Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Medicare Beneficiary Access 
to Skilled Nursing Facilities: 2000 
JUNE GIBBS BROWN 
Inspector General 
SEPTEMBER 2000 
OEI-02-00-00330  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's New York regional office prepared this report under the direction of John I. Molnar, 
Regional Inspector General, and Renee C. Dunn, Deputy Regional Inspector General.  Principal 
OEI staff included:

REGION
 HEADQUARTERS

Ellen Vinkey, Project Leader
 Susan Burbach, Program Specialist

Danielle Fletcher
 Brian Ritchie, Director, Technical Support Staff

Judy Lin
 Linda Moscoe, Technical Support

Jodi Nudelman
 Scott Horning, Technical support

Betti Weimersheimer, intern
 Barbara Tedesco, Mathematical Statistician

To obtain copies of this report, please call the New York Regional Office at 212 264-2000. 
Reports are also available on the World Wide Web at our home page address: 
http://www.hhs.gov/oig/oei  E X E C U T I V E  S U M M A R Y  
PURPOSE 
To assess the effects of the nursing home prospective payment system (PPS) on Medicare 
beneficiaries access to skilled nursing facilities. 
BACKGROUND 
The Health Care Financing Administration (HCFA) asked the Office of Inspector General 
(OIG) to assess the effects of the new prospective payment system for skilled nursing 
facilities (SNFs) on access to care for Medicare beneficiaries.  Concerns have been raised 
that the new payment system may change nursing facilities willingness and ability to serve 
Medicare beneficiaries and may adversely affect beneficiary access to SNFs.  This 
inspection is part of an on-going look at access to skilled nursing facilities. Previous 
inspections entitled, Early Effects of the Prospective Payment System on Access to Skilled 
Nursing Facilities, OEI-02-99-00400, and Early Effects of the Prospective Payment 
System on Access to Skilled Nursing Facilities: Nursing Home Administrators 
Perspective, OEI-02-99-00401 also examined the effects of PPS on quality of care. 
For this study, we interviewed a random sample of 202 hospital discharge planners, as 
well as analyzed HCFA data related to SNF discharges and hospital lengths of stay. 
FINDINGS 
Almost all Medicare beneficiaries can be placed in skilled nursing 
facilities 
Almost all discharge planners report that they are able to place Medicare beneficiaries in 
skilled nursing facilities (SNFs).  In fact, about 80 percent of discharge planners state that 
they could place all of the Medicare patients. Another 14 percent estimate that between 1 
and 5 percent of patients cannot be placed, while the remaining 5 percent of discharge 
planners put the estimate at over 5 percent.  Most discharge planners indicate that there 
are enough beds available in their particular area, and HCFA data indicate an increasing 
bed supply. 
Discharge planners also indicate that patients whom they are unable to place remain in the 
hospital or eventually go home with or without home health care.  Our analysis of HCFA 
data indicate that the medical profile of patients discharged to nursing homes remains 
i 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  largely unchanged after introduction of the new prospective payment system. 
Some Medicare beneficiaries experience delays 
When specifically asked how often they experience delays in placing Medicare patients in 
SNFs, 43 percent rarely or never experience delays while 44 percent of discharge planners 
report that they sometimes experience delays.  Twelve percent of discharge planners say 
