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Strategic Patient Discharge: The Case of Long-Term Care Hospitals

Author

Listed:
  • Paul J. Eliason
  • Paul L. E. Grieco
  • Ryan C. McDevitt
  • James W. Roberts

Abstract

Medicare's prospective payment system for long-term acute-care hospitals (LTCHs) provides modest reimbursements at the beginning of a patient's stay before jumping discontinuously to a large lump-sum payment after a prespecified number of days. We show that LTCHs respond to the financial incentives of this system by disproportionately discharging patients after they cross the large-payment threshold. We find this occurs more often at for-profit facilities, facilities acquired by leading LTCH chains, and facilities colocated with other hospitals. Using a dynamic structural model, we evaluate counterfactual payment policies that would provide substantial savings for Medicare.

Suggested Citation

  • Paul J. Eliason & Paul L. E. Grieco & Ryan C. McDevitt & James W. Roberts, 2018. "Strategic Patient Discharge: The Case of Long-Term Care Hospitals," American Economic Review, American Economic Association, vol. 108(11), pages 3232-3265, November.
    • Handle: RePEc:aea:aecrev:v:108:y:2018:i:11:p:3232-65
    Note: DOI: 10.1257/aer.20170092
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    Blog mentions

    As found by EconAcademics.org, the blog aggregator for Economics research:
    1. Sam Watson’s journal round-up for 12th November 2018
      by Sam Watson in The Academic Health Economists' Blog on 2018-11-12 15:46:49

    Citations

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    Cited by:

    1. Katalin Gaspar & Ramsis Croes & Misja Mikkers & Xander Koolman, 2024. "Length of hospital stays and financial incentives: evidence from Dutch rehabilitation centers," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 25(5), pages 731-741, July.
    2. Liran Einav & Amy Finkelstein, 2018. "Moral Hazard in Health Insurance: What We Know and How We Know It," Journal of the European Economic Association, European Economic Association, vol. 16(4), pages 957-982.
    3. Martin B. Hackmann & R. Vincent Pohl & Nicolas R. Ziebarth, 2024. "Patient versus Provider Incentives in Long-Term Care," American Economic Journal: Applied Economics, American Economic Association, vol. 16(3), pages 178-218, July.
    4. Berta, P.; & De Fraja, G.; & Verzillos, S.;, 2018. "Optimal Healthcare Contracts:Theory and Empirical Evidence from Italy," Health, Econometrics and Data Group (HEDG) Working Papers 18/33, HEDG, c/o Department of Economics, University of York.
    5. Atul Gupta & Sabrina T Howell & Constantine Yannelis & Abhinav Gupta, 2024. "Owner Incentives and Performance in Healthcare: Private Equity Investment in Nursing Homes," The Review of Financial Studies, Society for Financial Studies, vol. 37(4), pages 1029-1077.
    6. Moura, Ana, 2021. "Essays in health economics," Other publications TiSEM c93abd22-fa4a-42a5-b172-d, Tilburg University, School of Economics and Management.
    7. Chan, Marc K. & Zeng, Guohua, 2018. "Unintended consequences of supply-side cost control? Evidence from China's new cooperative medical scheme," Journal of Health Economics, Elsevier, vol. 61(C), pages 27-46.
    8. Maggie Shi, 2023. "Monitoring for Waste: Evidence from Medicare Audits," NBER Working Papers 31559, National Bureau of Economic Research, Inc.
    9. Clara Pott & Tom Stargardt & Udo Schneider & Simon Frey, 2021. "Do discontinuities in marginal reimbursement affect inpatient psychiatric care in Germany?," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 22(1), pages 101-114, February.
    10. Franziska Valder & Simon Reif & Harald Tauchmann, 2025. "Diagnosis Related Payment for Inpatient Mental Health Care: Hospital Selection and Effects on Length of Stay," Health Economics, John Wiley & Sons, Ltd., vol. 34(3), pages 472-499, March.
    11. Mizuma, Kimiko & Amitani, Marie & Mizuma, Midori & Kawazu, Suguru & Sloan, Robert A. & Ibusuki, Rie & Takezaki, Toshiro & Owaki, Tetsuhiro, 2020. "Clarifying differences in viewpoints between multiple healthcare professionals during discharge planning assessments when discharging patients from a long-term care hospital to home," Evaluation and Program Planning, Elsevier, vol. 82(C).
    12. Moura, Ana, 2022. "Do subsidized nursing homes and home care teams reduce hospital bed-blocking? Evidence from Portugal," Journal of Health Economics, Elsevier, vol. 84(C).
    13. Liran Einav & Amy Finkelstein & Yunan Ji & Neale Mahoney, 2022. "Voluntary Regulation: Evidence from Medicare Payment Reform," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 137(1), pages 565-618.
    14. Katalin Gaspar & Xander Koolman, 2022. "Provider responses to discontinuous tariffs: evidence from Dutch rehabilitation care," International Journal of Health Economics and Management, Springer, vol. 22(3), pages 333-354, September.
    15. Martin B. Hackmann & Juan S. Rojas & Nicolas R. Ziebarth, 2025. "Creative Financing and Public Moral Hazard: Evidence from Medicaid and the Nursing Home Industry," NBER Working Papers 34118, National Bureau of Economic Research, Inc.
    16. Martin Gaynor & Kate Ho & Robert J. Town, 2015. "The Industrial Organization of Health-Care Markets," Journal of Economic Literature, American Economic Association, vol. 53(2), pages 235-284, June.
    17. Liran Einav & Amy Finkelstein & Yunan Ji & Neale Mahoney, 2020. "Randomized trial shows healthcare payment reform has equal-sized spillover effects on patients not targeted by reform," Proceedings of the National Academy of Sciences, Proceedings of the National Academy of Sciences, vol. 117(32), pages 18939-18947, August.
    18. Coe, Norma B. & Rosenkranz, David A., 2025. "Provider payment incentives: Evidence from the U.S. hospice industry," Journal of Public Economics, Elsevier, vol. 248(C).
    19. Dillender, Marcus & Jinks, Lu & Lo Sasso, Anthony T., 2023. "When (and why) providers do not respond to changes in reimbursement rates," Journal of Public Economics, Elsevier, vol. 217(C).
    20. Liran Einav & Amy Finkelstein & Neale Mahoney, 2018. "Provider Incentives and Healthcare Costs: Evidence From Long‐Term Care Hospitals," Econometrica, Econometric Society, vol. 86(6), pages 2161-2219, November.
    21. Yang, Ou & Chan, Marc K. & Cheng, Terence C. & Yong, Jongsay, 2020. "Cream skimming: Theory and evidence from hospital transfers and capacity utilization," Journal of Economic Behavior & Organization, Elsevier, vol. 173(C), pages 68-87.
    22. Manuel Adelino & Katharina Lewellen & W. Ben McCartney, 2022. "Hospital Financial Health and Clinical Choices: Evidence from the Financial Crisis," Management Science, INFORMS, vol. 68(3), pages 2098-2119, March.

    More about this item

    JEL classification:

    • H51 - Public Economics - - National Government Expenditures and Related Policies - - - Government Expenditures and Health
    • I11 - Health, Education, and Welfare - - Health - - - Analysis of Health Care Markets
    • I13 - Health, Education, and Welfare - - Health - - - Health Insurance, Public and Private
    • I18 - Health, Education, and Welfare - - Health - - - Government Policy; Regulation; Public Health

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