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The Impact of Different Insurance Benefits for Skilled Nursing Care on Patient Recovery in the Long-term Care Setting
Abstract
Little is known about whether skilled nursing facility (SNF) care rehabilitation outcomes are influenced by insurance policy stringency for sustaining or not renewing SNF benefits. Different insurance sources for SNF care have different policies about duration and continuation of care that could influence patients’ attainment of therapist-guided goals. To understand any link between SNF insurance policies and patient therapeutic outcomes, the present retrospective study assessed whether the source of SNF care insurance correlated with patients’ achievement of rehabilitation goals. Medical records were examined of 234 patients from 3 large metropolitan nursing homes that accepted 3 major sources of insurance: Medicare, County Care, and commercial insurance. After using 2 different biostatistical models to examine the records with regard to the 3 insurance sources and patients’ achievement of rehabilitation goals, a strong inference was drawn. The insurance policy with weekly adjudication of SNF benefits more effectively helped patients toward their rehabilitation goals than did other insurance plans with more permissive coverage times. This is the first known observation of a link between patients’ SNF insurance plan policy and health care outcomes.
Introduction
Functional declines during hospitalization frequently impede the return of community-dwelling patients to their home. Skilled nursing facilities (SNFs) offer short-term care in transition to home. Services such as physical therapy (PT), occupational therapy (OT),1 intravenous antibiotics, and wound care help patients return to their prehospitalization state or better.
Regardless of insurance source, patient-centered SNF goals are determined by interdisciplinary and intradisciplinary teams of physicians, rehabilitation therapists, dietitians, social workers, nurses, and other allied health professionals. These goals are based on patients’ previous and current functional status, medical comorbidities, and goals that they or their proxies profess. Periodic patient assessments, often expressed as a percentage of SNF goals, help track responses to therapeutic interventions. Ultimately, functional recovery should enable patients to be safely discharged to a predetermined residence based on expected attainable goals.
As different insurance sources for SNF care have different policies about duration and continuation of care that could influence patients’ attainment of therapist-guided goals, this study sought to explore the relationship of insurance policy to rehabilitation outcomes by examining SNF patient medical records along with their respective insurer. Results may enable providers to better assist their patients in reaching their therapy goals.
Methods
Medical records of 234 patients from 3 urban SNF facilities were examined with respect to the main insurers for short-term rehabilitation: Medicare, County Care, and commercial insurance. Each insurance plan has a different policy for the number of covered SNF care days.2-7 Medicare pays the full cost of SNF care for the first 20 days and then requires copayment in the next 80 days. County Care covers the cost of SNF care for 30 days as a bundled package to residents of Cook County who have been legal US citizens for at least 5 years (aged 19-64 years), do not have any medical insurance, and have an income of not more than 133% of the federal poverty level. In contrast, commercial insurance policies renew support for SNF care every week if a patient demonstrates progress in attaining SNF care goals. Each of the 3 insurance sources cover physical therapy comparably in the number of hours per day and days per week.
Study Population and Setting
The retrospective chart review was conducted among patients admitted to the 3 SNFs between January 1, 2013 and December 31, 2013. All 3 SNFs admitted patients from multiple tertiary-care hospitals. Study participants were 18 years old or older, were enrolled in a rehabilitation program, and had expectations of returning home after SNF therapies. No participant was in custodial care before hospitalization. SNF residents with incomplete progress notes or incomplete demographic information were excluded.
Data Collection
Study data from the SNFs were collected and managed using Research Electronic Data Capture (REDCap) software.8
Risk Factors and Covariates
Patients’ insurance payment source was examined as the primary risk factor for attaining SNF goals. Secondary risk factors examined included patients’ age, gender, SNF admitting diagnosis, comorbidities, and functional status at SNF admission.
Functional status data were parsed over 5 categories: independent, supervision, limited assistance, extensive assistance, and total assistance. The domains examined included bed mobility, ability to stand and bear weight, ability to walk in the room, dressing, bathing, toileting, eating, and grooming. The level of support needed to perform these activities of daily living (ADLs) was scored as follows: no setup, setup help only, 1-person physical assistance, and 2 or more person physical assistance.
Outcome Measurements
Patient’s PT goals were measured; SNF PT staff members recorded PT goals according to the Functional Independence Measure (FIM) scoring system, with scores ranging from 1 (lowest) to 7 (highest) for each PT goal attained.
The relationship between the payer source and rehabilitation outcomes was assessed by way of 2 questions. In approach 1 (“all or none”), the question was, “Did the planned and achieved PT goals occur in an all-or-none fashion?” In approach 2 (percentage of completed goals), the question was, “Did the patient achieve a percentage of planned goals?” Different patient groups were assessed for how well they achieved their rehabilitation goals as expressed by their meeting more than 20%, 40%, 60%, and 80% of their planned goals.
Statistical Analysis
To determine homogeneity of the study groups, the independent t test was used to compare the baseline characteristics of Medicare patients and those covered by commercial insurance and County Care. Correlation analysis of baseline functional status variables used a Pearson correlation coefficient of more than 0.25 as being correlative. The ADL of grooming was used as a key functional status variable based on previous research demonstrating its predictive value relative to overall functional recovery.9 Patients requiring extensive and total grooming assistance were combined into 1 outcome group due to small differences in their overall functional status.
A generalized linear model for Poisson regression analysis, adjusted for age, gender, and functional status at SNF admission, was used to test the hypothesis that a correlation existed between individual attainment of established rehabilitation goals and the insurance payer model for each individual. Statistical analysis was performed using IBM SPSS Statistics V22.0 software and Stata 13 software.
Results
Patient Characteristics
Baseline characteristics of the 234 patients enrolled in the study are shown in Tables 1 and 2. The age range of study participants was 22 to 96 years, with the mean age of each insurance group reflecting the eighth decade of life among Medicare recipients, the seventh decade among commercially insured participants, and the fifth decade among County Care enrollees. Figure 1 shows whisker plots for the patient age distribution.
More than three-quarters of participants in all 3 insurance groups were of a minority race or ethnicity. Men out-represented women by 78.4% among County Care patients. In contrast, the percent of women and men was almost equal among Medicare and Medicaid patients. Both genders were largely single, by over 70% being either divorced, widowed, or never married. Participants in all 3 groups had multiple chronic conditions, with type 2 diabetes being the most common.
Table 2 shows the distribution of functional performance and different levels of assistance required for patients across 3 differently insured populations. The upper half of Table 2 shows the numbers and percentages of participants in each insurance group who either were independent or required extensive assistance. Medicare recipients had the highest overall ADL dependency, with almost 70% requiring extensive assistance in all ADL categories except feeding. More than 80% of commercially insured participants and less than 59% of County Care enrollees had total ADL dependency except feeding and bathing. More than 88% of patients in all groups required some form of bathing assistance. Walking independence was low for all 3 groups; only 10% of older Medicare recipients could walk without assistance, whereas 20% and 40% of commercially insured and County Care enrolled participants, respectively, ambulated independently.
In the second portion of Table 2, examination of “support needed” to achieve different physical functionality revealed that Medicare recipients and commercially insured patients were largely bed-bound, with nearly 80% requiring bed mobility as well as standing assistance. By contrast, nearly 60% of County Care enrollees were able to move in bed and stand on their own.
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Figure 2 shows the distribution of patients across the 3 insurance groups and their level of grooming assistance (ranging from independent to total assistance). A descending order of assistance was found with Medicare recipients, commercially insured participants, and County Care enrollees.
Two analytical approaches were used to ascertain whether the type of insurance coverage for rehabilitation influenced therapy outcomes. The first analytic approach focused on whether the type of insurance predicts an all-or-none attainment of therapy goals during SNF admission. The second analytical approach assessed the percentage of planned goals at the end of treatment as expressed by the following formula: [(goals status score at SNF discharge – goals status score during SNF admission) ÷ (planned goals score – goals status score during SNF admission)]. The rationale for this type of analysis was to determine whether a significant difference existed between the various insurance policies in terms of partially completed therapeutic goals. This type of analysis reflects previous studies that show that up to 40% of people in SNFs do not reach their pre-SNF functional level despite therapy.10
The study controlled for age, gender, and ADLs. All the other variables shown in the baseline characteristic table highly correlated with age, gender, or ADLs. Therefore, all the other factors shown in the baseline characteristics table were excluded from the regression model to prevent multicollinearity.
