Migraine Headache and Labor Market Outcomes

While migraine headache can be physically debilitating, no study has attempted to estimate its effects on labor market outcomes. Using data drawn from the National Longitudinal Study of Adolescent Health, we estimate the effect of being diagnosed with migraine headache on labor force participation, hours worked, and wages. Ordinary least squares (OLS) estimates suggest that migraines are associated with reduced labor force participation and lower wages among females. A negative association between migraine headache and the wages of female respondents is also obtained using an instrumental variables (IV) approach, although the IV estimates are imprecise relative to the OLS estimates. Copyright © 2014 John Wiley & Sons, Ltd.     

Classic or new monopsony? Searching for evidence in nursing labor markets

The market for registered nurses (RNs) is often offered as an example of "classic" monopsony, while a "new" monopsony literature emphasizes that firm labor supply is upward sloping independent of market structure. Using data from multiple sources, we explore the relationship between nursing wages in hospitals and measures of classic and new monopsony. Wage level analysis fails to provide support for classic monopsony, the relative wages of RNs in 240 U.S. labor markets being largely uncorrelated with hospital system concentration. Longitudinal analysis shows nursing wages declining with increases in hospital concentration. We interpret these results as providing support for classic monopsony effects in the short run, but question whether wage effects are sustained in the long run. No relationship is found between nursing wages and a new monopsony measure of mobility, but support for new monopsony is found for women elsewhere in the labor market. RNs display greater inter-employer mobility than do women (or men) in general. Two conclusions follow. First, upward sloping labor supply need not imply monopsonistic outcomes. Second, absent more compelling evidence, nursing should not be held up as a prototypical example of monopsony-classic or new.     

Monopsony power and relative wages in the labor market for nurses

This paper examines the thesis that monopsony power is an important determinant of wages in nursing labor markets. Using data from the 1985-93 Current Population Surveys, measures of relative nurse/non-nurse wage rates for 252 labor markets are constructed. Contrary to predictions from the monopsony model, no positive relationship exists between relative nursing wages and hospital density or market size. Nor is support found for the presence of monopsony power based on evidence on union wage premiums, slopes of experience profiles, or the mix of RN to total hospital employment.     

Nursing home spending patterns in the 1990s: the role of nursing home competition and excess demand

OBJECTIVE: To examine nursing home expenditures on clinical, hotel, and administrative activities during the 1990s and to determine the association between nursing home competition and excess demand on expenditures. DATA SOURCES/STUDY SETTING: Secondary data sources for 1991, 1996, and 1999 for 500 free-standing nursing homes in New York State. STUDY DESIGN: A retrospective statistical analysis of nursing homes' expenditures. The dependent variables were clinical, hotel, and administrative costs in each year. Independent variables included outputs (inpatient and outpatient), wages, ownership, New York City location, and measures of competition and excess demand. DATA COLLECTION/EXTRACTION METHOD: Variables were constructed from annual financial reports submitted by the nursing homes, the Patient Review Instrument and Medicare enrollment data. PRINCIPAL FINDINGS: Clinical and administrative costs have increased over the decade, while hotel expenditures have declined. Increased competition was associated with higher clinical and administrative costs while excess demand was associated with lower clinical and hotel expenditures. CONCLUSIONS: Nursing home expenditures are sensitive to competition and excess demand conditions. Policies that influence competition in nursing home markets are therefore likely to have an impact on expenditures as well.     

