Skilled-nursing facilities feel the pinch from fewer inpatient stays

Efforts to reduce hospitalizations among Medicare beneficiaries have sparked a steady decline in admissions over the past several years and have also hit the bottom lines of many skilled-nursing facilities.

A new analysis released Thursday by Avalere Health found that Medicare beneficiaries have spent 15% fewer days in SNFs between 2009 and 2016. Medicare fee-for-service claims fell from 1,808 days per 1,000 beneficiaries to 1,539 days per 1,000 over that period. Hospitals in recent years have shifted toward referring patients to home healthcare services instead of SNFs, in an effort to promote value-based care over fee-for-service models as well as improve patient satisfaction. But Avalere found the rise of home healthcare was not the main driver for the decline in SNF use between 2009 and 2016. It had to do more with hospitals increasingly placing patients in observation status over admitting them for inpatient services. Under CMS rules, Medicare covers up to 100 days of care at a SNF, but patients must have received at least three days of hospital inpatient care before they can qualify for coverage at a nursing facility. Patients placed in observation are not eligible to stay at a SNF after they are discharged. Per capita hospital discharges fell by 17% between 2009 and 2016 fell by 17% while the number observation stays increased, according to the analysis. "The market for post-acute care is changing radically as a result of managed care, the bundling of services, and frankly a more sophisticated approach that hospitals and health plans are taking to manage post-acute care," said Dan Mendelson, president of Avalere Health. The SNF market appears to be contracting, Mendelson said, and SNF operators should do what they can to distinguish themselves from their competition by showing they can reduce hospital readmissions and improve patient health outcomes. "What skilled-nursing facilities need to do is measure their outcomes and be able to communicate both costs and clinical outcomes to referral sources," Mendelson said. Patients should be mindful of whether cost-saving incentives lead to them receiving less care, he said. "It's just the flip side of fee-for-service," Mendelson said. "There's always a perverse incentive in any payment system, and this one happens to be that providers make more money when they provide less care."