Medicare Advantage and nursing home quality in the United States: a systematic review

As Medicare Advantage becomes the predominant form of Medicare coverage, understanding whether and how enrollment affects access to and quality of delivered care across settings has become an increasingly salient policy concern. This systematic review is designed to synthesize empirical evidence on whether skilled nursing facility quality differs between Medicare Advantage and Traditional Medicare beneficiaries. This systematic review of US-based cohort and cross-sectional studies was conducted in accordance with the PRISMA 2020 reporting guidelines by searching CINAHL Complete, PubMed, EconLit, and Scopus. We screened titles and abstracts, reviewed full texts, and hand-searched reference lists. Study quality and risk of bias were assessed using the Newcastle–Ottawa Scale. Thirty-three articles underwent full-text review, of which 7 met the final inclusion criteria. Evidence generated from included articles was mixed. Medicare Advantage enrollment was consistently associated with a lower likelihood of admission to higher-rated skilled nursing facilities as measured by the CMS Five-Star Quality Rating System. Several studies reported more favorable utilization outcomes among Medicare Advantage enrollees and at the nursing home level. However, associations varied by outcome domain and by short-stay versus long-stay populations. The relationship between Medicare Advantage enrollment and skilled nursing facility quality is nuanced. Although Medicare Advantage enrollment is often associated with favorable utilization outcomes, Medicare Advantage beneficiaries are disproportionately admitted to lower-rated skilled nursing facilities. This suggests potential misalignment between managed care incentives and factors captured by publicly reported measures of nursing home quality in post-acute care, particularly for long-stay residents. As Medicare Advantage enrollment continues to grow, additional research is warranted to examine whether current quality-measurement approaches adequately capture the dimensions of post-acute care performance most relevant to managed-care settings.