Hospital length of stay has been increasing more dramatically for Medicare Advantage beneficiaries than traditional Medicare beneficiaries, and this trend is especially pronounced for people who are discharged to a skilled nursing facility.

This is according to an article recently published in JAMA Internal Medicine. In the third quarter of 2023, hospital patients on Medicare Advantage were 3.1 percentage points more likely than similar patients on traditional Medicare to have a stay of at least 14 days before being discharged to a SNF, according to the study, which analyzed data from 2017 to through Q3 2023. 

Looking at all hospital patients – not just those discharged to a SNF – the probability of a Medicare Advantage beneficiary having a length of stay of at least 14 days in Q3 2023 increased by 1.2 percentage points relative to traditional Medicare beneficiaries.

Skilled nursing facilities’ capacity to admit new residents has been reduced since the COVID-19 pandemic due to challenges such as staffing shortages, the study authors noted. But they also cited Medicare Advantage requirements as possibly contributing to bottlenecks.

“Extensively documented barriers to discharge in Medicare Advantage due to prior authorization or more limited postacute care networks are plausible explanations for this pattern of care,” they wrote.

Medicare Advantage-related slowdowns in hospital discharges are driving up costs to hospitals, perhaps by as much as $5.5 billion in 2023, according to the article. But the situation also has negative effects on patients, who do not receive timely post-acute rehab and are at risk for longer periods of time to infections in the hospital.

“These analyses, although unable to establish causality, do imply that policy interventions should focus on the Medicare Advantage beneficiary population,” the study authors wrote. “Policy interventions could involve regulating or negotiating with Medicare Advantage payers, who are documented to have strong oversight of skilled nursing facility use, or targeting patient populations with increasing representation in Medicare Advantage plans, such as those eligible for Medicare and Medicaid.”

The study authors are affiliated with the Department of Medicine at the University of Rochester; Brown University School of Public Health; UCLA Anderson School of Management; Harvard Medical School; and Harvard T.H. Chan School of Public Health.

Shifting hospital, SNF dynamics

These study findings come as some skilled nursing provider executives are anticipating that hospitals soon will be under even more pressure to discharge patients to post-acute care in a timely way. This is because the One Big Beautiful Bill Act (OBBBA) could lead to a surge in people seeking hospital care, particularly in the emergency department, after they no longer qualify for Medicaid and therefore cannot pay for care delivered in other settings.

To prepare for this scenario, some SNF providers are expanding their clinical capabilities in order to take on more complex patients. For instance, Creative Solutions in Healthcare – which operates 174 long-term care facilities in Texas – is training nurses in advanced respiratory care and IV management, CEO Gary Blake said at the recent Skilled Nursing News RETHINK Conference in Chicago.

Likewise, Ocean Healthcare is expanding clinical programs to adapt to a world in which the SNF is becoming “the new hospital,” Chief Strategy Officer and Senior VP of Network Development Joseph Kiernan said at RETHINK.

Medicare Advantage-related impediments to discharge threaten to create a reverse scenario – rather than SNFs becoming more like hospitals, discharge bottlenecks force hospitals to fill the role of SNFs.

It’s a point reinforced by the recent JAMA Internal Medicine article on discharge delays among the Medicare Advantage beneficiaries.

“These delays could have meaningful clinical implications because patients who require postacute care are, by definition, not safe to be discharged home,” the study authors wrote. “In the absence of an available bed in skilled nursing facilities, hospitals may be forced de facto to take on the role of a skilled nursing facility, regardless of their ability to provide rehabilitative care.”