Substantial changes in Medicare payment policies are occurring for post-acute care (PAC), which provides a bridge from the hospital to home for individuals who require medical and rehabilitation (i.e., physical, occupational, and speech therapy) services to transition successfully back to the community. Skilled nursing facilities (SNFs) and home health agencies (HHAs) account for almost 80% of PAC spending. Rapid growth in PAC spending has been driven largely by prior payment systems that incentivized therapy services. However, new payment models were implemented in October 2019 for SNFs and January 2020 for HHAs that attempt to address (a) the growth in spending and (b) the potential for misuse of therapy services. These new models remove incentives for therapy but do not include controls for quality (e.g., community discharge, readmissions). In response, PAC stakeholders have raised concerns that payment reform may differentially impact access to and quality of care for vulnerable populations (e.g., racial and ethnic minorities, dually-eligible, rural-residing) and diagnostic subgroups (e.g., dementia/Alzheimer?s, hip fracture) due to changing reimbursements. While the new models are intended to promote appropriate and efficient care, the actual impact of payment reform is unknown. We hypothesize that SNFs and HHAs will not respond uniformly to changing reimbursements and that the new payment models will adversely impact quality of care for some, but not all, patient populations. Therefore, our overarching goal is to evaluate the impact of payment reform overall and among vulnerable populations and diagnostic subgroups. Using a natural experiment design that capitalizes on the timing of payment reform and a mixed methods approach that uses rich qualitative data collected from SNF and HHA staff and patients, as well as extensive patient-level Medicare claims and assessment data, we will:
Aim 1 : Identify SNF and HHA organizational responses to payment reform by quantifying changes in therapy staffing and payer mix pre-post payment reform and qualitatively exploring stakeholder perspectives on organizational processes, barriers, and facilitators to providing high-quality care under the new models.
Aim 2 : Characterize access to SNF and HHA after hospital discharge and utilization of therapy within SNF/HHA pre-post-payment reform overall and for vulnerable populations and diagnostic subgroups.
Aim 3 : Quantify the association between therapy utilization and quality outcomes (e.g., functional change) pre-post payment reform overall and for vulnerable populations and diagnostic subgroups. Rigorous qualitative and quantitative methodologies will allow us to (a) evaluate whether payment reform has the intended result of incentivizing efficient care and (b) identify any unintended consequences related to disparities in access to care and compromised quality. Findings will address stakeholders? concerns and provide critical information to policymakers, providers, system leaders, and payers on the impact of payment reform on patient access and quality across patient populations, including the most vulnerable.

Public Health Relevance

Over 5 million older adults annually receive post-acute care services from skilled nursing facilities and home health agencies to facilitate the transition from the hospital back to the community. Stakeholders have raised concerns that upcoming Medicare payment reforms for skilled nursing facilities and home health agencies may have negative effects for some patient populations. The proposed study will provide critical information for policymakers, healthcare providers, and payers on the impact of these payment reforms on access to and quality of care overall and across vulnerable patient populations and diagnostic subgroups.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Research Project (R01)
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Health Services Organization and Delivery Study Section (HSOD)
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Bhattacharyya, Partha
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University of Pittsburgh
Other Health Professions
Sch Allied Health Professions
United States
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