Claims-Based vs Agency-Reported Patient Outcomes Among Home Health Agencies, 2013-2019.

Importance: Given the growth of home health agency (HHA) care, it is important to understand whether quality reporting programs, such as star ratings, are associated with improved patient outcomes. Objective: To assess the immediate and long-term association of the introduction of HHA star ratings with patient-level quality outcomes, comparing claims-based and agency-reported measures. Design, Setting, and Participants: This cross-sectional study used Medicare HHA claims and agency-reported assessments to identify sequential patient episodes (ie, spells) among US adults with traditional Medicare who received HHA care (2013-2019). An interrupted time series (ITS) model was used to measure changes in trends and levels before and after the introduction of star ratings. Statistical analysis was performed from November 2022 to September 2023. Exposure: The exposure was the introduction of HHA star ratings. The postexposure period was set as starting January 1, 2016, to account for the period when both star ratings (quality of patient care and patient satisfaction rating) were publicly reported. Main Outcomes and Measures: The main outcomes included claims-based hospitalization measures (both during the patient spell and 30 days after HHA discharge) and agency-reported functional measures, such as improvement in ambulation, bathing, and bed transferring. There was also a measure to capture timely initiation of care among post-acute care HHA users, defined as HHA care initiated within 2 days of inpatient discharge. Results: This study identified 22 958 847 patient spells to compare annual changes over time; 9 750 689 patient spells were included during the pre-star ratings period from January 1, 2013, to December 31, 2015 (6 067 113 [62.2%] female; 1 100 145 [11.3%] Black, 512 487 [5.3%] Hispanic, 7 845 197 [80.5%] White; 2 656 124 [27.2%] dual eligible; mean [SD] patient spell duration, 70.9 [124.9] days; mean [SD] age, 77.4 [12.0] years); 13 208 158 patient spells were included during the post-star ratings period from January 1, 2016, to December 31, 2019 (8 104 69 [61.4%] female; 1 385 180 [10.5%] Black, 675 536 [5.1%] Hispanic, 10 664 239 [80.7%] White; 3 318 113 [25.1%] dual eligible; mean [SD] patient spell duration, 65.3 [96.2] days; mean [SD] age, 77.7 [11.6] years). Results from the ITS models found that the introduction of star ratings was associated with an acceleration in the mean [SE] hospitalization rate during the spell (0.39% [0.05%] per year) alongside functional improvements in ambulation (2.40% [0.29%] per year), bed transferring (3.95% [0.48%] per year) and bathing (2.34% [0.19%] per year) (P < .001). This occurred alongside a 1.21% (0.12%) per year reduction in timely initiation of care (P < .001). Conclusions and Relevance: This cross-sectional study found an observed improvement in agency-reported functional measures, which contrasted with slower increases in more objective measures such as hospitalization rates and declines in timely initiation of care. These findings suggest a complex picture of HHA quality of care after the introduction of star ratings.

New CMS Nursing Home Ownership Data: Major Gaps And Discrepancies.

Nursing home ownership has become increasingly complicated, partly because of the growth of facilities owned by institutional investors such as private equity (PE) firms and real estate investment trusts (REITs). Although the ownership transparency and accountability of nursing homes have historically been poor, the Biden administration's nursing home reform plans released in 2022 included a series of data releases on ownership. However, our evaluation of the newly released data identified several gaps: One-third of PE and fewer than one-fifth of REIT investments identified in the proprietary Irving Levin Associates and S&P Capital IQ investment data were present in Centers for Medicare and Medicaid Services (CMS) publicly available ownership data. Similarly, we obtained different results when searching for the ten top common owners of nursing homes using CMS data and facility survey reports of chain ownership. Finally, ownership percentages were missing in the CMS data for 82.40 percent of owners in the top ten chains and 55.21 percent of owners across all US facilities. Although the new data represent an important step forward, we highlight additional steps to ensure that the data are timely, accurate, and responsive. Transparent ownership data are fundamental to understanding the adequacy of public payments to provide patient care, enable policy makers to make timely decisions, and evaluate nursing home quality.

