Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
Cardiovascular Division, Department of Medicine, Washington University in St. Louis, St. Louis, Missouri.
JAMA Intern Med. 2023 Jul 1;183(7):637-645. doi: 10.1001/jamainternmed.2023.0770.
In response to the COVID-19 pandemic, Medicare introduced a public health emergency (PHE) waiver in March 2020, removing a 3-day hospitalization requirement before fee-for-service beneficiaries could receive skilled nursing facility (SNF) care benefits.
To assess whether there were changes in SNF episode volume and Medicare spending on SNF care before and during the PHE among long-term care (LTC) residents and other Medicare beneficiaries.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used Medicare fee-for-service claims and the Minimum Data Set for Medicare beneficiaries who were reimbursed for SNF care episodes from January 2018 to September 2021 in US SNFs.
The prepandemic period (January 2018-February 2020) vs the PHE period (March 2020-September 2021).
The main outcomes were SNF episode volume, characteristics, and costs. Episodes were defined as standard (with a preceding 3-day hospitalization) or waiver (with other or no acute care use).
Skilled nursing facility care was provided to 4 299 863 Medicare fee-for-service beneficiaries. Medicare beneficiaries had on average 130 400 monthly SNF episodes in the prepandemic period (mean [SD] age of beneficiaries, 78.9 [11.0] years; 59% female) and 108 575 monthly episodes in the PHE period (mean [SD] age of beneficiaries, 79.0 [11.1] years; 59% female). All waiver episodes increased from 6% to 32%, and waiver episodes without preceding acute care increased from 3% to 18% (from 4% to 49% among LTC residents). Skilled nursing facility episodes provided for LTC residents increased by 77% (from 15 538 to 27 537 monthly episodes), primarily due to waiver episodes provided for residents with COVID-19 in 2020 and early 2021 (62% of waiver episodes without preceding acute care). Skilled nursing facilities in the top quartile of waiver episodes were more often for-profit (80% vs 68%) and had lower quality ratings (mean [SD] overall star rating, 2.7 [1.4] vs 3.2 [1.4]; mean [SD] staffing star rating, 2.5 [1.1] vs 3.0 [1.2]) compared with SNFs in the other quartiles. Monthly Medicare spending on SNF care was $2.1 billion before the pandemic and $2.0 billion during the PHE. For LTC residents, monthly SNF spending increased from $301 million to $585 million while spending on hospitalizations remained relatively stable.
This cohort study found that the PHE waiver for SNF care was associated with a marked increase in the prevalence of SNF episodes without a preceding hospitalization, especially in the first year of the COVID-19 pandemic. The waiver was used primarily among certain types of facilities and for LTC residents with COVID-19. Although the effect of the waiver cannot be differentiated from that of the pandemic, overall SNF care costs did not increase substantially; for LTC residents, the waiver was applied primarily for COVID-19 care, suggesting the waiver's successful implementation.
为应对 COVID-19 大流行，医疗保险于 2020 年 3 月推出了公共卫生紧急情况（PHE）豁免，取消了服务付费受益人在接受熟练护理设施（SNF）护理福利之前必须住院 3 天的要求。
评估长期护理（LTC）居民和其他医疗保险受益人在 PHE 前后，SNF 发病数量和 Medicare 对 SNF 护理支出是否发生变化。
设计、地点和参与者：这项回顾性队列研究使用了医疗保险服务付费索赔和 Medicare 最小数据集，对 2018 年 1 月至 2021 年 9 月在美国 SNF 接受 SNF 护理发病的报销受益人进行了研究。
大流行前时期（2018 年 1 月至 2020 年 2 月）与 PHE 时期（2020 年 3 月至 2021 年 9 月）。
主要结局是 SNF 发病数量、特征和成本。发病被定义为标准（有前 3 天住院）或豁免（有其他或没有急性护理使用）。
熟练护理设施护理共提供给 4299863 名医疗保险服务付费受益人。在大流行前时期，医疗保险受益人每月有 130400 次 SNF 发病（受益人平均年龄[SD]为 78.9[11.0]岁；59%为女性），在 PHE 时期每月有 108575 次发病（受益人平均年龄[SD]为 79.0[11.1]岁；59%为女性）。所有豁免发病从 6%增加到 32%，没有先前急性护理的豁免发病从 3%增加到 18%（从 4%增加到 2020 年和 2021 年初 COVID-19 居民中的 49%）。LTC 居民提供的 SNF 发病增加了 77%（从每月 15538 次增加到 27537 次），主要是由于 2020 年和 2021 年初 COVID-19 居民的豁免发病（没有先前急性护理的豁免发病的 62%）。豁免发病数量最高的四分之一 SNF 更有可能是营利性的（80%比 68%），并且质量评级较低（总体星级评分的平均[SD]为 2.7[1.4]比 3.2[1.4]；人员配备星级评分的平均[SD]为 2.5[1.1]比 3.0[1.2]）与其他四分位数的 SNF 相比。大流行前每月 Medicare 用于 SNF 护理的支出为 21 亿美元，大流行期间为 20 亿美元。对于 LTC 居民，SNF 支出从每月 3.01 亿美元增加到 5.85 亿美元，而住院支出保持相对稳定。
这项队列研究发现，SNF 护理的 PHE 豁免与没有先前住院的 SNF 发病的显著增加有关，尤其是在 COVID-19 大流行的第一年。豁免主要用于某些类型的设施和 COVID-19 的 LTC 居民。尽管豁免的效果无法与大流行的效果区分开来，但总体 SNF 护理费用并没有大幅增加；对于 LTC 居民，豁免主要用于 COVID-19 护理，表明豁免的成功实施。
