Study Finds "Two-Tiered" System of Nursing Homes

[This article was originally published on June 25, 2004.  The links were updated on August 23, 2018.]

African-Americans are four times as likely as white Americans to reside in understaffed nursing homes that provide substandard care, according to a new study in the Milbank Quarterly, a health policy journal.

The study found that nationwide, 40 percent of African-American nursing home residents live in "lower-tier" nursing homes, compared to just 9 percent of all white nursing home residents.

A "lower-tier" facility is defined as having a high concentration of Medicaid residents (85 percent or more) and very limited resources. States with the most such facilities include Louisiana, Mississippi and Georgia, but they can be found in economically distressed communities across the country. In Missouri, for example, 33 percent of African-American nursing home residents are in lower-tier facilities, while only 5 percent of whites are in such facilities.

"It becomes a vicious cycle," said Vincent Mor, the study's lead author and a professor at Brown University's medical school. "Nursing homes are local. You rely on nursing homes that are near you. In a poor neighborhood, you can't attract richer people, so only poor people come to the nursing home. You have a harder time paying staff and you have a higher turnover rate. Care becomes substandard."

The report suggests that the rates the government pays nursing homes for Medicaid patients are a major cause of the deep division in the quality of facilities. "The Medicaid situation has gotten to the crisis point," said Larry Minnix, president and chief executive of the American Association of Homes and Services for the Aging, a Washington-based group representing 5,600 nonprofit aging services organizations. "The feds need to rethink what standardized benefits are, and what does a basic level of care cost."

The report also found that the nursing home "report card" approach begun by the Bush administration two years ago has only worsened the problem. This is a free-market approach similar to Bush's No Child Left Behind initiative, in which nursing homes are graded on quality with the assumption that patients or their families will vote with their feet, rewarding quality facilities while forcing substandard homes to improve. (See "Report Cards on 17,000 Nursing Homes Released.")

But the researchers found that many nursing homes with low report card scores do not have the funds to raise their scores and compete. As a result, such facilities are vulnerable to closing or continuing to offer substandard care to residents with the least means to take care of themselves or to move.

"Like the schools, you are trying to get nursing homes to compete on quality," Mor said. "It's a very admirable idea. It's just that in some neighborhoods, some nursing homes will be bearing the brunt of the failures. What are we prepared to do about this?"

The study, funded by the Robert Wood Johnson Foundation, was conducted by professors from Brown and Temple universities, who examined records from more than 14,000 nursing homes nationwide.

To reduce inequalities in nursing homes, the study suggests, among other things:





  • Increasing Medicaid payments so that lower tier facilities have more financial resources;
  • Offering training programs for nursing home managers to learn how to improve quality;
  • Having states more frequently monitor facilities with high concentrations of Medicaid beneficiaries;
  • Giving state and city governments the authority to take over apparently failing nursing homes.

For an article on the study in The Washington Post, click here.

For an article in the San Francisco Chronicle, click here.