Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09.
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SUBMITTER: Landon BE
PROVIDER: S-EPMC3587962 | biostudies-literature | 2012 Dec
REPOSITORIES: biostudies-literature
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Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09.
Landon Bruce E BE Zaslavsky Alan M AM Saunders Robert C RC Pawlson L Gregory LG Newhouse Joseph P JP Ayanian John Z JZ
Health affairs (Project Hope) 20121201 12
Enrollment in Medicare Advantage, the managed care program for Medicare beneficiaries, has grown rapidly, from 4.6 million enrollees in 2003 to 12.8 million by 2012, or 27 percent of all current Medicare beneficiaries. We analyzed utilization patterns of enrollees in Medicare Advantage health maintenance organization (HMO) plans compared to matched samples of people in traditional Medicare during 2003-09, to ascertain whether the HMO enrollees demonstrated different levels of use of services, wh ...[more]
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Project description:ObjectivesTo compare the prices paid to physicians by employer-sponsored Medicare Advantage (MA) plans with those paid by traditional Medicare (TM) and to determine whether the relationship between MA and TM prices is affected by the generosity of MA benchmarks.Study designDescriptive analysis of medical claims data from the 2014-2015 MarketScan Medicare Claims Database.MethodsWe focus on claims for low-complexity office visits with an established patient (Current Procedural Terminology [CPT] code 99213) and electrocardiograms (CPT code 93000). For a given service, we identify the prices paid by MA plans and by TM in a metropolitan statistical area (MSA), which is our definition of a market. We then construct an MA-to-TM price ratio for each MSA and report the median price ratio. In a subanalysis, we disaggregate the result for office visits by MA benchmark generosity.ResultsFor both services, the estimated median price ratio is close to 1.00. We also find that even as MA benchmarks (relative to local fee-for-service spending) increase, the median price ratio for office visits remains close to 1.00.ConclusionsAfter analyzing claims for common physician services, we find that employer-sponsored MA plans pay prices that are similar to TM rates. This holds even as the generosity of MA plan payment changes. Similarity between MA and TM prices appears to be stable over time, despite recent policy changes. Our findings emphasize the important role that TM plays in the MA market and that TM payment changes could have a spillover effect on MA prices and spending.
| S-EPMC6053627 | biostudies-literature
Project description:ImportanceLow-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care.ObjectivesTo compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care.Design, setting, and participantsThis cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022.ExposuresEnrollment in MA vs TM.Main outcomes and measuresLow-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries.ResultsAmong a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements.Conclusions and relevanceIn this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.
| S-EPMC9463603 | biostudies-literature
Project description:ImportancePrivate Medicare Advantage (MA) plans recently surpassed traditional Medicare (TM) in enrollment. However, MA plans are facing scrutiny for burdensome prior authorization and potential rationing of care, including home health. MA beneficiaries are less likely to receive home health, but recent evidence on differences in service intensity and outcomes among home health patients is lacking.ObjectiveTo examine differences in home health service intensity and patient outcomes between MA and TM.Design, setting, and participantsThis cross-sectional study was conducted from January 2019 to December 2022 in 102 home health locations in 19 states and included 178 195 TM and 107 102 MA patients 65 years or older with 2 or fewer 60-day home health episodes. It included a secondary analysis of standardized assessment and visit data. Inverse probability of treatment weighting regression compared service intensity and patient outcomes between MA and TM episodes, accounting for differences in demographic characteristics, medical complexity, functional and cognitive impairments, social environment, caregiver support, and local community factors. Models included office location, year, and reimbursement policy fixed effects. Data were analyzed between September 2023 and July 2024.ExposureTM vs MA plan.Main outcomes and measuresHome health length of stay and number of visits from nursing, physical, occupational, and speech therapy, social work, and home health aides. Patient outcomes included improvement in self-care and mobility function, discharge to the community, and transfer to an inpatient facility during home health.ResultsOf 285 297 total patients, 180 283 (63.2%) were female; 586 (0.2%) were American Indian/Alaska Native, 8957 (3.1%) Asian, 28 694 (10.1%) Black, 7406 (2.6%) Hispanic, 1959 (0.7%) Native Hawaiian/Pacific Islander, 237 017 (83.1%) non-Hispanic White, and 678 (0.2%) multiracial individuals. MA patients had shorter home health length of stay by 1.62 days (95% CI, -1.82 to 1.42) and received fewer visits from all disciplines except social work. There were no differences in inpatient transfers. MA patients had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively (mobility odds ratio [OR], 0.97; 95% CI, 0.94-0.99; self-care OR, 0.96; 95% CI, 0.92-0.99). MA patients were 5% more likely to discharge to the community compared with TM (OR, 1.05; 95% CI, 1.01-1.08).Conclusions and relevanceThe results of this cross-sectional study suggest that MA patients receive shorter and less intensive home health care vs TM patients with similar needs. Differences may be due to the administrative burden and cost-limiting incentives of MA plans. MA patients experienced slightly worse functional outcomes but were more likely to discharge to the community, which may have negative implications for MA patients, including reduced functional independence or increased caregiver burden.
