Health Insurance for the Aged:

Participating Extended-Care Facilities

by DAVID ALLEN*

BENEFITS for extended-care services following Covered services include room and board in a
hospitalization became available on January 1, semiprivat,e room (private room is covered if
1967, to persons enrolled in the hospital insurance medically necessary) ; nursing care under super-
program under the Social Security Act. The ex- vision of a registered nurse ; physical, occupa-
tended-care benefit is designed primarily for per- tional, or speech therapy; drugs and biologicals;
sons recently discharged from the hospital who medical social services ; diagnostic and thera -
continue to need full-time skilled nursing care for peutic services ordinarily furnished by extended-
a relatively short duration. The benefits do not care facilities ; and medical services of an intern
cover custodial care provided in nursing and or resident-in-training of the hospital that has
residential homes. a transfer agreement with the extended-care
Extended care represents a new level of care facility.
designed to provide skilled nursing services in a
high-quality extended-care facility at less cost
than in a hospital. For many patients, it will
provide the necessary skilled nursing care to re- EXTENDED-CARE FACILITY DEFINED
store good health and enable return to independ-
ent living in the community. For those with a An extended-care facility is defined as an insti-
continuing need for long-term nursing care, it tution, such as a skilled nursing home or rehabili-
will provide the early stages of such care. tation center, which has a transfer agreement in
This article describes the new benefit and pre- effect with one or more participating hospitals
sents data on the number of extended-care facili- and which is primarily engaged in providing
ties certified for participation under. the program skilled nursing care and related services for pa-
and on the characteristics of such facilities. tients who require medical or nursing care or in
providing services for the rehabilitation of in-
jured, disabled, or sick persons1
BENEFITS PROVIDED To be approved for participation under the
The hospital insurance program covers up to program as an extended-care facility, each insti-
100 days of extended-care services in a certified tution must meet special requirements, such as
facility during a single “spell of illness.” The pro- round-the-clock skilled nursing care, medical
gram pays the full cost of covered services for the supervision of each patient, and an arrangement
first 20 days of extended care and all but $5 a day with a hospital for appropriate transfer of pa-
for the next 80 days. tients. In addition, each approved facility agrees
Extended-care benefits are payable for eligible to comply with title VI of the Civil Rights Act
persons under the following conditions : of 1964, which prohibits discrimination based on
race, color, or national origin.2
-A minimum of 3 consecutive days of hospital care is As of March 31, 1967, a total of 3,669 facilities
required had been certified for participation in the health
-Admittance, on a doctor’s order, to the extended-care insurance program for the aged. The certifica--
facility is made within 14 days from the date of
hospital discharge
-Admittance to the extended-care facility is for further
treatment of the condition for which patient was r For a detailed definition of an extended-care facility
hospitalized see title XVIII, section 1861(j) of the Social Security
Act.
2 For a description of the conditions of participation
see Social Security Administration, Health Insurance for
*Division of Health Insurance Studies, Ofike of Re the Aged: Conditions of Participation for E&ended Care
search and Statistics. Facilities (HIM-3), 1966.

BULLETIN, JUNE 1967 a

tions made to the Department of Health, Educa- TABLE 1.-Number of participating extended-care facilities
and beds, by type of facility and control, as of March 31,
tion, and Welfare on the recommendation of State 1967
agencies indicate that the providers meet the con-
ditions for participation promulgated by the Type of facility
Secretary of Health, Education, and Welfare. A ,
participating provider is a certified institution Facilities
that has entered into an agreement with the Social
Total..----- .._. ._.___ --__-_.-_-._.- 3,669 2.485 317 867
Security Administration not to make charges for ----
Skilled nursing home .__________________. 2.832 2,277 145 410
covered items and services except deductible and Extended-care unit of-
Hospital . .._......_.___._.-.-...-.-.-.- 519 86 150 283
coinsurance amounts and to provide services on Domiciliary institution .________._____. 216 18 158
Rehabilitation center and other 1-e-e-e 102 ii 4 16
a nondiscriminatory basis in compliance with title
VI of the Civil Rights Act of 1964. Beds

