Assessment of Differences in Inpatient Rehabilitation Services for Length of Stay and Health Outcomes Between US Medicare Advantage and Traditional Medicare Beneficiaries

Abstract

IMPORTANCE Enrollment in Medicare Advantage (MA) has been increasing and has reached one-third of total Medicare enrollment. Because of data limitations, direct comparison of inpatient rehabilitation services between MA and traditional Medicare (TM) beneficiaries has been very scarce. Subgroups of elderly individuals admitted to inpatient rehabilitation facilities (IRFs) may experience different care outcomes by insurance types. OBJECTIVE To measure the differences in length of stay and health outcomes of inpatient rehabilitation services between TM and MA beneficiaries in the US. DESIGN, SETTING, AND PARTICIPANTS This multiyear cross-sectional study used the Uniform Data System for Medical Rehabilitation to assess rehabilitation services received by elderly (aged >65 years) Medicare beneficiaries in IRFs between 2007 and 2016 for stroke, hip fracture, and joint replacement. Generalized linear models were used to assess whether an association existed between Medicare insurance type and IRF care outcomes. Models were adjusted for demographic characteristics, clinical conditions, and facility characteristics. Data were analyzed from September 2018 to August 2019. EXPOSURES Medicare insurance plan type, TM or MA. MAIN OUTCOMES AND MEASURES Inpatient length of stay in IRFs, functional improvements, and possibility of returning to the community after discharge. RESULTS The sample included a total of 1 028 470 patients (634 619 women [61.7%]; mean [SD] age, 78.23 [7.26] years): 473 017 patients admitted for stroke, 323 029 patients admitted for hip fracture, and 232 424 patients admitted for joint replacement. Individuals enrolled in MA plans were younger than TM beneficiaries (mean [SD] age, 76.96 [7.02] vs 77.95 [7.26] years for stroke, 79.92 [6.93] vs 80.85 [6.87] years for hip fracture, and 74.79 [6.58] vs 75.88 [6.80] years for joint replacement) and were more likely to be black (17 086 [25.5%] vs 54 648 [17.9%] beneficiaries) or Hispanic (14 496 [28.5%] vs 24 377 [8.3%] beneficiaries). The MA beneficiaries accounted for 21.8% (103 204 of 473 017) of admissions for stroke, 11.5% (37 160 of 323 029) of admissions for hip fracture, and 11.8% (27 314 of 232 424) of admissions for joint replacement. The MA beneficiaries had shorter mean lengths of stay than did TM beneficiaries for both stroke (0.11 day; 95% CI, −0.15 to −0.07 day; 1.15% shorter) and hip fracture (0.17 day; 95% CI, −0.21 to −0.13 day; 0.85% shorter). The MA beneficiaries also had higher possibilities of returning to the community than did TM beneficiaries, by 3.0% (95% CI, 2.6%-3.4%) for stroke and 5.0% (95% CI, 4.4%-5.6%) for hip fracture. The shorter length of stay and better ultimate outcomes were achieved without substantially compromising the intermediate functional improvements. Facility type (freestanding vs (continued) Key Points Question Do Medicare Advantage beneficiaries experience different care services and outcomes from inpatient rehabilitation facilities than traditional Medicare beneficiaries do? Findings In this multiyear crosssection...

Inpatient rehabilitation service utilization and outcomes under US ACA Medicaid expansion

“…: STUDY00001563), used data from the Uniform Data System for Medical Rehabilitation (UDSMR). UDSMR maintains the world’s largest non-government data repository for inpatient medical rehabilitation in the United States and covers about 80% of the IRF in the industry [ 18 , 19 ]. Inclusion in UDSMR is primarily based on historical business administrative decisions unrelated to geographic area or facility type [ 18 ].…”

“…UDSMR uses the Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI) to document patient records. It includes sociodemographic variables, diagnoses (International Classification of Diseases Ninth Revision [ICD-9] codes), IRF characteristics, discharge disposition, and cost factors such as length of stay (LOS), source of payment, and facility charges [ 18 , 19 ]. In addition, IRF-PAI also documents patient functional measures of basic daily living using the Functional Independence Measure (FIM instrument).…”

“…Following from the team’s previously published study [ 19 ], length of stay (LOS) was calculated as the number of days spent in IRF excluding treatment or program interruptions (i.e., days when patients were absent from the facilities). LOS is proportional to treatment costs or per episode resource utilization [ 24 – 26 ].…”

“…The score ranges between 18 to 126 with higher scores indicating more independence [ 23 , 26 ]. Detailed information regarding the FIM instrument can be found in the team’s previous study [ 19 ]. The FIM instrument has also been validated and used by many other studies in the field [ 24 – 27 ].…”

“…Control variables in the study included patient basic demographics (e.g., age, sex, race/ethnicity), socioeconomic status (e.g., marital status, geographic region, and insurance type - Medicaid fee-for-service or managed care), clinical factors (FIM at admission, CMS defined comorbidity tiers and case-mix group) and facility characteristics. Selection of these variables was based on the availability of the UDSMR dataset and other studies on rehabilitation outcomes using the same dataset [ 19 , 24 – 27 ]. These four categories of control variables also resembled the general framework of determinants of population health covering factors in biology, socioeconomics, clinical conditions, health care policy and health care system/provider-level settings.…”