they always or usually confront delays in placing patients. 
Despite concerns about delays, Medicare data from the first three months of 1996 through 
2000 show a decrease in the average length of hospital stays for Medicare patients prior to 
a SNF admission.  These data suggest that Medicare patients do not have extended lengths 
of stay while waiting for a bed in a nursing home. 
Multiple factors affect the placement process 
Medical Needs: Eighty percent of hospital discharge planners who report delays in 
placing Medicare patients in SNFs state that patients with particular medical conditions or 
service needs are more likely to experience delays before being placed in skilled nursing 
facilities.  Discharge planners most often note that patients requiring intravenous or 
expensive drugs experience delays.  They say that medically complex patients are also 
more likely to experience delays. 
Prospective Payment System: Sixty-nine percent of discharge planners who mention 
delays in placement for medical conditions or service needs attribute these delays to PPS 
while the remainder note that they experienced these delays prior to the implementation of 
PPS.  About 54 percent of discharge planners volunteer that nursing homes have altered 
their admission practices for Medicare patients since the implementation of PPS.  A few 
discharge planners add that nursing homes analyze the reimbursement rates of the 
individual patients before they accept patients and that the routine screening and admission 
process takes longer. 
Other Reasons:  In addition to medical conditions and PPS, discharge planners most 
often mention the decision making process by patients and their family members as a 
source of delay.  In addition, discharge planners also note that secondary payor issues 
cause delays.  They point specifically to the Medicaid application process. 
Access improves for dialysis patients 
In a September 1999 we found that discharge planners most often listed end stage renal 
disease (ESRD) as the clinical condition that had become the hardest to place since the 
implementation of PPS.  The Balanced Budget Reform Act of 1999 extended pass-
ii 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  through payments to ambulance services for renal dialysis so that nursing homes no longer 
have to absorb these costs.  Although discharge planners continue to report delays for 
dialysis patients, dialysis patient delays dropped to the fifth most commonly cited delay. 
CONCLUSION 
The findings in this follow-up study are consistent with those in the original Early Effects 
of the Prospective Payment System on Access to Skilled Nursing Facilities, OEI-02-99-
00400.  While it reveals some practice adjustments, there do not appear to be any major 
disruptions as a result of implementing the prospective payment system.  To the extent 
that there are some disruptions, they appear to be localized. 
Agency Comments 
The Health Care Financing Administration provided comments on the draft report.  They 
concurred with our conclusion that there do not appear to be any major disruptions as a 
result of implementing PPS.  Furthermore, HCFA  notes that they will continue to 
aggressively monitor access to SNFs and the quality of SNF care.  The OIG will also 
continue our work in this area, being sensitive to any localized access issues. 
iii 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  T A B L E   O F   C O N T E N T S  
PAGE

EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  i

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

FINDINGS

Almost All Medicare beneficiaries can be placed in SNFs . . . . . . . . . . . . . . . . . . . . . . . . 5

Some beneficiaries experience delays in SNFs  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Multiple factors affect the placement process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Access improves for dialysis patients  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

APPENDICES 
A: Confidence intervals  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

B: Proportion of discharges to SNFs for top diagnoses . . . . . . . . . . . . . . . . . . . . . . . . .  13

C: Average hospital length of stay for top diagnoses . . . . . . . . . . . . . . . . . . . . . . . . . . .  14

D: Agency Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

iv 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  I N T R O D U C T I O N  
PURPOSE 
To assess the effects of the nursing home prospective payment system (PPS) on Medicare 
beneficiaries access to skilled nursing facilities. 
BACKGROUND 
The Health Care Financing Administration (HCFA) asked the Office of Inspector General 
(OIG) to assess the effects of the new prospective payment system for skilled nursing 
facilities (SNFs) on access to care for Medicare beneficiaries.  Concerns have been raised 
that the new payment system may change nursing facilities willingness and ability to serve 
Medicare beneficiaries and may adversely affect beneficiary access to SNFs. 
This inspection is part of an on-going look at access to skilled nursing facilities.  A 
previous study entitled, Early Effects of the Prospective Payment System on Access to 
Skilled Nursing Facilities, OEI-02-99-00400 was based on a survey of discharge planners 
and an analysis of Medicare data.  We found that at the time there were no serious 
problems placing Medicare patients in nursing homes.  However, nursing homes were 
changing their admissions practices in response to the prospective payment system.  As a 
result, we concluded that the Department must remain vigilant to potential problems and 
that as part of this effort, the OIG would periodically replicate this study. 
Another study conducted by the OIG entitled, Early Effects of the Prospective Payment 
System on Access to Skilled Nursing Facilities: Nursing Home Administrators 
Perspective, OEI-02-99-00401 found similar results.  Based on a survey of nursing home 
administrators, we found that few administrators believe that access to nursing home care 
had become a problem because of the prospective payment system.  However, many 
administrators noted that they had changed their admissions practices, and that medical 
condition has become more important in making admissions decisions. 
Medicare Payments to Nursing Homes 
Skilled nursing facility care is covered by Medicare Part A under certain conditions. 
Specifically, the patient must have been hospitalized for 3 or more days within the last 30 
days for the condition that will be treated in the SNF.  The SNF stay must also be certified 
as medically necessary and the patient must require daily skilled nursing or skilled 
rehabilitation services.  The number of SNF days provided under Medicare is 
1 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  limited to 100 days per benefit period, with a co-payment required for days 21 through 
100. 
Medicare Part A payments for SNF care cover routine costs such as the room, dietary 
service, nursing service, minor medical supplies, and social service.  Payments also cover 
capital costs for the building and equipment, and ancillary care for specialized services 
such as therapy, laboratory tests, and transportation.  Until recently, SNFs were 
reimbursed on a retrospective, reasonable cost basis. 
The Balanced Budget Act of 1997 changed SNF reimbursement to a prospective payment 
system in order to control Medicare Part A program costs.  Beginning with the SNFs first 
cost reporting period after July 1, 1998, SNFs are paid through per diem, prospective, 
case-mix adjusted payments which cover routine, ancillary, and capital-related costs, 
including most items and services for which payment was previously made under Medicare 
Part B.  The per diem payment is based on fiscal year 1995 Part A & B costs adjusted 
using the SNF market basket index (minus 1 percent), case-mix from resident assessments, 
and geographical wage variations.  The market basket index represents an inflation factor. 
The case-mix index recognizes that SNF residents require different levels of care and is 
based on an assessment that assigns each resident to one of 44 Resource Utilization 
Groups (RUGS-III).  This new payment system is being phased in over a three year 
transition period. 
In the Fall of 1999, Congress enacted the Balanced Budget Refinement Act (BBRA) in 
response to providers concerns that reductions were too severe.  The BBRA included a 4 
percent across-the-board increase in payments to SNFs for FY2001 and 2002 and a 
temporary 20 percent increase for 15 payment categories of patients considered medically 
complex.  In addition, several costly non-therapy ancillary services, including certain 
ambulance services, prostheses, and chemotherapy drugs, were excluded from the 
prospective payment system and are now paid for separately.  These changes addressed 
concerns that payments were too low for patients who need relatively high levels of non-
