State policies and nursing home investment in internal and external palliative care

Objective: To understand how Medicaid reimbursement policies may be associated with nursing home (NH) investment in palliative care (PC) Methods: In 2009/10 we surveyed a nationally representative sample of NH Directors of Nursing (DoNs) at 4,149 NHs. Contact was achieved with 3,520 DoNs and 61.6% responded. The survey included questions on PC knowledge and practices from the validated NH “PC Survey.” Based on scored responses, a variable representing whether a NH had made a substantial investment in “internal PC” (score above the median) was created. NH investment in (external) PC was represented by the proportion of days NH residents spend on hospice, and was obtained from the LTCFocUS internet site. Multivariate linear and logistic regression analyses were conducted. Controlling for hospice certificate of need, examined were the presence of Medicaid casemix reimbursement (with or without exclusion of hospice residents in its rate calculation) and NH pass-through payment (hospices receive Medicaid NH per diem payment and “pass-through” to NHs). Results: In states where Medicaid NH per diems for hospice residents are paid directly to NHs, NHs had a significantly lower likelihood of making a substantial investment in internal PC (AOR 0.44, CI 0.24, 0.83), but had a greater external investment (i.e., greater hospice use; coefficient 1.24, SE 0.42). In this cross-sectional analysis no significant association was observed between casemix policy and PC investment. Implications: Findings suggest that NHs are responsive to payment policies. Considering this, incorporating PC performance measures into Medicaid NH pay-for-performance systems could potentially increase NH investment in PC.