IMPORTANCE How often enrollees with complex care needs leave the Medicare Advantage (MA) program and what might drive their decisions remain unknown. OBJECTIVE To characterize trends in switching to and from MA among high-need beneficiaries and to evaluate the drivers of disenrollment decisions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of MA and traditional Medicare (TM) enrollees from January 1, 2014, through December 31, 2015, used a multinomial logit regression stratified by Medicare-Medicaid eligibility status. All 14 589 645 non-high-need MA enrollees and 1302 470 high-need enrollees in the United States who survived until the end of 2014 were eligible for the analysis. Data were analyzed from November 1, 2017, through August 1, 2018. EXPOSURES Enrollee dual eligibility and high-need status (based on complex chronic conditions, multiple morbidities, use of health care services, functional impairment, and frailty indicators), MA plan star rating, and cost sharing. MAIN OUTCOMES AND MEASURES The proportion of enrollees who disenrolled into TM, remained in the same MA plan, or who switched plans within the MA program. RESULTS A total of 13 901 816 enrollees were included in the analysis (56.2% women; mean [SD] age, 70.9 [9.9] years). Among the 1302 470 high-need enrollees, an adjusted 4.6% (95% CI, 4.5%-4.6%) of Medicare-only and 14.8% (95% CI, 14.5%-15.0%) of Medicare-Medicaid members switched from MA to TM compared with 3.3% (95% CI, 3.3%-3.3%) and 4.6% (95% CI, 4.5%-4.7%), respectively, among non-high-need enrollees. Among enrollees in low-quality plans, 23.0% (95% CI, 22.3%-23.9%) of Medicare and 42.8% (95% CI, 40.5%-45.1%) of dual-eligible high-need enrollees left MA. Even in high-quality plans, high-need members disenrolled at higher rates than non-high-need members (4.9% [95% CI, 4.6%-5.2%] vs 1.8% [95% CI, 1.8%-1.9%] for Medicare-only enrollees and 11.3% vs 2.4% dual eligible enrollees). Enrollment in a 5.0-star rated plan was associated with a 30.1-percentage point reduction (95% CI, −31.7 to −28.4 percentage points) in the probability of disenrollment among high-need individuals. A $100 increase in monthly premiums was associated with a 33.9–percentage point increase (95% CI, −34.9 to −33.0 percentage points) in the likelihood of switching plans, and a small reduction in the likelihood of disenrolling (−2.7 percentage points; 95% CI, −3.2 to −2.2 percentage points). Among Medicare-Medicaid eligible participants, 14.1% (95% CI, 14.0%-14.2%) of high-need and 16.7% (95% CI, 16.6%-16.7%) of non-high-need enrollees switched from TM to MA. CONCLUSIONS AND RELEVANCE Results of this study suggest that substantially higher disenrollment from MA plans occurs among high-need and Medicare-Medicaid eligible enrollees. This study’s findings suggest that star ratings have the strongest association with disenrollment trends, whereas increases in monthly premiums are associated with greater likelihood of switching plans.

Establishing preferred provider networks of skilled nursing facilities (SNFs) is one approach hospital administrators are using to reduce excess thirty-day readmissions and avoid Medicare penalties or to reduce beneficiaries’ costs as part of value-based payment models. However, hospitals are also required to provide patients at discharge with a list of Medicare-eligible providers and cannot explicitly restrict patient choice. This requirement complicates the development of a SNF network. Furthermore, there is little evidence about the effectiveness of network development in reducing readmission rates. We used a concurrent mixed-methods approach, combining Medicare claims data for the period 2009–13 with qualitative data gathered from interviews during site visits to hospitals in eight US markets in March–October 2015, to examine changes in rehospitalization rates and differences in practices between hospitals that did and did not develop formal SNF networks. Four hospitals had developed formal SNF networks as part of their care management efforts. These hospitals saw a relative reduction from 2009 to 2013 in readmission rates for patients discharged to SNFs that was 4.5 percentage points greater than the reduction for hospitals without formal networks. Interviews revealed that those with networks expanded existing relationships with SNFs, effectively managed patient data, and exercised a looser interpretation of patient choice.

Medicare’s more than 420 accountable care organizations (ACOs) provide care for a considerable percentage of the elderly in the United States. One goal of ACOs is to improve care coordination and thereby decrease rates of rehospitalization. We examined whether ACO-affiliated hospitals were more effective than other hospitals in reducing rehospitalizations from skilled nursing facilities. We found a general reduction in rehospitalizations from 2007 to 2013, which suggests that all hospitals made efforts to reduce rehospitalizations. The ACO-affiliated hospitals, however, were able to reduce rehospitalizations more quickly than other hospitals. The reductions suggest that ACO-affiliated hospitals are either discharging to the nursing facilities more effectively compared to other hospitals or targeting at-risk patients better, or enhancing information sharing and communication between hospitals and skilled nursing facilities. Policy makers expect that reducing readmissions to hospitals will generate major savings and improve the quality of life for the frail elderly. However, further work is needed to investigate the precise mechanisms that underlie the reduction of readmissions among ACO-affiliated hospitals.

Hospitals are now being held at least partly accountable for Medicare patients’ care after discharge, as a result of regulations and incentives imposed by the Affordable Care Act. However, little is known about how patients select a postacute care facility. We used a multiple case study approach to explore both how patients requiring postacute care decide which skilled nursing facility to select and the role of hospital staff members in this decision. We interviewed 138 staff members of sixteen hospitals and twenty-five skilled nursing facilities and 98 patients in fourteen of the skilled nursing facilities. Most patients described receiving only lists of skilled nursing facilities from hospital staff members, while staff members reported not sharing data about facilities’ quality with patients because they believed that patient choice regulations precluded them from doing so. Consequently, patients’ choices were rarely based on readily available quality data. Proposed changes to the Medicare conditions of participation for hospitals that pertain to discharge planning could rectify this problem. In addition, less strict interpretations of choice requirements would give hospitals flexibility in the discharge planning process and allow them to refer patients to higher-quality facilities.

An unintended consequence of increased hospital-SNF integration may be greater disparity. SNFs with high hospital referral rates may admit well-reimbursed or less medically complex patients than SNFs with lower referral rates. Without policy remediation, SNFs with lower referral rates may thus care for more medically complex long-term care patients.