Original Study
What Factors Contribute to Successful Appeals of Nursing Homes' Deficiencies in the Informal Dispute Resolution Process?

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Abstract

Objectives

To determine what factors contribute to successful appeals of nursing home deficiencies in the Informal Dispute Resolution (IDR) process.

Design

We merged Centers for Medicare and Medicaid Services' data about IDRs with Online Survey, Certification, and Reporting data about nursing home characteristics. We performed multivariate statistical analyses to predict successful appeals as a function of characteristics of the deficiency being appealed, the survey that triggered the deficiency, characteristics of the nursing home, and the state.

Setting

All nursing homes nationally in the period 2005–2008.

Measurements

Successful appeals were defined as those in which the deficiency was removed or its severity or scope reduced. Independent variables included the Centers for Medicare and Medicaid Services' measures of severity and scope of deficiency, abuse and neglect, substandard care, total number of deficiencies in the survey, whether the IDR was triggered by a survey or complaint, facility ownership and reputation, and state stringency of regulation.

Results

Twenty-six percent of submitted IDRs were successful in 2005–2008. Success was more likely for less severe deficiencies, when deficiencies were triggered by a survey rather than a complaint, and when fewer deficiencies were included in the appeal. Facility ownership and state stringency of regulation were not significantly associated with the IDR success.

Discussion

Overall, 2.6% of deficiencies issued were overturned through the IDR process. Further study is required to determine the appropriateness of these overturned cases and the opportunities they offer to improve the survey process.

Section snippets

Data

We obtained CMS data about all IDR requests submitted between 2005 and 2008 by all nursing homes in the United States. The data included facility identifiers, the original deficiency (or tag) being disputed, its scope and severity, and the outcome of the IDR. The scope of the deficiency refers to the number of residents affected by it, and the severity refers to the degree of harm inflicted. The outcome of the IDR could have been one of the following: complete removal of the deficiency, scope

Results

Table 1 lists descriptive statistics for the sample. The average nursing home requested an IDR for 3.81 deficiencies during the 4 years we studied. It succeeded (namely, the deficiency was either completely removed or its severity and scope reduced) in 26.4% of appeals.

Table 2 presents the results of the multivariate analysis. Odds ratio (OR) for dichotomous variables compare the odds for the indicated category with the odds of a reference category (eg, nonprofit facility with the reference of

Discussion

The IDR is a relatively new policy initiative implemented by CMS to streamline the process that nursing homes can use if they choose to appeal deficiencies issued by state surveyors. Little is known about how it works. A previous study5 examined nursing homes' decisions about whether to avail themselves of this mechanism. In this article, we examine what influences their success, once the IDR has been requested.

We observe an overall success rate of 26%. Absent a gold standard against which to

Conclusions

Whether a 26% success rate overall is reasonable is a matter of judgment. Some may view it as indicative of responsiveness to the concerns of nursing homes. Advocates10 have raised concerns that the IDR process further weakens a regulatory process that has been criticized by the General Accounting Office as inadequate to ensure adequate levels of quality.11, 12, 13, 14, 15 Others, in contrast, may argue that overturning a quarter of the deficiencies is a high rate, raising questions about the

Acknowledgments

We acknowledge the State Directors of Licensing and Certification offices for insightful comments.

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Cited by (0)

This work was funded by the National Institutes of Aging Grant AG027420.

The authors declare no conflicts of interest.

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