Prusynski RA, Frogner BK, Rundell SD, Pradham S, Mroz TM
Abstract
Objective
To determine if financially motivated therapy in Skilled Nursing Facilities (SNFs) is associated with patient outcomes.
Design
Cohort study using 2018 Medicare administrative data.
Setting and Participants
13,949 SNFs in the United States.
Participants
934,677 Medicare Part A patients admitted to SNF for post-acute rehabilitation.
Interventions
The primary independent variable was an indicator of financially motivated therapy, separate from intensive therapy, known as thresholding, defined as when SNFs provide ten or fewer minutes of therapy above weekly reimbursement thresholds.
Main Outcome Measures
Dichotomous indicators of successful discharge to the community versus institution and functional improvement on measures of transfers, ambulation, or locomotion. Mixed effects models estimated relationships between thresholding and community discharge and functional improvement, adjusted for therapy intensity, patient, and facility characteristics. Sensitivity analyses estimated associations between thresholding and outcomes when patients were stratified by therapy volume.
Results
Thresholding was associated with a small positive effect on functional improvement (odds ratio [OR] 1.07; 95% CI 1.06-1.09) and community discharge (OR 1.03, 95% CI 1.02-1.05). Effect sizes for functional improvement were consistent across patients receiving different volumes of therapy. However, effect sizes for community discharge were largest for patients in low-volume therapy groups (OR 1.27, 95% CI 1.18-1.35).
Conclusions
Patients who experienced thresholding during post-acute SNF stays were slightly more likely to improve in function and successfully discharge to the community, especially for patients receiving lower volumes of therapy. While thresholding is an inefficient and financially motivated practice, results suggest that even small amounts of extra therapy time may have contributed positively to outcomes for patients receiving lower-volume therapy. As therapy volumes decline in SNFs, these results emphasize the importance of Medicare payment policy designed to promote, not disincentivize, potentially beneficial rehabilitation services for patients.