Abstract
Objectives
In October 2019, the Centers for Medicare & Medicaid Services (CMS) implemented a
new payment model for skilled nursing facilities (SNFs) that eliminated financial
incentives to provide high-intensity therapy. Yet high-intensity therapy in SNFs has
been linked to better quality outcomes, potentially putting patients at risk if clinically
indicated therapy is reduced under the new payment model. A metric to help differentiate
between financially motivated vs clinically indicated therapy in SNFs is thresholding:
the percentage of patients receiving therapy within 10 minutes of reimbursement thresholds.
This study examined which SNF characteristics are associated with thresholding and
how thresholding relates to quality outcomes.
Design
Secondary analysis of 2016 CMS administrative data.
Setting and Participants
14,162 SNFs.
Methods
SNF Public Use Files, Nursing Home Compare, and Provider of Services files were linked.
We used linear regression models to (1) identify SNF characteristics associated with
thresholding and (2) determine associations between thresholding and quality outcomes,
controlling for SNF and patient characteristics.
Results
Thresholding was 6.4 percentage points [95% confidence interval (CI) 5.4, 7.4] higher
in SNFs with all contractor therapy staff vs all in-house staff. Compared with nonprofit
SNFs, thresholding was 2.5 (95% CI 0.1, 2.9) and 1.6 (95% CI 0.4, 2.9) percentage
points higher in governmental and for-profit SNFs, respectively. For each additional
therapist per 1000 patient-days, SNFs had 2.9 (95% CI –3.4, −2.4) percentage points
lower thresholding. Higher thresholding was significantly associated with worse quality
outcomes, including lower rates of functional improvement and community discharge
and higher rates of 30-day admissions, but magnitudes were small.
Conclusions and Implications
SNFs with higher thresholding behavior may respond to changes in financial incentives
under the new payment model by reducing clinically indicated therapy and should be
monitored to ensure access to necessary therapy is maintained. Although thresholding
behavior may indicate cost-intensive therapy practice, it may not have clinically
significant implications for patients.
Keywords
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References
- Skilled nursing facility services. Report to the congress: Medicare payment policy.(2019. Available at:)http://www.medpac.gov/-documents-/reports#Date accessed: August 3, 2019
- Medicare program: prospective payment system and consolidated billing for Skilled Nursing Facilities (SNF) final rule.Fed Regist. 2018; 83: 39162-39290
- Skilled Nursing Facilities Patient-Driven Payment Model: Technical Report.(2018. Available at:)https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/PDPM_Technical_Report_508.pdfDate accessed: May 29, 2020
- Medicare fee-for-service post-acute care and hospice provider utilization and payment public use files: Methodological overview.(2019. Available at:) (Accessed November 11, 2019)
- Skilled nursing facility services payment system: Payment basics.(2018. Available at:)http://medpac.gov/docs/default-source/payment-basics/medpac_payment_basics_19_snf_final_sec.pdf?sfvrsn=0Date accessed: May 30, 2019
- Questionable Billing by Skilled Nursing Facilities. December. Office of the Inspector General, Department of Health and Human Services,
2010 (OEI-02-09-00202. Available at:)https://oig.hhs.gov/oei/reports/oei-02-09-00202.pdfDate accessed: March 23, 2019
- Inappropriate payments to skilled nursing facilities cost medicare more than a billion dollars in 2009.(2012. Available at:)https://oig.hhs.gov/oei/reports/oei-02-09-00200.aspDate accessed: February 1, 2019
- The Medicare payment system for skilled nursing facilities needs to be reevaluated.2015 (OEI-02-13-00610)
- Effectiveness of multidisciplinary rehabilitation services in postacute care: State-of-the-science. A review.Arch Phys Med Rehabil. 2007; 88: 1526-1534
- Outcomes of rehabilitation services for nursing home residents.Arch Phys Med Rehabil. 2003; 84: 1129-1136
- Association between therapy intensity and discharge outcomes in aged medicare skilled nursing facilities admissions.Arch Phys Med Rehabil. 2018; 99: 107-115
- The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities.Arch Phys Med Rehabil. 2005; 86: 373-379
- Rehabilitation in skilled nursing facilities: Effect of nursing staff level and therapy intensity on outcomes.Am J Phys Med Rehabil. 2004; 83: 704-712
- Does more therapy in skilled nursing facilities lead to better outcomes in patients with hip fracture?.Phys Ther. 2016; 96: 81-89
- Skilled Nursing Facility Quality Reporting Program (SNF QRP): Requirements for the fiscal year (FY) 2018 reporting year.(2016. Available at:)
- Trends in post-acute care use among medicare beneficiaries: 2000 to 2015.JAMA. 2018; 319: 1616-1617
- Design for Nursing Home Compare five-star quality rating system: Technical users’ guide.(2019. Available at:)
- MDS 3.0 quality measures user’s manual.(2017. Available at:)
- Nursing Home Compare quality measure technical specifications final.(2016. Available at:) (Accessed September 12, 2019)
- Skilled Nursing Facility Quality Reporting Program measure calculations and reporting user’s manual.(2018. Available at:)
- Home health agency characteristics and quality outcomes for Medicare beneficiaries with rehabilitation-sensitive conditions.Arch Phys Med Rehabil. 2018; 99: 1090-1098.e4
- Medicare Fee-For-Service Skilled Nursing Facility Utilization & Payment Public Use File: A Methodological Overview.(2018. Available at:)
- Report to congress: Risk adjustment in medicare advantage.(2018. Available at:)https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/RTC-Dec2018.pdfDate accessed: July 17, 2019
- Observations on therapy utilization trends.(2014. Available at:)https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Therapy_Trends_Memo_04212014.pdfDate accessed: February 13, 2019
- Medicare prospective payment and the volume and intensity of skilled nursing facility services.J Health Econ. 2011; 30: 675-684
- The impact of the prospective payment system for skilled nursing facilities on therapy service provision: A transaction cost approach.Health Serv Res. 2003; 36: 1467-1485
- The relationship between quality of care, physical therapy, and occupational therapy staffing levels in nursing homes in 4 years’ follow-up.J Am Med Dir Assoc. 2019; 20: 462-469
- Quality of care in nursing homes: An analysis of relationships among profit, quality, and ownership.Med Care. 2003; 41: 1318-1330
- Financial performance, employee well-being, and client well-being in for-profit and not-for-profit nursing homes: A systematic review.Health Care Manage Rev. 2017; 42: 352-368
- Effect of nursing home ownership on the quality of post-acute care: An instrumental variables approach.J Health Econ. 2013; 32: 12-21
- The five-star skilled nursing facility rating system and care of disadvantaged populations.J Am Geriatr Soc. 2019; 67: 108-114
- Separate and unequal: Racial segregation and disparities in quality across U.S. nursing homes.Health Aff. 2007; 26: 1448-1458
- Factors predicting rehospitalization of elderly patients in a postacute skilled nursing facility rehabilitation program.Arch Phys Med Rehabil. 2012; 93: 1808-1813
- Restarting the cycle: Incidence and predictors of first acute care use after nursing home discharge.J Am Geriatr Soc. 2014; 62: 79-85
- Functional status is associated with 30-day potentially preventable readmissions following skilled nursing facility discharge among medicare beneficiaries.J Am Med Dir Assoc. 2018; 19: 348-354.e4
- Thirty-day hospital readmission following discharge from postacute rehabilitation in fee-for-service medicare patients.JAMA. 2014; 311: 604-614
Article info
Publication history
Published online: June 06, 2020
Footnotes
The authors declare no conflicts of interest.
Identification
Copyright
© 2020 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
