Nursing Home Medicaid Recipients Have Higher Hospitalization Rates, Study Shows

In a recent study, patients receiving Medicaid benefits were 27 percent more likely to be sent to the hospital from nursing homes than those with private insurance.

According to the study published in the journal Medical Care Research and Review, nursing homes may be enticed to send the low-reimbursing Medicaid recipients to the hospital for care because of financial incentives.

Helena Temkin-Greener, PhD, MPH, senior author of the study and associate professor of Community and Preventative Medicine at the University of Rochester Medical Center, told Long Term Living magazine that there is strong evidence that payer source may motivate decisions when determining if a patient needs to be transferred to a higher level of care. Nursing home residents' payer sources affect hospitalization rates

Why such a disparity?

Simple: Reimbursement. Medicaid simply does not reimburse as much as the other payer sources. For example, the average reimbursement of a Medicaid patient is around $200 per day, whereas a Medicare recipient can garner a reimbursement of over $400 per day, depending on care needs.  In many cases, Medicaid will also pick up the Medicare copay if the patient is eligible.

For those with the state-funded assistance program, a hospital stay means several things for the facility where the patient resides.  In several states, facilities are able to offer a “bed-hold,” meaning they will promise to save a space within the building for so long during a resident’s hospitalization.  Medicaid will continue to pay an agreed upon rate, in most states, for up to 15 days.

For a long-term resident, a new 3-day hospital stay may regenerate their Medicare benefits, increasing their daily reimbursement rate in the facility by nearly double in some cases.

Quality care regardless of payer

Researches were clear in the fact that nursing homes provided quality of care regardless of payer, but “hospitalization decisions are often different from the decisions involved in the provision of daily care and have a significant impact on the long-term health of residents.”

The study, representing 83 percent of New York State’s nursing home residents found that rates of hospitalization were highest in for-profit facilities.  Medicaid patients were 34 percent more likely to be hospitalized in the for-profit facilities, doubling the 17 percent in non-profit homes.

Nurses make the call

The nurses providing hands-on care to residents are usually those requesting a transfer to the hospital, but they aren’t the ones involved in the financial discussions.  In fact, many are encouraged to follow care-paths and protocols to reduce the number of rehospitalizations.  They are clinicians first and foremost; trained to care for each person based upon their medical needs, not their check books. Most are unaware of residents’ payer sources.

On the other hand, departments involved in behind-the-scenes administration do know each resident’s payer source, but they have little to no direct contact with residents. The director of nursing, nursing home administration and business office focus on fostering relationships with local hospitals and providers. Under federal, state and local scrutiny to reduce spending, hospital readmissions from nursing homes rank near the top of their reduction priorities.

Could it be that most patients who are receiving Medicaid benefits are older, long-term residents who are simply in a state of decline, more likely to fall or unable to bounce back from a common cold? Or perhaps they are a younger patient with higher acuities and more complexities requiring more advanced care?

What role do you think a resident’s payer status plays in hospitalization decisions?

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