Determinants of Nursing Home Regulatory Activity in the 50 States: An Analysis from the Political Economy Perspective

Christopher M. Kelly, Phoebe S. Liebig, and Lloyd J. EdwardsSAMSI Transition Workshop

November 10, 2005

Acknowledgments

Dr. Kelly was supported in part by a postdoctoral fellowship1 in the Carolina Program in Health and Aging Research (CPHAR) at the University of North Carolina at Chapel Hill

1Grant ST32AG00272 from the National Institute on Aging

Nursing Home Regulation in the United States

Under OBRA 87, states survey nursing homes, CMS oversees

State surveyors rate nursing home deficiencies according to scope and severity

Information is available to consumers on CMS’s Nursing Home Compare website

Research Questions

What is the extent of nursing home regulatory activity in the 50 states?

How did extent change over a three-year period?

What factors predict citation volume & severity in the 50 states?

Political Economy Perspective

State

Citizen/Public

Sex/Gender Capital

Ideology

RaceAge

Class

Estes (2001)

Linear Mixed Model

Used to identify predictors of the volume and severity of state citations

Provides estimation and hypothesis testing for modeling population and random effects

Can accommodate data missing completely at random

Linear Mixed Model is Useful for Studying State Regulatory Activity

Longitudinal data (i.e. nursing home quality over several years)

Population data - 50 U.S. states. Large sample techniques are

challenged. Parsimonious model needed (N =50) Random intercept and slope. Within-subject errors assumed i.i.d.

Nursing Home Deficiencies Stable, but Less Severe

Number of deficiencies has remained level (about 6 per nursing home)

Percentage of severe deficiencies has declined (about 7% of all deficiencies cause actual harm)

States vary widely in volume & severity of deficiency citations

Possible Predictors of the Extent of State Regulatory Activity

External Determinants

Urbanization Education Age Political Culture

Internal Determinants

Nursing Home State Surveying

Agency Legislature Interest Groups Governor

Linear Mixed Model Predicting State Citation VolumeVariable β

Intercept 10.3

Time .180

Education -.260****

Urbanization -.063**

Total Nursing Home Staffing 1.29**

Total Agency Funding .006**

Legislative Professionalism -40.2****

Democratic Governor .669

Time X Democratic Governor -.565***

Urbanization X Legislative Professionalism

.505***

*p<.1; **p<.05; ***p<.01; ****p<.005

Linear Mixed Model Predicting State Citation SeverityVariable β

Intercept .446

Time -1.87****

Education .482****

Legislative Professionalism -7.35**

Democratic Governor 6.71*

Education X Democratic Governor -.300*

*p<.1; **p<.05; ***p<.01; ****p<.005

Citation Volume: Effect of Governor’s Political Party

Citation Severity: Effect of Governor’s Political Party

Future Use of the Linear Mixed Model

1. Repetitive Scheduling of Annual Inspections: States are to avoid inspecting a nursing home during the same month in consecutive years

2. Deficiency Resolution: States are to resolve non-actual harm deficiencies within 60 days and actual harm deficiencies within 30 days

Contact Information

Christopher M. Kelly, Ph.D.CPHAR Post Doctoral FellowInstitute on AgingUniversity of North Carolina at

Chapel HillTel 919 843 8065ckelly@schsr.unc.edu