Amanda C. Chen

Objective: To estimate the effect of starting a provider‐led Institutional Special Needs Plan (I‐SNP) arrangement on facility‐level enrollment, utilization, and quality. Study Setting and Design: I‐SNPs are a type of Medicare Advantage (MA) plan that allows insurers to differentiate their benefits exclusively for long‐term residents in nursing homes. Since I‐SNPs first became available in 2006, there has been growth in provider‐led I‐SNPs where nursing homes are financially integrated or partnered with an insurer to operate a plan for their own residents. We used a difference‐in‐differences design to estimate the effect of starting a provider‐led I‐SNP arrangement on several facility‐level outcomes, including the share of a facility's long‐stay residents who were enrolled in an I‐SNP, hospitalizations, medication use, pressure ulcers, physical restraints, falls, and mortality. Data Sources and Analytic Sample: We used Medicare claims and nursing home resident assessments (2004–2021) to identify Medicare long‐stay nursing home residents. Principal Findings: The start of a provider‐led I‐SNP arrangement led to a 17.0 percentage point (pp) increase (standard error [SE]: 0.006) in I‐SNP enrollment among facility residents within 4 years relative to control nursing homes. We also estimate that the start of a provider‐led I‐SNP arrangement significantly decreased hospitalizations (−1.0 pp, SE: 0.002), increased the use of antipsychotic (0.4 pp, SE: 0.002) and hypnotic drugs (0.3 pp, SE: 0.001), and reporting of pressure ulcers (0.4 pp, SE: 0.002). Conclusions: Provider‐led I‐SNPs allow nursing homes to bear financial risk for their residents. These results suggest that this form of risk bearing may successfully reduce utilization (e.g., hospitalizations), but with unclear implications for quality as increased use of sedating drugs and rates of pressure ulcers could either reflect poorer care or retention of sicker patients due to lower hospitalization rates.

Importance: Enrollment in Medicare Advantage (MA) is expected to continue growing. Previous studies have examined differences in the use and quality of home health care between MA and traditional Medicare, but less is known about outcomes among patients receiving care from agencies with greater exposure to MA patients.Objective: To examine the association between home health agency (HHA) experience with caring for MA patients and quality of care delivered.Design, Setting, Participants: This cohort study included patients continuously enrolled in MA and who received HHA care in 2019. The data analysis was performed between July 16, 2024, and January 16, 2025.Exposure: Medicare beneficiaries who received home health care from agencies with differing levels of MA specialization.Main Outcomes and Measures: Primary outcomes included hospitalizations during the HHA episode and after HHA discharge (at 30 and 90 days), length of stay, and total number of visits. Secondary outcomes included postdischarge mortality and nursing home admission. The outcomes were measured using instrumental variable analysis. The treatment variable was a continuous measure of the HHA-level share of MA patients. The instrumental variable was the differential distance from the nearest MA-specialized HHA to nearest non–MA-specialized HHA (based on the 75th percentile of the HHA-level share of MA patients from January 1 to December 31, 2019 [ie, ≥36.4%]).Results: The study included 749 719 MA patients who received HHA care in 2019 (mean [SD] age, 76.2 [10.4] years; 61.6% female; 26.3% with dual eligibility), of whom 65.4% received care from an MA-specialized HHA and 34.6% received care from a non–MA-specialized HHA. A 1-mile increase in differential distance was associated with a lower likelihood of admission to more MA-specialized HHAs (0.3 percentage points; SE, 0.015 percentage points; F statistic, 450.73). In the instrumental variable analysis, receiving care from more specialized HHAs was associated with a shorter length of stay (coefficient [SE], −15.14 [2.84] days) and fewer total HHA visits (coefficient [SE], −9.40 [1.15] visits) alongside more hospitalizations and nursing home admissions after discharge from the HHA.Conclusion and Relevance: In this cohort study of MA patients who received HHA care, those receiving care from more MA-specialized HHAs had lower service use during the HHA episode, but no clear differences compared with non–MA-specialized HHAs were observed in care use after discharge. These findings are important given the costs associated with delivering HHA care and the expected growth in MA enrollment.

