The purpose of this study was to evaluate the impact of quality of care on costs in nursing homes. The sample consisted of 749 nursing homes in 5 states in 1996. Nursing home cost functionswere estimated using weighted 2-stage least-squares regression analysis. Costs are measured as the facility's total patient care costs. Two outcome measures are used as quality indicators: pressure ulcers worsening and mood decline. Nonmonotonic relationships are observed between quality and costs for nursing homes in the sample. However, the pattern of the relationship is different depending onthe quality indicator. For pressure ulcers, the authors observe an inverted U-shaped curvewith increasing costs at the lower range of quality but decreasing costs associated with higher quality after a threshold. The opposite pattern is observed for mood decline, with a relatively flat curve at the lower range of quality but increasing costs after a threshold.
General Accounting Office. Nursing Home Quality [GAO-03-561]. Washington, DC: General Accounting Office; 2003.
2.
Berg K, Fries BE, JonesR, et al. Identification and Evaluation of Existing Quality Indicators That Are Appropriate for Use in Long-term Care Settings. Baltimore, Md: Centers for Medicare and Medicaid Services; 2001.
3.
Centers for Medicare and Medicaid Services. Nursing home quality initiative. Available at: http://cms.hhs.gov/providers/nursinghomes/nhi/. Accessed December 4, 2002.
4.
Gage B. Impact of the BBA on post-acute utilization. Health Care Financ Rev. 1999;20:103-126.
5.
Pratt JR. Competition, Cooperation, and Integration: Long-term Care—Managing Across theContinuum. Gaithersburg, Md: Aspen; 1999.
6.
Zinn JS, MorV, CastleN, IntratorO, BrannonD. Organizational and environmental factors associated with nursing home participation in managed care. Health Serv Res. 1999;33:1753-1767.
7.
Smith V, Ramesh R, Gifford K, Ellis E, Wachino V. States Respond to Fiscal Pressure: StateMedicaid Spending Growth and Cost Containment in Fiscal Years 2003 and 2004. Washington, DC: Kaiser Commission on Medicaid and the Uninsured; 2003.
8.
Newhouse JP. Toward a theory of nonprofit institutions: an economic model of a hospital. Am Econ Rev. 1970;60:64-74.
9.
Fleming ST. The relationship between the cost and quality of hospital care: a review of the literature. Med Care Rev. 1990;47:487-502.
10.
DaighRD. Financial implications of a quality improvement process. Top Health Care Financ. 1991;17:42-52.
11.
Binns GS. The relationship among quality, cost, and market share in hospitals. Top Health Care Financ. 1991;18:21-32.
12.
PhillipsCD, HawesC, Fries BE. Reducing the use of physical restraints in nursing homes: will it increase costs?Am J Public Health. 1993;83:342-348.
13.
Frantz RA, Bergquist S, Specht J. The cost of treating pressure ulcers following implementation of a research-based skin care protocol in a long-term care facility. Adv Wound Care. 1995;8:36-45.
14.
Nyman JA. Improving the quality of nursing home outcomes: are adequacy-or incentive-oriented policiesmore effective?Med Care. 1988;26:1158-1171.
15.
Mukamel DB, Spector WD. Nursing home costs and risk-adjusted outcome measures of quality. Med Care. 2000;38:78-89.
16.
Morris JN, Murphy K, Nonemaker S, et al. Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual. Albertville, Ala: Heaton; 1995.
Luckenotte J. Characteristics of long-stay nursing residents. J Am Geriatr Soc. 2000;23:786-787.
19.
Mukamel DB, Brower CA. The influence of risk adjustment methods on conclusion about quality of care in nursing homes based on outcome measures. Gerontologist. 1998;38:695-703.
20.
Ramsay JD, Sainfort F, Zimmerman D. An empirical test of the structure, process, and outcome quality paradigm using resident-based, nursing facility assessment data. Am J Med Qual. 1995;10:63-75.
21.
Mukamel DB. Risk-adjusted outcome measures and quality of acre in nursing homes. Med Care. 1997;35:367-385.
22.
Burrows AB, Morris JN, Simon SE, Hirdes JP, Charles P. Development of aminimum data set-based depression rating scale for use in nursing homes. Age Ageing. 2000;29:165-172.
23.
Mor V, Morris J, Lipsitz L, Fogel B. Benchmarking quality in nursing homes: theQ-Metrics System. CanJQualHealthCare. 1998;14:12-17.
24.
Arling G, Karon SL, Sainfort F, Zimmerman DR, Ross R. Risk adjustment of nursing home quality indicators. Gerontologist. 1997;37:757-766.
25.
Cohen JW, Dubay LC. The effects of Medicaid reimbursement method and ownership on nursing home costs, case mix, and staffing. Inquiry. 1990;27:183-200.
26.
Nyman J. Excess demand, the percentage of Medicaid patients and the quality of nursing home care. J Hum Resour. 1987;23:76-91.
27.
NymanJ. Analysis of nursing home use and bed supply, Wisconsin 1983. Health Serv Res. 1989;24:511-538.
28.
Fleming ST. The relationship between quality and cost: pure and simple?Inquiry. 1991;28:29-38.
29.
Phillips LW, Chang DR, Buzzell RD. Product quality, cost position and business performance: a test of some key hypotheses. J Mark. 1983;47:26-43.
30.
Rudder C, Phillips C. 91 Ideas for Reducing Costs, Enhancing Revenue, and Maintaining Quality in Nursing Homes. New York: Nursing Home Community Coalition of New York State; 1998.
31.
DavisMA, Freeman JW, Kirby EC. Nursing home performance under case-mix reimbursement: responding to heavy-care incentives and market changes. Health Serv Res. 1998;33:815-834.
32.
Grabowski DC. Does an increase in the Medicaid reimbursement rate improve nursing home quality?J Gerontol B Psychol Sci Soc Sci. 2001;56B(2):S84-S93.
33.
Grabowski DC. Medicaid reimbursement and the quality of nursing home care. J Health Econ. 2001;20:549-569.
