June 04, 2019
2 min read

Medicare copays tied to early discharge in skilled nursing facilities

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With copayments starting on day 21, researchers found that Medicare beneficiaries were more commonly discharged on day 20 than on days 19 or 21, with those discharged at day 20 more likely to be racial/ethnic minorities and have lower socioeconomic status.

“Medicare pays for 100% of post-acute care provided by skilled nursing facilities (SNFs) during the first 20 days within a benefit period,” Paula Chatterjee, MD, MPH, of the division of general internal medicine at Perelman School of Medicine and the Leonard Davis Institute for Health Economics at the University of Pennsylvania, and colleague wrote in JAMA Internal Medicine. “However, on the 21st day, most patients become responsible for a daily copayment of more than $150.”

To determine if SNFs had discharge patterns associated with the copayment on day 21, researchers collected data from the Medicare Provider Analysis and Review files and from the Centers for Medicare and Medicaid Services’ Minimum Data Set 3.0. Medicare fee-for-service beneficiaries who were discharged from an acute-care hospital to an SNF between Jan. 1, 2012 and Nov. 1, 2016 were included in the study.

After exclusions, 4,566,162 SNF discharges were evaluated to determine the SNF benefit day and the time of SNF discharge. Researchers compared patient characteristics such as race/ethnicity, age, sex, and 31 comorbidities identified by the Elixhauser Comorbidity Index.

Data from the US Census Bureau’s American Community Survey from 2012 to 2016 were used to compare socioeconomic characteristics across groups based on zip codes. Bivariate linear regression analyses were used to evaluate differences between patients discharged on benefit days 19 and 20 and those who were discharged on benefit days 20 and 21.

Researchers identified 220,037 patients who discharged on day 20, 131,558 patients discharged on day 19 and 121,339 discharged on day 21. Compared with those discharged at day 19 or 21, those discharged on day 20 were more likely to be racial and ethnic minorities and to live in lower socioeconomic zip codes. Researchers found that more black and Hispanic patients were discharged on day 20 (12.5%) than on days 19 (8.2%; P < .001) and 21 (7.5%; P < .001).

Among those discharged on day 20, 15.2% lived in high-poverty areas compared with 13.8% of patients at day 19 and 13.4% at day 21. When measured across the first 40 days of the benefit period, the differences in patient characteristics were greatest on day 20.


Those discharged on day 20 were more likely to have at least five comorbidities (42.2%) than those discharged on days 19 (39.9%; P < .001) and 21 (40.6%; P < .001).

“These findings suggest an association between disproportionately high SNF discharge rates of vulnerable patients and existing Medicare payment policies,” Chatterjee and colleagues wrote. “Although the clinical implications of these discharge patterns are unknown, payment policies should be designed with consideration of the potential for such unintended consequences, and any potential consequences should be mitigated by balancing existing payment structures with incentives to provide optimal patient care.” – by Erin Michael

Disclosures: Chatterjee reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures.