Inpatient post-acute care utilization patterns and outcomes in Pennsylvania medicaid

The Medicaid expansion, one of the key provisions under the Affordable Care Act (ACA), has turned Medicaid into a larger player in the US healthcare system. The intent of the expansion was to increase access to essential healthcare services such as post-acute care (PAC) for low-income individuals. Studies have shown that variation in Medicare spending is attributed to the variation in post-acute care (PAC) utilization which includes care in home health, skilled nursing facilities (SNF), inpatient rehabilitation facilities (IRF), and long-term acute care hospitals (LTACH). However, very little is known about PAC utilization in the Medicaid population. For instance, Pennsylvania expanded Medicaid in January 2015, initially under a 1115 waiver and then under the original terms of the ACA. Many more individuals and families of low socioeconomic status were able to enroll in the Medicaid program as a result of the expansion. With studies pointing to PAC utilization and spending as the driver of variation in Medicare healthcare costs, the same may pertain to the Medicaid population. Chapter 1 provides the purpose, findings, and implications of the dissertation. Chapter 2 is a retrospective cohort study that determines the association between insurance type, either enrolled in Medicaid or commercial insurance, and the likelihood of being admitted to an inpatient PAC facility. The study found that hospitalized Medicaid beneficiaries were as likely as similar patients with commercial insurance to be admitted to any PAC facility but less likely to be admitted to an inpatient PAC facility (SNF, IRF, LTACH). This would inform policymakers that new Medicaid enrollees, which tend to be low-income and nondisabled adults, will certainly increase the cost of the Medicaid program. Chapter 3 is a retrospective cohort study that determines whether Medicaid managed care utilizes inpatient PAC differently than its FFS counterpart. The study found that Medicaid managed care beneficiaries were more likely to be admitted to an inpatient PAC than their FFS counterparts. This has significant cost implications since the majority of all Medicaid beneficiaries in the United States were enrolled in an MCO. Chapter 4 is a retrospective cohort study that determines the degree to which patient outcomes observed among Medicaid beneficiaries was mediated by variation in the intensity of PAC utilization. The study found that PAC utilization patterns for hospitalized Medicaid beneficiaries impacted readmissions and mortality to a degree. While we could not determine whether more PAC utilization would result in better quality of care, the effect of these patterns on outcomes should encourage states to standardize their approach to PAC and take necessary steps to improve patient management and care coordination among providers. Public Health Significance This dissertation addressed the three tenets of the healthcare iron triangle: access, cost, and quality. It will inform policymakers on how new Medicaid enrollees due to the expansion can potentially affect future cost to the program and impact the outcomes of Medicaid beneficiaries.