Organizational characteristics and cancer care for nursing home residents.

Over 60 percent of cancers diagnosed in the United States occur among adults over the age of 65 (Yancik and Ries 2000; Bourbonniere and Van Cleave 2006;), and cancer is the second leading cause of death for this group (Sahyoun et al. 2001). An important but largely unexplored provider for cancer care for the elderly is the nursing home, where the prevalence is estimated to be 9 percent (Johnson et al. 2005). Cancer and its treatment may prompt some patients to enter a nursing home, while other patients are nursing home residents at the time of diagnosis. The care of this latter group is of particular interest because these patients have a newly diagnosed condition that is exogenous to nursing home care. How a nursing home responds to a new condition that is unrelated to the quality of care patients receive during their residency (unlike pressure sores, for example) lends insight into the determinants of nursing home quality without the interference of selection that emerges from nonrandom pairing of facilities and patients. We integrate organization, market, policy, and resident characteristics in a model to explain timeliness of cancer diagnosis and pain management. The study group consists of Medicaid and Medicare-insured (dually eligible) elderly residents of Michigan nursing homes who entered facilities for long-term custodial care without a cancer diagnosis but were subsequently diagnosed with cancer from 1997 to 2000. All had been residents for at least 31 days. Our study informs two lines of inquiry. First, we address how nursing home and market variables are related to the care provided to residents. The rising number of elderly in the United States, combined with the absence of quality-of-care information on serious, painful, and costly diseases such as cancer, makes this investigation particularly relevant. This study uniquely examines the ability of nursing homes to recognize a condition that is not caused by facility care processes. The second line of inquiry concerns the 1997 Balanced Budget Act (BBA), which included some of the most substantial payment policy changes for nursing homes in the past two decades. It cut funding for Medicare skilled and rehabilitation care for short-stay residents significantly—by US$2 billion in 1999 (Medicare Payment Advisory Commission 2003)—and replaced cost-based payment with a prospective pricing system (PPS) phased in for fiscal years (FYs) starting on or after July 1, 1998. Such a large reduction in resources likely affected many internal nursing home care processes. Konetzka et al. (2006a) and Konetzka, Norton, and Stearns (2006b) found that the BBA payment changes for short-stay residents also negatively affected the quality of care for long-stay residents through more deficiencies and higher rates of pressure sores and urinary tract infections. Another BBA provision may have affected access of dually eligible residents to outpatient care necessary for cancer diagnosis by allowing states more flexibility in the amount they pay to cover Medicare cost-sharing for the dually Medicare and Medicaid insured. After a deductible is met, Medicare pays 80 percent of an allowable amount. States cover some or all of the deductible and remaining 20 percent for the dually insured. Although they did not specifically examine the dually eligible in nursing homes, Mitchell and Haber (2004/2005) report that after Michigan cut the cost-sharing amounts by nearly 76 percent, as allowed by the BBA, the dually insured in the state had significantly less access to outpatient services relative to the pre-BBA period.