Administrator Perspectives on the Impact of COVID-19 on the Administration of the Patient Driven Payment Model in U.S. Skilled Nursing Facilities.

The Patient Driven Payment Model (PDPM) was implemented in U.S. skilled nursing facilities (SNFs) in October 2019, shortly before COVID-19. This new payment model aimed to reimburse SNFs for patients' nursing needs rather than the previous model which reimbursed based on the volume of therapy received. Through 156 semi-structured interviews with 40 SNF administrators from July 2020 to December 2021, this qualitative study clarifies the impact of COVID-19 on the administration of PDPM at SNFs. Interview data were analyzed using modified grounded theory and thematic analysis. Our findings show that SNF administrators shifted focus from management of the PDPM to COVID-19-related delivery of care adaptations, staff shortfalls, and decreased admissions. As the pandemic abated, administrators re-focused their attention to PDPM. Policy makers should consider the continued impacts of the pandemic at SNFs, particularly on delivery of care, admissions, and staffing, on the ability of SNF administrators to administer a new payment model.

Clinical Risk and Outpatient Therapy Utilization for COVID-19 in the Medicare Population.

Importance: Multiple therapies are available for outpatient treatment of COVID-19 that are highly effective at preventing hospitalization and mortality. Although racial and socioeconomic disparities in use of these therapies have been documented, limited evidence exists on what factors explain differences in use and the potential public health relevance of these differences. Objective: To assess COVID-19 outpatient treatment utilization in the Medicare population and simulate the potential outcome of allocating treatment according to patient risk for severe COVID-19. Design, Setting, and Participants: This cross-sectional study included patients enrolled in Medicare in 2022 across the US, identified with 100% Medicare fee-for-service claims. Main Outcomes and Measures: The primary outcome was any COVID-19 outpatient therapy utilization. Secondary outcomes included COVID-19 testing, ambulatory visits, and hospitalization. Differences in outcomes were estimated based on patient demographics, treatment contraindications, and a composite risk score for mortality after COVID-19 based on demographics and comorbidities. A simulation of reallocating COVID-19 treatment, particularly with nirmatrelvir, to those at high risk of severe disease was performed, and the potential COVID-19 hospitalizations and mortality outcomes were assessed. Results: In 2022, 6.0% of 20 026 910 beneficiaries received outpatient COVID-19 treatment, 40.5% of which had no associated COVID-19 diagnosis within 10 days. Patients with higher risk for severe disease received less outpatient treatment, such as 6.4% of those aged 65 to 69 years compared with 4.9% of those 90 years and older (adjusted odds ratio [aOR], 0.64 [95% CI, 0.62-0.65]) and 6.4% of White patients compared with 3.0% of Black patients (aOR, 0.56 [95% CI, 0.54-0.58]). In the highest COVID-19 severity risk quintile, 2.6% were hospitalized for COVID-19 and 4.9% received outpatient treatment, compared with 0.2% and 7.5% in the lowest quintile. These patterns were similar among patients with a documented COVID-19 diagnosis, those with no claims for vaccination, and patients who are insured with Medicare Advantage. Differences were not explained by variable COVID-19 testing, ambulatory visits, or treatment contraindications. Reallocation of 2022 outpatient COVID-19 treatment, particularly with nirmatrelvir, based on risk for severe COVID-19 would have averted 16 503 COVID-19 deaths (16.3%) in the sample. Conclusion: In this cross-sectional study, outpatient COVID-19 treatment was disproportionately accessed by beneficiaries at lower risk for severe infection, undermining its potential public health benefit. Undertreatment was not driven by lack of clinical access or treatment contraindications.

Changes in Care Associated With Integrating Medicare and Medicaid for Dual-Eligible Individuals.

