The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs

Abstract

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.

Risk Factors of Skilled Nursing Facility Admissions and the Interrelation With Hospitalization and Amount of Informal Caregiving Received

“…Race/ethnic disparities in SNF admissions may be explained by differences in access to and quality of care facilities, family structures, social networks, and caregiving. Studies showed that African American older adults are less likely to endorse assisted living facilities and SNF admissions31 and receive more assistance and support from their family 32,33. We found that non-Hispanic Whites evidenced a greater likelihood of receiving informal caregiving, whereas there was no difference in the amount of informal caregiving received.…”

“…Studies showed that African American older adults are less likely to endorse assisted living facilities and SNF admissions 31 and receive more assistance and support from their family. 32,33 We found that non-Hispanic Whites evidenced a greater likelihood of receiving informal caregiving, whereas there was no difference in the amount of informal caregiving received. We identified race/ethnic disparities in SNF admission even after accounting for socioeconomic measures, as well as concurrent outcomes of informal caregiving hours received and hospitalizations.…”

“…These factors may influence dual-eligible beneficiaries’ decision to seek care at SNF after a hospitalization. Furthermore, out-of-pocket payments have been shown to influence the length of SNFs stays 33. While out-of-pocket payments may not restrict dual-eligible beneficiaries, SNFs receive higher payments for patients with private insurances.…”

Age Structural Transitions and Copayment Policy Effectiveness: Evidence from Taiwan’s National Health Insurance System

“…Another strand of the literature, on the effect of user fee (consisting of copayment and cost-sharing) changes on healthcare utilization, applied a difference-in-differences (DID) regression model to evaluate the effect of user fees on the utilization of various healthcare services. In general, a negative association between user fees and healthcare utilization was found for inpatient care services [13][14][15], outpatient care services [14,[16][17][18][19][20][21][22], long-term care utilization [23,24], psychiatric care services [25,26], rehabilitation care services [27] and prescription drug usage [28][29][30].…”

“…In addition to hospitals, local clinics in Taiwan are built to deal with primary care. Over 80% of children (age < 15) receive their outpatient care from the local clinics, and the elderly (aged 65 and older) and youth (aged [15][16][17][18][19][20][21][22][23][24] contribute the largest (approximately 36.88-38.90%) and smallest shares (approximately 3.03-3.83%) of total outpatient care visits, respectively, to medical centers, regional hospitals, and district hospitals [2,5]. It is important to note that the reimbursement payments per outpatient visit to district hospitals (NT$ 1770 or about USD 59), regional hospitals (NT$ 2445 or about USD 82) and medical centers (NT$ 3261 or about USD 109) were 2.37-4.36 times higher than those made to local clinics (NT$ 748 or about USD 25) in 2016 [2].…”