Abstract
Objectives:
To investigate disparities in admissions to highly rated skilled nursing facilities (SNFs) between Medicare beneficiaries with and without opioid use disorder (OUD).
Design:
Nationwide, retrospective observational cohort.
Setting and Participants:
Medicare fee-for-service beneficiaries aged 18+ admitted to SNFs following hospitalization during 2016-2020 (n=30,922 with OUD and n=137,454 without OUD).
Methods:
Data used were 100% Medicare inpatient claims, nursing home administrative databases, and Nursing Home Compare. We identified hospitalized patients with and without OUD and matched them on age, sex, Part D low-income subsidy (LIS), and residential county. We compared the overall and component (quality, staffing, and health inspections) star ratings of SNFs that beneficiaries entered. Beneficiary-level regression models were conducted adjusting for race and ethnicity, Medicare-Medicaid dual status, comorbidity score, hospital length of stay and state and year fixed effects.
Results:
The overall study sample had mean (standard deviation (SD)) age of 71.4 (11.4) years, 63.9% were female, and 57.4% had LIS. Among beneficiaries with OUD, 50.3% entered SNFs with above-average (4 or 5) overall rating compared with 51.3% among those without OUD. Distributions of above-average ratings among beneficiaries with and without OUD were: 63.9% versus 62.2% for quality, 32.8% versus 34.9% for health inspections, and 46.2% versus 45.0% for staffing; respectively. Adjusted regression models indicated beneficiaries with OUD were less likely to be admitted to facilities with above-average overall (OR=0.90, 95% CI:0.87-0.92), health inspection (OR=0.90, 95% CI:0.88-0.92), and staffing (OR=0.91, 95% CI:0.89-0.94) ratings compared with beneficiaries without OUD, while quality (OR=0.98, 95% CI:0.94-1.01) ratings did not differ.
Conclusions and Implications:
Despite mixed results on component ratings, our findings suggest a concerning disparity in the overall quality of SNFs admitting Medicare beneficiaries with OUD. Enhancing equitable access to high-quality to SNF care for individuals with OUD is imperative amid rising demand and legal protections under the American Disabilities Act.
Keywords: skilled nursing facility, opioid use disorder, post-acute care, Medicare, star rating
Brief summary:
Medicare beneficiaries diagnosed with OUD were admitted to skilled nursing facilities with lower overall star ratings than those without OUD. Findings on the component star ratings were mixed.
Background
Rates of opioid use disorder (OUD) and hospitalizations involving OUD are rising in Medicare.1 Skilled nursing facilities (SNFs) are an important provider of institutional post-acute care,2 and they are receiving more referrals for individuals with OUD.3 The quality of SNFs is a longstanding concern in the United States. Well-documented disparities related to socioeconomic status, race and ethnicity, and serious mental illness4-10 in access to high-quality SNFs raise questions about how other socially marginalized groups, such as individuals with OUD, fare.
Research suggests that individuals with OUD face barriers to accessing SNF care11-13 for reasons including limited facility resources,14-16 perceptions of individuals with OUD as threats to staff and other residents,14 and discriminatory admissions practices fueled by stigma.14, 17 Compared with hospitalized patients without OUD, those with OUD have been reported to experience statistically higher SNF referral rejection rates - exceeding 80% versus 66%.11-13 Moreover, there is notable county-level variation in OUD rates and the availability of treatment providers, which may exacerbate disparities in SNF access and quality for individuals with OUD.18, 19
Little is known about the characteristics of SNFs that admit individuals with OUD and national assessments are lacking. A Massachusetts study found that SNFs with a high proportion of referrals for individuals for OUD were less likely to be ranked highly (star rating of 4 or 5) compared with facilities with lower OUD referrals.12 High SNF referral rejection rates may limit SNF choice for individuals with OUD potentially contributing to disparities in access to higher-rated facilities. Therefore, our study objective was to assess whether OUD diagnosis affects admission to higher-quality SNFs.
