Muse & Associates
A Comparison of Medicare Nursing Home Residents Who Receive Services from a Respiratory Therapist With Those Who Do NotAugust 1999
Respiratory Therapy (RT) is an integral component of Medicare Skilled Nursing Facility (SNF) care. On July 1, 1998, the Health Care Financing Administration (HCFA) implemented a Prospective Payment System (PPS) for Medicare SNFs. Since SNF PPS implementation, the American Association for Respiratory Care (AARC) estimates that approximately 75 percent of SNF respiratory therapists are no longer employed.
AARC and its members believe that services provided by RTs improve patient outcomes as demonstrated by numerous studies. AARC believes that the reimbursement driven decrease in utilization of RTs in Medicare SNFs produces poorer outcomes and higher costs.
Given these developments, Muse & Associates was commissioned by the AARC to use Medicare data to:
- Test the hypothesis that Medicare beneficiaries with major respiratory diagnoses in SNFs who receive services from respiratory therapists have better outcomes and lower costs than those who did not receive services from RTs.
- Compare cost and utilization patterns between beneficiaries who, during an initial SNF stay, received RT treatment with those that did not and investigate subsequent encounters with the Medicare system for both of these groups.
The analysis found that Medicare beneficiaries treated by RTs had better outcomes and lower costs then those not treated by RTs. A multivariate analysis and subsequent analyses further showed that these findings were true regardless of age or sex, the presence of comorbidities, or the incidence of stroke. The primary results of the analysis are summarized below. The detail of methodology and analyses then follow.
How many Medicare beneficiaries who are admitted to a SNF setting on an initial encounter with a diagnosis of Diseases of the Lung received respiratory therapy services?
An analysis of 1996 HCFA data shows that 137,300 Medicare beneficiaries were treated in SNFs on an initial visit for Diseases of the Lung. Diseases of the Lung include: chronic bronchitis, chronic airway obstruction, pneumonitis due to solids and liquids, other diseases of the lung and pneumonia.
How many of these beneficiaries were treated by a respiratory therapist?
Approximately 73,540 (53.6 percent) of beneficiaries received services from a respiratory therapist during an initial SNF stay. In comparison, 63,760 (46.4 percent) beneficiaries did not receive services from a respiratory therapist on an initial SNF stay.
In comparing those receiving respiratory therapy from RTs and those not treated by RTs, what were the utilization rates and associated costs for hospital emergency room/outpatient visits after an initial SNF encounter?
About 31 percent more beneficiaries who were not treated by RTs but still received respiratory therapy from other health care practitioners during an initial SNF stay subsequently required services in a hospital emergency room/outpatient setting. In hospital ER/outpatient settings, Medicare spent 23 percent more to treat beneficiaries that did not initially receive services from RTs compared to those who did ($2.7 million vs. $2.2 million). For this group of ER treated first encounter beneficiaries, on a per capita basis, it cost approximately 11 percent more ($386 vs. $349) to serve a non-RT-treated patient as one who received RT services during the initial SNF stay.
What proportion of beneficiaries from the treated and not treated groups had to be readmitted to the SNF setting on their second encounter with the Medicare system during 1996?
A significantly higher proportion (14 percent) of Medicare beneficiaries who did not receive services from a RT during an initial SNF stay were readmitted to a SNF.
What proportion of beneficiaries had to be readmitted to the SNF setting on their third encounter with the Medicare system during 1996? How much less was spent on additional SNF stays for those beneficiaries who received RT services when compared to those who did not?
Those beneficiaries who received respiratory therapy services during an initial SNF stay are approximately 29 percent less likely to end up in a SNF on their third encounter. For third encounters, a lower proportion (25 percent) of dollars was spent on SNF care for RT-treated beneficiaries (24 percent RT-treated vs. 30 percent non-RT-treated).
Excluding physician visits, what is the most common treatment pattern for beneficiaries as they "flow" through the Medicare system?
For the most common flow pattern, after an initial SNF visit, the largest portion of Medicare beneficiaries have a first encounter in the hospital emergency room/outpatient setting, a second encounter back in the SNF setting, and a third encounter in the emergency room/outpatient setting. However, the RT treated group with an initial SNF stay appeared to have better outcomes and cost less than the non-RT treated group.
Were the better outcomes and lower costs for Medicare beneficiaries treated by RTs due to age, gender, and comorbidity differences between the groups?
No. A multivariate analysis showed that the better outcomes and lower cost findings were not due to age or sex differences between the groups. A comparison analysis of the two groups showed that the both groups had a similar number of comorbidities. Also, the incidence of stroke was about the same in both groups.
Do findings from this study support the conclusions of the earlier AARC-sponsored analyses that RT treated Medicare beneficiaries had shorter SNF lengths of stay (LOS)? If so, what are the Medicare savings associated with this shorter LOS?
Yes, subsequent analyses support the argument that shorter LOS for the RT-treated group can be attributed to the added expertise of a respiratory therapist and the efficacy of the clinical intervention. As a result of a 3.6 day shorter average length of stay for RT-treated beneficiaries in the SNF setting, RT care produced savings to Medicare of approximately $97.9 million.
Do RT-treated beneficiaries have lower death rates on subsequent contacts with the health care system than beneficiaries who did not receive RT services during their initial SNF stay?
Yes, for both the first and second contact beyond their initial SNF stay, RT treated beneficiaries had lower death rates than those who did not receive RT services during their initial SNF stay. At the time of first contact beyond the initial stay, the death rate for non-RT treated beneficiaries was 8.3 per 1,000. For the group of beneficiaries who received RT services during the initial SNF stay, the death rate was 4.8 per 1,000, 42 percent lower than for non-RT treated beneficiaries. At the second contact, the death rate was 14 percent lower than for non-RT treated beneficiaries.