Differences in Nursing Home Quality Between Medicare Advantage and Traditional Medicare Patients

Medicare Advantage enrollment and outcomes of post-acute nursing home care among patients with dementia

Enrollment in Medicare Advantage (MA) has been rapidly growing. We examined whether MA enrollment affects the outcomes of post-acute nursing home care among patients with Alzheimer's disease and related dementias (ADRD). We exploited year-to-year changes in MA penetration rates within counties from 2012 through 2019. After adjusting for patient-level characteristics and county fixed effects, we found that MA enrollment was not associated with days spent at home, nursing home days, likelihood of becoming a long-stay resident, hospital days, hospital readmission, or 1-year mortality. There was a modest increase in successful discharge to the community by 0.73 percentage points (relative increase of 2.4%) associated with a 10-percentage-point increase in MA enrollment. The results are consistent among racial/ethnic subgroups and dual-eligible patients. These findings suggest an imperative need to monitor and improve quality of managed care among enrollees with ADRD.

Opioid and CNS-Depressant Medication Prescribing among Older Adults Enrolled in Medicare Advantage Versus Fee-for-Service Medicare

OBJECTIVE

To examine whether prescription fills of opioids and central nervous system (CNS) depressants are lower in Medicare Advantage (MA) plans, which aim to provide more coordinated and integrated care, than fee-for-service (FFS) Medicare.

METHODS

Data from the 2015 National Health and Aging Trends Study linked with Medicare claims. Community-dwelling adults ≥65 enrolled in Medicare Part D were included (n = 5,652). Prescription fills of opioids, antipsychotics, benzodiazepines, gabapentinoids, and co-prescriptions of opioids with the other medications in MA versus FFS Medicare were examined using multivariate logistic models. Propensity score weighting was applied to account for differences in characteristics between MA and FFS beneficiaries.

RESULTS

MA enrollees were less likely to fill prescriptions for benzodiazepines (15.6% versus 19.0%; marginal difference: -3.4%, t = -2.54, df = 56, p = 0.01), and co-prescriptions of opioids and gabapentinoids (5.1% versus 6.7%; marginal difference: -1.6%, t = -2.07, df = 56, p = 0.04) than FFS beneficiaries. There were no significant differences among the other prescription outcomes.

CONCLUSIONS

MA was associated with slightly lower likelihood of receiving opioids and some CNS depressants.

Comparing Medicare Advantage And Traditional Medicare: A Systematic Review

Medicare Advantage enrollment has almost doubled since 2010 and now accounts for more than a third of all Medicare beneficiaries. We performed a systematic review to compare Medicare Advantage and traditional Medicare on key metrics. Evidence from forty-eight studies showed that in most or all comparisons, Medicare Advantage was associated with more preventive care visits, fewer hospital admissions and emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending. Medicare Advantage outperformed traditional Medicare in most studies comparing quality-of-care metrics. However, the evidence on patient experience, readmission rates, mortality, and racial/ethnic disparities did not show a trend of better performance in Medicare Advantage. Evidence to date might not fully account for selection bias, unobserved differences in social determinants of health, or risk adjustment challenges, in part because of differences in data quality that limit the comparability of outcomes between Medicare Advantage and traditional Medicare. With Medicare Advantage plans expected to grow in popularity, policy makers should support policies to improve data completeness and comparability, and health plans should focus on improving patient experience.

Assessing the Quality of Nursing Homes in Managed Care Organizations: Integrating LTSS for Dually Eligible Beneficiaries

Little is known about the quality of nursing homes in managed care organizations (MCOs) networks. This study (1) described decision-making criteria for selecting nursing home networks and (2) compared selected quality indicators of network and nonnetwork nursing homes. The sample was 17 MCOs participating in a California demonstration that provided integrated long-term services and supports to dually eligible enrollees in 2017. The findings showed that the MCOs established a broad network of nursing homes, with only limited attention to using quality criteria. Network nursing homes (602) scored significantly lower on 6 selected quality measures than nonnetwork (117) nursing homes. Low registered nurse and total nurse staffing were strong predictors of network nursing homes controlling for facility characteristics. Managed care organizations should consider greater transparency about the quality of their nursing homes and use specific quality criteria to improve the quality of their networks.

Physician Specialty and Radiologist Characteristics Associated with Higher Medicare Patient Complexity

RATIONALE AND OBJECTIVES

Meaningfully measuring physician outcomes and resource utilization requires appropriate patient risk adjustment. We aimed to assess Medicare patient complexity by physician specialty and to further identify radiologist characteristics associated with higher patient complexity.

MATERIALS AND METHODS

The average beneficiary Hierarchical Condition Category (HCC) risk scores (Medicare's preferred measure of clinical complexity) were identified for all physicians using 2014 Medicare claims data. HCC scores were compared among physician specialties and further stratified for radiologists based on a range of characteristics. Univariable and multivariable analyses were performed.

RESULTS

Of 549,194 physicians across 54 specialties, the mean HCC risk score was 1.62 ± 0.75. Of the 54 specialties, interventional radiology ranked 4th (2.60 ± 1.29), nuclear medicine ranked 16th (1.87 ± 0.45), and diagnostic radiology ranked 21st (1.75 ± 0.61). Among 31,175 radiologists, risk scores were higher (P < 0.001) for those with teaching (2.03 ± 0.74) vs nonteaching affiliations (1.72 ± 0.61), practice size ≥100 (1.94 ± 0.70) vs ≤9 (1.59 ± 0.79) members, urban (1.79 ± 0.69) vs rural (1.67 ± 0.59) practices, and subspecialized (1.85 ± 0.81) vs generalized (1.68 ± 0.42) practice patterns. Among noninterventional radiology subspecialties, patient complexity was highest for cardiothoracic (2.09 ± 0.57) and lowest for breast (1.08 ± 0.32) imagers. At multivariable analysis, a teaching affiliation was the strongest independent predictor of patient complexity for both interventional (β = +0.23, P = 0.005) and noninterventional radiologists (β = +0.21, P < 0.001).

CONCLUSIONS

Radiologists on average serve more clinically complex Medicare patients than most physicians nationally. However, patient complexity varies considerably among radiologists and is particularly high for those with teaching affiliations and interventional radiologists. With patient complexity increasingly recognized as a central predictor of clinical outcomes and resource utilization, ongoing insights into complexity measures may assist radiologists navigating emerging risk-based payment models.

Medicare Advantage Enrollees More Likely To Enter Lower-Quality Nursing Homes Compared To Fee-For-Service Enrollees

Unlike fee-for-service (FFS) Medicare, most Medicare Advantage (MA) plans have a preferred network of care providers that serve most of a plan's enrollees. Little is known about how the quality of care MA enrollees receive differs from that of FFS Medicare enrollees. This article evaluates the differences in the quality of skilled nursing facilities (SNFs) that Medicare Advantage and FFS beneficiaries entered in the period 2012-14. After we controlled for patients' clinical, demographic, and residential neighborhood effects, we found that FFS Medicare patients have substantially higher probabilities of entering higher-quality SNFs (those rated four or five stars by Nursing Home Compare) and those with lower readmission rates, compared to MA enrollees. The difference between MA and FFS Medicare SNF selections was less for enrollees in higher-quality MA plans than those in lower-quality plans, but Medicare Advantage still guided patients to lower-quality facilities.