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Comment & Response
June 2018

Shortcomings of Research Regarding Long-term Acute Care Hospitals and Skilled Nursing Facilities

Author Affiliations
  • 1Institute for Critical Care Foundation, Reston, Virginia
  • 2Global Hospital Services LLC, Tysons Corner, Virginia
  • 3Metropolitan Medical Group LLC, Washington, DC
  • 4Bridgepoint Hospital, Washington, DC
  • 5Select Medical International, Washington, DC
  • 6Inova Fairfax Hospital, Fairfax, Virginia
JAMA Intern Med. 2018;178(6):866. doi:10.1001/jamainternmed.2018.1763

To the Editor The Original Investigation by Makam et al1 that was published in a recent issue of JAMA Internal Medicine was presented without proper context, which makes several of its conclusions misleading and outdated.

The study by Makam et al1 is based entirely on Medicare data from 2012 and is framed in light of policy and practices then in place. This ignores the fact that the long-term acute care hospital (LTAC) sector has been undergoing transformational change since the adoption of new admissions criteria for Medicare patients in 2013. For a hospital to receive reimbursement under the LTAC prospective payment system, the 2013 criteria require that admitted patients must have experienced prolonged care in an intensive care unit during an immediately prior acute hospital stay or have been on mechanical ventilation for at least 96 hours. The effect of these policy changes has been significant in both clinical and economic terms, with both average patient acuity levels of admitted patients and LTAC closures on the rise. This asynchronistic limitation is most glaring when Makam et al1 cite a 2014 MedPAC report to assert that LTACs are the fastest growing segment in the postacute care sector. This statement is no longer accurate. Since 2013, LTAC spending growth has been negative while skilled nursing facility (SNF) cost growth has been accelerating. Based on the latest available MedPAC data,2 LTAC spending now accounts for less than 8% of Medicare’s postacute care and less than 1% of total program costs.

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