Importance: There is growing interest in expanding integrated models, in which 1 insurer manages Medicare and Medicaid spending for dually eligible individuals. Fully integrated dual-eligible special needs plans (FIDE-SNPs) are one of the largest integrated models, but evidence about their performance is limited. Objective: To evaluate changes in care associated with integrating Medicare and Medicaid coverage in a FIDE-SNP in Pennsylvania. Design, Setting, and Participants: This cohort study using a difference-in-differences analysis compared changes in care between 2 cohorts of dual-eligible individuals: (1) an integration cohort composed of Medicare Dual Eligible Special Needs Plan enrollees who joined a companion Medicaid plan following a 2018 state reform mandating Medicaid managed care (leading to integration), and (2) a comparison cohort with nonintegrated coverage before and after the start of Medicaid managed care. Analyses were conducted between February 2022 and June 2023. Main Outcomes and Measures: Analyses examined outcomes in 4 domains: use of home- and community-based services (HCBS), care management and coordination, hospital stays and postacute care, and long-term nursing home stays. Results: The study included 7967 individuals in the integration cohort and 3832 individuals in the comparison cohort. In the integration cohort, the mean (SD) age at baseline was 63.3 (14.7) years, and 5268 individuals (66.1%) were female and 2699 (33.9%) were male. In the comparison cohort, the mean (SD) age at baseline was 64.8 (18.6) years, and 2341 individuals (61.1%) were female and 1491 (38.9%) were male. At baseline, integration cohort members received a mean (SD) of 2.83 (8.70) days of HCBS per month and 3.34 (3.56) medications for chronic conditions per month, and the proportion with a follow-up outpatient visit after a hospital stay was 0.47. From baseline through 3 years after integration, HCBS use increased differentially in the integration vs comparison cohorts by 0.61 days/person-month (95% CI, 0.28-0.94; P < .001). However, integration was not associated with changes in care management and coordination, including medication use for chronic conditions (-0.02 fills/person-month; 95% CI, -0.10 to 0.06; P = .65) or follow-up outpatient care after a hospital stay (-0.01 visits/hospital stay; 95% CI, -0.04 to 0.03; P = .61). Hospital stays did not change differentially between the cohorts. Unmeasured factors contributing to differential mortality limited the ability to identify changes in long-term nursing home stays associated with integration. Conclusions and Relevance: In this cohort study with a difference-in-differences analysis of 2 cohorts of individuals dually eligible for Medicare and Medicaid, integration was associated with greater HCBS use but not with other changes in care patterns. The findings highlight opportunities to strengthen how integrated programs manage care and a need to further evaluate their performance.

Telemedicine Visits in US Skilled Nursing Facilities.

Importance: Telemedicine in skilled nursing facilities (SNFs) has the potential to improve access and timeliness of care. During the COVID-19 pandemic in 2020 to 2022, telemedicine coverage expanded, but little is known about patterns of use in SNFs. Objective: To describe patterns of telemedicine use in SNFs. Design, Setting, and Participants: This cohort study used 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records to identify short- and long-term care SNF residents. Clinician visits were grouped into routine SNF visits (ie, regular primary care within SNF) and other outpatient visits (ie, with non-SNF affiliated primary and specialty care clinicians). Using a difference-in-differences approach, assessments included whether off-hours visits (measured as weekend visits), new specialist visits, psychiatrist visits, or visits for residents with limited mobility changed differentially between 2018 to 2019 and 2020 to 2021 for SNFs with high compared with low telemedicine use in 2020. Exposure: Telemedicine adoption at SNF after 2020. Main Outcomes and Measures: Number and proportion of telemedicine SNF and outpatient visits. Results: Across 15 434 SNFs and 4 463 591 residents from the period January 2019 through June 2022 (mean [SD] age, 79.7 [11.6] years; 61% female in 2020), telemedicine visits increased from 0.15% in January 2019 to February 2020 to 15% SNF visits and 25% outpatient visits in May 2020. By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40). Psychiatry visits differentially increased in high vs low telemedicine-use SNFs (20.2% relative increase; 95% CI, 1.2% to 39.2%). In contrast, there was little change in outpatient visits for residents with limited mobility (7.2%; 95% CI, -0.1% to 14.6%) or new specialist visits (-0.7%; 95% CI, -2.5% to 1.2%). Conclusions and Relevance: In this cohort study of SNF residents, telemedicine was rapidly adopted in early 2020 but subsequently stabilized at a low use rate that was nonetheless higher than before 2020. Higher telemedicine use in SNFs was associated with improved access to psychiatry visits in SNFs. A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures.

