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

Introduction: Skilled nursing facility (SNF) performance under the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Value-Based Purchasing (SNF VBP) program is intended to reflect quality of care but may also be shaped by broader policy and structural contexts. This study evaluates whether Medicaid expansion status and structural disadvantage, measured using the Structural Racism Effects Index (SREI), are associated with high SNF performance. Methods: We conducted a pooled repeated cross-sectional analysis of facility-level data from fiscal years 2019-2021 and 2024, including 57 816 facility-year observations. High performance was defined as a total SNF VBP score ≥50 (upper quartile). Multivariable logistic regression estimated associations between Medicaid expansion, SREI, and high performance, adjusting for ownership, facility size, resident census, nurse staffing, prior penalties, and year. Results: Facilities in Medicaid expansion states had higher odds of high performance (aOR = 1.19; 95% CI: 1.13-1.24), while greater structural disadvantage was associated with lower odds (OR = 0.87; 95% CI: 0.85-0.89). Higher registered nurse staffing was associated with better performance, while ownership, LPN staffing, and penalties were not significant. Conclusion: SNF performance reflects both policy and structural conditions. Without accounting for these factors, value-based payment models may reinforce existing inequities.