Omnibus Budget Reconciliation Act Research Articles

Racial Politics and Welfare Retrenchment during the Reagan Presidency

How do conservative presidents use welfare state retrenchment to make political appeals, and in particular reach conservative whites on the basis of the sensitive subject of race? Using Reagan Presidential Library archival sources, I show that the Reagan administration’s welfare retrenchment efforts with the Omnibus Budget Reconciliation Act (OBRA) of 1981 were organized around a racially divisive political agenda that was intended to appeal to southern whites and northern white ethnics. Modifying Pierson’s (1994) approach to the politics of welfare retrenchment with focused attention on race, I explore the administration’s use of the strategies of “obfuscation, division and compensation.” I find that the Reagan administration pursued an overtly racially neutral approach to welfare retrenchment, while also pursuing a political agenda focused on conservative white voters. This is contrasted with an almost complete absence of concern over the disproportionate harm that African-Americans faced as a result of their agenda. Most telling, the administration responded to the criticisms of their budget cuts by African-American leaders through a combination of silences and symbols, offering very little in the way of direct material or procedural rewards for African-Americans.

Progress, Persistence, and Hope: Building a System of Services for CYSHCN and Their Families.

Progress, Persistence, and Hope: Building a System of Services for CYSHCN and Their Families.

Meaningful Assessment or Minimum Compliance: PASRR for Nursing Home Residents with Mental Illness

The Omnibus Budget Reconciliation Act (OBRA) of 1987 included provisions for the Preadmission Screening and Resident Review (PASRR) program, which requires states to create and maintain systems to assess persons with serious mental illness (SMI) seeking NH care. The prevalence of SMI in NHs is increasing, and little is known about the effectiveness of the PASRR program intervention. We conducted 20 interviews with state and national PASRR stakeholders, including assessors, hospital discharge planners, mental health advocates, geriatricians and geriatric psychiatrists. Interview data were triangulated with state provided materials on PASRR collection and implementation. Based on these interviews, we identified four themes: 1) variation in the implementation of federal PASRR legislation across states and jurisdictions, 2) the need for investment in professional development and workforce capacity, 3) lack of usefulness of PASRR in ongoing care planning, and 4) the need to consider the role of age, race/ethnicity, and stigma on quality of care for NH residents with SMI. Stakeholders agree that PASRR legislation was well intentioned, but also expressed concern regarding the completion of PASRR as an issue of compliance versus meaningful assessment. More work is needed to determine how best to develop and support the care needs of people with SMI, while being mindful of the original goals of deinstitutionalization that prompted OBRA passage. In order to assess the impact of the PASRR program on quality of care and mental health outcomes, further research should take an evaluative approach through meaningful use of PASRR data.

The Medical Model and Person-Centered Care: A Blended Approach

The Medical Model and Person-Centered Care: A Blended Approach

GRADUAL DOSE REDUCTION (GDR) CONCERNS IN GERIATRIC PATIENT WITH MENTAL HEALTH DISORDERS, LIVING IN LONG TERM CARE FACILITIES