Medicaid home and community-based services spending for older adults: Is there a "woodwork" effect?

BACKGROUND: Although older adults prefer to age at home, Medicaid has a longstanding institutional bias in funding long-term services and supports (LTSS). Some states have resisted expanding Medicaid funding for home- and community-based services (HCBS) due to budgetary concerns related to the so-called "woodwork" effect whereby individuals enroll on Medicaid to access HCBS. METHODS: To examine the implications associated with state Medicaid HCBS expansion, we obtained state-year data for 1999-2017 from various sources. We estimated difference-in-differences regressions comparing outcomes in states that expanded Medicaid HCBS aggressively versus those that expanded less aggressively, controlling for several covariates. We examined a range of outcomes including Medicaid enrollment, nursing home census, Medicaid institutional LTSS spending, total Medicaid LTSS spending, and Medicaid HCBS waiver enrollment. We measured HCBS expansion by the total share of state Medicaid LTSS spending for aged and disabled persons devoted to HCBS. RESULTS: HCBS expansion was not associated with increased Medicaid enrollment among individuals ages 65 and older. A 1% increase in HCBS spending was associated with reductions in the state nursing home population of 47.1 residents (95% confidence interval [CI]: -80.5, -13.8) and institutional Medicaid LTSS spending of $7.3 million (95% CI: -$12.1M, -$2.4M). A $1 increase in HCBS spending was associated with $0.74 increase (95% CI: $0.57, $0.91) in total LTSS spending, suggesting each dollar directed to HCBS was offset by $0.26 savings from decreased nursing home use. Increased HCBS waiver spending was associated with more older adults receiving LTSS at a lower cost per beneficiary served relative to the nursing home setting. CONCLUSIONS: We did not find evidence of a woodwork effect in those states that expanded Medicaid HCBS more aggressively, as measured by age 65 and older Medicaid enrollment. However, they did experience Medicaid savings from reduced nursing home use, suggesting states that expand Medicaid HCBS are able to use these additional dollars to serve more LTSS recipients.

Assessment of Medical and Public Assistance Expenditures and Employment Among US Adults With Cancer Diagnoses.

Importance: Prior research suggests significant social value associated with increased longevity due to preventing and treating cancer. Other social costs associated with cancer, such as unemployment, public medical spending, and public assistance, may also be sizable. Objective: To examine whether a cancer history is associated with receipt of disability insurance, income, employment, and medical spending. Design, Setting, and Participants: This cross-sectional study used data from the Medical Expenditure Panel Study (MEPS) (2010-2016) for a nationally representative sample of US adults aged 50 to 79 years. Data were analyzed from December 2021 to March 2023. Exposure: Cancer history. Main Outcomes and Measures: The main outcomes were employment, public assistance receipt, disability, and medical expenditures. Variables for race, ethnicity, and age were used as controls. A series of multivariate regression models were used to assess the immediate and 2-year association of a cancer history with disability, income, employment, and medical spending. Results: Of 39 439 unique MEPS respondents included in the study, 52% were female, and the mean (SD) age was 61.44 (8.32) years; 12% of respondents had a history of cancer. Individuals with a cancer history who were aged 50 to 64 years were 9.80 (95% CI, 7.35-12.25) percentage points more likely to have a work-limiting disability and were 9.08 (95% CI, 6.22-11.94) percentage points less likely to be employed compared with individuals in the same age group without a history of cancer. Nationally, cancer accounted for 505 768 fewer employed individuals in the population aged 50 to 64 years. A cancer history was also associated with an increase of $2722 (95% CI, $2131-$3313) in medical spending, $6460 (95% CI, $5254-$7667) in public medical spending, and $515 (95% CI, $337-$692) in other public assistance spending. Conclusions and Relevance: In this cross-sectional study, a history of cancer was associated with increased likelihood of disability, higher medical spending, and decreased likelihood of employment. These findings suggest there may be gains beyond increased longevity if cancer can be detected and treated earlier.

