1. 1 10/22/2015 Nursing Home Quality in New York State by Patricia Loubeau Discussion by Kristin J. Kleinjans, University of Aarhus and RAND ZEW Long-Term-Care Conference Mannheim, 2005

2. 2 10/22/2015 Summary – Objective of Study  to better understand what influences quality of care, specifically influence of staff hours ownership (profit vs. nonprofit) chain membership bed size (area) competition

3. 3 10/22/2015 Summary – Data and Variables Data from 7 counties in New York State big sample: 184 nursing homes (1/3 of beds) 3 measures of quality: o Facility rating by state department of health o # of state health code deficiencies o Composite level of harm

4. 4 10/22/2015 Summary - Results  no quality differences based on staffing (results only for state health code standards) ownership/ chain membership (measures?) size (measure?)  lower quality with higher competition (all 3 measures)

5. 5 10/22/2015 Summary – Data Shortcomings 1.No data on health status of residents quality measure means different things for different types of health problems (Ex.: staffing) 2.No data on cost of individual nursing home relation between quality and cost cannot be investigated 3.Not generalizable very different ownership and quality in NY state

6. 6 10/22/2015 Comments Interesting and important subject Comparable data, big sample Interesting conclusions, discussion of institutions and possible interpretations

7. 7 10/22/2015 Comments: Methods Unclear methods: From what are conclusions derived? Tables with coefficients, st errors, etc. needed by dependent variable  ordered logit/ probit with covariates X i as regressors Report results of sensitivity analysis & specification tests

8. 8 10/22/2015 Comments: Outcome Measures Explanation of quality measures needed: What are the exact deficiencies? (Table) Not all deficiencies equally important & might confound results e.g., # of state health deficiencies incl. personnel policies (potential for reversal causation – staffing measure) (Seem to) only concern health care quality ≠ quality (surroundings, social/ mental care,…) also excludes outside provision of services (such as hospice care)

9. 9 10/22/2015 Comments: Prices Missing prices can explain some of the results product differentiation: cheap and low quality vs. expensive and high quality Ex.: New York City; cost betw. $220 & $423 per day  individual choose according to preferences  higher quality not (always) better Problem: no price information in data maybe something to proxy? (room size, facilities, average income of zipcode)

10. 10 10/22/2015 Comment: Lack of Info on Health Status  Results are more interesting if health status of residents is known (otherwise, meaning of coefficients is unclear) Omitted variable bias if correlated with independent variables, e. g. staffing, size not in data, but maybe a proxy to be used as IV? Some potential candidates: ratio of personnel at night/day facilities (types of beds, … )

11. 11 10/22/2015 Minor Comments Table 2 needs units, min and max, explanation of variables (especially categories of quality measures) Table 3: source Table 4: sums do not all sum up to 100% (even with rounding) Table 5: Misleading title, comparison of average deficiencies in sample, state, and US as a whole