Organizational and environmental factors associated with nursing home participation in managed care

OBJECTIVE: To develop and test a model, based on resource dependence theory, that identifies the organizational and environmental characteristics associated with nursing home participation in managed care. DATA SOURCES AND STUDY SETTING: Data for statistical analysis derived from a survey of Directors of Nursing in a sample of nursing homes in eight states (n = 308). These data were merged with data from the On-line Survey Certification and Reporting System, the Medicare Managed Care State/County Data File, and the 1995 Area Resource File. STUDY DESIGN: Since the dependent variable is dichotomous, the logistic procedure was used to fit the regression. The analysis was weighted using SUDAAN. FINDINGS: Participation in a provider network, higher proportions of resident care covered by Medicare, providing IV therapy, greater availability of RNs and physical therapists, and Medicare HMO market penetration are associated with a greater likelihood of having a managed care contract. CONCLUSION: As more Medicare recipients enroll in HMOs, nursing home involvement in managed care is likely to increase. Interorganizational linkages enhance the likelihood of managed care participation. Nursing homes interested in managed care should consider upgrading staffing and providing at least some subacute services.     

The effect of Channeling on in-home utilization and subsequent nursing home care: a simultaneous equation perspective.

OBJECTIVE. This study explored the relationship between participation in a home/community-based long-term care case management intervention (known as the Channeling demonstration), use of formal in-home care, and subsequent nursing home utilization. STUDY DESIGN. Structural analysis of the randomized Channeling intervention was conducted to decompose the total effects of Channeling on nursing home use into direct and indirect effects. DATA COLLECTION METHOD. Secondary data analysis of the National Long-Term Care Data Set. PRINCIPAL FINDINGS. The use of formal in-home care, which was increased by the Channeling intervention, was positively associated with nursing home utilization at 12 months. However, the negative direct effect of Channeling on nursing home use was of sufficient magnitude to offset this positive indirect effect, so that a small but significant negative total effect of Channeling on subsequent nursing home utilization was found. CONCLUSIONS. This study shows why Channeling did not have a large total impact on nursing home utilization. The analysis did not provide evidence of direct substitution of in-home care for nursing home care because the direct reductions in nursing home utilization due to other aspects of Channeling (including, but not limited to case management) were substantially offset by the indirect increases in nursing home utilization associated with additional home care use.     

Medicare hospital payment adjustments and nursing wages

Despite the importance of the nursing profession for healthcare delivery, costs, and quality, there is relatively little research on how provider payments to hospitals affect the labor market for nurses. This study deals with the hospital wage index (HWI) adjustment to Medicare hospital payments, an area-level adjustment intended to compensate hospitals in high-cost labor markets. Since the HWI adjustment is based on hospital-reported labor costs, some argue that it incentivizes hospitals in concentrated markets to pay higher wages to nurses and other workers (the “circularity” critique). We investigate this critique using market-level data on the relative wages reported by nurses and hospital-level data on the average hourly wage for healthcare workers. For identification, we exploit a 2005 change in the geographic area used to define labor markets, which resulted in exogenous changes in the ability of some hospitals to influence their area’s wage index. We find that worker-reported relative nurse wages and hospital-reported healthcare worker wages are higher in some locations where hospitals experienced increased opportunities to game the circularity of the wage index, but these effects appear to be driven by pre-existing wage growth. Medicare’s HWI adjustment method does not appear to suffer from inefficiency due to circularity.     

Association of knowledge of adult protective services legislation with rates of reporting of abuse in Iowa nursing homes

OBJECTIVE: To determine if there is an association between abuse reporting to state authorities by nursing home administrators and directors of nursing and their characteristics and knowledge of the law. DESIGN: Survey. SETTING: Iowa's 409 Medicare certified nursing homes. PARTICIPANTS: Four hundred nine administrators and 409 directors of nursing. MEASUREMENTS: Nursing home abuse incidents, reports, and substantiations, Medicare's Nursing Home Compare Reports, Urban Influence Codes, and county census demographics. RESULTS: A single or double response was received from 369 (90%) of the 409 nursing homes. Being a male administrator and having a higher level of education is associated with higher substantiation rates. A greater knowledge of the dependent adult protective services law is associated with higher incident and report rates for directors of nursing. CONCLUSIONS: Nursing home administrators' and directors of nursing's knowledge of the law and their characteristics are associated with nursing home incident, report, and substantiation of abuse allegations.     

