About

R. Tamara Konetzka, PhD, is the Louis Block Professor of Public Health Sciences at the University of Chicago, with a secondary appointment in the Department of Medicine, Section of Geriatrics and Palliative Medicine. She is an internationally recognized expert in the health economics of long-term and post-acute care. Her research focuses on the incentives created by health care policy, including payment policy, and their effects on quality of care. She has led numerous major federal research grants, advancing knowledge on the drivers of nursing home quality, the impact of public reporting on provider and consumer behavior, and the unintended consequences of home-based long-term and post-acute care. She has testified before the U.S. Senate on COVID-19 and nursing homes and is an appointed member of the Medicare Payment Advisory Commission (MedPAC). Additionally, she serves on several editorial boards and is the Editor in Chief of Medical Care Research and Review.

Research topics

• Medicine
• Gerontology
• Nursing
• Virology
• Demography
• Emergency medicine
• Environmental health

Selected publications

• Is Medicare Home Health Care Utilization Substituting for Long‐Term Care? Evidence From Dual Eligible Beneficiaries

  Health Services Research · 2026-04-01

  articleOpen accessSenior author

  OBJECTIVE: To examine the plausibly causal effect of Medicaid home- and community-based services (HCBS) use on Medicare community-initiated home health care (CIHHC) utilization among dual-eligible older adults and to provide evidence on whether access to home-based long-term care (LTC) reduces use of Medicare home health care, with potential implications for whether Medicare home health care is used as a substitute for LTC services when they are not or less accessible. STUDY SETTING AND DESIGN: To address the endogeneity of Medicaid HCBS use, we employ an instrumental variable, the proportion of Medicaid HCBS enrollment in other counties within the same state in the previous quarter, in conjunction with a state-border design in estimating the effect of Medicaid HCBS use on Medicare CIHHC and its heterogeneity. DATA SOURCES AND ANALYTIC SAMPLE: We use national Medicare and Medicaid claims data along with home health and nursing home assessment data from 2016 to 2019. Our sample consists of 36,955,226 beneficiary-quarter-level observations of older adults (65+) dually enrolled in Medicaid and Medicare and residing in contiguous state-border counties. PRINCIPAL FINDINGS: Medicaid HCBS use reduces Medicare CIHHC utilization by approximately 1.02 percentage points (95% CI: -1.73 to -0.32), representing about 44% of the sample mean. This effect is concentrated among beneficiaries enrolled in Medicare-Medicaid integrated care plans and those living in urban counties. Moreover, the reduction is most pronounced among older adults who live alone and have around-the-clock assistance needs. CONCLUSIONS: Our findings suggest a substitution between Medicaid HCBS and Medicare CIHHC among dual-eligible older adults at the margin of using Medicaid HCBS, a relationship that should be taken into account when evaluating either program. These findings also align with the hypothesis that Medicare CIHHC is being used as a substitute for LTC, and the availability of home-based LTC may help to alleviate this potentially inefficient use.

  PublisherDOI

• The Metrics Matter: Improving Comparisons of COVID-19 Outbreaks in Nursing Homes

  UNC Libraries · 2025-05-22

  articleOpen access
  PublisherDOI

• Addressing Systemic Racism in Nursing Homes: A Time for Action

  UNC Libraries · 2025-05-24

  articleOpen access1st authorCorresponding
  PublisherDOI

• Comparing Outcomes Among Medicaid Home and Community‐Based Service Users: Private Homes vs. Assisted Living Facilities

