Nursing homes are a critical element of any country's healthcare system. The facilities provide different personal and health services not only to the elderly but also to people living with various mental and physical conditions. In the facilities, these people get a chance to lead a quality life. As the baby boomers get into old age, the aged population in the United States, as well as around the world, is rising. It is estimated that 10,000 Americans turn 65 every day. Looking at these statistics, the demand for nursing home services will inevitably increase. Therefore, there is a need for more investment in the nursing home sector. In the United States, the responsibility of ensuring quality within nursing homes is shared by the federal and state governments. Generally, the federal government delegates some duties, such as the inspection of nursing homes to the state governments. They also make recommendations on ways to improve the nursing homes to the government. Citizens seeking services in nursing homes can either pay privately or using Medicaid. Studies have shown that Medicaid accounts for 50% and 70% of nursing home expenditures and bed days, respectively (Grabowski et al., 2008). Though care for the elderly was a principal target of the Medicare-Medicaid Act passed in 1965, the quality of care given in Medicaid nursing homes has always been questioned over the years. Studies have often revealed that Medicaid recipients are often admitted to facilities with lower resources and also receive poorer quality of care as opposed to patients who pay privately. This is regardless of the fact that the Centers for Medicare & Medicaid Services (CMS) requires that nursing homes should provide equal quality of care to all residents. In this light, this paper seeks to establish whether the quality of care given to Medicaid recipients is poorer than that offered to privately-paying residents. Measures to rectify the situation will also be explored.
Differences Between Public and Private Healthcare Insurance
Before comparing the quality of care given in the two situations, it is important to describe the private and public long-term insurance first. As compared to other first-world countries, the cost of healthcare in the United States is higher. To ensure the health of the population, citizens are urged to get public or private insurance covers. However, debate on which of the two is more economical has raged on over the years, particularly following the enactment of the Affordable Care Act (ACA) in 2010 (Newkirk II, 2016). For instance, the legislation improved transparency within the nursing homes and also enhanced the protection of residents in nursing homes. Public healthcare coverage refers to insurance plans offered by the government for specific populations, such as the elderly and low-income citizens. Medicaid, Medicare, and CHIP are the primary healthcare insurance covers offered in the United States. Medicare is the federal social insurance package targeted at the elderly as well as citizens with certain disabilities. As the country's population ages, the costs of Medicare were bound to rise, and hence ACA took various measures to reduce the burden. Generally, public health insurance is more affordable. Its administrative costs are cheaper, and deductibles are not required most of the time. However, it is less flexible. For instance, policyholders can only choose from a limited number of providers.
Private healthcare coverage refers to insurance plans offered by private companies. They are mostly provided by employers or other institutions chosen by the policyholder. The plan can be purchased as a group or individually. The increasing costs of providing care for an aging population led to the promotion of private long0term care insurance (Boyer, De Donder, Fluet, Leroux, & Michaud, 2017). Resultantly, a majority of citizens in the country are covered by private insurance companies today. This option is more flexible as compared to public healthcare coverage. The policyholders have more options regarding the facilities or doctors they visit. However, they are more expensive and usually require the policyholder to make monthly or annual payments.
Comparison of Quality of Care
As mentioned above, CMS is charged with the development and enforcement of safety and quality standards in nursing homes, as well as other sectors of the healthcare system in the country. In partnership with the State Survey Agencies (SSAs), CMS licenses and strengthens oversight of nursing homes across the country. The institutions also ensure that the facilities comply with the set safety and health standards. Staffing is one of the vital elements that allow nursing homes to offer the required care to their residents. To this end, CMS collects and shares staffing data from nursing homes with SSAs to identify and address any staffing problems (Verma, 2019). Though the administration of antipsychotic sedative drugs to residents who have dementia-related psychosis is prohibited by the Federal Drug Administration (FDA), some nursing homes still use the intervention (Basnet et al., 2020). To ensure compliance with the guidelines, CMS has partnered with different bodies to reduce the use of drugs. Noncompliance leads to penalties such as sanctions, as the CMS seeks to improve the quality of care given to residents in the nursing homes.
