An examination of the effects of payer mix on hospital nurse to patient ratios and hospital quality of care

This dissertation examines the effect of payer mix on hospital staffing ratios and the resulting effect on quality of care, specifically outcomes of hospitalized patients. It is hypothesized that changes in hospital payer mix affect hospital revenue. These changes in hospital revenue affect hospital staffing which in turn affect the quality of patient care. An additional and related purpose is to explore the presence of spillover effects, which occur, in this case, when one patient\u27s insurance type affects the quality of care received by another patient with a different type of insurance. Because the role of nursing on quality is central to this dissertation, two patient level outcomes, surgical failure-to-rescue (FTR) and Acute Myocardial Infarction (AMI) mortality, will be used to measure overall patient quality and explore the existence of spillover effects. The dataset employed in the statistical analysis is an unbalanced panel database of hospitals over time for the staffing regressions and a dataset comprised of discharges from repeated cross-sectional samples of hospitals for the outcomes regressions. The regressions include the use of hospital fixed effects to control for unobserved, time-invariant hospital heterogeneity. The problem of reverse causality is addressed by lagging the time varying independent variables in the analyses. The results show a weak association between hospital patient revenue and staffing levels and also demonstrate a weak relationship between hospital payer mix and staffing levels. No relationship between payer mix and outcomes is found, nor is there any evidence of spillover effects