Is there evidence of cream skimming among nursing homes following the publication of the Nursing Home Compare report card?

Abstract

Purpose: A national quality report card for nursing homes, Nursing Home Compare, has been published since 2002. It has been shown to have some, albeit limited, positive impact on quality of care. The objective of this study was to test empirically the hypothesis that nursing homes have responded to the publication of the report by adopting cream skimming admission policies.

Design and methods: The study included all non-Medicare newly admitted patients to all Medicare- and Medicaid-certified nursing homes nationally during the 2001-2005 period. Using the Minimum Data Set data, we calculated for each quarter several admission cohort characteristics: average number of activity of daily living limitations and percent of residents admitted with pain, with pressure ulcers, with urinary incontinence, with diabetes, and with memory limitations. We tested whether residents admitted in the postpublication period were less frail and sick compared with residents admitted in the prepublication period by estimating fixed facility effects longitudinal regression models. Analyses were stratified by nursing home ownership, occupancy, reported quality ranking, chain affiliation, and region.

Results: Evidence for cream skimming was found with respect to pain and, to a lesser degree, with respect to memory limitation but not with respect to the 4 other admission cohort characteristics.

Implications: Despite the theoretical expectation, empirical evidence suggests only a limited degree of cream skimming. Further studies are required to investigate this phenomenon with respect to other admission cohort characteristics and with respect to post-acute patients.

Figure 1.

Admission cohort characteristics adjusted for facility fixed effects.

Figure 2.

Percent of the admission cohort with excruciating or daily moderate pain stratified by the facility’s quality ranking based on the pain quality measure.