Post-Acute Care Use Associated with Medicare Shared Savings Program and Disparities

Published:September 12, 2022DOI:



      Medicare Shared Savings Program (MSSP) was implemented in 2012, but the impact of the MSSP on institutional post-acute care (PAC) use, and by race/ethnicity and payer status is less studied. We studied the impact of hospital participation in the MSSP on institutional PAC use and variations by race/ethnicity and payer status among 3 Medicare patient groups: ischemic stroke, hip fracture, and elective total joint arthroplasty (TJA).


      A retrospective analysis of 2010–2016 Medicare Provider Analysis and Review files.

      Setting and Participants

      Medicare fee-for-service patients originally admitted for ischemic stroke, hip fracture, or elective TJA in MSSP-participating hospitals or nonparticipating hospitals.


      Patient-level linear probability models with difference-in-differences approach were used to compare the changes in institutional PAC use in MSSP-participating hospitals with nonparticipating hospitals as well as to compare the changes in differences by race/ethnicity and payer status in institutional PAC use over time.


      Hospital participation in MSSP was significantly associated with increased institutional PAC use for the ischemic stroke cohort by 1.5 percentage points [95% confidence interval (CI) 0.00–0.3, P < .05] compared with non-MSSP participating hospitals. Regarding variations by race/ethnicity and payer status, for the elective TJA patients, racial minority patients in MSSP-participating hospitals had 3.8 percentage points greater (95% CI 0.01–0.06, P < .01) in institutional PAC use than white patients. Also, for ischemic stroke cohort, dual-eligible patients in MSSP-participating hospitals had 2.0 percentage points greater (95% CI 0.00–0.04, P < .10) in institutional PAC use than Medicare-only patients.

      Conclusions and Implications

      This study found that hospital participation in the MSSP was associated with slightly increased institutional PAC use for ischemic stroke Medicare patients. Also, compared to non-MSSP participating hospitals, MSSP-participating hospitals were more likely to discharge racial minority patients for elective TJA and dual-eligible patients for ischemic stroke to institutional PAC.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Burke R.E.
        • Juarez-Colunga E.
        • Levy C.
        • Prochazka A.V.
        • Coleman E.A.
        • Ginde A.A.
        Rise of post-acute care facilities as a discharge destination of us hospitalizations.
        JAMA Intern Med. 2015; 175: 295-296
        • Buntin M.B.
        Access to postacute rehabilitation.
        Arch Phys Med Rehabil. 2007; 88: 1488-1493
        • Sandel M.E.
        • Wang H.
        • Terdiman J.
        • et al.
        Disparities in stroke rehabilitation: results of a study in an integrated health system in Northern California.
        PM&R. 2009; 1: 29-40
        • Li Y.
        • Ying M.
        • Cai X.
        • Kim Y.
        • Thirukumaran C.P.
        Trends in postacute care use and outcomes after hip and knee replacements in dual-eligible Medicare and Medicaid beneficiaries, 2013-2016.
        JAMA Netw Open. 2020; 3: e200368
        • Buntin M.B.
        • Garten A.D.
        • Paddock S.
        • Saliba D.
        • Totten M.
        • Escarce J.J.
        How much is postacute care use affected by its availability?.
        Health Serv Res. 2005; 40: 413-434
        • Werner R.M.
        • Coe N.B.
        • Qi M.
        • Konetzka R.T.
        Patient outcomes after hospital discharge to home with home health care vs to a skilled nursing facility.
        JAMA Intern Med. 2019; 179: 617-623
        • Centers for Medicare and Medicaid Services
        Medicare Shared Savings Program Accountable Care Organization participants.
        • Centers for Medicare and Medicaid Services
        Measure methodology.
        • Buntin M.B.
        • Deb P.
        • Escarce J.J.
        • Hoverman C.
        • Paddock S.M.
        • Sood N.
        Comparison of Medicare spending and outcomes for beneficiaries with lower extremity joint replacements.
        Medpac report WR-271. RAND, Santa Monica, CA2005
        • Keswani A.
        • Tasi M.C.
        • Fields A.
        • Lovy A.J.
        • Moucha C.S.
        • Bozic K.J.
        Discharge destination after total joint arthroplasty: an analysis of postdischarge outcomes, placement risk factors, and recent trends.
        J Arthroplasty. 2016; 31: 1155-1162
        • Horwitz L.I.
        • Bernheim S.M.
        • Ross J.S.
        • et al.
        Hospital characteristics associated with risk-standardized readmission rates.
        Med Care. 2017; 55: 528-534
        • Elixhauser A.
        • Steiner C.
        • Harris D.R.
        • Coffey R.M.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8-27
        • Centers for Medicare and Medicaid Services
        Medicare disproportionate share hospital (DSH).
        • Centers for Medicare and Medicaid Services
        Hospital compare data archive.
        • The National Bureau of Economic Research
        CMS impact file hospital inpatient prospective payment system (IPPS).
        • Centers for Medicare and Medicaid Services
        Provider of services current files.
        • Colla C.H.
        • Lewis V.A.
        • Stachowski C.
        • Usadi B.
        • Gottlieb D.
        • Bynum J.P.
        Changes in use of post-acute care associated with accountable care organizations in hip fracture, stroke, and pneumonia hospitalized cohorts.
        Med Care. 2019; 57: 444
        • Kaufman B.G.
        • O'Brien E.C.
        • Stearns S.C.
        • et al.
        The Medicare shared savings program and outcomes for ischemic stroke patients: a retrospective cohort study.
        J Gen Internal Med. 2019; 34: 2740-2748
        • McWilliams J.M.
        • Gilstrap L.G.
        • Stevenson D.G.
        • Chernew M.E.
        • Huskamp H.A.
        • Grabowski D.C.
        Changes in post-acute care in the Medicare Shared Savings Program.
        JAMA Intern Med. 2017; 177: 518-526
        • Kim Y.
        • Glance L.G.
        • Holloway R.G.
        • Li Y.
        Medicare Shared Savings Program and readmission rate among patients with ischemic stroke.
        Neurology. 2020; 95: e1071-e1079
        • Kim Y.
        • Thirukumaran C.
        • Temkin-Greener H.
        • Hill E.
        • Holloway R.
        • Li Y.
        Institutional post-acute care use may help reduce readmissions for ischemic stroke patients.
        Med Care. 2021; 59: 736-742
        • Joynt Maddox K.E.
        • Orav E.J.
        • Zheng J.
        • Epstein A.M.
        Post-acute care after joint replacement in Medicare's bundled payments for care improvement initiative.
        J Am Geriatr Soc. 2019; 67: 1027-1035
        • Johnston K.J.
        • Joynt Maddox K.E.
        The role of social, cognitive, and functional risk factors in Medicare spending for dual and nondual enrollees.
        Health affairs (Project Hope). 2019; 38: 569-576
        • Singh S.
        • Lin Y.-L.
        • Kuo Y.-F.
        • Nattinger A.B.
        • Goodwin J.S.
        Variation in the risk of readmission among hospitals: the relative contribution of patient, hospital and inpatient provider characteristics.
        J Gen Intern Med. 2014; 29: 572-578