Professional Documents
Culture Documents
Introduction
THERE IS BROAD INTEREST in improving resulting in greater functional and cognitive important role. Specific state and nursing
the quality and efficiency of the health care impairment for patients.5 facility characteristics – such as higher
system in the United States. Policymakers Nursing facilities are the dominant Medicaid payments and more generous
are increasingly focused on the rate of provider of Medicare post-acute care nurse staffing – also have significant
rehospitalizations as an area for potential services, and they represent an impor- impacts on rehospitalization. Although
improvement.1,2 An estimated one-fifth of tant element of any strategy to reduce some causes of rehospitalization are
Medicare beneficiaries who are discharged rehospitalizations. A more detailed not well understood, the research done
from the hospital are readmitted within 30 exploration of rehospitalizations from to date suggests that efforts to reduce
days. Ninety percent of those admissions nursing facilities suggests the issue is reshopitalizations will have the greatest
are unplanned, and they cost Medicare an complex and driven by the interplay of impact if they reach beyond the Medicare
estimated $17.4 billion in 2004.3,4 In addi- several factors. Rehospitalization rates program and consider nursing facilities’
tion to their cost, rehospitalizations appear vary substantially by region, implying broader operating and reimbursement
to increase the risk of health complications, that local practice norms may play an environment.
ALMOST ONE-FIFTH of Medicare 30 years. The rehospitalization rate 22.5 percent during the 1976-1978
beneficiaries are readmitted within 30 for fee-for-service Medicare beneficiaries period to 31.1 percent in the 2003–2004
days of discharge from a hospital, and within 60 days of discharge rose from period.9
this rate is increasing over time. There
are a number of ways to calculate
rehospitalization rates, but estimates The rate of Medicare rehospitalization has increased over
range from about 17.6 percent to the last 3 decades.
19.6 percent for Medicare beneficiaries
Figure 1: Rehospitalization Rate within 60 Days of Hospital Discharge, 1976–78 versus 2003–04.
within 30 days of discharge.6,7 The
share of Medicare beneficiaries who
Rehospitalization Rate
40%
are rehospitalized within 90 days of 31.1%
30% 22.5%
discharge is even greater, at 34 percent.8
20%
Rehospitalizations have become
10%
much more common over the past
0%
1976 to 1978 2003 to 2004
Source: Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee-For-Service Program.
New England Journal of Medicine, 360(14). 2 April 2009.
CARE CONTEXT TRENDS IN REHOSPITALIZATIONS FROM SKILLED NURSING FACILITIES
SEVERAL FACTORS MAY PLAY A ROLE in Medicare reimburses each provider Hospitals and other providers also lack
causing higher rates of rehospitalization. for the individual services furnished to financial incentives to invest in processes
The Centers for Medicare & Medicaid its patients. As a result, discharging that would reduce rehospitalization rates.
Services (CMS) uses a prospective pay- and admitting facilities are often focused Medicare does not explicitly reimburse for
ment system that pays hospitals a fixed on their individual treatment of patients services that may reduce rehospitaliza-
fee for each type of case, providing a instead of working together to treat tions, such as follow-up calls and other
powerful incentive for hospitals to reduce a patient over the course of an entire care management services. In addition,
costs and length of stay.10 In some cases, episode of illness. Insufficient coordina- rehospitalizations usually mean higher rev-
efforts by hospitals to transition patients tion and communication between the enues for hospitals – there is no financial
more quickly to post-acute care or back into discharging hospital and the community penalty for the rehospitalization because
the community may increase the risk of physician or post-acute care setting Medicare pays hospitals for both the initial
rehospitalization.11,12 can lead to a whole host of problems, stay and the rehospitalization, as long as
The fragmented nature of the including poor medication adherence, the rehospitalization occurs more than
health care system also contributes lack of a follow-up visit from the physi- 24 hours after the initial discharge.17 Both
to rehospitalizations as there can be cian, and inadequate understanding the House and the Senate health reform
insufficient communication and of the warning signs of a worsening bills would reduce Medicare hospital
continuity between settings of care. condition. 13,14,15,16 payments for certain rehospitalizations.