Methods
Data sources
We used 2016-2020 national claims from the 100% Medicare Provider Analysis and Review (MedPAR) file linked to the Master Beneficiary Summary File (MBSF), Minimum Data Set (MDS) 3.0, Certification and Survey Provider Enhanced Reports (CASPER), and Nursing Home Compare (NHC). Hospitalization data came from MedPAR and ICD-10 codes were used to distinguish hospitalizations with and without OUD diagnoses. The MBSF provided the beneficiary characteristics. We used the Residential History File algorithm, which creates a person-level chronological history of health services use and location of care,20 to identify the hospital discharge location. SNF identification numbers from MDS were linked to NHC using the CMS certification number from CASPER as a crosswalk. NHC is a resource designed to help consumers choose nursing homes and was used to obtain star rating scores. SNF star ratings range from 1 to 5 with higher values indicating better quality performance.21
Study sample
We included fee-for-service Medicare beneficiaries 18+ years of age who had inpatient care in short-stay or critical access hospitals and were admitted in SNFs upon hospital discharge. We required continuous Medicare enrollment 6 months before and after hospitalization or until death, whichever occurred first during follow-up. We excluded beneficiaries who died during hospitalization, enrolled in Medicare Advantage (MA) - their claims may be incomplete, or resided outside the 50 states and the District of Columbia. We also excluded beneficiaries with prior SNF/nursing home stays in the 6 months preceding hospitalization to minimize sample heterogeneity as beneficiaries with multiple transitions and long-stay residence may be distinct from those with incident SNF admissions. We matched each beneficiary with OUD by exact age, sex as recorded, low-income subsidy status, and county of residence to up to 5 beneficiaries whose hospitalization did not involve OUD.
Measures
Outcomes:
The overall and component (MDS-based quality measures, staffing ratios, and health inspections/survey) star ratings of SNFs. We used star ratings observed at the start of the calendar year hospitalization occurred. When January ratings were missing, we used mid-year (June) values, imputed from other years, and marked ratings unknown if they still could not be identified. Overall, 87.9% of SNFs were matched to a star rating from NHC representing 93.4% of beneficiaries in our analysis. SNF star ratings were assigned to each beneficiary who entered a facility. We then obtained the average star ratings among beneficiaries with and without OUD.
Exposure:
We distinguished beneficiaries by whether their hospitalizations preceding SNF admission involved an OUD diagnosis. Since beneficiaries with OUD are not evenly distributed across counties and the county prevalence of OUD could be correlated with availability of highly rated SNFs, we included prevalence of OUD as an explanatory variable to plot bivariable regression lines (details below). We calculated the county-level prevalence of OUD-related hospitalizations, defined as the percentage of hospitalizations involving OUD among all individuals enrolled in Medicare in each county. We transformed the county-level percentage of OUD-related hospitalizations into percentile rank to aid interpretation. Binary OUD status was included in beneficiary-level multivariable regression analyses.
Covariates:
We identified each beneficiary’s race and ethnicity and Medicare-Medicaid dual status given their association with admission to high quality SNFs. Additionally, we controlled for comorbidities based on the Gagne score,22 hospital length of stay, and state and year fixed effects.
Analysis
We used Chi-square tests for categorical variables and Wilcoxon tests as a nonparametric alternative to t-tests to compare the mean star ratings of SNFs that admitted individuals with and without OUD.
To assess how the disparity in access to highly rated SNFs varies across counties with different OUD prevalence, we plotted the average SNF star rating separately for individuals with and without OUD with respect to OUD prevalence in the residential county. We generated bivariable regression lines and 95% confidence intervals for the relationship between SNF star ratings and percentiles of the county-level prevalence of OUD. Additionally, we conducted beneficiary-level multivariable logistic regression to further assess the relationship between OUD and dichotomized SNF star ratings of above-average (4-5) or at/below average (1-3). Analyses were performed using SAS version 9.4 (SAS Institute, Inc, Cary, NC) and Stata 18 (Statacorp, College Station, TX). The Brown University Institutional Review Board approved this study.