Pay or conditions? The role of workplace characteristics in nurses’ labor supply

Empirically rigorous studies of nursing labor supply have to date relied on extant secondary data and focused almost exclusively on the role of pay. Yet the conditions under which nurses work and the timing and convenience of the hours they work are also important determinants of labor supply. Where there are national pay structures and pay structures are relatively inflexible, as in nursing in European countries, these factors become more important. One of the principal ways in which employers can improve the relative attractiveness of nursing jobs is by changing these other conditions of employment. This study uses new primary data to estimate an extended model of nursing labor supply. It is the first to explore whether and how measures of non-pecuniary workplace characteristics and observed individual (worker) heterogeneity over non–pecuniary job aspects impact estimates of the elasticity of hours with respect to wages. Our results have implications for the future sustainability of an adequately sized nurse workforce and patient care especially at a time when European healthcare systems are confronted with severe financial pressures that have resulted in squeezes in levels of healthcare funding.     

Physician labor supply: do income effects matter?

This paper estimates a model of physician labor supply, focusing on the impacts of wage and non-wage income. We find evidence of significant income effects. For male physicians, the income effect of a wage change on labor supply is negative, with an elasticity of -0.26. The pure substitution effect of a wage change increases labor supply: a 1% increase in wages leads to a 0.49% increase in labor supply, controlling for income effects. The results also suggest that the labor supply decisions of females are more responsive to variations in their earnings than are those of males.     

Alcohol taxes and labor market outcomes

We present reduced form estimates of the effect of alcohol taxes on employment, weekly work hours, and wages. The reduced form estimates are meaningful in two ways: first, they provide estimates of the effect of an important public policy tool--alcohol taxes--and second, they can be used to evaluate hypotheses about the structural effects of alcohol use on labor market outcomes. Estimates indicate that there is a weak and indeterminate relationship between alcohol taxes and labor market outcomes. This implies that alcohol use does not adversely affect labor market outcomes and is inconsistent with findings from previous studies.     

What determines the need for nursing home admission in a universally insured population?

OBJECTIVES: People in lower socio-economic groups are more likely to experience disability and cognitive impairments at earlier ages than those in higher status groups. As a result, the need for nursing home care would be expected to be greater among older people of lower socio-economic status. This study examines the effects of income and education on the probability of nursing home entry in a universally insured elderly population. METHODS: Using a prospective observational study design, a range of predictors of nursing home admission was examined over a three-year period in a representative sample of 7220 residents, aged 60 years or older, in a Canadian province. Individual census records and computerized administrative records of health care utilization were linked to form a database for analysis. RESULTS: An increased risk of institutionalization was associated with older age, male gender, unmarried status and self-reported disability. In addition, lower household income and lower attained education were independently associated with a higher risk of nursing home admission. CONCLUSIONS: These results emphasize the independent role of socio-economic status in accentuating or accelerating the need for institutional care towards the end of life. It is important that these effects are recognized in policies that determine the finance of both nursing home care and formal community-based supportive care.     

Nursing home social worker skills and end-of-life planning

Little empirical information exists on nursing home social worker's involvement in advance care planning and end-of-life decision- making with nursing home residents and their family members. The purpose of this exploratory study was twofold: (1) to identify the frequency of skills associated with advance care planning that social workers use, and (2) to explore the factor structure of the scale used in the study. Results from 138 nursing home social worker respondents from New York State showed high frequency of advance directive discussions, care planning, and conflict resolution with families. The instrument factors clustered around administrative duties, and grief issues. There was substantial interest in continuing education in grief counseling with families.     

