THE EFFECT OF MEDICAID RATE ON POTENTIALLY PREVENTABLE HOSPITALIZATIONS FROM NURSING HOME

1
THE EFFECT OF MEDICAID RATE ON POTENTIALLY
PREVENTABLE HOSPITALIZATIONS FROM NURSING HOME

• Orna Intrator
• with
• V. Mor, N. Wu, D. Grabowski,
• D. Gifford and Z. Feng
• Brown University and UAB

Funded by NIA RO1 AG20557
2
Objective

• Medicaid payment rates are reflected in the
  availability of the clinical and managerial
  infrastructure necessary to manage nursing home
  residents medical conditions.
• Over 60 of all nursing home residents are
  Medicaid recipients
• Differences in reimbursement rates and other
  Medicaid reimbursement policies likely to
  contribute to observed inter-state differences in
  hospitalization rates.

3
CONCEPTUAL MODEL
Direct and indirect effects
4
Hypotheses direct effects

• Nursing home residents in states with
• Higher Medicaid rates experience fewer
  potentially preventable hospitalizations.
• Bedhold policies will be more likely to be
  hospitalized
• With casemix reimbursement will be more likely to
  be hospitalized because a hospitalization would
  result in change in per-diem rate

5
Hypotheses Indirect effects

• Higher Medicaid rates ?
• More NP/PAs
• ? Less hospitalizations
• More RNs in nursing home nursing force
• ? Less hospitalizations
• More investment in physicians
• ? Less hospitalizations

6
Data and Cohort

• Minimum Data Set (MDS) to identify long-stay
  residents or urban free standing nursing homes in
  48 contiguous states in 2000 (N575,188 in 9124
  facilities)
• Facility data from Centers for Medicare and
  Medicaid Services Online Survey Certification
  and Reporting (OSCAR) system.
• Medicare claims of all hospitalizations within 5
  months of baseline MDS that were initiated from
  baseline nursing home (N101,105)
• Area Resource File for information on counties as
  NH markets

7
Survey of State Medicaid Policies

• 48 continguous states contacted
• Information on
• Method of calculation
• Casemix method and updating schedule
• Average per-diem payment rate and ancillary
  payments
• Bedhold rate and durations
• CON and moratorium

Forthcoming article in Health Affairs Web
Exclusive June 18, 2004
8
State Policy Measures

• Average per diem rate
• Total payments divided by total bed days
• Free standing and hospital based
• Annually, 1999-2002
• Used 2000 data in this study
• Bedhold policies
• Proportion of NH rate paid
• Maximum number days in period
• Minimum occupancy requirements

Poster at 6pm tonight
9
State Policy Measures

• Casemix reimbursement
• Type of system (RUG based, other)
• How frequently updated (annually, quarterly)
• Based on resident, facility, or both
• Four category variable
• No casemix (N17)
• Not resident specific only updated annually (N9)
• Facility specific quarterly or semi-annually
  (N14)
• Most responsive Resident specific quarterly or
  semi-annually or both and quarterly (N8)

10
Outcome Definition

• Hierarchical outcome
• Any potentially preventable hospitalization
  (using ambulatory care sensitive diagnoses)
• Any other hospitalization
• Death
• Remaining in the facility.

Distribution of outcome Any potentially
preventable 7.4 Other Hosp
... 12.6 Died ...
9.2
11
(No Transcript)
12
Model and Estimation

• Multinomial response (4 categories)
• Multilevel
• Resident
• Facility
• County
• State
• Estimation using MLWiN for binomial response
  Outcome vs. remain in NH

13
ResultsDirect Medicaid Policy Effects
14
ResultsIndirect Medicaid Policy Effects
15
Policy Implications

• Highlights competing motivation of Medicaid and
  Medicare
• Higher Medicaid rates ? lower Medicare
  expenditures from less hospitalizations
• ? higher Medicare expenditures from increased
  LOS
• Higher bedhold rates ? higher Medicare
  expenditures
• More bedhold days ? better quality of life
• What is optimal policy
• For Medicare? For Medicaid? For Residents?