Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay

Length of stay (LOS) among postacute care patients in skilled nursing facilities (SNFs) has been steadily decreasing for the past several years. Empirical studies on overall SNF LOS are scant because most studies focus on LOS for certain conditions or procedures (e.g., Haghverdian, Wright, and Schwarzkopf 2017). However, analysis of LOS data available at Brown University's LTCFocus website (www.ltcfocus.org) illustrates that SNF LOS has been dropping in recent years. These reductions have been due, in part, to Medicare policy changes and market based pressures, including the emergence of accountable care organizations (ACOs) and bundled payment and shared savings programs, as well as the growth of Medicare Advantage. However, little is known about how shorter LOS is affecting SNFs or their postacute care patients. Implementation of the Affordable Care Act (ACA) included several programs to improve care quality, increase efficiency, and reduce costs through value‐based payment models. In these programs, participating providers, including doctors, hospitals, and other health care organizations, join together voluntarily to provide coordinated care to their Medicare patients. These groups are reimbursed for episodes of care, payments are capitated and risk‐adjusted, and participating organizations share savings they achieve from their Medicare population (Centers for Medicare and Medicaid Services 2017). Because over 20% of Medicare patients who are hospitalized each year are discharged to postacute care (PAC; Tian 2016), many of the patients covered by these programs are cared for in SNFs. However, research has shown that a minority of ACOs, for example, actually include SNFs as full participants (Colla et al. 2016). This means that ACOs are relying on SNFs to provide better care at lower costs without including those SNFs in the shared savings or through contractual or other formal relationships. In the last several years, there has also been extraordinary growth in