Factors influencing the utilization of visiting nursing and home-help services

PURPOSE: To identify the respective characteristics of clients using visiting nursing service and home-help service. Since the past, research on the utilization of in-home care services has usually focused on different services collectively. METHODS: Interviews using structured questionnaires were carried out with 134 elderly individuals who were selected in October 1997 from the list for home visit of public health nurses in a town with a population of 36,000. With regard to the utilization of visiting nursing as well as home-help service, the relationship with three factors of the conceptual Andersen's model (predisposing factor, needs factor, enabling factor) were examined. RESULTS AND DISCUSSION: Of the 134 subjects, 38.1% utilized visiting nursing service and 36.6% used home-help services. Use of visiting nursing service was significantly associated with variables such as declining ADL in the elderly, hospitalization within the past two years, less caregiving by family members, and less resistance to service-use by caregivers. On the other hand, use of home help service was related to less caregiving by family members and resources of visiting nursing. The clients who used both visiting nursing and home-help service had more difficulty with caregiving by family members compared to those who used only nursing service, and the latter were inferior in them of physical conditions, including ADL, to those who employed only home-helpers. CONCLUSION: The factors promoting the use of visiting nursing are different to some extent from those for home-help service. Clients using both are characterized by the presence of a broader variety needs.     

Income and the utilization of long-term care services: evidence from the Social Security benefit notch

This paper estimates the impact of income on the long-term care utilization of elderly Americans using a natural experiment that led otherwise similar retirees to receive significantly different Social Security payments based on their year of birth. Using data from the 1993 and 1995 waves of the AHEAD, we estimate instrumental variables models and find that a positive permanent income shock lowers nursing home use but increases the utilization of paid home care services. We find some suggestive evidence that the effects are due to substitution of home care for nursing home utilization. The magnitude of these estimates suggests that moderate reductions in post-retirement income would significantly alter long-term utilization patterns among elderly individuals.     

County level socioeconomic position, work organization and depression disorder: a repeated measures cross-classified multilevel analysis of low-income nursing home workers

This study simultaneously tests the effect of county, organizational, workplace, and individual level variables on depressive disorders among low-income nursing assistants employed in US nursing homes. A total of 482 observations are used from two waves of survey data collection, with an average two-year interval between initial and follow-up surveys. The overall response rate was 62 percent. The hierarchically structured data was analyzed using multilevel modeling to account for cross-classifications across levels of data. Nursing assistants working in nursing homes covered by a single union in three states were asked about aspects of their working conditions, job stress, physical and mental health status, individual and family health-care needs, household economics and household strain. PARTICIPANTS: The 241 nursing assistants who participated in this study were employed in 34 nursing homes and lived in 49 counties of West Virginia, Ohio and Kentucky. MAIN RESULTS: The study finds that emotional strain, related to providing direct care to elderly and disabled clients, is associated with depressive disorder, as is nursing home ownership type (for-profit versus not-for-profit). However, when controlling for county level socioeconomic variables (Gini index and proportion of African Americans living in the county), neither workplace nor organizational level variables were found to be statistically significant associated with depressive disorder. CONCLUSIONS: This study supports previous findings that emotional demand in health-care environments is an important correlate of mental health. It also adds empirical evidence to support a link between financial strain and depression in US women. While this study does not find that lack of a seniority wage benefits--a factor that can conceivably exacerbate financial strain over time--is associated with depressive disorder among low-income health-care workers, it does find county level measures of poverty to be statistically significant predictors of depressive disorder. Longitudinal county level measures of low-income as predictors of depression may even offer a methodological advantage in that they are presumably more stable indicators of cumulative exposure of low income than are more transient workplace indicators. Incorporating measures of cumulative exposure to low income into empirical studies would be particularly timely given the global changes that are currently restructuring the labor force and influencing work organization and labor processes--most notably the growth in low income jobs and the deskilling of labor. Though this study provides evidence that workplace and organizational level variables are associated with depressive disorder among low-wage nursing assistants in US nursing homes, the fact that these relationships do not hold once county level measures of poverty are controlled for, suggests that more distal upstream determinants of workplace mental health problems, such economic inequality, may be at play in determining the mental health of low wage workers.     

