Some research suggests that risk adjustment plays a substantial role in explaining the high levels of government spending on Medicare Advantage (MA). We studied whether the reliance on diagnosis codes to risk-adjust payments to MA plans leads to the inflation of submitted diagnoses. Our approach relied on a comparison among diagnoses included in hospital claims, health status measures from similarly timed health assessments completed by skilled nursing facility (SNF) clinicians, and short-term mortality data. SNF assessments are completed for both MA and traditional Medicare enrollees and, in contrast to diagnoses in claims, cannot be directly manipulated by MA plans or inform their payments. We found that among patients with the same assessment-based health status discharged to the same SNF, claims-based disease scores were 4.1 percent higher for MA enrollees, on average, relative to traditional Medicare enrollees. However, short-term mortality risk was, on average, 8.8 percent lower for MA enrollees. About 60 percent of the payer-based difference in disease scores was attributable to MA chart review updates to diagnoses, and additional codes from chart reviews were unrelated to assessment-based health status. Given the growth of MA and current spending on the program, which reached $321 billion in 2021, this evidence of potential coding inflation may have large fiscal implications.
Objective To characterize the nature and degree of hospitals’ efforts to collaborate with skilled nursing facilities ( SNF s) and associated patient outcomes. Data Sources/Study Setting Qualitative data were collected through 138 interviews with staff in 16 hospitals and 25 SNF s in eight markets across the United States in 2015. Quantitative data include Medicare claims data for the 290,603 patients discharged from those 16 hospitals between 2008 and 2015. Study Design/Data Collection Semi‐structured interviews with hospital and SNF staff were coded and used to classify hospitals’ collaboration efforts with SNF s into high versus low collaboration hospitals, and risk‐adjusted, claims‐based hospital readmission rates from SNF were compared. Principal Findings Hospital collaboration efforts were defined as establishing SNF partners, transition management initiatives, and hospital staff visits to SNF s. High collaboration hospitals were more likely to send patients to SNF s (as opposed to home, home with home health, or other PAC settings), sent a higher share of patients to high quality SNF s, and had fewer hospital readmissions from SNF sooner than did low collaboration hospitals. Conclusions Although collaboration with SNF requires significant administrative and clinical time investment, it is associated with positive patient outcomes.
Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients’ SNF length of stay. Using a set of fee-for-service beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid.
Abstract The 30-Day All-Cause Readmission Measure is part of the Skilled Nursing Facility Value-Based Purchasing (SNFVBP) beginning 2019. The objective of the study was to characterize racial and ethnic disparities in 30-day rehospitalization rates from SNF among fee-for-service (FFS) and Medicare Advantage (MA) patients using the Minimum Data Set. The American Health Care Association risk-adjusted model was used. The primary independent variables were race/ethnicity and enrollment in FFS and MA. The sample included 1,813,963 patients from 15,412 SNFs across the US in 2015. Readmission rates were lower for whites. However, MA patients had readmission rates that were ~1 to 2 percentage points lower. In addition, we also found that African-Americans had higher readmission rates than whites, even when they received care within the same SNF. The inclusion of MA patients could change SNF penalties. Successful efforts to reduce rehospitalizations in SNF settings often require improving care coordination and care planning.
Abstract Emergency department (ED) visits are associated with poor outcomes; however, state variation in ED use among assisted living (AL) residents is not well understood. Using 2017 Medicare data, we identified a cohort of 88,880 beneficiaries with dementia residing in larger ALs (25+ beds) and calculated risk-adjusted rates of all-cause and injury-related ED use per 100 person years, by state, adjusting for demographics and chronic conditions. Risk-adjusted state rates of all-cause ED visits ranged from 129.5 visits/100 person-years (95%CI=114.6,148.2) in New Mexico to 246.1 visits/100 person-years (95%CI= 224.9,274.8) in Rhode Island. The risk-adjusted rate of injury-related ED visits ranged from 91.4 visits/100 person-years (95%CI=83.0,101.4) in New Mexico to 135.9 visits/100 person-years (95%CI=126.9,146.6) in Montana. Potential reasons for these state variations will be discussed. Part of a symposium sponsored by Assisted Living Interest Group.
