Date of Award


Document Type

Open Access Dissertation

Degree Name

Doctor of Philosophy (PhD)



First Advisor

Edward Alan Miller

Second Advisor

Pamela Nadash

Third Advisor

Jeffrey Stokes


Heart failure (HF) is a leading cause of rehospitalizations for Medicare beneficiaries from skilled nursing facilities (SNFs). This research sought to determine if HF patients’ insurance type (Medicare Fee-for-Service (FFS) vs. Medicare Advantage (MA)) influences their risk for readmission within 30 days of hospital discharge to a SNF. This research is particularly timely in light of new penalties under the Protecting Access to Medicare Act SNF Value-Based Purchasing (SNF-VBP) program directed at SNFs for 30-day rehospitalizations. Previous literature finds FFS beneficiaries with HF in SNF at greater risk for rehospitalization compared to MA members. This research contributes to the literature by using a mixed methods approach. The quantitative portion of this research relied on several modeling approaches to determine if insurance type has an effect on risk for rehospitalization. The qualitative portion of this research used semi-structured interviews to describe the relationship between MA plans and SNFs from the perspective of key decision-makers in SNFs. Research questions were guided by a conceptual framework derived from Resource Dependence Theory and Principal-Agent Theory.

In the quantitative results, insurance type was not a significant predictor of risk for rehospitalization. However, all of the analyses pointed to MA beneficiaries having slightly less risk for rehospitalization compared to FFS beneficiaries. Patients with a shorter length of SNF stay and two or more hospitalizations in the previous 12 months were at a greater risk for rehospitalization. SNFs with fewer contracted MA plans, lower health inspection rating and higher quality of resident care star rating were associated with a greater risk for 30-day rehospitalizations. Interviewees described case management and length of SNF stay as key mechanisms of control used by MA plans to influence the care of their members. The qualitative results also indicated that SNFs prefer to provide care for FFS beneficiaries over MA members due to the higher reimbursement rate and perception of more autonomy in the decision-making process compared to feelings of constraint under MA plans. This research contributes to our understanding of how insurance type may influence the risk for rehospitalization by providing a mixed methodological perspective and directs future policies and research.

Included in

Gerontology Commons