However, regardless of the measures by CMS, it has been shown that nursing homes that depend on Medicaid provide poorer quality of care to their residents. For the sake of this paper, quality refers to both the quality of care and quality of life. Quality of care can be defined as the technical competency of staff at the nursing homes. Quality of life, on the other hand, refers to factors such as dignity, comfort, sense of security, as well as the spiritual well-being of the residents. The factors used to measure the quality of care offered in nursing homes include; performance of the facilities during government inspections, the number of nurses and aides employed, as well as the health of the residents as determined by factors such as rates of infections and admission to hospital. Nursing homes with a majority of residents covered by public insurance perform worse on almost all these indicators. The number of health violations is also higher in nursing homes with more Medicaid beds. Concerns regarding the poor quality of care in nursing homes have been raised since the 1970s prompting various legislative responses over the years (Wiener, 2003). For instance, the Omnibus Reconciliation Act of 1987 was meant to raise the quality of care given in nursing facilities on both the Medicaid and Medicare programs. Studies carried immediately after the enactment of the legislation established that the quality of care given in nursing homes had improved. However, a series of studies carried out later found out that nursing homes across the country had serious deficiencies that placed the residents at the risk of serious injuries and even death. For example, in 2000, almost 100,000 complaints relating to poor quality of care in nursing homes were reported (Wiener, 2003).
The inability to employ the recommended number of nurses has been blamed for the disparity. The ability of the facilities to purchase medications, equipment, and maintain operations at maximum is also affected where the majority of residents have public insurance covers. All these challenges can be linked to the lower Medicaid reimbursements (Wood, 2019). The low reimbursements make it difficult for the management of nursing homes to attract and retain talented staff. The acquisition of other essential infrastructure and equipment also becomes difficult. Resultantly, the quality of care given is low, and it has also been proven that facilities that depend on Medicaid are cited for neglect more frequently (Wood, 2019). Ultimately, the problem does affect not only the publicly insured residents but also private-pay patients who use facilities dominated by Medicaid residents.
Ways to Improve the Quality of Care Given in Public Nursing Homes
Owing to the risks that poor quality of care poses to the country's most vulnerable population, there is a need to improve the quality of care offered to residents covered by public insurance. Some of the measures that can be used to achieve this goal include strengthening of the regulatory process, increasing Medicaid reimbursements, increasing awareness among the consumers, and strengthening the workforce in the nursing homes.
Strengthening of the Regulatory Process
As mentioned earlier, different legislations have been enacted over the years to enhance the quality of care of residents in nursing homes. However, the legislations are often ignored or overlooked, and hence the need to strengthen the regulatory process (Harrington et al., 2017). With the rise of Electronic Health Records (EHR), information systems should also be improved to boost quality monitoring. The strategy would enable reliable and timely sharing of data regarding the quality of care received. Regulatory bodies can then promptly act on any form of violations.
Strengthening the Workforce
The shortage of staff is one of the primary reasons for the provision of poor quality of care in nursing homes. Both the state and federal governments should seek to improve the staffing ratios within these facilities. The staff should also be highly trained to ensure their competence. Finally, the working conditions within the facilities as well as the wages and benefits of the workers should also be improved. The efficacy of these measures has been proven in various studies (Harrington et al., 2016).
Increasing Awareness Among the Consumers
Other than helping the consumers choose the best facilities, information also exposes them to the existing regulatory data. As such, they can detect and report violations. Consumer advocacy programs should also be promoted to help residents with conflicts get justice (Woo, Milworm, & Dowding, 2017). The groups also advocate for public policies meant to improve the quality of nursing homes.
Increasing Medicaid Reimbursements
As shown in the discussion above, the quality of care is worse in facilities with more Medicaid beds. Therefore, the federal government should seek to increase Medicaid reimbursements (Ng & Ritter, 2016). Higher reimbursements can be used to improve factors such as staffing ratios, which in turn improves the quality of care given.
As the country's population ages, the demand for services offered by nursing homes is bound to rise. While the existing regulations demand that nursing homes should provide equal services to all, this study has proved that residents covered by public insurance receive poorer quality of care as compared to those on private insurance covers. Moreover, the study has shown that nursing homes dominated by Medicaid residents offer poorer quality of care to both the public and private insurance recipients. The residents in such facilities are at higher risk of injury and death due to poor staffing rations, as well as lack of essential medications and equipment. As such, there is a need for both the federal and state governments to develop measures to address the issue. Some measures identified in this paper include strengthening of the regulatory process, addressing deficiencies in the quantity and quality of the workforce.
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