Post-acute referral patterns for hospitals and implications for bundled payment initiatives

Emulating Three Clinical Trials that Compare Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities

OBJECTIVE

To inform the design of a potential future randomized controlled trial, we emulated three trials where patient-level outcomes were compared following stroke rehabilitation at Inpatient Rehabilitation Facilities (IRFs) to Skilled Nursing Facilities (SNFs).

DESIGN

Trials were emulated using a 1:1 matched propensity score analysis. The three trials differed as facilities from rehabilitation networks with different case-volumes were compared. Rehabilitation network case-volumes were based on the number of stroke patients that each hospital discharged to each specific IRF or SNF. Trial 1 included 60,529 patients from all networks, trial 2 included 34,444 patients from networks with medium- and large case-volumes (i.e., ≥5 patients), trial 3 included 19,161 patients from networks with large case-volumes (i.e., ≥10 patients). E-values were calculated to estimate the minimum strength that an unmeasured confounder would need to be to nullify the results.

SETTING

A national sample of IRFs and SNFs from across the United States.

PARTICIPANTS

Acute Fee-for-service Medicare stroke patients who received IRF or SNF based rehabilitation.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

1-year successful community discharge (home for >30 consecutive days) and all-cause mortality.

RESULTS

Overall, 29,500, 15,156, and 7,450 patients were matched for trials 1, 2 and 3. For 1-year successful community discharge, absolute risk differences for IRF patients were 0.21 (95% CI: 0.20, 0.22), 0.17 (95% CI: 0.16, 0.19), and 0.12 (95% CI: 0.10, 0.14) in trials 1, 2 and 3, respectively. For 1-year all-cause mortality, corresponding risk differences were -0.11 (95% CI: -0.12, -0.11), -0.11 (95% CI: -0.12, -0.09), and -0.08 (95% CI: -0.10, -0.06). E-values indicated that a moderately sized unmeasured confounder, with a relative risk of 1.6 to 2.0 would nullify differences in successful community discharge.

CONCLUSION(S)

IRF patients had superior outcomes, but differences were attenuated when IRFs and SNFs from larger rehabilitation networks were compared. The vulnerability of the findings to unmeasured confounding supports the need for an RCT.

Rationale for a Clinical Trial That Compares Acute Stroke Rehabilitation at Inpatient Rehabilitation Facilities to Skilled Nursing Facilities: Challenges and Opportunities

In the United States, approximately 400,000 patients with acute stroke are discharged annually to inpatient rehabilitation facilities (IRFs) or skilled nursing facilities (SNFs). Typically, IRFs provide time-intensive therapy for an average of 2-3 weeks, whereas SNFs provide more moderately intensive therapy for 4-5 weeks. The factors that influence discharge to an IRF or SNF are multifactorial and poorly understood. The complexity of these factors in combination with subjective clinical indications contributes to large variations in the use of IRFs and SNFs. This has significant financial implications for health care expenditure, given that stroke rehabilitation at IRFs costs approximately double that at SNFs. To control health care spending without compromising outcomes, the Institute of Medicine has stated that policy reforms that promote more efficient use of IRFs and SNFs are critically needed. A major barrier to the formulation of such policies is the highly variable and low-quality evidence for the comparative effectiveness of IRF- vs SNF-based stroke rehabilitation. The current evidence is limited by the inability of observational data to control for residual confounding, which contributes to substantial uncertainty around any magnitude of benefit for IRF- vs SNF-based care. Furthermore, it is unclear which specific patients would receive the most benefit from each setting. A randomized controlled trial addresses these issues, because random treatment allocation facilitates an equitable distribution of measured and unmeasured confounders. We discuss several measurement, practical, and ethical issues of a trial and provide our rationale for design suggestions that overcome some of these issues.

Geographic location of buprenorphine-waivered physicians and integration with health systems

Efforts are underway to expand buprenorphine treatment for opioid use disorder (OUD) in hospitals and affiliated health systems, yet we do not know whether physicians who prescribe buprenorphine are likely to be health-system affiliated. Our study draws upon SK&A data covering primary care physicians and psychiatrists in eight states (California, Florida, Georgia, Maryland, Ohio, Rhode Island, Wisconsin, and West Virginia), which were linked to a list of waivered buprenorphine prescribers from the U.S. Drug Enforcement Agency. We calculated waivered rates stratified by patient limits, physician type, health system affiliation, and area-level characteristics. We mapped the spatial relationship between hospitals and waivered physicians in four metro areas. We found that primary care physicians affiliated with hospital health systems were less likely to have waivers than unaffiliated physicians (3.6% versus 8.2%), but the reverse was true for psychiatrists (33.2% versus 26.2%). Waivered physicians affiliated with health systems were less likely to practice in high-poverty areas than unaffiliated counterparts, and affiliated physicians were also more likely to cluster near hospitals. Health systems may be able to improve access to buprenorphine treatment in their communities by creating either incentives or mandates for more affiliated physicians to obtain a waiver.

