Temple Times Online Edition
    SEPTEMBER 2, 2004
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Fox School professor details
racial disparities in health care

African Americans are four times more likely than white Americans to find themselves in poorly funded, understaffed nursing homes that offer substandard care, according to a comprehensive study of nursing homes conducted by Jacqueline Zinn, an associate professor of healthcare management at The Fox School of Business and Management, and her co-investigator, Vincent Mor, a professor of community health at Brown University Medical School.

The study, published on June 21 in The Millbank Quarterly, finds a two-tiered nursing home system with widespread socioeconomic and racial disparities in the quality of care provided.

Nationwide, 40 percent of African-American nursing home residents live in lower-tier nursing homes, compared with just 9 percent of white nursing home residents. In fact, African Americans are grossly overrepresented in lower-tier nursing homes in virtually every state in the country.

Zinn and Mor define lower-tier nursing homes as those facilities with a high proportion of Medicaid residents (85 percent or more) and very limited resources. Poor, frail and minority residents in these homes are more likely to receive substandard care.

Nevertheless, Zinn and Mor recommend that federal and state governments take steps now to prevent these lower-tier nursing homes from closing.

“We don’t want the message to be, ‘These are awful places. Let’s close them down,’” Zinn told The Philadelphia Inquirer. “Our real bottom line is, ‘Let’s improve them.’”

Many lower-tier nursing homes are located in the Deep South in such states as Louisiana, Mississippi and Georgia. Yet lower-tier facilities operate in poor communities across the country. More than one-quarter of nursing homes in poor rural communities are lower-tier. Nursing homes in the Northwest, however, are much less likely to have a high concentration of Medicaid patients.

In Philadelphia, 22 percent of homes were mostly Medicaid-covered, compared with 9 percent in Montgomery County and none in Chester County. In New Jersey, the percentage of Medicaid homes in Camden and Burlington counties was 12 percent, compared with 0.2 percent in Gloucester County.

In reviewing more than 14,000 non-hospital-based Medicare- and Medicaid-certified nursing homes, Zinn and Mor observed:

• Lower-tier nursing homes have significantly fewer registered nurses than those with more resources. No such difference exists for licensed practical nurses, suggesting that in lower-tier facilities, less-qualified staff are substituted for more-qualified professional staff.
• Administrators, nurse practitioners and physician assistants are less prevalent in lower-tier nursing homes.
• Lower-tier nursing homes offer worse care than their less-Medicaid-concentrated counterparts on three out of four quality measures — restraint use, high-risk pressure ulcers and low-risk anti-psychotic use — surveyed and reported by the Centers for Medicare & Medicaid Services.
• Lower-tier facilities are significantly more likely to serve residents with psychiatric conditions or those with a history of mental retardation.

Although quality care should be available to all, Zinn and Mor question the current trend of allowing poorly funded and operated nursing facilities to close because they can no longer compete in the marketplace.

“The implications of closing these facilities are more complicated than we thought,” Zinn said. “These homes are concentrated in various parts of the country and disproportionately serve African Americans. Instead, states must do more to identify the nursing homes in trouble and to help them survive.”

The Robert Wood Johnson Foundation funded the study as part of a grant under the Investigator Awards in Health Policy Research program. The foundation created the program in 1992 to support innovative and crosscutting research that promises to contribute meaningfully to understanding difficult health problems and to improving health policy in the United States.

The Milbank Memorial Fund and Blackwell are publishers of The Milbank Quarterly. The multidisciplinary journal offers in-depth assessments of the social, legal and ethical dimensions of healthcare policy.

-By Lisa Meritz

Recommendations for reducing inequalities in nursing homes
As public reporting of annual survey results steers prospective residents away from poor homes, Fox School researcher Jacqueline Zinn and her co-investigator from Brown University Medical School, Vincent Mor, caution that poorly funded nursing homes may find themselves in even worse circumstances as admissions and revenues drop.
They recommend a variety of policy solutions that would require government to take greater responsibility for homes that are failing:
• Increase the level of Medicaid payments so that lower-tier facilities, which primarily serve Medicaid patients, have more financial resources.
• Offer training for nursing home managers in order to improve quality.
• Give states or municipal governments the authority to take over or rescue apparently failing nursing home facilities.
• Create a risk pool for the purpose of relocating lower-tier residents to alternate facilities if the current nursing home cannot be saved.