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Grabowski Web Exclusive
D A T A W A T C H
N U R S I N G H O M E P A Y M E N T
W E B E X C L U S I V E
16 June 2004
Recent Trends In State Nursing Home Payment Policies
States appear to have maintained
the level of their Medicaid payment rates since 1999,
in spite of the repeal of the Boren amendment.
By David C. Grabowski, Zhanlian
Feng, Orna Intrator, and Vincent Mor
ABSTRACT:
State Medicaid programs pay for a sizable portion of overall nursing home
expenditures. The repeal of the Boren amendment in 1997 gave states greater
freedom to set Medicaid nursing home policy. This study presents data from a
comprehensive survey of state nursing home payment policies during 1999–2002.
Aggregate inflation-adjusted Medicaid payment rates rose steadily, and there
was no sizable increase in the adoption of other cost-cutting policies. Although
these findings can be interpreted with some optimism from a nursing home financing
perspective, areas of concern remain for state nursing home policy during the
next several years.
Escalating costs have dominated nursing home policy discussions in recent years.
In 1960 nursing home spending represented about 3.4 percent of all personal
health spending, but by 2001 they had grown to 8.0 percent (or $98.9 billion).1
State Medicaid programs account for 47.5 percent of these expenditures. Historically,
the two primary approaches to lowering state nursing home spending have involved
reducing state Medicaid payment rates and limiting the number of Medicaid recipients
in homes via certificate-of-need (CON) laws and construction moratoria.2
The first mechanism constrains the price of care, and the second theoretically
constrains the quantity of available Medicaid beds.
These state policies may be particularly important in light of concerns regarding
quality of care and access to services for Medicaid nursing home recipients.3
There is evidence that lower Medicaid payment rates and the use of prospective
payment methods are associated with poorer nursing home quality.4
Similarly, lower payment rates have been found to be associated with worse access
to nursing home care for Medicaid recipients.5 Finally,
by serving as a barrier to entry, CON laws have historically been thought to
impede nursing home competition and lower both quality of care and access to
services for Medicaid residents.6
Prior to 1998, federal law linked Medicaid nursing home payment policy with
minimum federal and state quality-of-care standards through the Boren amendment,
which was adopted as part of the Omnibus Budget Reconciliation Act (OBRA) of
1980 and required that Medicaid nursing home rates be “reasonable and adequate
to meet the costs which must be incurred by efficiently and economically operated
facilities in order to provide care and services in conformity with applicable
state and federal laws, regulations, and quality and safety standards”
(Section 1902(a)(13) of the Social Security Act). State Medicaid officials opposed
the Boren amendment because they believed that it caused states to spend too
much on nursing home care relative to other services.7
Thus, the Balanced Budget Act (BBA) of 1997 repealed the Boren amendment and
gave states greater latitude to set payment rates for nursing home care. Surprisingly,
there are few recent data examining whether states have shifted nursing home
policy in response to the repeal of the amendment. The last comprehensive survey
of state nursing home policy was conducted in 1998.8
This paper reports the results of a survey of state Medicaid programs for the
period 1999–2002.
Background On State Nursing Home Policy
Medicaid, the dominant purchaser of U.S. nursing home services, gives indigent
people access to nursing homes by directly reimbursing facilities for the care
of Medicaid-eligible residents. State Medicaid programs are responsible for
approximately half of all nursing home spending, and Medicaid recipients constitute
70 percent of all bed days. The remainder of care is financed primarily by private
out-of-pocket payments.9
States have considerable discretion in setting Medicaid payment methods and
rates. There are three broad Medicaid payment methodologies for nursing home
care: retrospective, prospective, and combination systems. Under a retrospective
system, Medicaid payment is determined after the provision of care and is based
completely on the costs incurred by the facility. As a result, it is thought
that homes have a strong incentive to drive up costs to increase revenue.