Examining variation in treatment costs: a cost function for outpatient methadone treatment programs

OBJECTIVES: To estimate a hybrid cost function of the relationship between total annual cost for outpatient methadone treatment and output (annual patient days and selected services), input prices (wages and building space costs), and selected program and patient case-mix characteristics. DATA SOURCES: Data are from a multistate study of 159 methadone treatment programs that participated in the Center for Substance Abuse Treatment's Evaluation of the Methadone/LAAM Treatment Program Accreditation Project between 1998 and 2000. STUDY DESIGN: Using least squares regression for weighted data, we estimate the relationship between total annual costs and selected output measures, wages, building space costs, and selected program and patient case-mix characteristics. PRINCIPAL FINDINGS: Findings indicate that total annual cost is positively associated with program's annual patient days, with a 10 percent increase in patient days associated with an 8.2 percent increase in total cost. Total annual cost also increases with counselor wages (p<.01), but no significant association is found for nurse wages or monthly building costs. Surprisingly, program characteristics and patient case mix variables do not appear to explain variations in methadone treatment costs. Similar results are found for a model with services as outputs. CONCLUSIONS: This study provides important new insights into the determinants of methadone treatment costs. Our findings concur with economic theory in that total annual cost is positively related to counselor wages. However, among our factor inputs, counselor wages are the only significant driver of these costs. Furthermore, our findings suggest that methadone programs may realize economies of scale; however, other important factors, such as patient access, should be considered.     

Analysis of nursing home use and bed supply: Wisconsin, 1983.

This article presents evidence that in 1983 excess demand was a prevailing characteristic of nursing home care markets in Wisconsin, a state with one of the highest bed to elderly population ratios. It further shows that excess demand is the source of at least three types of error in use-based estimates of the determinants of the need for nursing home care. First, if excess demand is present, estimates of the determinants of Medicaid use may simply represent a crowding out of Medicaid patients, driven by the determinants of private use. As a result, factors associated with greater overall need in an area will be correlated with fewer Medicaid patients in nursing homes, ceteris paribus. Second, estimates of the substitutability of home health care for nursing home care may be misleadingly insignificant if they are based on the bed supply-constrained behavior of Medicaid-eligible subjects. Third, because the determinants of bed supply become the determinants of overall use under excess-demand conditions, the determinants of use will reflect, to some extent, the nursing home's desire for profits. Because profitability considerations are reflected in use based estimates of need, these estimates are likely to be misleading.     

Managing the Impact of COVID-19 in Nursing Homes and Long-Term Care Facilities: An Update

Older adults in nursing homes are at greatest risk of morbidity and mortality from SARS-CoV-2 infection. Nursing home residents constituted one-third to more than half of all deaths during the early waves of the COVID-19 pandemic. Following this, widespread adaptation of infection prevention and control measures and the supply and use of personal protective equipment resulted in a significant decrease in nursing home infections and deaths. For nursing homes, the most important determinant of experiencing a SARS-CoV-2 outbreak in the first instance appears to be community-transmission levels (particularly with variants of concern), although nursing home size and quality, for-profit status, and sociodemographic characteristics are also important. Use of visitation bans, imposed to reduce the impact of COVID-19 on residents, must be delicately balanced against their impact on resident, friend or family, and staff well-being. The successful rollout of primary vaccination has resulted in a sharp decrease in morbidity and mortality from SARS-CoV-2 in nursing homes. However, emerging evidence suggests that vaccine efficacy may wane over time, and the use of a third or additional vaccine “booster” doses in nursing home residents restores protection afforded by primary vaccination. Ongoing monitoring of vaccine efficacy in terms of infection, morbidity, and mortality is crucial in this vulnerable group in informing ongoing SARS-CoV-2 vaccine boosting strategies. Here, we detail the impact of SARS-CoV-2 on nursing home residents and discuss important considerations in the management of nursing home SARS-CoV-2 outbreaks. We additionally examine the use of testing strategies, nonpharmacologic outbreak control measures and vaccination strategies in this cohort. Finally, the impact of SARS-CoV-2 on the sector is reflected on as we emphasize the need for adoption of universal standards of medical care and integration with wider public health infrastructure in nursing homes in order to provide a safe and effective long-term care sector.