REDUCING THE RATE of rehospitalization serious risk with an estimated 1.7 million facility residents return from the hospital
is important for several reasons. First, HAIs occurring in hospitals each year.21 with other complications, such as new
rehospitalizations are costly. One study In addition to infections, many nursing pressure ulcers.22
estimated that the cost of unplanned
rehospitalizations within 30 days of
hospital discharge accounted for $17.4
Unplanned rehospitalizations represent 17 percent of total
billion of the $102.6 billion in total
Medicare inpatient hospital spending.
Medicare inpatient payments to hospitals
in 2004.18 The $17.4 billion figure includes Figure 2: Unplanned Rehospitalizations as a Share of Total Inpatient Hospital
only unplanned rehospitalizations; the Spending, 2004.
study found that 10 percent of rehospital- Total Hospital Spending: $102.6 Billion
izations were a planned part of a patient’s
course of treatment and did not include Unplanned rehospitalizations
spending, $17.4 billion
them in its estimate.19
Recent research indicates that a sig-
nificant share of unplanned rehospitaliza-
Other hospital spending,
tions are preventable. MedPAC estimates $85.2 billion
that the cost of potentially preventable
hospital readmissions within 30 days of
discharge alone is $12 billion.20
A return trip to the hospital also
increases the risk that a patient will expe- Source: Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee-For-Service
Program. New England Journal of Medicine, 360(14). 2 April 2009.
rience a health complication. Healthcare
associated infections (HAI) represent a
2
JANUARY 2010
Rehospitalizations expose nursing greater functional and cognitive higher risk of developing complications,
facility residents to possible treatment- impairment.23 Those nursing facility such as delirium, when hospitalized.24
related complications, which can lead to residents with dementia have an even
As the Dominant Provider of Medicare Post-Acute Care Services, Nursing Facilities are an
Important Element of any Strategy to Reduce Rehospitalizations
22%
20%
18.2%
18%
CONSIDER
16%
14%
12%
In 2004, Medicare spent an
2000 2001 2002 2003 2004 2005 2006
estimated $17.4 billion on
unplanned rehospitalizations Source: Vincent Mor et al. The Revolving Door of Rehospitalization from Skilled Nursing Facilities, Health Affairs.
January 2010.
3
CARE CONTEXT TRENDS IN REHOSPITALIZATIONS FROM SKILLED NURSING FACILITIES
Hospitalization Rates for Long-Stay Residents Have Increased Along With Rehospitalization
Rates of Short-Stay Residents
NURSING FACILITIES CARE for two medical conditions and limitations hospitalization rate for long-stay nursing
distinct patient populations – short-stay in activities of daily living (ADLs) or facility residents by state increased from
patients who are recuperating following instrumental activities of daily living 18.9 percent in 2000 to 20.9 percent in
an acute episode and long-stay residents (IADLs), and may, in some instances, 2004, an increase of almost 11 percent.32
with complex medical needs. Short-stay be cognitively impaired.31 Care for Studies suggest that some portion of
patients receive intensive medical long-stay patients is funded principally nursing home-to-hospital transfers are
or therapeutic care and rehabilitative through Medicaid or individual and unnecessary because the conditions
services following a hospitalization, and family expenditures. for which the patient was admitted could
their services are generally covered As rates of Medicare rehospitalizations have been safely treated in the nursing
by Medicare or private payers.29,30 have increased, so have hospitalizations facility.33
Long-stay patients often have complex of long-stay patients. The average
IN CONTEXT F
or most states, there is a positive correlation between nursing facility
rehospitalization and hospitalization rates – states with high rates of rehospitalization
tend to have high rates of hospitalization for long-stay residents.
4
JANUARY 2010
CONSIDER
AZ NM AR
GA 16.1% – 18.9%
AL
LA
TX 19.0% – 24.9%
FL
Local areas that tend to AK N
o information
available
use more Medicare services HI
generally are also more
likely to hospitalize nursing Source: Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of States’ Medicaid Payment
facility residents and Bed-Hold Policies. Health Services Research. 2008.
suggesting local areas that tend to use Source: Vincent Mor and David Grabowski. Understanding Skilled Nursing Facility Re-Hospitalizations:
more Medicare services generally are Variation by Patient Type and Region. 2008.
