KFGO had a great article about a recent study in JAMA Internal Medicine which indicated that nursing homes often discharge Medicare patients before daily co-payments kick in which suggests that nursing homes send some patients home for financial reasons before they’re medically ready to leave.

“Medicare pays for 100% of postacute care provided by skilled nursing facilities (SNFs) during the first 20 days within a benefit period. However, on the 21st day, most patients become responsible for a daily copayment of more than $150.1 This copayment may present a significant financial burden for some patients—particularly those with limited economic means—and motivate them to discharge from SNFs on the 20th day of care based on their financial resources rather than their recovery status. Skilled nursing facilities may also prematurely discharge some patients to avoid the risk of accruing bad debt from partially uncompensated postacute care. However, it is not known whether patterns of SNF discharge are associated with this change in Medicare payment responsibility on day 20.”

To see how the start of co-payments might impact discharge timing, researchers examined data on more than 4.5million skilled nursing facility discharges from January 2012 through November 2016.

Overall, a total of 220,037 patients were discharged on day 20, more than the 131,558 sent home on day 19 and the 121,339 released on day 21. Compared to patients discharged on days 19 or 21, those sent home on day 21 were more likely to suffer from multiple chronic medical conditions, live in poor neighborhoods, and be racial or ethnic minorities, the study found.

“Our results suggest that skilled nursing facilities are more likely to discharge economically vulnerable patients right before their copay kicks in,” lead study author Dr. Paula Chatterjee of the Perelman School of Medicine at the University of Pennsylvania in Philadelphia said by email.

On day 20, for example, 12.5 percent of patients discharged were black or Hispanic, compared with 8.2 percent one day earlier and 7.5 percent one day later, the study found.

And on day 20, 15.2 percent of patients discharged were living in poverty and 7.7 percent were unemployed. These economically vulnerable patients represented a smaller proportion of those discharged one day earlier or later.

On day 20, however, 42.2 percent of discharges were patients with at least five different chronic health problems, compared with 39.9 percent on day 19 and 40.6 percent on day 21.

At the same time, patients more likely to be discharged on day 20 tended to fit the profile of patients who have had higher rates of hospital use and repeat hospitalizations in other studies, said Dr. Jennifer Goldstein of the Christiana Care Health and Sidney Kimmel Medical College in Philadelphia.

Those characteristics include male sex, African American race, Hispanic ethnicity, low-income demographics and a high burden of disease,” Goldstein, who wasn’t involved in the study, said by email.

The results “raise concerns that patients are forgoing needed medical care because of ability to pay, and/or that skilled nursing facilities are selectively discharging such patients out of concern patients will not be able to afford the copay,” said Dr. Ann Sheehy of the University of Wisconsin School of Medicine and Public Health in Madison.

“If financial reasons, as opposed to medical readiness, drive skilled nursing facility discharge, this could negatively impact health and safety for the most vulnerable Medicare beneficiaries,” Sheehy, who wasn’t involved in the study, said by email.

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