Center for Gerontology and Healthcare Research, Alpert Medical School, Brown University, Providence, RI 02912, USA.
Med Care. 2011 Sep;49(9):797-802. doi: 10.1097/MLR.0b013e318223c0ae.
To understand how changes in Medicaid nursing home (NH) reimbursement policy and rates affect a NH's approach to end-of-life care (ie, its use of hospice).
This longitudinal study merged US NH decedents' (1999 to 2004) resident assessment data (MDS) with Part A claims data to determine the proportion of a NH's decedents using hospice. Freestanding NHs across the 48 contiguous US states were included. A NH-level analytic file was merged with NH survey (ie, OSCAR) and area resource file data, and with annual data on state Medicaid NH rates, case-mix reimbursement policies, and hospice certificate of need (CON). NH fixed-effect (within) regression analysis examined the effect of changing state policies, controlling for differing time trends in CON and case-mix states and for facility-level and county-level attributes. Models were stratified by urban/rural status.
A $10 increase in the Medicaid rate resulted in a 0.41% [95% confidence interval (CI): 0.275, 0.553] increase in hospice use in urban NHs and a 0.37% decrease (95% CI: -0.676, -0.063) in rural NHs not adjacent to urban areas. There was a nonstatistically significant increase in rural NHs adjacent to urban areas. Introduction of case-mix reimbursement resulted in a 2.14% (95% CI: 1.388, 2.896) increase in hospice use in urban NHs, with comparable increases in rural NHs.
This study supports and extends previous research by showing changes in Medicaid NH reimbursement policies affect a NH's approach to end-of-life care. It also shows how policy changes can have differing effects depending on a NH's urban/rural status.
了解医疗补助（Medicaid）疗养院（NH）报销政策和费率的变化如何影响 NH 临终关怀的方法（即其对临终关怀的使用）。
本纵向研究将美国 NH 死亡者（1999 年至 2004 年）居民评估数据（MDS）与 A 部分索赔数据合并，以确定 NH 死亡者使用临终关怀的比例。包括美国 48 个州的独立 NH。将 NH 级分析文件与 NH 调查（即 OSCAR）和区域资源文件数据以及关于州 Medicaid NH 费率、病例组合报销政策和临终关怀证书需求（CON）的年度数据合并，并进行 NH 固定效应（内部）回归分析，以研究不断变化的州政策的影响，同时控制 CON 和病例组合状态的不同时间趋势以及设施级别和县级属性。模型按城乡状况分层。
医疗补助费率增加 10 美元，导致城市 NH 中临终关怀使用增加 0.41%（95%置信区间[CI]：0.275，0.553），而与城市不相邻的农村 NH 中临终关怀使用减少 0.37%（95% CI：-0.676，-0.063）。与城市相邻的农村 NH 中增加不具有统计学意义。引入病例组合报销导致城市 NH 中临终关怀使用增加 2.14%（95% CI：1.388，2.896），农村 NH 中也有类似的增加。
本研究通过显示医疗补助 NH 报销政策的变化影响 NH 临终关怀的方法，支持并扩展了以前的研究。它还表明，政策变化可能根据 NH 的城乡地位产生不同的影响。
