Medicare Advantage Patients More Likely to Experience Extended Hospital Stays Post-COVID

Medicare Advantage beneficiaries experienced disproportionately greater increases in hospital length of stay after the COVID-19 pandemic than those with traditional Medicare, particularly among those discharged to skilled nursing facilities, according to a study published today in JAMA Internal Medicine.¹

After the onset of the COVID-19 pandemic in the US, the care-seeking patterns and flow of patients through hospital systems substantially shifted. One disruption the researchers highlighted is the increasing challenge of discharging clinically stable hospitalized patients promptly.² They noted that patients have often been “stuck” in the hospital for days, weeks, or months due to a lack of suitable post-acute discharge destinations.¹

Although the reasons for the apparent backup of hospital discharges are not fully understood, 1 explanation is the reduced supply of skilled nursing facility beds, which are the main source of institutional post-acute care following the COVID-19 pandemic. Administrative burdens related to Medicare Advantage managed care practices also impede timely discharges; these include prior authorization and narrow networks that may severely restrict placement options when skilled nursing facility beds are scarce.

Despite the potential of delayed discharges to harm patients and disrupt hospital operations, the researchers emphasized the lack of rigorous empirical evidence about the causes and magnitude of extended hospital stays and the contribution of Medicare Advantage insurers to them. To address this evidence gap, they conducted a retrospective cohort study, quantifying changes in the frequency of extended hospital stays post-COVID-19 pandemic for patients by Medicare coverage type.

Extended hospital stays among Medicare Advantage beneficiaries translated to an estimated 1.8 million additional hospital bed days in 2022. | Image Credit: Gorodenkoff - stock.adobe.com

To do so, they used data from the Medicare Provider Analysis and Review dataset combined with Medicare enrollment data, spanning 2017 through the third quarter of 2023. The initial sample included all short-stay inpatient admissions to US acute care and critical access hospitals. For adjusted analyses, due to computational complexity, the researchers used a 20% random sample of the initial sample. Additionally, they conducted a subgroup analysis that examined the outcomes among patients discharged to skilled nursing facilities vs other locations.

The primary outcomes included length of stay and indicators for extended stays (greater than 7, 14, 21, and/or 28 days). The researchers used difference-in-differences regression models to estimate changes in the length of stay for Medicare Advantage vs traditional Medicare beneficiaries, adjusting for patient demographics and hospital fixed effects.

The full sample comprised 89.3 million admissions from 4075 hospitals. There were 13.7 million admissions in 2017 and 12.9 million in 2022, the last full year of data available. Of these, Medicare Advantage beneficiaries had 4.2 million admissions in 2017 and 5.9 million in 2022. In comparison, there were 9.4 million admissions for traditional Medicare beneficiaries in 2017 vs 6.8 million in 2022.

A key finding was the growing prevalence of extended hospital stays, particularly among Medicare Advantage beneficiaries. From 2017 to 2023, the share of admissions lasting at least 14 days rose from 6.7% to 8.8% for patients with Medicare Advantage, compared with a smaller increase among those with traditional Medicare (5.9% to 6.5%). Longer stays of 21 and 28 days also increased disproportionately among Medicare Advantage beneficiaries.

Adjusted analyses confirmed that patients with Medicare Advantage had significantly higher probabilities of extended stays, especially after 2020. By 2023, Medicare Advantage admissions were 19.5% more likely than traditional Medicare to last at least 14 days, with even larger relative increases observed for 21- and 28-day stays.

The impact was most pronounced among patients discharged to skilled nursing facilities. In 2023, Medicare Advantage beneficiaries discharged to these facilities were 3.1 percentage points (95% CI, 2.6-3.6) more likely than their traditional Medicare counterparts to have stays of at least 14 days, reflecting a 28.1% increase from baseline.

Overall, the extended lengths of stay resulted in an estimated 1.8 million additional hospital bed days in 2022 alone, equivalent to 288,000 additional admissions with average stays, highlighting the substantial implications of these trends for hospitals and payers.

The researchers acknowledged their study’s limitations, including its focus on Medicare beneficiaries; the results may not reflect patterns among other US patients. Additionally, the study is observational and does not prove the causal relationship between Medicare Advantage enrollment and hospital length of stay. Still, the researchers expressed confidence in their findings, making suggestions for future actions.

“As Medicare Advantage enrollment continues to expand, policymakers may need to address administrative barriers to discharge to mitigate adverse consequences for hospital operations and patient outcomes,” the authors concluded.

References

1. McGarry BE, Wilcock AD, Gandhi AD, Grabowski DC, Barnett ML. Extended hospital stays in Medicare Advantage and Traditional Medicare. JAMA Intern Med. Published online September 8, 2025. doi:10.1001/jamainternmed.2025.4411
2. Readlynn JK, Zagursky J, Burke RE, Lee JSG, Olson APJ. Gridlock in hospital medicine. J Hosp Med. 2024;19(8):736-738. doi:10.1002/jhm.13259