5
CARE CONTEXT TRENDS IN REHOSPITALIZATIONS FROM SKILLED NURSING FACILITIES
Targeted Care Models Can Reduce Rehospitalizations and Health Care Costs
Enhanced Staffing and Higher Medicaid Payments Contribute to Lower Nursing Facility
Hospitalization and Rehospitalization Rates
WITHIN THE NURSING FACILITY SETTING, More generous nurse staffing levels recommended 4.55 hours per resident
higher staffing levels and more generous also appear to significantly lower rates of day and higher proportions of registered
Medicaid payment rates also have a hospitalization. Nurse staffing beyond the nurses to total nurses in a facility have
measurable impact on hospitalization
and rehospitalization.45 The two factors
are interrelated since higher Medicaid
payment rates are associated with more
As Medicaid rates increase, nursing levels rise.
staffing, suggesting that nursing facilities Figure 9: Mean Number of Nurses per 100 Residents, by Medicaid Rate.
staff at higher levels where Medicaid
payments support them.46,47 Medicaid Rate Registered Licensed Practical Nurses’
Staffing characteristics, such as the Nurses (RNs) Nurses (LPNs) Assistants
availability of nurse practitioners (NPs) $65 6.45 13.27 40.73
and physician assistants (PAs) in nursing $75 6.81 13.72 41.86
facilities, appears to significantly reduce $85 7.17 14.16 42.99
rates of initial hospital admissions and $95 7.53 14.60 44.10
rehospitalizations.48,49 NPs and PAs allow $105 7.89 15.04 45.21
some conditions that would otherwise Source: Grabowski, David C. Does an Increase in the Medicaid Reimbursement Rate Improve Nursing
require hospital admission to be managed Home Quality? The Journals of Gerontology. March 2001.
6
JANUARY 2010
been shown to be effective at reducing in Medicaid payments bring additional risk A bed-hold policy reserves a nursing
hospital admissions.51 Overall, rates of of hospitalization.54 facility resident’s bed for a specified period
hospitalization are lower in facilities that Varying Medicaid payment rates to of time while the resident is hospitalized.
have higher nurse aide and licensed staff nursing facilities based on case mix also Nursing facility residents in states with
levels and high staff retention rates.52 appears to reduce rates of hospitalization. bed-hold policies have a 36 percent higher
Higher Medicaid nursing facility Patients in states that adjusted payments frequency of hospitalization than residents
payment rates are also associated with for case mix were 12 percent less likely to in states without them.56 It is not known
lower odds of hospitalization. A $10 be hospitalized than patients in states that if the lower prevalence of hospitalization
increase in the daily Medicaid payment relied on uniform payment rates.55 reflects more appropriate utilization or
rate above the state average, for example, On the other hand, one factor that some patients’ refusal to obtain necessary
is associated with a 5 percent lower odds appears to increase hospitalization rates is medical treatment because they fear
of hospitalization.53 Conversely, reductions the existence of state bed-hold policies. losing their bed.57
FOR NURSING FACILITIES in particular, Medicare beneficiaries but 31 percent of such as the use of bundled payments, are
policies aimed at reducing rehospitaliza- total Medicare spending.58 unlikely to affect rates of hospitalization
tion must consider the complex interplay Although Medicare and Medicaid for long-stay patients. The challenge in any
between Medicare and Medicaid. More cover many of the same beneficiaries, Federal policy effort, therefore, is ensuring
than 88 percent of people in nursing they have conflicting incentives because that costs are not simply transferred
facilities at any point in time are over age saving money in one program may shift from one program to the other.59 Some
65. Since nearly all people over 65 are costs to the other program without saving researchers suggest that combining
covered by Medicare, the vast majority much money overall. Although higher Medicare and Medicaid payments into a
of Medicaid-covered residents in nursing Medicaid payments contribute to reduced single capitated rate or making the federal
facilities are dually eligible. Medicare typi- hospitalizations, State Medicaid programs government completely responsible for
cally covers acute care services, including have little financial incentive to increase providing long-term care to dual eligibles
hospitalizations and post-acute care, while payments because the resulting savings are worth exploring because they would
Medicaid pays for long-term care in the accrue mainly to the Medicare program promote greater coordination and align
nursing facility and Medicare cost sharing. (in the form of reduced spending for acute incentives to reduce hospitalizations
Dual eligibles are disproportionately care episodes) rather than to Medicaid. across payers and patients.60,61
costly, accounting for 19 percent of total Conversely, Medicare-only proposals,
Key Considerations
Rehospitalizations occur in every post- this setting could have a dramatic impact rehospitalization, should policy
acute care setting, including the home. on the rate of rehospitalizations and proposals give states an incentive to
Efforts to address this issue must take into hospitalizations. Key considerations for maintain adequate Medicaid rates?
