Previously reported nursing home to nursing home transfer was 2–3 percent annually (Mor et al. 1997
; Hirth et al. 2000
), lower than the rate observed in this cohort of long-stay residents following hospitalization (5.4 percent). Whereas the cohorts and unit of analysis were different in those earlier studies, this suggests that the majority of nursing home to nursing home transfers occur via an intervening hospitalization. Moreover, residents who stayed longer in the hospital were more likely to be transferred to other nursing homes. These results suggest that a hospitalization is a catharsis for re-evaluation of a relative's goals of care and needs.
The study confirmed the hypothesis that bed-hold policies were associated with a lower rate of transfer to other nursing homes. Interestingly, this result did not vary by the generosity of the bed-hold policy. Moreover, higher Medicaid reimbursement was associated with a greater likelihood of return to the original nursing home, continuing a line of research that suggests that higher Medicaid payments for nursing home resident care are associated with better nursing home quality and resident outcomes, possibly due to financial stability allowing investment in infrastructure and staffing (Grabowski 2001
; Grabowski et al. 2004
; Intrator and Mor 2004
; Intrator et al. 2005
; Feng et al. 2008
). These findings indicate the need for a comprehensive analysis of the relative merits of bed-hold policies compared to their price and to other policies that might achieve comparable merits.
Nursing home transfer may be a consequence of potential quality differences between the baseline and new nursing home. A previous study showed that nursing home to nursing home transfer, though infrequent, was more common from lower quality facilities (Hirth et al. 2000
). However, the relative quality of the new facility was not investigated. Among residents transferred to another nursing home in this study, 48.8 percent subsequently returned to their baseline nursing home within 92 days, indicating that quality might not have been the reason for those transitions. Moreover, lower occupancy rate at the baseline nursing home did not appear to guarantee a return to that nursing home. Indeed, contrary to our expectations, lower occupancy was associated with more transfers to another nursing home, suggesting that occupancy per se might be a surrogate measure of nursing home quality with lower occupancy serving as a marker of poorer quality. Other literature suggests the relationship between lower occupancy and poor nursing home quality (Mor et al. 2004
; Smith et al. 2007
Medicare policies allow SNF care following a hospitalization of 3 days or more. Thus, it was hypothesized that one reason for hospitalization would be to establish resident eligibility for Medicare SNF-level care, which is generally compensated at higher rates than Medicaid (MEDPAC 2005
). Among residents returning to their baseline nursing home, only 20,387 (29.1 percent) returned with Medicare SNF level of care, while among residents transferred to another nursing home, 53.7 percent received Medicare SNF level of care from their new nursing home. Even though most nursing homes in the country were dually certified to provide Medicaid and Medicare covered services, it is likely that the type of SNF care required following a hospitalization was not available in residents’ baseline nursing home requiring the temporary transition.
There has been a growing concern regarding unnecessary hospitalizations (Saliba et al. 2000
; Miller et al. 2003
; Intrator et al. 2004
; Porell and Carter 2005
), another indicator of poor quality of care in nursing homes. Indeed, among the hospitalizations in this cohort, 30.6 percent were for an Ambulatory Care Sensitive condition, indicating the hospitalization could potentially have been avoided (Intrator et al. 2004
). Moreover, the fact that many hospitalizations did not result in SNF care increases doubts regarding the circumstances of the hospitalizations. As bed-hold policies have been associated with increased hospitalizations (albeit not more potentially preventable than otherwise), the number of potentially preventable hospitalizations would necessarily have been higher than without the policy.
Our cross-sectional analysis has several limitations. We identified associations between policy and discharge destination, but could not ascertain causality. Whereas we have controlled for occupancy with annually updated OSCAR data, we were unable to consider the day-to-day variations in occupancy that could disallow bed-hold payments. Therefore, some hospitalizations in states, which require minimum nursing home occupancy (e.g., 90 percent) in order to activate a bed-hold policy, may not have resulted in bed-hold payments. Furthermore, our cohort includes nongovernment paid nursing home residents for whom Medicaid bed-hold payments would not apply. However, both limitations serve to bias our results towards the null hypothesis of no bed-hold policy effect on discharge destination.
We conducted a rough cost estimate based on the model presented in and assuming 17.4 percent hospitalization rate without bed-hold and 22.3 percent with bed-hold (assuming AOR=1.36, based on prior literature). Using these figures, we estimated that bed-hold policies were associated with 9.5 fewer annual relocations for every 1,000 residents, with an associated 77.9 more hospitalizations. It is therefore instructive to examine the associated budgetary implications, especially in light of arguments made by the nursing home industry that bed-hold payments were integral to the financial viability of nursing homes (Florida 1999
; Massachusetts 2003
; Rotstein 2006
). A simple calculation shows that with a generous bed-hold policy such as in Massachusetts and New York, and other states that pay for bed-hold at 100 percent for 12 calendar days or more, the average Medicaid payment for the bed-hold would be $201.31 per resident per year.2
With a less generous bed-hold policy such as in Oklahoma, with a maximum of 5 days reimbursed annually at 50 percent, the extra revenue to nursing homes from the bed-hold policy would be $1.18 per resident year.3
A simple calculation shows that by increasing Medicaid daily reimbursement rate by 55 cents, the most generous bed-hold policies would be offset. Assuming that the causal effect of increased Medicaid rate on limiting hospitalizations and increasing return to baseline nursing home is unchanged, this substitution would encourage better quality care, and ultimately cost Medicare less by saving payments for the additional hospitalizations. These rough calculations, coupled with the lower levels of nursing home occupancy in today's markets, appear to indicate that bed-hold policies may have reached the end of their life.
In making this estimation, we acknowledge that we do not have all the inputs to conduct a full cost–benefit analysis regarding bed-hold policy. Specifically, any benefit or harm associated with relocation has yet to be quantified. For example, when a state has no bed-hold policy, some residents may refuse hospitalization to avoid loss of their bed (Nohlgren 2004
). In particular, if ill patients refuse hospitalization, mortality may increase. Providing care to more acutely ill patients in nursing homes ill-prepared to do so may take time away from other residents, increasing the potential for adverse events and litigation (Stevenson and Studdert 2003
). Absence of a bed-hold policy may prolong hospitalization due to difficulty in determining a locale for hospital discharge (Nohlgren 2004
). Verification of these potential effects will require further research.
A full-scale cost analysis examining all cost implications of removing or adding a bed-hold policy should be considered to further elucidate the issues of financial viability. A cost–benefit study could be designed to examine the costs relative to the social and personal benefits of such policies.