As the largest single source of health care spending, hospitals have drawn considerable attention from policymakers. Efforts to reduce costs have led to decreased lengths of hospital stays, but far less attention has been paid to where those patients go immediately after discharge. Medicare payment reforms implemented in the wake of the Affordable Care Act, such as hospital readmissions penalties and bundled payments, have made hospitals accountable for care beyond their walls, including institutional post-acute care. In a new Research Letter in JAMA, Rachel Werner and R. Tamara Konetzka assess how post-acute care has changed for Medicare beneficiaries from 2000-2015.

The authors analyzed more than 137 million hospital discharges, and adjusted for patient age, sex, race, and comorbidities. They find that the percentage of discharges to institutional post-acute care, including skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs) increased from 21% in 2000 to 26.3% in 2015.

Proportion of Medicare Beneficiaries Discharged to Institutional Post-Acute Care vs. Discharged Home, JAMA. 2018;319(15):1616-1617. doi:10.1001/jama.2018.2408

Among patients discharged to post-acute care, the hospital length of stay decreased from 9 days in 2000 to 7.3 days in 2015, while the length of stay in post-acute care increased from 21.7 days to 25.7 days in 2014 (with a slight decrease to 25.1 days in 2015).

Mean Length of Stay in the Hospital, in Post-Acute Care, and in the Combination of Hospital and Post-Acute Care, JAMA. 2018;319(15):1616-1617. doi:10.1001/jama.2018.2408

The increases in post-acute care and length of stay might come as a surprise to those who assumed that payment reform would lead to declines in PAC use, although more time may be needed for changes to occur. Payment reform could affect post-acute care in different ways. SNFs account for 85% of institutional post-acute care, at considerable expense. Hospitals operating under a system than bundles payment for acute and post-acute care, for example, might try to reduce post-acute care to save money, as was shown in an analysis of bundled payment for joint replacement. Alternately, hospitals might increase use of institutional post-acute care if such care might improve recovery and reduce readmissions (and the penalties attached to them). SNFs are paid per diem, giving them a strong incentive to maintain longer lengths of stay.

Werner and Konetzka note that the benefit to patients of post-acute care is relatively uncertain, even as its use increases. Their study underscores the importance of further research on where patients should go after hospital discharge, and aligning financial incentives to achieve optimal outcomes.