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Objective: Medicaid-funded long-term services and supports are increasingly provided through home- and community-based services (HCBS) to promote continued community living. While an emerging body of evidence examines the direct benefits and costs of HCBS, there may also be unexplored synergies with Medicare-funded post-acute care (PAC). This study aimed to provide empirical evidence on how the use of Medicaid HCBS influences Medicare PAC utilization among the dually enrolled., Data Sources: National Medicare claims, Medicaid claims, nursing home assessment data, and home health assessment data from 2016 to 2018., Study Design: We estimated the relationship between prior Medicaid HCBS use and PAC (skilled nursing facilities [SNF] or home health) utilization in a national sample of duals with qualifying index hospitalizations. We used inverse probability weights to create balanced samples on observed characteristics and estimated multivariable regression with hospital fixed effects and extensive controls. We also conducted stratified analyses for key subgroups., Data Extraction Methods: The primary sample included 887,598 hospital discharges from community-dwelling duals who had an eligible index hospitalization between April 1, 2016, and September 30, 2018., Principal Findings: We found HCBS use was associated with a 9 percentage-point increase in the use of home health relative to SNF, conditional on using PAC, and a meaningful reduction in length of stay for those using SNF. In addition, in our primary sample, we found HCBS use to be associated with an overall increase in PAC use, given that the absolute increase in home health use was larger than the absolute decrease in SNF use. In other words, the use of Medicaid-funded HCBS was associated with a shift in Medicare-funded PAC use toward home-based settings., Conclusion: Our findings indicate potential synergies between Medicaid-funded HCBS and increased use of home-based PAC, suggesting policymakers should cautiously consider these dynamics in HCBS expansion efforts., (© 2024 The Author(s). Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: To examine the relationship between growth in Medicare Advantage (MA) enrollment and changes in finances at skilled nursing facilities (SNFs)., Data Sources: Medicare SNF cost reports, LTCFocus.org data, and county MA penetration rates., Study Design: We used ordinary least squares regression with SNF and year fixed effects. Our primary outcomes were SNF revenues, expenses, profits, and occupancy. Our primary independent variable was the yearly county Medicare Advantage penetration., Data Collection/extraction: We linked facility-year data from 2012 to 2019 obtained from cost reports and LTCFocus.org to county-year MA penetration., Principal Findings: A 10 percentage point increase in county MA enrollment was associated with a $213,883.89 (95% Confidence Interval [CI]: -296,869.08, -130,898.71) decrease in revenue, a $132,456.19 (95% CI: -203,852.28, -61,060.10) decrease in expenses, and a 0.59 percentage point (95% CI: -0.97, -0.21) decrease in profit margin. A 10 percentage point increase in county MA enrollment was associated with a decline (-318.93; 95% CI: -468.84, -169.02) in the number of resident-days (a measure of occupancy) as well as a decline in the revenue per resident day ($4.50; 95% CI: -6.81, -2.20), potentially because of lower prices in MA. There was also a decline in expenses per patient day (-2.35; 95% CI: -4.76, 0.05), though this was only statistically significant at the 10% level. While increased MA enrollment was associated with a substantial decline in the number of Medicare resident days (487.53; 95% CI: -588.70, -386.37), this was partially offset by an increase in other payer (e.g., private pay) resident days (285.91; 95% CI: 128.18, 443.63). Increased MA enrollment was not associated with changes in the number of Medicaid resident days or a decrease in staffing per resident day., Conclusion: SNFs in counties with more MA growth had substantially greater relative declines in revenue, expenses, and profit margins. The continued growth of MA may result in significant changes in the SNF industry., (© 2024 Health Research and Educational Trust.)

Objective: To examine whether stronger referral relationships between hospitals and skilled nursing facilities (SNF) are associated with lower-risk patients being admitted to SNF., Data Sources/collection: We used MedPAR data to estimate referral relationship strength and nursing home survey data (OSCAR and CASPER) to determine the risk of patient admissions at nearly 14 000 SNFs from 2008 to 2014., Study Design: We examined the association of hospital referral concentration with the percentage of higher-risk patients admitted to non-hospital-based (freestanding) SNFs using an instrumental variables approach. We used the distance between patients and SNFs and hospitals and SNFs as the instrument., Data Collection/extraction Methods: We used previously collected MedPAR and OSCAR/CASPER survey data., Principal Findings: We find greater observed referral concentration among freestanding SNFs is associated with lower percentages of patients with pressure sores (coefficient, -2.64; 95% CI, [-2.82 to -2.46]), catheters (-0.55; [-0.74 to -0.36]), and physical restraints (-0.16; [-0.29 to -0.03]) at admission to a skilled nursing facility., Conclusions: We find evidence that freestanding SNFs with stronger hospital referral relationships may be admitting less risky patients, possibly contributing to disparities across SNFs., (© 2021 Health Research and Educational Trust.)