  Health Services Research · 2025-05-14 · 2 citations

  articleOpen accessSenior author

  OBJECTIVE: To compare outcomes of Medicaid home and community-based services (HCBS) users residing in a private home vs. in an assisted living facility among dually eligible individuals aged 65 or older. STUDY SETTING AND DESIGN: Medicaid HCBS occurred either in private homes or assisted living facilities in 883 counties in 39 states in the United States from 2016 to 2019. We used an instrumental variable (IV) approach to account for unmeasured factors that might confound the association between HCBS settings and outcomes. Our IV was the monthly proportion of HCBS users in a private home (vs. in an assisted living facility) in surrounding counties within the same state. We examined four outcomes: hospitalizations, emergency department visits, days at home, and Medicare spending. DATA SOURCES AND ANALYTIC SAMPLE: We used Medicare and Medicaid claims linked at the individual level. Our sample included dually eligible individuals aged 65 or older, enrolled in Medicare fee-for-service plans, who used HCBS either in a private home or an assisted living facility, between 2016 and 2019. PRINCIPAL FINDINGS: Our sample included 8,140,213 person-months from 383,607 individuals, of whom 85% lived at home and 15% in assisted living facilities. Compared to those in assisted living facilities, in-home HCBS users were 1.3 percentage points more likely to be hospitalized each month (95% CI: 0.8-1.8) and had 0.3 fewer days at home per month (95% CI: -0.4 to -0.1). In an analysis using a sample matched on observed person-months, HCBS users at home had higher likelihoods of hospitalizations and emergency department visits, fewer days at home, and higher Medicaid spending. CONCLUSIONS: Overall, in-home HCBS users were more likely to experience adverse health events than those in assisted living facilities, suggesting that policymakers should consider improving care for HCBS users in private homes.

  PublisherOA PDFDOI

• Home‐Based Care Outcomes: Does the Care Provider Matter?

  Health Economics · 2025-04-28 · 2 citations

  articleOpen accessSenior author

  Long-term services in the home are predominately provided by family or friends, with a growing proportion of individuals receiving formal care, or paid care by a professional, or a combination of both. However, the relative benefits to the care recipient of who provides the care are largely unknown. A person's use of formal and family care is affected by factors that also may affect their outcomes, complicating the estimation of any causal relationship. Using the 2002-2018 Health and Retirement Study (HRS), we examine three types of home-based care combinations: family only, formal only, and both formal and family care. We use an instrumental variables strategy, using family structure as instruments for both formal care and the combination of formal and family care, to estimate the plausibly causal impact of the care provider on self-reported mental and physical health outcomes. We find that, once the endogeneity of the care provider is accounted for, having both formal and family care leads to better self-rated health, mobility and lower depression compared to people receiving family care only. Receiving formal care only does not affect care recipient outcomes compared to receiving family care only. These results are robust to several sensitivity analyses, including different instrument specifications, subsamples of care recipients that do not have a spouse/partner, among women care recipients, and changing the timing of the measurement of the outcomes. These findings are important to consider as we strive to best meet the growing demand for person-centered, high-quality long-term care in the least restrictive setting possible.

  PublisherOA PDFDOI

• Correct Usage and Limitations of Differential Distance as an Instrumental Variable

  JAMA Network Open · 2025-08-04 · 1 citations

  articleOpen access1st authorCorresponding

  No abstract

  PublisherDOI

• Home Health Care Use Among Medicare Beneficiaries From 2010 to 2020

  Medical Care Research and Review · 2025-02-19 · 7 citations

  articleOpen access

  Medicare home health coverage is an important resource for Medicare beneficiaries requiring health care at home. However, there have been changes in the United States health care system that might impact home health utilization such as pressures to constrain Medicare spending, growth in Medicare Advantage (MA) plan enrollment, decline in institutional long-term care and growth of Medicaid home- and community-based services. Given these changes, we examined home health care use trends among beneficiaries enrolled in traditional Medicare (TM) and MA from 2010 to 2020. We separately examined home health episodes that were initiated after a hospital or skilled nursing facility discharge and those initiated within the community and among dually and non-dually eligible beneficiaries. Home health use decreased among TM enrollees for both community-initiated and post-discharge needs but increased among MA enrollees for community-initiated home health use. Increases in community-initiated home health use were concentrated in non-dually eligible beneficiaries.

