Despite Shorter Stays, Medicare Advantage Improved Skilled Nursing Outcomes

Patients enrolled in Medicare Advantage (MA) plans had a shorter rehabilitation stay in a skilled nursing facility and were more likely to be successfully discharged to the community, compared with patients on fee-for-service (FFS) Medicare, according to a new study published in PLOS Medicine.

MA patients were also less likely to experience a 30-day hospital readmission, the retrospective cohort study found.

Specifically, the study examined the treatment processes and outcomes for 212,296 FFS and 75,554 MA patients with hip fracture who were admitted to SNFs directly. It found MA patients spent 5.1 fewer days in the SNF and got 463 fewer minutes of total rehabilitation therapy in the first 40 days following SNF admission, compared with FFS patients.


That difference could translate to significant savings, according to Amit Kumar of Brown University, one of the researchers on the study.

“Our study results suggest we can reduce length of stay by five days, and if you convert that into the money and the costs, it’s almost $3,000 to $4,000 per patient,” he told SNN. “I think that’s most important.”

Shorter stays, better discharge


The researchers had hypothesized that patients who received more care would have better outcomes after their release, but the findings revealed the opposite. After hospitalizations for hip fractures, patients covered by Medicare Advantage had a SNF stay of 25 days on average, while FFS patients spent an average of 31 days in a SNF.

But MA patients had a 30-day readmission rate that was 1.2 percentage points lower than that of FFS patients, as well as a 3.2 percentage point higher rate of successful discharge to the community, compared with FFS patients.

Successful discharge was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute and post-acute settings for at least 30 days.

“We were expecting that MA patients would stay fewer days … but we were not expecting that they would do so well in terms of patient outcomes,” Kumar told SNN. “It was surprising to us, the difference was so high.”

A different study from Brown that was published in Health Affairs found that patients in MA plans tended to go to nursing homes with lower ratings on the Five-Star Quality Rating System from the Center for Medicare & Medicaid Services’ (CMS) Nursing Home Compare. But the study sought to account for any differences in SNF quality, Kumar stressed.

They also tried to account for any bias of healthier patients electing to enroll in MA plans and relatively sicker patients in FFS ones.

“We used the fixed effect, so that both MA and FFS patients are going to a similar nursing home or the same nursing home,” Kumar said. “And then we looked up their length of stays and outcomes. MA [plans] already have bias, having a healthier population in them, and so we did the propensity score matching make sure that both MA and FFS patients looked very similar … so we’re comparing apples to apples.”

Key takeaways

The study has ramifications for the debate on value-based payment reform, and Kumar stressed this to SNN. Whether it’s the new Bundled Payments for Care Improvement (BPCI) model announced early this year or the new Patient Driven Payment Model (PDPM) for SNFS, the core goal of value-based care is to reduce costs without affecting — or even while improving — the patient outcome, Kumar said.

The study shows that more care isn’t necessarily better, he explained.

The readmission finding could draw attention as the SNF value-based purchasing program (SNF-VBP) draws near. Under those rules, which take effect October this year, SNF operators automatically lose 2% of their Medicare reimbursement, and can earn that back by hitting certain performance benchmarks. Readmissions will be a key metric in that assessment.

And to that end, Kumar recommends SNFs get a bit more active when patients leave their doors.

“SNFs can be proactively involved in the progress and discharge destinations [of patients],” he told SNN. “Involving the rehab managers proactively in their discharge planning would be an ideal suggestions, and sending patients home with home health would be advised.”

Written by Maggie Flynn

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