Dataset Information

Comparison of the Quality of Hospitals That Admit Medicare Advantage Patients vs Traditional Medicare Patients.

ABSTRACT: Importance:In the Medicare Advantage (MA) program, Medicare enrollees may be steered by their health plan to specific hospitals. Little is known about the quality of hospitals that serve MA enrollees. Objective:To compare the quality of hospitals that admit MA enrollees with the quality of those that admit traditional Medicare enrollees. Design, Setting, and Participants:This cross-sectional study used data from the 2012 to 2016 Medicare Provider Analysis and Review to compare quality of care, as measured by the star rating given by the Centers for Medicare and Medicaid Services and readmission rates, in hospitals that serve MA enrollees and traditional Medicare enrollees using multinomial logit models. Participants were 7?130?610 Medicare beneficiaries admitted to 2994 acute care hospitals across the United States in 2016. Data were analyzed between August 2018 and August 2019. Exposures:The exposure was MA enrollment. Adjusters included demographic and clinical characteristics and zip code fixed effects. Main Outcomes and Measures:Hospital Compare star ratings and quintiles of performance in 30-day readmission rates. Results:The sample included 7?130?610 Medicare beneficiaries in 2016 (54.3% female; mean [SD] age, 72.7 [13.2] years). Of 12?190?270 total hospitalizations, 1?211?293 traditional Medicare and 494?352 MA patients were admitted to 718 low-readmission hospitals and 1?205?586 traditional Medicare and 526?955 MA patients were admitted to 597 high-readmission hospitals. Accounting for observed patient characteristics, MA enrollees less often entered either low- or high-quality hospitals and were more often admitted to average-quality hospitals. For nonemergent hospitalizations, MA enrollees were 1.9 percentage points (95% CI, 1.5-2.2 percentage points) less likely to enter a low-readmissions hospital, 5.1 percentage points (95% CI, 4.6-5.6 percentage points) more likely to enter an average-readmissions hospital, and 3.2 percentage points (95% CI, 2.9-3.5 percentage points) less likely to enter a high-readmissions hospital compared with traditional Medicare enrollees. Patients with MA were also 2.6 percentage points (95% CI, 2.2-2.9 percentage points) less likely to enter a 1- to 2-star hospital, 5.5 percentage points (95% CI, 4.9-5.9 percentage points) more likely to enter a 3-star hospital, and 2.8 percentage points (95% CI, 2.5-3.2 percentage points) less likely to enter a 4- to 5-star hospital compared with traditional Medicare enrollees. The differences were less pronounced for emergency admissions. Conclusions and Relevance:This study found that enrollees in MA plans were more likely to be admitted to average-quality hospitals instead of either high- or low-quality hospitals, suggesting that MA plans may be steering their enrollees to specific hospitals.

SUBMITTER: Meyers DJ

PROVIDER: S-EPMC6991262 | biostudies-literature | 2020 Jan

REPOSITORIES: biostudies-literature

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Comparison of the Quality of Hospitals That Admit Medicare Advantage Patients vs Traditional Medicare Patients.

Meyers David J DJ Trivedi Amal N AN Mor Vincent V Rahman Momotazur M

JAMA network open 20200103 1

<h4>Importance</h4>In the Medicare Advantage (MA) program, Medicare enrollees may be steered by their health plan to specific hospitals. Little is known about the quality of hospitals that serve MA enrollees.<h4>Objective</h4>To compare the quality of hospitals that admit MA enrollees with the quality of those that admit traditional Medicare enrollees.<h4>Design, setting, and participants</h4>This cross-sectional study used data from the 2012 to 2016 Medicare Provider Analysis and Review to comp ...[more]