therapy ancillary services. 
In 1989, Medicare paid $2.8 billion to nursing homes, or about  4.7 percent of the 
Medicare budget.  In 1997, this amount increased to $12.2 billion, which was about 5.9 
percent of the Medicare budget.  In general, Medicare payments represent a relatively 
small share of nursing homes revenues, about 10 percent on average. 
Discharge Planners 
By definition, all Medicare Part A beneficiaries in SNFs are discharged from hospitals. 
Hospital discharge planners who are responsible for coordinating SNF care are therefore 
in a unique position to assess the effects of the prospective payment system on access to 
nursing home care. 
2 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  Federal regulations require all hospitals to offer discharge planning services.  The goal of 
these services is to identify a patients post-hospital needs and ensure that he or she is 
discharged to a safe environment with the appropriate level of services.  In most hospitals, 
the social work, case management, or utilization review department has primary 
responsibility for discharge planning.  Patients can be placed in a variety of settings 
including SNFs, home health care, hospices, or intermediate care. 
Discharge planning staff generally follow a standard process.  In a typical scenario, staff 
screen patients records within 24 hours of admission.  They attempt to identify patients 
who will require discharge planning services, such as those who are 65 years and older and 
living alone or those with possibly life-threatening illnesses.  They then conduct a psycho-
social assessment and discuss the patients care plan with his or her nurses and physicians, 
as well as utilization review staff, and other relevant interdisciplinary team members. 
Discharge planners also solicit the patients preferences and contact family members or 
other potential caregivers to get their input and cooperation.  Based on this information, 
they attempt to place the patient in the most appropriate setting. 
METHODOLOGY 
Discharge Planner Interviews 
We used a combination of methods to analyze information for this inspection.  We chose a 
random sample of 225 acute care hospitals with 30 beds or more.  The sample was drawn 
from the 50 states in addition to the District of Columbia.  We conducted interviews with 
202 directors of discharge planning or their designees within a 3 week period from May 
22 until June 23, 2000.  Twelve of the remaining 23 hospitals did not discharge Medicare 
patients to SNFs.  We were unable to reach a discharge planner to schedule an interview 
at the other 11 hospitals. 
Analysis of Medicare Data 
Secondly, we analyzed Medicare data.  Using HCFAs National Claims History data, we 
identified all Medicare beneficiaries who were discharged from a hospital between January 
1, 1996, and March 31, 1996.  We then identified patients who met this criteria for an 
analogous period in 1997, 1998, 1999, and 2000.  We analyzed beneficiaries in the 
diagnosis related groups (DRGs) that are most commonly discharged to SNFs for these 
four time periods.  As part of this analysis we assessed whether SNFs are admitting 
different types of beneficiaries since the implementation of PPS.  We also analyzed 
hospital length of stay for beneficiaries discharged to SNFs care by these DRGs to 
examine whether certain patients are experiencing longer delays before being admitted to 
SNFs since PPS.  Lastly, using HCFA's Provider of Services File, we analyzed trends in 
the number of SNFs. 
3 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  This inspection was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and Efficiency. 
4 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  F I N D I N G S  
Almost all Medicare beneficiaries can be placed in skilled 
nursing facilities 
Most Medicare beneficiaries can be placed 
Almost all discharge planners report that they are able to place Medicare beneficiaries in 
skilled nursing facilities (SNFs).  In fact, about 80 percent of discharge planners state that 
they could place all of the Medicare patients.  Another 14 percent estimate that between 1 
and 5 percent of patients cannot be placed, while the remaining 5 percent of discharge 
planners put the estimate at over 5 percent.  Most discharge planners indicate that there 
are enough beds available in their particular area to accommodate Medicare patients. 
Many volunteer that they have flexibility because their own hospital beds are certified by 
the Medicare program to be used as SNF beds when needed.  Discharge planners also 
indicate that patients whom they are unable to place remain in the hospital or eventually 
go home with or without home health care. 
More Medicare beds are available 
Medicare data support the response of discharge planners that there are adequate skilled 
nursing home beds available for Medicare patients.  As shown in Table 1, Medicare SNFs 
have increased 0.9 percent from 1997 to 1999.  The number of Medicare certified beds 
has seen a substantial increase at 22.8 percent.  This increase is largely due to the increase 
in dual certified beds which are available for either a Medicare or Medicaid patient. 
Similarly, the total number of certified nursing home beds also increased 1.9 percent. 
Total nursing home beds includes Medicare only, dual certified, and Medicaid only beds. 
Currently, about 54 percent of the total nursing home beds are Medicare certified. 
Table 1