Total..-----.------.----------------- 262,321 179,303 32,864

I-I-I-A!!
Skilled nursing home ____________________213,248 167,321 17,064 28,863
Extended-care unit of-
Hospital ___._._._. __________..._...... 27,716 4,788 11,006 11.922
Domiciliary institution .._._._.___._.._ 15,491 2,919 4,468 8.104
TYPE AND CONTROL OF PARTICIPATING Rehabilitation center and other I- _.___ 5.866 4.275 326 1,265
FACILITIES
Average number of beds
An extended-care facility may be a skilled
Total...... ____________.___._..______ 71 1 72 1 104 1 58
nursing facility, or it may be a distinct part of an
Skilled nursing homes _.______________.._ 75 73 118 70
institution for custodial care or a rehabilitation Extended-care unit of-
Hospital..-- _______....._.______------. ;; 42
center or other medical institution, where skilled Domiciliary institution . . . . . .._._._.___ E 2::
Rehabilitation center and other 1.. 58 52 82 ;:,
nursing and related services are provided. A “dis-
tinct part of an institution” must be physically 1 Includes extendedare units of specialty institutions.
separated from the rest of the institution and
represent an entire, physically identifiable unit by type of control or ownership, shows that they
such as a separate building, floor, wing, or ward. are predominantly proprietary. More tha-i two-
Various beds scattered throughout the inst,itution thirds of the participating facilities are proprie-
would not comprise a distinct part for purposes tary, about one-fourth are nonprofit, and less
of being certified as an extended-care facility. than one-tenth are non-Federal government hos-
The 3,669 extended-care facilities cert,ified for pitals. State and local extended-care facilities are
participation include 262,321 skilled-nursing beds by far the largest, averaging 104 beds per facility.
-an average of 71 beds per facility (table 1). The average number of beds in proprietary facili-
Excluded from this count are the custodial beds ties is 72, and nonprofit facilities average 58 beds.
in the facility. Skilled nursing homes comprise Distribution of the extended-care facilities by
‘77 percent of the total facilities and include 81 control and type of facility shows some variation.
percent, of the beds. The average number of beds Skilled nursing homes comprise about nine-tenths
in the participating skilled nursing home is 75. of the proprietary facilities but less than half the
The remaining facilities are classified as ex- nonprofit and State and local facilities. Extended-
tended-care units of various types of institutions. care units of hospitals, on the other hand, consti-
Most of these units are in hospitals. Of the 837 tute almost half the State and local facilities,
extended-care units participating under the pro- about one-third of the nonprofit facilities but less
gram, 62 percent are parts of hospitals, 26 per- than 4 percent of the proprietary institutions.
cent are parts of domiciliary institutions for cus- Although the average size of participating ex-
todial care or homes for the aged, and 12 percent tended-care facilities is 71 beds, there is consider-
are in distinct parts of rehabilitation centers or able variation in size of facilities, ranging from
other special institutions, such as cancer research fewer than 25 beds to more than 500 beds. Ap-
centers. Extended-care units of hospitals have proximately one-eighth of the facilities have less
relatively fewer beds than other types, averaging than 25 beds, half have 25-74 beds, and one-third
53 beds per unit. have 75-200 beds. Only 3 percent represent facili-
Analysis of the data on extended-care facilities, ties with 200 beds or more (table 2).

4 SOCIAL SECURITY
TABLE2.-Number and distribution of participating extended-care facilities, by type and size of facility, as of March 31, 1967
Number of beds
Type of facility
Total Let+? 2549 m-74 7&QQ loo-IQQ ZOO-299 300 or more
than 25

Number of facilities
I
Total. ________________________________________------ 1 3,669 t
______461 1 947 1 919 1 531 1 651 1
~-
75 1 35
Skilled nursing home ___________________________________ 2,332 214 695 767 510 567 56 23
Extended-care unit of-
Hospital________
-_-_.________________________________
519 174 155 11
Domiciliary instituttonm _______-_- _.__________________ 216 ii ii ii if
Rehabilitation center and other l._____________________ 102 ii ii 29 10 9 i 1
1 1 I I I I I

Percentage distribution

Total ________________________________________------- 100.0 12.6 25.8 25.0 15.8 17.7 2.0 0.9
______
Skilled nursing home- __________________________-___-___ loo.0 7.6 24.5 27.1 18.0 20.0 2.0 .Q
Extendedcare unit of-
Hospital.~~~.~~~~~~~~~~~~~~~~~~~-~~~-~~~~~-~-~-~~~~~-.
Domiciliaryinstitution-.--- _._____ ---_- ______________ 100.0 if:: 33.6
29.9 16.8
16.7 10.6
7.3 12.0
9.4 2: 2:
Rehabilitation center and other I._____________---__-._ 106.0 25.5 23.5 28.4 9.6 8.8 2:Q l:o

* Includes extended-care units of specialty institutions.