Objective: To evaluate the association of skilled nursing facility (SNF) quality with days spent alive in nonmedical settings ("home time") after SNF discharge to the community., Data Sources: Secondary data are from Medicare claims for New York State (NYS) Medicare beneficiaries, the Area Health Resources File, and Nursing Home Compare., Study Design: We estimate home time in the 30- and 90-day periods following SNF discharge. Two-part zero-inflated negative binomial regression models characterize the association of SNF quality with home time., Data Extraction Methods: We use Medicare claims data to identify 25 357 NYS fee-for-service Medicare beneficiaries aged 65 years and older with an SNF admission for postacute care who were subsequently discharged to home in 2014., Principal Findings: Following 30 and 90 days after SNF discharge, the average home time is 28.0 (SD = 6.1) and 81.6 (SD = 20.2) days, respectively. A number of patient- and SNF-level factors are associated with home time. In particular, within 30 and 90 days of discharge, respectively, patients discharged from 2- to 5-star SNFs spend 1.2-1.5 (P < .001) and 3.2-4.3 (P < .001) more days at home than those discharged from 1-star (lowest quality) SNFs., Conclusions: Improved understanding of what is contributing to differences in home time could help guide efforts into optimizing post-SNF discharge outcomes., (© 2020 Health Research and Educational Trust.)

Objective: To assess the accuracy of nursing home self-report of major injury falls on the Minimum Data Set (MDS)., Data Sources: MDS assessments and Medicare claims, 2011-2015., Study Design/methods: We linked inpatient claims for major injury falls with MDS assessments. The proportion of claims-identified falls reported for each fall-related MDS item was calculated. Using multilevel modeling, we assessed patient and nursing home characteristics that may be predictive of poor reporting. We created a claims-based major injury fall rate for each nursing home and estimated its correlation with Nursing Home Compare (NHC) measures., Principal Findings: We identified 150,828 major injury falls in claims that occurred during nursing home residency. For the MDS item used by NHC, only 57.5 percent were reported. Reporting was higher for long-stay (62.9 percent) than short-stay (47.2 percent), and for white (59.0 percent) than nonwhite residents (46.4 percent). Adjusting for facility-level race differences, reporting was lower for nonwhite people than white people; holding constant patient race, having larger proportions of nonwhite people in a nursing home was associated with lower reporting. The correlation between fall rates based on claims vs the MDS was 0.22., Conclusions: The nursing home-reported data used for the NHC falls measure may be highly inaccurate., (© 2019 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust.)

Purpose: Skilled nursing care (SNC) provides Medicare beneficiaries short-term rehabilitation from an acute event. The purpose of this study is to assess beneficiary, market, and hospital factors associated with beneficiaries receiving care near home., Methods: The population includes Medicare beneficiaries who live in a rural area and received acute care from an urban facility in 2013. "Near home" was defined 3 different ways based on distances from the beneficiary's home to the nearest source of SNC. Results include unadjusted means and odds ratios from logistic regression., Findings: About 69% of rural beneficiaries receiving acute care in an urban location returned near home for SNC. Beneficiaries returning home were white (odds ratio [OR] black: 0.69; other race: 0.79); male (OR: 1.07); older (OR age 85+ [vs 65-69]: 1.14); farther from SNC (OR: 1.01 per mile); closer to acute care (OR: 0.28, logged miles); and received acute care from hospitals that did not own a skilled nursing facility (owned OR: 0.77) and hospitals with: no swing bed (swing bed OR: 0.47), high case mix (OR: 3.04), and nonprofit status (for-profit OR: 0.85). Results varied somewhat across definitions of "near home.", Conclusions: Rural Medicare beneficiaries who received acute care far from home were more likely to receive SNC far from home. Because Medicare beneficiaries have the choice of where to receive SNC, policy makers may consider ensuring that new payment models do not incentivize provision of SNC away from home., (© 2019 National Rural Health Association.)

Objective: To assess whether an electronic health record (EHR) portal to enable health information exchange (HIE) between a hospital and three skilled nursing facilities (SNFs) reduced likelihood of patient readmission., Setting/data: Secondary data; all discharges from a large academic medical center to SNFs between July 2013 and March 2017, combined with portal usage records from SNFs with HIE access., Design: We use difference-in-differences to determine whether portal implementation reduced likelihood of readmission over time for patients discharged to HIE-enabled SNFs, relative to those discharged to nonenabled facilities. Additional descriptive analyses of audit log data characterize portal use within enabled facilities., Data Collection: Encounter-level clinical EHR data were merged with EHR audit log data that captured portal usage in the timeframe associated with a patient transition from hospital to SNF., Principal Findings: Declines in likelihood of 30-day readmission were not significantly different for patients in HIE-enabled vs control SNFs (diff-in-diff = 0.022; P = .431). We observe similar null effects with shorter readmission windows. The portal was used for 46 percent of discharges, with significant usage pattern variation within/across facilities., Conclusions: Implementation of a hospital-SNF EHR portal did not reduce readmissions from enabled SNFs. Emergent HIE use cases need to be better defined and leveraged for design and implementation that generates value in the context of postacute transitions., (© Health Research and Educational Trust.)

