Medicaid and Quality: An AHCA/NCAL Study

The Research team at AHCA/NCAL has been working on a research project to describe the relationship between the proportion of Medicaid beneficiaries in a nursing home and the quality of care, adjusted for facility characteristics. AHCA/NCAL looked at a national sample (n=13,625) of non-hospital based skilled nursing facilities with 25 beds or more who were Medicaid and Medicare certified between November 28, 2015 to November 28, 2017, that are still actively providing care.

The primary independent variable was the proportion of Medicaid beneficiaries, defined as the census of Medicaid beneficiaries over the total resident count at the time of the annual recertification inspection. AHCA/NCAL compared the difference in average percentage of Medicaid beneficiaries by facility bed size, ownership status, location, and chain membership and the overall and each component of Five-Star rating. The team controlled for facility characteristics using logistic regression to estimate the effect of increasing Medicaid prevalence on the odds of achieving average or above average Five-Star ratings (i.e. greater than or equal to 3 stars).

The study showed that, on average, for-profit facilities took care of a significantly higher percentage of Medicaid beneficiaries as compared to not-for-profit (62.5% vs. 48.2%) as did rural facilities compared to urban facilities (63.5% vs. 57.8%). Similarly, larger facilities with more than 120 beds had more Medicaid beneficiaries than smaller facilities with fewer than 50 beds (64.5% vs. 45.9%).

Moreover, in this study, AHCA/NCAL found that Medicaid census and quality are inversely related. More specifically, for facilities with a higher Medicaid beneficiary population, the team observed poorer quality, as compared to facilities with a lower Medicaid beneficiary population. This relationship held even when the team adjusted for facility characteristics.

These preliminary findings were accepted for presentation at the 2019 National Health Policy Conference in Washington, D.C. and were presented by Marsida Domi, AHCA/NCAL’s Senior Research Analyst, on February 05, 2019. The team is currently working on expanding the study to understand the mechanisms of action in the relationship between Medicaid and quality.