Econ Papers Daily / 期刊论文
更高成本的机构是否带来更好的结果？医疗保险专业护理机构与家庭健康机构的急性后期护理效率
Do Higher-Cost Settings Deliver Better Outcomes? Post-Acute Care Efficiency in Medicare Skilled Nursing Facilities and Home Health Agencies
摘要
Determining the value of different post-acute care settings for clinically similar patients is important for providers and payers. This study examines the causal effect of post-acute care (PAC) setting on Medicare spending and short-term patient outcomes among beneficiaries discharged from hospitals following treatment for stroke or congestive heart failure (CHF). Using 2013–2017 Medicare claims data, we implement an instrumental variable strategy that exploits daily variation in skilled nursing facility (SNF) bed occupancy at the hospital service area level to estimate the local average treatment effect of SNF versus home health agency (HHA) care. Our findings reveal no significant differences, on average, in 30-day mortality or rehospitalization rates between SNF and HHA care among stroke and CHF patients. However, the 95% confidence intervals do not exclude clinically meaningful reductions in 30-day mortality. Meanwhile, SNF care is associated with approximately $4,700 more in Medicare spending per PAC episode. The spending gap is larger in markets with more constrained SNF capacity, particularly in states with Certificate of Need regulations, rural areas, and low-income neighborhoods. However, we do not detect statistically significant differences in short-term health outcomes across these markets on average, suggesting that supply constraints may amplify the spending implications of SNF use while the relationship between PAC setting and short-term clinical outcomes remains uncertain. These findings highlight the importance of aligning PAC discharge decisions with both clinical needs and local capacity considerations, particularly under value-based payment models.
中文摘要
确定临床相似患者在不同急性后期护理环境中的价值，对医疗服务提供者和支付方而言至关重要。本研究考察了急性后期护理（PAC）环境对中风或充血性心力衰竭（CHF）治疗后出院受益人的医疗保险支出及短期患者结局的因果效应。利用2013-2017年医疗保险索赔数据，我们实施了一种工具变量策略，利用医院服务区域层面熟练护理机构（SNF）床位占用率的日常变化，来估计SNF相对于家庭健康机构（HHA）护理的局部平均处理效应。研究结果显示，在中风和CHF患者中，SNF与HHA护理在30天死亡率或再入院率方面平均无显著差异。然而，95%置信区间并未排除30天死亡率在临床上显著降低的可能性。与此同时，SNF护理与每个PAC疗程约4，700美元的额外医疗保险支出相关。在SNF容量受限更严重的市场中，这一支出差距更大，尤其是在实施需求证明法规的州、农村地区及低收入社区。然而，我们未在这些市场中检测到短期健康结局的统计学显著差异，这表明供给约束可能放大SNF使用的支出影响，而PAC环境与短期临床结局之间的关系仍不确定。这些发现强调了在基于价值的支付模式下，将PAC出院决策与临床需求及当地容量考量相结合的重要性。