Operators Report Rising Length of Stay Pressure Under New Payment Models

Skilled nursing facilities are feeling pressure from several fronts to discharge patients within a specified time to meet strict length-of-stay (LOS) goals, according to a study recently published in Health Services Research.

Those include Medicare policy changes and market-based pressures, particularly from Medicare Advantage (MA) plans and hospitals participating in accountable care organizations (ACOs) and bundled payment programs.

The findings drew from 70 interviews with staff in 25 SNFs in eight U.S. cities, along with the LOS data for patients in those facilities.


ACOs’ strict target

One director of nursing in the Midwest region reported pressure from a hospital participating in an ACO program to reduce her facility’s LOS to 17 days. And she wasn’t the only one to run into that number as an LOS target when dealing with ACOs.

Several of the interviews reported SNFs running into 17 days as a target LOS, Denise Tyler of the nonprofit research institute RTI International, who was one of the study authors, told Skilled Nursing News.


“It’s not just the MA plans,” Tyler said. “It almost seems from our interviews that the ACOs were a little bit more strict in terms of ‘You’ve got your 17 days and that’s it.’ Whereas with the MA plans, there was some flexibility. You had to jump through a lot of hoops if you were the SNF, but [the SNFs] were able to have flexibility.”

Though she’s not sure where the 17-day SNF LOS metric came from, because of how consistently it came up in different areas of the country, Tyler speculated that some internal analysis identified that timeframe as particularly ideal.

Regardless of whether or not SNFs had reductions in their LOS, they all reported increased burdens in dealing with managed care organizations.

Those challenges included difficulties with additional paperwork and reauthorization processes, patients becoming unexpectedly responsible for the cost of part of their stay, and having to discharge patients that SNF staff felt would not be safe at home, the study reported.

How facilities respond

SNFs haven’t taken the pressure to reduce LOS lying down, and some have responded better than others, the study suggested. Several facilities reported developing programs and processes to follow up with patients that could be either unsafe at home or at risk of rehospitalization as a means of coping with LOS pressures.

Others resorted to slightly more underhanded methods. One facility secretly switched patients who lacked funds and could be at risk outside the facility to non-ACO doctors so the patients could “use their 100 days” under Medicare.

Other SNFs reported avoiding patients who could become long-stay and drive up the average LOS.

For Tyler, the biggest takeaway is that there are positive ways a SNF can respond to the pressure to drive down LOS. But there needs to be more discussion between the facilities and the payers: MA programs, for instance, could do a better job of explaining their obligations and benefits, she noted.

The relationship between SNFs and ACOs could also improve.

“SNFs might be more willing to invest in programs to further reduce LOS and facilitate coordinated transitions to the community were they more tightly integrated contractually [with ACOs],” the study said. “As it is, by not including SNFs as partners, ACOs could run the risk of SNFs seeking to remove patients from the ACO, as one of our SNFs reported doing.”

Written by Maggie Flynn

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