Total Number of SNFs and Nursing Home Beds, 1997 to 1999

Percent Change 
1997  1998  1999  1997-1999 
SNF Facilities  14,772  15,025  14,911  0.9% 
Total Medicare Beds  681,456  722,278  836,701  22.8% 
Total Certified Beds  1,528,061  1,556,495  1,556,569  1.9% 
Source: Provider of Services File 
5 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  Medical profile remains unchanged 
We also looked at pre- and post-PPS data for patients with diagnostic related groups 
(DRGs) from the first 3 months of years 1996 to 2000 to see if the proportion of patients 
with certain medical conditions is decreasing which would possibly indicate that certain 
patient types are experiencing a reduction in access to SNFs.  We did not find any large 
decreases.  Three DRGs had decreases over 1 percent: specific cerebrovascular disorder 
(-1.6 percent), respiratory infections and inflammations (-1.1 percent), and hip and femur 
procedures except major joint (-1.0 percent).  Four DRGs had decreases of less than 1 
percentage point.  Three DRGs showed an increase of less than 1 percent in the 
proportion of patients being discharged to SNFs.  The largest increase was for simple 
pneumonia at 2 percent.  (See Appendix B) 
Some Medicare beneficiaries experience delays 
Some discharge planners experience delays in placing patients.  For purposes of discharge 
planning, a delay occurs when a patient is medically cleared by a doctor for discharge, 
however, no SNF bed has been secured. When specifically asked how often they 
experience delays in placing Medicare patients in SNFs, 43 percent rarely or never 
experience delays while 44 percent of discharge planners report that they sometimes 
experience delays.  Twelve percent of discharge planners say they always or usually 
confront delays in placing patients.  While 62 percent of discharge planners experience the 
same percentage of delays as prior to PPS implementation, 28 percent state that they have 
a higher percentage of delays since PPS implementation. 
On average, discharge planners state that they have to contact about three nursing homes 
to place a Medicare patient in a SNF.  Sixty-six percent of discharge planners had to 
contact approximately the same number of nursing homes prior to the implementation of 
PPS.  Twenty-three percent respond that they had to contact fewer nursing homes since 
PPS implementation, and 9 percent respond that they contact more nursing homes. 
However, hospital length of stays are shorter 
Despite concerns about delays, Medicare data from the first 3 months of 1996 through 
2000 show a decrease in the average length of hospital stays for Medicare patients prior to 
a SNF admission.  These data suggest that Medicare patients do not have extended lengths 
of stay while waiting for a bed in a nursing home.  As can be seen in Appendix C, the 
average lengths of stay for the top 10 DRGs of patients discharged to SNFs show that the 
length of hospital stays decreased ranging from 1.8 days (specific cerebrovascular 
disorders) to .2 days (septicemia). 
6 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  Multiple factors affect the placement process 
Medical Needs:  Eighty percent of hospital discharge planners who report delays in 
placing Medicare patients in SNFs state that patients with particular medical conditions or 
service needs are more likely to experience delays before being placed in skilled nursing 
facilities.  Discharge planners most often note that patients requiring intravenous or 
expensive drugs experience delays.  They say that medically complex patients are also 
more likely to experience delays.  These patients typically require extensive services by the 
nursing home staff to adequately care for their medical needs.  See Table 2.  Discharge 
planners point to similar medical conditions or service needs when asked which patients 
they are never able to place in nursing homes. 
Table 2