Spillover effect of the Patient Drive Payment Model on skilled nursing facility therapy delivery among Medicare Advantage enrollees.

In a multi-payer health care system, economic theory suggests that different payers can impose spillover effects on one another. This study aimed to evaluate the spillover effect of the Patient Driven Payment Model (PDPM) on Medicare Advantage (MA) enrollees, despite it being designed for Traditional Medicare (TM) beneficiaries. We applied a regression discontinuity approach by comparing therapy utilization before and after the implementation of PDPM in October 2019 focusing on patients newly admitted to skilled nursing facilities. The results showed that both TM and MA enrollees experienced a decrease in individual therapy minutes and an increase in non-individual therapy minutes. The estimated reduction in total therapy use was 9 min per day for TM enrollees and 3 min per day for MA enrollees. The effect of PDPM on MA beneficiaries varied depending on the level of MA penetration, with the smallest effect in facilities with the highest MA penetration quartile. In summary, the PDPM had directionally similar effects on therapy utilization for both TM and MA enrollees, but the magnitudes were smaller for MA beneficiaries. These results suggest that policy changes intended for TM beneficiaries may spillover to MA enrollees and should be assessed accordingly.

Increased Medicare Advantage Penetration Is Associated With Lower Postacute Care Use For Traditional Medicare Patients.

Medicare Advantage (MA) plans, which accounted for 45 percent of total Medicare enrollment in 2022, are incentivized to minimize spending on low-value services. Prior research indicates that MA plan enrollment is associated with reduced postacute care use without adverse impacts on patient outcomes. However, it is unclear whether a rising MA enrollment level is associated with a change in postacute care use in traditional Medicare, especially given growing participation in traditional Medicare Alternative Payment Models that have been found to be associated with lower postacute care spending. We hypothesize that market-level MA expansion is associated with reduced postacute care use among traditional Medicare beneficiaries-a "spillover" effect of providers modifying their practice patterns in response to MA plans' incentives. We found increased MA market penetration associated with reduced postacute care use among traditional Medicare beneficiaries, without a corresponding increase in hospital readmissions. This association was generally stronger in markets with a greater share of traditional Medicare beneficiaries attributed to accountable care organizations, suggesting that policy makers should account for MA penetration when evaluating potential savings in Alternative Payment Models within traditional Medicare.

Medicare Skilled Nursing Facility Use and Spending Before and After Introduction of the Public Health Emergency Waiver During the COVID-19 Pandemic.

Importance: In response to the COVID-19 pandemic, Medicare introduced a public health emergency (PHE) waiver in March 2020, removing a 3-day hospitalization requirement before fee-for-service beneficiaries could receive skilled nursing facility (SNF) care benefits. Objective: To assess whether there were changes in SNF episode volume and Medicare spending on SNF care before and during the PHE among long-term care (LTC) residents and other Medicare beneficiaries. Design, Setting, and Participants: This retrospective cohort study used Medicare fee-for-service claims and the Minimum Data Set for Medicare beneficiaries who were reimbursed for SNF care episodes from January 2018 to September 2021 in US SNFs. Exposures: The prepandemic period (January 2018-February 2020) vs the PHE period (March 2020-September 2021). Main Outcomes and Measures: The main outcomes were SNF episode volume, characteristics, and costs. Episodes were defined as standard (with a preceding 3-day hospitalization) or waiver (with other or no acute care use). Results: Skilled nursing facility care was provided to 4 299 863 Medicare fee-for-service beneficiaries. Medicare beneficiaries had on average 130 400 monthly SNF episodes in the prepandemic period (mean [SD] age of beneficiaries, 78.9 [11.0] years; 59% female) and 108 575 monthly episodes in the PHE period (mean [SD] age of beneficiaries, 79.0 [11.1] years; 59% female). All waiver episodes increased from 6% to 32%, and waiver episodes without preceding acute care increased from 3% to 18% (from 4% to 49% among LTC residents). Skilled nursing facility episodes provided for LTC residents increased by 77% (from 15 538 to 27 537 monthly episodes), primarily due to waiver episodes provided for residents with COVID-19 in 2020 and early 2021 (62% of waiver episodes without preceding acute care). Skilled nursing facilities in the top quartile of waiver episodes were more often for-profit (80% vs 68%) and had lower quality ratings (mean [SD] overall star rating, 2.7 [1.4] vs 3.2 [1.4]; mean [SD] staffing star rating, 2.5 [1.1] vs 3.0 [1.2]) compared with SNFs in the other quartiles. Monthly Medicare spending on SNF care was $2.1 billion before the pandemic and $2.0 billion during the PHE. For LTC residents, monthly SNF spending increased from $301 million to $585 million while spending on hospitalizations remained relatively stable. Conclusions and Relevance: This cohort study found that the PHE waiver for SNF care was associated with a marked increase in the prevalence of SNF episodes without a preceding hospitalization, especially in the first year of the COVID-19 pandemic. The waiver was used primarily among certain types of facilities and for LTC residents with COVID-19. Although the effect of the waiver cannot be differentiated from that of the pandemic, overall SNF care costs did not increase substantially; for LTC residents, the waiver was applied primarily for COVID-19 care, suggesting the waiver's successful implementation.

Understanding Nursing Home Spending And Staff Levels In The Context Of Recent Nursing Staff Recommendations.

To provide context for evaluating proposed nursing home staff regulations, we examined the proportion of facility revenues spent on nursing staff, as well as nursing staff levels in hours worked and paid per resident day, in 2019. Nationally, the median proportion of revenues spent on nursing staff was 33.9 percent, and median nursing staff levels were 3.67 hours worked and 4.08 hours paid per resident day. Facilities with higher shares of Medicaid residents spent a larger share of revenues on nursing staff but had lower staffing levels. States varied significantly with respect to median spending on nursing staff (26.8-44.0 percent of revenues) and median nursing staff levels (3.2-5.6 hours worked and 3.6-5.7 hours paid per resident day). These findings indicate that raising the proportion of revenues spent by nursing homes on nursing staff to a regulated minimum would not guarantee the achievement of adequate nursing staff levels unless it was paired with other regulatory mechanisms.

Specialty care after transition to long-term care in nursing home.

BACKGROUND: Nursing home residents face many barriers to accessing specialist physician outpatient care. However, little data exists on how specialty care use changes when individuals transition to a nursing home in the US. METHODS: We studied specialist outpatient visits for new long-term care (LTC) residents within 1 year before and after their transition to nursing home residence using the Minimum Data Set v3.0 (MDS) and a 20% sample of Medicare fee-for-service claims in 2014-2018. To focus on residents requiring specialty care at baseline, we limited the cohort to residents with specialty care in the 13-24 months before LTC transition. We then measured the proportion of residents receiving at least one visit in the 12 months before the transition and the 12 months after the transition. We also examined subgroups of residents with a prior diagnosis likely requiring long-term specialty care (e.g., multiple sclerosis). Finally, we examined whether there was continuity of care within the same specialty care provider. RESULTS: Among 39,288 new LTC transitions identified in 2016-2017, 17,877 (45.5%) residents had a prior specialist visit 13-24 months before the transition. Among them, the proportion of residents with specialty visits decreased consistently in all specialties in the 12 months after the transition, ranging from a relative decrease of 14.4% for orthopedics to 67.9% for psychiatry. The relative decrease among patients with a diagnosis likely requiring specialty care ranged from 0.9% for neurology in patients with multiple sclerosis to 67.1% for psychiatry in patients with severe mental illness. Among residents who continued visiting a specialist, 78.9% saw the same provider as before the transition. CONCLUSIONS: The use of specialty care falls significantly after patients transition to a nursing home. Further research is needed to understand what drives this drop in use and whether interventions, such as telemedicine can ameliorate potential barriers to specialty care.