In contrast, prospective methods set rates in advance of care, regardless of
actual costs the facility incurs during the rate year. Generally, prospective
methods use facility- and resident-level information from previous years to
determine the rate. The prospective category can be grouped into four subclasses
indicating the level at which payment rates for nursing facility care are defined:
(1) class method (flat rate set for groups of facilities); (2) facility specific
(rate set for each facility based on historical costs and other factors); (3)
resident specific (rate set based on resident characteristics); and (4) both
facility and resident specific. Prospective reimbursement systems can resemble
retrospective systems if the base from which the rate is determined is updated
yearly or if strong efficiency incentives are absent.10
However, a prospective system is generally thought to constrain costs through
the inclusion of such features and the fact that rates are set in advance of,
rather than following, the rate year.
Combination methods are hybrid systems incorporating aspects of both prospective
and retrospective reimbursement. That is, the rate is set in advance for some
cost components and afterward for others based on actual costs. In the early
1980s states almost universally employed retrospective payment, but by 1997
states had largely made the transition to prospective and combination systems.11
A majority of states have CON and construction moratorium regulations in place,
with the goal of constraining nursing home costs by preventing the “unnecessary”
construction of beds. The underlying logic of these laws is that fewer total
nursing home beds lead to fewer Medicaid patients in nursing homes, ultimately
resulting in lower state Medicaid spending. During 1981–1998 sixteen states
repealed their CON laws, and twenty-five imposed moratoria on new beds.12
Study Data And Methods
Data collection.
Beginning in May 2002 a research team at the Brown University Center for Gerontology
and Health Care Research developed a protocol for data collection of state policies
under the auspices of a National Institute on Aging (NIA) grant (no. AG20557-01,
with Vincent Mor as principal investigator). Information sources were identified
using the state Medicaid toll-free telephone lines available from the Centers
for Medicare and Medicaid Services (CMS) Web site, www.cms.hhs.gov/medicaid/tollfree.pdf.
Following the links on this site, each state’s Medicaid office was contacted
to identify the person most knowledgeable about the state’s Medicaid policies.
In September 2002 a draft survey protocol was sent to Connecticut to field-test
the survey. After receiving responses and comments from the state, the questions
were revised, and a second field test of the survey was sent to Colorado, Illinois,
New Mexico, Ohio, and Rhode Island in January 2003. Based on responses from
these states, the survey instrument was further refined, and the final questionnaire
was mailed to the identified contacts in the forty-eight contiguous states in
March 2003.
The states responded to the survey during the ensuing months; the study team
then reviewed the responses and followed up with respondents to clarify any
inconsistencies and request additional information if needed. When necessary,
the primary contact in the state referred the study team to other state officials
for additional or clarifying information. The study team made every effort to
ensure that the data collected were as complete and accurate as possible. For
example, survey responses were validated with information available from other
sources on an ongoing basis.13 The survey process
was completed for all forty-eight states in August 2003.
Adjustments and analysis.
In an effort to account for inflation over our period of study, we adjusted
the Medicaid payment rates using the overall Consumer Price Index (CPI). Also,
because of the need to interpret Medicaid payment policy changes in the context
of increasing resident acuity in many nursing home markets, we also present
aggregate state data from the Minimum Data Set (MDS) for nursing home care on
the average annual percentage change in the Resource Utilization Groups (RUGs)
case-mix index (version 5.12) between 1999 and 2002.
Study Results
Medicaid payment rates.
