Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data

Background Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees. Methods and findings This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer