Medicare Advantage Enrollees More Likely to Enter Low-Quality SNFs

Fee-for-service (FFS) Medicare has been increasingly de-emphasized in favor of newer payment models such as Medicare Advantage (MA), but a new study in the journal Health Affairs suggests that FFS might provide better skilled-nursing choices for its beneficiaries.

“Even after accounting for the quality of nursing homes in a geographic area and the quality of Medicare Advantage plans in a geographic area, patients in Medicare Advantage plans tended to go to lower-starred nursing homes,” David Meyers of the Brown University School of Public Health told Skilled Nursing News.

For the research — released late Monday — Meyers and colleagues studied data for all Medicare beneficiaries who were newly admitted to SNFs between 2012 and 2014, with the goal of assessing the link between SNF quality ratings with selection choices among FFS and MA patients.


The team included all Medicare enrollees aged 65 and older who were admitted to a SNF in the time period and not admitted to one in the previous year. The patient sample included 3.34 million FFS patients, 945,885 patients in lower-quality MA plans and 302,761 in higher-quality MA plans. Higher-quality MA plans were defined as those with four or more stars from the Centers for Medicare & Medicaid Services (CMS); lower-quality MA plans were those with fewer than four stars.

For SNF quality, the researchers used publicly available Five-Star Quality Rating System data from Nursing Home Compare.

Meyers and the team found that Medicare Advantage enrollees were more likely to enter lower-quality SNFs than FFS enrollees. In addition, after adjusting for distance and other factors, MA plan enrollees were less likely to choose SNFs of higher quality.


“If you were in a five-star Medicare Advantage plan, you still went to a lower-quality nursing home than someone in traditional Medicare,” Meyers added.

Networks and preferred partnerships

Enrollees in lower-quality MA plans entered SNFs with significantly higher rehospitalization rates, compared with enrollees in FFS Medicare, the study found. Though the actual outcomes for MA patients is unknown, they tend to go to SNFs that produce worse outcomes, Meyers told SNN.

“MA patients went to nursing homes that had these higher rehospitalization rates,” he said. “When people go to homes that have better star ratings and better hospitalization rates, they tend to have better outcomes.”

Though it’s hard to say with certainty why FFS Medicare enrollees went to higher-quality nursing homes, one factor Meyers noted was steering. Doctors and family members might help someone with traditional Medicare choose a location based on distance or star ratings, Meyers noted. In other words, those in traditional Medicare could prioritize quality without being constrained by a fixed MA network.

Meanwhile, most MA plans have a stable of preferred providers, and this could play a part in MA beneficiary decisions in several ways, Meyers said.

“A MA plan might be incentivized to send patients to a given nursing home regardless of what the quality ratings are, because of a relationship with that nursing home or because they have a lot of patients in that nursing home and can better manage their care,” he explained.

Still, there’s a scarcity of data about MA enrollee claims, the study noted. This lack of hard evidence makes it a challenge to say anything definitive about the outcomes for MA enrollees, Meyers observed.

“CMS’s rehospitalization measures for SNFs do not include MA patients in their calculations,” the researchers wrote in the study. “Including MA patients in these measures could help better track any differences in outcomes between FFS and MA SNF patients. Also, CMS could require MA plans to be more transparent about the quality of SNFs in their networks when beneficiaries make their Medicare enrollment decisions.”

Written by Maggie Flynn

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