The quality of health care is the consequence of strong link between service providers and user of the services. Perceived quality is one of the principal determinant of utilisation and non-utilisation of health services, a major issue in developing countries. Considering this, the present study was aimed to assess the quality of care in in-patient and outpatient departments of rural and urban government hospitals in Bangladesh. A total of 2420 patients were interviewed. The patients were selected by using systematic random sampling technique. Results revealed that age, waiting time, time spent for patient examination, place of treatment, income, years of schooling and male sex appeared to be independent predictors of patient satisfaction (p<0.001). Age, waiting time and years of schooling were negatively related with level of satisfaction indicating younger patients, less waiting time and patients with less education were more satisfied, whereas time spent for examination, income were positively related with patient's satisfaction. Patients attending at the urban hospitals and male sex were also significantly associated with patient's satisfaction. The study recommends that both short and long-term policy action should be adopted for quality assurance of the existing health care facilities in Bangladesh.
Although people living in rural areas of the United States are disproportionately older and more likely to die of conditions that require postacute care than those living in urban areas, rural-urban differences in postacute care utilization and outcomes have been understudied.
Objective
To describe rural-urban differences in postacute care utilization and postdischarge outcomes.
Design, Setting, and Participants
This retrospective cohort study used data from Medicare beneficiaries 66 years and older admitted to 4738 US acute care hospitals for stroke, hip fracture, chronic obstructive pulmonary disease, congestive heart failure, or pneumonia between January 1, 2011, and September 30, 2015. Participants were tracked for 180 days after discharge. Data analyses were conducted between October 1, 2018, and May 30, 2019.
Exposures
County of residence was classified as urban or rural using the US Department of Agriculture Rural-Urban Continuum Codes. Rural counties were divided into those adjacent and not adjacent to urban counties.
Main Outcomes and Measures
Primary outcomes were discharge to community vs a formal postacute care setting (ie, skilled nursing facility, home health care, or inpatient rehabilitation facility) and readmission and mortality within 30, 90, and 180 days of hospital discharge.
Results
Among 2 044 231 hospitalizations from 2011 to 2015, 1 538 888 (75.2%; mean [SD] age, 80.4 [8.3] years; 866 540 [56.3%] women) were among patients from urban counties, 322 360 (15.8%; mean [SD] age, 79.6 [8.1] years; 175 806 [54.5%] women) were among patients from urban-adjacent rural counties, and 182 983 (9.0%; mean [SD] age, 79.8 [8.1] years; 98 775 [54.0%] women) were among patients from urban-nonadjacent rural counties. The probability of discharge to community without postacute care did not differ by rurality. However, compared with patients from urban counties, patients from the most rural counties were more frequently discharged to a skilled nursing facility (adjusted difference, 3.5 [95% CI, 2.8-4.3] percentage points), while discharge to an inpatient rehabilitation facility was less common among patients from rural counties than among those from urban counties (urban vs urban-adjacent rural: adjusted difference, –1.9 [95% CI, –2.4 to –1.4] percentage points; urban vs urban-nonadjacent rural: adjusted difference, –1.8 [95% CI, –2.4 to –1.2] percentage points) as was discharge to home health care (urban vs urban-adjacent rural: adjusted difference, –1.7 [95% CI, –2.3 to –1.2] percentage points; urban vs urban-nonadjacent rural: adjusted difference, –2.4 [95% CI, –3.0 to –1.8]). For patients from the most rural counties, adjusted 30-day readmission rates were 0.4 (95% CI, 0.2-0.6) percentage points higher than those of patients from urban counties among those who were discharged to the community but 0.3 (95% CI, –0.6 to –0.1) percentage points lower among patients receiving postacute care. Adjusted 30-day mortality rates were 0.4 (95% CI, 0.3-0.5) percentage points higher for patients from the most rural counties discharged to the community and 2.0 (95% CI, –1.7 to 2.3) percentage points higher among those receiving postacute care. Rural-urban differences in 90-day and 180-day outcomes were similar.
Conclusions and Relevance
These findings suggest that rates of discharge to the community and postacute care settings were similar among patients from rural and urban counties. Rural-urban differences in mortality following discharge were much larger for patients receiving postacute care compared with patients discharged to the community setting. Improving postacute care in rural areas may reduce rural-urban disparities in patient outcomes.