Introduction Omnibus Budget Reconciliation Act (OBRA) of 1987 limited the use of psychotropic medications in residents of long-term care facilities. Update of OBRA guidelines have even farther increased some dosing restrictions, however documentation of necessity and periodic trials of medication withdrawal (GDR) are still emphasized. Almost 20% of American age 55 and older are suffering from some type of mental health disorders which include but not limited to mood disorders (Unipolar/Bipolar), psychosis, anxiety as well as symptomatic management of agitated patients due to other medical condition. Mental health disorders are implicated as a factor for suicide. Men aged 85?years or older have a suicide rate of 45.23 per 100,000, compared to an overall rate of 11.01 per 100,000 for all ages. While other treatment modalities (psychotherapy etc.) are implemented most of the time one or more psychotropic medication are used for management of these patient's population. In 2006 Center for Medicare and Medicaid Services (CMS) published guidelines about antipsychotic drug therapy only for specific condition, prescribed at the lowest possible dose, used for the shortest period, and continually undergo gradual dose reduction (GDR). There is significant literatures on guidelines and recommendation of GDR in geriatric patients. However, there is limited research and publications on prohibiting or avoiding GDR in some circumstances. We are presenting a case of a patient suffering from mental health disorder comorbid with other medical condition whose GDR might have been the cause of her symptom relapse and the need for acute inpatient management. Methods Ms. GM is 70?years old female with psychiatric diagnosis of schizoaffective disorder bipolar type has been admitted to VA Community Living Center (CLC), after she is medically diagnosed with stage III endometrial cancer and CVA for palliative chemotherapy. She was managed initially with Risperidone 5mg in the morning and 3mg at night, Haloperidol 2mg in the morning and 1mg at night, Gabapentin 200mg twice daily, under the GDR protocol her medication was decreased to Risperidone 2mg twice daily and stop the Haldol all together. Her response were monitored and documented on Computerized Patient Record System (CPRS). While she was initially stable with GDR, gradually she developed hypomanic sxs of paranoid ideation, irritability with hypersexuality as well as expansive thought, disorganized behavior. Ms. GM was not responding to initial behavioral intervention which rendered to an acute inpatient admission for management of her symptom. Once stabilized in the acute inpatient setting, Ms. GM was re-admitted to CLC for continuation of her palliative care of her endometrial cancer, CVA and schizoaffective disorder. Her current psychotropic medication is Risperidone 2mg in the morning and 3mg at night, Gabapentin 300mg QHS, she is responding to the current psychiatric intervention with minimal residual depressive symptoms still remaining. In the last visit her affect improved and she is no longer on one-one observation of irregular behavior. Results Consideration for the exceptions can be as part of GDR for some patient with mental health problem. With proper documentation of patient's response to GDR, utilizing clinical expertise and medication side effects will help prevent relapse of symptoms. Conclusions The goal of recommending psychotropic medication in patients 50 and older is to address mental health disorder and provide quality of life to patients suffering from mental health disorders with or without other medical comorbidities. With respect to their side effects and to avoid polypharmacy, CMS recommended guideline of GDR is an optimal consideration to most of psychiatric patients. However, applying these guidelines are challenging and complex, which requires knowledge of existing clinical evidence, standard of practice on using psychotropic medication with appropriate professional rational on attempting to reduce its dosage. This research was funded by: Zero funding

Trend Change in the Intellectual Disability Nursing Home Census From 1977 to 2004.

The Omnibus Budget Reconciliation Act (OBRA) of 1987 was expected to reduce inappropriate residential placements of persons with intellectual disability (ID) in nursing homes. Utilizing the nationally representative 1977, 1985, 1995, and 2004 National Nursing Home Surveys (NNHS), we estimate trend change in the ID nursing home census pre- and post-OBRA. We find a marked decrease in number and percentage, and a shift in the age distribution of the ID nursing home census, most pronounced between 1985 and 1995. We contend that these trend changes, concurrent with growth in the overall nursing home population, provide empirical evidence that policy changes that occurred during the OBRA enactment period were successful in reducing inappropriate residential placements of persons with ID in nursing homes.

A Good Doctor Can Give Bad Advice on Antipsychotics

A Good Doctor Can Give Bad Advice on Antipsychotics

Provision of Mental Health Services in U.S. Nursing Homes, 1995–2004

Provision of Mental Health Services in U.S. Nursing Homes, 1995–2004

Provision of Mental Health Services in U.S. Nursing Homes, 1995–2004

This study tracked the ability of U.S. nursing homes to provide on-site mental health services after the Omnibus Budget Reconciliation Act (OBRA) of 1987 mandated the detection and treatment of mental illness among nursing home patients. The study also determined cross-sectional correlates of service availability and models of services. Retrospective analyses were done using National Nursing Home Surveys from 1995, 1997, 1999, and 2004 (the most recent survey). The surveys are periodically conducted by the Centers for Disease Control and Prevention and represent the nation's approximately 17,000 nursing homes. The longitudinal trend of mental health service provision was analyzed for all facilities and for subgroups of facilities. Multivariate regression determined facility and geographic correlates in 2004. Roughly 80% of facilities provided on-site mental health services each survey year. In 2004, 25% of facilities provided mental health services regularly or at routinely scheduled times (regular basis), 24% provided them in an on-call manner (or as needed), and 28% provided them on both a regular and on-call basis. The remaining 22% of facilities provided no on-site mental health services. Multivariate analyses found that largest facilities (> or = 200 beds) were more able than small facilities (< 100 beds) to serve persons with mental illness (odds ratio=3.80, p=.024); compared with their counterparts, facilities were more likely to provide on-site services if they had a larger proportion of residents covered by Medicare or Medicaid programs, were in the Northeast region, or were in metropolitan areas. Similar correlates were found when the types of service provision models (regular basis, on-call basis, both a regular and on-call basis) were examined. The overall availability of nursing home-based mental health services did not improve over time during the post-OBRA era. Service availability is more problematic for certain facilities, such as small or rural ones. Financial, regulatory, and system-level efforts are needed to address this issue.

