Study links poor financial performance and 'de facto' nursing home segregation; raises questions abo

Nursing homes with a high proportion of black residents tend to underperform financially, according to recently published research that raises difficult questions about admissions practices and healthcare disparities.

The researchers, led by the University of Central Florida’s Latarsha Chisholm, Ph.D., analyzed 1999-2004 data for nearly 11,500 nursing homes. They found financial performance was worse in nursing homes that had predominantly black residents, as these residents are identified through Minimum Data Set questions regarding race.
This is not a surprising finding, according to Drexel University’s David Barton Smith, Ph.D., who peer reviewed the article. Previous studies have found that minorities rely on Medicaid in greater numbers than other demographic groups, so nursing homes that primarily serve minorities see bottom-line impacts, Smith told McKnight’s. This latest research stands out for how closely it looked at financial information, he noted.
Prior studies used the proportion of Medicaid reimbursement as a “proxy” for overall financial performance of a facility, Chisholm told McKnight’s. Her work, published in Health Services Research, considered information such as total profit margin, operating margin and operating revenue per patient day. 
Financial strain on a facility is associated with lower-quality care, as measured by indicators such as bedsore prevention and total catheter use, the researchers found. Other studies have concluded black residents are less likely to get a flu shot and are more likely to be hospitalized, develop bedsores, and need help with activities of daily living.

Shifting factors impact admissions

Residents of predominantly black communities may opt for local long-term care facilities. However, there may be other forces at work in creating racially distinct resident populations, according to Smith and Chisholm.
Some facilities simply must maintain a certain proportion of private pay residents to remain solvent, Smith said. Race may not be a consideration in the admissions process for these facilities, but the net result is having financially stronger facilities that are not diverse.
More controversially, Smith contends that some nursing homes may turn away black residents, even if they are private pay, in order maintain appeal for white, private-pay residents.
Some nursing homes quietly tell hospitals not to refer black residents, although these facilities may phrase this by referring to patients by payer status rather than race, Smith said. 

Still, he was quick to stress that it’s unclear how common this practice is, and more research is needed. He said he has lobbied the Department of Health and Human Services Office for Civil Rights to conduct a study.
“They assured me in the early 90s they were going to start a testing program, but it didn’t happen,” he said.

He added that long-term care is the only part of the healthcare system in which every provider fully discloses the racial composition of individuals served. This transparency enables work like Chisholm’s, while it is much more difficult to research whether hospitals and other providers may exhibit the same “disparities in quality and fiscal viability.” 

Chisholm did not want to speculate on this issue, but expressed respect for Smith’s work in the field and the connections he’s made with stakeholders. However, she did suggest that even if racist attitudes are at currently at play, “de facto segregation” in nursing homes may be alleviated naturally due to demographic shifts and changes in the culture.
“I think the disparities we’re seeing may decrease over time, due to the increase of minorities in the country and the more diverse that our communities are becoming,” she said.

Smith added that declining demand for nursing home beds, associated with expanding care options such as assisted living, is also opening up admissions to Medicaid patients in high quality facilities.
Still, both Smith and Chisholm agreed that policymakers and healthcare professionals need to keep this issue in mind to ensure that nursing homes serving minorities are supported and not further challenged by changing Medicaid rates and care coordination efforts.