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Researchers studying patients with hip fractures found that patients with Medicare Advantage (MA) plans have shorter stays in skilled nursing facilities (SNFs) and receive less rehabilitation than patients in traditional Medicare, but are, nevertheless, less likely to be readmitted to an acute care hospital within 30 days or to become long-term care residents.[1]  These findings are inconsistent with findings in prior recent studies, discussed below, by some of the same researchers.

This study found that MA patients with hip fractures received care and services in a SNF for 36.9 days, compared to 44.7 days for patients with traditional Medicare, and that the MA patients received 12.1 fewer minutes of rehabilitation per day than patients in traditional Medicare.  Their study documented that patients in traditional Medicare received 462.8 more minutes of therapy in up to the first 40 days of their SNF stay, compared to MA patients.  The retrospective cohort study looked at 75,554 beneficiaries with MA plans and 211,296 beneficiaries in traditional Medicare who went to a SNF between January 1, 2011 and June 30, 2015.  The study also looked at the patients for 180 days following their SNF stays.

The researchers, who had hypothesized that MA beneficiaries would have worse outcomes than beneficiaries in traditional Medicare, offer two explanations for their counter-intuitive findings: (1) “MA plans encourage the use of narrow networks of efficient SNFs” and (2) case managers employed by MA plans monitor beneficiaries’ therapy and status while in the SNF, making it “possible for MA plans to be actively involved in the discharge planning process.”

The Center for Medicare Advocacy is skeptical about these explanations.  With respect to the first point, MA plans’ “narrow networks” generally include lower quality nursing facilities.  In earlier research, two of the researchers involved in the study discussed here found that beneficiaries enrolled in MA plans were admitted to SNFs with lower ratings on CMS’s Five Star Quality Rating System.[2]  This 2018 study also reported that MA beneficiaries went to SNFs with higher rates of rehospitalization than beneficiaries in traditional Medicare.[3]  In addition, one of the study’s authors co-authored another earlier study that found that the increased numbers of therapy services at SNFs received by residents with hip fractures between 2000 and 2009 led to an increased likelihood of being discharged home.[4]  In the 2016 study, researchers reported, “our estimate of a 3-percentage-point increase in the likelihood of being discharged to home for every additional hour of therapy suggests the possibility that the increased duration of therapy services was an important contributor to the increased rate of discharge to home for patients after hip fracture.”[5]  

With respect to the second point, if additional discharge planning is actually provided by MA plans and helps assure that SNF residents with hip fractures can successfully return to, and remain in, the community, such additional discharge planning services should be provided to all residents in Medicare, those in traditional Medicare as well as those in MA plans.

July 12, 2018 – T. Edelman


[1] Amit Kumar, Momotazur Rahman, Amal N. Trivedi, Linda Resnik, Pedtro Gozalo, Vincent Mor, “Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data,” PLoS Med 15(6):31002592, https//doi.org/10.1371/journal.pmed.1002592, available at http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002592.
[2] David J. Meyers, Vincent Mor, Momotazur Rahman, “Medicare Advantage Enrollees More Likely To Enter Lower-Quality Nursing Homes Compared To Fee-For-service Enrollees,” Health Affairs 37, No. 1 (2018): 78-85.  See CMA, “Medicare Advantage Enrollees Have Fewer SNF Options than Traditional Medicare Beneficiaries” (CMA Alert, Jan. 24, 2018), http://www.medicareadvocacy.org/medicare-advantage-enrollees-have-fewer-snf-options-than-traditional-medicare-beneficiaries/.
[3] Id.
[4] Hye-Young Jung, Amal N. Trivedi, David C. Grabowski, Vincent Mor, “Does More Therapy in Skilled Nursing Facilities Lead to Better Outcomes in Patients With Hip Fracture?” Phys Ther. 2016; 96-81-9, https://academic.oup.com/ptj/article/96/1/81/2686383.
[5] Id.

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