The influence of national policy change on subnational policymaking: Medicaid nursing facility reimbursement in the American states

This study proposes that exogenous shocks emanating from national governments can significantly change health policy processes among subnational units. The relevance of this insight for comparative health policy research is examined in the context of Medicaid nursing facility reimbursement policymaking in the American states. Event history techniques are used to model state adoption of case-mix methods for reimbursing nursing homes under Medicaid from 1980 to 2004. Case-mix adjusts Medicaid nursing home payments for patient acuity, thereby enabling states to pay more for residents with higher care needs and to pay less for residents with lower care needs. The goal is to improve access for more resource intensive Medicaid beneficiaries and to distribute payments more equitably across the providers who serve them. The most noteworthy national policy changes affecting case-mix implementation by state governments were adoption of nursing home quality reform with the Omnibus Budget Reconciliation Act (OBRA) of 1987 and case-mix by Medicare with the Balanced Budget Act (BBA) of 1997. In light of the 1990 and 1999 implementation of OBRA 1987 and the BBA, respectively, five models were estimated, which in addition to covering the entire time period studied (1980-2004) include pre-/post-BBA comparisons (1980-1998, 1999-2004) and pre-/post-OBRA 1987 comparisons (1980-1989, 1990-1998). Results suggest that in contrast to early adoption, which tended to be grounded in the capabilities of innovative states, later adoption tended to take place among less capable states influenced more by the changing federal policy environment. They also highlight the salience of programmatic and fiscal conditions but during the middle of the adoption cycle only. Future research should clarify the ways in which national policy changes influence health policy adoption at the subnational level, both in other nations and across different levels of government.

Racial Disparities in Medicaid Enrollment and Prenatal Care Initiation Among Pregnant Teens in Florida

Teens and racial and ethnic minority women are less likely to initiate prenatal care (PNC) in the first trimester of pregnancy than their counterparts. This study examines the impact of Medicaid program changes in the late 1990s on the timing of Medicaid enrollment and PNC initiation among pregnant teens by race and ethnicity. Using Medicaid enrollment and claims data and a difference-in-differences method, we examine how the patterns of prepregnancy Medicaid enrollment, PNC initiation, and racial and ethnic disparities in PNC changed over time after controlling for person- and county-level characteristics. We included 14,089 teens in Florida with a Medicaid-covered delivery in fiscal years 1995 and 2001. Prepregnancy enrollment was defined as enrollment 9 or more months before delivery; late or no PNC was defined as initiation of PNC within 3 months of delivery or not at all. For teens enrolled in traditional welfare-related categories, the proportion with prepregnancy Medicaid enrollment increased and the proportion with late or no PNC declined from 1995 to 2001. Teens enrolled under the Omnibus Budget Reconciliation Act (OBRA) expansion category in 2001 were less likely than welfare-related teen enrollees to have prepregnancy coverage but were more likely to initiate PNC early. Racial disparities were found in PNC initiation among the 1995 welfare-related group and the 2001 expansion group but were eliminated or greatly reduced among the 2001 welfare-related group. Providing public insurance coverage improves access to care but is not sufficient to meet Healthy People 2010 goals or eliminate racial and ethnic disparities in PNC initiation.

Changes in the Effectiveness of State Medicaid Drug Program Cost‐Containment Policies Following OBRA 1990

Abstract. Containment of Medicaid pharmaceutical drug program costs continues to be an important policy problem. Perhaps the most important policy of the past two decades with significant implications for Medicaid pharmaceutical drug programs was the Omnibus Budget Reconciliation Act (OBRA) of 1990. This study analyzes Medicaid drug spending data from 1985 to 1997 to determine how OBRA 1990 influenced the effectiveness of existing drug cost‐containment policies and if the Act produced its anticipated cost savings. The descriptive evidence indicates that reductions in drug expenditure growth rates, following the passage of OBRA 1990, resulted from factors that are independent from that Act. Furthermore, the analytical evidence shows that changes in the effectiveness of major cost‐containment policies (drug formularies, drug utilization review programs, and reimbursement rates) offset, at least in part, savings from the drug rebate program included in OBRA 1990.

Financial contracting and operating performance: The case for OBRA and efficient contracting

When corporate governance is effective, new managerial contracts should maximize shareholder wealth. This paper examines operating performance measures after the Omnibus Budget Reconciliation Act (OBRA) of 1993 was passed. We find that firms affected by OBRA’s $1 million cap on cash compensation experience an improvement in operating performance improves during the three years following contract revisions. Although prior performance was low, the postcontracting performance for affected firms is on par with comparison group. These findings are consistent with effective corporate governance and efficient contracting and contrary to expropriation theory.

