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Medicare Advantage Enrollees’ Use of Nursing Homes: Trends and Nursing Home Characteristics
Hye-Young Jung, PhD; Qijuan Li, PhD; Momotazur Rahman, PhD; and Vincent Mor, PhD

Medicare Advantage Enrollees’ Use of Nursing Homes: Trends and Nursing Home Characteristics

Hye-Young Jung, PhD; Qijuan Li, PhD; Momotazur Rahman, PhD; and Vincent Mor, PhD
The share of Medicare Advantage (MA) beneficiaries in the nursing home (NH) population has been steadily rising, while MA plans appear to be increasingly concentrating beneficiaries in select NHs with better performance on quality measures.
ABSTRACT

Objectives: To examine temporal trends in the prevalence of nursing home (NH) patients participating in Medicare Advantage (MA) and to identify the characteristics of both these patients and the NHs that provide care for them.

Study Design: Retrospective cohort study.

Methods: Data sources included the Medicare enrollment file, Minimum Data Set, and facility-level data from the Certification and Survey Provider Enhanced Reporting system. Longitudinal trends of NH use by MA enrollees were examined over the period 2000 to 2013 and logistic regression models were used to identify facility characteristics associated with having a high proportion of MA patients.

Results: The proportion of MA enrollees in NHs more than doubled between 2000 and 2013, increasing 125% during this period. Notable differences in facility characteristics were found between NHs that serve high proportions of MA enrollees and other NHs. High-MA NHs tended to be larger facilities affiliated with chains. These NHs also had better quality indicators, such as higher staffing levels, lower use of antipsychotics, and lower odds of rehospitalization. Additionally, high-MA NHs were more likely to be in counties with higher Medicare managed care penetration and less market concentration.

Conclusions: MA plans may be selectively contracting with NHs, as evidenced by the larger shares of MA patients who have been placed in facilities with better performance on quality measures. This may reflect MA plans concentrating enrollees in specific facilities and building “networks” of postacute and long-term care providers that provide better and more efficient care.

Am J Manag Care. 2018;24(8):e249-e256
Takeaway Points
  • The share of Medicare Advantage (MA) beneficiaries in the nursing home (NH) population has been steadily increasing over time, reflecting the overall growth of the MA population.
  • MA plans appear to be concentrating enrollees in specific NHs and building “networks” of postacute and long-term care facilities that provide better and more efficient care.
  • This is the first national examination of the prevalence of MA penetration in NHs and the characteristics of NHs with high concentrations of MA patients.
Medicare has promoted beneficiaries’ enrollment in private risk-bearing plans for more than 25 years. The role of these plans, currently known as Medicare Advantage (MA), was expanded with the passage of the Medicare Modernization Act (MMA) of 2003.1 In the decade following implementation of the MMA, the number of beneficiaries in MA plans doubled to 16.8 million, representing 31% of all Medicare beneficiaries in 2015.2 The goal of increased privatization of Medicare has been to incentivize closer management of beneficiaries’ healthcare through capitation, thereby increasing the efficiency of care. MA plans established since the MMA’s passage have several advantages over their predecessors by offering coverage for prescription drugs (Part D) and a broader array of preventive services. These plans also typically include higher compensation for providers that serve medically complex beneficiaries; the plans are allowed to establish narrow networks of providers while locking enrollees into plans for a year at a time.1,3,4

Another trend over the last decade or more has been the increasing use of nursing homes (NHs) for postacute care following hospitalization. More than one-fifth of Medicare fee-for-service hospitalizations are now discharged to NHs for postacute care.5 Despite the rapid growth in MA enrollment and the contemporaneous phenomenon of Medicare beneficiaries receiving postacute care in nursing facilities, little is known about MA participants’ use of NHs or the characteristics of NHs that provide care for them.

In this study, we explored temporal trends in the prevalence of MA enrollees in NHs, the characteristics of MA patients who receive care in NHs, and the characteristics of NHs that provide care to MA participants. Understanding trends in the use of NH care by beneficiaries in MA plans is increasingly important given the added focus in the Affordable Care Act on the dually eligible and special-needs populations and given the fact that numerous states are initiating efforts to enroll their aged and disabled Medicaid enrollees in managed care plans for the dually eligible.6,7 These populations are disproportionately represented in NHs, which suggests that further growth in the prevalence of NH patients covered by MA plans will occur.8 To our knowledge, this is the first nationwide study of trends in NH use among MA enrollees and of the characteristics of NHs in which they receive care.

METHODS

Using data that include information on nearly every NH in the country, we examined trends in the prevalence of MA enrollees in NHs over the period 2000 through 2013. We included MA enrollees receiving postacute or long-term care in our prevalence estimates. Data from 2013 were used to identify the characteristics of MA participants receiving care in NHs and the characteristics of the facilities that provided care to this population.

Data

The study used 4 data sources: the Medicare enrollment file; the Minimum Data Set (MDS); the Online Survey, Certification and Reporting system (OSCAR), currently known as the Certification and Survey Provider Enhanced Reporting system; and information on NHs compiled by investigators at Brown University. The Medicare enrollment file contains information on beneficiaries, including demographics, date of death, managed care enrollment, and Medicaid participation. MDS assessments were used to identify individuals who were admitted to an NH. The MDS is federally mandated and conducted upon NH admission, periodically thereafter, and upon discharge. It includes more than 400 items with measures of both cognitive and physical functioning. OSCAR is an administrative database maintained by CMS, which collects and records the results of the state survey and certification process. NH characteristics, including staffing levels, ownership, and chain membership, were derived from OSCAR. Longitudinal characteristics of NHs available from Long-Term Care: Facts on Care in the US (LTCfocus) supplemented information available in OSCAR. LTCfocus creates facility-level data based on Medicare enrollment files, Medicare claims, and MDS assessments of beneficiaries in NHs. These data have been widely used in previous studies of NHs.9-11


 
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