Results
We analyzed 30,922 beneficiaries with OUD matched to 137,454 without OUD who were admitted to 16,715 distinct SNFs from 2016-2020. The mean and standard deviation (SD) of age among beneficiaries with OUD was 70.6 (11.8) years, 63.5% were female, and 58.9% received the Part D low-income subsidy (Supplementary Table S1).
Approximately half of beneficiaries entered SNFs with above-average (4 or 5) overall star ratings (OUD: 50.3% vs. without OUD: 51.3%) – facilities are not mutually exclusive (Table 1). The mean (SD) of overall ratings was 3.40 (1.38) for SNFs that admitted beneficiaries with OUD and 3.46 (1.37) for SNFs that beneficiaries without OUD entered. Most beneficiaries entered SNFs with above-average star ratings for quality (OUD: 63.9% vs. without OUD: 62.2%). The mean (SD) of quality ratings was 3.90 (1.24) for SNFs that admitted beneficiaries with OUD and 3.88 (1.25) for SNFs that beneficiaries without OUD entered. A minority of beneficiaries entered SNFs with above-average health inspection ratings (OUD: 32.8% vs. without OUD: 34.9%). The mean (SD) of health inspection ratings was 2.82 (1.30) for SNFs that admitted beneficiaries with OUD and 2.92 (1.29) for SNFs that beneficiaries without OUD entered. The bivariable plots showed upward sloping lines indicating greater availability of higher rated SNFs in counties with higher OUD prevalence. The lines for beneficiaries without OUD were above the lines for beneficiaries with OUD for three of the four panels in Figure 1 implying that beneficiaries with OUD had a lower likelihood of admission to higher rated SNFs. The differences in overall ratings were narrow in counties with low OUD prevalence and widened as the prevalence increased (Figure 1A). Overlapping confidence intervals were observed for SNF quality ratings; however, SNFs entered by beneficiaries with OUD had lower mean staffing and health inspection ratings regardless of the county-level OUD prevalence (Figure 1B-D).
Table 1:
Characteristics of skilled nursing facilities entered by Medicare beneficiaries after hospitalization, overall and by opioid use disorder status
| Overall N=168,376 |
With OUD N=30,922 |
Without OUD N=137,454 |
P-value | |
|---|---|---|---|---|
| Facility characteristics, n (%) | ||||
| Ownership | ||||
| For profit | 116,028 (69.0) | 22,866 (74.0) | 93,162 (67.8) | |
| Nonprofit | 35,347 (21.0) | 5,515 (17.8) | 29,832 (21.7) | <.0001 |
| Government | 6,644 (4.0) | 997 (3.2) | 5,647 (4.1) | |
| Unknown | 10,357 (6.2) | 1,544 (5.0) | 8, 813 (6.4) | |
| Overall Star Rating | ||||
| Mean (SD) | 3.45 (1.37) | 3.40 (1.38) | 3.46 (1.37) | <.0001 |
| 1 | 17,584 (10.4) | 3,391 (11.0) | 14,193 (10.3) | |
| 2 | 28,426 (16.9) | 5,734 (18.5) | 22,692 (16.5) | |