Convergence of Clinical Staff Ratings and Research Ratings to Assess Patients With Schizophrenia in Nursing Homes

Convergence of Clinical Staff Ratings and Research Ratings to Assess Patients With Schizophrenia in Nursing Homes

Neuroleptic and benzodiazepine use in long-term care in urban and rural Alberta: characteristics and results of an education intervention to ensure appropriate use

To examine the use of psychotropic drugs in 24 rural and urban long-term care (LTC) facilities, and compare the effect of an education intervention for LTC staff and family members on the use of psychotropic drugs in intervention versus control facilities. Interrupted time series with a non-equivalent no-treatment control group time series. Data on drug use were collected in 24 Western Canadian LTC facilities (10 urban, 14 rural) for three 2-month time periods before and after the intervention. Pharmacy records were used to collect data on drug, class of drug, dose, administration, and start/stop dates. Chart reviews provided demographics, pro re nata (prn) use, and indications for drug use. Subjects comprised 2443 residents living in the 24 LTC facilities during the 1-year study. An average of 796.33 residents (32.7%) received a psychotropic drug. An education intervention on psychotropic drug use in LTC was offered to intervention physicians, nursing staff, pharmacists and family members. Approximately one-third of residents received a psychotropic drug during the study, often for considerable lengths of time. A minority of psychotropic drug prescriptions had a documented reason for their use, and 69.5% of the reasons would be inappropriate under Omnibus Budget Reconciliation Act (OBRA) legislation. Few psychotropic drug prescriptions were discontinued or reduced during the study. More urban LTC residents received neuroleptics and benzodiazepines than their rural counterparts (26.1% vs. 15.7%, and 18.0% vs. 7.6%, respectively). The education intervention did not result in any significant decline in the use of these drugs in intervention facilities. The results suggest substantial use of psychotropic drugs in LTC, although rural LTC residents received approximately half the number of psychotropic drugs compared with urban residents. A resource-intensive intervention did not significantly decrease the use of psychotropics. There is a need for better monitoring of psychotropic drugs in LTC, particularly given that voluntary educational efforts alone may be ineffective agents of change.

Using customer satisfaction surveys to improve quality of care in nursing homes.

********** The public policies that pertain to quality of care in nursing homes were last stated in 1986 Institute of Medicine (IOM) Report (Hawes, 1991) and subsequent Nursing Home Reform Act, which is part of 1987 Omnibus Budget Reconciliation Act (OBRA) (P.L. 100-203) legislation. These documents remain basis for regulating nursing home industry. State and federal regulations drive evaluation standards for nursing homes, and annual inspections help determine certification for both Medicare and Medicaid reimbursement. Despite considerable efforts, however, regulations cannot guarantee quality of care received by nursing home residents. One hurdle is lack of a universally accepted definition of quality. Donabedian (1988) conceived of quality of care in three categories: structure, process, and outcome. Structure refers to attributes of physical setting (that is, facility, equipment, money), human resources (that is, number and qualifications of personnel), organizational structure, and methods of reimbursement. Process refers to hands-on patient care. Outcome refers to effects of care on patient and patient satisfaction with that care. The three categories are interconnected--good structure increases likelihood of good process, which increases likelihood of good outcomes--and together constitute quality of care. Regulations concentrate on process and structural aspects of quality of care because they are easy to measure and document. Nursing homes routinely collect and report information about their performance. Our case study site measures quality of clinical care with 24 clinical quality indicators including fractures, weight loss, prevalence of pressure ulcers, use of antipsychotic medications, and so forth. These indicators are monitored on a monthly basis. Structural characteristics such as staff-to-patient ratios, and process assessment (the provision of actual health care) are used as proxy measures to demonstrate quality, but compliance with regulations on those measures will still not ensure that resident receives quality care (Davis, 1991). Outcome assessment is most consumer-oriented portion of Donabedian's framework; it alone addresses actual impact of care on resident's physical and emotional well-being (Davis, 1991). The IOM committee, in 1986, and Congress, in 1987 OBRA regulations, agreed that it was important to focus on the quality of life experienced by residents, as well as making regulations more resident-centered and outcome-oriented [emphasis added] (Hawes, 1991, p. 158). Resident-centered care emphasizes quality of care as defined by resident. Although views of all stakeholders are important, it is vital to focus on residents' views because they may not agree with views of others about importance of many items (Young, Minnick, & Marcantonio, 1996), and they are difficult to assess accurately. Many believe there has been too little emphasis on quality aspects most meaningful to residents (Davis, Sebastian, & Tschetter, 1997). A customer satisfaction survey can monitor concerns about nursing home quality. In fact, a survey can empower residents, because its primary purpose is to communicate the point of view of people for whom long-term care services are created in first place (CohenMansfield, 2000, p. 1). Despite well-known limitations to surveys of nursing home residents (such as fear of reprisals, difficulty in interviewing residents with dementia, disagreement about what to measure), satisfaction surveys may be best way to comprehend and address resident-identified problems. It is interesting that quality assurance mechanisms that have looked at other areas are now beginning to focus on resident rights and on techniques to assess resident satisfaction with care (Applebaum, Straker, & Geron, 2000). Social workers are essential to this type of assessment given their communication and interpersonal skills and training. …

