Advisor(s)
Allyson Hall
Committee Member(s)
Gavin Jenkins
Lisa Juckett
Robert Weech-Maldonado
Seung-Yup Lee
Soumya Niranjan
Document Type
Dissertation
Date of Award
6-1-2026
Degree Name
Doctor of Philosophy (PhD)
School
School of Health Professions
Department
Administration/Health Services
Abstract
The Jimmo v. Sebelius settlement mandate of 2013 requires Medicare coverage determinations to rely on the need for skilled care to maintain function or prevent decline instead of restoration potential. The study evaluates implementation fidelity and health equity implications of the mandate within United States freestanding skilled nursing facilities. A longitudinal panel spanning Federal Fiscal Years 2013 through 2019 provides 89,717 facility-year observations across 14,132 unique facilities. Moderated facility-level fixed effects regression models quantify shifts in service utilization across three policy phases. These phases include Pre-Jimmo baseline years, Post-Jimmo years from 2014 through 2017, and Post-Cap Repeal years from 2018 through 2019. Service utilization is operationalized through inflation-adjusted real outpatient therapy charges per patient day. Empirical results demonstrate a statistically significant and systemwide contraction in service utilization. The transition to the Post Jimmo phase is associated with a significant decline in therapy charges, with a coefficient of -0.081 and a p-value of .001. This decline increased following the 2018 repeal of Medicare outpatient therapy caps with a coefficient of -0.421 and a p-value under .001. Racial and ethnic composition moderated these impacts. Facilities serving high proportions of Black residents exhibit lower baseline utilization that persisted throughout the study window. During the Post Cap Repeal phase, facilities serving high concentrations of residents classified as other race experienced a compounded reduction in access with a coefficient of -0.007 and a p-value of .010. These results indicate a failure in policy implementation fidelity. Coercive auditing pressures, administrative documentation burdens, and structural risk aversion drive the access-denied phenomenon within the fragmented reimbursement ecosystem. The legal clarification prompted a systemic reduction of maintenance services that disproportionately burdened marginalized populations and widened health disparities. Keywords: Jimmo v. Sebelius, Maintenance Therapy, Skilled Nursing Facilities, Health Equity, Implementation Fidelity, Medicare Part B
Keywords
Health Equity;Implementation Fidelity;Jimmo v. Sebelius;Maintenance Therapy;Medicare Part B;Skilled Nursing Facilities
ProQuest ID
Recommended Citation
Murrell, James Edward, "Policy Clarified, Access Denied: Equity And Implementation Gaps In Skilled Nursing Facility Maintenance Therapy Post-Jimmo" (2026). ETDs from 2020-2029. 243.
https://digitalcommons.library.uab.edu/etd-2020s/243
