Data Drives Skilled Nursing Referral Partnerships, But Residents Ignore It

As referral networks narrow and skilled nursing providers feel increased pressure to prove their worth to hospitals and doctors, one government agency says residents still frequently miss the highest-quality options in their own areas.

In its most recent report to Congress, the Medicare Payment Advisory Commission (MedPAC) asserts that many hospitals discharge post-acute care patients into skilled nursing facilities or home health agencies (HHAs) that aren’t necessarily the best in their region.

“Over 94% of beneficiaries who used HHA or SNF services had at least one provider within a 15-mile radius that had higher performance on a composite quality indicator than the provider they selected,” MedPAC observed in its June report, released late Friday.


In addition, about half of all eventual skilled nursing residents had at least five better options, at least from a quality measure standpoint, than the building where they eventually received care.

The non-partisan agency, which serves to advise Congress on Medicare matters, highlighted a growing disconnect in the long-term care world: Even while skilled nursing providers have increasingly turned to hard data on readmissions and other metrics to earn coveted spots in hospital referral networks, the actual residents face continued confusion around the SNF selection process.

Writing in the journal Health Affairs last summer, a group of researchers asserted that “little is known about how patients select a post-acute facility,” and compiled interviews with real-life residents who described the SNF-choosing process as stressful and hectic.


“They’d end up choosing the nearest place to their home from the list, or, if a friend or family member had been at a facility, they went to that one,” policy analyst Denise Tyler told SNN at the time. “For a third of people interviewed, this was not their first time at a SNF. They returned to the same one [where they had stayed before], even in cases where people had bad experiences.”

MedPAC took issue with the Centers for Medicare & Medicaid Services’ (CMS) Nursing Home Compare system, citing research showing that the expansion of publicly available information for SNF quality has had little to no impact on referrals to better-performing properties.

“The lack of impact is consistent with studies of the use of information about quality for consumers in other settings,” MedPAC noted. “Reviews of the health services literature have found that, while provider quality information can be useful for consumers, it has had limited or minimal success in getting beneficiaries to select higher-quality providers.”

The commission came up with multiple potential solutions for this problem, including the so-called flexible and prescriptive approaches. Under the former, each individual hospital network would develop benchmarks that all of the post-acute care providers in its network must meet, with oversight from CMS. The latter, meanwhile, would see CMS determine firm performance levels and require hospitals to tell residents about better-quality options in their areas.

Each has its drawbacks: The flexible approach would lead each hospital network to have its own set of quality benchmarks that couldn’t be easily compared across providers, while the prescriptive plan could shut some providers out of smaller markets.

“The number of PAC providers designated as high-quality would vary across markets,” MedPAC wrote. “Beneficiaries could find it difficult to select a higher-quality provider in areas with limited supply.”

Despite its call to push more residents into higher-quality facilities, MedPAC allowed that an individual’s personal calculus when picking a SNF also includes qualitative concerns.

“Beneficiaries may have important concerns that are not necessarily reflected in standard quality measures, such as language competency or proximity to family members,” the commission wrote. “These preferences may lead them to select a PAC provider that has lower performance on some quality measures, but additional quality information would allow them to better understand the nature of their options and any trade-offs.”

MedPAC releases a pair of detailed reports to Congress about Medicare issues twice per year, typically in March and June. Though the recommendations are specifically addressed to House Speaker Paul Ryan and Vice President Mike Pence — in his capacity as president of the Senate — lawmakers are under no obligation to incorporate MedPAC’s suggestions into their policymaking agendas.

Written by Alex Spanko

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