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.

Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement.

BACKGROUND: In 2016, Medicare implemented Comprehensive Care for Joint Replacement (CJR), a national mandatory bundled-payment model for hip or knee replacement in randomly selected metropolitan statistical areas. Hospitals in such areas receive bonuses or pay penalties based on Medicare spending per hip- or knee-replacement episode (defined as the hospitalization plus 90 days after discharge). METHODS: We conducted difference-in-differences analyses using Medicare claims from 2015 through 2017, encompassing the first 2 years of bundled payments in the CJR program. We evaluated hip- or knee-replacement episodes in 75 metropolitan statistical areas randomly assigned to mandatory participation in the CJR program (bundled-payment metropolitan statistical areas, hereafter referred to as "treatment" areas) as compared with those in 121 control areas, before and after implementation of the CJR model. The primary outcomes were institutional spending per hip- or knee-replacement episode (i.e., Medicare payments to institutions, primarily to hospitals and post-acute care facilities), rates of postsurgical complications, and the percentage of "high-risk" patients (i.e., patients for whom there was an elevated risk of spending - a measure of patient selection). Analyses were adjusted for the hospital and characteristics of the patients and procedures. RESULTS: From 2015 through 2017, there were 280,161 hip- or knee-replacement procedures in 803 hospitals in treatment areas and 377,278 procedures in 962 hospitals in control areas. After the initiation of the CJR model, there were greater decreases in institutional spending per joint-replacement episode in treatment areas than in control areas (differential change [i.e., the between-group difference in the change from the period before the CJR model], -$812, or a -3.1% differential decrease relative to the treatment-group baseline; P<0.001). The differential reduction was driven largely by a 5.9% relative decrease in the percentage of episodes in which patients were discharged to post-acute care facilities. The CJR program did not have a significant differential effect on the composite rate of complications (P=0.67) or on the percentage of joint-replacement procedures performed in high-risk patients (P=0.81). CONCLUSIONS: In the first 2 years of the CJR program, there was a modest reduction in spending per hip- or knee-replacement episode, without an increase in rates of complications. (Funded by the Commonwealth Fund and the National Institute on Aging of the National Institutes of Health.).

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.

For-Profit and Not-for-Profit Inpatient Rehabilitation in Traumatic Brain Injury: Analysis of Demographics and Outcomes.

OBJECTIVE: To describe differences in characteristics and outcomes of patients with traumatic brain injury by inpatient rehabilitation facility (IRF) profit status. DESIGN: Retrospective database review using the Uniform Data System for Medical Rehabilitation. SETTING: IRFs. PARTICIPANTS: Individual discharges (N=53,630) from 877 distinct rehabilitation facilities for calendar years 2016 through 2018. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Patient demographic data (age, race, primary payer source), admission and discharge FIM, FIM gain, length of stay efficiency, acute hospital readmission from for-profit and not-for-profit IRFs within 30 days, and community discharges by facility profit status. RESULTS: Patients at for-profit facilities were significantly older (69.69 vs 64.12 years), with lower admission FIM scores (52 vs 57), shorter lengths of stay (13 vs 15 days), and higher discharge FIM scores (88 vs 86); for-profit facilities had higher rates of community discharges (76.8% vs 74.6%) but also had higher rates of readmission (10.3% vs 9.9%). CONCLUSIONS: The finding that for-profit facilities admit older patients who are reportedly less functional on admission and more functional on discharge, with higher rates of community discharge but higher readmission rates than not-for-profit facilities is an unexpected and potentially anomalous finding. In general, older, less functional patients who stay for shorter periods of time would not necessarily be expected to make greater functional gains. These differences should be further studied to determine if differences in patient selection, coding and/or billing, or other unreported factors underlie these differences.

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.

Memory care reduces nursing home admissions among assisted-living residents with dementia.

