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

In Reply Carey and Moawad, as well as Koenig and Votto, raise concerns regarding similar themes: context and policy relevance of our findings,¹ residual confounding, and whether skilled nursing facilities (SNFs) are suitable alternatives to long-term acute care hospitals (LTACs). First, we agree the use of LTACs has slightly declined in recent years partly owing to the Pathway for SGR (Sustainable Growth Rate) Reform Act of 2013² stipulating reduced site-neutral payment (SNP) for less sick individuals. However, SNP will not be fully implemented until 2020.³ In the interim, LTACs will be reimbursed at a blended rate halfway between LTAC and inpatient prospective payer system rates,³ thus making many SNP admissions still profitable. As such, the most recent data shows that LTACs still account for over 130 000 annual admissions and $5.3 billion in annual Medicare spending, which is 18% of the spending on SNFs.⁴ Furthermore, the modest decline in LTAC use among fee-for-service beneficiaries may also reflect increasing enrollment in Medicare Advantage. Release of Medicare Advantage data would greatly strengthen our understanding of postacute care.⁵