consideration the complex factors that policymakers include: • How does regional variation and cor-
cause rehospitalizations. Policymakers • Do current Medicare proposals to relation of nursing facility rehospitaliza-
must also consider the unique challenges reduce rehospitalizations promote tions with other Medicare expenditures
that nursing facilities face as the dominant interventions, such as coordinated inform future policy development?
provider of post-acute care, the site of care models, higher Medicaid rates, • Given the interaction of multiple providers
care that is most dramatically affected or enhanced staffing that would lead and settings of care in rehospitalizations,
by conflicting Medicare and Medicaid to lower rates of hospitalization or should policy development focus on
financial incentives, and a care setting rehospitalization? promoting system-wide coordination
where the frailest population resides for
• Given the relationship between through, for example, providing support
longer stretches of time. Policy focused on
Medicaid funding, staffing, and for electronic health record adoption?
7
CARE CONTEXT TRENDS IN REHOSPITALIZATIONS FROM SKILLED NURSING FACILITIES
ENDNOTES
1 National Quality Forum, Candidate Hospital Care Additional Priorities: 2007 34 Vincent Mor et al. The Revolving Door of Rehospitalization. Health Affairs. January/
Performance Measure. Washington DC, 2007. February 2010.
2 Application of Incentives to Reduce Avoidable Readmissions to Hospitals. Federal 35 Mor, Vincent, and David C. Grabowski. Understanding Skilled Nursing Facility
Register 2008; 73(84):23673-5. Rehospitalizations: Variation by Patient Type and Region. December 2008.
3 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater 36 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
Efficiency in Medicare. June 2007. States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
4 Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee- August 2007.
For-Service Program, 360(14). New England Journal of Medicine. 2 April 2009. 37 Mor, Vincent et al. Changes in the Quality of Nursing Homes in the US: A Review
5 Ouslander, J.G., A.D. Weinberg, and V. Philips. Inappropriate Hospitalization of and Data Update. 15 August 2009.
Nursing Facility Residents: A Symptom of a Sick System of Care for Frail Older 38 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
People. Journal of American Geriatric Society, 48(2). 2000. States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
6 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater August 2007.
Efficiency in Medicare. June 2007. 39 Mor, Vincent, and David C. Grabowski. Understanding Skilled Nursing Facility
7 Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee- Rehospitalizations: Variation by Patient Type and Region. December 2008.
For-Service Program, 360(14). New England Journal of Medicine. 2 April 2009. 40 Vincent Mor et al. The Revolving Door of Rehospitalization. Health Affairs. January/
8 Ibid. February 2010.
9 Ibid. 41 Peikes D, Chen A, Schore J, and Brown R. Effects of Care Coordination on
10 Michael Morrisey et al. Shifting Medicare Patients out of the Hospital. Health Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare
Affairs. Winter 1988. Beneficiaries: 15 Randomized Trials. JAMA 2009; 301:603-618.
11 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater 42 Eric A. Coleman et al. The Care Transitions Intervention. Archives of Internal
Efficiency in Medicare. June 2007. Medicine, 166(17). September 2006.
12 Vincent Mor et al. Changes in the Quality of Nursing Homes in the US: A Review 43 Ibid.
and Data Update. 15 August 2009. 44 Ibid.
13 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater 45 Bruce Leff et al. Guided Care and the Cost of Complex Healthcare: A Preliminary
Efficiency in Medicare. June 2007. Report. The American Journal of Managed Care, 15(8). August 2009.
14 Vincent Mor et al. Changes in the Quality of Nursing Homes in the US: A Review 46 David C. Grabowski. Medicare and Medicaid: Conflicting Incentives for Long-Term
and Data Update. 15 August 2009. Care. The Milibank Quarterly, 85(4). December 2007.
15 Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee- 47 Grabowski, David C. Does an Increase in the Medicaid Reimbursement Rate
For-Service Program, 360(14). New England Journal of Medicine. 2 April 2009. Improve Nursing Home Quality? The Journals of Gerontology. March 2001.
16 Coleman, Eric A et al. The Care Transitions Intervention. Archives of Internal 48 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
Medicine, 166(17). September 2006. States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
17 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater August 2007.
