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The Patient Driven Payment Model (PDPM) was implemented in U.S. skilled nursing facilities (SNFs) in October 2019, shortly before COVID-19. This new payment model aimed to reimburse SNFs for patients' nursing needs rather than the previous model which reimbursed based on the volume of therapy received. Through 156 semi-structured interviews with 40 SNF administrators from July 2020 to December 2021, this qualitative study clarifies the impact of COVID-19 on the administration of PDPM at SNFs. Interview data were analyzed using modified grounded theory and thematic analysis. Our findings show that SNF administrators shifted focus from management of the PDPM to COVID-19-related delivery of care adaptations, staff shortfalls, and decreased admissions. As the pandemic abated, administrators re-focused their attention to PDPM. Policy makers should consider the continued impacts of the pandemic at SNFs, particularly on delivery of care, admissions, and staffing, on the ability of SNF administrators to administer a new payment model. [ABSTRACT FROM AUTHOR]

Objective: The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high‐volume preferred skilled nursing facility (SNF) partners. Data Sources: The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017–2019. Study Design: We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics. Data Collection: Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019. Principal Findings: Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital‐SNF relationship, and (c) comparing patients with more versus less advanced ADRD. Conclusions: Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high‐volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems). [ABSTRACT FROM AUTHOR]

The 2003 Medicare Modernization Act (MMA) increased payments to Medicare Advantage plans and instituted a new risk-adjustment payment model to reduce plans' incentives to enroll healthier Medicare beneficiaries and avoid those with higher costs. Whether the MMA reduced risk selection remains debatable. This study uses mortality differences, nursing home utilization, and switch rates to assess whether the MMA successfully decreased risk selection from 2000 to 2012. We found no decrease in the mortality difference or adjusted difference in nursing home use between plan beneficiaries pre- and post the MMA. Among beneficiaries with nursing home use, disenrollment from Medicare Advantage plans declined from 20% to 12%, but it remained 6 times higher than the switch rate from traditional Medicare to Medicare Advantage. These findings suggest that the MMA was not associated with reductions in favorable risk selection, as measured by mortality, nursing home use, and switch rates. [ABSTRACT FROM AUTHOR]

Over the past two decades, nursing homes and home health care agencies have been influenced by several Medicare and Medicaid policy changes including the adoption of prospective payment for Medicare-paid postacute care and Medicaid-paid long-term home and community-based care reforms. This article examines how spending growth in these sectors was affected by state certificate-of-need (CON) laws, which were designed to limit the growth of providers and have remained unchanged for several decades. Compared with states without CON laws, Medicare and Medicaid spending in states with CON laws grew faster for nursing home care and more slowly for home health care. In particular, we observed the slowest growth in community-based care in states with CON for both the nursing home and home health industries. Thus, controlling for other factors, public postacute and long-term care expenditures in CON states have become dominated by nursing homes. [ABSTRACT FROM AUTHOR]

In this paper, we examine the contributions of travel distance and preferences for racial homogeneity as sources of nursing home segregation and racial disparities in nursing home quality. We first theoretically characterize the distinctive implications of these mechanisms for nursing home racial segregation. We then use this model to structure an empirical analysis of nursing home sorting. We find little evidence of differential willingness to pay for quality by race among first-time nursing home entrants, but do find significant distance and race-based preference effects. Simulation exercises suggest that both effects contribute importantly to racial disparities in nursing home quality. [ABSTRACT FROM AUTHOR]

Background Dual eligibles, persons who qualify for both Medicare and Medicaid coverage, often receive poorer quality care relative to other Medicare beneficiaries. Objectives To determine whether dual eligibles are discharged to lower quality post-acute skilled nursing facilities ( SNFs) compared with Medicare-only beneficiaries. Research Design Following the random utility maximization model, we specified a discharge function using a conditional logit model and tested how this discharge rule varied by dual-eligibility status. Subjects A total of 692,875 Medicare fee-for-service patients (22% duals) who were discharged for Medicare paid SNF care between July 2004 and June 2005. Measures Medicare enrollment and the Medicaid Analytic Extract files were used to determine dual eligibility. The proportion of Medicaid patients and nursing staff characteristics provided measures of SNF quality. Results Duals are more likely to be discharged to SNFs with a higher share of Medicaid patients and fewer nurses. These results are robust to estimation with an alternative subsample of patients based on primary diagnoses, propensity of being dual eligible, and likelihood of remaining in the nursing home. Conclusions Disparities exist in access to quality SNF care for duals. Strategies to improve discharge planning processes are required to redirect patients to higher quality providers, regardless of Medicaid eligibility. [ABSTRACT FROM AUTHOR]

Hospitalizations among nursing home residents are frequent, expensive, and often associated with further deterioration of resident condition. The literature indicates that a substantial fraction of admissions is potentially preventable and that nonprofit nursing homes are less likely to hospitalize their residents. However, the correlation between ownership and hospitalization might reflect unobserved resident differences rather than a causal relationship. Using national minimum data set assessments linked with Medicare claims, we use a national cohort of long-stay residents who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for ownership status, we found that IV estimates of the effect of nonprofit ownership on hospitalization are at least as large as the non-instrumented effects, indicating that selection bias does not explain the observed relationship. We also found evidence suggesting the lower rate of hospitalizations among nonprofits was due to a different threshold for transfer. [ABSTRACT FROM AUTHOR]

Objective To estimate the effect of a nursing home's share of residents with a serious mental illness ( SMI) on the quality of care. Data Sources Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims. Study Design We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects. Principal Findings An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non- SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents. Conclusions Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight. [ABSTRACT FROM AUTHOR]

Report cards on provider performance are intended to improve consumer decision-making and address information gaps in the market for quality. However, inadequate risk adjustment of report-card measures often biases comparisons across providers. We test whether going to a skilled nursing facility (SNF) with a higher star rating leads to better quality outcomes for a patient. We exploit variation over time in the distance from a patient's residential ZIP code to SNFs with different ratings to estimate the causal effect of admission to a higher-rated SNF on health care outcomes, including mortality. We found that patients who go to higher-rated SNFs achieved better outcomes, supporting the validity of the SNF report card ratings. [ABSTRACT FROM AUTHOR]

Abstract: Given the preferential tax treatment afforded nonprofit firms, policymakers and researchers have been interested in whether the nonprofit sector provides higher nursing home quality relative to its for-profit counterpart. However, differential selection into for-profits and nonprofits can lead to biased estimates of the effect of ownership form. By using “differential distance” to the nearest nonprofit nursing home relative to the nearest for-profit nursing home, we mimic randomization of residents into more or less “exposure” to nonprofit homes when estimating the effects of ownership on quality of care. Using national Minimum Data Set assessments linked with Medicare claims, we use a national cohort of post-acute patients who were newly admitted to nursing homes within an 18-month period spanning January 1, 2004 and June 30, 2005. After instrumenting for ownership status, we found that post-acute patients in nonprofit facilities had fewer 30-day hospitalizations and greater improvement in mobility, pain, and functioning. [Copyright &y& Elsevier]