| S-EPMC10907922 | biostudies-literature
Project description:ImportanceBetter evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes.ObjectiveTo compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees.Design, setting, and participantsThis cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design.ExposuresEnrollment in MA and dual eligibility for Medicare and Medicaid.Main outcomes and measuresPostacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services.ResultsIncluded in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility.Conclusions and relevanceIn this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.
| S-EPMC10439482 | biostudies-literature
Project description:ImportanceNearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services. Medicare Advantage insurers typically also sell commercial plans, and the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear.ObjectiveTo compare prices paid for physician and other health care services in MA, traditional Medicare, and commercial plans.Design, setting, and participantsRetrospective analysis of claims data evaluating MA prices paid to physicians and for laboratory services and durable medical equipment between 2007 and 2012 in 348 US core-based statistical areas. The study population included all MA and commercial enrollees with a large national health insurer operating in both markets, as well as a 20% sample of TM beneficiaries.ExposuresEnrollment in an MA plan.Main outcomes and measuresMean reimbursement paid to physicians, laboratories, and durable medical equipment suppliers for MA and commercial enrollees relative to TM rates for 11 Healthcare Common Procedure Coding Systems (HCPCS) codes spanning 7 sites of care.ResultsThe sample consisted of 144 million claims. Physician reimbursement in MA was more strongly tied to TM rates than commercial prices, although MA plans tended to pay physicians less than TM. For a mid-level office visit with an established patient (Current Procedural Terminology [CPT] code 99213), the mean MA price was 96.9% (95% CI, 96.7%-97.2%) of TM. Across the common physician services we evaluated, mean MA reimbursement ranged from 91.3% of TM for cataract removal in an ambulatory surgery center (CPT 66984; 95% CI, 90.7%-91.9%) to 102.3% of TM for complex evaluation and management of a patient in the emergency department (CPT 99285; 95% CI, 102.1%-102.6%). However, for laboratory services and durable medical equipment, where commercial prices are lower than TM rates, MA plans take advantage of these lower commercial prices, ranging from 67.4% for a walker (HCPCS code E0143; 95% CI, 66.3%-68.5%) to 75.8% for a complete blood cell count (CPT 85025; 95% CI, 75.0%-76.6%).Conclusions and relevanceTraditional Medicare's administratively set rates act as a strong anchor for physician reimbursement in the MA market, although MA plans succeed in negotiating lower prices for other health care services for which TM overpays. Reforms that transition the Medicare program toward some premium support models could substantially affect how physicians and other clinicians are paid.