Efficiency in Medicare. June 2007. 49 Robert L. Kane et al. The Effect of Evercare on Hospital Use. Journal of the
18 Stephen F. Jencks et al. Rehospitalizations Among Patients in the Medicare Fee- American Geriatrics Society, 51:10. 23 September 2003.
For-Service Program, 360(14). New England Journal of Medicine. 2 April 2009. 50 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
19 Ibid. States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
20 Medicare Payment Advisory Commission. Report to Congress: Promoting Greater August 2007.
Efficiency in Medicare. June 2007. 51 Robert L. Kane et al. The Effect of Evercare on Hospital Use. Journal of the
21 R. Monina Klevens et al. Estimating Health Care-Associated Infections and Deaths American Geriatrics Society, 51:10. 23 September 2003.
in U.S. Hospitals, 2002. Public Health Reports, 22. March-April 2007. 52 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
22 D.D. Tresch et al. Relationship of Long-Term and Acute-Care Facilities: The Problem States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
of Patient Transfer and Continuity of Care. Journal of the American Geriatrics August 2007.
Society, 33. 1985. 53 Kramer, A.M., and R. Fish. The Relationship between Nurse Staffing Levels and
23 Ouslander, J.G., A.D. Weinberg, and V. Philips. Inappropriate Hospitalization of the Quality of Nursing Home Care. Centers for Medicare and Medicaid Services.
Nursing Facility Residents: A Symptom of a Sick System of Care for Frail Older In ABT Associates, Appropriateness of Minimum Nurse Staffing Ratios in Nursing
People. Journal of American Geriatric Society, 48(2). 2000. Homes: Phase II final report, December 2001.
24 Cunningham, A.C. Supporting People with Dementia in Acute Hospital Settings. 54 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
Nursing Standard, 20. 2006. States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
August 2007.
25 Vincent Mor et al. The Revolving Door of Rehospitalization from Skilled Nursing
Facilities, Health Affairs. January 2010. 55 Ibid.
26 Avalere analysis of 2006 Medicare 100 Percent Standard Analytic File (SAF) 56 Intrator, Orna, and Vincent Mor. Effect of State Medicaid Reimbursement Rates on
claims data vase from the Centers for Medicare & Medicaid Services (CMS). Hospitalizations from Nursing Homes. Journal of the American Geriatrics Society,
52(3). March 2004.
27 Vincent Mor et al. The Revolving Door of Rehospitalization. Health Affairs. January/
February 2010. 57 Orna Intrator et al. Hospitalization of Nursing Home Residents: The Effects of
States’ Medicaid Payment and Bed-Hold Policies. Health Services Research, 42(4).
28 Ibid.
August 2007.
29 Alecxih, Lisa. Nursing Home Use by Oldest Old Sharply Declines. Presented at
58 Ibid.
National Press Club, November 21, 2006.
59 Coughlin, Teresa, Timothy Waidmann, and Molly O’Malley Watts. Where Does
30 Medicare Payment Advisory Commission. Report to the Congress: Medicare
the Burden Lie? Medicaid and Medicare Spending for Dual Eligible Beneficiaries,
Payment Policy, March 2009.
Kaiser Commission on the Uninsured, April 2009.
31 Alecxih, Lisa. Nursing Home Use by Oldest Old Sharply Declines. Presented at
National Press Club, November 21, 2006. 60 Grabowski, David C., A. James O’Malley, and Nancy R. Barhydt. The Costs And
Potential Savings Associated with Nursing Home Hospitalizations, Health Affairs,
32 Mor, Vincent, and David C. Grabowski. Understanding Skilled Nursing Facility
November/December 2007.
Rehospitalizations: Variation by Patient Type and Region. December 2008.
33 Grabowski, David, A. James O’Malley, and Nancy R. Barhydt. The Costs and 61 Grabowski, David C. Medicare and Medicaid: Conflicting Incentives for Long-Term
Potential Savings Associated with Nursing Home Hospitalizations. Health Affairs Care. The Milibank Quarterly, 85(4). December 2007.
26(6). November/December 2007. 62 Vincent Mor et al. The Revolving Door of Rehospitalization from Skilled Nursing
Facilities, Health Affairs. January/February 2010.
Care Context is produced by the Alliance for Quality Nursing Home Care with research and analytic support by Avalere Health.