Area variation in rehabilitation use in nursing homes
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Area Variation in Rehabilitation Use in Nursing Homes. Wen-Chieh Lin, PhD 1 Gregory F. Petroski, PhD 2 David R. Mehr, MD, MS 1 Steven C. Zweig, MD, MSPH 1 Robert L. Kane, MD 3. 1. Department of Family and Community Medicine, University of Missouri-Columbia

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Area Variation in Rehabilitation Use in Nursing Homes

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Area variation in rehabilitation use in nursing homes

Area Variation in Rehabilitation Use in Nursing Homes

Wen-Chieh Lin, PhD1

Gregory F. Petroski, PhD2

David R. Mehr, MD, MS1

Steven C. Zweig, MD, MSPH1

Robert L. Kane, MD3

1. Department of Family and Community Medicine, University of Missouri-Columbia

2. Biostatistics Group, Office of Medical Research, University of Missouri-Columbia

3. Division of Health Policy and Management, University of Minnesota

Funding Sources: Agency for Healthcare Research and Quality

Nursing home nh residents

Nursing Home (NH) Residents

  • Long-stay vs. short-stay

    • Long-stay: Medicaid or private pay

    • Short-stay: Medicare covered skilled nursing facility (SNF) care

      • Provides services to patients after being discharged from acute care hospitals

      • Replaces a portion of hospital care

      • Facilitates recovery and/or rehabilitation

Medicare skilled nursing facility service

Medicare Skilled Nursing Facility Service

  • Eligibility

    • >= 3-day hospitalization within 30 days prior to admission

    • requiring skilled nursing or skilled rehabilitation services

  • Coverage

    • 100 days per benefit period

    • copayment required for days 21-100

  • Payment

    • Case-mix adjusted per-diem prospective payment

Resource utilization groups rugs

Resource Utilization Groups (RUGs)

  • Case-mix adjustment for the SNF prospective payment system

  • Based on services provided

  • 10 major RUG-III groups with 5 rehabilitation groups

    • Ultra high, very high, high, medium, and low rehabilitation groups

    • Strong financial incentives for providing rehabilitation services

Area variation in rehabilitation rugs classification

Area Variation in Rehabilitation RUGs Classification

  • The proportion of SNF stays classified into rehabilitation RUGs in calendar year 2000

    • Nationally 64.9%

    • Among states

      • 25th-percentile 57.5%

      • Median 64.8%

      • 75th-percentile 68.9%

Research question

Research Question

  • What factors are associated with the area variation in NH rehabilitation use, i.e. the proportion of rehabilitation RUGs?

    • Population differences

    • Substitution between SNFs and inpatient rehabilitation facilities (IRFs) under Medicare’s post-acute care services

    • Varied levels of treatment and “aggressiveness”



  • Data

    • Medicare covered SNF stays by state of provider and major RUG-III groups in calendar year 2000

  • Logit regression on grouped data

Independent variables considered

Independent Variables Considered

  • Population

    • Proportion of elderly population, proportion of Medicare and Medicaid dually eligible elderly, proportion of hospice users

  • Needs

    • The ratio of SNF use to IRF use in patients discharged from hospital for stroke, hip and knee procedures, and hip fracture

  • Supply

    • The number of SNF beds per 1,000 elderly, the number of IRF beds per 1,000 elderly, the proportion of for-profit SNFs

      Note: Considering the small sample size, variables in the Italic font were excluded from the final model.



  • Negative associationwith % of SNF stays being classified into rehabilitation RUGs(** p-value < 0.01, * p-value < 0.05)

    • The number of IRF beds per 1,000 elderly (β = -0.26**)

    • The ratio of SNF use to IRF use (β = -0.03*)

    • The proportion of dually eligible elderly (β = -0.04**)

  • An example – holding other covariates at their median values



  • Substitution between SNF and IRF use

    • Increased IRF beds supply was associated with decreased likelihood of receiving rehabilitation services during SNF stays



  • State-level data

    • Patient and facility characteristics uncontrolled for in the model

  • Lack of assessment data upon admission and discharge



  • Heterogeneous groups of SNF residents

  • Case-mix adjustment based on services provided, but not clinical needs

  • Financial incentives for rehabilitation

  • Appropriateness and outcomes of rehabilitation use in SNFs

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