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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. Objective.

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the effect of medicaid rate on potentially preventable hospitalizations from nursing home

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

objective
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.
slide3

STATE

Policies

MARKET Context

NURSING

HOME

Context

Hospitalization

RESIDENT

Characteristics

CONCEPTUAL MODEL

Direct and indirect effects

hypotheses direct effects
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
hypotheses indirect effects
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
data and cohort
Data and Cohort
  • Minimum Data Set (MDS) to identify long-stay residents or urban free standing nursing homes in 48 contiguous states in 2000 (N=575,188 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 (N=101,105)
  • Area Resource File for information on counties as NH markets
survey of state medicaid policies
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

state policy measures
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

state policy measures1
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 (N=17)
      • Not resident specific only updated annually (N=9)
      • Facility specific quarterly or semi-annually (N=14)
      • Most responsive: Resident specific quarterly or semi-annually or both and quarterly (N=8)
outcome definition
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%

model and estimation
Model and Estimation
  • Multinomial response (4 categories)
  • Multilevel:
    • Resident
    • Facility
    • County
    • State
  • Estimation using MLWiN for binomial response: Outcome vs. remain in NH
policy implications
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?