Size of facility varies considerably according
to its type. Skilled nursing homes are the largest,
with almost one-fourth of the total in this group
having 100 or more beds. Extended-care units of
hospitals have the highest proportion of small
facilities, and one-third of these units have less
than 25 beds. Although these extended-care units
are relatively smaller t,han other types, they are
hospit,al-based and distinct parts of larger facili-
ties certified to render extended-care services as
integral parts of comprehensive health care pro-
vided in the hospital.
GEOGRAPHIC LOCATION
The distribution of extended-care facilities and
beds by geographic location shows some variation
according to type of facility. In general, the
skilled nursing home is the predominant type of
facility. For the entire Nation, more than three-
fourths of the facilities are skilled nursing homes.
In the New England States, however, skilled
nursing homes represent more than nine-tenths
of the facilities. By contrast,, only three-fifths
the facilities in the West North Central States
are skilled nursing homes (table 3). The distri-
bution of beds by type of facility shows the same
general pattern among the nine geographic di-
visions.
Skilled nursing homes as proportions of total
extended-care facilities and beds vary somewhat
more among the States. All of the eight partici-
pating extended-care facilities in Vermont are
skilled nursing homes. In the District of Colum-
bia, the largest, proportion of beds, 71 percent, are
in extended-care units of domiciliary institutions
and only 29 percent are in skilled nursing homes.
In Wyoming, less than a fourth of the 204 ex-
tended-care beds are in skilled nursing homes. In
Alaska, Kansas, and Montana, extended-care
units of hospitals are the most frequent facility,
but skilled nursing homes have the most beds.
Analysis of the data according to control or
ownership of facilities also shows some variation
among the geographic divisions and States. More
than two-thirds of the participating extended-
care facilities and beds in the Nation are owned
and operated for profit. In the West North Cen-
tral States, however, about a third of the facili-
ties and two-fifths of the beds are proprietary
(table 4). For this geographic division, nonprofit
facilities are the predominant type of control. In
the New England States, on the other hand,
proprietary extended-care facilities are signifi-
cantly more numerous, comprising more than
four-fifths of the total.
of The proportion of all extended-care beds that
are proprietary ranges from 16 percent in the
District of Columbia to 98 percent in Mississippi.
In 10 States and the District of Columbia, less
than half the beds are in proprietary facilities. In
Alaska, the District of Columbia, and Wisconsin,
State and local facilities have the greatest num-
ber of beds.

BULLETIN, JUNE 1967 6

 Significant regional and State variations are sons enrolled in the hospital insurance program
evident when the total number of certified ex- as of July 1, 1966. The national average of beds
tended-care beds is related to the number of per- per 1,000 enrollees is 14.0 and the median is 12.2,

