Trends in Post-Acute Care in US Nursing Homes: 2001-2017

Abstract

Objective: To describe recent trends in post-acute care provision within nursing homes, focusing specifically on nursing homes' degree of specialization in post-acute care.

Design: Retrospective cohort study.

Setting and participants: All US nursing homes between 2001 and 2017 and all fee-for-service Medicare admissions to nursing homes for post-acute care during that time.

Methods: We measured post-acute care specialization as annual Medicare admissions per bed for each nursing home and examined changes in the distribution of specialization across nursing homes over the study period. We described the characteristics of nursing homes and the patients they serve based on degree of specialization.

Results: The average number of Medicare admissions per bed increased from 1.2 in 2001 to 1.6 in 2017, a relative increase of 41%. This upward trend in the number of Medicare admissions per bed was largest among new nursing homes (those established after 2001), increasing 68% from 2001 to 2017. In contrast, nursing homes that eventually closed during the study period experienced no meaningful growth in the number of admissions per bed. Over time, the number of Medicare admissions per bed increased among highly specialized nursing homes. The number of Medicare admissions per bed grew by 66% at the 95th percentile and by 25% at the 99th percentile. Nursing homes delivering the most post-acute care were more likely to be for-profit or part of a chain, had higher staffing levels, and were less likely to admit patients who were Black, Hispanic, or dually enrolled in Medicare and Medicaid.

Conclusions and implications: Over the last 2 decades, post-acute care has become increasingly concentrated in a subset of nursing homes, which tend to be for-profit, part of a chain, and less likely to serve racial and ethnic minorities and persons on Medicaid. Although these nursing homes may benefit financially from higher Medicare payment, it may come at the expense of equitable access and patient care.

Keywords: Skilled nursing facilities; medicare; post-acute care.

Figure 1.

Medicare admissions per bed across all nursing homes, and by whether the nursing home newly opened and entered the market during the study period (new nursing homes), closed and exited the market during the study period (exiting nursing homes), and remained in operation throughout the study period (staying nursing homes).

Figure 2.

Medicare admissions per bed in each year of the study. Each dot represents one nursing home. The 50^th, 95^th, and 99^th percentiles are marked with black horizontal lines. Note: The top 0.5 percent of the distribution in each year is not shown. This excludes between 62 and 70 nursing homes per year from this chart.