Close to three million unique individuals per year in the United States receive care in about 15,000 nursing homes. Compared with other health care providers, nursing homes disproportionately serve the frail elderly, individuals impacted by poverty, and individuals with cognitive or functional disability. As such, nursing homes are considered to be safety-net health care providers and the quality of care they provide has been a persistent area of concern for policy makers. Despite years of regulation and market-based efforts, nursing home quality remains mixed and is described as two-tiered. The welfare effects of poor nursing home quality are likely to be substantial, given the frailty of the population and that one in three older adults uses a nursing home in their lifetimes. Accordingly, the overall objective of this dissertation is to identify the causes and consequences of exposure to low- versus high-quality nursing homes. In Chapter 1, I investigate whether misalignment between Medicare and Medicaid payment rules creates a disparity in the nursing home admissions process contributing to the fragmented system of quality. Using a discrete choice model, I show that post-acute patients most likely to become long-stay residents are less able to access higher quality nursing homes. In Chapter 2, I estimate the causal impact of admission to a higher versus lower quality nursing home on patients’ health outcomes. I use a novel identification strategy that exploits temporal variation in nursing homes’ capacity to provide care. I find that admission to a nursing home with a higher staffing rating has a substantial and beneficial impact on hospitalization and mortality risk. In Chapter 3, I specifically examine the outcomes of nursing home post-acute care for patients with dementia and Medicare-Medicaid dual enrollees. These patients may be less likely to access high-quality nursing homes due to payment incentives, but also be more impacted by poor quality. Consistent with this notion, I find that patients with dementia and dual enrollees were less likely to be discharged to high-quality nursing homes compared with patients without dementia and non-dual enrollees. At the same time, I provide evidence that higher nursing home quality may be more beneficial for these patients through a greater reduction in readmission or mortality rates. This finding implies a level of inefficiency in how nursing home quality is currently allocated, since patients who are less likely to receive high quality care may actually benefit more from it.
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Citation
Kosar, Cyrus M.,
"Allocation and Effects of Nursing Home Quality"
(2021).
Health Services, Policy & Practice Theses and Dissertations.
Brown Digital Repository. Brown University Library.
https://repository.library.brown.edu/studio/item/bdr:3mmzkwgy/
