We investigated whether the reason why MS patients may be facing barriers to SNF care access because their care may be more costly than what facilities spend on other SNF residents. We found no significant association between the percentage of MS residents-days in an SNF in a given year and facility inpatient costs. We also found that government-owned SNFs were more likely to care for MS patients and that such facilities tended to have higher daily costs.
This finding could have several interpretations. First, government-owned facility may be less likely to discriminate against patients with unique needs and those who could potentially be a high burden on staff, like patients with MS. Second, these high-cost facilities are likely to have greater staff-to-residents ratio and may be able to provide more specialized services which patients with MS require and seek (e.g., mental health and psychological counseling; physical, occupational, and speech rehabilitation; and therapy [20
]). As a result, larger facilities may attract and admit more MS patients. Finally, public/government-sponsored facilities may serve a greater proportion of Medicaid-eligible residents including MS patients who often become eligible for Medicaid because of disability-related unemployment, long history of high medical bills, and, subsequently, poverty.
Our results also demonstrated that facilities with higher percentage of MS residents had lower resident turn-around and, actually, had lower CMI (average patient severity of illness). This is consistent with prior findings that MS residents are more likely to have permanent (custodial) SNF stays rather than transient stays, for rehabilitation or care-giver respite [21
]. Earlier studies also have indicated that MS patients with both functional and cognitive impairment were more likely to have a permanent nursing home admission [2
We also note that, on average, the percentage of MS patients among SNF residents (1.2%) was higher than that of MS prevalence among general population (0.1%) of the same age [22
]. This supports earlier reports [2
] that MS patients may have greater long-term and institutional care needs compared with general population. Our findings that SNFs in the South tended to have fewer residents with MS are consistent with the epidemiology of MS and the fact that MS prevalence is higher in the Northern regions compared with the Southern parts of the USA.
The fact that our study did not demonstrate an association between MS and SNF costs may have several explanations. Using the data from a national survey of informal caregivers, Buchanan et al. (2010) [2
] demonstrated that, in MS patients, age, bowel dysfunction, poorer health, functional decline, and caregiver burden were associated with increased probability of SNF admission. This is different from the general population where the need for long-term SNF care is often determined by patient cognitive status. MS patients are younger and have higher education and better cognitive status [23
] but worse functional status than a typical SNF resident. Current RUG-III systems include multiple qualifiers that may help better match level of a resident's need with facility reimbursement including ADL scores, special care (MS, tube feeding, and pressure ulcers), and impaired cognition among others. It is conceivable that the protective effect of age and education (positive predictors for cognition) and the negative effect of functional deficiencies (negative predictor of cognitive decline) cancel each other in terms of SNF costs. Bowblis (2012) [24
] also suggested that patients with long-term care needs and higher socioeconomic statuses may choose to reside in assisted-care facilities instead of SNFs. Similarly, Buchanan (2006) reported that the use of physical and occupational therapies by residents with MS at admission to the nursing facility was significantly associated with payment source, controlling for other independent variables [25
]. They concluded that when reimbursement was available, these therapies were more likely to be prescribed suggesting that type of health insurance coverage would be associated with patient SNF expenses. Finally, MS patients with greater resources and informal support may be benefiting from nursing home transitions programs that became available since the late 1990s [26
Because of the nature and timeframe of the administrative data used in this study, our analysis may have several limitations. First, the costs data were aggregated at the facility level, and, hence, we could only make indirect inferences about individual patient costs [27
]. We could not assess whether the patients with MS who received SNF care were representative of the entire population of MS patients with SNF needs, nor could we confirm that MS patients who did receive SNF care were selectively admitted to SNF because their perceived needs (at the time of admission) were comparable with facility resources. Another limitation of the analysis presented here is the lack of information about quality of care MS patients receive in these facilities. It is conceivable that in order to keep the costs similar for patients with special healthcare needs (like residents with MS) and other SNF residents, SNF administrators limit either quantity or selection of services necessary for patients with MS [25
]. Furthermore, behavioral and cognitive problems are common among long-term care residents and may substantially influence cost of their care [6
]. However, this study did not take into account the absence of mental or behavioral health diagnoses or symptoms among facility residents with or without MS. Finally, one may speculate that since resource utilization groups- (RUGs-) based case-mix measurement system [12
] was introduced to calculate nursing home reimbursement while adjusting for the resident's severity of illness and resource use, facilities no longer have financial disincentive for selectively avoiding patients with heavier or unique care needs, such as MS patients. Results of the CMS-funded Staff Time and Resource Intensity Verification (STRIVE) Projects provide SNF staff time use data that could help researchers examine the quality of nursing home care, including residents with and without MS [13
In summary, we found that providing SNF care for a greater proportion of MS patients has no significant effect on facility costs. There is some evidence indicating that MS patients are more likely to reside in larger, government-owned facilities, which are also more likely to serve Medicaid population and provide a greater variety of services that MS patients need and seek out. More research is needed to understand the needs and attitudes towards institutional care among community-dwelling individuals with MS and to identify optimal strategies for providing high-quality and cost-effective skilled nursing care to MS population. In addition to costs, future studies should examine quality of care and health outcomes in this population of MS patients.