More Than Black and White
Monday April 11, 2005
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A new study suggests that the care patients get in long-term care facilities has more to do with how much green is in their pockets, not how much tint is in their skin. Photo By Roly Rodriguez
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Researchers have long looked at health disparities among races in the general population and have found that indeed there are differences in the health care received by blacks and whites. But it was only recently that they started to uncover what might be similar types of disparities in the long-term care setting.
Researchers report in a study published last year that there is no doubt there are racial disparities in nursing home care. The root cause, however, is not necessarily prejudice, but rather money.
Vincent Mor, PhD, professor and chair of the department of community health at Brown Medical School in Providence, R.I., is a leading researcher in the area of health disparities in long-term care. He was among the authors of the Minimum Data Set for Nursing Home Resident Assessment, which is now mandatory and used for every assessment of every nursing home resident in the U.S.
Mor's work is detailed in the study, "Driven to Tiers: Socioeconomic and Racial Disparities in the Quality of Nursing Home Care" (published in The Milbank Quarterly and available at www.milbank.org/quarterly/8202feat.html). Mor and his colleagues found in a national examination of nursing home care that minority patients - particularly black patients - were four times more likely on average than whites to be residing in a nursing home that was judged to be in the bottom 15% of all nursing homes in the country.
The lower tier, according to the study, includes facilities with high proportions of Medicaid residents, and, as a result, limited resources. These facilities tend to be in poor communities. Compared to upper-tier facilities, the lower-tier counterparts have significantly fewer RNs for each resident. All in all, the nearly 15% of American nonhospital-based nursing homes that serve predominately Medicaid residents have fewer nurses, lower occupancy rates, and more health-related deficiencies, according to Mor.
Caregivers are not the problem
Although some believe disparities in care can be traced to caregivers, Mor says he found something quite different. In his study, the disparity in care wasn't a case of unequal treatment by nurses, physicians, and other health care providers, but rather that black patients were more likely to be residing in lower-quality homes because of socioeconomics.
"So, the effect is not the individual nurse seeing a white or black patient and treating the white patient better," Mor says. "It's rather that, on average, black patients are entering homes that aren't as good. It is fundamentally related to geographic or neighborhood segregation because people tend to go to nursing homes that are relatively close to where they live."
That creates nursing homes of haves and have-nots, with some nursing homes depending on Medicaid dollars, while others have the relief of higher-paying Medicare and private-pay patients.
According to Mor's report, states in the Southeastern U.S. had the highest percentages of nonhospital-based lower-tier facilities. Georgia, Mississippi, and Louisiana were in the category with the highest percentage (between 36.63% and 87.98%) of nonhospital-based facilities in the lower tier. Florida and Alabama were in the second-to-lowest category, with 3.67% to 12.03% of all such facilities in the lower tier. New York, New Jersey, North Carolina, and South Carolina fell in the middle range, with 12.03% to 23.18% of nonhospital-based facilities in the lower tier. The mean national percentage was 12.61%
About 9% of all white nursing home residents in the U.S. are in lower-tier facilities, compared to 40% of black nursing home residents. Florida was higher, at 4.1 to 5.44, than Alabama, Georgia, South Carolina, and North Carolina in the state's rate ratio of the percentage of blacks in lower-tier versus upper-tier facilities. The other Southeastern states came in at 2.61 to 4.1, as did both New York and New Jersey, and the mean rate ratio was 2.86.
Problems are rooted in the system
Researchers are questioning where the problem lies. Is it that Medicaid recipients don't know they have options or choose not to exercise them? Or are they locked out of better options for quality of long-term care?
Access could very well be an issue, says Carol Wellman, nursing home administrator, Laurel Park at Henry Medical Center, Stockbridge, Ga. Wellman says nursing home beds for Medicaid patients who do not enter a nursing home based on their Medicare eligibility are few and far between. According to Wellman, Laurel Park, an 89-bed skilled facility with an active rehab unit and an average of 25 Medicare admissions and discharges a month, admits most of its patients straight from the hospital to be rehabilitated.
"Most long-term care facilities do tend to admit the Medicare patient first," she says.
To meet Medicare guidelines for nursing home care, patients must be on the heels of a three-day hospital stay and have diagnoses that make them Medicare eligible.