Variations in the treatment culture of nursing homes and responses to regulations to reduce drug use.

The study examined the relationship between treatment cultures of nursing homes and their responses to regulations to reduce use of psychotropic drugs mandated by the 1987 Omnibus Budget Reconciliation ACT: The authors hypothesized that reduction in use of antipsychotic drugs was more likely to occur in homes with a resident-centered culture emphasizing psychosocial care, avoidance of psychotropic drugs, pharmacist feedback, and involvement of mental health workers. The authors also predicted greater reductions in drug use in facilities with a less severe case mix and better capacity for change. Data were collected in a stratified random sample of 16 skilled nursing facilities in Wisconsin. Participants included 1,181 residents in the baseline study and 1,650 residents in the follow-up study. Treatment culture was measured with a questionnaire for assessing nurses' beliefs and philosophies of care and their interactions with pharmacists and mental health workers. No significant change was observed in the use of benzodiazepines, antidepressants, or polymedicine (two or more psychotropic medications). However, use of antipsychotic drugs decreased significantly, from 24 percent to 16 percent. The change in use varied dramatically across facilities, from an 85 percent reduction to a 19 percent increase. Findings also revealed significant variability in treatment cultures. Greater reductions in use of antipsychotic drugs were found in facilities with a resident-centered culture, a less severe case mix, and a higher nurse-to-resident staffing ratio. Future policy and quality improvement efforts must address treatment cultures, staffing, and other organizational barriers to nursing home reform.

PRACTITIONER APPLICATION: New Factors in the Antitrust Regulation of Hospital Mergers

PRACTITIONER APPLICATION: New Factors in the Antitrust Regulation of Hospital Mergers

Use of antipsychotic drugs in nursing homes: current compliance with OBRA regulations.

To examine the degree and patterns of compliance with the Omnibus Budget Reconciliation Act (OBRA) regulations regarding the use of antipsychotic drugs in nursing homes. Retrospective chart review of all resident records. Eight nursing homes: five community, two county-owned, and one university-affiliated Veterans Administration facility. A structured assessment instrument to track compliance with each aspect of the OBRA regulations regarding antipsychotic drug use. A total of 1573 nursing home residents' pharmacy records were reviewed between August 1994 and March 1996. Two hundred seventy-nine residents were actively taking antipsychotic medications (prevalence = 17.7%). Mean compliance greater than 70% was found for (1) appropriate diagnostic indication (mean = 70.9%), (2) dosage within recommended limits (mean = 90.1%), and 3) documented appropriate target symptoms (mean = 90.4%). Dosages were more likely to exceed limits in those patients with histories of major mental illness, particularly schizophrenia. Nursing homes were better able to comply with those guidelines that are most specific. Educational interventions now need to focus on behavioral interventions, monitoring of adverse effects, and efficacy. These data are useful in establishing threshold levels of performance and can be used by nursing homes for continuous quality improvement. OBRA continues to impact neuroleptic drug prescribing practices in nursing homes significantly.

Pharmacotherapy for long-term care residents with dementia-associated behavioral disturbance.

The Nursing Home Reform Amendments of the Omnibus Budget Reconciliation Act (OBRA) of 1987 have resulted in specific mandates for documentation regarding behavioral indication for psychotropic drugs and the monitoring of their efficacy and side effects. The national guidelines also require drug holidays, behavioral management in lieu of drugs when possible, systematic dosage reductions unless contraindications are documented, and an overall reduction of drugs considered unnecessary. This article describes OBRA 87 guidelines for benzodiazepine and antipsychotic drug use in long-term care facilities. Specific pharmacological interventions for persons with behavioral disturbances associated with dementia, the phenomena most significantly affected by these federal guidelines, are summarized.