Objective: To compare outcomes between patients admitted to different clinicians within skilled nursing facilities for post‐acute care, leveraging the plausibly random distribution of patients to admitting clinicians in the case of clinicians who specialize in nursing facility care (SNFists). We also compare patient outcomes between SNFists who are physicians versus advanced practice providers (APPs). Study Setting and Design: We used multi‐level modeling to estimate within‐SNF variation in the characteristics and outcomes of patients admitted to different SNFists and linear regression to compare patient characteristics and outcomes between physician and APP SNFists. Our main outcomes were 30‐day hospitalizations, 30‐day mortality, and antipsychotic use. Data Sources and Analytic Sample: We analyzed claims data for a 20% sample of traditional Medicare beneficiaries admitted to a SNF for post‐acute care from 2016 to 2019. Principal Findings: The sample included 81,789 post‐acute patients seen by 6273 SNFists at 1479 facilities between 2016 and 2019. Within‐facility variation in patient characteristics across admitting SNFists was modest and substantially greater across admitting clinicians who were not SNFists, consistent with our key assumption that patients are distributed in a more balanced fashion across admitting clinicians who are SNFists. With patient‐level confounding limited by this focus on SNFists, there was minimal to modest variation in the rates of mortality (adjusted standard deviation: −0.14), hospitalization (0.40), and antipsychotic use (1.10) across admitting clinicians. Outcomes also did not differ between APP and physician admitting SNFists (mortality: 0.001 [95% CI: −0.001, 0.003]; hospitalization: 0.004 [95% CI: −0.001, 0.010], antipsychotic use: −0.001 [95% CI: −0.006, 0.003]). In contrast, outcomes varied substantially across admitting clinicians who were not SNFists. Conclusions: Quasi‐experimental assignment of patients to clinicians in SNFs reveals that the admitting clinician appears to have little influence on key outcomes in the post‐acute setting, in contrast with similar research conducted in other care settings. An analysis of non‐SNFists might falsely conclude that the impact of clinician factors is large because of evident non‐random sorting of patients to non‐SNFist clinicians in SNFs.

Two-thirds of US hospices were not given a star rating when the Centers for Medicare and Medicaid Services (CMS) introduced its hospice star rating system in 2022. Since then, the share of hospices without a star rating has steadily increased, including through the most recent reporting period of 2024. This suggests that the CMS hospice star rating is having limited impact. We provide recommendations for CMS and other policy makers to improve the value for hospice patients of publicly reported star ratings.

Background: Because Traditional Medicare (TM) and Medicare Advantage (MA) have different reimbursement structures and incentives, it is important to understand differences in home health agency (HHA) use by payer type. Objective: To quantify differences in care patterns and outcomes between TM and MA HHA users. Research Design and Subjects: Medicare HHA claims were used to identify postacute HHA episodes among US adults aged 65 and older enrolled in MA or TM (2015–2019). Adjusted regression models with and without HHA fixed effects assessed whether TM and MA beneficiaries are treated differently within an HHA. Measures: We examined process (timely initiation of care, receipt of a skilled nursing visit, and length of stay) and quality measures (hospital readmission and healthy days at home). Results: The study included 4,029,527 beneficiaries (3,034,452 TM and 995,075 MA). We identified large differences in the share of beneficiaries experiencing timely initiation of care (81.4% TM vs. 77.4% MA) and receipt of skilled nursing visits (86.8% TM vs. 81.9% MA). After including HHA fixed effects in the regression model, MA beneficiaries were 2.1 percentage points (pp) less likely to experience timely initiation of care and were 3.1 pp less likely to receive a skilled nursing visit (and 8.9 pp less likely to receive any type of skilled visit) within 2 days of starting HHA care compared with TM beneficiaries (P<0.001). Conclusions: Our findings suggest differential treatment between MA and TM beneficiaries within the same HHA. Further research is needed to understand the mechanisms driving these within-agency differences.

Objective: To quantify quality of care following an admission to a nursing home with low or high antipsychotic drug use. Background: Misuse of antipsychotics in U.S. nursing homes is a huge concern for policymakers. Methods: We utilized an instrumental variable approach to estimate the effect of facility-level antipsychotic use on patient outcomes. The instrument was the differential distance to the nearest low-use antipsychotic nursing home relative to the nearest high-use antipsychotic nursing home. Post-acute care short-stay and long-stay residents in U.S. nursing homes were identified using Medicare administrative claims and the Minimum Dataset 3.0 (2014–2019). Outcomes included hospitalizations, falls, pressure ulcers, physical restraint use, medication use, and diagnosis of schizophrenia, bipolar disease, anxiety, or depression. Results: Among long-stay residents, receiving care from a low-use facility reduced the diagnosis of schizophrenia, use of restraints, and hospitalizations. There was also a reduction in the hospitalization rate [−0.9 percentage point (pp)], likelihood of long-stay status (−1.8 pp), and diagnosis of schizophrenia (−0.2 pp) at 90 days among short-stay residents. We also observed larger reductions among residents with dementia and serious mental illness. Conclusions: Admission to a nursing home with a low use of antipsychotics led to decreased hospitalizations, restraint use, and diagnosis of schizophrenia. Curbing the high use of antipsychotics remains a priority of policymakers as the centers for medicare and medicaid services conducts off-site audits to assess whether nursing homes accurately code residents with schizophrenia. It will be important to monitor if centers for medicare and medicaid services downgrades any quality star ratings due to inappropriate coding and assess the implications on quality of care.

Objective: To estimate differences in facility‐level outcomes between nursing homes which reached Institutional Special Needs Plan (I‐SNP) maturity and those which never cared for I‐SNP enrollees.Study Setting and Design: We used a difference‐in‐differences design to estimate the effect of I‐SNP maturity, defined as having at least 33.75% of Medicare long‐stayers in the nursing home enrolled in any I‐SNP. Our main outcome was the hospitalization rate in each nursing home‐year. Secondary outcomes included the share of residents with medication use, fall, urinary tract infection, catheter insertion, pressure ulcer, physical restraint use, increased need for help with activities of daily living (ADLs), and mortality.Data Sources and Analytic Sample: This repeated cross‐sectional study used 100% Medicare claims, Minimum Data Set assessments, and publicly available Medicare Advantage (MA) plan characteristics data (2004–2021). We included all MA beneficiaries who resided in US nursing homes which reached I‐SNP maturity and those without I‐SNP enrollees.Principal Findings: We identified 2530 nursing homes which reached I‐SNP maturity (treated) and 9830 nursing homes without I‐SNP enrollees (untreated). There were some differences observed between these nursing homes, including shares of residents who were White (76.42% vs. 84.84%) and on Medicaid (66.94% vs. 55.45%). These nursing homes were also larger on average (141.76 beds vs. 87.56 beds). From the difference‐in‐differences model, nursing homes which reached I‐SNP maturity experienced declines of 4.1 percentage points (pp) for hospitalizations, 1.0 pp for pressure ulcers, 1.3 pp for urinary tract infections (p < 0.001) alongside increases in the need for help with ADLs, use of antipsychotics, falls, and physical restraints.Conclusions: Nursing homes which reached I‐SNP maturity experienced fewer hospitalizations and pressure ulcers but a decline in function and increase in other negative outcomes. I‐SNPs may be a promising model to improve care for long‐stay residents, but more research is needed to understand potential adverse consequences.