PMID: 31940041

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Project description:ImportanceMedicare beneficiaries with disabilities aged 18 to 64 years face barriers accessing ambulatory care. Past studies comparing Medicare Advantage (MA) with traditional Medicare (TM) have not assessed how well these programs meet the needs of beneficiaries with disabilities.ObjectiveTo compare differences in enrollment rates, ambulatory care access, and ambulatory care quality for beneficiaries with disabilities in MA vs TM.Design setting and participantsThis cohort study included a nationally representative, weighted sample of 7201 person-years for beneficiaries aged 18 to 64 years with disability entitlement in the Medicare Current Beneficiary Survey from 2015 through 2018. Differences in program enrollment and in measures of access and quality by program enrollment were compared after adjusting for demographic, insurance, social, health, and area characteristics and after reweighting the sample by propensity to enroll in MA as estimated by observed confounders. Data analyses were conducted between November 1, 2020, and November 11, 2021.ExposuresMedicare Advantage vs TM program enrollment.Main outcomes and measuresSix patient-reported measures of ambulatory care access (usual source of care, primary care usual source of care, specialist visit) and quality (cholesterol screening, influenza vaccination, colon cancer screening).ResultsThe mean (SD) age of the overall study population was 52.1 (11.0) years; 49.5% were female and 50.5% were male; 1.6% were Asian/Pacific Islander; 17.4%, Black; 10.2% Hispanic; 1.4%, Native American; 65.1%, White, and 4.2%, multiracial. Among all beneficiaries living in the community, individuals with disability entitlement were less likely to enroll in MA than other beneficiaries (34.8% vs 41.2%). The final sample of beneficiaries with disabilities included 2444 person-years in MA and 4757 person-years in TM. Beneficiaries with disabilities in MA vs TM were more likely to be of a minority race or ethnicity (35.7% vs 27.6%) and less likely to be enrolled in private insurance (11.9% vs 25.0%). Comparing MA with TM among beneficiaries with disabilities, those in MA had significantly better rates of access to a usual source of care (90.2% vs 84.9%; adjusted propensity-weighted marginal difference [APWMD], 2.9%; 95% CI, 0.2%-5.7%), access to specialist visits (53.2% vs 44.8%; APWMD, 5.5%; 95% CI, 0.6%-10.5%), cholesterol screenings (91.1% vs 86.4%; APWMD, 3.8%; 95% CI, 0.9%-6.7%), influenza vaccinations (61.4% vs 51.5%; APWMD, 10.4%; 95% CI, 5.3%-15.5%), and colon cancer screenings (68.4% vs 54.6%; APWMD, 10.3%; 95% CI, 4.8%-15.8%).Conclusions and relevanceIn this cohort study, Medicare beneficiaries with disabilities were enrolled in MA at significantly lower rates than those without disabilities. However, MA was associated with significantly better ambulatory care access and quality for these beneficiaries on 5 of 6 measures compared with TM.

Project description:ImportanceMedicare Advantage (MA) insures an increasing proportion of Medicare beneficiaries, but evidence is lacking on patient or family perceptions of the quality of end-of-life care in MA vs traditional Medicare.ObjectiveTo determine if there is a difference in quality of care reported by family and friends of individuals who died while insured by MA vs traditional Medicare at the end of life.Design, setting, and participantsThis cross-sectional study used the 2011 to 2017 Medicare-linked National Health and Aging Trends Study to conduct population-based survey research representing 8 668 829 Medicare enrollees. Included individuals were 2119 enrollees who died when aged 65 years or older, with quality of care reported by a family member or close friend familiar with the individual's last month of life. Analysis was conducted in July 2020.ExposuresMA enrollment at the time of death or before hospice enrollment.Main outcomes and measuresPerception of end-of-life care was measured with 9 validated items, with the primary outcome variable being overall care rated not excellent. We conducted a propensity score-weighted multivariable model to examine the association of each item with MA vs traditional Medicare enrollment. The propensity score and multivariable model included covariates capturing demographic and socioeconomic factors, function and health, and relationship of the respondent to the individual who died. The sample was then stratified by hospice enrollment and setting of care in the last month.ResultsOf 2119 people in the sample, 670 individuals were enrolled in MA at the time of death or prior to hospice (32.7%) and 1449 were enrolled in traditional Medicare (67.3%). In survey-weighted percentages, 53.6% (95% CI, 51.0% to 56.1%) were women and 43.4% (95% CI, 41.5% to 45.3%) were older than 85 years at the time of death. In the adjusted model, family and friends of individuals in MA were more likely to report that care was not excellent (odds ratio, 1.28; 95% CI, 1.01 to 1.61; P = .04) and that they were not kept informed (odds ratio, 1.48; 95% CI, 1.06 to 2.05; P = .02). For those in nursing homes, there was an estimated probability of 57.2% of respondents reporting that care was not excellent for individuals with traditional Medicare, compared with 77.9% of respondents for individuals with MA (marginal increase for those in MA, 0.21; 95% CI, 0.08 to 0.32; P = .001).Conclusions and relevanceIn this cross-sectional study of people who died while enrolled in Medicare, friends and family of those in MA reported lower-quality end-of-life care compared with friends and family of those enrolled in traditional Medicare. These findings suggest that, given the rapid growth of MA, Medicare should take steps to ensure that MA plans are held accountable for quality of care at the end of life.

