Nursing homes remain segregated in most parts of the United States, providing unequal care that appears to be perpetuated by their growth in segregated residential areas and the practices of not-for-profit facilities, according to a report on survey data from the year 2000.
“The more segregated a metropolitan area, the more likely, and the larger, the black-white disparity in access to good-quality nursing home care,” Vincent Mor, Ph.D., said during a teleconference briefing on the study.
“Disparities in treatment will persist even in the absence of any disparities of treatment within nursing homes because of the differences in the homes providing care to blacks and whites,” said David Barton Smith, Ph.D., emeritus professor at Temple University, Philadelphia, and his colleagues (Health Aff. 2007;26:1448–58).
The disparities found in the report, which the researchers suggest differ little from other parts of the health system, could be reduced several ways. These include paying adjustments to nursing homes that have a higher proportion of Medicaid residents, equalizing Medicaid and private-pay payments, responding to racial-disparity concerns in regional planning, and performing ongoing monitoring and rigorous enforcement of Title VI of the 1964 Civil Rights Act, which prohibits segregation and other forms of discrimination in any organization receiving federal funds.
Although it would take a long time to eliminate such disparities, Dr. Smith said immediate steps can be taken, such as having patients review the quality measures of nursing homes in their area, providing patients with all available choices, discharging hospital patients to higher-quality nursing homes, and considering segregation and disparities during state inspections.
The investigators sought to analyze segregation and disparities across nursing home facilities in the United States because little data have been available to document the extent of these disparities since Title VI was enacted. Unlike hospitals, nursing homes never were required to certify their compliance with Title VI to qualify for Medicare when it began in 1967. They had only to post signs and certify that they did not discriminate. No requests were made for information on admission practices or racial or ethnic composition, and no federal civil rights inspections were made.
Based on data from the Centers for Medicare and Medicaid Services' Online Survey Certification and Reporting System and Nursing Home Minimum Data Set, they analyzed 147 metropolitan statistical areas (MSAs) with at least a 5% black residential population, four or more freestanding nursing homes, and 100 or more black nursing home residents. This included 7,196 non-hospital-based nursing homes and 837,810 residents, or about 50% of all freestanding nursing homes and residents in the United States.
Black residents were concentrated in a small percentage of nursing homes. More than 50% of blacks in for-profit facilities lived in fewer than 10% of for-profit homes, and more than 70% of blacks in nonprofit facilities lived in fewer than 10% of nonprofit homes.
Nationwide, nursing homes had a dissimilarity index of 0.65. The index, the most commonly used measure of segregation, calculates the combined percentage of black and white residents who would have to be relocated for there to be the same proportion of black and white residents in every nursing home within an MSA. Homes seemed to be most segregated in MSAs in the Midwest and least segregated in the South, ranging from 0.77 in Cleveland to 0.16 in Columbus, Ga.
Within most MSAs, blacks were significantly more likely to be in facilities that fell into the bottom quartile of many structural and performance measures of quality. They were 31%–70% more likely to be in a facility that was in the highest quartile of total severe inspection deficiencies for a particular MSA, was cited with a deficiency causing actual harm or immediate jeopardy to residents, and was later terminated from participation in Medicare and Medicaid than were white residents.
Compared with white residents, black residents were 19% less likely to be in a home in an MSA with the highest staffing level of direct-care providers and 23% less likely to be in facilities with the highest ratio of registered nurses to all nursing staff. The study was funded by the Commonwealth Fund.