TABLE 3.-Number of participating extended-care facilities, by geographic division and State and by type of facility, as of
March 31, 1967
- -
Extended-care unit of-
- -
Skilled nursing home
Hospital 1Domiciliary institution Rehabilitation center
and other ’
- - -
Facilities Beds Facilities Beds Beds Facilities Beds Facilities
-- _- -- _-
Total, all areas __________ 3,669 282.321 213,248 519 27,716 216 15,491 5.866 102
-- -- -- _-
united states _____________ 3,663 261, w)7 213,268 514 27,342 216 15.491 102 5,866
-- _- -- _-
New England _________________ 1,015 10 390 b 377
Maine--.-..------___--------
New Hampshire _____________
Vermont----------_---------
lg%i
ii
__‘:____
_______-___. 145
- - - - - _ __ _
---_____-- -_- _____- _- _.. _______- _- - _____-__.___
1 21 ________-_ ___________
----______ __-___-_---- . ___-__ _----. . ______---___
Massachusetts _______________ 7.452 5 697 2 147 2
Rhode Island ________________ ___- _- ___ - - - - __ _ __ “ii
Connecticut ---______________ lO,% 5 273 i 14775 ; 42
Middle Atlantic _______________ 326 32,633 38 yg 5,235 11 723
New York------------------- ;:g 157 17,lQQ 18 ii “,O@$ 5 189
New Jersey __________________ 4.750 4 ‘637 603
Pennsylvania ________________ 13: 124 1:: 10,684 16 726 21: 1.689 : 31
East North Central.-. _________ 4;Jl; 438 76 3,959 15 1,084
Ohio....--.----__-_--------- 116 15 :i 807 6 278
Indiana....----.-.---------- 3:343 4 ________-. ____________
Blinois- - - ----- --_--_-_--_ ___ IO.292 ii 15 1: iii;
Michigan ____________________ 10,274 1,058 i i.z
Wisconsin -----_____-________ 10.857 1: s ; 1,035 4 133
West North Central. __________ 18.280 191 13,374 101 3,469 21 1.124
Minnesota- __________________ 7,261 5,034 32 1,344 11 646 3” E
Iowa----.------___._-------. 2,363 1,720 11 436 3 157
Missouri------_------------- 4,3$ ii 3,541 15 767 40 : 3”s
North Dakota _______________ 15 759 95 ; 131 ___________-___________
South Dakota _______________ 268 7 ; __ ____________-___________
Nebraska .___________________ 1,215 i% 2:: 114 __-___-.__ -------___-
Kansas----------__---------- 1,814 ;: 1,263 3: 515 36 ______-___ . _-___-______
South Atlantic ________________ , 1,680 1,746 17 1,265
Delaware....-.-------------- 23% “: 60 ___________-______-____
41
Maryland ___________________ , 3,456 1 104 1 50
District of Columbia- _______ , _-..----__-__ E _-_.______ _-_________-_
Virginian -- - ---__ _-_---_- ____ 2% 313 208 1 81
West Virginia _______________ , 274 ____-.____ -_-----___-
North Carolina ______________ ;,g 133 ti __________ _____-_-____
South Carolina ______________ , __ 126
Qeorgia ______________________ 2:740 12 _--___-_____ i 253
Florida---.---.-------------- I 9,08a 659 4 157 7 755
East South Central ____________ I 136 7,742 17 953 2 56 1 78
Kentucky ___________________ 30 2.129 4 112 ---_______ _ --___._____ _ _____-_____ __--_---____
Tennessee----.----..-------- 1,439 580 2 56 1 79
Alabama-------..--.-------- ii : 249 _ _._-______ ________-.__ _--_-_-_-____
Mississippi- _________________ , 13 “*% 2 12 __ _____________-__-_-______
West South Central ___________ I 296 19,674 44 2,218 10 595 13 439
Arkansas- __________________ I 25 1,757 226 ---_______ _--_________
Imlis1ana. - - -_______----____ 102 5,605 : 187 5 483 : 2::
Oklahoma. __________________ 855 251 1 60
Texss.-..--------.---------- 1: 11,457 2: 1,574 : ii 4 120
Mountain. ____________________ I 12,824 2,132 447
Montana ____________________ 1,024 485 2’ z
Idaho- ______________________ I 1,706 156 ---_____-_ _ --_-_______ :!:
Wyoming. - --__-_-__-_--_-__ 1 48 ---_______ _ -__. _______ 108
Colorado. ----_________--___- I 6,O:: 433 2 34 211
New Mexico _________________ 1 / 642 314 _ __-_____-_-_ _-__-_-______
Arizona- ____________________ 1 1.801 370 ---___-_-_
_- 31
Utah -____----_---_--_---____ 1 1,239 190 ---_______
_- : 12
Nevada. ___ _________________ 1 346 142 ---_-_-_-._- __-------___ . -___________
Pa&l0 ____-_----_ ___------ --_ - _ I 5i.56; 663 48,394 139 7,710 51 27 1,129
Washington _________________ 93 24 1,016 14 6 239
Oregon- _____________________ I 3:612 44 xz 379
californils. _____________-____ , 45.98; 516 37&l t: 5,748 3; 1: 8E
Alaska. _____________________ 4 - _- _- - - ___ . -_--__--__._
Hawaii ______________________ 1 1,174 : ii: 5 5E 1 . _- _- _____ . -__-________
Other areas.. ______________ 414 374 - - - ___- ___.. -________- _ . ___-________ -..---_--____
Puerto Rico- ---______-------- _ 414 : El i 374 __ . _- - __- _- ___ -.--- _--. ____
Other’-.----------.-----.----- 1 0 .-_-- ___-_ - _.. _- ___- _- _ .-- --_____ _ _. ._ . ___________ -..__________
- - - - -
* Includes extended-care units of specialty institutions. 2 American Samoa, Guam, and the Virgin Islands.

