Association of Medicare Advantage Enrollment With Post-Acute Care Use and Associated Patient Outcomes

Enrollees in Medicare Advantage (MA) receive less intensive post-acute care (PAC) than those in traditional Medicare, but the implications of this lower intensity, particularly for patients with complex needs, remain poorly understood.

To estimate the association of MA enrollment with PAC use and patient outcomes for hospitalized beneficiaries with hip fracture or stroke.

A quasi-experimental difference-in-differences analysis leveraging the geographic expansion of MA from 2012 to 2017. The study included 148,396 stroke and 126,046 hip fracture hospitalizations, representing quasi-exogenous hospitalization events in high MA-growth counties.

Initial PAC setting, 30-day all-cause hospital readmission, and 30- and 90-day all-cause mortality.

MA enrollment was associated with fewer discharges to inpatient rehabilitation facilities (stroke: -8.9 pp; 95% CI, -9.88 to -7.92; hip fracture: -14.4 pp; 95% CI: -15.38 to -13.42). While 30-day readmissions were modestly lower for MA enrollees in both cohorts, MA enrollees experienced a 7.1% relative increase in 30-day mortality for stroke (0.6 pp; 95% CI: 0.01 to 1.19) and an 11.9% relative increase in 90-day mortality for hip fracture (1.3 pp; 95% CI: 0.52 to 2.08). This adverse mortality effect was concentrated in markets with high baseline IRF use (> = 33.3% of discharges, top tercile), where MA enrollment was associated with an 18.0% relative increase in 90-day mortality for stroke (2.0 pp; 95% CI: 0.82 to 3.18) and a 22.3% relative increase in 90-day mortality for hip fracture (2.3 pp; 95% CI: 0.93 to 3.67).

MA enrollment was associated with lower IRF use, modestly lower readmissions, and a higher mortality risk for hip fracture and stroke. These findings suggest that MA's strategy of shifting patients to lower-cost settings may carry unintended adverse consequences for clinically complex patients.