The states were asked to provide their average daily Medicaid nursing facility
payment rate for each of the four years during 1999–2002 (usually averaged
over the state fiscal year).14 The national trends
in average Medicaid per diem rates in real and nominal terms over the 1999–2002
period are illustrated using box-plot graphs (Exhibit
1).15 The left-hand panel shows the annual
distribution of nominal (unadjusted) rates, which reveals a strong upward trend
over the four-year period. The average state Medicaid per diem rate was $97.98
in 1999, $103.51 in 2000, $110.46 in 2001, and $117.73 in 2002, for an average
annual increase of 6.5 percent. The right-hand panel shows the annual distribution
of adjusted rates in constant 2002 dollars (using the overall CPI), which indicates
a moderate increase over the study period. The average per diem rate was $105.80
in 1999, $108.14 in 2000, $112.21 in 2001, and $117.73 in 2002, for an average
annual increase of 3.8 percent. By comparison, the inflation-adjusted average
annual increase for the period 1995–1998 was 0.4 percent.16
Based on these two trends, it would be difficult to conclude that the repeal
of the Boren amendment caused a sizable decline in the generosity of state Medicaid
payment rates. In fact, the 1999–2002 period was a time of incredible growth
in payment rates compared with the prior four years.
Importantly, however, the national trend in Medicaid payment rates may mask
cross-state differences over time. There was much variation across states over
the period 1999–2002 (Exhibit
2). In nominal terms, every state had a higher payment rate in 2002 relative
to 1999. In inflation-adjusted terms, however, Illinois, New York, and Missouri
did not increase their Medicaid payment rates over this period. Delaware experienced
the largest percentage growth in its per diem rate, from $105.22 in 1999 to
$159.67 in 2002 for an inflation-adjusted annual growth rate of 12.4 percent,
which was largely attributable to interim increases in the direct care (that
is, nursing component) portion of the rate mandated by state legislative changes.
Other states that experienced a large inflation-adjusted annual increase in
Medicaid payment rates included Arkansas (10.9 percent), Oklahoma (9.8 percent),
Nevada (9.1 percent), and Maryland (7.6 percent). The states with the lowest
annual inflation-adjusted growth rates in Medicaid payment rates were Illinois
(–1.4 percent), New York (–0.7 percent), Missouri (0.0 percent), North
Carolina (0.2 percent), and Washington (0.2 percent).
As one might expect, states with a lower baseline rate in 1999 experienced a
greater percentage increase relative to states with higher baseline payment
rates. If we divide the forty-eight states into tertiles (three sixteen-state
groups) based on their 1999 Medicaid payment levels, the low payment group experienced
a 4.7 percent annual inflation-adjusted increase, the middle group experienced
a 3.9 percent increase, and the high group experienced a 2.9 percent increase.
One potential conclusion is that the majority of states have continued to increase
Medicaid payment rates even with the repeal of the Boren amendment. However,
descriptive trends, even at the state level, may mask other changes in the nursing
home industry. One important development has been the growth of potential nursing
home substitutes such as home and community-based services. The proportion of
total Medicaid long-term care spending directed to these services increased
from 11 percent in 1988 to 27 percent in 2000.17
Nursing home occupancy rates have fallen in recent years as Medicaid home and
community-based services and private-pay assisted living have siphoned off lower-acuity
nursing home residents.18 Thus, a state that increased
its Medicaid payment rate only to offset an increasingly more disabled Medicaid
population would actually have a less generous payment policy over time because
of inflation.
The final two columns in Exhibit
2 examine this issue of increased acuity levels in nursing homes by reporting
the average annual increase in a case-mix index for new admissions and one for
all residents who were in the nursing home for at least one year.19
Nationally, the average annual increase in the case-mix index was 0.82 percent
for new admissions and 0.60 percent for the long-stay population over the period
1999 through 2002. All but four states (Louisiana, Oklahoma, Texas, and Arkansas)
experienced a positive annual increase in case-mix among new admissions, and
all but two states (Texas and Arkansas) experienced a positive annual increase
among the long-stay population. Although there was a modest positive correlation
between the annual percentage change in resident acuity (either at admission
or for the long-stay population), these data highlight the importance of considering
resident acuity when evaluating payment generosity.20
Medicaid payment methods.
As of fiscal year 2002, thirty-nine states used prospective reimbursement methods
to set nursing facility Medicaid payment rates, compared with forty-four states
in 1998.21 Among states using a prospective system,
rates were set using a class- or flat-rate method in four states (same as FY
1998), facility-specific in nineteen states (down from thirty-three states in
FY 1998), resident-specific in two states (down from three states in FY 1998),
and both facility- and resident-specific in fourteen states (up from four states
in FY 1998). Compared with 1998, there was a large shift within the prospective
category from states that used only facility-specific methods to states that
used both facility and resident factors. This shift was largely attributable
to the restructuring of existing case-mix payment systems.
Only two states, Maryland and Wyoming, used retrospective methods in FY 2002
(up from one in FY 1998).22 The number of states
using combination methods increased from three in 1998 (North Carolina, Tennessee,
and Virginia) to seven in 2002 (North Carolina and Virginia remained the same;
Tennessee considered its method to be prospective instead of combination in
2002; and Alabama, Kentucky, Michigan, New York, and Texas considered their
methods to be combination in 2002 while they were reported as prospective in
1998). In sum, except within the prospective category, where facilities shifted
toward a greater use of resident-specific methods, there was not a major change
in the Medicaid payment methods over the past several years.
Certificate-of-need and
construction moratoria.
As of 2002, thirty states had a CON program to regulate nursing facilities,
compared with thirty-five states in 1998. States that terminated CON programs
for nursing home care during this period included Delaware, Georgia, Iowa, Indiana,
and Wyoming. No state added a CON program between 1998 and 2002. A construction
moratorium for nursing facilities was in effect in seventeen states in 2002,
compared with eighteen states in 1998. During this period five states terminated
moratoria (Maine, Michigan, Missouri, Mississippi, and Wisconsin), and four
states added moratoria (Florida, Kentucky, New York, and Wyoming). Thus, there
was actually a decrease in the use of supply constraints such as CON and construction
moratoria over the study period.
Discussion
Widespread adoption of cost-cutting measures by state Medicaid programs was
not observed over the period 1999–2002. In particular, the average Medicaid
payment rate for nursing home care experienced a sizable increase over this
period after adjusting for inflation. This is particularly noteworthy because
inflation-adjusted payment rates were relatively flat over the period 1995–1998.
Moreover, despite a trend during the 1980s and early 1990s away from cost-based
Medicaid payment systems, there was no further adoption of prospective payment
systems by state Medicaid programs. Finally, six states repealed CON during
the period of study, and two fewer states had construction moratoria in place
in 2002 than in 1998.
Our finding of relatively generous nursing home policies during the past several
years is supported by a recent report from the U.S. General Accounting Office,
which examined Medicaid payment rates over the period 1998 through the proposed
rates for fiscal year 2004 for nineteen states.23
The report concluded that there were no major cuts to state Medicaid payment
rates or major changes in payment methods over this period. Taken together with
our findings, states appear to have maintained Medicaid payment rates and methods
in spite of the repeal of the Boren amendment.
Although these results paint a relatively positive picture, several concerns
must be acknowledged in evaluating these findings. First, as we documented in
this study, states are caring for an increasingly sicker and more disabled nursing
home population. On average, states are admitting residents with 0.82 percent
higher case-mix index scores than the previous year over the study period. Moreover,
many states are using case-mix-adjusted Medicaid payment systems, which pay
higher rates for more-disabled residents. As expected, we observed the largest
increase in resident acuity in states with these systems in place.24
Thus, when evaluating Medicaid payment generosity over time, it is important
to acknowledge the increasing care needs of a more disabled nursing home population.
Second, to meet these increasing care needs, nursing homes must hire additional
staff. Labor is the dominant input in the production of care, accounting for
nearly two-thirds of all nursing home costs. With the decline over the past
twenty years in the number of younger women entering the nursing profession,
we are experiencing the initial phase of a potentially severe nurse workforce
shortage.25 Peter Buerhaus and colleagues predict
that unless the trend is reversed, the registered nurse workforce will decline
nearly 20 percent below projected requirements by 2020.26
Ceteris paribus, a decrease in the supply of nurses will lead to higher nursing
home wages and an even greater strain on state Medicaid budgets for nursing
home care.
