Study Finds Quality Gains in Skilled Nursing Facilities Come at a Price

The federal government has taken major steps over the last decade to reduce spending while also improving resident care, but a recent study finds that achieving the goal might not be so easy.

A team of researchers led by Kathleen Carey of the Boston University School of Public Health found that quality gains at Veterans Administration nursing homes were consistent with increases in spending — a somewhat straightforward conclusion, but one that goes against previous research in the field.

“This finding contrasts with a patient-level study of the relationship between quality and costs in VA inpatient settings. That study … found higher rates of adverse patient safety events to be associated with higher patient costs,” the team noted in the study, published last week in the journal PLOS One.


The researchers used facility-level data on 13 adverse events categories for fiscal years 2014 and 2015, encompassing residents at 132 of the VA’s “community living centers” (CLCs) — its term for nursing homes. They then compared that data with the costs associated with operating those facilities, calculated as both total direct costs as well as the specific price tag for nursing and residential care.

The results showed a correlation between spending and reductions in adverse events: For instance, facilities in the 75th percentile had 1,768 incidents compared to a total cost of $7.1 million, while CLCs in the 25th percentile achieved just 485 negative events with almost $8.0 million in costs; in terms of nursing costs alone, those figures were $4.1 million and $4.5 million, respectively.

“Using two different metrics based on 13 outcome measures of quality, we found that higher level of quality was associated with higher predicted cost, consistent with the economic interpretation,” the team concluded.


The analysis had several limitations, the researchers noted, as it did not reflect patient-level data. In addition, it only focused on VA data, largely because that department keeps detailed public information about outcomes and cost, and did not account for potential changes in case mix across the government-run CLCs.

“Another possible contributor to the positive association between quality and cost is unmeasured case mix. Residents who are in poorer health may be more likely to have a fall, pressure ulcers, or receive antipsychotic medication, for example, and may also be relatively high cost residents,” the team wrote.

Written by Alex Spanko

Companies featured in this article: