The Effect of Hospitals’
Post-Acute Care Ownership on
Medicare Post-Acute Care Use
Wen-Chieh Lin, PhD 1
Robert L. Kane, MD 2
David R. Mehr, MD, MS 1
Richard W. Madsen, PhD 3
Greg F. Petroski, PhD 3
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
Funding Sources: Agency for Healthcare
Research and Quality
Post-Acute Care (PAC)

Replace a portion of hospital care
–
–

Hospitals discharge patients as soon as medically
possible
Hospitals minimize resources used through
shortened length of stay
Medicare PAC payment system reforms
–
–
New financial incentives for PAC settings, but not
to hospitals directly
More influential on hospitals owning PAC settings
Study Objectives


To examine the association between PAC
use and hospitals’ PAC ownership
To examine the relationship between PAC
use and changes in hospitals’ PAC
ownership, i.e., added or discontinued PAC
ownership, between 1996 and 2000 (preand post- payment reforms on HHAs and
SNFs)
Data


5% Medicare beneficiary sample in year 2000
6 disease groups with the most frequent PAC
utilization
–
Rehabilitative conditions

–
Stroke, hip and knee procedures, and hip fracture
Medical conditions

Chronic obstructive pulmonary disease (COPD),
pneumonia, and congestive heart failure (CHF)
Statistical Analysis

Multinomial logit regression
–
Dependent variable: immediate type of PAC
service used after hospital discharge
 SNF,
–
IRF, HHA, and No Service (reference)
Independent variables
 Patient
characteristics
 Hospital characteristics
 Market area characteristics
Hospitals’ PAC Ownership

Own rehabilitation unit
–

Own SNF
–

related hospitals for SNFs indicating hospital-based
Own swing bed
–

a hospital has a PPS exempt rehabilitation unit
a hospital provides swing bed services
Own home care
–
home care services are provided by staff
The Number and Proportion of
Hospitals owning PAC Settings
Hospitals’ PAC
Ownership
Number of hospitals in
our study sample
Rehabilitation unit
CY 1996
CY 1998
CY 2000
4,761
4,638
4,427
845 (17.7%)
887 (19.1%)
909 (20.5%)
Skilled nursing facility
1,795 (37.7%) 1,913 (41.2%) 1,634 (36.9%)
Swing bed
1,256 (26.4%) 1,242 (26.8%) 1,176 (26.6%)
Home care unit
2,012 (42.3%) 2,123 (45.8%) 2,041 (46.1%)
The Association between PAC Use and
Hospitals’ PAC Ownership
Rehabilitative Conditions
(ORs and 95% CIs)
SNF vs.
No Service
IRF vs.
No Service
HHA vs.
No Service
Own rehabilitation unit
0.78 (0.69, 0.87)
2.07 (1.83, 2.33)
0.85 (0.74, 0.99)
Own SNF
1.68 (1.52, 1.85)
0.67 (0.59, 0.77)
0.84 (0.74, 0.96)
Own swing bed
1.66 (1.46, 1.88)
0.65 (0.53, 0.80)
1.03 (0.85, 1.24)
Own home care
1.18 (1.08, 1.29)
0.92 (0.82, 1.03)
1.00 (0.89, 1.12)
Own SNF & rehab. unit
0.78 (0.69, 0.89)
1.28 (1.10, 1.49)
1.02 (0.86, 1.21)
Own SNF & home care
0.91 (0.80, 1.03)
1.02 (0.88, 1.18)
0.99 (0.84, 1.17)
Own rehab. Unit & home care
0.99 (0.87, 1.13)
1.16 (1.00, 1.34)
1.19 (1.00, 1.42)
The Association between PAC Use and
Hospitals’ PAC Ownership (Contd.)
Medical Conditions
(ORs and 95% CIs)
SNF vs.
No Service
HHA vs.
No Service
Own rehabilitation unit
0.98 (0.92, 1.04)
1.04 (0.97, 1.10)
Own SNF
1.26 (1.19, 1.33)
0.87 (0.82, 0.92)
Own swing bed
1.36 (1.24, 1.49)
0.84 (0.76, 0.94)
Own home care
1.02 (0.92, 1.04)
1.03 (0.98, 1.09)
Changes in Hospitals’ PAC Ownership

