Association of Medicare Advantage Enrollment With Post-Acute Care Use and Associated Patient Outcomes
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IMPORTANCE: 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. OBJECTIVES: To estimate the association of MA enrollment with PAC use and patient outcomes for hospitalized beneficiaries with hip fracture or stroke. DESIGN, SETTING, AND PARTICIPANTS: 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. MAIN OUTCOME MEASURES: Initial PAC setting, 30-day all-cause hospital readmission, and 30- and 90-day all-cause mortality. RESULTS: 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). CONCLUSIONS: 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.