Finally, in the context of the recent economic recession and state budget shortfalls,
state Medicaid spending has been targeted as a potential area of cost savings.
A Henry J. Kaiser Family Foundation survey of state Medicaid directors found
that forty-nine states plan to reduce the rate of growth in Medicaid spending,
while nineteen plan actual cuts in their Medicaid spending for long-term care.27
To account for shortfalls in state Medicaid budgets, the GAO reported that states
have relied on alternative funding sources such as tobacco settlement, budget
stabilization, increased cigarette taxes, and Medicaid trust funds.28
In addition, states have recently adopted or proposed taxes on nursing home
providers in an effort to fund nursing home payments or to avert service reductions.
However, there may be reason to suspect that the coming years may result in
cuts to Medicaid payment rates if states cannot uncover additional sources of
revenue. An April 2003 study by the National Conference of State Legislatures
(NCSL) found that twenty-eight states and the District of Columbia expected
budget shortfalls totaling more than $53 billion in FY 2004.29
Moreover, the GAO notes that many states have depleted their alternative funding
sources such as the tobacco settlement funds. Thus, it is more likely that state
Medicaid payment cuts will be observed in FY 2004 and beyond.
The bottom line is that aggregate inflation-adjusted Medicaid payment rates
increased steadily, and there was no major increase in the adoption of other
cost-cutting policies over the period 1999–2002. From a nursing home financing
perspective, this finding can be viewed in a positive light following the repeal
of the Boren amendment. Looking forward, it will be important to monitor Medicaid
payment policies and the use of supply regulations over the next few years to
determine whether factors such as an increasingly disabled nursing home population,
rising nursing wages, and state budget shortfalls have implications for state
nursing home policy.
This research was supported by the National Institute on Aging (Grants no.
AG20557 and no. AG11624), and data were analyzed under Data Use Agreements no.
12432 and no. 12434. The authors acknowledge the assistance of Linda Laliberte-Cote
and Susan Miller in the development of the survey, Nancy Grossman and Bram Poquette
in the collection of the data, and Jeff Hiris in the presentation of the data.
NOTES
1. National Center for Health Statistics, Health, United
States, 2003 (Hyattsville, Md.: NCHS, 2003).
2. Another potential cost-saving policy would be to restrict
Medicaid eligibility for nursing home care, but there have been very few instances
of states’ lowering the nominal Medicaid income and asset eligibility tests.
However, Connecticut, Massachusetts, and Minnesota have recently requested Medicaid
waivers to lengthen the amount of time they can “look back” into an
applicant’s financial and other records to identify transfers of assets.
By lengthening the look-back period from three to six years under the waiver,
Connecticut has projected $87 million in savings over five years by limiting
the number of people who qualify for Medicaid services. L. Greider, “A
New Squeeze on Nursing Home Aid: Some States Move to Make It Harder for Older
People to Receive Medicaid,” November 2003,
www.aarp.org/bulletin/longterm/Articles/a2003-10-30-squeeze.html
(13 December 2003).
3. Institute of Medicine, Improving the Quality of Long-Term
Care (Washington: National Academies Press, 2001); and U.S. General Accounting
Office, Nursing Homes: Admission Problems for Medicaid Recipients and Attempts
to Solve Them, Pub. no. HRD-90-135 (Washington: GAO, 1990).
4. D.C. Grabowski, “Medicaid Reimbursement and Nursing
Home Quality,” Journal of Health Economics 20, no. 4 (2001): 549–569;
and J.W. Cohen and W.D. Spector, “The Effect of Medicaid Reimbursement
on Quality of Care in Nursing Homes,” Journal of Health Economics
15, no. 1 (1996): 23–48.