Comparing the status of a hospital’s PAC
ownership between 1996 and 2000 (pre- and
post- payment reforms on HHAs and SNFs)
–
–
–
–
Yes in 1996 and Yes in 2000
No in 1996 and Yes in 2000
Yes in 1996 and No in 2000
No in 1996 and No in 2000 (reference category)
The Association between PAC Use and
Changes in Hospitals’ PAC Ownership
Rehabilitative Conditions
SNF vs. No service
IRF vs. No Service
HHA vs. No service
Yes 1996 – Yes 2000
0.77 (0.68, 0.86)
2.04 (1.80, 2.31)
0.85 (0.73, 0.99)
No 1996 – Yes 2000
0.91 (0.76, 1.10)
2.27 (1.88, 2.75)
0.83 (0.64, 1.08)
Yes 1996 – No 2000
0.95 (0.66, 1.37)
0.57 (0.32, 1.03)
0.89 (0.52, 1.53)
Yes 1996 – Yes 2000
1.67 (1.50, 1.85)
0.68 (0.59, 0.78)
0.85 (0.74, 0.98)
No 1996 – Yes 2000
1.53 (1.33, 1.75)
0.67 (0.56, 0.80)
0.79 (0.65, 0.96)
Yes 1996 – No 2000
0.86 (0.75, 0.98)
1.14 (0.99, 1.30)
1.08 (0.92, 1.27)
Yes 1996 – Yes 2000
1.73 (1.50, 1.98)
0.64 (0.51, 0.81)
1.02 (0.83, 1.25)
No 1996 – Yes 2000
1.22 (0.92, 1.62)
0.67 (0.44, 1.03)
1.03 (0.68, 1.55)
Yes 1996 – No 2000
1.28 (0.87, 1.88)
1.11 (0.67, 1.84)
1.04 (0.58, 1.84)
Yes 1996 – Yes 2000
1.18 (1.07, 1.30)
0.93 (0.82, 1.04)
1.02 (0.90, 1.15)
No 1996 – Yes 2000
1.25 (1.08, 1.44)
0.92 (0.78, 1.10)
0.87 (0.71, 1.06)
Yes 1996 – No 2000
1.21 (1.02, 1.43)
1.17 (0.96, 1.43)
1.31 (1.06, 1.64)
Own rehabilitation unit
Own SNF
Own swing bed
Own home care
The Association between PAC Use and
Changes in Hospitals’ PAC Ownership
Medical Conditions
SNF vs. No service
HHA vs. No service
Yes 1996 – Yes 2000
0.98 (0.92, 1.05)
1.02 (0.96, 1.09)
No 1996 – Yes 2000
0.94 (0.82, 1.08)
1.06 (0.93, 1.21)
Yes 1996 – No 2000
1.02 (0.74, 1.41)
0.76 (0.52, 1.11)
Yes 1996 – Yes 2000
1.25 (1.18, 1.32)
0.87 (0.82, 0.93)
No 1996 – Yes 2000
1.35 (1.22, 1.49)
0.90 (0.81, 1.00)
Yes 1996 – No 2000
1.02 (0.91, 1.15)
1.07 (0.96, 1.20)
Yes 1996 – Yes 2000
1.33 (1.21, 1.47)
0.80 (0.72, 0.90)
No 1996 – Yes 2000
1.19 (0.95, 1.48)
0.98 (0.76, 1.26)
Yes 1996 – No 2000
1.37 (1.05, 1.79)
0.86 (0.61, 1.20)
Yes 1996 – Yes 2000
1.03 (0.97, 1.09)
1.04 (0.98, 1.10)
No 1996 – Yes 2000
1.05 (0.94, 1.17)
1.04 (0.93, 1.17)
Yes 1996 – No 2000
1.17 (1.01, 1.36)
1.07 (0.92, 1.25)
Own rehabilitation unit
Own SNF
Own swing bed
Own home care
Conclusions



The link between PAC use and hospitals’
PAC ownership remained significant in the
post-BBA era
A hospital’s PAC ownership was associated
with an increased use in this PAC modality,
while the likelihood of using other PAC
modalities decreased
Substitution between PAC modalities is also
driven by hospitals’ PAC ownership
Limitations

Data cover only the initial period (1996 to
2000) of the BBA changes on PAC services
–
–

October 2000: HHA prospective payment system
January 2002: IRF prospective payment system
Analyses did not include the partnership and
contractual relationship between hospitals
and PAC settings
Discussion

Discharging patients to hospitals’ own PAC
setting
–
–
–

Improve information sharing
Reduce adverse outcomes during the transition
Unknown whether outcomes are comparable in
alternative settings
Implications of outcomes and costs of
substitution between PAC settings