| S-EPMC5710575 | biostudies-literature
Project description: Not available
| S-EPMC10755621 | biostudies-literature
Project description:Medicare Advantage (MA) enrollment growth could make it difficult for MA plans to maintain their track record of limiting discretionary utilization while delivering higher-quality care than traditional Medicare. We compared quality and utilization measures in Medicare Advantage and traditional Medicare in 2010 and 2017. Clinical quality performance was higher in MA health maintenance organizations (HMOs) and preferred provider organizations (PPOs) than in traditional Medicare for almost all measures in both years. MA HMOs outperformed traditional Medicare on all measures in 2017. MA HMOs' performance on nearly all seven patient-reported quality measures improved, and MA HMOs outperformed traditional Medicare on five of those measures in 2017. MA PPOs performed the same as or better than traditional Medicare on all but one patient-reported quality measure in 2010 and 2017. The number of emergency department visits was 30 percent lower, the number of elective hip and knee replacements was approximately 10 percent lower, and the number of back surgeries was almost 30 percent lower in MA HMOs than in traditional Medicare in 2017. Utilization trends were similar in MA PPOs, but differences from traditional Medicare were narrower. Despite increased enrollment, overall utilization remains lower in Medicare Advantage than in traditional Medicare, whereas quality performance is the same or higher.
| S-EPMC10171780 | biostudies-literature
Project description:ImportanceA growing proportion of the population is enrolling in Medicare Advantage (MA), which typically offers additional benefits compared with traditional Medicare (TM).ObjectiveTo determine whether frailty and frailty trajectories differ between MA enrollees and TM enrollees.Design, setting, and participantsThis retrospective cohort study used data from the National Health and Aging Trends Study (2015-2016). Analyses were conducted from August 2023 to March 2024. Participants were community-dwelling Medicare beneficiaries aged 65 years and older.ExposureEnrollment in MA vs TM.Main outcomes and measuresFrailty was calculated by a frailty index (FI) (range, 0-1, with higher values indicating greater frailty) and the Fried Frailty Phenotype (FFP) score (range, 0-5, with higher values indicating greater frailty). Physical performance, including Short Physical Performance Battery (SPPB) score (range, 0-12, with higher values indicating better performance), and gait speed (meters per second) were measured. The primary outcome was the difference in FI and FFP scores from the 2015 baseline assessment to the 2016 follow-up assessment. Secondary outcomes include the 1-year changes in SPPB and gait speed.ResultsThe final cohort consisted of 7063 participants (2775 [23.1%] aged >80 years; 4040 [54.7%] female), representing a sample of the 38.8 million beneficiaries. There were 2583 (35.0%) MA enrollees (13.6 million) and 4480 (65.0%) TM enrollees (25.2 million). At baseline, the FI score was similar between MA and TM enrollees (mean [SD], 0.22 [0.15] vs 0.21 [0.14]), although MA enrollees had worse phenotypic frailty (496 participants [15.2%] vs 811 participants [13.7%] considered frail by FFP score), SPPB scores (mean [SD], 6.91 [3.34] vs 7.21 [3.27]), and gait speed (0.79 [0.24] m/s vs 0.82 [0.23] m/s) than TM enrollees. One year later, there were no differences between MA and TM enrollees in the 1-year change in FI score (mean [SD], 0.016 [0.071] vs 0.014 [0.066]; adjusted mean difference, 0.001 [95% CI, -0.004 to 0.005]), FFP score (mean [SD], 0.017 [1.004] vs 0.007 [0.958]; adjusted mean difference, -0.009 [95% CI, -0.067 to 0.049]), SPPB score (mean [SD], -0.144 [2.064] vs -0.211 [1.968]; adjusted mean difference, 0.068 [95% CI, -0.076 to 0.212]), and gait speed (mean [SD], -0.0160 [0.148] m/s vs -0.007 [0.148] m/s; adjusted mean difference, -0.010 m/s [95% CI, -0.067 to 0.049 m/s]).Conclusions and relevanceIn this cohort study of Medicare beneficiaries from 2015, MA enrollees experienced similar declines in frailty over 1 year compared with TM enrollees. Future work should examine whether the specific types of services covered by health insurance can impact frailty and health trajectories for older adults.