INTRODUCTION: We compare nursing-home and hospital admissions among residents with Alzheimer's disease and related dementias (ADRD) in memory-care assisted living to those in general assisted living. METHODS: Retrospective study of Medicare beneficiaries with ADRD in large (>25 bed) assisted-living communities. We compared admission to a hospital, to a nursing home, and long-term (>90 day) admission to a nursing home between the two groups, using risk differences and survival analysis. RESULTS: Residents in memory-care assisted living had a lower adjusted risk of hospitalization (risk difference = -1.8 percentage points [P = .014], hazard ratio = 0.93 [0.87-1.00]), a lower risk of nursing-home admission (risk difference = -2.2 percentage points [P < .001], hazard ratio = 0.87 [-.79-0.95]), and a lower risk of a long-term nursing home admission (risk difference = -1.1 percentage points [P < .001], hazard ratio = 0.71 [0.57-0.88]). DISCUSSION: Memory care is associated with reduced rates of nursing-home placement, particularly long-term stays, compared to general assisted living.

Presymptomatic Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 Among Residents and Staff at a Skilled Nursing Facility: Results of Real-time Polymerase Chain Reaction and Serologic Testing.

High rates of asymptomatic coronavirus disease 2019 infection suggest benefits to routine testing in congregate care settings. Screening was undertaken in a single nursing facility without a known case of coronavirus disease 2019, demonstrating an 85% prevalence among residents and 37% among staff. Serology was not helpful in identifying infections.

Use of Telemedicine for Emergency Triage in an Independent Senior Living Community: Mixed Methods Study.

BACKGROUND: Older, chronically ill individuals in independent living communities are frequently transferred to the emergency department (ED) for acute issues that could be managed in lower-acuity settings. Triage via telemedicine could deter unnecessary ED transfers. OBJECTIVE: We examined the effectiveness of a telemedicine intervention for emergency triage in an independent living community. METHODS: In the intervention community, a 950-resident independent senior living community, when a resident called for help, emergency medical technician-trained staff could engage an emergency medicine physician via telemedicine to assist with management and triage. We compared trends in the proportion of calls resulting in transport to the ED (ie, primary outcome) in the intervention community to two control communities. Secondary outcomes were telemedicine use and posttransport disposition. Semistructured focus groups of residents and staff were conducted to examine attitudes toward the intervention. Qualitative data analysis used thematic analysis. RESULTS: Although the service was offered at no cost to residents, use was low and we found no evidence of fewer ED transfers. The key barrier to program use was resistance from frontline staff members, who did not view telemedicine triage as a valuable tool for emergency response, instead perceiving it as time-consuming and as undermining their independent judgment. CONCLUSIONS: Engagement of, and acceptance by, frontline providers is a key consideration in using telemedicine triage to reduce unnecessary ED transfers.

Association of Skilled Nursing Facility Participation in a Bundled Payment Model With Institutional Spending for Joint Replacement Surgery.

Importance: Medicare recently concluded a national voluntary payment demonstration, Bundled Payments for Care Improvement (BPCI) model 3, in which skilled nursing facilities (SNFs) assumed accountability for patients' Medicare spending for 90 days from initial SNF admission. There is little evidence on outcomes associated with this novel payment model. Objective: To evaluate the association of BPCI model 3 with spending, health care utilization, and patient outcomes for Medicare beneficiaries undergoing lower extremity joint replacement (LEJR). Design, Setting, and Participants: Observational difference-in-difference analysis using Medicare claims from 2013-2017 to evaluate the association of BPCI model 3 with outcomes for 80 648 patients undergoing LEJR. The preintervention period was from January 2013 through September 2013, which was 9 months prior to enrollment of the first BPCI cohort. The postintervention period extended from 3 months post-BPCI enrollment for each SNF through December 2017. BPCI SNFs were matched with control SNFs using propensity score matching on 2013 SNF characteristics. Exposures: Admission to a BPCI model 3-participating SNF. Main Outcomes and Measures: The primary outcome was institutional spending, a combination of postacute care and hospital Medicare-allowed payments. Additional outcomes included other categories of spending, changes in case mix, admission volume, home health use, length of stay, and hospital use within 90 days of SNF admission. Results: There were 448 BPCI SNFs with 18 870 LEJR episodes among 16 837 patients (mean [SD] age, 77.5 [9.4] years; 12 173 [72.3%] women) matched with 1958 control SNFs with 72 005 LEJR episodes among 63 811 patients (mean [SD] age, 77.6 [9.4] years; 46 072 [72.2%] women) in the preintervention and postintervention periods. Seventy-nine percent of matched BPCI SNFs were for-profit facilities, 85% were located in an urban area, and 85% were part of a larger corporate chain. There were no systematic changes in patient case mix or episode volume between BPCI-participating SNFs and controls during the program. Institutional spending decreased from $17 956 to $15 746 in BPCI SNFs and from $17 765 to $16 563 in matched controls, a differential decrease of 5.6% (-$1008 [95% CI, -$1603 to -$414]; P < .001). This decrease was related to a decline in SNF days per beneficiary (from 26.2 to 21.3 days in BPCI SNFs and from 26.3 to 23.4 days in matched controls; differential change, -2.0 days [95% CI, -2.9 to -1.1]). There was no significant change in mortality or 90-day readmissions. Conclusions and Relevance: Among Medicare patients undergoing lower extremity joint replacement from 2013-2017, the BPCI model 3 was significantly associated with a decrease in mean institutional spending on episodes initiated by admission to SNFs. Further research is needed to assess bundled payments in other clinical contexts.

