Hospital Ownership of a Postacute Care Facility Influences Discharge Destinations After Emergent Surgery

Abdelsattar, Zaid M.; Gonzalez, Andrew A.; Hendren, Samantha; Regenbogen, Scott E.; Wong, Sandra L.

doi:10.1097/sla.0000000000001498

Cited by 10 publications

(8 citation statements)

References 21 publications

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“…Our study found that health care networks with vertical integration of SNFs utilized SNFs at modestly higher rates, which extends prior work that found that hospital ownership of an SNF provided a 9% absolute contribution to the adjusted SNF utilization rate of 51% for patients undergoing emergency surgery. 17 Considering current trends to transform total hip arthroplasty into an outpatient procedure, 24 our findings could possibly be interpreted as overutilization. The current diagnosis-related group–based reimbursement system, which reimburses hospitals a fixed amount per procedure regardless of length of stay, incentivizes hospitals to limit length of stay and could result in patients being discharged to post–acute care settings such as SNFs to open hospitals beds and increase efficiency.…”

Section: Discussionmentioning

confidence: 90%

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Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending

et al. 2023

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ImportanceHealth care mergers and acquisitions have increased vertical integration of skilled nursing facilities (SNFs) in health care networks. While vertical integration may result in improved care coordination and quality, it may also lead to excess utilization, as SNFs are paid a per diem rate.ObjectiveTo determine the association of vertical integration of SNFs within hospital networks with SNF utilization, readmissions, and spending for Medicare beneficiaries undergoing elective hip replacement.Design, Setting, and ParticipantsThis cross-sectional study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals performing at least 10 elective hip replacements during the study period. Fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent elective hip replacement between January 1, 2016, and December 31, 2017, with continuous Medicare coverage for 3 months before and 6 months after surgery were included. Data were analyzed from February 2 to August 8, 2022.ExposuresTreatment at a hospital within a network that also owns at least 1 SNF based on the 2017 American Hospital Association survey.Main Outcomes and MeasuresRates of SNF utilization, 30-day readmissions, and price-standardized 30-day episode payments. Hierarchical multivariable logistic and linear regression clustered at hospitals was performed with adjusting for patient, hospital, and network characteristics.ResultsA total of 150 788 patients (61.4% women; mean [SD] age, 74.3 [6.4] years) underwent hip replacement. After risk adjustment, vertical SNF integration was associated with a higher rate of SNF utilization (21.7% [95% CI, 20.4%-23.0%] vs 19.7% [95% CI, 18.7%-20.7%]; adjusted odds ratio [aOR], 1.15 [95% CI, 1.03-1.29]; P = .01) and lower 30-day readmission rate (5.6% [95% CI, 5.4%-5.8%] vs 5.9% [95% CI, 5.7%-6.1%]; aOR, 0.94 [95% CI, 0.89-0.99]; P = .03). Despite higher SNF utilization, the total adjusted 30-day episode payments were slightly lower ($20 230 [95% CI, $20 035-$20 425] vs $20 487 [95% CI, $20 314-$20 660]; difference, −$275 [95% CI, −$15 to −$498]; P = .04) driven by lower postacute payments and shorter SNF length of stays. Adjusted readmission rates were particularly low for patients not sent to an SNF (3.6% [95% CI, 3.4%-3.7%]; P &lt; .001) but were significantly higher for patients with an SNF length of stay less than 5 days (41.3% [95% CI, 39.2%-43.3%]; P &lt; .001).Conclusions and RelevanceIn this cross-sectional study of Medicare beneficiaries undergoing elective hip replacements, vertical integration of SNFs in a hospital network was associated with higher rates of SNF utilization and lower rates of readmissions without evidence of higher overall episode payments. These findings support the purported value of integrating SNFs into hospital networks but also suggest that there is room for improving the postoperative care of patients in SNFs early in their stay.

