Wang Huiying, Kosar Cyrus, Rahman Momotazur, Mor Vince
Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island, USA.
Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island, USA.
J Am Geriatr Soc. 2025 May;73(5):1551-1557. doi: 10.1111/jgs.19328. Epub 2024 Dec 31.
With the growing number of Medicare beneficiaries attributed to Accountable Care Organizations (ACO) or enrolled in Medicare Advantage (MA) and their financial incentives to lower the cost of the cared patients, it is essential to understand how these alternative payment models affect post-acute outcomes among beneficiaries, with or without dementia diagnoses. In this study, we examined the quality of skilled nursing facilities (SNFs) that beneficiaries entered after hospital discharge under different payment models.
Medicare beneficiaries who were discharged from hospitals and admitted to SNFs between 2013 and 2018.
The exposure variable was a payment indicator, including ACO, MA, or non-ACO traditional Medicare (TM) fee-for-service. The dependent variable was high overall quality SNF, defined as with at least 4-star rating in the CMS Nursing Home Care Compare.
We examined the payer distribution by dementia diagnosis using ZIP Code Tabulation Areas (ZCTAs) fixed effects and adjusted for age, gender, and race. We also estimated the probabilities of entering high-quality SNF as a function of payer status and dementia diagnosis each year using hospital and ZCTA fixed effects and accounting for beneficiary-level covariates.
Among SNF admissions from 2013 to 2018, the share of ACO-attributed beneficiaries increased from 7.6% to 20.2%, MA enrollees increased from 25.2% to 32.8%, and non-ACO-attributed TM enrollees decreased from 67.2% to 47.3%. Consistently, ACO-attributed beneficiaries were the most likely, while MA enrollees were the least likely to enter high-quality SNFs, regardless of dementia diagnosis.
Our findings highlight significant differences in access to high-quality SNFs across Medicare payment models, with ACO-attributed beneficiaries consistently experiencing better access than their MA or traditional Medicare counterparts, regardless of dementia diagnosis. These results underscore the need for further investigation into how payment models influence care quality and access, particularly for vulnerable populations.
随着归属可问责医疗组织（ACO）或参加医疗保险优势计划（MA）的医疗保险受益人数不断增加，以及它们在降低所护理患者成本方面的经济激励措施，了解这些替代支付模式如何影响有或没有痴呆症诊断的受益人的急性后期结局至关重要。在本研究中，我们调查了不同支付模式下受益人出院后进入的熟练护理机构（SNF）的质量。
2013年至2018年间从医院出院并入住SNF的医疗保险受益人。
暴露变量是一个支付指标，包括ACO、MA或非ACO传统医疗保险（TM）按服务收费。因变量是高质量SNF，定义为在医疗保险和医疗补助服务中心（CMS）疗养院护理比较中至少获得四星评级。
我们使用邮政编码分区（ZCTA）固定效应，按痴呆症诊断检查付款人分布，并对年龄、性别和种族进行调整。我们还使用医院和ZCTA固定效应，考虑受益人层面的协变量，每年估计作为付款人状态和痴呆症诊断函数进入高质量SNF的概率。
在2013年至2018年入住SNF的患者中，归属ACO的受益人的比例从7.6%增加到20.2%，参加MA的人数从25.2%增加到32.8%，非ACO归属的TM参保人数从67.2%下降到47.3%。一致的是，无论痴呆症诊断如何，归属ACO的受益人最有可能进入高质量SNF，而参加MA的人最不可能进入。
我们的研究结果突出了医疗保险支付模式在获得高质量SNF方面的显著差异，无论痴呆症诊断如何，归属ACO的受益人始终比其MA或传统医疗保险同行有更好的获得机会。这些结果强调需要进一步调查支付模式如何影响护理质量和获得机会，特别是对于弱势群体。
