Payment Systems, Market Factors and Long-term Care Hospitals

描述（由申请人提供）：令人惊讶的是，人们对长期护理医院（LTCH）及其在急性后护理（PAC）市场中的作用以及近年来他们的做法如何改变以应对医疗保险的预期支付系统（LTCH-PPS）知之甚少。LTCH是经认证的急性护理医院，主要为患有复杂疾病的长期住院患者提供服务。LTCH在历史上在医疗保健系统中发挥了相当小的作用， 但近年来，在数量、医疗保险支出和重要性方面都迅速增长。围绕LTCH的政策问题突出表明，人们对LTCH的作用和做法知之甚少，并反映了有关不同支付系统如何相互作用和影响治疗和入院决策的基本未回答的问题。随着美国人口老龄化和医疗护理的地点继续从急性医院环境转移，重要的是要充分理解在特定PAC环境中提供的护理的价值。这种理解是有效分配卫生资源的必要组成部分。LTCH通常是最昂贵的PAC设置，临床相似患者的付款率高达其他PAC提供者收到的费率的12倍。LTCH在全国的分布极不均匀：一些城市有多个LTCH，而几个州没有LTCH在运行。LTCH护理的相对昂贵及其分布不均匀引发了人们对LTCH护理“必要性”的质疑。一方面，无LTCH的市场的健康结局并不比有LTCH的市场差（MedPAC 2003 a）。另一方面，相对密集的长期医院护理的益处可能集中在通常由LTCH服务的小群体中。本论文有三个具体目标。首先，本文将描述LTCH及其在PAC市场中的作用，与其他共存的PAC提供商（熟练护理设施（SNF）和住院康复设施（IRF））相比。该分析将确定LTCH可能与其他供应商竞争患者的程度，LTCH入院的目标人群是最有可能从LTCH护理中受益的少数患者，并确定可能与LTCH位置决策相关的市场因素。其次，本文将测试LTCH如何响应LTCH-PPS。由于医院必须有资格作为LTCH获得医疗保险支付，LTCH在预期支付下面临竞争性的财务激励。这项分析将把PPS下的竞争性财务激励与住院时间和LTCH实践模式的变化联系起来。 最后，本论文将通过比较一小部分患者的健康结果来衡量LTCH护理相对于PAC替代品的附加价值。该分析将使用PAC设置（LTCH，SNF和IRF）中临床相似患者的医疗保险支付率的变化，以确定PAC中治疗强度对患者结局的“相对价格效应”。

DESCRIPTION (provided by the applicant): Surprisingly little is know about Long-Term Care Hospitals (LTCHs), their role in markets for post-acute care (PAC) and how their practices have changed in recent years in response to Medicare's prospective payment system (the LTCH-PPS). LTCHs are accredited acute care hospitals and primarily serve long-staying patients with complex medical conditions. LTCHs have historically played a fairly minor role in the health care system, but in recent years have grown quickly in number, in Medicare outlays and in importance. The policy issues surrounding LTCHs highlight just how little is known about LTCHs' role and practices and reflect largely unanswered questions about how distinct payment systems may interact and influence treatment and admission decisions. As the US population ages and as the site of medical care continues to shift away from the acute hospital setting, it is important that the value of care delivered in particular PAC settings is well understood. This understanding is a necessary component to efficient allocation of health resources. LTCHs are generally the most expensive PAC setting and payment rates for clinically similar patients have been as high as 12 times the rates received by other PAC providers. LTCHs have an extremely uneven distribution across the country: some cities have multiple LTCHs while several states have no LTCHs in operation. The relative costliness of LTCH care and their uneven distribution raise questions as to the 'necessity' of LTCH care. On one hand, markets without LTCHs have not experienced worse health outcomes than those with LTCHs (MedPAC 2003a). On the other hand, the benefits of relatively intense long-term hospital care may be concentrated in the small population typically served by LTCHs. This dissertation has three specific aims. First, this dissertation will describe LTCHs and their role in markets for PAC vis-¿-vis other co-existing PAC providers (skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs)). This analysis will identify the extent that LTCHs may compete with other providers for patients, the extent that LTCH admissions are targeted among the narrow set of patients most likely to benefit from LTCH care, and identify market factors potentially related to LTCH location decisions. Second, this dissertation will test how LTCHs have responded to the LTCH-PPS. Because hospitals must qualify as LTCHs for Medicare payment, LTCHs face competing financial incentives under prospective payment. This analysis will relate competing financial incentives under PPS to changes in length of stay and LTCHs' practice patterns. Finally, this dissertation will measure the additional value of LTCH care over its PAC alternatives by comparing the health outcomes of a narrow set of patients. This analysis will use variation in Medicare payment rates for clinically similar patients across PAC settings (LTCHs, SNFs and IRFs) to identify the 'relative price effect' of treatment intensity on patient outcomes in PAC.