The BEDPAN Award: Misinformed Research on SNF Policy

The following is the first of a two-part series.

If imitation is the highest form of flattery, and insanity is repeating the same behavior while expecting a different outcome, the newest public warning about nursing-home supply leaves me telling psychiatrists how wonderful it feels that the Universe chose me to play tricks on. The article has everything needed for Skilled Nursing’s 2026 Benchmarking Errors Distorting Policy Analysis in Nursing Homes (BEDPAN) Award.

The BEDPAN recognizes published policy analysis that seems directionally correct because its perspective is one-dimensional. Nominees can be dangerous: they skip stones across a pond and disregard the unpredictable ripples. They disturb, distract, and confuse.

In July, The New England Journal of Medicine served up “Colliding Forces – The Aging of the Baby Boom Generation and Contracting Nursing-Home Supply.” Apparently, the nation is aging while institutional long-term care loses functional capacity. In unrelated news, it gets dark when the sun goes down. Enough sarcasm. This serious publication gives gravitas to commentary identifying a real problem while stripping away the context needed to solve it. Its recommendations are uncannily familiar, making the piece more irritating: the direction is often right; the analytical machinery is not.

An irrationally complex system becomes harder to comprehend the deeper you dig. Once intellectual and emotional gravity settle into the hole, the first step out is the hardest. Prestige-policy commentary compounds the problem when it discovers the obvious, detaches it from operating reality, and presents the result as high-concept logic.

Zero for Three

Researchers apparently receive technical latitude when deemed directionally right. When the article and publisher gain traction, bad data begets bad policy. Failed policy is expensive, and it fails when distorted, non-comparable data is presented as truth. This commentary embraces three assumptions common to BEDPAN nominees: all SNFs are comparable, the country is one homogeneous market, and providers control their available options. Start 0-for-3, and directionality cannot get you home.

“Skilled Nursing Facility” is one designation applied to healthcare’s most diverse provider class. CMS often treats the label as a comparable unit, even while its own files, payment systems, and reports define related measures differently. Much of what we think we know about SNF data is therefore wrong or analytically unstable. A third of providers are not like the others, state rules differ, reporting errors are common, and a critical guardrail rusted over when cost-based reimbursement became price-based payment.

“Colliding Forces” demonstrates why this conversation needs sharper terminology and comparable, contextualized metrics. “Nursing homes are closing” is insufficient. A 12-bed Transitional Care Unit inside an acute-care hospital contributes little to long-term care capacity. Neither does a newly constructed “Rehab Spa” attracting Medicare Part A admissions and forgoing a Medicaid license.

Cutting Through the Clutter

Those facilities can add certified beds without adding Functional LTC Supply. They may also divert higher-paying Medicare admissions from mixed-payer providers that rely on them to offset inadequate Medicaid rates. The resulting pressure must be relieved – either by higher Medicaid revenue or lower spending. When that proves insufficient, a facility shutters. This cycle is both cause and effect and frames the Certificate of Need debate as a social issue.

Outside metropolitan areas, a half-empty rural provider does nothing to relieve urban demand. The authors acknowledge that national data masks local conditions and licensed beds may not reflect actual supply. Then they use a national facility count and aggregate occupancy as load-bearing evidence. Apparently, policy commentary can acknowledge context before proceeding without it. Geography, payers, acuity, and operating function determine whether a bed is real. Ignoring which SNF closed, where, what market it served, and whether access was constrained is not analysis; it’s mythology with methodology attached. The inadequacy of Skilled Nursing as a single provider designation should have been central to the discussion.

Structural Fatigue and Phantom Pain

Skilled Nursing once seemed ascendant, with subacute care a product of Natural Selection. Intentionally or not, the policies identified by the red squares disrupted that evolution and disadvantaged the provider class.

The sector has lost so much institutional memory that fighting inertia grows harder each year. Experienced professionals are replaced by a new generation whose entry point becomes the baseline; “back in my day” is not analysis, but neither is pretending the past never happened. SNF profile-policy was once more deliberate, identifiable, and equipped with a pressure-release valve that helped maintain supply when demand peaked.

Define and Counter

Policy research is difficult to take seriously when its terminology cannot support conclusions about an intensely localized issue like capacity. Before counting supply, define it. Legacy terms require so many qualifiers that researchers routinely confuse the label with the asset.

