State Quality of Care Laws and Nursing Home Outcomes in the United States

Introduction: Low quality of care in nursing homes has been well documented and is a long-standing problem. However, few of the studies in this area have focused on the regulation of nursing homes outside of staffing regulations. This study was the first of its kind to empirically examine the relationship between state nursing home quality of care regulations and quality outcomes. Quality was measured by quality indicators used by the federal regulatory body, Center for Medicare and Medicaid Services (CMS), and consumer determined quality measured by complaints reported by state long-term care ombudsmen programs (LTCOMP). Methods: The study first compiled and analyzed state quality of care regulations and a coding scheme and longitudinal dataset of state alignment with federal standards for nine key markers was created. The law dataset was then empirically linked to outcomes, utilizing a natural experiment whereby nursing homes in some states are regulated entirely by federal standards, while nursing homes in other states are subject to federal and additional state regulations. Both pooled regression analyses and a Difference in Differences design were employed. Results: Results provided some evidence that more stringent regulation may lead to or is associated with better CMS quality outcomes, but the associations or effects were not consistent across multiple dimensions of quality. Specificity in the laws mattered. Laws with targeted and defined requirements and incorporating more clinical best practices were often associated with the intended CMS outcome, while laws which were generic in their language and without specific directions, or had relatively looser requirements, were associated with undesirable CMS outcomes. Using a difference in differences design, results showed a worsening of outcomes when a state relaxed its standards and better outcomes when a state enhanced their standards. States that went above federal standards were also often associated with increased complaints made to LTCOMPs. Conclusion: While causal inference should be limited in scope, this study can help inform policy makers at all levels and help guide important decisions about current and future regulatory initiatives. Ultimately, the results from this study have implications for over 15,000 nursing homes and 1.4 million nursing home residents.