This study finds that Blacks have higher odds of experiencing risk adjusted pressure ulcer outcomes than Whites in NYS nursing home. Furthermore, we find that the higher rates of pressure ulcers experienced by Blacks can be attributed to their disproportionate congregation in facilities with lower quality of care rather than within facility disparities. That is, all residents in such facilities have higher risks of pressure sores, regardless of race.
The within-facility racial disparities in treatment have not been previously studied (20
). However, studies that did examine the within-facility disparities in quality of care delivered to Medicaid and private-pay residents also found no significant within-facility differences (34
). These findings suggest that daily care staff are not likely to systematically render better or worse care to residents on the basis of race or insurance status. Similarly, consistent with other studies (20
), we find that residents in facilities with higher proportion of Blacks have higher risk of pressure ulcers than their counterparts from facilities with lower penetration of Blacks. This may be explained by the fact that Blacks are more likely to reside in nursing homes with higher percentage of Medicaid residents. Such facilities have been shown to have fewer resources and poorer quality of care (18
Since the disparity we observed is mostly due to variations across facilities, it may be necessary to improve overall quality in facilities serving a large percent of Blacks in order to bring about equality in outcomes. Such efforts may require a substantial influx of new resources to facilitate upfront investments necessary to institute quality improvement processes in these facilities. In recent years, a number of state Medicaid agencies started to implement Medicaid pay-for-performance (P4P) strategies in nursing homes, using either a bonus or an add-on to facility daily rate based on quality improvement (35
). Such strategies may provide some financial incentives for nursing homes where Blacks tend to congregate to improve their quality of care. However, whether as a result of such incentives the differential in quality of care between these facilities and those with mostly White residents will narrow, remains to be seen. Furthermore, P4P alone may not be sufficient to bring about quality improvement. Blacks are more likely to congregate in facilities with Medicaid concentration, which tend to be more strapped for resources. Moreover, as suggested by Mor et al (18
), poor-quality facilities are not randomly distributed, but rather they are aggregated in poor communities. Therefore, such facilities may require additional funding to bring them up to par, so that eventually they may be able to successfully compete for P4P rewards and produce better outcomes. A simple subsidy of these poor quality facilities is, however, costly and inefficient. A better approach may be a subsidy based on the continuous evaluation of quality of these facilities (18
The congregation of Blacks into “poorer” quality nursing homes may also be the result of “better” quality nursing homes denying or delaying admissions based on individual’s race (37
). Although nursing homes in New York State are required not to discriminate against Medicaid residents with regard to admission (New York regulation section 415.3), perhaps not all facilities faithfully follow this regulation. This may be true especially of those homes that have long waiting lists are also the one “better” quality. Additional research is needed to prove or disprove this supposition. It has been suggested that higher Medicaid payments, on behalf of the access-disadvantaged populations, may more equitably redistribute them across facilities (36
). However, the impact of such a strategy has not as yet been tested.
Several limitations should be mentioned. First, we only examine racial disparity with regard to the risk of pressure ulcers in nursing homes. CMS measures nursing home quality of care using nineteen quality indicators. It has been shown that there is no association between quality performance in one area with that of another (31
). For example, a facility that provides poor quality of care in prevention of pressure ulcers may have average or good performance with regard to a different quality indicator. It would be prudent to examine the relationship between race and other quality indicators before concluding that there is no within-facility disparity in the overall quality of care provided to Blacks and Whites in other dimension of care. Second, this study is only focused on facilities in NYS. Therefore, its findings might not generalize to other states.
In conclusion, we find that in New York State higher odds of risk adjusted pressure ulcers among Black nursing homes residents are largely a function of differences across facilities rather than of within-facility discrimination. To improve the quality of pressure ulcer care for Black nursing home residents, efforts should focus on improving the overall quality of care in facilities with higher proportion of Black residents.