| S-EPMC11365002 | biostudies-literature
Project description:ObjectivesTo compare use of diabetes medications between beneficiaries enrolled in Medicare Advantage (MA) and traditional Medicare (TM).Study designRetrospective cohort analysis of Medicare enrollment and Part D event claims during 2015-2016.MethodsData came from 1,027,884 TM and 838,420 MA beneficiaries who received at least 1 prescription for an oral or injectable diabetes medication. After matching MA and TM enrollees by demographic characteristics and geography, we analyzed use of medication overall, choices of first diabetes medication for those new to medication, and patterns of adding medications.ResultsOverall and for patients on 1, 2, or 3 diabetes medications, use of metformin was higher in MA by about 3 percentage points, but use of newer medication classes was 5.1 percentage points higher in TM overall (21.3% vs 16.2%). Use of guideline-recommended first-line agents was higher in MA. For those who started metformin first, use of a sulfonylurea as a second medication was 7.8 percentage points higher in MA than TM (61.5% vs 53.7%), whereas use of medications from newer classes was 7.7 percentage points lower (22.0% vs 29.7%). Mean total spending was $149 higher in TM for those taking 1 medication and $298 higher for those taking 2 medications. Differences in spending among MA plans were of similar magnitude to the MA-TM differences.ConclusionsMA enrollees are more likely to be treated with metformin and sulfonylureas and less likely to receive costly newer medications than those in TM, but there also is substantial variation within MA. A limitation of the study is that we could not assess glucose control using glycated hemoglobin levels.
| S-EPMC7967940 | biostudies-literature
Project description:ImportanceHealth insurance literacy helps individuals make informed choices. However, evidence suggests that Medicare beneficiaries experience low health insurance literacy, leading to high-cost or poor-quality coverage choices.ObjectiveTo examine how health insurance literacy was associated with coverage choices between traditional Medicare (TM) and Medicare Advantage (MA), as well as within MA.Design, setting, and participantsThis cross-sectional study included 6627 TM and MA enrollees, using data from the 2015-2016 Medicare Current Beneficiary Survey. Data analyses were conducted between May 1 and June 30, 2021.ExposuresThree self-reported measures of health insurance literacy (presence of information to make an informed comparison, ease in reviewing and comparing coverage options, and annual review and comparison of coverage options).Main outcomes and measuresEnrollment in TM vs MA and enrollment in an MA plan with different characteristics (star rating, monthly plan premium, in-network maximum out-of-pocket limit, plan type, and provision of supplemental benefits).ResultsWe included 6627 Medicare beneficiaries (3578 women [54.0%]; mean [SD] age, 75.13 [7.12] years). A total of 77 individuals were Asian (1.2%), 696 were Black (10.5%), 488 were Hispanic (7.4%), 5277 were non-Hispanic White (79.6%), and 225 (3.4%) were single races not of Hispanic origin (including American Indian or Alaska Native and Native Hawaiian) or were 2 or more races. Medicare Advantage enrollment was higher among individuals with higher health insurance literacy than those with lower health insurance literacy, especially for those who reviewed or compared coverage options annually than among those who did not (38.0%; 95% CI, 36.0%-40.1% vs 27.8%; 95% CI, 25.8%-29.7%). Among MA beneficiaries, those who reviewed or compared coverage options annually were more likely to enroll in plans with 4 to 4.5 stars and plans with monthly premiums of $1 to $50 by 4.6 percentage points (95% CI, 0.1-9.2 percentage points) and 4.8 percentage points (95% CI, 0.6-9.0 percentage points), respectively. However, enrollment in plans with 5 stars was 3.8 percentage points lower (95% CI, -5.8 to -1.9 percentage points) among individuals who reviewed or compared coverage options annually than among those who did not. Among individuals with low socioeconomic status, the likelihood of reviewing or comparing coverage options annually was lower for those with Medicare and Medicaid dual eligibility than for those without it (odds ratio, 0.79; 95% CI, 0.63-0.99).Conclusions and relevanceResults of this study suggest that higher health insurance literacy-particularly, annual review and comparison of coverage choices-is associated with higher MA enrollment and choice of a particular MA plan. Policy makers should develop programs to encourage frequent review and comparison of coverage options for informed decision making.
| S-EPMC8814909 | biostudies-literature