Objective: To investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs., Data Sources and Study Setting: Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee-for-service beneficiaries., Study Design: We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment., Principal Findings: From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1-day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4-1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8-1.0), lower total Medicare payment for the 90-day episode after hospital discharge ($396; 95% CI 361-431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149-210, P < .001), offsetting the lower payment for the shorter index SNF stay., Conclusions: Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes., (© 2019 The Authors. Health Services Research published by Wiley Periodicals, Inc. on behalf of Health Research and Educational Trust.)

Objective: To measure the association between clinician specialization in nursing home (NH) practice and outcomes of patients who received postacute care in skilled nursing facilities (SNFs)., Data Sources: Medicare claims and NH assessments for 2 118 941 hospital discharges to 14 526 SNFs in January 2012-October 2014 and MD-PPAS data for 52 379 clinicians., Study Design: Generalist physicians and advanced practitioners with ≥ 90 percent of claims for NH-based care were considered NH specialists. The primary clinician during each SNF stay was determined based on plurality of claims during that stay. We estimated the effect of being treated by a NH specialist on 30-day rehospitalizations, successful discharge to community, and 60-day episode-of-care Medicare payments (Parts A and B). All models included patient demographics, clinical variables, and SNF fixed effects., Principal Findings: Nursing home specialists' patients were less likely to be rehospitalized (14.71 percent vs 16.23 percent; adjusted difference, -1.51 percent, 95% CI -1.78 to -1.24), more likely to be successfully discharged to community (56.33 percent vs 55.49 percent; adjusted difference, 0.84 percent, 95% CI 0.54 to 1.14), but had higher 60-day Medicare payments ($31 628 vs $31 292; adjusted difference, $335; 95% CI $242 to $429)., Conclusions: Clinicians who specialize in NH practice may achieve better postacute care outcomes at slightly higher costs., (© Health Research and Educational Trust.)

Objective: To determine whether skilled nursing facilities (SNFs) chosen by health systems to participate in preferred provider networks exhibited differences in quality, costs, and patient outcomes relative to other SNFs after accounting for differences in case mix., Data Sources: Medicare provider and claims data, 2012 and 2013., Study Design: We compared SNFs included in preferred networks relative to other SNFs in the same market, prior to the establishment of preferred provider networks., Data Extraction Methods: We linked the SNFs in our sample to facility characteristics and quality data. We identified SNF admissions and hospitalizations in claims data and limited the analysis to patients discharged from the hospitals in our sample. We obtained patient characteristics from Medicare summary files and the preceding hospital stay., Principal Findings: Preferred SNFs exhibited better performance across publicly reported quality measures. Patients admitted to preferred SNFs exhibited shorter stays, lower Medicare payments, and lower probability of SNF readmission relative to nonpreferred SNFs., Conclusions: Our results imply that health systems selected SNFs with lower resource use and better performance on quality measures. Thus, the trend toward preferred provider networks could have implications for Medicare spending and patient health., (© Health Research and Educational Trust.)

Objective: To test for differences in patient outcomes when hospital and post-acute care (PAC) providers participate in accountable care organizations (ACOs)., Data/setting: Using Medicare claims, we examined changes in readmission, Medicare spending, and length of stay among patients admitted to ACO-participating hospitals and PAC providers., Design: We compared changes in outcomes among patients discharged from ACO-participating hospitals/PACs before and after participation to changes among patients discharged from non-participating hospitals/PACs over the same time period., Results: Patients discharged from an ACO-participating hospitals and skilled nursing facilities (SNF) had lower readmission rates (-1.7 percentage points, p-value = .03) than before ACO participation and non-participants; and lower per-discharge Medicare spending (-$940, p-value = .001), and length of stay (-3.1 days, p-value <.001) in SNF. Effects among ACO-participating hospitals without a co-participating SNF were smaller. Patients discharged from an ACO-participating hospital and home health agency had lower Medicare per-discharge spending (-$209; p-value = .06) and length of stay (-1.6 days, p-value <.001) for home health compared to before ACO participation and non-participants. Discharge from an ACO-participating hospital and inpatient rehabilitation facility did not impact patient outcomes or spending., Conclusions: Hospital and SNF participation in an ACO was associated with lower readmission rates, Medicare spending on SNF, and SNF length of stay. These results lend support to the ACO payment model., (© Health Research and Educational Trust.)

