{"doi":"10.1111/jgs.18260","title":"Paying for Nursing Home Quality: An Elusive But Important Goal","abstract":"On a given day, almost 1.3 million individuals receive care from approximately 15,000 nursing homes nationwide (Kaiser Family Foundation, 2020). Nursing home residents have high levels of medical complexity, have physical and cognitive impairments, and often lack financial resources. As such, these are among the frailest and most vulnerable individuals in our health-care system. In 2020, the United States spent $196.8 billion on nursing home care, the majority of which came from public sources (Hartman et al., 2022). Yet, questions persist about the effectiveness of this investment (Halifax and Harrington, 2022). Nursing home quality of care continues to be an important public policy issue (Ouslander and Grabowski, 2020), despite prolonged public outcry (Institute of Medicine, 1986, Institute of Medicine, 2001; Mendleson, 1974; Vladeck and Twentieth Century Fund, 1980) and government reports (Office of Inspector General, 2014; U.S. Government Accountability Office, 2018; U.S. Senate, 1974). Often, the number of nurses per resident is low, with 75% of nursing homes failing to meet Centers for Medicare & Medicaid Services' (CMS’) expected registered nurse staffing levels based on residents' acuity (Geng et al., 2019). Staffing is also highly variable from day to day (Geng et al., 2019; Mukamel et al., 2022), and the average annual staff turnover rate exceeds 120% (Gandhi et al., 2021). Residents may develop new health problems after nursing home admission due to unsafe care practices. Amenities that are common within a nursing home—including the food, activities, and public spaces—are too often substandard (Miller et al., 2014). Feelings of isolation and loneliness are consistently reported in the states that collect information on quality of life and care experiences (Roberts and Ishler, 2018; Shippee et al., 2015). These quality issues predate the COVID-19 pandemic, but all have been magnified since March 2020 (Levere et al., 2021; McGarry and Grabowski, 2021; Montgomery et al., 2020). Although Medicaid and Medicare pay for most nursing home care in the United States, very little of this public payment is linked to quality, either through bonuses or penalties. In other parts of the health-care system, an increasing number of payers has implemented value-based payment models that hold participating providers accountable for overall spending and quality (Barnett, Wilcock, et al., 2019; Joynt Maddox et al., 2018; McWilliams et al., 2016). A key question for policy-makers is whether and how to increase the accountability of nursing homes for the quality of care they provide under Medicaid and Medicare. Although Medicaid and Medicare pay for most nursing home care in the United States, very little of this public payment is linked to quality, either through bonuses or penalties. In 2022, a National Academies of Science, Engineering, and Medicine (NASEM) report concluded that quality is substandard in many U.S. nursing homes. The report offered a series of recommendations to transform how the United States delivers, regulates, finances, and pays for nursing home services. One of the payment recommendations focused directly on testing expanded value-based payments for nursing home care. Specifically, recommendation 4E states: This paper first reviews the U.S. experience with value-based payments for nursing home services. Unfortunately, most of the models tested to date have not shown improvements in the quality of nursing home care. The paper then considers how policy-makers can implement the NASEM recommendation to ensure a greater likelihood of success relative to prior efforts. The first documented attempt to improve nursing home quality through incentive payments was a randomized experiment conducted in 36 San Diego–area nursing homes over the period of 1981 to 1983 (Weissert et al., 1983). The experimental group received three separate bonus Medicaid payments for admitting heavy-care patients, meeting outcome goals on some patie","journal":"Journal of the American Geriatrics Society","year":2023,"id":345681,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":12,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9427,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2023-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1079883,"name":"Amanda Chen","orcid":"0000-0003-3933-8570","position":1,"is_corresponding":false},{"id":330669,"name":"Debra Saliba","orcid":"0000-0001-5177-6616","position":2,"is_corresponding":false},{"id":316545,"name":"David C. Grabowski","orcid":"0000-0003-2915-5770","position":0,"is_corresponding":true}],"reference_count":44,"raw_metadata":null,"created_at":"2026-07-19T01:11:44.152490Z","pmid":"36795634","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}