What Are the Uses and Limitations of Time-driven Activity-based Costing in Total Joint Replacement?

BACKGROUND

With increasing emphasis on value-based payment models for primary total joint arthroplasty (TJA), there is greater need for orthopaedic surgeons and hospitals to better understand the actual costs and resource use of TJA. Time-driven activity-based costing (TDABC) is a methodology for accurate cost estimation, but its application in the TJA care pathway across institutions/regions has not yet been analyzed.

QUESTIONS/PURPOSES

In this systematic review of studies applying TDABC to primary TJA, we investigated the following: (1) Is there variation in TDABC methodology and cost estimates across institutions? (2) Is a standard set of direct and indirect costs included across studies? (3) Is there a difference in cost estimates derived from TDABC and traditional hospital cost-accounting approaches? and (4) How are institutions using TDABC (process and outputs) with respect to the TJA care pathway?

METHODS

A comprehensive search strategy was developed that included the keywords "TDABC," "time-driven activity-based cost," "THA," "TKA," "THR," "TKR," and "TJR" in the PubMed/MEDLINE, EMBASE, Web of Science, Ovid SP, Scopus, and ScienceDirect databases for articles published between 2004 and 2018 as well as extensive hand searching and citation mining. Relevant studies (n = 15) were screened to include THA or TKA as the focus of the TDABC model, full-text articles, TDABC-based cost estimates for TJA, and studies written in English (n = 8). Due to the heterogeneity of outcomes/methodology in TDABC studies involving TJA, quality assessment was based on each study's adherence to the seven steps delineated by Kaplan et al. in their original publication introducing TDABC in health care.

RESULTS

There was substantial variation in TDABC methodology (especially in scope), adherence to the seven steps of TDABC, and data collection. Only five of eight studies incorporated indirect costs into their TDABC calculation, with notable differences in which direct and indirect expenses were included. TDABC-based cost estimates for TJA ranged from USD 7081 to USD 29,557, with variation driven by the TJA timeframe and whether implant costs were included in the costing calculation. TDABC was most frequently used to compare against traditional hospital accounting methods (n = 4), to increase operational efficiency (n = 4), to reduce wasted resources (n = 3), and to mitigate risk (n = 3).

CONCLUSIONS

TDABC-based cost estimates are more granular and useful in practice than those calculated via traditional hospital accounting; however, there is a lack of standardized principles to guide TDABC implementation (especially for indirect costs) due to institutional and regional differences in TDABC application. Although TDABC methodology will likely continue to vary somewhat between studies, standardized principles are needed to guide the definition, estimation, and reporting of costs to enable detailed examination of study methodology and inputs by readers.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

Medicare's bundled payment model did not change skilled nursing facility discharge patterns

OBJECTIVES

To evaluate whether participation in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) model was associated with changes in discharge referral patterns to skilled nursing facilities (SNFs), specifically number of SNF partners and discharge concentration.

STUDY DESIGN

Retrospective observational study using difference-in-differences analysis.

METHODS

We used Medicare claims data from 2010 to 2015 to identify admissions for lower joint replacement surgery and the following medical conditions: congestive heart failure, renal failure, sepsis, pneumonia, urinary tract and kidney infections, chronic obstructive pulmonary disease, and stroke. We used difference-in-differences analyses to assess changes in discharge patterns among BPCI-participating hospitals compared with matched control hospitals.

RESULTS

Our analytic sample included 3078 acute care hospitals and 14,866 Medicare-certified SNFs in the United States, encompassing more than 47 million hospital discharges. Of these hospitals, 416 participated in BPCI, with the majority selecting into joint replacement episodes (n = 295). BPCI participation was not associated with any change in number of SNF partners (increase by 0.8 SNFs among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -0.2 to 1.9; P = .11) or in discharge concentration (increase in Herfindahl-Hirschman Index of 0.2 among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -68.7 to 69.1; P = .36). Results did not vary across clinical conditions and were robust across duration of BPCI participation and with different comparison groups.

CONCLUSIONS

Hospital participation in BPCI was not associated with changes in the number of SNF partners or in discharge concentration relative to non-BPCI hospitals. More research is needed to understand how hospitals are responding to bundled payment incentives and specific practices that contribute to improvements in cost and quality.