Institutional Special Needs Plans (I-SNPs) are a type of Medicare Advantage (MA) plan designed for long-term residents of nursing homes or those who live in the community but need a nursing home level of care. I-SNPs provide for on-site nurse practitioners in nursing homes to help improve primary care, care planning, and care coordination. Our study was the first to undertake a nationwide descriptive analysis of the I-SNP market. The share of long-stay nursing home residents enrolled in I-SNPs quadrupled from 2006 to 2021, from 2.2 percent to 8.8 percent. Despite this growth, nearly 70 percent of nursing homes did not have any residents enrolled in I-SNPs in 2021, and in more than 60 percent of US counties, there were no I-SNPs available. Nearly 94 percent of long-stay nursing home residents who were enrolled in I-SNPs in 2021 were eligible for both Medicare and Medicaid. More research is needed to understand why I-SNPs enter certain markets and why long-stay nursing home residents choose to enroll in them; to assess I-SNP enrollment barriers; and to compare hospital admission rates and quality outcomes among long-stay nursing home residents by I-SNP enrollment status. Increased understanding of I-SNPs could inform policies to address long-standing concerns about the quality of care in nursing homes.

Importance: Given the growth of home health agency (HHA) care, it is important to understand whether quality reporting programs, such as star ratings, are associated with improved patient outcomes.Objective: To assess the immediate and long-term association of the introduction of HHA star ratings with patient-level quality outcomes, comparing claims-based and agency-reported measures.Design, Setting, and Participants: This cross-sectional study used Medicare HHA claims and agency-reported assessments to identify sequential patient episodes (ie, spells) among US adults with traditional Medicare who received HHA care (2013-2019). An interrupted time series (ITS) model was used to measure changes in trends and levels before and after the introduction of star ratings. Statistical analysis was performed from November 2022 to September 2023.Exposure: The exposure was the introduction of HHA star ratings. The postexposure period was set as starting January 1, 2016, to account for the period when both star ratings (quality of patient care and patient satisfaction rating) were publicly reported.Main Outcomes and Measures: The main outcomes included claims-based hospitalization measures (both during the patient spell and 30 days after HHA discharge) and agency-reported functional measures, such as improvement in ambulation, bathing, and bed transferring. There was also a measure to capture timely initiation of care among post–acute care HHA users, defined as HHA care initiated within 2 days of inpatient discharge.Results: This study identified 22 958 847 patient spells to compare annual changes over time; 9 750 689 patient spells were included during the pre–star ratings period from January 1, 2013, to December 31, 2015 (6 067 113 [62.2%] female; 1 100 145 [11.3%] Black, 512 487 [5.3%] Hispanic, 7 845 197 [80.5%] White; 2 656 124 [27.2%] dual eligible; mean [SD] patient spell duration, 70.9 [124.9] days; mean [SD] age, 77.4 [12.0] years); 13 208 158 patient spells were included during the post–star ratings period from January 1, 2016, to December 31, 2019 (8 104 69 [61.4%] female; 1 385 180 [10.5%] Black, 675 536 [5.1%] Hispanic, 10 664 239 [80.7%] White; 3 318 113 [25.1%] dual eligible; mean [SD] patient spell duration, 65.3 [96.2] days; mean [SD] age, 77.7 [11.6] years). Results from the ITS models found that the introduction of star ratings was associated with an acceleration in the mean [SE] hospitalization rate during the spell (0.39% [0.05%] per year) alongside functional improvements in ambulation (2.40% [0.29%] per year), bed transferring (3.95% [0.48%] per year) and bathing (2.34% [0.19%] per year) (P < .001). This occurred alongside a 1.21% (0.12%) per year reduction in timely initiation of care (P < .001).Conclusions and Relevance: This cross-sectional study found an observed improvement in agency-reported functional measures, which contrasted with slower increases in more objective measures such as hospitalization rates and declines in timely initiation of care. These findings suggest a complex picture of HHA quality of care after the introduction of star ratings.