Fewer Bonuses, More Penalties At Skilled Nursing Facilities Serving Vulnerable Populations

Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model

Importance

The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model.

Objective

To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients' social risk.

Design, Setting, and Participants

A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021.

Exposure

Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics.

Main Outcomes and Measures

Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization.

Results

Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001).

Conclusions

In the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.

Increasing illness severity of skilled nursing facility patients over time: Implications for readmission penalties

BACKGROUND

Current financial penalties for rehospitalization of skilled nursing facilities (SNFs) patients are based in part on the studies by Ouslander et al., 2011, and Mor et al., 2010, demonstrating that many SNF hospitalizations were avoidable. With increasing age, complex illness severity, and use of SNFs for subacute rehabilitation, readmission metrics and financial penalties based on previous data may be due for reevaluation.

METHODS

Retrospective electronic medical record (EMR) review of 21,591 admissions and discharges between 2010 and 2019 inclusive. Data extracted included demographics, LACE, Charlson comorbidity index (CCI), and simplified HOSPITAL score parameters. The scores were calculated for the study years from the extracted data. Patients readmitted to the hospital within 30 days were identified.

RESULTS

Mean yearly score of all three indices rose steadily: LACE score 10.76-12.04 (0.43 estimated annual increase, 95% CI [0.39, 0.46]), CCI 4.26-5.05 (0.31 estimated annual increase, 95% CI [0.27, 0.34]), and simplified HOSPITAL score 3.46-4.03 (0.21 estimated annual increase, 95% CI [0.18, 0.24]). The estimated probability of readmission across observed CCI scores ranged from 15.4% to 15.9%, 95% CI bounds (10.8%, 22.7%). The estimated probability of readmission across observed LACE scores ranged from 4.7% to 36.3%, 95% CI bounds (3.4%, 54.7%). The estimated probability of readmission across observed HOSPITAL scores ranged from 5.8% to 54.1%, 95% CI bounds (6.2%, 66.0%).

CONCLUSIONS AND IMPLICATIONS

The study confirms anecdotal experience that the illness acuity of patients admitted to SNFs increased progressively over time and was associated with an increased risk of 30-day readmissions to the hospital. Our study suggests that the use of clinically validated readmission risk assessment tools instead of the Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP) current risk adjustors may be a more accurate reflection of the current illness severity of a facility's patient population at the time of payment adjustment.

Skilled Nursing Facility Performance and Readmission Rates Under Value-Based Purchasing

IMPORTANCE

The new Medicare Skilled Nursing Facility Value-Based Purchasing program (SNF VBP) seeks to improve patient outcomes by awarding financial incentives or penalties based on 30-day hospital readmission rates. Skilled nursing facilities (SNFs) can avoid a penalty through low baseline readmission rates or improvement over time.

OBJECTIVE

To assess the baseline performance and improvement over time of SNFs in the SNF VBP program.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study examined readmission rates, financial penalties and incentives, and facility and patient characteristics associated with these outcomes at 14 959 US SNFs that received Medicare payments between January 1, 2015, and December 31, 2019.

MAIN OUTCOMES AND MEASURES

Outcomes were readmission rates and financial penalties by facility. The SNFs were classified as improvers in the analysis if they had better improvement scores than baseline scores under the program and achievers if they had higher baseline scores than improvement scores.

RESULTS

Of 14 959 SNFs studied, 1849 (12.3%) were assigned their improvement score as their performance score in the first year of the program. Of these, 1167 (63.1%) received a financial penalty, whereas 374 (20.2%) received a bonus. Only 52 facilities that performed poorly at baseline (0.3% of all SNFs and 0.7% of below-median performers) were able to improve enough to avoid a financial penalty, despite large improvements in readmission rates. Improver SNFs treated larger racial minority populations (mean [SD], 74.57% [23.42%] White in the improver group vs 79.15% [22.18%] in the achiever group) and were located in counties with larger minority populations (mean [SD], 15.48% [14.05%] Black in the improver group vs 11.57% [12.72%] Black in the achiever group). The most important predictors of improvement were related to SNF finances, such as operating margin (mean [SD], -0.74 [13.87]) and occupancy rates (mean [SD], 79.93 [14.81]).