Skilled Nursing Facility Placement Process After Total Hip and Total Knee Arthroplasty: Revised Rating System and Opportunities for Intervention

BACKGROUND

With the advent of bundled payment models, identifying high-performing skilled nursing facilities (SNFs) has become increasingly important. The goal of this study is to develop a rating system to rank SNFs within our health system and to use this system to improve the SNF discharge process at our institution.

METHODS

All SNF-discharged primary total joint arthroplasty cases in 2017 at a multi-hospital academic health system were queried. Discharge patterns were assessed using heat map analysis. Regression analyses in conjunction with structured discussions with subject matter experts were used to identify measures of SNF efficiency and care quality. A revised rating system was developed and used to identify high-performing facilities within our health system. Opportunities to re-direct patients to higher performing facilities were identified.

RESULTS

A revised rating system for SNFs was constructed based on risk-adjusted SNF length of stay, 30-day re-admission rate, and 30-day emergency department visit rate. As 82% of patients were discharged to SNFs in close proximity to their home, high-performing SNFs (according to the revised rating system) were identified by geographic region. Mapping of the discharge process revealed multiple opportunities where patients could be re-directed to a higher performing SNF in their area. Using conservative estimates (25% of discharges re-directed), this is expected to achieve a cost saving of $2,600,000 over a 5-year period, mainly through reductions in SNF length of stay.

CONCLUSION

This study describes the development of a revised rating system for SNFs which, when implemented, is expected to achieve substantial cost savings over a 5-year period.

Hospitals Using Bundled Payment Report Reducing Skilled Nursing Facility Use And Improving Care Integration

A goal of Medicare's bundled payment models is to improve quality and control costs after hospital discharge. Little is known about how participating hospitals are focusing their efforts to achieve these objectives, particularly around the use of skilled nursing facilities (SNFs). To understand hospitals' approaches, we conducted semistructured interviews with an executive or administrator in each of twenty-two hospitals and health systems participating in Medicare's Comprehensive Care for Joint Replacement model or its Bundled Payments for Care Improvement initiative for lower extremity joint replacement episodes. We identified two major organizational responses. One principal strategy was to reduce SNF referrals, using risk-stratification tools, patient education, home care supports, and linkages with home health agencies to facilitate discharges to home. Another was to enhance integration with SNFs: fifteen hospitals or health systems in our sample had formed networks of preferred SNFs to exert influence over SNF quality and costs. Common coordination strategies included sharing access to electronic medical records, embedding providers across facilities, hiring dedicated care coordination staff, and creating platforms for data sharing. As hospitals presumably move toward home-based care and more selective SNF referrals, more evidence is needed to understand how these discharge practices affect the quality of care and patient outcomes.

What Characteristics Influence Whether Rural Beneficiaries Receiving Care From Urban Hospitals Return Home for Skilled Nursing Care?

PURPOSE

Skilled nursing care (SNC) provides Medicare beneficiaries short-term rehabilitation from an acute event. The purpose of this study is to assess beneficiary, market, and hospital factors associated with beneficiaries receiving care near home.

METHODS

The population includes Medicare beneficiaries who live in a rural area and received acute care from an urban facility in 2013. "Near home" was defined 3 different ways based on distances from the beneficiary's home to the nearest source of SNC. Results include unadjusted means and odds ratios from logistic regression.

FINDINGS

About 69% of rural beneficiaries receiving acute care in an urban location returned near home for SNC. Beneficiaries returning home were white (odds ratio [OR] black: 0.69; other race: 0.79); male (OR: 1.07); older (OR age 85+ [vs 65-69]: 1.14); farther from SNC (OR: 1.01 per mile); closer to acute care (OR: 0.28, logged miles); and received acute care from hospitals that did not own a skilled nursing facility (owned OR: 0.77) and hospitals with: no swing bed (swing bed OR: 0.47), high case mix (OR: 3.04), and nonprofit status (for-profit OR: 0.85). Results varied somewhat across definitions of "near home."

CONCLUSIONS

Rural Medicare beneficiaries who received acute care far from home were more likely to receive SNC far from home. Because Medicare beneficiaries have the choice of where to receive SNC, policy makers may consider ensuring that new payment models do not incentivize provision of SNC away from home.

Are Medicare's Nursing Home Compare Ratings Accurate Predictors of 90-Day Complications, Readmission, and Bundle Cost for Patients Undergoing Primary Total Joint Arthroplasty?

BACKGROUND

Nursing Home Compare (NHC) ratings, created and maintained by Medicare, are used by both hospitals and consumers to aid in the skilled nursing facility (SNF) selection process. To date, no studies have linked NHC ratings to actual episode-based outcomes. The purpose of this study was to evaluate whether NHC ratings are valid predictors of 90-day complications, readmission, and bundle costs for patients discharged to an SNF after primary total joint arthroplasty (TJA).

