitalizations suggesting they provided more information about quality than any ED.

Primary care competition and quality of care: Empirical evidence from Medicare.

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 PCP practices in more concentrated areas provide lower quality of care. More specifically, PCPs in more concentrated areas are less likely to perform screening and follow-up care for high blood pressure, unhealthy bodyweight, and tobacco use. They are also less likely to document current medications. Furthermore, PCPs in more concentrated areas have a higher amount of opioid prescriptions as a fraction of total prescriptions.

COVID-19 Pandemic: Exacerbating Racial/Ethnic Disparities in Long-Term Services and Supports.

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 communities both in the rate of infection and virus-related mortality. By examining these disparities in the context of the pandemic, we bring to light the challenges and issues faced in LTSS by minority communities with regard to this virus as well as the disparities in LTSS that have always existed.

The principal-agent problem and owner-managers: An instrumental variables application to nursing home quality.

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 and its relationship to quality among for-profit nursing homes (NHs). We identify NH administrators with more than 5% ownership (owner-manager) from Ohio Medicaid Cost Reports (2005-2010) and link these data to long-stay resident records in the Minimum Data Set. Using differential distance to the nearest NHs with a salaried manager relative to an owner-manager, we address the differential selection into these two types of NHs. After instrumenting for admissions to owner-managed NHs, quality among long-stay residents at owner-managed NHs is generally better than NHs with salaried managers. We find suggestive evidence that the magnitudes of quality difference are larger when the principal-agent problem is likely more pronounced, such as when NHs that are part of a multifacility chain and located in more concentrated markets.

Antipsychotic medication use in nursing homes: a proposed measure of quality.

OBJECTIVE: The potential misuse of antipsychotic medications (APMs) is an ongoing quality concern in nursing homes (NHs), especially given recent black box warnings and other evidence regarding the risk of APMs when used in NH populations. One mechanism regulators could use is public reporting of APM use by NHs; however, there is currently no agreed-upon measure of guideline-inconsistent APM use. In this paper, we describe a proposed measure of quality of APM use that is based on Centers for Medicare and Medicaid Services (CMS) Interpretive Guidelines, Food and Drug Administration (FDA) indications for APMs, and severity of behavioral symptoms. METHODS: The proposed measure identifies NH residents who receive an APM but do not have an approved indication for APM use. We demonstrate the feasibility of this measure using data from Medicaid-eligible long-stay residents aged 65 years and older in seven states. Using multivariable logistic regressions, we compare it to the current CMS Nursing Home Compare quality measure. RESULTS: We find that nearly 52% of residents receiving an APM lack indications approved by CMS/FDA guidelines compared with 85% for the current CMS quality measure. APM guideline-inconsistent use rates vary significantly across resident and facility characteristics, and states. Only our measure correlates with another quality indicator in that facilities with higher deficiencies have significantly higher odds of APM use. Predictors of inappropriate use are found to be consistent with other measures of NH quality, supporting the validity of our proposed measure. CONCLUSION: The proposed measure provides an important foundation to improve APM prescribing practices without penalizing NHs when there are limited alternative treatments available.

Medicare skilled nursing facility reimbursement and upcoding.

Post-acute care provided by skilled nursing facilities (SNFs) is reimbursed by Medicare under a prospective payment system using resource utilization groups (RUGs) that adjust payment intensity on the basis of predefined ranges of weekly therapy minutes provided and the functionality of the patient. Individual RUGs account for differences in the intensity of care provided, but there exists significant regional variation in the payments SNFs receive from Medicare due to the use of geographic adjustment factors. This paper is the first to use this geographic variation in the generosity of Medicare reimbursement to empirically test if SNFs respond to payment differences between RUG categories. The results are highly suggestive that SNFs upcode patients by providing additional therapy minutes to increase revenue, whereas we find no evidence of upcoding related to patient functionality scores. Simulating how different payment differentials affect RUG selection, we predict that reducing the financial incentive to upcode could result in significant savings to Medicare.

Nursing Home Resident Preferences for Daily Care and Activities: A Latent Class Analysis of National Data.