Trends in post-acute care and outcomes for Medicare beneficiaries hospitalized for heart failure between 2008 and 2015.

BACKGROUND: Heart failure (HF) is the leading cause of hospitalization among older adults in the United States and results in high rates of post-acute care (PAC) utilization. Federal policies have focused on shifting PAC to less intensive settings and reducing length of stay to lower spending. This study evaluates the impact of policy changes on PAC use among Medicare beneficiaries hospitalized with HF between 2008 and 2015 by (1) characterizing trends in PAC use and cost and (2) evaluating changes in readmission, mortality, and days in the community, overall and by frailty. METHODS: Annual cross-section prospective cohorts of all HF admissions between 1/1/2008 and 9/30/2015 among a 20% random sample of all Medicare Fee-for-Service beneficiaries (n = 718,737). The Claims-based Frailty Index (CFI) was used to classify frailty status. Multivariable regression models were used to evaluate trends in first discharge location, readmissions, mortality, days alive in the community, and costs; overall and by frailty status. RESULTS: Frailty was prevalent among HF patients: 54.1% were prefrail, 37.0% mildly frail, and 6.9% moderate to severely frail. Between 2008 and 2015, almost 4% more HF beneficiaries received PAC, with most of the increase concentrated in skilled nursing facilities (SNF) (+2.3%) and home health agencies (HHA) (+1.1%), and PAC cost increased by $123 (3.5%). Over the 180-days follow-up after hospitalization, hospital readmissions decreased significantly (-3.4% at 30-day; -6.3% at 180-day), days alive in the community increased (+1.5), and 180-day Medicare costs declined $2948 (-18.7%) without negative impact in mortality (except a minor increase in the pre-frail group). Gains were greatest among the frailest patients. CONCLUSIONS: Medicare beneficiaries hospitalized with HF spent more time in the community and experienced lower rehospitalization rates at lower cost without significant increases in mortality. However, important opportunities remain to optimize care for frail older adults hospitalized with HF.

CMS Initiative to Reduce Potentially Avoidable Hospitalizations Among Long-Stay Nursing Facility Residents: Lessons Learned.

Policy Points Misaligned incentives between Medicare and Medicaid may result in avoidable hospitalizations among long-stay nursing home residents. Providing nursing homes with clinical staff, such as nurse practitioners, was more effective in reducing resident hospitalizations than providing Medicare incentive payments alone. CONTEXT: In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations Among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions (Clinical-Only) aimed to reduce hospitalizations among long-stay nursing home residents. In Phase 2 (2016 to 2020), the Initiative also included a Medicare payment incentive for treating residents with certain conditions within the nursing home. Nursing homes participating in Phase 1 continued their previous interventions and received the incentive (Clinical + Payment) and others received the incentive only (Payment-Only). METHODS: Mixed methods were used to determine the effectiveness of the Initiative and explore facilitators of and barriers to implementation that participating nursing homes experienced. We used telephone and in-person interviews to investigate aspects of implementation and a difference-in-differences regression model framework comparing residents in participating and nonparticipating nursing homes to determine the effect of the Initiative on measures of utilization, expenditures, and quality. FINDINGS: Three key components were necessary for successful implementation of the Initiative-staff retention and leadership stability, leadership and staff support, and provider engagement and support. Nursing homes that lacked one or more of these three components experienced greater challenges. The Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations. We did not find evidence that the Clinical + Payment or Payment-Only interventions were successful in reducing hospitalizations. CONCLUSIONS: Reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.

Nursing Home Residents Younger Than Age Sixty-Five Are Unique And Would Benefit From Targeted Policy Making.

