More than 50% of Dual-eligibles Steered to Low-rated Nursing Homes

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Accepting the risks of the current health care system, for seniors, their families, and caregivers, often includes accepting the risks of referral to a nursing home after Medicare hospital benefits expire. Most assume that the transition is, like other aspects of health care, handled carefully and competently, and with the patient's best interest being paramount.  Unfortunately, that assumption is dangerously incorrect.

A recent study found that seniors who are eligible for both Medicare and Medicaid are more likely to wind up in low-quality skilled nursing facilities rather than available higher quality alternatives.  The authors summarize by concluding "(duals) are concentrated in lower quality [with ratings from 1 or 2 of five stars] nursing homes, relative to those not on Medicaid." Implicit is that Medicaid residents find themselves in the lowest quality facilities.

The study is significant because "dual eligible" seniors have, or should have, access to the widest variety of institutions, since they can be referred to both institutions accepting Medicaid and Medicare, and are not excluded from either those that don't accept Medicaid, or Medicaid-only facilities (the latter characterization is often misnomer since most institutions will accept both, but some institutions become Medicaid-primarily, or Medicaid-only). Implicit is the suggestion that Medicaid residents find themselves in the lowest quality facilities. The results of the study are the subject of an article published in McKnight's Long-term Care News. 

The study identified patient education and proximity to quality skilled nursing facilities as key reasons for the disparity.   This blog has repeatedly warned that the proximity of a care choice to the resident's home, or family, or hospital is a poor bases upon which to select a care provider.  

The study is published in the Journal of Applied Gerontology. According to the study's authors, the solutions are is not limited to investment in formal education and relocating high-quality facilities into areas where dual-eligible beneficiaries live. Rather, experts suggest that health care leaders should work to better disseminate information on high-quality care options to duals, and to improve lagging nursing homes in low-income areas:

“More interactions among nursing home leaders from both high-quality and low-quality facilities can help identify ways to improve low-quality facilities in poorer neighborhoods,” lead author Hari Sharma, Ph.D., an assistant professor in the University of Iowa’s Department of Health Management and Policy, told McKnight’s on Thursday.

Sharma and colleagues reached their conclusions based on nursing home quality data from 2009 — the first year after Five-Star ratings were made public, before facilities had a chance to substantially improve scores (by 2011, a large proportion of SNFs were rated as four or five stars, authors wrote). They found that duals were 9.7 percentage points more likely than non-duals to be admitted to a SNF rated as one or two stars (50.7% compared to 40.9% for non-duals).  

Authors note that healthcare leaders must find ways to address those additional factors that contribute to disparity. For instance, hospitals might work to steer duals to high quality nursing homes, Sharma said. Another important takeaway for SNF leaders from the study is the need to form partnerships with legislators to help eradicate inequalities:

“Our research highlights the need to invest more resources to improve existing low-quality nursing homes in areas that do not have many alternatives. Since investment of additional resources requires the commitment from both policymakers and nursing home leaders, it is imperative that both sides actively work together to improve existing low-quality nursing homes.”

For those planning to "Age in Place," this study provides more evidence for justification, and illustrates the importance of educating caregivers and fiduciaries regarding the workings of the health care and legals systems.