| 3 | 25,864 (15.4) | 4,685 (15.1) | 21,179 (15.4) | <.0001 |
| 4 | 37,222 (22.1) | 6,846 (22.1) | 30,376 (22.1) | |
| 5 | 48,923 (29.1) | 8,722 (28.2) | 40,201 (29.2) | |
| Unknown | 10,357 (6.2) | 1,544 (5.0) | 8,813 (6.4) | |
| Health Inspections Star Rating | ||||
| Mean (SD) | 2.90 (1.29) | 2.82 (1.30) | 2.92 (1.29) | <.0001 |
| 1 | 28,858 (17.1) | 5,975 (19.3) | 22,883 (16.7) | |
| 2 | 34,501 (20.5) | 6,591 (21.3) | 27,910 (20.3) | |
| 3 | 36,484 (21.7) | 6,678 (21.6) | 29,806 (21.7) | <.0001 |
| 4 | 39,206 (23.3) | 6,887 (22.3) | 32,319 (23.5) | |
| 5 | 18,970 (11.3) | 3,247 (10.5) | 15,723 (11.4) | |
| Unknown | 10,357 (6.2) | 1,544 (5.0) | 8,813 (6.4) | |
| Quality Star Rating | ||||
| Mean (SD) | 3.88 (1.24) | 3.90 (1.24) | 3.88 (1.25) | 0.0008 |
| 1 | 8, 654 (5.1) | 1, 593 (5.1) | 7, 061 (5.1) | |
| 2 | 18, 221 (10.8) | 3, 275 (10.6) | 14, 946 (10.9) | |
| 3 | 25, 826 (15.3) | 4, 727 (15.3) | 21, 099 (15.3) | 0.0129 |
| 4 | 35, 388 (21.0) | 6, 524 (21.1) | 28, 864 (21.0) | |
| 5 | 69, 880 (41.5) | 13, 242 (42.8) | 56, 638 (41.2) | |
| Unknown | 10, 407 (6.2) | 1, 561 (5.0) | 8, 846 (6.4) | |
| Staffing Star Rating | ||||
| Mean (SD) | 3.32 (1.14) | 3.33 (1.11) | 3.31 (1.14) | 0.1239 |
| 1 | 14, 008 (8.3) | 2,452 (7.9) | 11,556 (8.4) | |
| 2 | 20,166 (12.0) | 3,585 (11.6) | 16,581 (12.1) | |
| 3 | 45,799 (27.2) | 8,726 (28.2) | 37,073 (27.0) | <.0001 |
| 4 | 54,792 (32.5) | 10,509 (34.0) | 44,283 (32.2) | |
| 5 | 21,424 (12.7) | 3,769 (12.2) | 17,655 (12.8) | |
| Unknown | 12,187 (7.2) | 1,881 (6.1) | 10,306 (7.5) | |
| Prevalence of OUD hospitalizations in county (%) | ||||
| Mean (SD) | 2.1 (1.4) | 2.7 (1.9) | 2.0 (1.2) | <.0001 |
| Prevalence of county-level OUD hospitalizations (Percentile) | ||||
| Mean (SD) | 50.5 (28.9) | 61.8 (27.8) | 47.9 (28.5) | <.0001 |
| Overall star rating by OUD hospitalizations percentile, mean (SD) | ||||
| Percentile <21 | 3.34 (1.41) | 3.27 (1.41) | 3.35 (1.40) | 0.0015 |
| Percentile 21-50 | 3.42 (1.39) | 3.38 (1.40) | 3.43 (1.39) | 0.0007 |
| Percentile 51-75 | 3.49 (1.36) | 3.41 (1.38) | 3.51 (1.35) | <.0001 |
| Percentile ≥76 | 3.53 (1.38) | 3.45 (1.37) | 3.56 (1.34) | <.0001 |
OUD, opioid use disorder; SD, standard deviation
Figure 1:
Variations in overall, quality, staffing, and health inspection star ratings by the county prevalence of opioid use disorder (OUD) hospitalizations.
Regression analyses indicated that beneficiaries with OUD were less likely to be admitted to higher-rated SNFs for overall (adjusted OR, 95% confidence interval=0.90 (0.87-0.92), staffing (aOR=0.91(0.89-0.94), and health inspection (aOR=0.90(0.88-0.92) measures, with no statistical differences for the quality (aOR=0.98(0.94-1.01) measure (Supplementary Table S2).
