Is More Always Better? Financially Motivated Therapy and Patient Outcomes in Skilled Nursing Facilities

Abstract

ObjectiveTo determine if financially motivated therapy in Skilled Nursing Facilities (SNFs) is associated with patient outcomes. DesignCohort study using 2018 Medicare administrative data. Setting and Participants13,949 SNFs in the United States. Participants934,677 Medicare Part A patients admitted to SNF for post-acute rehabilitation (N=934,677). InterventionsThe primary independent variable was an indicator of financially motivated therapy, separate from intensive therapy, known as thresholding, defined as when SNFs provide 10 or fewer minutes of therapy above weekly reimbursement thresholds. Main Outcome MeasuresDichotomous indicators of successful discharge to the community vs institution and functional improvement on measures of transfers, ambulation, or locomotion. Mixed effects models estimated relations between thresholding and community discharge and functional improvement, adjusted for therapy intensity, patient, and facility characteristics. Sensitivity analyses estimated associations between thresholding and outcomes when patients were stratified by therapy volume. ResultsThresholding was associated with a small positive effect on functional improvement (odds ratio 1.07; 95% CI 1.06-1.09) and community discharge (odds ratio 1.03, 95% CI 1.02-1.05). Effect sizes for functional improvement were consistent across patients receiving different volumes of therapy. However, effect sizes for community discharge were largest for patients in low-volume therapy groups (odds ratio 1.27, 95% CI 1.18-1.35). ConclusionsPatients who experienced thresholding during post-acute SNF stays were slightly more likely to improve in function and successfully discharge to the community, especially for patients receiving lower volumes of therapy. While thresholding is an inefficient and financially motivated practice, results suggest that even small amounts of extra therapy time may have contributed positively to outcomes for patients receiving lower-volume therapy. As therapy volumes decline in SNFs, these results emphasize the importance of Medicare payment policy designed to promote, not disincentivize, potentially beneficial rehabilitation services for patients.