Blog PostJoseph Gaspero

Aging with Dignity: Ensuring Equity in Nursing Homes

Blog PostJoseph Gaspero
Aging with Dignity: Ensuring Equity in Nursing Homes
 

Aging with Dignity: Ensuring Equity in Nursing Homes

September 7, 2024  |  Blog Post 


In recent years, intense scrutiny has been directed toward nursing homes regarding inadequacies in quality of care, as staffing issues and thin profit margins have forced many to close since the COVID-19 pandemic began. Research has revealed a two-tiered system of these facilities based upon the primary payer, in which nursing homes with large percentages of residents enrolled in Medicaid are far more likely to provide substandard or inadequate care than those with mostly private-pay or Medicare patients. [1] This disparity, although bleak, is unsurprising in the context of [1] the broader American healthcare system. Those enrolled in Medicaid, disproportionately people of color, fare worse off than other Americans in both access to and quality of the health services they receive. [2]


As of 2023, more than 1.2 million people live in certified nursing facilities across the United States. [3] Of this population, approximately 74% are White, while Black and Hispanic residents make up just 15% and 6%, respectively. [4] And both nursing homes and skilled nursing facilities are highly racially segregated, even more so than other healthcare facilities in the United States. In fact, one 2018 study found that 80% of Black patients in the study were admitted to a subset of just 28% of nursing facilities and that 80% of Latino patients were admitted to 20% of nursing facilities. [5]


The nursing homes in these subsets, which primarily serve historically underrepresented groups, have a greater reliance than other facilities on Medicaid reimbursement, often resulting in a lower standard of care. Because the federal government reimburses at a lower rate than private insurers, facilities with a greater percentage of Medicaid patients are far more likely to deliver care of a lower quality, and their residents are far more likely to be hospitalized. [6] This system also results in racial disparities in areas such as antipsychotic medication use, COVID-19 infections and mortality, and even overall resident outcomes. [7]


The two-tiered system, in which Black and Latino patients are highly concentrated in a small group of nursing facilities—almost all of which score worse than predominantly White facilities on a variety of quality metrics—is a glaring example of the inequities endemic within our system of long term services and supports (LTSS). Although some cultural attitudes regarding end-of-life care emphasize home care rather than nursing facilities, families who do want or need to utilize nursing homes should be able to do so with the comfort of knowing that their loved ones will receive high-quality care and be treated with dignity. [8] With an aging and increasingly diverse population, it is vital we take actionable steps to address these disparities now. 


One of the most commonly cited and obvious factors contributing to substandard care in nursing homes is the issue of staffing. Nursing facility work has long been recognized as a particularly physically and mentally demanding role, and workers tend to agree that this is generally not reflected in their wages. It was not until the COVID-19 pandemic, however, that this issue began to garner media attention. During the pandemic, the virus claimed the lives of more than 167,000 nursing home residents, and frontline workers tasked with caring for them had one of the deadliest jobs in the country. [9] As a result, the pandemic has exacerbated staffing shortages in nursing homes across the country, directly impacting the quality of patient care.


In response to this crisis, the Centers for Medicare and Medicaid Services (CMS) recently released a federal rule requiring all nursing homes to comply with new national staffing standards for both registered nurses and nurse aides. [10] Proponents of the rule argue that this national standard will increase the quality of care for all nursing home residents but that it will also have a particularly positive impact on those in Medicaid-reliant facilities. It could be a pivotal moment in the fight for equity in nursing homes. 


Despite this, however, staffing progress may be slow. Many nursing homes are already struggling with the financial implications of coming into compliance with the new regulation, and even for those that are not, hiring new staff takes time and resources. 


Dismantling the segregated and inequitable system that currently exists in our nursing homes will not be easy, and there is no one simple solution. Yet, there are ways to continue making progress. 

Research has shown that even small increases in Medicaid payments to nursing homes can improve outcomes for residents, reducing disparities and particularly benefiting patients of color. [11] Tuition reimbursement, career ladder programs, and subsidies for nursing home staff are all viable options for replenishing the drastically diminished workforce. Increasing diversity and cultural competence skills within the next generation of nurses and aides are vital to addressing disparities in the system. The government, advocacy groups, and any other stakeholders involved must continue fighting to make a more equitable system for our elderly—not just for today but for generations to come. 

REFERENCES:

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8821413/ 

  2. https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/ 

  3. https://www.kff.org/medicaid/issue-brief/a-look-at-nursing-facility-characteristics/ 

  4. https://www.cdc.gov/nchs/data/series/sr_03/sr03-047.pdf

  5. https://pubmed.ncbi.nlm.nih.gov/29697778/ 

  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442243/ 

  7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8821413/ 

  8. https://www.hmpgloballearningnetwork.com/site/altc/article/cultural-influences-clinician-elderly-nursing-home-resident-relationship 

  9. https://www.nytimes.com/2023/08/19/health/nursing-homes-covid.html

  10. https://www.kff.org/medicaid/press-release/in-45-states-fewer-than-half-of-nursing-facilities-have-enough-staff-to-meet-new-federal-requirements/

  11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442243/

 
 

Authors

Julian Schwendeman

Healthcare Analyst, Center for Healthcare Innovation
 

Joseph Gaspero is the CEO and Co-Founder of CHI. He is a healthcare executive, strategist, and researcher. He co-founded CHI in 2009 to be an independent, objective, and interdisciplinary research and education institute for healthcare. Joseph leads CHI’s research and education initiatives focusing on including patient-driven healthcare, patient engagement, clinical trials, drug pricing, and other pressing healthcare issues. He sets and executes CHI’s strategy, devises marketing tactics, leads fundraising efforts, and manages CHI’s Management team. Joseph is passionate and committed to making healthcare and our world a better place. His leadership stems from a wide array of experiences, including founding and operating several non-profit and for-profit organizations, serving in the U.S. Air Force in support of 2 foreign wars, and deriving expertise from time spent in industries such as healthcare, financial services, and marketing. Joseph’s skills include strategy, management, entrepreneurship, healthcare, clinical trials, diversity & inclusion, life sciences, research, marketing, and finance. He has lived in six countries, traveled to over 30 more, and speaks 3 languages, all which help him view business strategy through the prism of a global, interconnected 21st century. Joseph has a B.S. in Finance from the University of Illinois at Chicago. When he’s not immersed in his work at CHI, he spends his time snowboarding backcountry, skydiving, mountain biking, volunteering, engaging in MMA, and rock climbing.