Discussion
We found that Medicare beneficiaries with OUD were admitted to SNFs with lower overall star ratings, influenced by staffing and health inspection ratings, relative to SNFs that admitted beneficiaries without OUD. There were mixed findings across the component star ratings. Differences in bivariable distributions of all star ratings between SNFs that admitted individuals with OUD versus those that did not were small in magnitude but statistically significant; however, only the overall, health inspection, and staffing ratings remained statistically significant after regression adjustment. The clinical significance of the findings is difficult to ascertain and deserves further research. Differences in overall ratings of SNFs that admitted beneficiaries with and without OUD could be explained by two primary factors. First, beneficiaries with OUD may reside in regions with lower access to highly rated SNFs. Second, within the same region, beneficiaries with and without OUD may be segregated into SNFs with different star ratings. Since individuals with OUD and highly rated SNFs are not randomly distributed across counties,4, 23, 24 the relationship between star ratings of admitting SNFs and county prevalence of OUD hospitalizations implies that individuals in regions with high OUD prevalence have higher overall access to highly rated SNFs. This relationship could be explained by greater social awareness of OUD and willingness to provide care in response to local demand for SNF services among individuals with OUD. However, despite this positive relationship, the lines representing individuals with and without OUD were nearly parallel, suggesting that individuals with OUD were admitted to SNFs with lower overall ratings than individuals without OUD residing in the same county.
With increases in adults aging with OUD and continued growth in opioid-related acute care use in Medicare,1, 25, 26 it is imperative to address disparities in the choice and quality of SNFs that individuals with OUD can access. Although administrators have cited concerns about managing OUD in SNFs,13, 14, 16 OUD is a chronic and treatable condition for which evidence-based medications are available. Recent policy changes including expanded coverage of OUD treatment in Medicare, elimination of the buprenorphine DATA-waiver (also known as the X-waiver) requirement and flexibilities for take-home methadone present opportunities to reduce barriers to SNF admission related to providing medications for OUD.27, 28 Other policy changes are still needed. These may include CMS incentives that provide enhanced reimbursement for SNFs to admit individuals with OUD and ensuring that SNFs providing behavioral health services for OUD are not penalized in health inspections and star ratings.
This study has limitations. First, we captured the ultimate hospital discharge location and lacked contextual information about SNF referral rejections which may disproportionately affect individuals with OUD.11 Therefore, individuals with OUD included in this analysis may differ from their counterparts with unsuccessful SNF referrals, potentially contributing to mixed findings and more conservative estimates of differences in star ratings between SNFs admitting individuals with and without OUD. Second, we ascertained OUD diagnosis from hospitalization data, excluding individuals with OUD when it is not a presenting or historic diagnosis. However, documentation of OUD during hospitalization is potentially more directly relevant for SNF admission considerations because such information is expected to be transmitted to SNFs in referrals. Lastly, this study focused on fee-for-service enrollees; therefore, the findings may not generalize to MA because of differences in use of services and preferred provider relationships between MA plans and SNFs.29, 30 Despite these limitations, post-acute care use and quality among individuals with OUD is understudied and this study is among the first to our knowledge to provide empirical national data that compares the distributions of SNF star ratings between facilities entered by Medicare beneficiaries with and without OUD.
In conclusion, this analysis suggests that Medicare beneficiaries with OUD received care in SNFs with lower overall star ratings than SNFs entered by beneficiaries without OUD; however, findings on the component ratings were mixed. While preliminary, these findings highlight the complexities of claims-based examinations of SNF use among individuals with OUD because of potentially meaningful differences between individuals with OUD who are accepted versus rejected by SNFs. It is imperative for future research to employ mixed-methods to evaluate access to, utilization, and outcomes of post-acute care among individuals with OUD to promote their receipt of equitable, evidence-based, and high quality SNF care.
Supplementary Material
Funding sources:
This work was supported by the National Institute on Drug Abuse (R21DA053518). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Sponsor’s role:
The funding sources for this study played no role in the design or conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
Footnotes
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Conflicts of interest: No conflicts of interest to report
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