Exhibit 4.

Effect Of State Nursing Home Payment Policies On Nurse Staffing Hours Per Patient Day And Racial/Ethnic Disparities^a

	Staffing hours per patient day
State policy	RN	LPN	All licensed nurse	CNA	All nurse	RN hours as % of all nurse hours
Medicaid payment rate (in $10)	−0.001	0.006****	0.006***	0.006***	0.012****	−0.065****
Case-mix payment (yes or no)	−0.010**	0.002	−0.008	0.004	−0.005	−0.389***
Payment rate (in $10) multiplied by concentration of minority residents
Low	Ref	Ref	Ref	Ref	Ref	Ref
Medium	−0.001	0.001	−0.000	0.004**	0.003	−0.039**
Medium-high	0.002**	0.002**	0.004***	0.006**	0.009***	0.053**
High	0.004****	0.000	0.004***	−0.001	0.001	0.163****
Case-mix payment multiplied by concentration of minority residents
Low	Ref	Ref-	Ref	Ref	Ref	Ref
Medium	−0.001	0.000	−0.001	0.003	0.002	−0.033
Medium-high	−0.003	−0.012**	−0.015**	−0.045***	−0.061***	0.141
High	−0.007	−0.011	−0.018**	−0.086****	−0.106****	0.300

SOURCE Authors’ analysis of data for 2001–10 from the Online Survey Certification and Reporting (OSCAR) System files and the LTCfocus files (see Note 27 in text). NOTES “All licensed nurses” is registered nurses (RNs) and licensed practical nurses (LPNs). “All nurses” is RNs, LPNs, and certified nursing assistants (CNAs). Concentration groups of minority residents are: low, less than 5%; medium, 5–14.9%; medium-high, 15–34.9%; and high, 35% or more. Multivariable longitudinal (2001–10) random-effects linear regression estimated each staffing measure as a function of minority concentration groups, year dummies, and their interactions; each state policy variable and its interactions with minority concentration groups; bed size; chain affiliation; nonprofit ownership; government ownership; occupancy rate; percentage of Medicare residents; percentage of Medicaid residents; case-mix; percentage of female residents; average age of residents; market competition; rural location; and state dummies.

^**p < 0.05

^***p < 0.01

^****p < 0.001