Medical Conditions or Service Needs Associated with Delays

Medical Condition/Service Need  Percent of Discharge 
Planners Reporting 
Delays 
IV antibiotics or expensive drugs  44% 
Medically complex patients  34% 
Ventilator patients  32% 
Infectious diseases/isolation patients  27% 
Renal failure/dialysis patients  25% 
Behavior Problems  20% 
(Alzheimers/Dementia) 
Total parenteral feedings  20% 
* Categories are not mutually exclusive  Source: OEI Discharge Planning Survey, June 2000 
Prospective Payment System:  Sixty-nine percent of discharge planners who 
acknowledge delays in placement for medical conditions or service needs attribute these 
delays to PPS.  The remaining discharge planners note that they experienced delays for 
these particular medical conditions or services prior to the implementation of PPS.  About 
54 percent of discharge planners volunteer that nursing homes have altered their admission 
process for Medicare patients since the implementation of PPS.  For example, discharge 
planners report that nursing homes request additional patient information and on-site visits 
to evaluate the patient.  A few discharge planners add that nursing homes analyze the 
reimbursement rates of the individual patients before they accept patients and 
7 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  that the routine screening and admission process takes longer.  Most discharge planners 
respond that the reimbursement levels for these patients are too low to cover the expenses 
of the nursing homes.  About a third of discharge planners also state that patients requiring 
rehabilitation services (physical, speech, or occupational therapy) are experiencing fewer 
delays because of PPS.  They indicate that higher reimbursement levels for these patients 
makes it advantageous for nursing homes to accept these patients.  They also mention that 
rehabilitation patients are often short-term with foreseeable discharge dates and that their 
service needs are easily administered. 
Other Reasons:  In addition to medical conditions and PPS, discharge planners note other 
reasons that Medicare beneficiaries experience delays before being placed in a SNF.  The 
decision making process by patients and their family members is mentioned most often as a 
source of delays.  The patient and the family may be considering placement options or 
waiting for a bed to become available in their nursing home of choice.  Lack of nursing 
home beds is also mentioned by the discharge planners in some areas.  In addition, 
discharge planners also note that secondary payor issues cause delays.  They explain that 
Medicare patients applying for Medicaid may experience delays waiting for approval. 
Access improves for dialysis patients 
In a September 1999 OIG report, Early Effects of PPS on Access to SNFs, OEI-02-99-
00400, we found that discharge planners most often listed end stage renal disease (ESRD) 
as the clinical condition that had become the hardest to place since the implementation of 
PPS.  Discharge planners noted that the transportation to dialysis facilities for ESRD 
residents was not covered in the per diem rate.  The Balanced Budget Refinement Act of 
1999, which became effective April 1, 2000, extended pass-through payments to 
ambulance services for renal dialysis so that nursing homes no longer have to absorb these 
costs.  Although discharge planners continue to report delays for dialysis patients, dialysis 
patient delays dropped to the fifth most commonly cited delay.  About a third of the 
discharge planners who say that ESRD patients experience delays state that transportation 
costs are a factor in the delay despite the changes in the regulations.  It is important to 
note that the regulation had only been effective for approximately 2 months at the time we 
surveyed discharge planners. 
8 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  C O N C L U S I O N  
The findings in this follow-up study are consistent with those in the original Early Effects 
of the Prospective Payment System on Access to Skilled Nursing Facilities, OEI-02-99-
00400.  While it reveals some practice adjustments, there do not appear to be any major 
disruptions as a result of implementing the prospective payment system.  To the extent 
that there are some disruptions, they appear to be localized. 
9 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  A G E N C Y  C O M M E N T S  
The Health Care Financing Administration provided comments on the draft report.  They 
concurred with our conclusion that there do not appear to be any major disruptions as a 
result of implementing PPS.  Furthermore, HCFA  notes that they will continue to 
aggressively monitor access to SNFs and the quality of SNF care.  The OIG will also 
continue our work in this area, being sensitive to any localized access issues. 
10 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  APPENDIX A 
Confidence Intervals for Key Findings 

We calculated confidence intervals for key findings for discharge planners.  The point estimate 
and 95% confidence interval are given for each of the following: 
POINT  CONFIDENCE 
KEY FINDINGS  ESTIMATE  INTERVAL 
Eighty percent of discharge planners report they can place  80%  +/- 5.5 
all of their patients. 
Most discharge planners indicate that there are enough 
available beds in their particular area to accommodate  79%  +/- 5.6 
Medicare patients. 
When specifically asked how often they experience delays  43%  +/- 6.8 
in placing Medicare patients in SNFs, 43 percent report 
they rarely or never experience delays. 
When specifically asked how often they experience delays 
in placing Medicare patients in SNFs, 44 percent of  44%  +/- 6.9 
discharge planners report that they sometimes experience 
delays. 
Twenty-three percent of discharge planners responded 
they had to contact fewer nursing homes to place a  23%  +/- 5.8 
Medicare patient in a SNF since the implementation of 
PPS. 
Eighty percent of discharge planners who report delays 
state that patients with particular medical conditions are  80%  +/- 5.9 
more likely to experience delays. 
Discharge planners most often note that patients requiring 
intravenous drugs or expensive drugs are associated with  44%  +/- 8.1 
delays. 
11 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  About 54 percent of discharge planners volunteer that 
nursing homes have altered the process of placing  54%  +/- 6.9 
Medicare patients in SNFs. 
About a third of discharge planners also state that patients 
requiring rehabilitation services are experiencing fewer  39%  +/- 8.0 
delays because of PPS. 
In addition to medical conditions, discharge planners note 
other reasons that Medicare beneficiaries experience 
delays before being placed in a SNF.  The decision making  23%  +/- 6.2 
by patients and their family members is mentioned most 
often as a source of delays. 
12 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  APPENDIX B 
Proportion of Discharges to SNFs by DRG