BACKGROUND AND OBJECTIVES: Uncovering subgroups of nursing home residents sharing similar preference patterns is useful for developing systematic approaches to person-centered care. This study aimed to (i) identify preference patterns among long-stay residents, and (ii) examine the associations of preference patterns with resident and facility characteristics. RESEARCH DESIGN AND METHODS: This study was a national cross-sectional analysis of Minimum Data Set assessments in 2016. Using resident-rated importance for 16 preference items in the Preference Assessment Tool as indicators, we conducted latent class analysis to identify preference patterns and examined their associations with resident and facility characteristics. RESULTS: We identified 4 preference patterns. The high salience group (43.5% of the sample) was the most likely to rate all preferences as important, whereas the low salience group (8.7%) was the least likely. The socially engaged (27.2%) and the socially independent groups (20.6%) featured high importance ratings on social/recreational activities and maintaining privacy/autonomy, respectively. The high salience group reported more favorable physical and sensory function than the other 3 groups and lived in facilities with higher staffing of activity staff. The low salience and socially independent groups reported a higher prevalence of depressive symptoms, whereas the low salience or socially engaged groups reported a higher prevalence of cognitive impairment. Preference patterns also varied by race/ethnicity and gender. DISCUSSION AND IMPLICATIONS: Our study advanced the understanding of within-individual variations in preferences, and the role of individual and environmental factors in shaping preferences. The findings provided implications for providing person-centered care in NHs.

Nursing Homes Increasingly Rely On Staffing Agencies For Direct Care Nursing.

When nursing homes experience a shortage in directly employed nursing staff, they may rely on temporary workers from staffing agencies to fill this gap. This article examines trends in the use of staffing agencies among nursing homes during the prepandemic and COVID-19 pandemic era (2018-22). In 2018, 23 percent of nursing homes used agency nursing staff, accounting for about 3 percent of all direct care nursing hours worked. When used, agency staff were commonly present for ninety or fewer days in a year. By 2022, almost half of all nursing homes used agency staff, accounting for 11 percent of all direct care nursing staff hours. Agency staff were increasingly used to address chronic staffing shortages, with 13.8 percent of nursing homes having agency staff present every day. Agency staff were 50-60 percent more expensive per hour than directly employed nursing staff, and nursing homes that used agency staff often had lower five-star ratings. Policy makers need to consider postpandemic changes to the nursing home workforce as part of nursing home reform, as increased reliance on agency staff may reduce the financial resources available to increase nursing staff levels and improve the quality of care.

Assessment of Consumer Complaint Investigation Scores, Recertification Survey Scores, and Overall Nursing Home Health Inspection Star Quality Rating.

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 recertification surveys and specific to complaint investigations to discern whether they provide different information. Design, Setting, and Participants: In this quality improvement study, the Nursing Home Compare Five-Star Quality Rating System was used to calculate three 5-star ratings: 1 overall health inspection rating combining recertification survey scores and complaint investigation scores, 1 using only recertification scores, and 1 using only complaint investigation scores. The study included US nursing homes. The sample calculated star ratings for nursing homes in November 2017. This sample included all whose most recent recertification surveys occurred in 2016 up to and including November 2017, and those with 36 months of data from the ASPEN Complaints/Incidents Tracking System and the Certification and Survey Provider Enhanced Reports. Data analyses were completed on different days in 2022, depending on which questions were being addressed. Main Outcomes and Measures: Comparison of the 3 star rating distributions. The recertification survey and complaint investigation star ratings were compared with respect to the overall health investigation rating. The recertification and complaint star ratings were cross-tabulated. Results: Among the 15 499 nursing homes, 19.8% had 1 overall health inspection star, 23.2% had 2, 23.2% had 3, 23.2% had 4, and 9.8% had 5 overall health inspection stars. Most had the same overall and recertification star ratings; for example, 79.4% had 5 overall stars and 5 recertification survey stars. However, overall and complaint-based star ratings were discordant, with a relatively large proportion of nursing homes (25.7%) having no complaint deficiencies and therefore high star ratings. Conclusions and Relevance: In this quality improvement study assessing the 2 components of the Five-Star Quality Rating System, results of recertification surveys were largely similar to health inspection star ratings. However, recertification survey scores differed from complaint inspection scores, suggesting health inspection ratings may not reflect consumers' views of care, services, or other valued amenities. A complaint-focused metric may have utility. However, research is needed concerning the many nursing homes with no or very few complaint deficiencies.

Beyond Nursing Staff Levels: The Association of Nursing Home Quality and the Five-Star Quality Rating System's New Staffing Measures.

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 existing studies have evaluated the relationship between CMS's newly introduced staffing measures and quality. This study uses regression analysis to estimate the relationship between 13 quality measures (used in Care Compare) and CMS's new staffing measures (i.e., weekend nursing staff levels, total nursing and registered nurse staff turnover, and administrator turnover) as well as a measure of daily staffing variation recently introduced in the literature called the coefficient of variation. Regressions analysis finds strong evidence of an association between quality and these staffing measures, though some measures (e.g., nursing staff turnover) are highly correlated and may be duplicative.