5. P. Gertler, “Medicaid and the Cost of Improving Access
to Nursing Home Care,” Review of Economics and Statistics 74, no.
2 (1992): 338–345.
6. W.J. Scanlon, “A Theory of the Nursing Home Market,”
Inquiry 17, no. 1 (1980): 25–41.
7. J.M. Wiener and D.G. Stevenson, Repeal of the “Boren
Amendment”: Implications for Quality of Care in Nursing Homes, New
Federalism: Issues and Options for States, Series A, no. A-20 (Washington: Urban
Institute, 1998).
8. C. Harrington et al., 1998 State Data Book on Long Term
Care Program and Market Characteristics (San Francisco: University of California,
San Francisco, 1999).
9. J.A. Rhodes and J.P. Sommers, Nursing Home Expenses, 1987
and 1996, MEPS Chartbook no. 6, AHRQ Pub. no. 01-0029 (Rockville, Md.: Agency
for Healthcare Research and Quality, 2001).
10. J. Cohen and L. Dubay, “The Effects of Medicaid Reimbursement
Method and Ownership on Nursing Home Costs, Case-Mix, and Staffing,” Inquiry
27, no. 2 (1990): 183–200.
11. J.H. Swan et al., “Medicaid Nursing Facility Reimbursement
Methods: 1979–1997,” Medical Care Research and Review 57, no.
3 (2000): 361–378.
12. D.C. Grabowski, R.L. Ohsfeldt, and M.A. Morrisey, “The
Effects of CON Repeal on Medicaid Nursing Home and Long Term Care Expenditures,”
Inquiry 40, no. 2 (2003): 146–157.
13. Harrington et al., 1998 State Data Book; and American
Health Care Association, A Briefing Chartbook on Shortfalls in Medicaid Funding
for Nursing Home Care, 30 August 2001, www.ahca.org/brief/seidmanstudy.pdf
(26 May 2004).
14. In fourteen states, freestanding and hospital-based facilities
were reimbursed at different Medicaid per diem rates. In these states, average
per diem rates for freestanding facilities are presented instead of the all-facility
weighted average rates, because data on patient days were incomplete in some
of the states. In most of the states with available data, however, the all-facility
weighted average rate was very similar to the freestanding rate because of the
small number of patient-days in hospital-based facilities. As an important robustness
check to the data collection effort, payment rates from a 2001 American Health
Care Association report for thirty-seven states in 2000 were compared with the
corresponding values obtained from our survey. AHCA, A Briefing Chartbook.
A close match was found between these two independent sources in the distribution
of rates. Note that in both distributions, the minimum and maximum rates were
obtained for the same states (Oklahoma and New York, respectively). The correlation
between the two sources of rates is strong (Pearson = 0.91, Spearman = 0.88;
p < .001 for both). A t-test (two-tailed) indicates no significant
difference between the two rates (mean difference = $1.06, standard error =$1.33,
t = 0.79, p =.43).
15. The study team was unable to obtain the average Medicaid
per diem rate for Iowa in 1999, for Nevada in 1999 and 2001, for Virginia in
2002, and for Wyoming in 1999. Rates were imputed for these states in the missing
years by increasing the last year rate (rates for 1998 and earlier years are
from Harrington et al., 1998 State Data Book) by a percentage that is
the average annual growth rate in rates over the period from 1993 up to the
last year (prior to the missing year) with data available.
16. According to multiple editions of the State Data Book
published by Harrington and colleagues.
17. J.M. Wiener, J. Tilly, and L.M.B. Alecxih, “Home and
Community-Based Services in Seven States,” Health Care Financing Review
23, no. 3 (2002): 89–114.
18. C.E. Bishop, “Where Are the Missing Elders? The Decline
in Nursing Home Use, 1985 and 1995,” Health Affairs 18, no. 4 (1999):
146–155.
