Center for Health Policy and Research (CHPR) Publications


Changes in the use of postacute care during the initial Medicare payment reforms

UMMS Affiliation

Center for Health Policy and Research

Publication Date


Document Type



Acute Disease; Data Collection; *Health Care Reform; Home Care Services; Humans; Insurance Claim Reporting; Logistic Models; Medicare; Patient Discharge; Rehabilitation Nursing; Reimbursement Mechanisms; United States


Health Services Administration | Health Services Research | Public Health


OBJECTIVE: To examine changes in postacute care (PAC) use during the initial Medicare payment reforms enacted by the Balanced Budget Act of 1997.

DATA SOURCES: We used claims data from the 5 percent Medicare beneficiary sample in 1996, 1998, and 2000. Linked data from the Denominator file, Provider of Service file, and Area Resource File provided additional patient, hospital, and market-area characteristics.

STUDY DESIGN: Six disease groups with high PAC use were selected for analysis. We used multinomial logit regression to examine how PAC use differed by year of service, controlling for patient, hospital, and market-area characteristics.

PRINCIPAL FINDINGS: There were major changes in PAC use, and a portion of services shifted to settings where reimbursement remained cost-based. During the first reform, the home health agency interim payment system, home health use decreased consistently across disease groups. This decrease was accompanied by increased use in skilled nursing facilities (SNFs). Following the implementation of the prospective payment system for SNFs, the use of inpatient rehabilitation facilities increased.

CONCLUSIONS: The shift in usage among settings occurred in two stages that corresponded to the timing of payment reforms for home health agencies and SNFs. Evidence strongly suggests the substitutability between PAC settings. Financial incentives, in addition to clinical needs and individual preferences, play a major role in PAC use.

DOI of Published Version



Health Serv Res. 2006 Aug;41(4 Pt 1):1338-56. Link to article on publisher's site

Journal/Book/Conference Title

Health services research


At the time of publication, Wen-Chieh Lin was not yet affiliated with the University of Massachusetts Medical School.

Related Resources

Link to Article in PubMed