Objective: To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30-day rehospitalization., Data Sources/settings: Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization., Study Design: We ranked hospitals and SNFs into quartiles based on previous years' adjusted rehospitalization rates (ARRs) and examined how rehospitalizations from a given hospital vary depending upon the admitting SNF ARR quartile. We examined whether the availability of SNFs with low rehospitalization rates influenced hospitals' SNF readmission rates and whether changes in a hospital's ARR over 3 years is associated with changes in the SNFs to which they discharge., Principal Findings: Hospital readmission rates from SNFs varied 5 percentage points between patients discharged to SNFs in the lowest and the highest rehospitalization quartiles. Low rehospitalization rate hospitals sent a larger fraction of their patients to the lowest rehospitalization SNFs available in the area. A 10 percent increase in hospital's share of discharges to the lowest rehospitalization quartile SNFs is associated with a 1 percentage point reduction in hospital's ARR., Conclusions: The SNF rehospitalization rate has greater influence on patients' risk of rehospitalization than the discharging hospital. Identifying high-performing SNFs may be a powerful strategy for hospitals to reduce rehospitalizations., (© Health Research and Educational Trust.)

Objective: To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity., Settings: Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization., Study Design: We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV., Principal Findings: The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013., Conclusions: Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection., (© Health Research and Educational Trust.)

Objective: To determine if regions with high Medicare expenditures in a given setting remain high cost over time., Data Sources/study Setting: One hundred percent of national Medicare Parts A and B fee-for-service beneficiary claims data and enrollment for 1992-2010., Study Design: Patients are classified into regions. Claims are price-standardized. Risk adjustment is performed at the beneficiary level using the CMS Hierarchical Condition Categories model. Correlation analyses are conducted., Data Collection/extraction Methods: The data were obtained through a contract with CMS for a study performed for the Institute of Medicine., Principal Findings: High-cost regions in 1992 are likely to remain high cost in 2010. Stability in regional spending is highest in the home health, inpatient hospital, and outpatient hospital settings over this time period. Despite the persistence of a region's relative spending over time, a region's spending levels in all settings except home health tend to regress toward the mean., Conclusions: Relatively high-cost regions tend to remain so over long periods of time, even after controlling for patient health status and geographic price variation, suggesting that the observed effect reflects real differences in practice patterns., (© Health Research and Educational Trust.)

Objective: To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility (SNF) care and whether differences in outcomes are related to states' Medicaid long-term care policies., Data Sources/collection: We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009., Study Design: We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need (CON) laws; and Medicaid home and community-based services (HCBS) spending., Principal Findings: Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps., Conclusions: Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid., (© Health Research and Educational Trust.)

Objective: To determine whether the rate of rehospitalization is lower among patients discharged to skilled nursing facilities (SNFs) with which a hospital has a strong linkage., Data Sources/collection: We used national Medicare enrollment, claims, and the Minimum Data Set to examine 2.8 million newly discharged patients to 15,063 SNFs from 2,477 general hospitals between 2004 and 2006., Study Design: We examined the relationship between the proportion of discharges from a hospital and alternative SNFs on the rehospitalization of patients treated by that hospital-SNF pair using an instrumental variable approach. We used distances to alternative SNFs from residence of the patients of the originating hospital as the instrument., Principal Findings: Our estimates suggest that if the proportion of a hospital's discharges to an SNF was to increase by 10 percentage points, the likelihood of patients treated by that hospital-SNF pair to be rehospitalized within 30 days would decline by 1.2 percentage points, largely driven by fewer rehospitalizations within a week of hospital discharge., Conclusions: Stronger hospital-SNF linkages, independent of hospital ownership, were found to reduce rehospitalization rates. As hospitals are held accountable for patients' outcomes postdischarge under the Affordable Care Act, hospitals may steer their patients preferentially to fewer SNFs., (© Health Research and Educational Trust.)

Objective: To examine the effect of reductions in hospital-based (HB) skilled nursing facility (SNF) bed supply on the rate of rehospitalization of patients discharged to any SNF from zip codes that lost HB beds., Data Source: We used Medicare enrollment records, Medicare hospital and SNF claims, and nursing home Minimum Dataset assessments and characteristics (OSCAR) to examine nearly 10 million Medicare fee-for-service hospital discharges to SNFs between 1999 and 2006., Study Design: We calculated the number of HB and freestanding (FS) SNF beds within a 22 km radius from the centroid of all zip codes in which Medicare beneficiaries reside in all years. We examined the relationship between HB and FS bed supply and the rehospitalization rates of the patients residing in corresponding zip codes in different years using zip code fixed effects and instrumental variable methods including extensive sensitivity analyses., Principal Findings: Our estimated coefficients suggest that closure of 882 HB homes during our study period resulted in 12,000-18,000 extra rehospitalizations within 30 days of discharge. The effect was largely concentrated among the most acutely ill, high-need patients., Conclusions: SNF patient-based prospective payment resulted in closure of higher cost HB facilities that had served most postacute patients. As other, less experienced SNFs replaced HB facilities, they were less able to manage high acuity patients without rehospitalizing them., (© Health Research and Educational Trust.)

