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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.
DISCUSSION

The role of private plans has become increasingly important, considering that nearly 1 in 3 Medicare beneficiaries is now covered by one. In this study, we examined whether this phenomenon is reflected in the NH setting. We explored national trends and geographic concentrations of MA patients in NHs, in addition to the characteristics of facilities based on the share of their patients covered by MA plans. We found that growth in the number of Medicare beneficiaries enrolled in MA plans32,33 is reflected in the prevalent NH population. The proportion of MA enrollees in NHs increased 125% between 2000 and 2013. The rate of increase of NH patients covered by MA outpaced the growth in MA enrollment for the overall Medicare population (55% vs 41%). A recent Medicare Payment Advisory Commission (MedPAC) report shows that although the number of dually eligible enrollees in special-needs MA plans increased over the last 10 years, enrollment in these plans among the dually eligible residing in institutional settings steadily declined. This may indicate that the increase in MA concentration in NHs is being driven by patients receiving postacute care. In our study, patients from high-MA facilities had higher odds of being admitted from hospitals, which also suggests higher prevalence of postacute care users among these NHs.

Notable differences were also found in facility characteristics between NHs that serve high proportions of MA patients and other NHs. High-MA NHs tended to be larger facilities affiliated with chains. These NHs also had better quality indicators, as demonstrated by higher staffing, lower use of antipsychotics, and lower odds of rehospitalization.

Our results suggest that MA plans may have increasingly placed patients in NHs that provide higher-quality care. 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 NHs and building “networks” of postacute and long-term care providers that provide better and more efficient care. This is suggested by the results of both a recent study and a report by MedPAC, which indicate that MA plans have been building referral networks by selectively contracting with higher-quality NHs for postacute care.34,35 It is also important to note that high-MA NHs were more likely to be in mature markets with higher managed care penetration, which could be reflective of the long-standing presence of MA plans in these areas. Additionally, it is possible that the larger proportions of MA patients found in higher-quality NHs reflects self-selection. Because beneficiaries self-select into MA and tend to be healthier than beneficiaries in traditional Medicare, MA beneficiaries may also be selectively choosing these NHs.

High-MA NHs are more likely than other facilities to have nurse practitioners, which is a hallmark of the “EverCare” model of managed care in the NH setting.36-39 This model of care relies on concentrating patients in NHs to increase the ability of the insurer’s medical staff to monitor their beneficiaries in the NH more efficiently, allowing better integration of different types of care providers and enhanced coordination of services. It is possible that MA plans are pursuing similar strategies.

There is evidence of hospitals that discharge patients to narrower networks of NHs having lower rehospitalization rates,40 suggesting that practiced interorganizational exchanges are effective in improving overall quality.41 If similar benefits are associated with collaborative arrangements between MA plans and NHs, policy changes that include efforts to package long-term care benefits with MA plans may be warranted.

Limitations

This study has limitations to consider. First, we conducted a facility-level analysis and did not provide information on the individual experiences of MA enrollees. Second, we did not examine individual MA plans and contracts. We acknowledge that there may be substantial variation in the approaches toward care taken by those that contract with select providers. Lastly, we did not differentiate between incident admissions for postacute care and long-stay NH patients but combined them in an omnibus manner at the time of estimating the prevalent population. Although this is a facility-level analysis and we examined MA growth by the percentage of Medicaid patients in the NH, which could be considered a proxy for the percentage of long-stay patients, future study is warranted to examine the MA status of NH patients as they transition from postacute to long-term care in these facilities.

CONCLUSIONS

This study represents the first known national examination of the prevalence of MA penetration in NHs and the characteristics of NHs with high concentrations of MA patients. We provide a comprehensive description of the growth of MA enrollment among the NH population over a 14-year period. The findings of this study suggest that MA plans may act on incentives to provide more efficient care by selectively placing enrollees in NHs that provide higher-quality care. Further study is needed to illuminate the experiences of MA plans that contract with NHs and to identify patient outcomes associated with these agreements. Lastly, it is important to identify any unintended consequences of increased MA penetration in NH settings, such as inequitable access to MA plans and associated disparities in patient outcomes, as more growth is anticipated in these plans.

Author Affiliations: Department of Healthcare Policy and Research, Weill Cornell Medical College (H-YJ), New York, NY; Department of Health Services, Policy and Practice, Brown University (QL, MR, VM), Providence, RI.

Source of Funding: National Institute on Aging (R01 AG047180-02).

Author Disclosures: Dr Mor is chair of the scientific advisory board for naviHealth, has grants pending and received from the National Institutes of Health, and has attended AcademyHealth meetings. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (H-YJ, QL, MR, VM); acquisition of data (QL, MR, VM); analysis and interpretation of data (H-YJ, QL, MR, VM); drafting of the manuscript (H-YJ, QL, MR); critical revision of the manuscript for important intellectual content (H-YJ, QL, MR, VM); statistical analysis (H-YJ, QL, MR, VM); provision of patients or study materials (H-YJ); obtaining funding (MR, VM); administrative, technical, or logistic support (VM); and supervision (VM).

Address Correspondence to: Hye-Young Jung, PhD, Department of Healthcare Policy and Research, Weill Cornell Medical College, 402 E 67th St, New York, NY 10065. Email: arj2005@med.cornell.edu.
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