Table 3 shows different correlative factors that influence PT goals by comparing non-Medicare recipients with Medicare recipients. These data represent an analysis of 154 patients who received PT; 11.9% of Medicare recipients, 29.4% of commercially insured participants, and 36.4% of County Care enrollees attained all of their PT goals. Commercially insured participants most likely attained their PT goals (relative risk [RR], 2.51; 95% CI, 1.33-4.73) compared with Medicare recipients. The difference in the attainment of SNF goals between County Care enrollees and Medicare recipients was due to age, gender, and the baseline functional status (ie, ADLs). These held up as statistically significant “effect modifiers.” Participants who were less than 51 years and between 51 and 60 years old had a higher chance of achieving PT goals than did participants aged 80 years or older (P = .02). In addition, ADL analysis revealed that patients with grooming independence achieved their PT goals more often than those who needed extensive and total assistance combined (P = .02). Another strong correlation was gender. Women were less likely than men to achieve their rehabilitation goals (P = .02), a finding that was further compounded by age.
Patients whose SNF care expenses were covered by commercial and County Care insurance policies had the highest average percent of rehabilitation goals gained at the 50th and 75th percentiles compared with Medicare recipients (Table 4). A similar trend was observed in a subset analysis of patients who required extensive assistance with the ADL of grooming (data not shown). Thus, both highly disabled and moderately disabled individuals fared better in attaining their rehabilitation goals under the non-Medicare plans than under Medicare.
As described in Table 5, participants with County Care contracts were more than twice as likely to attain greater than 80% of their rehabilitation goals compared with Medicare recipients. Indeed, in all categories, County Care enrollees had a higher chance of achieving more than 20%, 40%, and 60% of their PT goals compared with Medicare recipients. By contrast, the RR of attaining more than 40%, 60%, and 80% of the PT goals among commercially insured patients was better than among Medicare recipients but more modest compared with County Care enrollees.
Overall SNF Goals
Using Medicare patient data as a baseline for comparison, the overall goals of rehabilitation (Table 6) were assessed with non-Medicare-insured patients (commercial and County Care insurance). Overall goals consisted of physical functionality, infection therapy, and wound care. County Care enrollees had an RR of 1.94 (95% CI, 1.24-3.04) of achieving overall goals, and commercially insured patients had a RR of 1.68 (95% CI, 1.05-2.70). These values were controlled for age and baseline functional status upon SNF admission.
Multivariate analysis showed that patients aged 80 years or older had the least likely chance of attaining overall SNF goals compared with those who were less than 50 years old (RR, 0.40; 95% CI, 0.20-0.82). Regardless of age, when patients required extensive and total assistance with grooming, they also had a diminished chance of attaining their overall SNF goals compared with those who were more independent upon SNF admission (RR, 0.63; 95% CI, 0.41-0.97).
Discussion
Based on these study findings, the health insurance policies with a weekly renewal of SNF benefits based on attainment of SNF goals appear to be more effective in patient’s achieving SNF rehabilitation goals than Medicare benefits. The data presented here indicate that the terms of an insurance policy may now be added to the list of variables that influence posthospitalization recovery in SNFs. This study also suggests that factors such as age, gender, comorbidities, and baseline functional status influence attainment of SNF care goals. The apparent inefficacy of additional therapy sessions for older patients was surprising and suggests that the quality rather than quantity of therapy is key to recovery.
Various factors can influence recovery from an acute illness. Antecedent disability, mood, cognition, personal goals, social support, race, gender, age, and type of facility and its staff can greatly influence posthospitalization recovery. Similarly, hospitalization itself can lead to altered rehabilitation potential in the face of newly prescribed medications, iatrogenic events, and new-onset depression or anxiety. The effect of an insurance policy’s terms on recovery needs to be taken in the context of remarkably varied posthospitalization ADL trajectories. In one study, nearly 40% of patient functionality deteriorated to levels below prehospitalization levels.10 One large study of poststroke veterans categorized 5 care trajectories.11 The Yale Precipitating Events Project also suggested 5 distinct cognitive and disability trajectories after hospitalization.12 Patient attitudes, such as preparedness for SNF rehabilitation through long-term care insurance, may influence the recovery cycle after an acute illness.13 These attitudes may be influenced further by long-term care innovations such as the Green House nursing home model.14
With these mitigating factors in mind, one hypothesis is that a health insurance benefit with the longest rehabilitation provision would lead to the highest percentage of recipients achieving rehabilitation goals. At the upper end of coverage, Medicare recipients can receive up to 100 therapy days with a copay.15 On the other hand, County Care enrollees get renewable SNF care contracts for 30 days. At the lower end of coverage, commercially insured SNF care strictly provides week-to-week coverage coupled to clear progress in attaining therapy goals. Contrary to expectations, data from this study indicate that the length of coverage did not seem to increase the achievement of established rehabilitation goals. This observation was true for both the week-to-week and 30-day SNF benefit insurance program when compared with Medicare in terms of reaching 100% of anticipated rehabilitation goals. The association was statistically significant even after adjusting for age, gender, and baseline functional status at SNF admission.
