Do the Best Nursing Homes Have to Be Expensive?

Surprise—rates of bedsores and other problems don't seem to have much to do with price.


"Affordable nursing home," like "deafening silence" (or "healthcare system"), is an oxymoron. The U.S. national average cost of a nursing home, as reported by my colleague Michelle Andrews last week, is $203 a day, according to the latest survey by Genworth Financial. Few Americans can, well, afford to think of $74,000 a year as affordable.

Some nursing homes even cost considerably more than that. But does their higher cost mean they provide better care? Maybe so, especially at the local level, where nursing homes hotly compete and another few bucks per resident per day might pay for, say, more or better-paid nurses. But no one knows, and my impression from other new data (more on that in a moment) is that it doesn't account for significant variations in nursing home performance from state to state.

The quality of individual homes can be evaluated. We do that in America's Best Nursing Homes with the help of government data. Collecting cost data on all of the nation's more than 15,000 nursing homes in order to reach conclusions about cost vs. quality, however, is far beyond the scope of this blog. The Genworth survey doesn't do that, either—it shows the average daily costs state by state. Louisiana is at the low end at $139 a day; Alaska is highest at $514.

A few days after the Genworth survey was released, however, another tool appeared that I thought might be teamed with the survey to gin up a rough idea of nursing home cost vs. quality—a new report by an industry-government-consumer-think-tank coalition called Advancing Excellence in America's Nursing Homes. The group signs up nursing homes that agree to pursue specific quality goals, such as reducing the incidence of bedsores and the percentage of residents in physical restraints, and then tracks their progress using data submitted to the federal government. Slightly below half of all nursing homes have joined the campaign.

The report was an opportunity to compare affordability with quality. Let's see what emerged from a few of the measures used as targets.

Bedsores: The goal is to push the share of residents with bedsores below 10 percent. The current national average for all nursing homes is 11.5 percent. The average for signed-up homes is 11.2 percent, not much better than average. There doesn't seem to be a connection between affordability and bedsore rate. The most affordable state, Louisiana, had the worst bedsore rate of 17 percent, while the second cheapest, Missouri, was slightly better than the national average, at 11 percent. The top bedsore performance of 7 percent was shared by four states, and they ranked Nos. 9, 12, 28, and 50 in affordability.

Restraints: The goal is to have no more than 5 percent of residents strapped into wheelchairs or otherwise restrained. It has been met—the national average is just under 4 percent. Homes in the campaign report are slightly worse, just above 4 percent. Again, affordability doesn't seem to be much of a factor. The worst performers, California and Louisiana at 8 percent and Tennessee and Utah at 7 percent, respectively rank Nos. 38, 1, 15, and 10 in affordability. The best, half a dozen states at 1 percent, ranged from No. 7 to No. 51 on the affordability scale. (Washington, D.C., was included.)

Chronic pain: The goal is for no more than 4 percent of residents to be in pain that lasts longer than 90 days. The national and campaign average is 3.9 percent. Utah has the worst rate at 8 percent and, as noted, is No. 10 in affordability. Ohio, the next worst at 7 percent, ranks No. 25. The best, Washington, D.C., at 1 percent, is 34th in affordability.

As my colleague observed, the affordable states tend to be clustered away from the coasts. But quality, to my eye, literally is all over the map. This says to me, among other things, that quality is about far more than cost. I also have to note, at the urging of Dr. Bernadine Healy, another colleague, that cost is a major concern for states and the federal government—and therefore taxpayers—because Medicaid and Medicare pay for the majority of nursing home care. But only at private-pay facilities are families burdened with the full crushing weight of the cost of care.