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The American Journal of Managed Care August 2018
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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.

Trends in the Share of MA Patients Across NHs

Figure 1 shows the prevalence of MA patients across NHs nationally from 2000 through 2013. A clear upward trend is seen in the average share of MA patients. The percentage of NH patients covered by MA more than doubled from 6.9% in 2000 to 15.5% in 2013. High-MA NHs increased from 9.1% in 2000 to 18.6% in 2013, whereas the share of NHs with any MA patients grew from 48.3% to 90.9% over the same period. MA enrollment among all Medicare beneficiaries over the same period also showed a rapidly increasing trend (Figure 1). NHs that were larger in size had consistently higher proportions of MA patients, whereas nonprofit NHs and those with a low percentage of Medicaid patients experienced more rapid growth in the proportion of MA patients after 2006 (Figure 2). The proportion of MA patients in NHs was higher in counties with greater MA penetration rates, and NHs in urban areas and those located in the Western region of the United States had higher proportions of MA patients over the study period (Figure 3).

Unadjusted Characteristics of NHs by the Proportion of MA Patients

Differences were seen in the unadjusted characteristics of high-MA NHs compared with low-MA NHs and no-MA NHs (Table 1). Compared with low- and no-MA facilities, high-MA NHs tended to be larger, had a higher likelihood of being part of a multifacility NH system, and were more likely to have a physician extender. High-MA facilities also performed better on 2 of the 3 quality indicators, with fewer patients who received antipsychotics and lower rehospitalization rates, but there was no significant difference in the use of physical restraints. Some differences in patient demographics and case mix were observed among the 3 groups. Patients in high-MA NHs were somewhat older on average, were more likely to be female, had lower percentages of racial and ethnic minorities, and were less likely to be Medicaid beneficiaries. A larger proportion of high-MA NHs were located in the Northeast and West regions of the United States and in urban counties (Table 1). High-MA NHs were more likely to be located in counties with greater Medicare managed care penetration and less market concentration.

Adjusted Differences Among NHs by the Proportion of MA Patients

Estimates from our primary regression analysis suggested a number of differences among NHs based on the share of MA patients (Table 2). Estimates indicated that high-MA NHs were slightly larger, on average, than other NHs. However, high-MA NHs were much more likely to be part of a chain compared with low- or no-MA NHs (odds ratio [OR], 1.244; 95% CI, 1.120-1.382). Estimates also indicated that high-MA NHs were significantly more likely to have a physician extender than were low- or no-MA NHs (OR, 1.379; 95% CI, 1.249-1.523). High-MA facilities also tended to have much more RN and LPN staffing compared with the other 2 groups, but lower CNA staffing. Estimates reflecting the quality of care indicated that patients in high-MA NHs were somewhat less likely to receive antipsychotics (OR, 0.985; 95% CI, 0.980-0.991) or to be rehospitalized (OR, 0.951; 95% CI, 0.942-0.960). Although differences in patient demographics were statistically significant, the magnitude of the differences was minimal. Case-mix indicators were generally similar for the 2 groups, with the exception of high-MA facilities having more patients admitted from hospitals. High-MA facilities were more likely to be in the West region of the United States and in counties with higher Medicare managed care penetration (OR, 1.114; 95% CI, 1.108-1.120) and less market concentration (OR, 0.491; 95% CI, 0.351-0.688). Lastly, compared with low- or no-MA facilities, high-MA NHs were less likely to be in urban counties (OR, 0.837; 95% CI, 0.717-0.977).

Regression estimates from our secondary analysis using ordered logistic regression were consistent with the results of our primary analysis, except that high-MA facilities were more likely to be run for profit and RN hours per resident day were not statistically different compared with no-MA or low-MA NHs (eAppendix Table [eAppendix available at]). Estimates from our robustness check using only non-MA NHs as the reference group were also similar to those from the primary analysis, but with larger estimated ORs for some covariates. For example, high-MA facilities were significantly more likely to be part of a chain (OR, 1.885; 95% CI, 1.524-2.333), be run for profit (OR, 1.523; 95% CI, 1.188-1.951), and have a physician extender (OR, 1.885; 95% CI, 1.517-2.342) compared with those without any MA patients.

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