METHODS

All SNF-discharged primary TJA cases in 2017 at a multihospital academic health system were queried. Demographic, psychosocial, and clinical variables were manually extracted from the health record. Medicare NHC ratings were then collected for each SNF. For patients in the Medicare bundle, postacute and total bundle cost was extracted from claims.

RESULTS

Four hundred eighty-eight patients were discharged to a total of 105 unique SNFs. In multivariate analysis, overall NHC rating was not predictive of 90-day readmission/major complications, >75th percentile postacute cost, or 90-day bundle cost exceeding the target price. SNF health inspection and quality measure ratings were also not predictive of 90-day readmission/major complications or bundle performance. A higher SNF staffing rating was independently associated with a decreased odds for >75th percentile 90-day postacute spend (odds ratio, 0.58; P = .01) and a 90-day bundle cost exceeding the target price (odds ratio = 0.69; P = .02) but was similarly not predictive of 90-day readmission/complications.

CONCLUSION

Results of our study suggest that Medicare's NHC tool is not a useful predictor of 90-day costs, complications, or readmissions for SNFs within our health system.

Do Skilled Nursing Facilities Selected to Participate in Preferred Provider Networks Have Higher Quality and Lower Costs?

OBJECTIVE

To determine whether skilled nursing facilities (SNFs) chosen by health systems to participate in preferred provider networks exhibited differences in quality, costs, and patient outcomes relative to other SNFs after accounting for differences in case mix.

DATA SOURCES

Medicare provider and claims data, 2012 and 2013.

STUDY DESIGN

We compared SNFs included in preferred networks relative to other SNFs in the same market, prior to the establishment of preferred provider networks.

DATA EXTRACTION METHODS

We linked the SNFs in our sample to facility characteristics and quality data. We identified SNF admissions and hospitalizations in claims data and limited the analysis to patients discharged from the hospitals in our sample. We obtained patient characteristics from Medicare summary files and the preceding hospital stay.

PRINCIPAL FINDINGS

Preferred SNFs exhibited better performance across publicly reported quality measures. Patients admitted to preferred SNFs exhibited shorter stays, lower Medicare payments, and lower probability of SNF readmission relative to nonpreferred SNFs.

CONCLUSIONS

Our results imply that health systems selected SNFs with lower resource use and better performance on quality measures. Thus, the trend toward preferred provider networks could have implications for Medicare spending and patient health.

Hospital Postacute Care Referral Networks: Is Referral Concentration Associated with Medicare-Style Bundled Payments?

OBJECTIVE

To evaluate whether Medicare-style bundled payments are lower or higher for beneficiaries discharged from hospitals with postacute care (PAC) referrals concentrated among fewer PAC providers.

DATA SOURCE

Medicare Part A and Part B claim (2008-2012) for all beneficiaries residing in any of 17 market areas: the Provider of Service file, the Healthcare Cost Report Information System, and the Dartmouth Atlas.

STUDY DESIGN

An observational study in which hospitals were distinguished according to PAC referral concentration, which is the tendency to utilize fewer rather than more PAC providers. We tested the hypothesis that higher referral concentration would be associated with total Medicare bundled payments.

DATA COLLECTION/EXTRACTION METHODS

The data represent a convenience sample of market areas that were defined by the locations of grantees from the ONC Beacon Community Program.

PRINCIPAL FINDINGS

The four most-used PAC providers accounted for an average of 60 percent of patients discharged from hospitals in the sample. Regression analysis suggested that higher referral concentration was associated with lower Medicare costs per bundle.

CONCLUSIONS

Hospitals that tend to use fewer PAC providers may lead to lower costs for payers such as Medicare. The study results reinforce the importance of limited networks for PAC services under bundling arrangements for hospital and PAC payments.

Skilled Nursing Facility Care for Patients With Heart Failure: Can We Make It "Heart Failure Ready?"

Skilled nursing facilities (SNFs) have emerged as an integral component of care for older adults with heart failure (HF). Despite their prominent role, poor clinical outcomes for the medically complex patients with HF managed in SNFs are common. Barriers to providing quality care include poor transitional care during hospital-to-SNF and SNF-to-community discharges, lack of HF training among SNF staff, and a lack of a standardized care process among SNF facilities. Although no evidence-based practice standards have been established, various measures and tools designed to improve HF management in SNFs are being investigated. In this review, we discuss the challenges of HF care in SNFs as well as potential targets and recommendations that can help improve care with respect to transitions, HF management within SNFs, and modifiable factors within facilities. Policy considerations that might help catalyze improvements in SNF-based HF management are also discussed.