Varied Regional Responses to
Medicare Post-Acute Care (PAC)
Prospective Payment Systems
Wen-Chieh Lin, PhD 1
Robert L. Kane, MD 2
David R. Mehr, MD, MS 1
Richard W. Madsen, PhD 3
Greg F. Petroski, MS 3
Post-Acute Care (PAC)
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–
1. Department of Family and Community
Medicine, University of Missouri-Columbia
2. Division of Health Services Research and
Policy, University of Minnesota
3. Office of Medical Research/Biostatistics,
University of Missouri-Columbia
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Funding Sources: Agency for Healthcare
Research and Quality, Centers for Medicare
and Medicaid Services
PAC Prospective Payment Systems (PPS)
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Different case-mix adjustment
Different instruments for assessment
Different implementation timelines
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–
–
–
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Rehabilitative conditions
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Medical conditions
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The fastest growing components of Medicare
spending in the 1990s
Geographic variation in PAC use
Changes in PAC payment systems enacted by the
Balanced Budget Act (BBA) of 1997
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To investigate whether geographic regions
responded to the initial changes (1996 to
2000) in PAC payment systems enacted by
the Balanced Budget Act (BBA) of 1997
Statistical Analysis
5% Medicare beneficiary sample, 1996 to 2000
6 disease groups (8 DRGs) with the most
frequent PAC utilization
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Skilled nursing facilities (SNFs), inpatient rehabilitation units
or hospitals (IRFs), and home health agencies (HHAs)
Study Objectives
SNF-PPS: July 1998 with a 3-year transition period
IRF-PPS: January 2002 with a 1-year transition period
HHA-IPS: July 1997 interim payment system (non-PPS)
HHA-PPS: October 2000 prospective payment system
Data
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Major PAC services covered by Medicare Part A
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Multinomial logit regression (1996 and 2000 data)
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Dependent variable: immediate type of PAC service
used after hospital discharge
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Independent variables
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Stroke, hip and knee procedures, and hip fracture
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COPD, pneumonia, and CHF
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SNF, IRF, HHA, and No PAC (reference)
Patient, hospital, and market area characteristics, Year
2000, Census Divisions, and interaction terms of Year
2000 and Census Divisions
Adjusted odds ratios representing changes in PAC use
from 1996 to 2000 within each individual census division
1
Regional responses: SNF use
2.5
2.0
2.0
1.5
1.0
1.5
1.0
0.5
0.5
0.0
0.0
ESC
MAL
MOT
NED
PAC
SAL
WNC
2.5
2.5
2.0
2.0
1.5
1.0
ESC
MAL
MOT
NED
PAC
SAL
WNC
WSC
ESC
Census Divisions
Hip and knee procedures
2.5
2.5
2.0
2.0
A d ju s te d O R s
3.0
1.5
1.0
0.5
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–
1.5
–
1.0
0.0
ENC
ESC
MAL
MOT
NED
PAC
Census Divisions
SAL
WNC
WSC
ENC
ESC
MAL
MOT
NED
PAC
SAL
WNC
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–
WSC
Census Divisions
Limitations
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MOT
NED
PAC
SAL
WNC
WSC
ENC
ESC
MAL
MOT
NED
PAC
SAL
WNC
WSC
Census Divisions
Regions’ responses to the BBA changes on
PAC services differed by types of PAC services
0.5
0.0
MAL
Conclusions
Hip fracture
3.0
1.0
0.0
ENC
Census Divisions
Regional responses: IRF use
1.5
0.5
0.0
Census Divisions
A d ju s te d O R s
3.0
0.5
ENC
WSC
CHF
3.0
A d ju s te d O R s
3.0
2.5
A d ju s te d O R s
3.0
ENC
Hip fracture
CHF
A d ju s te d O R s
A d ju s te d O R s
Hip and knee procedures
Regional responses: HHA use
Data cover only the initial period (1996 to
2000) of the BBA changes on PAC services
Association between varied regional
responses and adverse outcomes is not
clear
Changes in SNF use differed in direction and
magnitude across census divisions
HHA use decreased across-the-board for medical
conditions with some regional variation; selective
decrease for rehabilitative conditions
IRF use increased in some census divisions, but also
remained unchanged in some census divisions
Discussion
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Similar regional responses across DRGs for
SNF use, but not for HHA and IRF use
No strong association between regional
responses and prior PAC use
Expected responses to the full PAC-PPS
across regions
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