A vision of a rough shaven Wild West gunslinger comes to mind: a dirty-faced bandit who shoots up the floor under someone’s feet, just to see him jump.

Can we think of what’s happening to nursing homes at the hands of managed care companies any differently?

Now, a new study points out that decreasing lengths of stay (LOS), which are compelled largely by managed care and other group entities, are playing havoc with traditional long-term care operations. The pressure to create increasingly shorter lengths of stay has sometimes led providers to discharge patients prematurely.

In addition, charges are increasingly shifting to the individual beneficiary, and skilled nursing providers are incurring more non-reimbursable costs because they feel pressured to create more oversight positions.

In other words, beneficiaries pay more, providers pay more. Managed care companies breathe heavy and pick everyone else’s pocket, sometimes putting individuals at risk. There has been a huge flow of dollars out of skilled nursing as lengths of stay have sunk.

As Harvard researcher and MedPAC commissioner David Grabowski insightfully put it: “Post-acute care is the ATM of value-based healthcare. Everyone is trying to take money out of PAC.”

To soften the blow, providers have become creative, as researcher Denise A. Tyler, Ph.D., puts it. She and colleagues undertook the study “Challenges and Consequences of Reduced Skilled Nursing Facility Lengths of Stay.” They conducted 70 interviews with SNF administrators, admissions coordinators and directors of nursing.

Their findings revealed more complicated re-authorization processes, pressure to send patients home sooner (and weaker), greater caregiver stress, and a rise in non-reimbursable costs.

Providers, however, have used the added stress to form more creative patient tracking and follow-up programs. But even that has not been a 100% feel-good: There have been additional time, labor and related in soft costs.

Perhaps worst of all, the researchers’ candid interviews found providers admitting they have been avoiding certain patient populations altogether in order to be more profitable. The interviews are startling for their frankness and skepticism about how providers view the managed care vice grip.

Yes, there’s a big bandit in the room. With a really big gun.