influence Medicare discharges.
Skilled nursing providers may be discharging some Medicare patients prematurely just as their financial obligations change, a review of more than 4.5 million stays has found.
More patients were discharged on the last day of full Medicare coverage — Day 20 — than on days 19 or 21, researchers at the University of Pennsylvania’s Perelman School of Medicine learned. For most patients, a Medicare co-pay of more than $150 kicks in on Day 21 of a skilled nursing stay.
The team also found that patients discharged on Day 20 were more likely to be racial or ethnic minorities, live in lower socioeconomic status areas and have five or more comorbidities, versus those who left care on days 19 or 21.
“Our results suggest that SNFs are more likely to discharge economically vulnerable patients right before their copay kicks in,” lead author Paula Chatterjee, M.D., told McKnight’s. “It’s critically important to understand whether patients are involved in the decision about timing of discharge in relation to the copay.”
Chatterjee said the research didn’t make clear whether the SNF or the patients were more likely to initiate the discharge.
But in a statement to McKnight’s, David Gifford, M.D., senior vice president of quality and regulatory affairs for the American Health Care Association said the copay “often leads patients and families to request to go home because they can’t afford it.”
He said the copay, though collected under mandate from the Centers for Medicare & Medicaid Services, in no way affects the care provided.
But Chatterjee argued that both the perception of bad debt and the personal financial strain of the copay are likely to affect poor and vulnerable patients more than other patients.
“SNFs may be more likely to discharge patients with fewer financial resources to avoid bad debt from defaulted payments,” she said. “It could also be that these patients are more likely to ask to be discharged before the copay kicks in order to avoid Medicare’s high daily cost sharing.”
A next step would be to work with patients and patient advocates to better understand whether shared decision-making is taking place. The team also said payment models should balance payment structures with incentives to provide optimal patient care.
Chatterjee said it’s unclear what the health implications could be from earlier-than-necessary discharges, though she pointed to other recent research by her co-authors showing patients discharged directly home instead of to a SNF have higher readmission rates.
The findings were highlighted online in JAMA Internal Medicine this week.
