Care Delivery in Nursing Homes: The Role of Quality, Insurance, and Specialty Clinicians

Abstract

Abstract This dissertation describes three papers evaluating factors which contribute to the care and wellbeing of nursing home residents. Taken together, the chapters will provide important evidence on how the quality of care experienced in U.S. nursing homes is influenced by a multitude of factors – including the prevalence of antipsychotic use, availability of insurance plans with targeted benefits, and role of the admitting clinician in a nursing home. This work informs how policy research can improve the care experience and outcomes among post-acute care short-stay and long-stay nursing home residents. Chapter 1 (with David Grabowski) quantifies quality of care following an admission to a nursing home with low or high antipsychotic drug use. We use an instrumental variable approach to estimate the effect of facility-level antipsychotic use on patient outcomes for both post-acute care short-stay and long-stay residents. Our instrument, differential distance, measures how much farther an individual would have to travel to avoid a high-use facility. Receiving care from a low-use facility reduces the diagnosis of schizophrenia, use of restraints, and hospitalizations among both short-stay and long-stay residents. We also observe larger reductions among residents with dementia. Given concerns about the misuse of antipsychotics in U.S. nursing homes, these findings highlight the need for continued monitoring and intervention by policymakers. Chapter 2 (with David Grabowski, Mary Beth Landrum, and J. Michael McWilliams) studies the growth of provider-led Institutional Special Needs Plans (I-SNPs), nursing homes which engage in financial partnerships with an insurer to operate a plan for their own residents. We use a stacked difference-in-differences design to estimate the effect of offering a provider-led I-SNP on enrollment and quality of care. Offering a provider-led I-SNP led to a 17.0 percentage point increase in I-SNP enrollment among facility residents within four years relative to control nursing homes. We also estimate that offering provider-led I-SNPs significantly decreased hospitalizations and increased the use of hypnotic drugs and reporting of pressure ulcers. These results suggest that risk bearing by nursing homes in the form of provider-led I-SNPs may successfully reduce utilization, but with unclear implications for quality and competition. Chapter 3 (with J. Michael McWilliams) assesses how patients are distributed within skilled nursing facilities (SNFs) to clinicians who specialize in nursing facility care (SNFists) to understand the influence of clinician factors on patient outcomes. Using multi-level modeling, we find that the variation in patient characteristics across admitting clinicians is substantially less among patients admitted to SNFists vs. non-SNFists, consistent with a less selective distribution of patients to clinicians within a facility when the admitting clinician is a SNFist. We find minimal variation in the rates of mortality, hospitalization, and antipsychotics across SNFists and outcomes did not differ between advanced practice provider and physician SNFists. Our results suggest that the admitting clinician appears to have little influence on key outcomes in the post-acute setting, in contrast with similar research conducted in other care settings.