For-Profit Care and Quality: An Oxymoron? Joel Lexchin School of Health Policy and Management York University

Points to Cover Measures of quality of care and long-term care facility status Explanation for differences – Payment mechanisms – Staffing

Post-Acute Care Residents

Antipsychotic Prescribing Manitoba – Odds of being dispensed antipsychotic medications were 1.7 times greater for residents of for-profit homes in the Winnipeg Regional Health Authority versus not-for-profit and public homes in Manitoba Minnesota – Medicare and Medicaid certified for-profit facilities had higher antipsychotic use rates than did not-for-profit facilities United States – All 14,631 Medicare and Medicaid certified homes – Antipsychotic use was higher in those operated on a for- profit basis versus those on a not-for-profit basis

Outside North America (Israel) Scores adjusted for daily paid rate, institutional size & staffing level

Overall Level of Care British Columbia (Canada) for-profit versus not-for-profit facilities – Higher adjusted hospitalization rates for pneumonia, anemia, and dehydration – No difference for falls, urinary tract infections, or decubitus ulcers/gangrene – No difference in mortality rates Two meta-analyses (American data) – “systematic differences exist between for-profit and not-for-profit nursing homes. For profit nursing homes appear to provide lower quality of care in many important areas of process and outcome” – Not-for-profit facilities delivered higher quality care than did for-profit facilities for two of the four most frequently reported quality measures” and for the two others there were non-significant results favouring not-for-profit homes

Newly Admitted Residents Residents admitted to for-profit, independently owned facilities were younger, took fewer medications and had fewer falls in the 30 day prior to admission

For-Profit Status or Other Factors? US study looking at pressure ulcers – May not be profit status but the extent to which practice environment supports staff nurses Poorer performance among US for-profit homes may relate to them having lower occupancy, higher Medicaid census, and operating in US states with lower Medicaid payments compared to not-for-profit homes – Higher percent Medicaid residents and lower payments put fiscal pressures on both for-profit and not-for profit homes – Restraint use increased and nursing levels decreased in both types of homes

Amount of Care By Type of Ownership Residents requiring more complex care – Types 2 and 3 – reside predominantly in government-owned facilities in four of five Canadian regions. On the other hand, in four of five regions, residents needing Type 1 Care reside in Not-For-Profit facilities where we generally observe the highest unregulated staffing levels.

Can Other Factors Explain Staffing Levels? Residents requiring more complex care – Types 2 and 3 – reside predominantly in government- owned facilities in four of five Canadian regions In four of five regions, residents needing Type 1 Care reside in Not-For-Profit facilities where we generally observe the highest unregulated staffing levels Public payment levels differ by province but are the same to all types of homes in each province

Conclusions Better quality of care by multiple measures in not-for profit facilities Better staffing in not-for profit facilities Staffing not explained by type of patient, size of facility or payment

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