Substantial changes in Medicare payment policies are occurring for post-acute care (PAC), which provides a
bridge from the hospital to home for individuals who require medical and rehabilitation (i.e., physical,
occupational, and speech therapy) services to transition successfully back to the community. Skilled nursing
facilities (SNFs) and home health agencies (HHAs) account for almost 80% of PAC spending. Rapid growth in
PAC spending has been driven largely by prior payment systems that incentivized therapy services. However,
new payment models were implemented in October 2019 for SNFs and January 2020 for HHAs that attempt to
address (a) the growth in spending and (b) the potential for misuse of therapy services. These new models
remove incentives for therapy but do not include controls for quality (e.g., community discharge, readmissions).
In response, PAC stakeholders have raised concerns that payment reform may differentially impact access to
and quality of care for vulnerable populations (e.g., racial and ethnic minorities, dually-eligible, rural-residing)
and diagnostic subgroups (e.g., dementia/Alzheimer’s, hip fracture) due to changing reimbursements. While
the new models are intended to promote appropriate and efficient care, the actual impact of payment reform is
unknown. We hypothesize that SNFs and HHAs will not respond uniformly to changing reimbursements and
that the new payment models will adversely impact quality of care for some, but not all, patient populations.
Therefore, our overarching goal is to evaluate the impact of payment reform overall and among vulnerable
populations and diagnostic subgroups. Using a natural experiment design that capitalizes on the timing of
payment reform and a mixed methods approach that uses rich qualitative data collected from SNF and HHA
staff and patients, as well as extensive patient-level Medicare claims and assessment data, we will:
Aim 1: Identify SNF and HHA organizational responses to payment reform by quantifying changes in therapy
staffing and payer mix pre-post payment reform and qualitatively exploring stakeholder perspectives on
organizational processes, barriers, and facilitators to providing high-quality care under the new models.
Aim 2: Characterize access to SNF and HHA after hospital discharge and utilization of therapy within
SNF/HHA pre-post-payment reform overall and for vulnerable populations and diagnostic subgroups.
Aim 3: Quantify the association between therapy utilization and quality outcomes (e.g., functional change)
pre-post payment reform overall and for vulnerable populations and diagnostic subgroups.
Rigorous qualitative and quantitative methodologies will allow us to (a) evaluate whether payment reform has
the intended result of incentivizing efficient care and (b) identify any unintended consequences related to
disparities in access to care and compromised quality. Findings will address stakeholders’ concerns and
provide critical information to policymakers, providers, system leaders, and payers on the impact of payment
reform on patient access and quality across patient populations, including the most vulnerable.