Changes in patient sorting to nursing homes under public reporting: improved patient matching or provider gaming?

To test whether public reporting in the setting of postacute care in nursing homes results in changes in patient sorting.

All postacute care admissions from 2001 to 2003 in the nursing home Minimum Data Set.

We test changes in patient sorting (or the changes in the illness severity of patients going to high- versus low-scoring facilities) when public reporting was initiated in nursing homes in 2002. We test for changes in sorting with respect to pain, delirium, and walking and then examine the potential roles of cream skimming and downcoding in changes in patient sorting. We use a difference-in-differences framework, taking advantage of the variation in the launch of public reporting in pilot and nonpilot states, to control for underlying trends in patient sorting.

There was a significant change in patient sorting with respect to pain after public reporting was initiated, with high-risk patients being more likely to go to high-scoring facilities and low-risk patients more likely to go to low-scoring facilities. There was also an overall decrease in patient risk of pain with the launch of public reporting, which may be consistent with changes in documentation of pain levels (or downcoding). There was no significant change in sorting for delirium or walking.

Public reporting of nursing home quality improves matching of high-risk patients to high-quality facilities. However, efforts should be made to reduce the incentives for downcoding by nursing facilities.