Nursing Home or Hospital: State Policy Has Big Impact on Elderly
A team led by Brown University researchers has traced the connections between state nursing home policies and a critical decision in the care of nursing home residents: whether to send these frail elderly to the hospital.
This study resulted in 2 major findings. The lower the state Medicaid reimbursement rate to nursing homes, the more likely those homes were to hospitalize residents. Hospitalization odds were also significantly higher in states that reimburse nursing homes for holding the beds of hospitalized residents.
To conduct the study, the Brown team tracked the status of 570,614 residents aged 65 and older living in 8,997 urban, freestanding nursing homes with 25 or more beds located in 48 states. Residents were followed for a 5-month period to see how many were hospitalized. Researchers found that, on average, 17% of all residents were admitted to hospitals at least once during those 5 months, with rates varying from a low of 8% in Utah to a high of 25% in Louisiana.
Researchers found a strong link between the size of Medicaid payments and the number of hospital admissions. The higher the Medicaid per diem payment for nursing homes, researchers found, the lower the odds of hospitalization for residents. States with the lowest hospitalization rates tended to be located in the West and in New England: Utah, New Mexico, Maine, New Hampshire, and Oregon. States with the highest hospitalization rates tend to be located in the South and the Midwest: Louisiana, Mississippi, Texas, Kentucky, and Oklahoma.
Researchers saw a similar—and surprising—relationship between bed-hold policies and hospitalizations. The odds of hospitalization were 36% higher in states with bed-hold policies. The researchers explained the result this way: because homes receive some money from the state for holding a bed, the financial penalty for hospitalizing residents is reduced. Currently, 36 states reimburse nursing homes for holding the beds of patients admitted to the hospital to guarantee that these residents can return home after recovery. For reserving a bed, states reimburse nursing homes anywhere from 25% to 100% of the Medicaid daily payment rate to offset lost revenue.
“We think the reason we see this relationship is that in states with higher payment rates, nursing home operators can afford to keep more medical professionals, such as nurse practitioners, on staff,” Vincent Mor, lead investigator, said. “With more staff, and more skilled staff, homes are better able to treat residents on site, and they’re better able to practice preventive care to head off problems such as pneumonia, bed sores, or urinary tract infections.” Results are published in the online edition of Health Services Research, http://www.blackwell-synergy.com/links/toc/hsr (December 5, 2006).
Seniors’ Health and Daily Function Improves, Study Finds
The health and daily function of elderly U.S. residents has improved as the incidence of chronic disability has “dropped dramatically.” The results were based on an analysis of the National Long-Term Care Survey, a periodic survey of about 20,000 Medicare beneficiaries. The study found that the percentage of individuals aged over 65 who have heart disease, arthritis, hypertension, or other chronic health conditions dropped from 27% in 1982 to 19% last year. During the same time, the percentage of seniors in nursing homes dropped from 8% to 4%, and the percentage of seniors considered “nondisabled” increased from 73% to 81%.
If the trend continues, Medicare is projected to save about $73 billion over 3 years, according to the study. National Institute on Aging (NIA) director Richard Hodes said, “This continuing decline in disability among older people is one of the most encouraging and important trends of the aging population.” Richard Sulzman, director of NIA’s Behavioral Research Program, said, “The challenge now is to see how this trend can be maintained and accelerated, especially in the face of increasing obesity. Doing so over the next several decades will significantly lessen the societal impact of the aging baby boom generation.”
Benzodiazepine use was not shown to be associated with hip fractures after all, according to a new study from the Department of Ambulatory Care and Prevention (of Harvard Medical School and Harvard Pilgrim Health Care) and supported by the National Institute on Aging and the National Institute on Drug Abuse. Previous epidemiological studies suggesting an association have been used to support legislation and policy decisions that limit access to these drugs among the elderly. These policies may need to be reexamined on the basis of these new findings, which were published in the January 16, 2007, Annals of Internal Medicine.
Concerns about abuse, misuse, and adverse effects of Benzodiazepines, including hip fractures among the elderly, have prompted state and national policies intended to regulate access to them. Since January 2006, benzodiazepines have been excluded from coverage through the Medicare Part D drug benefit.
Researchers studied whether a state policy that drastically decreased use of benzodiazepines resulted in fewer hip fractures among the elderly. They looked for changes in hip fracture rates in a stable population of more than 90,000 Medicaid recipients aged 65 and older before and after a policy was implemented in New York in 1989 requiring benzodiazepine prescribing on triplicate forms.
Since then, all providers in the state are required to obtain, pay for, and use serially numbered triplicate forms to prescribe benzodiazepines. Pharmacists forward 1 copy of the prescription to state health authorities for surveillance, allowing for monitoring of each physician’s prescribing, each pharmacy’s dispensing, and each patient’s receipt of benzodiazepines.
The policy resulted in an immediate 60% reduction in benzodiazepine use among women and 58% among men. The neighboring demographically similar state New Jersey did not regulate benzodiazepine prescribing, and benzodiazepine use did not change. Incidence of hip fracture before and after the policy change was similar.
There are several possible explanations for the study results. Most plausible, however, are biases in the previous studies that found a relationship between these drugs and hip fractures.
“It is very challenging to answer the question whether or not benzodiazepines cause hip fractures. People who get benzodiazepines, such as chronically ill elderly patients with dementia, have conditions, like dementia, that can cause hip fractures—and their hip fractures may not be due to their benzodiazepines,” says researcher Anita Wagner.
“The challenge of disentangling the effects of benzodiazepines from other causes of hip fractures in the elderly is especially concerning when study results are used to guide policies that restrict access to medicines for huge populations,” says senior author Stephen Soumerai.
Policy makers may expect that reducing access to benzodiazepines under Medicare Part D and other policies will decrease hip fracture risk. “Our study suggests that these expectations are not justified,” says Soumerai.
Additionally, if benzodiazepine medications are abruptly terminated, as may be the case when people lose coverage of a drug, negative effects can occur, such as withdrawal reactions, seizures, emergency department visits, and hospital admissions. These may offset any potential savings achieved by limiting coverage of benzodiazepines.
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