title: The effect of state policies on nursing home resident outcomes.
abstract: OBJECTIVE
  To test the effect of changes in Medicaid reimbursement on clinical outcomes of long-stay nursing home (NH) residents.
  
  
  METHODS
  Longitudinal, retrospective study of NHs, merging aggregated resident-level quality measures with facility characteristics and state policy survey data.
  
  
  METHODS
  All free-standing NHs in urban counties with at least 20 long-stay residents per quarter (length of stay > 90 days) in the continental United States between 1999 and 2005.
  
  
  METHODS
  Long-stay NH residents
  
  
  METHODS
  Annual state Medicaid average per diem reimbursement and the presence of case-mix reimbursement in each year.
  
  
  METHODS
  Quarterly facility-aggregated, risk-adjusted quality-of-care measures surpassing a threshold for functional (activity of daily living) decline, physical restraint use, pressure ulcer incidence or worsening, and persistent pain.
  
  
  RESULTS
  All outcomes showed an improvement trend over the study period, particularly physical restraint use. Facility fixed-effect regressions revealed that a $10 increase in Medicaid payment increased the likelihood of a NH meeting quality thresholds by 9% for functional decline, 5% for pain control, and 2% for pressure ulcers but not reduced use of physical restraints. Facilities in states that increased Medicaid payment most showed the greatest improvement in outcomes. The introduction of case-mix reimbursement was unrelated to quality improvement.
  
  
  CONCLUSIONS
  Improvements in the clinical quality of NH care have been achieved, particularly where Medicaid payment has increased, generally from a lower baseline. Although this is a positive finding, challenges to implementing efficient reimbursement policies remain.
authors.affiliation: Center for Gerontology and Health Care Research and Department of Community Health, Alpert Medical School, Brown University, Providence, Rhode Island, USA. vincent_mor@brown.edu
authors.forename: Vincent
authors.initials: V
authors.lastname: Mor
authors.forename: Andrea
authors.initials: A
authors.lastname: Gruneir
authors.forename: Zhanlian
authors.initials: Z
authors.lastname: Feng
authors.forename: David C
authors.initials: DC
authors.lastname: Grabowski
authors.forename: Orna
authors.initials: O
authors.lastname: Intrator
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Zinn
mesh_terms: D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000191:economics / Q000331:legislation & jurisprudence*; D008134:Long-Term Care; D008137:Longitudinal Studies; D008484:Medicaid / Q000191:economics / Q000331:legislation & jurisprudence*; D009735:Nursing Homes / Q000191:economics*; D017063:Outcome Assessment, Health Care; D011640:Public Policy; D012051:Reimbursement Mechanisms; D012189:Retrospective Studies; D020379:Risk Adjustment; D014481:United States