Objective: To determine the degree to which racial and ethnic disparities in the use of postacute rehabilitation care (PARC) are explained by observed characteristics., Data Sources: State inpatient databases (SIDs) for 2005 and 2006 from four diverse states were used to identify patients with stays for joint replacement, stroke, or hip fracture., Study Design: Our primary outcomes were use of institutional PARC (versus discharge home) and, conditional on discharge to an institution, skilled nursing facility (versus inpatient rehabilitation facility) care. We modified the Oaxaca-Blinder decomposition method to account for the dichotomous outcome and multilevel nature of the data., Data Collection/extraction Methods: Discharges from the four SIDs were included if the principal diagnosis (stroke, hip fracture) or procedure (joint replacement) was in the sample inclusion criteria., Principal Findings: Observed characteristics explained roughly half of the unadjusted differences in use of institutional PARC. Patient-level factors (clinical, age) were more explanatory of disparities in institutional PARC use, while hospital-level factors were more explanatory of skilled nursing facility versus inpatient rehabilitation facility care., Conclusions: Adjustment for characteristics influencing PARC use both mitigated and exacerbated racial/ethnic disparities in use. The degree to which the characteristics explained the disparity varied across conditions and outcomes., (© Health Research and Educational Trust.)

Objective: To construct a data tool, the Residential History File (RHF), that summarizes information from Medicare claims and nursing home (NH) Minimum Data Set (MDS) assessments to track people through health care locations, including non-Medicare-paid NH stays., Data Sources: Online Survey of Certification and Reporting (OSCAR) data for 202 free-standing NHs, Medicare Denominator, claims (parts A and B), and MDS assessments for 60,984 people who were present in one of these NHs in 2006., Methods: The algorithm creating the RHF is outlined and the RHF for the study data are used to describe place of death. The identification of residents in NHs is compared with the reports in OSCAR and part B claims., Principal Findings: The RHF correctly identified 84.8 percent of part B claims with place-of-service in NH, and it identified 18.3 less residents on average than reported in the OSCAR on the day of the survey. The RHF indicated that 17.5 percent non-Medicare NH decedents were transferred to the hospital to die versus 45.6 percent skilled nursing facility decedents., Conclusions: The population-based design of the RHF makes it possible to conduct policy-relevant research to examine the variation in the rate and type of health care transitions across the United States., (© Health Research and Educational Trust.)

Objective: To analyze the effect of states' Medicaid bed-hold policies on the 30-day rehospitalization of Medicare postacute skilled nursing facility (SNF) residents., Data Sources: Minimum data set assessments were merged with Medicare claims and eligibility files for all first-time SNF admissions (N = 3,322,088) over the period 2000 through 2005; states' Medicaid bed-hold policies were obtained via survey., Study Design: Regression specification incorporating facility fixed effects to examine changes in Medicaid bed-hold policies on the likelihood of a 30-day SNF rehospitalization., Principal Findings: Using a continuous measure of bed-hold generosity, state Medicaid bed-hold was positively related to Medicare SNF rehospitalization. Specifically, the introduction of a bed-hold policy with average generosity increases Medicare rehospitalizations by 1.8 percent, representing roughly 12,000 SNF rehospitalizations at a cost to Medicare of approximately U.S.$100 million over our study period., Conclusions: Although facilities do not receive a Medicaid bed-hold payment for Medicare SNF stays, we found that the adoption of more generous policies led to greater SNF rehospitalizations. This type of spillover is largely ignored in current discussions of Medicare payment reforms such as bundled payment. Neither Medicare nor Medicaid has an incentive to internalize the risks and benefits of its actions as they affect the other., (© Health Research and Educational Trust.)

Objective: Evidence supporting the use of public reporting of quality information to improve health care quality is mixed. While public reporting may improve reported quality, its effect on quality of care more broadly is uncertain. This study tests whether public reporting in the setting of nursing homes resulted in improvement of reported and broader but unreported quality of postacute care., Data Sources/study Setting: 1999-2005 nursing home Minimum Data Set and inpatient Medicare claims., Study Design: We examined changes in postacute care quality in U.S. nursing homes in response to the initiation of public reporting on the Centers for Medicare and Medicaid Services website, Nursing Home Compare. We used small nursing homes that were not subject to public reporting as a contemporaneous control and also controlled for patient selection into nursing homes. Postacute care quality was measured using three publicly reported clinical quality measures and 30-day potentially preventable rehospitalization rates, an unreported measure of quality., Principal Findings: Reported quality of postacute care improved after the initiation of public reporting for two of the three reported quality measures used in Nursing Home Compare. However, rates of potentially preventable rehospitalization did not significantly improve and, in some cases, worsened., Conclusions: Public reporting of nursing home quality was associated with an improvement in most postacute care performance measures but not in the broader measure of rehospitalization.

