May 28, 2019
By Lisa Rapaport
(Reuters Health) - Skilled nursing facilities in the U.S. often discharge Medicare patients before daily co-payments kick in, according to a new U.S. study that suggests some patients may be sent home for financial reasons before they're medically ready to leave.
Medicare, the U.S. health program for the elderly and disabled, pays the entire bill for post-hospital care provided by skilled nursing facilities for the first 20 days within a benefit period, researchers noted may 28 online in JAMA Internal Medicine. After that, most patients become responsible for a daily co-payment of more than $150.
To see how the start of co-payments might impact discharge timing, researchers examined data on more than 4.5 million skilled nursing facility discharges from January 2012 through November 2016.
Overall, a total of 220,037 patients were discharged on day 20, more than the 131,558 sent home on day 19 and the 121,339 released on day 21. Compared to patients discharged on days 19 or 21, those sent home on day 20 were more likely to suffer from multiple chronic medical conditions, live in poor neighborhoods, and be racial or ethnic minorities, the study found.
"Our results suggest that skilled nursing facilities are more likely to discharge economically vulnerable patients right before their copay kicks in," lead study author Dr. Paula Chatterjee of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia said by email.
On day 20, for example, 12.5 percent of patients discharged were black or Hispanic, compared with 8.2 percent one day earlier and 7.5 percent one day later, the study found.
And on day 20, 15.2 percent of patients discharged were living in poverty and 7.7 percent were unemployed. These economically vulnerable patients represented a smaller proportion of those discharged one day earlier or later.
Most patients in the study had one or more chronic medical problems like asthma or diabetes or heart disease.
On day 20, however, 42.2 percent of discharges were patients with at least five different chronic health problems, compared with 39.9 percent on day 19 and 40.6 percent on day 21.
The study wasn't a controlled experiment designed to prove whether or how discharge timing might impact patient health.
While day 20 may have been too soon for some patients to go home, it's also possible that some people remained in skilled nursing facilities through day 20 even though they were ready to leave sooner, said Dr. Kumar Dharmarajan, chief scientific officer of Clover Health and a researcher at Yale School of Medicine in New Haven, Connecticut.
"In some cases, it is likely that these individuals should have been discharged earlier, but that the financial incentive to skilled nursing facilities to retain these patients won out," Dharmarajan, who wasn't involved in the study, said by email. "Unnecessarily long stays in a facility can likewise increase complications including falls and infections."
At the same time, patients more likely to be discharged on day 20 tended to fit the profile of patients who have had higher rates of hospital use and repeat hospitalizations in other studies, said Dr. Jennifer Goldstein of the Christiana Care Health and Sidney Kimmel Medical College in Philadelphia.
"Those characteristics include male sex, African American race, Hispanic ethnicity, low-income demographics and a high burden of disease," Goldstein, who wasn't involved in the study, said by email.
One limitation of the analysis is that it focused just on people with fee-for-service Medicare who didn't have other types of insurance, the study authors note. Many Medicare enrollees get supplemental insurance or sign up for coverage through private health plans or Medicaid.
Still, the results "raise concerns that patients are forgoing needed medical care because of ability to pay, and/or that skilled nursing facilities are selectively discharging such patients out of concern patients will not be able to afford the copay," said Dr. Ann Sheehy of the University of Wisconsin School of Medicine and Public Health in Madison.
"If financial reasons, as opposed to medical readiness, drive skilled nursing facility discharge, this could negatively impact health and safety for the most vulnerable Medicare beneficiaries," Sheehy, who wasn't involved in the study, said by email.
JAMA Intern Med 2019.
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