Medicare Advantage and Traditional Medicare Hospitalization Intensity and Readmissions

Is there an advantage? Considerations for researchers studying the effects of the type of Medicare coverage

OBJECTIVE

To describe common methodological problems that arise in comparisons of Medicare Advantage (MA) and Traditional Medicare (TM) and within-MA studies and provide suggestions of how researchers can address these issues.

STUDY SETTING

Published research evaluating Medicare coverage options in the United States.

STUDY DESIGN

We considered key conceptual challenges and promising solutions that have been used thus far and suggest additional directions.

DATA COLLECTION

Not available.

PRINCIPAL FINDINGS

Many existing studies of MA versus TM include significant limitations, such as failing to account for unobserved confounders driving both beneficiary coverage choice and health outcomes once enrolled, not accounting for variation in benefit generosity, provider networks, or plan design across MA plans, and/or having been conducted at a time when MA enrollment was less than a third of all Medicare beneficiaries. We provide a review of methods that can help researchers to overcome these weaknesses and suggest additional methods and data sources that may aid future research.

CONCLUSIONS

The MA program is becoming an essential part of the US healthcare system. By accounting for non-random movement into and out of MA and studying the heterogeneity of beneficiary experience across plan and market characteristics, researchers can provide the high-quality evidence necessary for policymakers to design the program and reform TM in ways that maximize beneficiary outcomes.

Association of 7-Day Follow-Up With 6-Month Suicide Mortality Following Hospitalization for Suicidal Thoughts or Behaviors Among Older Adults

OBJECTIVE

To evaluate whether timely follow-up outpatient mental health care is associated with reduced short-term suicide risk following hospitalization for suicidal thoughts or behaviors.

METHODS

Retrospective cohort analysis using 2015 Medicare data for adults aged ≥ 65 years who were hospitalized for suicidal ideation or behaviors (n = 36,557) linked with the National Death Index. Adjusted risk ratios (ARR) estimated the association between 7-day follow-up and suicide risk at 30-, 90-, and 180-days, adjusted for confounding by indication using inverse probability of treatment weights of observable covariates.

RESULTS

Overall, 39.3% of patients received 7-day follow-up, which was associated with 41% higher risk of suicide within 180 days. Follow-up care was associated with higher suicide risk for Medicare Advantage enrollees, patients with no recent prior mental health care, and those admitted for suicidal behaviors.

CONCLUSION

Results suggest 7-day follow-up care was not associated with lower post-discharge suicide risk. For this high-risk group, suicide-specific interventions may be needed during the critical postdischarge period.

Association Between Medicare Program Type and Health Care Access, Acute Care Utilization, and Affordability Among Adults With Cardiovascular Disease

BACKGROUND

Medicare Advantage plans now provide health insurance coverage to >24 million older adults in the United States, and enrollment is increasing among individuals with cardiovascular disease (CVD). Whether Medicare Advantage enrollment is associated with similar health care access, acute care utilization, and financial strain for adults with CVD compared with traditional Medicare is unknown.

METHODS

We performed a cross-sectional study of Medicare beneficiaries 65 years or older with CVD using the 2019 National Health Interview Survey. We fit multivariable logistic regression models to examine the association of Medicare program type (Medicare Advantage versus traditional Medicare) with measures of health care access, acute care utilization, and affordability.

RESULTS

The weighted population included 11 013 437 Medicare beneficiaries, of whom 3 922 104 (35.6%) were enrolled in Medicare Advantage, and 7 091 334 (64.4%) were enrolled in traditional Medicare. Medicare Advantage and traditional Medicare enrollees were similar with respect to age, sex, racial/ethnic distribution, and household income; however, Medicare Advantage beneficiaries were more likely to live in an urban setting (82.7% versus 76.0%; P=0.01) and to be college educated (24.2% versus 19.0%; P=0.01). Medicare Advantage beneficiaries were more likely to have a usual source of care (93.5% versus 88.9%; OR, 1.99 [95% CI, 1.33-2.98)]; however, there were no other differences in health care access or utilization. Medicare Advantage beneficiaries were more likely to have problems paying medical bills (16.5% versus 11.6%; OR, 1.68 [1.17-2.40]) and to worry about paying medical bills (40.1% versus 33.8%; OR, 1.37 [1.07-1.76]) compared with those enrolled in traditional Medicare.