  PublisherDOI

• Value‐Based Purchasing and the Conundrum of Socioeconomic Risk Factors

  Journal of the American Geriatrics Society · 2025-09-12

  editorialOpen access1st authorCorresponding

  In this issue of JAGS, Wheeler et al. examine the association between facility-level attributes and the probability of receiving the largest penalties in 2024 under the Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program mandated by the Centers for Medicare & Medicaid Services [1]. They found that SNFs with a greater share of Black or Hispanic patients, for-profit SNFs, urban SNFs, and SNFs located in the South and in areas with higher deprivation were more likely to receive the maximum penalty. They note that these findings are largely consistent with earlier analyses of SNF VBP conducted prior to the COVID-19 pandemic, despite the dramatic upheaval to the SNF sector caused by the pandemic [2]. The finding that SNFs located in areas of greater deprivation and serving more Black and Hispanic residents exhibit worse performance reflects a large and longstanding literature on disparities in nursing home quality. These disparities transcend post-acute care funded by Medicare as well as long-term care funded largely by Medicaid, as these are typically provided in the same facilities. Nursing homes that are the most dependent on Medicaid funding are also those that tend to serve more Black and Hispanic residents, have lower staffing ratios, be located in low-income neighborhoods, and generally have fewer resources with which to improve quality [3-6]. Thus, in many ways, the findings by Wheeler et al. are not surprising, and indeed the same phenomenon exists for other types of health care providers. In the hospital sector, for example, safety-net hospitals tend to exhibit less improvement on standard quality measures than non-safety-net hospitals [7]. The conundrum with socioeconomic risk factors in the context of VBP is that quality improvement often requires the investment of resources, and providers serving populations with high socioeconomic risk tend to have the fewest resources as well as the greatest challenges in producing improvement from any given investment, given the social risk of the population served. Without adjusting for socioeconomic risk, VBP can perpetuate and exacerbate differences in quality by rewarding already high-resourced providers and penalizing low-resourced providers. At the same time, it is virtually impossible to separate inadequate risk adjustment from true differences in quality, because adequate data on socioeconomic risk factors—factors such as family support, lifetime health habits and access to care, prior environmental exposures—will never be completely observable and measured. Statistically adjusting for race or location is an overly blunt tool that might capture some of these unobservable factors but may also inadvertently justify the provision of low quality to non-white and low-income populations. In its 2021 Report to the Congress, the Medicare Payment Advisory Commission (MedPAC) recommended peer grouping as a possible solution to this problem within the SNF VBP program [8]. The idea is that SNFs serving populations of similar social risk (likely based on the percent of residents who qualify for Medicaid) would be compared with each other when performance is translated into payment penalties or rewards, rather than with all facilities. This would implicitly acknowledge that improving performance is more difficult when serving populations of higher social risk. Raw (non-grouped) scores would also be available for transparency. This would be a partial solution to the conundrum; while addressing social risk and evening the playing field, it may still reward low quality and dampen the incentive for quality improvement among SNFs serving populations of higher social risk. The Centers for Medicare and Medicaid Services have made changes to the SNF VBP program to be implemented in Fiscal Year 2026 [9]. The most substantial change is an expansion of the set of performance measures from one (30-day rehospitalization) to four (with the addition of infections requiring hospitalization, total nursing hours per resident-day, and total nursing staff turnover). This is a welcome change, as these are well-established measures that address different aspects of overall quality. However, the addition of these measures is unlikely to solve the problem of unmeasured social risk, as they will suffer from the same conundrum described above. Indeed, a planned “health equity” adjustment in the spirit of MedPAC's recommendation of peer grouping has been rescinded. Although adding features like peer grouping could improve the SNF VBP program, the broader problem is that SNF quality is disparate and has been so for decades. As Mor et al. described more than 20 years ago [5], there exists a bottom tier of nursing homes characterized by high Medicaid dependence and low quality, and countless policies such as regulatory sanctions, public reporting of quality, and VBP have been largely ineffective in changing that. Any real change that could improve the outcomes of nursing home residents in this lower tier of facilities would have to involve more fundamental, structural change. First, it is difficult to imagine reducing disparities in outcomes when there exist large disparities in resources; given that Medicaid rates in nursing homes are substantially lower than other payers, facilities that are heavily dependent on Medicaid will always be at a disadvantage and their residents will be likely to have worse outcomes—even post-acute residents in those facilities with shorter stays funded by Medicare. Moving toward a less disjointed payment system, perhaps through a federal benefit for long-term care [10], would start to even the playing field in terms of resources. Second, even under such a change in payment, SNFs located in areas with greater deprivation and serving populations with higher social risk will find quality improvement more challenging than other SNFs. As difficult as payment reform would be, this second problem is even harder to solve: It would take broad investment in low-income communities to reduce social risk factors over the life course. This may not be the moment for such policies to be considered, but in the long run, they are essential to address the all-too-typical patterns that Wheeler et al. identify. Prof. R. Tamara Konetzka takes full responsibility for the content of the commentary. The author has nothing to report. The author declares no conflicts of interest. Professor R. Tamara Konetzka currently serves as a Medicare Payment Advisory Commission (MedPAC) Commissioner but does not speak for MedPAC; the views expressed in this commentary are solely her own. This publication is linked to related article by Wheeler et al. To view this article, visit https://doi.org/10.1111/jgs.70025.

