Institutional Post-Acute Care Use After Hospitalization by Medicare Type, 2017-2022

OBJECTIVES: To compare national discharge to inpatient rehabilitation facilities (IRF) and skilled nursing facilities (SNF) after short-stay hospitalization among Medicare Advantage (MA) and Traditional Medicare (TM) beneficiaries. DESIGN: Retrospective cohort study using publicly available aggregate Medicare utilization data. SETTING AND PARTICIPANTS: Participants included United States MA and TM beneficiaries from 2017 to 2022. METHODS: Primary outcomes were discharge rates to IRFs and SNFs per 1000 acute hospital discharges and in-facility mortality. Secondary outcomes included community discharge and 30-day readmission among TM beneficiaries. Year-adjusted Poisson regression with acute discharges as an offset estimated incidence rate ratios (IRRs) comparing MA and TM utilization. Discharge-weighted logistic regression estimated odds ratios (ORs) for mortality, community discharge, and readmission. Trends in IRF vs SNF utilization were evaluated using year-adjusted logistic regression. RESULTS: Compared with TM beneficiaries, MA beneficiaries had lower discharge rates to IRF (IRR, 0.397; 95% CI, 0.395-0.398), with a smaller difference for SNF (IRR, 0.904; 95% CI, 0.903-0.905). Within IRF, in-facility mortality odds were higher for MA beneficiaries (OR, 14.69; 95% CI, 14.21-15.18). Within SNF, in-facility mortality odds were lower for MA beneficiaries (OR, 0.447; 95% CI, 0.444-0.450). Across both payers combined, mortality was lower in IRF than SNF (0.71% vs 2.46%; OR, 0.28; 95% CI, 0.278-0.286; P < .001). Among TM beneficiaries, discharge to IRF was associated with lower odds of 30-day readmission (OR, 0.76; 95% CI, 0.75-0.76) and higher odds of community discharge (OR, 1.84; 95% CI, 1.83-1.85). CONCLUSIONS AND IMPLICATIONS: MA beneficiaries had lower downstream use of IRF after hospitalization than TM beneficiaries. In-facility mortality differed among post-acute settings and payer. Patient-level case-mix at the referral source is needed to evaluate whether these differences persist after case mix adjustment.