6 SOCIAL SECURITY
but the range in number of beds is from 7.5 per States is even greater, ranging from 3.0 per 1,000
1,000 in the East South. Central region to 27.6 enrollees in Mississippi to 39.4 in Connecticut.
in the Pacific region. The variation among the The 50 States and the District of Columbia are

TDLE 4.-Number of participating extended-care facilities and beds and beds per 1,000 hospital insurance enroll&s, by geo-
graphic division and State and by control, aa of March 31, 1967

Total
.-
Qeographic division and State
Facilities
Beds Proprietary
I State and local Nonprofit

Number Per 1,Mx) Facilities Beds Facilities Beds Facilities Beds

mollees 1

Total, all area.-..---- _.______________ 3,669 262,321 14.0 2,485 179,303 317 32,864 867 5o.lb4
United States.---------.--------------- 3,663 261,607 14.1 2,485 179,303 314 32,584 864 50,020
New Ennland--.- __________________________1 21,234 17.3 276 17,290 13 1,269 48 2m;
Maine_---.------------------------------ % 748 10 482 1 29
New Hampshire.-.-------.-------------- 6 E 246 ._________ 2” 61
Vermont-----------------~--------------- 8 ii: 6:8 : 2 2 70
Massachusetts ___________________________ 116 8,515 13.8 100 7,% 5 11
Rhode Island ____________________________ 13 692 7.0 9 448 _________ ._________ z
Connecticut _________- _______-_______.___ 175 10,649 39.4 149 8,785 5 593 2: 1,271
Middle Atlantic ____________________________ 42,536 11.3 289 25,877 8.774 107 7,885
New York...---------------------------. 2;#505 12.2 143 14,853 4,504 3,702
New Jersey-_.-.._.--..------------------ 9.8 4,215 1,132 ::
Pennsylvania--.--...---..-.--.---.------ 13: 124 10.7 1;; 6,809 3,138 51 ::E
EastNorth Central------------------------ 578 44.715 12.2 324 24,117 10,sBo 9,708
Ohio _____________________________________ 150 9,949 10.4 107 6,844 814 2,291
Indiana---------------------------------- 3,343 7.0 1,897 769 677
Illinois------.---------------------------- 1;: 10,262 9.7 ii 7,145 1,130 y2’
Michigan-----------.---.---------------- 108 10,274 14.2 53 4,784 3,858
Wisconsin ________._______________________ 154 10.857 24.1 55 3,447 4,319 3: 091
West North Central ________ _______________ 318 112 7,878 1,819 168
Minnesota------.--.--------------------- 110 ‘;%i 2,032 1,252 65
Iowa---------------------------------.--- 44 2:363 ii 1,347 161
Missouri--------------------------------- 4.384 2,822 124 ii
North Dakota...-...-.-.-..----.-----~--- iTi 98.5 “t 158 3 19
South Dakota----.--.-.------------------ 4 157 5
Nebraska.-.--.------------------------.- 1: 1,2! 7 10
Kansas.------------.-.------------------- 54 1.814 16 % 31
South Atlantic _____________________________ 28,354 11.8 21,685 13 1,570 6,099
Delaware-.------------------------------ “ii 11.8 ._________ _________ ‘i 147
Maryland _______________________________- 40 3% 15.0 3,z 798
District of Columbia _________________.___ 1,357 20.3 211 : 8:: 2”
Virginia-..-----.------------------------- 3i 2,935 9.0 2,115 2 247 %
West Virginia _________.__________________ 4.7 501 1 43 : 352
North Carolina __________________________ 2 2,:: 6.3 1.651 _________ 11
South Carolina _______.___._______________ 50 2,797 16.2 2,177 151 %
Qeorgia---------------------------------- 43 3,138 9.5 2.473 133 6” 532
Florida-------.------.-.------------------ 130 10,554 14.8 9,190 106 21 1,258
East South Central ________________________ 150 8,830 6.33’3 1.278 1,222
Kentucky-..---.-.-------------------.--- 2,241 ::o” 1,352 “i: 178 “i 711
Tennessee.-.-.---..---------------------- i:: 2,154 6.1 598 10 356
Alsbsms------.-------------------------- 64 37% 12.9 :%i 1: 49il 4 lbb
Mississippi----.-------------------------- 15 3.0 -614 2 12 _- - - ____
West South Central _______ ______________-- 22,926 14.0 277 17,450 15 71 4,837
Arksnsss.---.----.----------------------- “ii 2,018 9.3 1,334 b z: 10 510
Louisiana-------------------------------- 117 6,489 2 5.197 2 113 1.179
Oklahoma--------.--.-..----------------- 22 1,174 7; 12 625 3 147 ‘! 402
Texas------------------------------------ 191 13,245 15:1 148 10,294 b 205 38 2,746
Mount8in____________________--------------
( 15,455 25.3 146 11.188 1,570
Montana _____________________________-- --I 1.575 23.4 757 342 z
Idaho- _________________________________- - 1.893 ii I.386 284 3
Wyoming _-_______-_-_ _-__----_-------- -- 7: 24 1
Colorado----------.------------------.--- 6,% 38:2 6i b,% 17
New Merico----..-..-------------------- 15.4 239 iii
Arlsona ________________________________-- 2,% 18.2 2i 1,617 125 :
Utah ___________________________________ -- 1,441 21.0 15
Nevada---------------------------------- 488 29.1 6 iii :: :
Paciflo-.-.-----..-------------------------- 880 bO.E67 27.6 675 47,488 69 4.775 146
W8ShingtOIl____________________~~~~-~--- - 137 8,641 28.6 102 7,358 4 :*z
Oregon--------.--.----------------------- 3,612 17.5 41 2,337 5 E 2 I:921
California-..-.---.----------------------- 6; 45.981 28.6 526 37,z 45 3.913 81 4.688
Alaska ________________.________________-- lb9
Hawall _________________________________-- lb 1.174 2:: : 378 : 3;; : 4:
Other BTeBs----------.----------------- 414 - _________
Puerto Rico__~-_-___-_-_.----~~------------ 414 - - - - - - ____. : iit : ::
Other a_________________________________-_-- % 0 - _- ___- ___ __-_______ .-----__-- ________- .__-__--- --