CONCLUSIONS AND RELEVANCE

This cross-sectional study suggests that the SNF VBP program did not offer a viable path for nearly all low-performing SNFs to avoid financial penalties through improved readmission rates.

Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization

Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.

First Year of Skilled Nursing Facility Value-based Purchasing Program Penalizes Facilities With Poorer Financial Performance

BACKGROUND

The Skilled Nursing Facility Value-based Purchasing Program (SNF-VBP) incentivizes facilities to coordinate care, improve quality, and lower hospital readmissions. However, SNF-VBP may unintentionally punish facilities with lower profit margins struggling to invest resources to lower readmissions.

OBJECTIVE

The objective of this study was to estimate the SNF-VBP penalty amounts by skilled nursing facility (SNF) profit margin quintiles and examine whether facilities with lower profit margins are more likely to be penalized by SNF-VBP.

RESEARCH DESIGN

We combined the first round of SNF-VBP performance data with SNF profit margins and characteristics data. Our outcome variables included estimated penalty amount and a binary measure for whether facilities were penalized by the SNF-VBP. We categorized SNFs into 5 profit margin quintiles and examined the relationship between profit margins and SNF-VBP performance using descriptive and regression analysis.

RESULTS

The average profit margins for SNFs in the lowest profit margin quintile was -14.4% compared with the average profit margin of 11.1% for SNFs in the highest profit margin quintile. In adjusted regressions, SNFs in the lowest profit margin quintile had 17% higher odds of being penalized under SNF-VBP compared with facilities in the highest profit margin quintile. The average penalty for SNFs in the lowest profit margin quintile was $22,312.

CONCLUSIONS

SNFs in the lowest profit margins are more likely to be penalized by the SNF-VBP, and these losses can exacerbate quality problems in SNFs with lower quality. Alternative approaches to measuring and rewarding SNFs under SNF-VBP or programs to assist struggling SNFs is warranted, particularly considering the coronavirus disease 2019 pandemic, which requires resources for prevention and management.

Savings and outcomes under Medicare's bundled payments initiative for skilled nursing facilities

BACKGROUND

Model 3 of Medicare's Bundled Payments for Care Improvement (BPCI) was a voluntary alternative payment model that held participating skilled nursing facilities (SNFs) accountable for 90-day costs of care. Its overall impact on Medicare spending and clinical outcomes is unknown.

METHODS

Retrospective cohort study using Medicare claims from 2012 to 2017. We used an interrupted time-series design to compare participating vs matched control SNFs on total 90-day Medicare payments and payment components (initial SNF stay, readmissions, and outpatient/clinician), case mix (volume, proportion Medicaid, proportion black, number of comorbidities), and clinical outcomes (90-day readmission, mortality and healthy days at home, and length of initial SNF stay), overall and among key subgroups with frailty or dementia, for 47 of the 48 conditions in the program (excluding major lower extremity joint replacement).

RESULTS

Our sample included 1001 participating and 3873 matched control SNFs. At baseline, total Medicare institutional payments were increasing at BPCI SNFs at a rate of $121 per episode per quarter; during the intervention period, payments decreased at a rate of -$398/episode/quarter. Among controls, payments were stable in the baseline period (+$17/episode/quarter) but decreased at -$424/episode/quarter during the intervention period, yielding a nonsignificant difference in slope changes of -$79/episode/quarter (95% confidence interval [CI] -$188, $31, p = 0.16). However, among patients with frailty, spending declined by $620/episode/quarter in the BPCI group, compared with $330/episode/quarter in the non-BPCI group, for a difference in slope changes of -$289 (95% CI -$482, -$96, p = 0.003). There were no differences in the change in slopes in case selection or clinical outcomes overall or in any clinical subgroup.

CONCLUSIONS

SNF participation in BPCI was associated with no overall differential change in total Medicare payments per episode, case selection, or clinical outcomes. Exploratory analyses revealed a decrease in Medicare payments in patients with frailty that may warrant further study.

