Changes in skilled nursing and home health admissions associated with Medicare payment reforms and the COVID-19 pandemic

Background

Shortly after Medicare implemented post-acute care payment reforms, the COVID-19 pandemic began, but little is known about how these reforms and the pandemic impacted admissions to the most common post-acute settings—skilled nursing facilities (SNF) and home health agencies (HHAs)—for the full Medicare fee-for-service population.

Methods

Using 100% of Medicare fee-for-service data, we conducted adjusted interrupted time series analyses of 31,730,994 hospital stays of all adult beneficiaries discharged alive from the hospital between 2018 and 2021 to examine whether payment reforms and the pandemic were associated with differences in admissions to SNFs and HHAs compared to pre-reform and pre-COVID (baseline) trends.

Results

At baseline, an average 18.0% of hospitalized beneficiaries were admitted to SNFs and 14.8% to HHAs. While SNF payment reform in October 2019 was associated with an immediate reduction in SNF admissions, a positive temporal trend reversed this decrease in admissions. HHA payment reform implemented in January 2020 was associated with increased HHA admissions compared to baseline. Post-COVID, admissions to SNF declined to 15.5% of patients being discharged from hospitals and HHA admissions increased to 19.2%.

Conclusions

SNF and HHA payment reforms were associated with small increases in admissions to their respective settings, suggesting that Medicare reforms did not negatively impact access. However, the baseline trends of decreasing admissions to SNF and increasing HHA admissions were greatly accelerated by the COVID-19 pandemic. Results highlight changes in the demand for these settings, which must be recognized in policy efforts and research examining impacts on specific patient populations.