Paying for Nursing Home Quality: An Elusive But Important Goal

The pandemic of viral infection with the severe acute respiratory syndrome coronavirus-2 that causes COVID-19 disease has put the nursing home industry in crisis. The combination of a vulnerable population that manifests nonspecific and atypical presentations of COVID-19, staffing shortages due to viral infection, inadequate resources for and availability of rapid, accurate testing and personal protective equipment, and lack of effective treatments for COVID-19 among nursing home residents have created a "perfect storm" in our country's nursing homes. This perfect storm will continue as society begins to reopen, resulting in more infections among nursing home staff and clinicians who acquire the virus outside of work, remain asymptomatic, and unknowingly perpetuate the spread of the virus in their workplaces. Because of the elements of the perfect storm, nursing homes are like a tinderbox, and it only takes one person to start a fire that could cause many deaths in a single facility. Several public health interventions and health policy strategies, adequate resources, and focused clinical quality improvement initiatives can help calm the storm. The saddest part of this perfect storm is that many years of inaction on the part of policy makers contributed to its impact. We now have an opportunity to improve nursing homes to protect residents and their caregivers ahead of the next storm. It is time to reimagine how we pay for and regulate nursing home care to achieve this goal. J Am Geriatr Soc 68:2153-2162, 2020.

In 2016, Medicare implemented the Comprehensive Care for Joint Replacement Model (CJR), a national mandatory bundled payment model for lower extremity joint replacement (LEJR) in randomly selected metropolitan statistical areas (MSAs). Hospitals in selected MSAs receive bonuses or pay penalties based on LEJR spending through 90 days post-discharge. We conducted difference-in-differences analyses using Medicare claims from 2015–2017, comparing LEJR episodes in 75 MSAs randomized to mandatory participation in CJR (treatment MSAs) with episodes in 121 control MSAs, before vs. after CJR implementation. Our primary outcomes were institutional spending per LEJR episode (primarily hospital and post-acute facility payments), rates of post-surgical complications, and the proportion of patients with higher spending risk (a measure of patient selection). Analyses adjusted for hospital of admission and beneficiary and procedure characteristics. In 2015–2017 there were 280,161 LEJR procedures in 803 hospitals in treatment MSAs and 377,278 procedures in 962 hospitals in control MSAs. After CJR initiation, institutional spending per LEJR episode declined more in treatment than in control MSAs (differential change: -$812 or −3.1% relative to the treatment group baseline; p<0.001). The differential reduction was driven largely by a 5.9% relative decrease in the fraction of episodes with any institutional post-acute care. The program had no effect on complication rates (p=0.67) or the fraction of LEJR procedures performed on higher-risk patients (p=0.81). In its first 18 months, the CJR program resulted in a modest reduction in spending per LEJR episode, before accounting for program bonuses and penalties, without increasing complication rates

Nursing staff turnover has long been considered an important indicator of nursing home quality. However, turnover has never been reported on the Nursing Home Compare website, likely because of the lack of adequate data. On July 1, 2016, the Centers for Medicare and Medicaid Services began collecting auditable payroll-based daily staffing data for US nursing homes. We used 492 million nurse shifts from these data to calculate a novel turnover metric representing the percentage of hours of nursing staff care that turned over annually at each of 15,645 facilities. Mean and median annual turnover rates for total nursing staff were roughly 128 percent and 94 percent, respectively. Turnover rates were correlated with facility location, for-profit status, chain ownership, Medicaid patient census, and star ratings. Disseminating facilities' nursing staff turnover rates on Nursing Home Compare could provide important quality information for policy makers, payers, and consumers, and it may incentivize efforts to reduce turnover.