Table 5 and Table 6 present basic administrative statistics for ICF-MR and noncertified facilities by type of operation and facility size. The statistics presented on facility capacity, current residents and certified capacity have the limitations discussed above.
Proportion of Capacity Occupied
Data from the 1987 National Medical Expenditure Survey indicate occupancy of mental retardation facilities to be 90.2% of the maintained capacity of facilities. ICF-MR certified facilities had an occupancy of 9ZO%. The noncertified facilities were 87.5% occupied. Small ICFs-MR reported a 8-9.0% occupancy rate; large ICFs-MR an 94% occupancy. The lowest occupancy rates were among the large prime non-ICF-MR facilities (78.7%). Facilities of 800 or more residents had by far the lowest proportions of their reported maintained capacity currently occupied (66.2%). In fact, although facilities of 800 or more residents had only 9.4% of the total estimated maintained capacity, they had 35.3% of the unoccupied maintained capacity.
Proportion of Residents with Mental Retardation and Related Conditions
Based on NMES data, 91.2% of the residents of mental retardation facilities were persons with mental retardation and related conditions. Prime for profit facilities were most likely to have residents who were reported not to have mental retardation and related conditions (23.6% of residents). Among non-ICF-MR, private for profit facilities, an estimated 32.3% of residents did not have mental retardation or related conditions.
Medicaid Certified Capacity
According to the National Medical Expenditure Survey, mental retardation facilities nationwide had a total of 156,736 "beds" certified for Medicaid participation. The Medicaid capacity within mental retardation facilities was overwhelmingly concentrated in the ICF-MR program (98.7%). The estimates of Skilled Nursing Facility (SNF) and Intermediate Care Facility (ICF) capacities (584 and 1,489 total "beds" respectively) were based on so few sampled facilities that they cannot be considered reliable estimates of SNF and ICF certification of units in mental retardation facilities.
The Medicaid participation in mental retardation facilities was indicated to be highly concentrated in large facilities. About 84% of total (ICF-MR, ICF and SNF) Medicaid certified capacity was estimated to be in large facilities, as was 84% of ICF-MR certified capacity alone. Generally speaking, the smaller the facility grouping the less likely it was to have its residential capacity certified for Medicaid participation. For example, facilities with 800 or more residents had 100% of their capacity Medicaid certified; those with 300-799 residents were 96.6% certified; those with 76-299 residents were 66.9% certified; and facilities with 16-75 residents were 31.3% certified. The undercounting of small (less than 16 residents) facilities is confined almost exclusively to small, noncertified facilities which greatly affects estimated proportion of small facility capacity certified. While the NMES estimated that 32.6% of small facility capacity was ICF-MR certified, and that 32.5% of small facility residents with mental retardation and related conditions were in ICF-MR units, state reports of small facilities and small facilities with ICF-MR certifications for 1987 indicated 19.8% to be ICF-MR certified (Lakin et al., 1989).
Direct Care Personnel
Substantial differences were found among facilities in their ratios of direct care personnel to their total current "set up beds." Generally, NMES indicated that there were now more people providing direct care nationally than are receiving it (1.06:1). But given 168 hours in a week and the prevailing 40 hour work week, this translated to an average resident to direct care staff ratio of about 4 to 1 at any one time. Ratios of staff to residents were highest in the (overlapping) categories of ICF-MR certified facilities (1.33:1), government operated facilities (1.48:1) and large facilities (1.18:1). The lowest ratios were among non-ICFs-MR (.66:1), private for profit facilities (.61:1), and small facilities (.72:1). Small for profit facilities had the lowest staff to resident ratios for both certified and non-certified facilities (.60 and .44 staff member's per resident, respectively). One factor in these lower ratios was the fact that in many of the smaller proprietary facilities the owner/operators lived in the "facility" and were providing care and supervision for considerably more hours than was indicated by their treatment as a single full-time direct care position. Another important factor In the lower ratios was, as will be described later, that the residents of these facilities generally appeared to have less extensive needs for care and supervision than did residents of other types of facilities.
Per Diem Costs
A major limitation of the NMES facility data was that costs were coded into 5 broad cost categories from continuous cost statistics that were originally gathered. The categories created for the NMES data and the weighted proportion of residents within the facilities of each range were: (a) $30 or less per day (23.5%), (b) $31-$55 (14.8%), (c) $56-$80 (15.6%), (d) $81-$105 (14.2%), and (e) $106 or more per day (31.8%). Based on other surveys (Hill et al., 1989; White, Lakin, Hill, Wright, & Bruininks, 1988), facility costs generally range from $15 to well over $300 per day, so that the extreme data reduction in the NMES data files drastically decreased the usefulness of the facility cost statistics.
ICF-MR certified facilities, regardless of operator or size, were much less likely to be found in the lower cost ranges (e.g., $55 per day or less) than non-certified facilities. Among private for profit facilities, 83% of residents in non-certified facilities were in places with a daily cost of $55 or less as compared with 51% of residents of ICFs-MR. Among nonprofit facilities, 64% of residents in non-certified facilities and 35% of those in ICFs-MR were in places with a cost of $55 or less. Among government operated facilities, 21% of non-certified facility residents were in places costing $55 or less per day, as compared with an estimated 1% of persons in public ICFs-MR. Conversely, an estimated 65% of public and private ICF-MR facility residents were in places that cost $81 or more per day as compared with 18% of persons in non-certified facilities.