Do Higher-Cost Settings Deliver Better Outcomes? Post-Acute Care Efficiency in Medicare Skilled Nursing Facilities and Home Health Agencies
Journal of Health Economics · 2026 · Fangli Geng、Jianyun Gong、Pedro L. Gozalo、David C. Grabowski
中文摘要
对于临床相似的患者，确定不同事后急性期照护环境的价值对服务提供方和支付方而言十分重要。本研究考察了事后急性期照护（PAC）环境对联邦医疗保险支出及短期患者结果的因果效应，研究对象为因中风或充血性心力衰竭（CHF）接受治疗后出院的受益人。使用2013-2017年联邦医疗保险索赔数据，我们实施了一项工具变量策略，利用医院服务区层面上专业护理机构（SNF）床位占用率的日度变异，以估计SNF相对于家庭卫生机构（HHA）照护的局部平均处理效应。我们的发现表明，平均而言，在中风和CHF患者中，SNF照护与HHA照护在30天死亡率或再住院率上无显著差异。然而，95%置信区间并未排除30天死亡率在临床上具有意义的下降。同时，SNF照护与每PAC周期约4700美元更多的联邦医疗保险支出相关联。在SNF产能更受限的市场中，支出差距更大，尤其是在实施需求认证法规的州、农村地区和低收入社区。然而，平均而言，我们未能在这些市场中检测到短期健康结果上具有统计显著的差异，这表明供给约束可能放大了SNF使用的支出影响，而PAC环境与短期临床结果之间的关系仍不确定。这些发现强调了将PAC出院决策与临床需求及当地产能考量相一致的重要性，尤其是在基于价值的支付模式下。
Abstract
Determining the value of different post-acute care settings for clinically similar patients is important for providers and payers. This study examines the causal effect of post-acute care (PAC) setting on Medicare spending and short-term patient outcomes among beneficiaries discharged from hospitals following treatment for stroke or congestive heart failure (CHF). Using 2013-2017 Medicare claims data, we implement an instrumental variable strategy that exploits daily variation in skilled nursing facility (SNF) bed occupancy at the hospital service area level to estimate the local average treatment effect of SNF versus home health agency (HHA) care. Our findings reveal no significant differences, on average, in 30-day mortality or rehospitalization rates between SNF and HHA care among stroke and CHF patients. However, the 95% confidence intervals do not exclude clinically meaningful reductions in 30-day mortality. Meanwhile, SNF care is associated with approximately $4700 more in Medicare spending per PAC episode. The spending gap is larger in markets with more constrained SNF capacity, particularly in states with Certificate of Need regulations, rural areas, and low-income neighborhoods. However, we do not detect statistically significant differences in short-term health outcomes across these markets on average, suggesting that supply constraints may amplify the spending implications of SNF use while the relationship between PAC setting and short-term clinical outcomes remains uncertain. These findings highlight the importance of aligning PAC discharge decisions with both clinical needs and local capacity considerations, particularly under value-based payment models.