  PublisherOA PDFDOI

• Long-term care insurance within married couples: Can’t insure one without the other?

  Review of Economics of the Household · 2025-05-23

  articleOpen access

  Although long-term care remains one of the largest uninsured risks facing older Americans, demand for insurance remains low. While there is a long literature estimating a variety of factors that contribute to this low demand, much of it has overlooked the fact that most private long-term care insurance (LTCI) purchases are made within couples, adding a host of additional reasons for low demand. This paper examines the role of financial decision-making power within the couple and the association with LTCI purchase decisions. We document LTCI purchase patterns among married couples and find that, among couples who ever purchase LTCI, they are roughly equally likely to purchase for the woman exclusively (10.0%), the man exclusively (11%), or both (11%). However, among couples where women have more bargaining power, LTCI purchases are more likely overall (40% vs. 33%), and more likely to cover the woman, either exclusively (16% vs. 11%) or as part of both members of the couple (14% vs. 11%), than among couples with more traditional gender roles. In adjusted analyses, we find that women are more likely to be insured when they have more bargaining power. These findings suggest that intra-household bargaining power may be another potential explanation for the particularly low LTCI take-up, especially in the time period in which policies were unisex-priced.

  PublisherOA PDFDOI

• Trends in Co-morbid Dementia and Chronic Kidney Disease

  Journal of General Internal Medicine · 2025-01-14 · 3 citations

  articleOpen accessSenior author
  PublisherOA PDFDOI

Recent grants

• NIH Grant R21HS021877

  NIH · $922k · 2016

• NIH Grant R21AG040498

  NIH · $418k · 2014

• The University of Chicago and Northwestern University Predoctoral Health Services Research Program-Renewal

  NIH · $9.0M · 1998–2028

• NIH Grant R01AG041108

  NIH · $809k · 2015

• NIH Grant R01HS018718

  NIH · $964k · 2015

Frequent coauthors

• Rachel M. Werner

  129 shared

• Debra Saliba

  RAND Corporation

  42 shared

• Courtney H. Van Houtven

  Duke University

  41 shared

• Jingsan Zhu

  University of Pennsylvania

  40 shared

• Kevin G. Volpp

  University of Pennsylvania

  39 shared

• Norma B. Coe

  University of Pennsylvania

  36 shared

• Edward C. Norton

  University of Michigan–Ann Arbor

  35 shared

• Karen B. Lasater

  28 shared

Education

• Ph.D., Public Health Sciences

  University of Chicago

• M.S., Health Services Administration

  University of Illinois at Chicago

• B.S., Health Services Administration

  University of Illinois at Chicago

Awards & honors

• Appointed Member, Medicare Payment Advisory Commission (MedP…
• Invited Testimony on COVID-19 and Nursing Homes, US Senate F…
• Invited Testimony on COVID-19 and Nursing Homes, US Senate S…
• Invited member, Five-Star Quality Rating System Technical Ex…
• Member, Committee on the Quality of Care in Nursing Homes, N…