Effect of Swing Bed Use on Medicare Average Daily Cost and Reimbursement in Critical Access Hospitals.

摘要

The Medicare Payment Advisory Commission (MedPAC) has expressed concern that cost-based reimbursement has led to more rapid cost growth among Critical Access Hospitals (CAHs) as compared to other rural hospitals, with much of the growth driven by disproportionately high payments for post-acute skilled care services provided in swing beds.1 For CAHs, that receive 101% of allowable costs for most Medicare patients, the concern is that the Medicare program pays more per day for a skilled nursing patient in a hospital swing bed than for a similar patient who is in a skilled nursing facility (SNF). Although direct comparison of the cost of skilled care across multiple settings is quite complex and is thus beyond the scope of this study, this brief computes the daily cost of swing beds. However, the daily cost to Medicare of a swing bed patient in a CAH is not known, as the cost of swing bed care is not reported separately on hospital cost reports. CAHs are only required to report costs aggregated across both acute and swing bed patients; therefore, the average daily cost for inpatient care (acute and swing combined) is likely an understatement of the cost of care for acute patients, and an overstatement of the cost of care for skilled patients in swing beds. To the extent that fixed costs2 drive the cost of providing skilled care in swing beds, then any savings to Medicare from reduced swing bed utilization would be offset by higher costs per day for acute patients in hospitals receiving cost-based reimbursement. In this analysis, the terms net cost and net expenditures are used to refer to Medicare expenditures on swing bed care, net of increases in Medicare spending on acute inpatient days if swing bed days are reduced. The overall effect of swing bed days on Medicare expenditures is influenced both by the effect of swing bed days on the inpatient (acute and swing) cost per day, and by the percent of inpatients (in both acute and swing beds) that are covered by Medicare. This analysis estimates the average net cost to Medicare of a SNF swing day by simulating the elimination of all Medicare SNF swing bed days in CAHs in 2009.