Objective: To test how the implementation of new Medicare post-acute payment systems affected the use of inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies., Data Sources: Medicare acute hospital, IRF, and SNF claims; provider of services file; enrollment file; and Area Resource File data., Study Design: We used multinomial logit models to measure realized access to post-acute care and to predict how access to alternative sites of care changed in response to prospective payment systems., Data Extraction Methods: A file was constructed linking data for elderly Medicare patients discharged from acute care facilities between 1996 and 2003 with a diagnosis of hip fracture, stroke, or lower extremity joint replacement., Principal Findings: Although the effects of the payment systems on the use of post-acute care varied, most reduced the use of the site of care they directly affected and boosted the use of alternative sites of care. Payment system changes do not appear to have differentially affected the severely ill., Conclusions: Payment system incentives play a significant role in determining where Medicare beneficiaries receive their post-acute care. Changing these incentives results in shifting of patients between post-acute sites.

Objective: The impact of quality improvement incentives on nontargeted care is unknown and some have expressed concern that such incentives may be harmful to nontargeted areas of care. Our objective is to examine the effect of publicly reporting quality information on unreported quality of care., Data Sources/study Setting: The nursing home Minimum Data Set from 1999 to 2005 on all postacute care admissions., Study Design: We studied 13,683 skilled nursing facilities and examined how unreported aspects of clinical care changed in response to changes in reported care after public reporting was initiated by the Centers for Medicare and Medicaid Services on their website, Nursing Home Compare, in 2002., Principal Findings: We find that overall both unreported and reported care improved following the launch of public reporting. Improvements in unreported care were particularly large among facilities with high scores or that significantly improved on reported measures, whereas low-scoring facilities experienced no change or worsening of their unreported quality of care., Conclusions: Public reporting in the setting of postacute care had mixed effects on areas without public reporting, improving in high-ranking facilities, but worsening in low-ranking facilities. While the benefits of public reporting may extend beyond areas that are being directly measured, these initiatives may also widen the gap between high- and low-quality facilities.

Objective: To examine the relationship between nursing staffing levels in U.S. nursing homes and state Medicaid reimbursement rates., Data Sources: Facility staffing, characteristics, and case-mix data were from the federal On-Line Survey Certification and Reporting (OSCAR) system and other data were from public sources., Study Design: Ordinary least squares and two-stage least squares regression analyses were used to separately examine the relationship between registered nurse (RN) and total nursing hours in all U.S. nursing homes in 2002, with two endogenous variables: Medicaid reimbursement rates and resident case mix., Principal Findings: RN hours and total nursing hours were endogenous with Medicaid reimbursement rates and resident case mix. As expected, Medicaid nursing home reimbursement rates were positively related to both RN and total nursing hours. Resident case mix was a positive predictor of RN hours and a negative predictor of total nursing hours. Higher state minimum RN staffing standards was a positive predictor of RN and total nursing hours while for-profit facilities and the percent of Medicaid residents were negative predictors., Conclusions: To increase staffing levels, average Medicaid reimbursement rates would need to be substantially increased while higher state minimum RN staffing standards is a stronger positive predictor of RN and total nursing hours.

Objective: To assess the relative impact of clinical factors versus nonclinical factors-such as postacute care (PAC) supply-in determining whether patients receive care from skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after discharge from acute care., Data Sources and Study Setting: Medicare acute hospital, IRF, and SNF claims provided data on PAC choices; predictors of site of PAC chosen were generated from Medicare claims, provider of services, enrollment file, and Area Resource File data., Study Design: We used multinomial logit models to predict PAC use by elderly patients after hospitalizations for stroke, hip fractures, or lower extremity joint replacements., Data Collection/extraction Methods: A file was constructed linking acute and postacute utilization data for all medicare patients hospitalized in 1999., Principal Findings: PAC availability is a more powerful predictor of PAC use than the clinical characteristics in many of our models. The effects of distance to providers and supply of providers are particularly clear in the choice between IRF and SNF care. The farther away the nearest IRF is, and the closer the nearest SNF is, the less likely a patient is to go to an IRF. Similarly, the fewer IRFs, and the more SNFs, there are in the patient's area the less likely the patient is to go to an IRF. In addition, if the hospital from which the patient is discharged has a related IRF or a related SNF the patient is more likely to go there., Conclusions: We find that the availability of PAC is a major determinant of whether patients use such care and which type of PAC facility they use. Further research is needed in order to evaluate whether these findings indicate that a greater supply of PAC leads to both higher use of institutional care and better outcomes-or whether it leads to unwarranted expenditures of resources and delays in returning patients to their homes.