"I don't think there is a facility that discriminates based on age or sex," Wellman says. "Most nursing homes are going to admit patients that are Medicare-eligible because that's the highest reimbursement. Because it is so costly to take care of patients, we have to do whatever we can to get the most revenue that we can."
In Georgia, for example, Medicaid pays $104.90 a patient a day while Medicare's reimbursement goes from $200 to $350 a day.
Wellman says nursing home administrators tend to prioritize admissions based on Medicare criteria. If those people stay long-term, they convert from Medicare to Medicaid. But the chances of admitting a straight Medicaid patient are slim, she says.
Genie Thomas, RN, C, Medicare case manager and assessment coordinator at Laurel Park, has worked in long-term care for 14 years. Before joining Laurel Park, she worked at a nursing home in Metro Atlanta, where about 80% of the residents were Medicaid recipients.
"The level of care in the prior facility was more of a custodial type care, [with] just one person to help bathing and dressing, supervision, and medications," Thomas says.
It seems to be a vicious circle when nursing homes depend on Medicaid reimbursement. They get less money to spend on nursing staff, supplies, and more, and, therefore, they don't attract as many good nurses. The quality of nurses who work at these facilities makes a big difference, according to Meg Bourbonniere, RN, PhD, assistant professor of nursing, Yale University School of Medicine. Bourbonniere conducted a study on the use of contract nurses in nursing homes.
After examining data from 1992 to 2002, and assessing 15,000 nursing homes nationwide, Bourbonniere and her colleagues found that facilities that employed more contracted RNs and LPNs appeared to have a profile of a poor facility. She defines a poor facility as one that has a low occupancy rate, lower proportion of residents paying for their care privately, and those facilities that are more likely to receive serious health-related deficiency citations.
"The Medicaid payment policies in states often contribute to poorer quality of care," Bourbonniere says. "And I think policies can create disparities. At least from the work that I've done ... with impoverished older adults, it doesn't matter what race or ethnicity or gender they are. People who are poor often don't get the best care," she says.
Nurses can make a difference
Mor says his findings and those of others are a cry to get good nurses to work in those homes that aren't as resource-rich.
"That's a horrible thing to ask nurses to do - to sort of try to help society's structural problems with patients who are sick in nursing homes that have relatively few resources," Mor says. "They won't get paid as well. The patients are more likely to have psychiatric problems, and the administrators and managers won't be as good. But we need nurses, managers, and administrators who are high-quality to seek out those places."
And nurses can also be residents' advocates. "[Nurses] can communicate with their state and federal legislators about the things that they observe in clinical practice," Bourbonniere says. "If their practice setting is failing because they're not getting enough reimbursement, it doesn't hurt to talk to their lawmakers in the state."
But it will take more than good-hearted nurses to cure the ills in the long-term care setting. Experts say academia and government will play big roles in the lives of future residents, and that nursing schools should make nursing home care part of their geriatric rotations. And partnerships with medical schools that send residents to care for nursing home residents could help with care quality.
But government plays perhaps the biggest role by focusing on health care policy.
Larry Minnix, CEO of the American Association of Homes and Services for the Aging, Washington, D.C., which represents about 5,000 not-for-profit organizations that serve the elderly throughout the country, says the way to address a problem this vast is to "level the playing field through standardizing Medicaid benefits [which vary from state to state] and making sure that good nursing home care is reimbursed adequately." He adds that the tendency to blame the facilities is misdirected.
"The facilities, for the most part, are doing the best they can with what they have," Minnix says. "The responsibility to solve this thing is the public's responsibility through the taxpayer and government making the decision that we want good care, and if we want good care, we are going to have to pay for good care."
He says the first step would be to reinforce nursing, by making sure the nursing staffs have livable wages, benefits, and opportunities for development.
"Through the nursing education programs, we need to find ways to incentivize nurses to go into the long-term care field because it's one of the least-preferred nursing professional tracts," Minnix says. "And we need to encourage all the nursing schools - especially those that get federal money to make sure their curriculum includes significant geriatric nursing information and clinical experience.
"They don't call them 'nursing' homes for nothing. Nursing is the essential care ingredient in nursing home care."
Lisette Hilton is a freelance health care reporter.
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