Skilled Nursing Facility Discharges Spike When Medicare Copayments Kick In

Patients are discharged from skilled nursing facilities at notably higher rates around day 20 of their Medicare benefit period, compared with day 19 or day 21, a study published Tuesday in JAMA Internal Medicine found.

The authors of the study, who hailed from the University of Pennsylvania and the University of Chicago, studied patients discharged from an acute care hospital to a SNF between January 1, 2012, and November 1, 2016.

During that span, 220,037 patients were discharged from the SNF on benefit day 20, compared with 131,558 discharges on benefit day 19 and 121,339 discharges on benefit day 21.


On the 21st day of a Medicare SNF stay, most patients become responsible for a daily copayment of more than $150.

In addition, patients discharged on benefit day 20 were more likely to live in areas of lower socioeconomic status, compared with those discharged from a SNF before or after day 20. They were also more likely to be racial or ethnic minorities.

“Our results suggest that SNFs are more likely to discharge economically vulnerable patients right before their copay kicks in,” Dr. Paula Chatterjee, one of the study authors, told Skilled Nursing News via email. “It’s critically important to understand whether patients are involved in the decision about timing of discharge in relation to the copay.”


There could be different reasons a patient leaves on day 20, she explained. SNFs could want to discharge patients unable to pay the copay, which increase from $0 to $150 from day 20 to day 21, as the associated bad debt reduces the profitability of the SNF stay. Alternatively, the patients who can’t afford it may be requesting discharge to avoid getting hit by the charges, Chatterjee said.

“Both the perception of bad debt and the personal financial strain of the copay are likely to affect poor and vulnerable patients more than other patients,” she told SNN.

The study was limited to fee-for-service Medicare beneficiaries without other sources of insurance, so the discharge trends may not necessarily apply to Medicare population as a whole, the authors noted. In addition, the socioeconomic findings were based on the ZIP code associated with each resident, rather than at the individual level.

“Nonetheless, these findings suggest an association between disproportionately high SNF discharge rates of vulnerable patients and existing Medicare payment policies,” the researchers wrote.

The authors used data from the Centers for Medicare & Medicaid Services’ (CMS) Minimum Data Set (MDS) 3.0 and the Medicare Provider Analysis and Review files; certain residents — including those dually eligible for Medicare and Medicaid, those with supplemental insurance, and those who had received hospice care — were excluded from the analysis.

Payment policies need to be designed while keeping in mind the potential for unintended consequences like the discharge patterns found in the study — and those outcomes must be offset by balancing existing payment structures with the incentive to provide the best outcomes regardless of insurance, the authors wrote.

Those outcomes are another unknown element in the study, Chatterjee noted.

“Unfortunately, we don’t know what the health implications are at this point,” she told SNN.

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