Assessing Value and Optimizing Decision-Making in Post-Acute Care Across Diverse Populations

Abstract

My dissertation investigates the enhancement of value in post-acute care (PAC) within the U.S. healthcare system, focusing on the largest source of geographic variation in Medicare costs. It combines individual preferences, clinical evidence, and payment model impacts to provide comprehensive insights into PAC. Chapter 1 - Patient and Caregiver Preferences in Post-Acute Care: this chapter examines the preferences of patients and caregivers for facility-based versus home-based care. Using primary data and choice modeling, we found a strong preference for high-quality, home-based care. However, preferences shift towards facility-based care under conditions of high caregiving burden or socioeconomic challenges. Across varied demographics, there was consistent willingness to pay more for home-based care, especially among those with prior PAC experience. The chapter concludes that while home-based care is generally preferred, policy considerations must be tailored to support disadvantaged groups facing unique challenges. Chapter 2 - Health Outcomes in Skilled-Nursing Facilities vs. Home-Based Services: here, we compared health outcomes between skilled-nursing facilities and home-based services, using an instrumental variable design to minimize selection bias. The analysis, covering traditional Medicare beneficiaries from 2013-2017, revealed no significant differences in mortality or rehospitalization rates between the two settings. However, higher Medicare spending was noted in skilled-nursing facilities for specific patient cohorts. This chapter underscores the importance of cost-effective discharge planning and informs policy decisions for optimizing post-acute care referrals. Chapter 3 - Impact of Medicare Advantage Expansion on PAC Utilization: this chapter evaluates the implications of expanding Medicare Advantage (MA) on traditional Medicare PAC utilization. The study found that increased MA market penetration is associated with reduced PAC use in traditional Medicare without an increase in hospital readmissions. The findings highlight the influence of MA expansion on PAC use and suggest the need for policymakers to consider MA penetration in the evaluation of alternative payment models. Overall, my dissertation offers significant insights into improving the efficiency, quality, and equity of PAC discharge practices and payment model designs. The combined findings from each chapter contribute to a deeper understanding of the complexities in PAC decision-making and highlight areas for policy intervention and improvement.