19. The nursing case-mix index was developed by Brant Fries
and colleagues and reflects the amount of staff time required on average to
care for forty-four different types of nursing home residents. It is highly
related to residents’ acuity levels, as it includes items such as therapies,
functional and cognitive capacity, and other issues related to resident acuity.
Acuity was examined using admission assessments, representing the short-stay,
postacute residents who have become more prominent in nursing homes, especially
those relying on Medicare payments. Acuity levels for long-stay, long-term-care
residents was measured using annual assessments. See B.E. Fries et al., “Refining
a Case-Mix Measure for Nursing Homes: Resource Utilization Groups (RUGS-III),”
Medical Care 32, no. 7 (1994): 668–685.
20. In evaluating the correlation of payment changes and resident
acuity changes over time, the Pearson correlation coefficient was 0.16 (p
= .06) for resident acuity at admission and 0.19 (p = .02) for resident
acuity in the long-stay population.
21. When possible, the survey results were compared with earlier
findings in 1998 as reported by Harrington and colleagues, a comprehensive data
source on state policies most recently available prior to this current data
collection effort. This comparison facilitated the examination of changes in
relevant state policies over the past five years. Unless otherwise noted, hereafter
all references to earlier data in comparison to ours are made to Harrington
et al., 1998 State Data Book.
22. Both Maryland and Wyoming were classified by Harrington
and colleagues as having prospective methods in 1998. Ibid. The contact in Maryland
confirmed that there was no substantive policy change in that state since 1998.
In Maryland rates are set based on historical cost and are projected forward
to reflect what they may be at midyear. Facilities report costs at the end of
each fiscal year. If facilities underspent their rate, the state takes back
a portion of the unspent dollars. Because the payments are retroactively adjusted
to actual costs based on cost reports, the state considers its reimbursement
method as retrospective (as do we) and suggests that different classifications
of the state’s payment method may merely be a matter of interpretation.
In the case of Wyoming, the state contact confirmed that the state has a retrospective
payment system, except for “contracted rates for extraordinary care residents.”
23. GAO, Medicaid Nursing Home Payments: States’ Payment
Rates Largely Unaffected by Recent Fiscal Pressures, Pub. no. GAO-04-143
(Washington: GAO, 2003).
24. This result is supported by earlier multivariate work.
For example, see D.C. Grabowski, “The Economic Implications of Case-Mix
Medicaid Reimbursement for Nursing Home Care,” Inquiry 39, no. 3
(2002): 258–278.
25. L.H. Aiken et al., “Hospital Nurse Staffing and Patient
Mortality, Nurse Burnout, and Job Dissatisfaction,” Journal of the American
Medical Association 288, no. 16 (2002): 1987–1893; and R. Steinbrook,
“Nursing in the Crossfire,” New England Journal of Medicine
346, no. 22 (2002): 1757–1766.
26. P.I. Buerhaus, D.O. Staiger, and D.I. Auerbach, “Implications
of an Aging Registered Nurse Workforce,” Journal of the American Medical
Association 283, no. 22 (2000): 2948–2954.
27. V. Smith, K. Gifford, and R. Ramesh, State Budgets under
Stress: How Are States Planning to Reduce the Growth in Medicaid Costs?
(Washington: Henry J. Kaiser Family Foundation, 2003).
28. GAO, Medicaid Nursing Home Payments.
29. National Conference of State Legislatures, State Budget
Update: April 2003 (Washington: NCSL, 2003).
David Grabowski (grabowsk{at}uab.edu)
is an assistant professor in the Department of Health Care Organization and
Policy, University of Alabama at Birmingham. Zhanlian Feng is a project analyst
and Orna Intrator, an assistant professor, in the Center for Gerontology and
Health Care Research, Brown University, in Providence, Rhode Island. Vincent
Mor is a professor and head of the Department of Community Health, School of
Medicine, at Brown.
DOI: 10.1377/hlthaff.W4.363
©2004 Project HOPE–The People-to-People Health Foundation, Inc.
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