Project description:ImportanceMedicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown.ObjectiveTo compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018.Design, setting, and participantsRetrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non-ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019).ExposuresEnrollment in Medicare Advantage vs traditional Medicare.Main outcomes and measuresThe primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions).ResultsThe study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, -1.5 percentage points [95% CI, -2.2 to -0.7] and 12.0% vs 12.5% for NSTEMI; difference, -0.5 percentage points [95% CI, -0.9% to -0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, -0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, -0.2 percentage points [95% CI, -0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, -0.9 percentage points [95% CI, -1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, -1.3 percentage points [95% CI, -2.0 to -0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, -1.5 to 0.0]).Conclusions and relevanceAmong Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.

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.

Project description:ImportanceOlder adults in Medicare Advantage (MA) enroll in hospice at higher rates than those in traditional Medicare (TM), but it is unclear whether the pathway of care prior to hospice use differs between MA and TM.ObjectiveTo examine the site of care prior to hospice enrollment for MA beneficiaries compared with those in TM.Design, setting, and participantsThis population-based, retrospective cross-sectional study used Medicare claims data for decedents in calendar years 2011, 2013, 2016, and 2018 who enrolled in hospice in the last 90 days of life. Data were analyzed from February 11, 2022, to October 24, 2022.ExposuresEnrollment in MA or TM in the last month of life.Main outcomes and measuresThe main outcome was the site of care prior to hospice enrollment, defined as hospital, nursing home, and home with or without home health, dichotomized as community vs hospital in a logistic regression model. Covariates included decedent demographics, hospice primary diagnosis, and county-level MA penetration. Differences in hospice length of stay between MA beneficiaries and TM beneficiaries were assessed using linear and logistic regression models.ResultsIn this study of 3 164 959 decedents, mean (SD) age was 83.1 (8.6) years, 55.8% were female, and 28.8% were enrolled in MA. Decedents in MA were more likely to enroll in hospice from a community setting than were those in TM, although the gap narrowed over time from an unadjusted 11.1% higher rate of community enrollment in MA vs TM in 2011 (50.1% vs 39.0%) to 8.1% in 2018 (46.4% vs 38.3%). In the primary adjusted analysis over the entire study period, MA enrollment was associated with an 8.09-percentage point (95% CI, 7.96-8.21 percentage points) higher rate of hospice enrollment from the community vs all other sites. This association remained in multiple sensitivity analyses to account for potential differences in the populations enrolled in MA vs TM. The mean overall hospice length of stay was 0.29 days (95% CI, 0.24-0.34 days) longer for MA decedents compared with TM decedents.Conclusions and relevanceCompared with TM beneficiaries, those in MA were more likely to enroll in hospice from community settings vs following inpatient stays. However, hospice length of stay was not substantially different between MA and TM. Further research is needed to understand how MA plans influence hospice use and the direct association with quality of end-of-life care as reported by older adults and their families.

