Do policy context and structural disadvantage shape SNF VBP performance? Evidence from national facility-year data

Area of Science:

• Healthcare policy analysis
• Health services research
• Socioeconomic determinants of health

Background:

• Skilled nursing facility (SNF) performance metrics, like the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program, aim to reflect care quality.
• However, SNF performance may be influenced by external policy and structural factors, potentially impacting equity.
• Understanding these influences is crucial for fair value-based purchasing programs.

Purpose of the Study:

• To evaluate the association between Medicaid expansion status and structural disadvantage (using the Structural Racism Effects Index - SREI) with high SNF performance.
• To determine if policy and structural contexts influence SNF performance within the SNF VBP program.

Main Methods:

• A pooled, repeated cross-sectional analysis of 57,816 facility-year observations from fiscal years 2019-2021 and 2024.
• High performance was defined as a SNF VBP score ≥50 (upper quartile).
• Multivariable logistic regression was used to assess associations, adjusting for facility characteristics and prior penalties.

Main Results:

• Facilities in Medicaid expansion states showed higher odds of high performance (aOR = 1.19).
• Increased structural disadvantage, measured by SREI, was associated with lower odds of high performance (OR = 0.87).
• Higher registered nurse staffing correlated with better performance; ownership, LPN staffing, and prior penalties were not significant.

Conclusions:

• SNF performance is demonstrably shaped by both policy (Medicaid expansion) and structural conditions (SREI).
• Value-based payment models, if not accounting for these factors, risk perpetuating existing health inequities.
• Policy interventions should consider socioeconomic and structural contexts to ensure equitable SNF performance evaluation.