Addressing Systemic Racism in Nursing Homes: A Time for Action

Long-term services and supports for older persons in the United States are provided in a complex, racially segregated system, with striking racial disparities in access, process, and outcomes of care for residents, which have been magnified during the Coronavirus Disease 2019 pandemic. These disparities are in large measure the result of longstanding patterns of structural, interpersonal, and cultural racism in US society, which in aggregate represent an underpinning of systemic racism that permeates the long-term care system's organization, administration, regulations, and human services. Mechanisms underlying the role of systemic racism in producing the observed disparities are numerous. Long-term care is fundamentally tied to geography, thereby reflecting disparities associated with residential segregation. Additional foundational drivers include a fragmented payment system that advantages persons with financial resources, and reimbursement policies that systematically undervalue long-term care workers. Eliminating disparities in health outcomes in these settings will therefore require a comprehensive approach to eliminating the role of systemic racism in promoting racial disparities.

Black-White Disparities in Moves to Assisted Living and Nursing Homes Among Older Medicare Beneficiaries

OBJECTIVES

Investigate black-white disparities in older adults' moves to assisted living and nursing homes and draw from the Andersen Healthcare Utilization Model to test explanations for any disparities.

METHODS

Data are from a nationally representative sample of older community-dwelling Medicare beneficiaries from the 2015 (N = 5,212) National Health and Aging Trends Study (NHATS). We use stepwise multinomial logistic regression to examine black-white disparities in moves out of community housing to assisted living or a nursing home over 2 years, before and after adjusting for predisposing (age, gender), enabling (income, housing tenure, Medicaid, living arrangement) and need (activities of daily living [ADL] limitation, physical capacity, self-rated health, and dementia) factors.

RESULTS

Black older adults are less likely to move to assisted living and are more likely to move to a nursing home compared to white older adults. Black-white disparities in moves to nursing homes are explained by black-white differences in enabling and need factors, whereas black-white disparities in moves to assisted living remain even after adjusting for enabling and need factors.

DISCUSSION

Unmeasured factors related to systemic racism (e.g., residential racial segregation, racial discrimination) and/or black-white differences in care preferences might further explain black-white disparities in moves to assisted living and warrant further investigation.

Cancer Pain in Relation to Metropolitan Area Segregation and Nursing Home Racial and Ethnic Composition

OBJECTIVES

To estimate pain reporting among residents with cancer in relation to metropolitan area segregation and NH racial and ethnic composition.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

383,757 newly admitted black (B), Hispanic (H), or white (W) residents with cancer in 12,096 US NHs (2011-2013).

METHODS

Using the Minimum Data Set 3.0, pain in past 5 days was determined by self-report or use of pain management. The Theil entropy index, a measure of metropolitan area segregation, was categorized [high (up to 0.20), very high (0.20-0.30), or extreme (0.30-0.53)].

RESULTS

Pain prevalence decreased across segregation level (black: high = 77%, very high = 75%, extreme = 72%; Hispanic: high = 79%, very high = 77%, extreme = 70%; white: high = 80%, very high = 77%, extreme = 74%). In extremely segregated areas, all residents were less likely to have recorded pain [adjusted prevalence ratios: blacks, 4.6% less likely, 95% confidence interval (CI) 3.1%-6.1%; Hispanics, 6.9% less likely, 95% CI 4.2%-9.6%; whites, 7.4% less likely, 95% CI 6.5%-8.2%] than in the least segregated areas. At all segregation levels, pain was recorded more frequently for residents (black or white) in predominantly white (>80%) NHs than in mostly black (>50%) NHs or residents (Hispanic or white) in predominantly white NHs than mostly Hispanic (>50%) NHs.

CONCLUSIONS AND IMPLICATIONS

We observed decreased pain recording in metropolitan areas with greater racial and ethnic segregation. This may occur through the inequitable distribution of resources between NHs, resident-provider empathy, provider implicit bias, resident trust, and other factors.

Patients discharged from higher-quality skilled nursing facilities spend more days at home

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.