Association for Public Policy Analysis & Management

Introduction: Low quality of care in nursing homes has presented longstanding policy challenges for consumers, researchers and policy-makers. However, the impact of regulation on quality has only recently been addressed and current studies focus on enforcement stringency. Although all nursing homes are subject to federal standards, some states have adopted additional regulations in different areas of care. Using this natural experiment, this study is the first to analyze the contents of quality of care state regulations, compare them to federal regulations, tease apart specific components and link them to a corresponding quality outcome.

Methods: State laws for all 50 states and D.C. were compiled using primary legal research methods and secondary sources. Next, quality of care laws were analyzed and linked quantitatively to quality indicators developed and publicly
reported by CMS . The federal dataset has been used widely not only to provide consumers with information when selecting a nursing home, but also to evaluate policy and provider performance, and provide a foundation for evidence-based policy making. Quality indicators in the dataset were the result of extensive testing that included both provider and consumer concerns of what indicators were the most useful. County level and state level data obtained from the U.S. census and other sources are also used as covariates.

Results: Using data from 2011 and coding laws as dichotomous variables, adjusted regression results on outcome variables showed that compared to states that were only subject to federal standards, states that went above federal regulations had better outcomes such as less high-risk residents with pressure ulcers, less residents who self-report moderate to severe pain and less residents experiencing one or more falls with major injury.

Discussion: There is some evidence to support that more stringent state regulations have a positive relationship with quality of care in nursing homes. Based on an important national datset that provides publicly available standardized quality information on most nursing homes in the United States, this study is well positioned to inform policy-makers on existing regulations and whether and how regulation is associated with better quality of care in the nursing home setting.