* Based on the number in hospital insurance program, as of July 1,1966. * American Samoa, Guam, and the Virgin Islands.

BULLETIN, JUNE 1967 7

grouped in six categories according to the ratio percent) have between 10 and 20 beds per 1,000
of beds per 1,000 enrollees, as follows: enrollees. Only 13 Stat,es (26 percent) have more
than 20 beds per 1,000 enrollees. These statewide
ratios reflect the overall supply of beds within
NUIllbSX Percentage the State. They do not reflect occupancy or turn-
Of states distribution
over rates; thus the number shown as certified
Total _____________________________________ 51 100.0 may not represent the number of beds actually
Under 5.0 _____________________________________ 5 9.3 available. It is recognized that where the State
5.0-9.9 _____________ __________________________ 17 33.3
10.0-14.9~~.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ 15.7 ratios are high, there may be many localities with
15.0-19.9-------------------------------------- : 15.7
20.0-24.9 __-___-_-_____-__--_------------------ 11.3 a relatively low supply. Conversely, in States
25.0 or more _________________________________^_ t 13.7
with a low extended-care bed supply in relation
to the aged population, there may be local areas
More than two-fifths of the States (43 percent) with high ratios. Additional facilities will un-
currently have less than 10 certified extended-care doubtedly be certified in the future as they meet
beds for every 1,000 persons enrolled under the the conditions for participation under the
hospital insurance program. Sixteen States (31 program.

R SOCIAL SRCURITY