Context: Under the Medicare post-acute-care (PAC) transfer policy, acute-care hospitals are reimbursed under a per-diem formula whenever beneficiaries are discharged from selected diagnosis-related groups (DRGs) to a skilled nursing facility, home health care, or a prospective payment system (PPS)-excluded facility. Total per-diem payments are below the full DRG payment only when the patient's length of stay (LOS) is short relative to the geometric mean LOS for the DRG; otherwise, the full DRG payment is received. This policy originally applied to 10 DRGs beginning in fiscal year 1999 and was expanded to additional DRGs in FY2004. The Secretary may include other DRGs and types of PAC settings in future expansions., Purpose: This article examines how the initial policy change affected rural and urban hospitals and investigates the likely impact of the FY2004 expansion and other possible future expansions., Methods: The authors used 1998-2001 Medicare Provider Analysis and Review (MEDPAR) data to investigate changes in hospital discharge patterns after the original policy was implemented, compute the change in Medicare revenue resulting from the payment change, and simulate the expected revenue reductions under expansions to additional DRGs and swing-bed discharges., Findings: Neither rural nor urban hospitals appear to have made a sustained change in their discharge behavior so as to limit their exposure to the transfer policy. Financial impacts from the initial policy were similar in relative terms for both types of hospitals and would be expected to be fairly similar for an expansion to additional DRGs. On average, including swing-bed discharges in the transfer policy would have a very small financial impact on small rural hospitals; only hospitals that make extensive use of swing beds after a short inpatient stay might expect large declines in total Medicare revenue., Conclusion: Rural hospitals are not disproportionately harmed by the PAC transfer policy. An expanded policy may even benefit rural hospitals by recognizing their lower use of post-acute-care and readjusting DRG weights so that they are paid more appropriately when providing the full course of inpatient care.

Objective: To examine skilled nursing facilities (SNFs) "make-or-buy" decisions with respect to rehabilitation therapy service provision in the 1990s, both before and after implementation of Medicare's Prospective Payment System (PPS) for SNFs., Data Sources: Longitudinal On-line Survey Certification and Reporting (OSCAR) data (1992-2001) on a sample of 10,241 freestanding urban SNFs., Study Design: We estimated a longitudinal multinomial logistic regression model derived from transaction cost economic theory to predict the probability of the outcome in each of four service provision categories (all employed staff, all contract, mixed, and no services provided)., Principal Findings: Transaction frequency, uncertainty, and complexity result in greater control over therapy services through employment as opposed to outside contracting. For-profit status and chain affiliation were associated with greater control over therapy services. Following PPS, nursing homes acted to limit transaction costs by either exiting the rehabilitation market or exerting greater control over therapy services by managing rehabilitation services in-house., Conclusions: The financial incentives associated with changes in reimbursement methodology have implications that extend beyond the boundaries of the health care industry segment directly affected. Unintended quality and access consequences need to be carefully monitored by the Medicare program.

Objective: To obtain information relevant to development of prospective payment for Medicare rehabilitation facilities (RFs) and skilled nursing facilities (SNFs): compares service utilization, length of stay (LOS), case mix, and resource consumption for Medicare patients receiving postacute institutional rehabilitation care., Data Sources/study Setting: Longitudinal patient-level and related facility-level data on Medicare hip fracture (n = 513) and stroke (n = 483) patients admitted in 1991-1994 to a sample of 27 RFs and 65 SNFs in urban areas in 17 states., Study Design: For each condition, two-group RF-SNF comparisons were made. Regression analysis was used to adjust RF-SNF differences in resource consumption per stay for patient condition (case mix) and other factors, since random assignment was not possible., Data Collection/extraction Methods: Providers at each facility were trained to collect patient case-mix and service utilization information. Secondary data also were obtained., Principal Findings: RF patients had shorter LOS, fewer total nursing hours (but more skilled nursing hours), and more ancillary hours than SNF patients. After adjustment, ancillary resource consumption per stay remained substantially higher for RF than SNF patients, particularly for stroke. The adjusted nursing resource consumption differences were smaller than the ancillary differences and not statistically significant for hip fracture. Supplemental outcome findings suggested minimal differences for hip fracture patients but better outcomes for RF than SNF stroke patients., Conclusions: Much can be gained from an integrated approach to developing prospective payment for RFs and SNFs. In that context, consideration of condition-specific per-stay payment methods applicable to both settings appears warranted.