Project description:ImportanceThe Medicare Advantage (MA) program has doubled in size during the past decade, and enrollment among adults with low income has increased rapidly. Such adults face significant barriers in accessing care, leading to poorer health outcomes. Therefore, understanding how health care access, preventive care, and care affordability compare for adults with low income who are enrolled in MA vs traditional Medicare (TM) is critically important.ObjectiveTo compare measures of health care access, preventive care use, and affordability of care between adults with low income who are enrolled in MA vs TM.Design, setting, and participantsThis nationally representative cross-sectional study used the 2019 National Health Interview Survey to compare 2622 adults aged 65 years or older with low income who were enrolled in MA vs TM. Data were analyzed from December 5, 2021, to April 10, 2022.Main outcomes and measuresMeasures of health care access, preventive care use, and health care affordability.ResultsThe study cohort included 2622 adults aged 65 years or older with low income, resulting in a weighted cohort of 14 222 243 adults, of whom 5 641 049 (39.7%) were enrolled in MA and 8 581 194 (60.3%) in TM. The overall age of the cohort was 74.6 years (95% CI, 74.3-74.9). Between the MA and TM groups, the mean age (74.5 years [95% CI, 74.1-75.0] vs 74.7 years [95% CI, 74.3-75.1]; P = .63) and sex distribution (63.6% women [95% CI, 59.8%-67.3%] vs 60.4% women [95% CI, 57.4%-63.3%]; P = .17) were similar, but adults with low income in MA were more likely to be non-Hispanic Asian (7.6% [95% CI, 5.0%-10.1%] vs 3.8% [95% CI, 2.4%-5.3%]; P = .01) or Hispanic (18.1% [95% CI, 14.3%-21.9%] vs 9.4% [95% CI, 7.2%-11.7%]; P < .001). Adults with low income in MA compared with those enrolled in TM were more likely to have a usual place of care (97.7% vs 94.9%; adjusted odds ratio [aOR], 2.37 [95% CI, 1.38-4.07]), but similarly likely to have a recent physician visit (95.5% vs 93.5%; aOR, 1.39 [95% CI, 0.88-2.17]) and to delay medical care (5.3% vs 5.7%; aOR, 0.83 [95% CI, 0.56-1.24]) or not seek medical care (5.6% vs 5.9%; aOR, 0.86 [95% CI, 0.56-1.30]) due to costs. For preventive care measures, adults with low income in MA were more likely than those in TM to have undergone a recent cholesterol screening (98.7% vs 96.6%; aOR, 2.58 [95% CI, 1.27-5.22]). However, there were no significant differences between the MA and TM groups in the likelihood of diabetes screening (90.6% vs 87.6%; aOR, 1.21 [95% CI, 0.87-1.66]), blood pressure screening (96.8% vs 95.2%; aOR, 1.37 [95% CI, 0.84-2.23]), or receipt of an influenza vaccination in the past year (66.3% vs 63.8%; aOR, 1.16 [95% CI, 0.93-1.45]). Adults with low income in MA or TM were similarly likely to be concerned about paying medical bills (47.3% vs 44.2%; aOR, 1.09 [95% CI, 0.88-1.35]) or have problems paying medical bills (17.1% vs 17.2%; aOR, 0.94 [95% CI, 0.69-1.27]) and were also similarly likely to delay filling prescriptions (7.4% vs 6.2%; aOR, 1.22 [95% CI, 0.78-1.92]) or to not fill prescriptions (7.8% vs 7.4%; aOR, 1.01 [95% CI, 0.70-1.45]) due to costs.Conclusions and relevanceIn this study of Medicare beneficiaries with low income, key measures of health care access, preventive care use, and health care affordability generally did not differ between those enrolled in MA vs TM.

Dataset Information

Comparison of the Quality of Hospitals That Admit Medicare Advantage Patients vs Traditional Medicare Patients.

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Comparison of the Quality of Hospitals That Admit Medicare Advantage Patients vs Traditional Medicare Patients.

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