Skilled Nursing Facilities:

Available Data Show Average Nursing Staff Time Changed Little after Medicare Payment Increase

GAO-03-176: Published: Nov 13, 2002. Publicly Released: Nov 13, 2002.

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Alan Bruce Steinwald
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The nation's 15,000 skilled nursing facilities (SNF) play an essential role in our health care system, providing Medicare-covered skilled nursing and rehabilitative care each year for 1.4 million Medicare patients who have recently been discharged from acute care hospitals. In recent years, many analysts and other observers, including members of Congress, have expressed concern about the level of nursing staff in SNFs and the impact of inadequate staffing on the quality of care. GAO's analysis of available data shows that, in the aggregate, SNFs' nurse staffing ratios changed little after the increase in the nursing component of the Medicare payment took effect. Overall, SNFs' average nursing time increased by 1.9 minutes per patient day, relative to their average in 2000 of about 3 and one-half hours of nursing time per patient day. For most SNFs, increases in staffing ratios were small. Further, GAO found that the share of SNF patients covered by Medicare was not a factor in whether facilities increased their nursing time. Similarly, SNFs that had a total revenues considerably in excess of costs before the added payments took effect did not increase their staffing substantially more than others.

Matter for Congressional Consideration

  1. Status: Closed - Implemented

    Comments: In 2000, the Congress increased the nursing component of Medicare's daily rate for skilled nursing facilities by l6.66 percent for the period April 1, 2001, through October 2, 2002. The Congress considered whether to reinstate it when it expired. Our analysis of available data showed that, in the aggregate, SNFs' nursing staff ratios changed little after the increase took effect. We recommended that the Congress consider our finding that this increase was not effective in raising nurse staffing when determining whether to reinstate the nursing component increase. We briefed the staffs of the committees of jurisdiction prior to the report's issuance. At each committee briefing, the staff expressed strong interest in our finding and recommendation, and indicated that our work would help them as their committee and the Congress considered Medicare payment legislation. A key health staff member for the House Ways and Means Committee stated that our work influenced the Ways and Means Committee and Chairman Thomas to decide against reinstating the increase in the nursing component. To date, the nursing component increase has not been reinstated.

    Matter: GAO's analysis of available data on SNF nursing staff indicates that, in the aggregate, SNFs did not have significantly higher nursing staff time after the increase to the nursing component of Medicare's payment. Congress may wish to consider GAO's finding that increasing the Medicare payment rate was not effective in raising nurse staffing as it determines whether to reinstate the increase to the nursing component of the Medicare SNF rate.


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