Existing public policies often fail to acknowledge differences between older (ages sixty-five and older) and younger (younger than age sixty-five) people with disabilities residing in nursing homes. We compared long-stay (over sixty days) residents across age groups and then documented state-level variation in their age-adjusted prevalence in 2019 and trends in prevalence during the period 2013-19. Compared with older residents, younger residents tended to have different diagnoses and were more likely to reside in for-profit and lower-quality facilities, as well as to be non-White and male. Among younger people with disabilities, nursing home use varied widely across states, and trends in use were only weakly correlated with trends for older adults. Although rates of state-level nursing home placement among older adults generally declined, in many states they stagnated or grew among those younger than age sixty-five, with no convergence of trends in placement across states. Our findings suggest the value of approaching younger people with disabilities as a distinct population. We offer targeted policies to divert these people from nursing homes to home and community-based settings.

Association Between the Patient Driven Payment Model and Therapy Utilization and Patient Outcomes in US Skilled Nursing Facilities.

Importance: 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.

Changes in Health and Quality of Life in US Skilled Nursing Facilities by COVID-19 Exposure Status in 2020.

Importance: During the COVID-19 pandemic, the US federal government required that skilled nursing facilities (SNFs) close to visitors and eliminate communal activities. Although these policies were intended to protect residents, they may have had unintended negative effects. Objective: To assess health outcomes among SNFs with and without known COVID-19 cases. Design, Setting, and Participants: This retrospective observational study used US Medicare claims and Minimum Data Set 3.0 for January through November in each year beginning in 2018 and ending in 2020 including 15 477 US SNFs with 2 985 864 resident-years. Exposures: January through November of calendar years 2018, 2019, and 2020. COVID-19 diagnoses were used to assign SNFs into 2 mutually exclusive groups with varying membership by month in 2020: active COVID-19 (≥1 COVID-19 diagnosis in the current or past month) or no-known COVID-19 (no observed diagnosis by that month). Main Outcomes and Measures: Monthly rates of mortality, hospitalization, emergency department (ED) visits, and monthly changes in activities of daily living (ADLs), body weight, and depressive symptoms. Each SNF in 2018 and 2019 served as its own control for 2020. Results: In 2018-2019, mean monthly mortality was 2.2%, hospitalization 3.0%, and ED visit rate 2.9% overall. In 2020, among active COVID-19 SNFs compared with their own 2018-2019 baseline, mortality increased by 1.60% (95% CI, 1.58% to 1.62%), hospitalizations decreased by 0.10% (95% CI, -0.12% to -0.09%), and ED visit rates decreased by 0.57% (95% CI, -0.59% to -0.55%). Among no-known COVID-19 SNFs, mortality decreased by 0.15% (95% CI, -0.16% to -0.13%), hospitalizations by 0.83% (95% CI, -0.85% to -0.81%), and ED visits by 0.79% (95% CI, -0.81% to -0.77%). All changes were statistically significant. In 2018-2019, across all SNFs, residents required assistance with an additional 0.89 ADLs between January and November, and lost 1.9 lb; 27.1% had worsened depressive symptoms. In 2020, residents in active COVID-19 SNFs required assistance with an additional 0.36 ADLs (95% CI, 0.34 to 0.38), lost 3.1 lb (95% CI, -3.2 to -3.0 lb) more weight, and were 4.4% (95% CI, 4.1% to 4.7%) more likely to have worsened depressive symptoms, all statistically significant changes. In 2020, residents in no-known COVID-19 SNFs had no significant change in ADLs (-0.06 [95% CI, -0.12 to 0.01]), but lost 1.8 lb (95% CI, -2.1 to -1.5 lb) more weight and were 3.2% more likely (95% CI, 2.3% to 4.1%) to have worsened depressive symptoms, both statistically significant changes. Conclusions and Relevance: Among skilled nursing facilities in the US during the first year of the COVID-19 pandemic and prior to the availability of COVID-19 vaccination, mortality and functional decline significantly increased at facilities with active COVID-19 cases compared with the prepandemic period, while a modest statistically significant decrease in mortality was observed at facilities that had never had a known COVID-19 case. Weight loss and depressive symptoms significantly increased in skilled nursing facilities in the first year of the pandemic, regardless of COVID-19 status.