Trends in Skilled Nursing Facility and Swing Bed Use (Post Medicare Modernization Act of 2003)

Return to search

Background of trends in skilled nursing facility and swing bed use in rural areas

Reimbursement for facility-based post-acute skilled care has been affected by multiple regulatory changes, particularly during the period from 1997 to 2003. Payment for post-acute skilled care received in freestanding or hospital-based skilled nursing facilities (SNFs) was changed from cost-based to a 100% per diem prospective payment system (SNFPPS). Reimbursement for swing bed care in hospitals paid under the prospective payment system (PPS hospitals) changed from a mix of cost-based payment for ancillary services and per-diem payment for routine care to 100% SNFPPS. In contrast, reimbursement for swing bed care in Critical Access Hospitals (CAHs) changed from a mix of cost and per diem to 101% of cost. Now that the reimbursement policy changes begun in the late 1990s have been fully implemented, has the availability of post-acute skilled care stabilized, and how and where is it being provided today? To answer these questions, we used hospital and SNF Medicare Cost Reports linked with county demographic information to analyze changes in facility-based post-acute skilled care availability and use in recent years. Results are presented comparing micropolitan counties (those with an urban core population of at least 10,000 but less than 50,000) to more rural non-core based statistical area (non-CBSA) counties, those with an urban core of less than 10,000 or no urban core. In the case of hospital-based care, we compared the two predominant types of hospitals in rural areas, i.e., PPS hospitals and CAHs. KEY FINDINGS • The availability of post-acute skilled care varies by rural county size. SNFs and/or swing beds are available in most micropolitan counties. The most rural counties (non-CBSA counties) are more likely to have no skilled care and depend more on swing beds. • Overall days in post-acute skilled care are dominated by care in community-based SNFs. Over 90% of skilled care days in 2008 were provided in community-based SNFs. Hospital-based SNF days outnumbered swing days by 8 to 1. • The availability of hospital-based SNFs decreased over the period under study. Most of the decrease was among hospitals in micropolitan counties (37% had SNFs in 2003 v. 29% in 2008) and among PPS hospitals (34% in 2003 v. 28% in 2008). There was little change in non-CBSA counties (25% v. 23%) and among CAHs (26% v. 23%). • The percent of rural hospitals with swing beds changed little. Over 90% of hospitals that were always CAH or that converted during the study period offered swing bed care. PPS hospitals with swing beds represented about 60% of all PPS hospitals across all years. • The number of CAHs increased from 2003 to 2008 but their use of swing beds as measured by average daily census (ADC) increased modestly and only in non-CBSA counties. The swing bed ADC in non-CBSA CAHs increased from 1.73 to 1.97. For CAHs in micropolitan counties and for PPS hospitals in micropolitan and non- CBSA counties, swing bed ADC decreased (1.89 v. 1.69, 0.78 v. 0.73, and 1.48 v. 1.27, respectively).

Download the findings report