Objective: This study examines the effects of resident and facility characteristics on the probability of nursing home residents receiving treatment by mental health professionals., Data Sources/study Setting: The study uses data from the Institutional Population Component of the 1987 National Medical Expenditure Survey, a secondary data source containing data on 3,350 nursing home residents living in 810 nursing homes as of January 1, 1987., Study Design: Andersen's health services use model (1968) is used to estimate a multivariate logistic equation for the effects of independent variables on the probability that a resident has received services from mental health professionals. Important variables include resident race, sex, and age; presence of several behaviors and reported mental illnesses; and facility ownership, facility size, and facility certification., Data Collection/extraction Methods: Data on 188 residents were excluded from the sample because information was missing on several important variables. For some additional variables residents who had missing information were coded as negative responses. This left 3,162 observations for analysis in the logistic regressions., Principal Findings: Older residents and residents with more ADL limitations are much less likely than other residents to have received treatment from a mental health professional. Residents with reported depression, schizophrenia, or psychoses, and residents who are agitated or hallucinating are more likely to have received treatment. Residents in government nursing homes, homes run by chains, and homes with low levels of certification are less likely to have received treatment., Conclusions: Few residents receive treatment from mental health professionals despite need. Older, physically disabled residents need special attention. Care in certain types of facilities requires further study. New regulations mandating treatment for mentally ill residents will demand increased attention from nursing home administrators and mental health professionals.

Objective: This study examines the effect of strategic group membership on nursing home performance and strategic behavior., Data Sources and Study Setting: Data from the 1987 Medicare and Medicaid Automated Certification Survey were combined with data from the 1987 and 1989 Pennsylvania Long Term Care Facility Questionnaire. The sample consisted of 383 Pennsylvania nursing homes., Study Design: Cluster analysis was used to place the 383 nursing homes into strategic groups on the basis of variables measuring scope and resource deployment. Performance was measured by indicators of the quality of nursing home care (rates of pressure ulcers, catheterization, and restraint usage) and efficiency in services provision. Changes in Medicare participation after passage of the 1988 Medicare Catastrophic Coverage Act (MCCA) measured strategic behavior. MANOVA and Turkey HSD post hoc means tests determined if significant differences were associated with strategic group membership., Findings: Cluster analysis produced an optimal seven-group solution. Differences in group means were significant for the clustering, performance, and conduct variables (p < .0001). Strategic groups characterized by facilities providing a continuum of care services had the best patient care outcomes. The most efficient groups were characterized by facilities with high Medicare census. While all strategic groups increased Medicare census following passage of the MCCA, those dominated by for-profits had the greatest increases., Conclusions: Our analysis demonstrates that strategic orientation influences nursing home response to regulatory initiatives, a factor that should be recognized in policy formation directed at nursing home reform.

Objective: The case mix-adjusted pattern of use of health care services, especially posthospital care, is compared before and after the introduction of Medicare's Prospective Payment System (PPS)., Data Sources: The 1982 and 1984 National Long Term Care Surveys (NLTCS) linked to Medicare administrative records 1982-1986 provide health and health service use data for 12-month periods before and after the introduction of PPS., Study Design: Case-mix differences between pre- and post-periods are controlled by using the Grade of Membership model to identify health groups from the NLTCS data. Differences in timing (e.g., hospital length of stay) were controlled using life table models estimated for each health group, that is, service use patterns pre- and post-PPS are compared within groups., Principal Findings: Hospital LOS and admission rates declined post-PPS. Changes in the timing and location of death occurred but, overall, mortality did not increase. Changes in post-acute care service use by elderly, chronically disabled Medicare beneficiaries were observed: home health service use increased overall and among the unmarried disabled population., Conclusions: PPS did not adversely affect quality of care as reflected in mortality or in hospital readmissions. Moreover, the differential use of post-acute care, and changes in hospital LOS by health group, indicate that the system responded, specific to marital status and age, to the severity of needs of chronically disabled persons.

The introduction of Medicare's prospective payment system (PPS) has led to changes in the way hospitals are being used. This article examines concomitant changes in the use of Medicare-covered services during the last 90 days of life, using data on more than 34,000 Medicare beneficiaries who died during the years 1982-1986. We focus on questions pertaining to changes in practice patterns that include location of death, hospital utilization, use of other covered services, and spending. We find that use of hospitals and other health services by Medicare beneficiaries during the last 90 days of life changed markedly over this period, which included the introduction of PPS in late 1983. The percentage of deaths occurring in hospitals decreased sharply from 1982 to 1986, especially in PPS states relative to waivered states; this effect seems primarily due to reductions in length of stay rather than reduced admission rates, which did not change significantly. Use of home care, durable medical equipment (DME), and physicians' office services also increased sharply during the last 90 days of life, but with no consistent evidence that the introduction of PPS was associated with these changes or with the level or mix of Medicare expenditures for these patients. Medicare spending in this period of life rose at the same rate as medical care price inflation, and about 75 percent of reimbursements continued to be hospital payments, despite the utilization changes.