Medicare’s Patient Driven Payment Model (PDPM) significantly altered the way skilled nursing facilities (SNFs) are paid, removing the financial incentive to maximize the volume of therapy services delivered to patients. Using federal payroll-based staffing data, we examined the effect of the PDPM on SNF therapy and nursing staff hours. After PDPM implementation, which took effect October 1, 2019, SNFs significantly reduced their therapy staff hours. Physical therapist and occupational therapist staffing levels were reduced by 5–6 percent during October–December 2019 relative to pre-PDPM levels, and physical therapy assistant and occupational therapist assistant levels were reduced by about 10 percent. These reductions were concentrated among contracted employees and were larger in SNFs with higher shares of Medicare-eligible short-stay residents. No meaningful increases in nursing staff in response to the PDPM were found. Further research is needed to determine the effect of these therapy staff reductions on SNF patient outcomes.
In October 2019, Medicare changed its skilled nursing facility (SNF) reimbursement model to the Patient Driven Payment Model (PDPM), which has modified financial incentives for SNFs that may relate to therapy use and health outcomes.
Objective
To assess whether implementation of the PDPM was associated with changes in therapy utilization or health outcomes.
Design, Setting, and Participants
This cross-sectional study used a regression discontinuity (RD) approach among Medicare fee-for-service postacute-care patients admitted to a Medicare-certified SNF following hip fracture between January 2018 and March 2020.
Exposures
Skilled nursing facility admission after PDPM implementation.
Main Outcomes and Measures
Main outcomes were individual and nonindividual (concurrent and group) therapy minutes per day, hospitalization within 40 days of SNF admission, SNF length of stay longer than 40 days, and discharge activities of daily living score.
Results
The study cohort included 201 084 postacute-care patients (mean [SD] age, 83.8 [8.3] years; 143 830 women [71.5%]; 185 854 White patients [92.4%]); 147 711 were admitted pre-PDPM, and 53 373 were admitted post-PDPM. A decrease in individual therapy (RD estimate: −15.9 minutes per day; 95% CI, −16.9 to −14.6) and an increase in nonindividual therapy (RD estimate: 3.6 minutes per day; 95% CI, 3.4 to 3.8) were observed. Total therapy use in the first week following admission was about 12 minutes per day (95% CI, −13.3 to −11.3) (approximately 13%) lower for residents admitted post-PDPM vs pre-PDPM. No consistent and statistically significant discontinuity in hospital readmission (0.31 percentage point increase; 95% CI, −1.46 to 2.09), SNF length of stay (2.7 percentage point decrease in likelihood of staying longer than 40 days; 95% CI, −4.83 to −0.54), or functional score at discharge (0.04 point increase in activities of daily living score; 95% CI, −0.19 to 0.26) was observed. Nonindividual therapy minutes were reduced to nearly zero in late March 2020, likely owing to COVID-19–related restrictions on communal activities in SNFs.
Conclusions and Relevance
In this cross-sectional study of SNF admission after PDPM implementation, a reduction of total therapy minutes was observed following the implementation of PDPM, even though PDPM was designed to be budget neutral. No significant changes in postacute outcomes were observed. Further study is needed to understand whether the PDPM is associated with successful discharge outcomes.
With more than $62 billion in annual spending, post-acute care (PAC) has become Medicare’s fastest growing category of health care expenditures and a major source of regional variation in overall Medicare spending. Yet, studies have not evaluated care quality for minority patients who are discharged to skilled nursing facilities (SNFs) after acute care hospitalizations. The objective of this paper is to assess the concentration and quality of SNFs that care for black and Hispanic patients, including those in Medicare fee-for-service (FFS) and Medicare Advantage (MA). We used cross-sectional data of SNF performance measures and facility characteristics associated with quality of care from 2013. There were approximately 575,147 White, 65,562 African American and 33,354 Hispanic Medicare enrollees in FFS and MA aged 65 and older admitted to a SNF. Approximately 27% of SNFs accounted for 80% of all admissions for black patients. Care was even more concentrated for Hispanics, with 19% of all SNFs accounting for 80% of Hispanic patient care. SNFs with higher fraction of blacks (~30%) were more likely to have less direct care: Total RN hrs/day/resident (0.02), higher hospitalization rate (3.00%), and lower star ratings (0.63) compared to SNFs with no black patients. Differences remained the same after we stratified by whether patients were in MA. Only minor differences were found for SNFs with higher fraction of Hispanics. Racial and ethnic minorities in the Medicare program, particularly blacks, are concentrated within a small number of SNFs with worse measured performance and characteristics associated with lower quality.