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Section: Discussionmentioning

confidence: 90%

“… 15 , 16 However, networks that own SNFs may have a perverse financial incentive to overutilize SNFs. One study of patients undergoing emergency surgery 17 found that hospital ownership of SNFs was associated with higher rates of nonhome discharge, which included SNFs.…”

Section: Introductionmentioning

confidence: 99%

Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending

et al. 2023

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“…Prior work has suggested that hospital ownership of a PAC facility is a factor in their use. 13 However, another recent study showed that…”

Section: Discussionmentioning

confidence: 99%

“…8,12 Unfortunately, hospital use of PAC facilities remains highly variable, despite controlling for several patient-, clinical-, and hospital-level factors. 10,[13][14][15][16][17] Equity in discharge to a PAC facility is of critical importance in the trauma population, where individuals are commonly affected during their most productive years of life and where discharge to an inpatient rehabilitation facility (IRF) is associated with improved postinjury functional status, quality of life, and 1-year survival. 2,4,18 The importance of this benefit at the individual and population level is reflected in the Centers for Medicare & Medicaid Services "60% rule," which stipulates that IRFs must have at least 60% of patients with 1 of 13 primary diagnoses, of which 5 are injury-related (spinal cord injury, femur/hip fracture, brain injury, burns, and major multiple trauma).…”

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confidence: 99%

Hospital effects drive variation in access to inpatient rehabilitation after trauma

Lussiez

Montgomery

Sangji

et al. 2021

J Trauma Acute Care Surg

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BACKGROUND:Postacute care rehabilitation is critically important to recover after trauma, but many patients do not have access. A better understanding of the drivers behind inpatient rehabilitation facility (IRF) use has the potential for major cost-savings as well as higher-quality and more equitable patient care. We sought to quantify the variation in hospital rates of trauma patient discharge to inpatient rehabilitation and understand which factors (patient vs. injury vs. hospital level) contribute the most. METHODS:We performed a retrospective cohort study of 668,305 adult trauma patients admitted to 900 levels I to IV trauma centers between 2011 and 2015 using the National Trauma Data Bank. Participants were included if they met the following criteria: age >18 years, Injury Severity Score of ≥9, identifiable injury type, and who had one of the Centers for Medicare & Medicaid Services preferred diagnoses for inpatient rehabilitation under the "60% rule." RESULTS:The overall risk-and reliability-adjusted hospital rates of discharge to IRF averaged 18.8% in the nonelderly adult cohort (18-64 years old) and 23.4% in the older adult cohort (65 years or older). Despite controlling for all patient-, injury-, and hospital-level factors, hospital discharge of patients to IRF varied substantially between hospital quintiles and ranged from 9% to 30% in the nonelderly adult cohort and from 7% to 46% in the older adult cohort. Proportions of total variance ranged from 2.4% (patient insurance) to 12.1% (injury-level factors) in the nonelderly adult cohort and from 0.3% (patient-level factors) to 26.0% (unmeasured hospital-level factors) in the older adult cohort. CONCLUSION:Among a cohort of injured patients with diagnoses that are associated with significant rehabilitation needs, the hospital at which a patient receives their care may drive a patient's likelihood of recovering at an IRF just as much, if not more, than their clinical attributes.

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“…Anecdote and emerging evidence suggests that some hospitals have responded by pursuing strategies to increase their connections with SNFs, which may increase care coordination, improve quality and reduce costs. Hospitals may do this and influence discharge decisions 13 through formal channels, such as acquisition and ownership of SNFs. Hospitals may also pursue tighter connections with SNFs by developing informal relationships or “preferred networks”, in which SNFs receive greater discharge referral volume in exchange for working with hospitals to increase quality and reduce costs.…”

Section: Introductionmentioning

confidence: 99%

Trends in hospital-SNF relationships in the care of Medicare beneficiaries

2018

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Improving the value of post-acute care at skilled nursing facilities (SNFs) has become a Medicare policy priority. Anecdotally, hospitals have responded by formally acquiring or pursuing tighter informal connections with SNFs. We evaluated the trend in connections between US acute care hospitals and Medicare-certified SNFs between 2000 and 2013 using vertical integration and two novel network-based measures (number of SNF partners, and discharge concentration). Among 4441 hospitals and 17,215 SNFs, hospitals with weaker connections with SNFs were more often non-profit, major teaching hospitals with a larger number of discharges and beds. We found an apparent weakening of hospital-SNF connections over time for all three measures. Over one-third (39%) of hospitals were vertically integrated in 2000 compared to 8.2% in 2013. The number of SNF partners increased between 2000 and 2013, while hospitals' discharge concentration declined steadily. Additional work is needed to understand the implications of these trends.

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Hospital Ownership of a Postacute Care Facility Influences Discharge Destinations After Emergent Surgery

Cited by 10 publications

References 21 publications

Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending

Association of Skilled Nursing Facility Ownership by Health Care Networks With Utilization and Spending

Hospital effects drive variation in access to inpatient rehabilitation after trauma

Trends in hospital-SNF relationships in the care of Medicare beneficiaries

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