Persistence and Drivers of High-Cost Status Among Dual-Eligible Medicare and Medicaid Beneficiaries: An Observational Study.

Background: Little is known about the persistence of high-cost status among dual-eligible Medicare and Medicaid beneficiaries, who account for a substantial proportion of expenditures in both programs. Objective: To determine what proportion of this population has persistently high costs. Design: Observational study. Setting: Medicare-Medicaid Linked Enrollee Analytic Data Source data for 2008 to 2010. Participants: 1 928 340 dual-eligible Medicare and Medicaid beneficiaries who were alive all 3 years. Measurements: Medicare and Medicaid payments for these beneficiaries were calculated for each year. Beneficiaries were categorized as high-cost for a given year if their spending was in the top 10% for that year. Differences in spending were then examined for those who were persistently high-cost (all 3 years) versus those who were transiently high-cost (2008 but not 2009 or 2010) and those who were non-high-cost in all 3 years. Results: In the first year, 192 835 patients were high-cost. More than half (54.8%) remained high-cost across all 3 years. These patients were younger than transiently high-cost patients, with fewer medical comorbidities and greater intellectual impairment. Persistently high-cost patients spent $161 224 per year compared with $86 333 per year for transiently high-cost patients and $22 352 per year for non-high-cost patients. Most of the spending among persistently high-cost patients (68.8%) was related to long-term care, and very little (<1%) was related to potentially preventable hospitalizations for ambulatory care-sensitive conditions. Limitation: Potential misclassification of preventable spending and lack of detailed clinical data in administrative claims. Conclusion: A substantial majority of high-cost dual-eligible beneficiaries had persistently high costs over 3 years, with most of the cost related to long-term care and very little related to potentially preventable hospitalizations. Primary Funding Source: Peterson Center on Healthcare.

A Methodology to Identify a Cohort of Medicare Beneficiaries Residing in Large Assisted Living Facilities Using Administrative Data.

BACKGROUND: Assisted living is a popular option for housing and long-term care. OBJECTIVE: To develop and test a methodology to identify Medicare beneficiaries residing in assisted living facilities (ALFs). RESEARCH DESIGN: We compiled a finder file of 9-digit ZIP codes representing large ALFs (25+ beds) by matching Outcome and Assessment Information Set (OASIS) assessments and Medicare Part B Claims to the Medicare enrollment records and addresses of 11,751 ALFs. Using this finder file, we identified 738,567 beneficiaries residing in validated ALF ZIP codes in 2007-2009. We compared characteristics of this cohort to those of ALF residents in the National Survey of Residential Care Facilities (n=3009), a sample of community-dwelling Medicare beneficiaries (n=33,025,690), and long-stay nursing home residents (n=1,287,572). DATA SOURCES: A national list of licensed ALFs, Medicare enrollment records, and administrative health care databases. RESULTS: The ALF cohort we identified had good construct validity based on their demographic characteristics, health, and health care utilization when compared with ALF residents in the National Survey of Residential Care Facilities, community-dwelling Medicare beneficiaries, and long-stay nursing home residents. CONCLUSIONS: Our finder file of 9-digit ZIP codes enables identification of ALF residents using administrative data. This approach will allow researchers to examine questions related to the quality of care, health care utilization, and outcomes of residents in this growing sector of long-term care.

Constructing a Measure of Private-pay Nursing Home Days.

BACKGROUND: Nursing home (NH) care is financed through multiple sources. Although Medicaid is the predominant payer for NH care, over 20% of residents pay out-of-pocket for their care. Despite this large percentage, an accepted measure of private-pay NH occupancy has not been established and little is known about the types of facilities and the long-term care markets that cater to this population. OBJECTIVES: To describe 2 novel measures of private-pay utilization in the NH setting, including the proportion of privately financed residents and resident days, and examine their construct validity. DESIGN: Retrospective descriptive analysis of US NHs in 2007-2009. MEASURES: We used Medicare claims, Medicare Enrollment records, and the Minimum Data Set to create measures of private-pay resident prevalence and proportion of privately financed NH days. We compared our estimates of private-pay utilization to payer data collected in the NH annual certification survey and evaluated the relationships of our measures with facility characteristics. RESULTS: Our measures of private-pay resident prevalence and private-pay days are highly correlated (r=0.83, P<0.001 and r=0.83, P<0.001, respectively) with the rate of "other payer" reported in the annual certification survey. We also observed a significantly higher proportion of private-pay residents and days in higher quality facilities. CONCLUSIONS: This new methodology provides estimates of private-pay resident prevalence and resident days. These measures were correlated with estimates using other data sources and validated against measures of facility quality. These data set the stage for additional work to examine questions related to NH payment, quality of care, and responses to changes in the long-term care market.

The Impact of Chain Standardization on Nursing Home Staffing.

BACKGROUND: Standardization in production is common in multientity chain organizations. Although chains are prominent in the nursing home sector, standardization in care has not been studied. One way nursing home chains may standardize is by controlling the level and mix of staffing in member homes. OBJECTIVES: To examine the extent to which standardization occurred in staffing, its relative presence across different types of chains, and whether facilities became more standardized following acquisition by a chain. RESEARCH DESIGN: We estimated predictors of the difference between facility and chain staffing using Generalized Estimating Equations with 2000-2010 data. SUBJECTS: This study included nursing homes nationally, excluding hospital-based homes and homes in Alaska, Hawaii, and the District of Columbia. MEASURES: Chain ownership was coded from text identifying chain names. Two nurse staffing measures were used: staff hours per resident day and staff mix. RESULTS: Very large for-profit chain nursing homes and large nonprofits had less variation in staff hours per resident day (P<0.001) but greater variation in staffing mix (P<0.001) compared with the chain average nationally. Large for-profit chains and medium nonprofit chains had greater dispersion on staff hours per resident day (P<0.001), while large nonprofit chains had greater dispersion in staffing mix (P<0.001). The difference between facility and chain staffing decreased over time. CONCLUSIONS: The largest chains (for-profit and nonprofit) had less staffing variation compared with national standards, suggesting they were best at implementing corporate practices. Following ownership changes, staffing converged towards chain averages over time, suggesting standardization takes time to implement.

Nursing Home Chain Affiliation and Its Impact on Specialty Service Designation for Alzheimer Disease.

Specialty care units (SCUs) in nursing homes (NHs) grew in popularity during the 1990s to attract residents while national policies and treatment paradigms changed. Alzheimer disease has consistently been the dominant form of SCU. This study explored the extent to which chain affiliation, which is common among NHs, affected SCU bed designation. Using data from the Online Survey Certification and Reporting (OSCAR) from 1996 through 2010 with 207 431 NH-year observations, we described trends and compared chain-affiliated NHs with independent NHs. Designation of beds for Alzheimer disease SCUs grew from 1996 to 2003 and then declined. At the peak, 19.6% of all NHs had at least one Alzheimer disease SCU bed. In general, chain affiliation promoted Alzheimer disease SCU bed designation across time, chain size, and NH profit status. During the period of largest growth from 1996 to 2003, the likelihood of designation of Alzheimer disease SCU beds was 1.55 percentage points higher among for-profit NHs affiliated with large chains than independent for-profit NHs ( P < .001) and remained 1.28 percentage points higher from 2004 to 2010. However, chain-affiliated NHs generally had a lower percentage of residents with dementia than independent NHs. For example, although for-profit NHs affiliated with large chains had more Alzheimer disease SCU beds, they had nearly 3% fewer residents with dementia than independent NHs ( P < .001). We conclude that organizational decisions to designate beds for Alzheimer disease SCUs may be related to marketing strategies to attract residents since adoption of Alzheimer disease SCUs has fluctuated over time, but did not appear driven by demand.