Percent  Percent  Percent  Percent  Percent  Difference 
Initial Hospital DRG  1996  1997  1998  1999  2000  1996-2000 
DRG 014- Specific 
cerebrovascular disorders  7.1  6.5  5.9  5.7  5.5  -1.6 
DRG 079- Respiratory infections 
3.5  3.8  3.2  2.9  2.4 
and inflammations  -1.1 
DRG 210- Hip and femur 
5.3  4.8  4.3  4.4  4.3 
procedures except major joint  -1.0 
DRG 209- Major joint and limb 
8.1  7.9  7.6  7.7  7.6 
reattachment procedures  -0.5 
DRG 416- Septicemia  2.4  2.5  2.3  2.1  1.9 
-0.5 
DRG 127- Heart failure and 
shock  4.8  4.8  4.9  4.9  4.7  -0.2 
DRG 296- Nutritional and misc. 
metabolic disorders  2.8  2.7  2.7  2.8  2.7  -0.1 
DRG 320- Kidney and urinary 
2.0  1.9  2.0  2.1 
tract infections  2.1  +0.1 
DRG 462- Rehabilitation  2.1  2.1  2.0  2.1 
2.4  +0.3 
DRG 088- Chronic obstructive 
2.4  2.8  3.2  3.3 
pulmonary disease  3.0  +0.6
DRG 089- Simple pneumonia 
5.1  5.9  7.4  7.5 
and pleurisy  7.2  +2.0
Source: National Claims History File 
13 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  APPENDIX C 
Average Hospital Lengths of Stay for Top DRGs

Discharged to SNFs

Days  Days  Days  Days  Days  Difference 
Initial Hospital DRG  1996  1997  1998  1999  2000  1996-2000 
DRG 014- Specific cerebrovascular 
10.7  9.8  9.4  9.0  8.9  -1.8 
disorders 
DRG 296- Nutritional and misc. 
8.7  7.7  7.4  7.4  7.2  -1.5 
metabolic disorders 
DRG 210- Hip and femur 
8.0  7.2  6.9  6.9  6.9  -1.1 
procedures except major joint 
DRG 209- Major joint and limb 
6.7  6.1  5.8  5.8  5.7  -1.0 
reattachment procedures 
DRG 320- Kidney and urinary tract 
7.8  7.5  7.0  7.0  6.9  -0.9 
infections 
DRG 127- Heart failure and shock  8.7  8.2  8.0  8.0  7.9  -0.8 
DRG 088- Chronic obstructive 
8.6  8.1  7.8  7.7  7.8  -0.8 
pulmonary disease 
DRG 089- Simple pneumonia and 
8.6  8.3  8.0  7.8  8.0  -0.6 
pleurisy 
DRG 079- Respiratory infections 
10.6  10.3  10.2  10.2  10.3  -0.3 
and inflammations 
DRG 416- Septicemia  10.2  9.7  9.6  9.7  10.0  -0.2 
Source: National Claims History File 
14 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  APPENDIX D 
Comments on the Draft Report

In this appendix, we present in full the comments from the Health Care Financing 
Administration. 
15 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  16 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330  17 
Medicare Beneficiary Access to SNFs  OEI-02-00-00330