Multivariate analysis showed that age and baseline functional status at SNF admission were the strongest factors predictive of recovery, an observation that is consistent with those of other studies.16-21 This study suggests that the total number of PT and OT sessions is not a primary determinant of successful recovery after hospitalization. This conclusion is similar to other findings that demonstrate the futility of extra PT and OT visits to facilitate SNF facility discharge.19-21 Unknown is whether more-intensive therapy rather than the total amount of therapy would make a difference in recovery. Also, adherence to therapy can be critical to recovery.
Commercially insured patients may do better than patients with other insurance coverage due to a “sword of Damocles” factor—namely, the week-to-week renewal of SNF insurance coverage based on attainment of SNF goals may be a potent factor that drives commercially insured patients toward their rehabilitation goals. Less apparent may be that PT teams “favor” commercially insured patients and demand more of them in the face of potentially premature insurance coverage cessation. Given that the number of hours per day a patient spends on therapy improves the chances of functional recovery, patients with commercial insurance might have spent more hours on therapy.22-26 Shorter but more frequent therapy sessions in a day and positive behavioral feedback can impact the rate of recovery.27
Weekly reevaluation of SNF insurance rehabilitation coverage in the absence of meaningful progress may or may not be useful in older patients. A psychological stressor such as withdrawal of benefits may be offset by problematic osteoarthritis and pain in older patients.28 Moreover, older patients have a lower tolerance to exercise compared with younger patients, perhaps partly driven by a lower maximum oxygen consumption and perhaps lower bioenergetics.29,30 Undoubtedly, the higher incidence of cognitive impairment in Medicare patients than in patients with other forms of insurance also can hinder functional recovery, even if the cognitive impairment is transient.
The SNF patients with County Care contracts were more likely to attain 20%, 40%, 60%, and 80% of their PT goals compared with Medicare recipients. The difference in the attainment of the all-or-none PT goals between County Care and Medicare enrollees was due to age, gender, and baseline functional status. We found that women were less likely to achieve their PT goals, a finding that contrasts with other studies that show women as being more likely than men to improve in their functional status.31,32
This study has some limitations in defining the relationship of patients’ recovery to the terms of their insurance policy. These limitations include the following: a relatively young cohort of older patients; patients who predominantly are among a racial minority; an urban setting; a lack of data about patients’ nutritional status; a lack of data about patients’ rate of depression; a lack of data about patients’ nutritional status; a lack of data on how soon they start in-hospital PT and OT; and possible variation in how patients’ SNF goals are determined.
It is well known that race and income disparities influence functionality with age.33-36 Medicare recipients also were significantly older than patients covered by commercial insurance, but the average functional status of Medicare recipients was not significantly different from that of commercially insured patients, thus suggesting that physiologic condition rather than chronologic age dictates posthospitalization functional status.
Conclusion
In conclusion, based on this study, health insurance policies with a weekly renewal of SNF benefits based on attainment of SNF goals appear to be more effective in patient’s achieving SNF rehabilitation goals than the Medicare benefits. Different insurance sources for SNF care have different policies about duration and continuation of care that could influence patients’ attainment of therapist-guided goals. These results present the first known observation of a link between patients’ SNF insurance plan policy and health care outcomes.
Affiliations, Disclosures, & Correspondence
Authors: Samson Barasa, MD, MS1 ; Donald A Jurivich, DO2
Affiliation:
1 Hospitalist Family Medicine and Geriatrics at Peace Health Sacred Medical Center, Eugene, OR
2 University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND
Disclosures:
The authors report no relevant financial relationships.
Acknowledgements:
The Division of Academic Internal Medicine and Geriatrics,
University of Illinois at Chicago.
The Clinical and Translation Science Program at the School of Public Health,
University of Illinois at Chicago.
Address correspondence to:
Donald A Jurivich
501 North Columbia Road, Stop 9037
Grand Forks, ND 58202-9037
Phone: (701) 777-6949 Fax: (701) 777-6478
Email: donald.jurivich@med.und.edu
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