Geng Fangli, Lu Xinran, White Elizabeth M, McGarry Brian E, Santostefano Christopher, Meehan Amy, Gadbois Emily, Rahman Momotazur, Grabowski David C
Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island.
Department of Medicine, University of Rochester, Rochester, New York.
JAMA Intern Med. 2025 Jul 21. doi: 10.1001/jamainternmed.2025.2881.
The Patient Driven Payment Model (PDPM), implemented in October 2019, fundamentally changed how Medicare reimburses skilled nursing facilities (SNFs) for postacute care, shifting from therapy volume-based payment to reimbursement based on patient clinical and functional characteristics. Understanding the relationship of the PDPM to SNF coding practices, Medicare expenditures, and clinical outcomes is essential for evaluating its policy and clinical implications.
To evaluate changes in SNF diagnostic coding intensity, Medicare expenditures, and patient outcomes before and after PDPM implementation.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used regression discontinuity analysis of traditional Medicare beneficiaries aged 65 and older who were admitted to SNFs for postacute care after hospitalization between January 2018 and February 2020. All analysis was completed between August 2024 and April 2025.
PDPM implementation on October 1, 2019.
Primary outcomes included SNF relative coding intensity measured as the difference between SNF and hospital Elixhauser Comorbidity index scores, 30-day rehospitalization, 30-day mortality, SNF episode expenditures, SNF length of stay, and mean daily therapy minutes.
The study included 2 065 809 Medicare beneficiaries (mean [SD] age, 81.2 [8.6] years; 61% female individuals; 8.8% Black, 1.3% Hispanic, and 86.8% White). PDPM implementation was associated with a significant increase in SNF relative coding intensity (0.54 points; 95% CI, 0.40-0.68; P < .001) and a $665 increase (95% CI, $437-$892; P < .001) in SNF episode expenditures. No significant changes were observed in 30-day rehospitalization or mortality rates. Increases in spending were concentrated among beneficiaries with higher clinical complexity and in for-profit SNFs.
This study found that PDPM implementation was associated with increased coding intensity and Medicare expenditures in SNFs, without changes in patient mortality and readmissions. These findings suggest that SNFs responded to PDPM incentives through changes in coding practices, underscoring the importance of continued monitoring to ensure that the financial incentives of PDPM promote support accurate coding, equitable reimbursement, and high-quality care.
2019年10月实施的患者驱动支付模式（PDPM）从根本上改变了医疗保险对熟练护理机构（SNF）急性后护理的报销方式，从基于治疗量的支付转变为基于患者临床和功能特征的报销。了解PDPM与SNF编码实践、医疗保险支出和临床结果之间的关系对于评估其政策和临床意义至关重要。
评估PDPM实施前后SNF诊断编码强度、医疗保险支出和患者结局的变化。
设计、设置和参与者：这项回顾性队列研究对2018年1月至2020年2月期间住院后因急性后护理入住SNF的65岁及以上传统医疗保险受益人进行了回归间断分析。所有分析于2024年8月至2025年4月完成。
2019年10月1日实施PDPM。
主要结局包括SNF相对编码强度，以SNF与医院埃利克斯豪泽合并症指数评分之差衡量，30天再住院率、30天死亡率、SNF发作费用、SNF住院时间和平均每日治疗分钟数。
该研究纳入了2065809名医疗保险受益人（平均[标准差]年龄，81.2[8.6]岁；61%为女性；8.8%为黑人，1.3%为西班牙裔，86.8%为白人）。PDPM的实施与SNF相对编码强度显著增加（0.54分；95%置信区间，0.40 - 0.68；P < .001）以及SNF发作费用增加665美元（95%置信区间，437 - 892美元；P < .001）相关。30天再住院率或死亡率未观察到显著变化。支出增加集中在临床复杂性较高的受益人和营利性SNF中。
本研究发现，PDPM的实施与SNF编码强度增加和医疗保险支出增加相关，而患者死亡率和再入院率没有变化。这些发现表明，SNF通过编码实践的改变对PDPM激励措施做出了反应，强调了持续监测的重要性，以确保PDPM的财务激励措施促进准确编码、公平报销和高质量护理。
