Health Services Regulatory Analysis: A Novel Method to Connect Policy to Health Services
Authors: Smith L. , Carder P. , Bucy T. , Winfree J. , Brazier J. , Zhang W. , Kaskie B. , Thomas K. 
Published: August 2020

Research ObjectiveStates regulate licensed care settings, such as assisted living (AL) residences, to protect residents, including many with cognitive impairments such as ADRD. States take varying approaches to critical issues in AL, including defining admission criteria, safety, and egress features, and discharge and eviction processes. Yet, researchers have not fully explored how state regulations affect resident care outcomes, which is the purpose of this study. To accomplish this goal, we developed a novel approach.Study DesignPrevious work by team members linked administrative lists of licensed AL facilities to Medicare claims. The current project created a dataset of states’ regulations with the use of methods from health services research, legal epidemiology, qualitative content analysis, and text mining. Our team sourced state AL license and certification regulations from Nexis Uni legal database for current requirements and changes over time. This method produced documents that describe states’ regulations for each of the 192 licensed or certified settings. We then coded these documents into dichotomous categories that can be linked to our existing dataset of Medicare claims.Population StudiedThis study examined all states’ AL regulations between 2007 and 2018, and lists maintained by state licensing agencies.Principal FindingsWe identified 192 unique types of state‐licensed or certified AL settings distinguished in the regulations, of which 171 were matched to state administrative records. Many states have subcategories or additional certifications with a range of between 2 and 22 license types, and 38 states license or certify at least one dementia‐specific setting. The ability to link our existing dataset of Medicare claims and our categorization of state regulatory requirements allowed for analysis of the relationships between regulatory changes and resident care outcomes.ConclusionsThis method advances previous observations that AL regulation varies by state. However, we extend prior knowledge by establishing a novel and reliable method for sourcing regulations and conducting text analysis that identifies the most salient aspects of facility licensure and certification and determining how these change over time. Our dataset allows us to quantify differences within and across states and to estimate how these regulatory variations impact AL residents’ health service use and outcomes.Implications for Policy or PracticeState agencies lack evidence about what works when implementing administrative requirements for AL settings. This study presents a reliable method for sourcing and analyzing the content of regulatory codes and identifying substantive changes made from one year to the next. This method allows researchers to conduct analyses that provide evidence regarding the impact of regulatory requirements on AL residents’ access to and use of health services. An added benefit to our approach is that researchers can use these methods to conduct more sophisticated analyses of state and intrastate variation on health outcomes. State licensing officials may benefit from and use this information when making regulatory changes.Primary Funding SourceNational Institutes of Health.