This is not semantics. John Ray’s 1670 collection recorded the comparison, “As like as an apple to an oyster.” I do not know when oranges entered the picture, but “apples to oranges” does not apply either. SNF beds share a broad family but vary in form, function, and flavor: oranges, grapefruits, lemons, kumquats, and limes. Calling them “citrus” does not make them interchangeable. Distinguish the payment designation from the operating asset before comparing providers, beds, and occupancy.

Quantifying Supply

The article says nearly 10 percent of U.S. nursing homes closed between 2011 and 2021. That is a defensible gross closure statistic, not a national supply measure. Closures, net changes in certified providers, and lost Functional Supply are different. Facilities open, merge, decertify, convert, change provider numbers, and re-enter under new ownership. KFF describes its facility decline as a net change accounting for newly certified and decertified facilities. The closure study answers a different question. Conflate them, and a statistic becomes evidence for a conclusion it cannot support.

The most acute access failures are often rural, where a common economic framework cannot preserve every essential service. That is a serious and distinct policy problem. In 2024, rural SNFs represented 27 percent of facilities but only 14 percent of fee-for-service Medicare-covered stays. That comparison describes utilization, not the social importance of preserving rural access. Staffing, payer mix, acuity, occupancy, and local alternatives differ, and the differences themselves are not uniform. Are these problems to solve or realities to manage? Probably both. Either way, they are distinct from the commentary’s national premise. Pretending otherwise is how policy people get dangerous before lunch.

MedPAC’s participating-SNF series illustrates the distinction; it does not disprove the gross closure statistic. MedPAC counted 14,935 participating SNFs in 2011 and 14,720 in 2021, a net decline of 215. KFF counted 14,742 CMS-certified facilities in July 2025; MedPAC counted 14,518 Medicare-participating SNFs that same month. MedPAC also cautions that ending Medicare participation does not necessarily mean closure. Gross closures, certified facilities, and Medicare participants are separate measures. None independently quantifies lost Functional Supply.

Four counts. Three definitions. No national access conclusion.

Closures matter. In some markets, consolidation improves operating efficiency; elsewhere, a closure eliminates a community’s only practical access point. Licensed beds also carry regulatory and strategic value, encouraging owners to retain them despite unsustainable operations. Decertification may therefore reflect payment policy, ownership strategy, or regulation, not simply resident demand.

North Carolina led the nation in net domestic migration between July 2024 and July 2025. Its certified nursing-facility count changed little, yet planning rules allowed some providers, particularly continuing care retirement communities, to convert nursing-facility beds to Adult Care Home capacity. Certified supply, licensed capacity, and practical access do not necessarily move together. Those distinctions distort national comparisons, but details do not matter when direction gets you published. Do not say “closures” when you mean “measurable net certified supply relative to local market need.”

For residents with dementia or behavioral-health needs, access may depend as much on payment architecture as staffing. A 2020 analysis coauthored by Charlene Harrington found that staff-time scores understated RN and LPN/LVN needs in the Behavioral Symptoms and Reduced Physical Functioning categories. Researchers substituted recommended staffing values because the underlying scores were too low. That does not prove CMS used a proxy in PDPM or that every affected resident is underpaid. It does raise a question missing from the minimum-staffing debate: What happens when staffing obligations and reimbursement fail to describe the same resident? Think about that for 3.48 moments.

What We Are Measuring

Payment policy determines the type of available capacity. New Jersey has not updated its Medicaid nursing-facility payment base year since 2010 or dynamically adjusted rates for acuity in more than a decade. Outside specialized arrangements, the system can price a tracheostomy like a hangnail. The state had 16 fewer certified facilities in 2025 than in 2019, but that reveals nothing about which beds accommodate higher-acuity residents. Certified capacity is not Functional capacity.

Whether the issue is a rural closure, conversion, unstaffed bed, or reimbursement physics, national net inventory barely moves. The question is what we are measuring, and the answer cannot be a misleading denominator. Do not use one term, imply another, and pull readers toward the wrong crisis. That produces reactive policy, then another article announcing that the obvious problem persists. Wonderful. We have invented an expensive way to rediscover arithmetic.

In the second part of this series, we start with Hospital-Based SNFs. It could be a bumpy ride.