Nursing home 5-star rating system exacerbates disparities in quality, by payer source.
Market-based reforms in health care, such as public reporting of quality, may inadvertently exacerbate disparities. We examined how the Centers for Medicare and Medicare Services' five-star rating system for nursing homes has affected residents who are dually enrolled in Medicare and Medicaid ("dual eligibles"), a particularly vulnerable and disadvantaged population. Specifically, we assessed the extent to which dual eligibles and non-dual eligibles avoided the lowest-rated nursing homes and chose the highest-rated homes once the five-star rating system began, in late 2008. We found that both populations resided in better-quality homes over time but that by 2010 the increased likelihood of choosing the highest-rated homes was substantially smaller for dual eligibles than for non-dual eligibles. Thus, the gap in quality, as measured by a nursing home's star rating, grew over time. Furthermore, we found that the benefit of the five-star system to dual eligibles was largely due to providers' improving their ratings, not to consumers' choosing different providers. We present evidence suggesting that supply constraints play a role in limiting dual eligibles' responses to quality ratings, since high-quality providers tend to be located close to relatively affluent areas. Increases in Medicaid payment rates for nursing home services may be the only long-term solution.
R. Tamara Konetzka (konetzka@uchicago.edu) is an associate professor of health services research in the Department of Public Health Sciences at the University of Chicago, in Illinois.
R Tamara
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Konetzka
David C. Grabowski is a professor of health care policy at Harvard Medical School, in Boston, Massachusetts.
David C
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Grabowski
Marcelo Coca Perraillon is a PhD candidate in the Department of Public Health Sciences at the University of Chicago.
Marcelo Coca
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Perraillon
Rachel M. Werner is an associate professor of medicine at the University of Pennsylvania, in Philadelphia.
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Werner
D000368:Aged; D000369:Aged, 80 and over; D003258:Consumer Behavior / Q000191:economics / Q000706:statistics & numerical data; D005260:Female; D016330:Frail Elderly; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D054625:Healthcare Disparities / Q000191:economics* / Q000706:statistics & numerical data*; D006801:Humans; D007349:Insurance, Health, Reimbursement / Q000191:economics* / Q000706:statistics & numerical data*; D008297:Male; D008484:Medicaid / Q000191:economics / Q000706:statistics & numerical data; D006278:Medicare / Q000191:economics / Q000706:statistics & numerical data; D009735:Nursing Homes / Q000191:economics* / Q000592:standards*; D011787:Quality of Health Care / Q000191:economics* / Q000592:standards*; D014481:United States
Access To Care; Long-Term Care; Medicaid; Medicare; Quality Of Care