PhD Seminar: Adding New Targets to an Old Scorecard: Nursing Home Responses to the 2022 Staffing Rating Reform

Adding New Targets to an Old Scorecard: Nursing Home Responses to the 2022 Staffing Rating Reform

I study the addition of staff turnover and weekend staffing measures to the U.S. nursing home Five-Star staffing rating in 2022. Using internal comparisons across component scores, occupations, and time, I examine how nursing homes responded to new incentives within a nationwide redesign of an established public reporting system. In matched facilities with greater marginal scoring opportunities for registered nurse (RN) turnover, the share of new RN employment spells with fewer than 120 hours worked in their first 90 days increases by 8.711 percentage points relative to jobs not directly scored on the turnover measure (standard error = 4.107). This response is concentrated among directly employed nurses rather than contract staff. Three complementary analyses of the weekend staffing component find no systematic additional increase in weekend staffing or reallocation of staffing toward weekends among facilities with greater marginal scoring opportunities. I then examine whether the rewarded turnover measure remains informative about broader workforce outcomes. In national samples observed consistently across periods, lower RN turnover is strongly associated with more care provided by familiar RNs, a higher share of care supplied by longer-tenured staff, and less workforce fragmentation. Matched incentive comparisons show no systematic weakening of these relationships under stronger turnover incentives, but also no detectable improvement in the underlying workforce outcomes. These findings highlight a distinction between a performance measure’s informativeness as a signal and its effectiveness as an incentive target.