CONCLUSIONS

Adults with CVD in Medicare Advantage were more likely to experience financial strain related to their medical bills compared with those in traditional Medicare. As enrollment in Medicare Advantage grows, policy efforts should focus on ensuring care is affordable for patients with CVD.

Measuring resource use in Medicare Advantage using Encounter data

OBJECTIVE

To check the completeness of Medicare Advantage (MA) Encounter data and to illustrate a process to measure resource use among MA enrollees using Encounter data.

DATA SOURCES

2015 Preliminary MA Encounter, Medicare Provider Analysis and Review (MedPAR), Healthcare Effectiveness Data and Information System (HEDIS), and 2013 Traditional Medicare (TM) claims data.

STUDY DESIGN

Secondary data analysis.

DATA COLLECTION/EXTRACTION METHODS

We calculated the percentage of each contract's total hospitalizations in Encounter data after identifying total inpatient stays from Encounter and MedPAR data. We constructed each contract's ambulatory visits and emergency department (ED) visits per 1000 enrollees using Encounter data and compared those visit counts with the counts from HEDIS. We defined high data completeness as having less than 10% missing hospital stays and less than ±10% difference in ambulatory and ED visits between Encounter and HEDIS data. We used TM payments as standardized prices of services to examine resource use among MA enrollees with cancer in the contracts with high data completeness.

PRINCIPAL FINDINGS

We identified 83 of 380 MA contracts with high data completeness. Total resource use per enrollee with cancer in the 83 contracts was $14,715 in 2015. Service-specific resource use was $5342 for inpatient care, $5932 for professional services and $3441 for outpatient facility services. These represent what an MA enrollee with cancer would have cost on average if MA plans paid providers at TM payment rates, holding the observed utilization constant.

CONCLUSIONS

Checking the completeness of Encounter data is an important step to ensure the validity of research on MA resource use. Using Encounter data to measure MA resource use is feasible. It can compensate for the lack of payment information in Encounter data. It will be important to identify and refine ways to best use Encounter data to learn about care provision to MA enrollees.

Effect of Race/ethnicity, Insurance Status, and Area Deprivation on Hip Fracture Outcomes Among Older Adults in the United States

This retrospective cohort study used electronic health records to explore the effect of race/ethnicity, insurance status, and area deprivation on post-discharge outcomes in older patients undergoing hip fracture surgery between 2015 and 2018 (N = 1,150). Inverse probability of treatment weight-adjusted regression analysis was used to identify the effects of the predictors on outcomes. White patients had higher 90- and 365-day readmission risks than Black patients and higher all-period readmissions than the Other racial/ethnic (Hispanic, Asian, American Indian, and Multicultural) group (p < .000). Black patients had a higher risk of 30- and 90-day readmission than the Other racial/ethnic group (p < .000). Readmission risk across 1-year follow-up was generally higher among patients from less deprived areas than more deprived areas (p < .05). The 90- and 365-day mortality risk was lower for patients from less deprived areas (vs. more deprived areas) and patients with Medicare Advantage (vs. Medicare), respectively (p < .05). Our findings can guide efforts to identify patients for additional post-discharge support. Nevertheless, the findings regarding readmission risks contrast with previous knowledge and thus require more validation studies.

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.

Acute Kidney Injury Requiring Dialysis and Incident Dialysis Patient Outcomes in US Outpatient Dialysis Facilities

BACKGROUND AND OBJECTIVES

About 30% of patients with AKI may require ongoing dialysis in the outpatient setting after hospital discharge. A 2017 Centers for Medicare & Medicaid Services policy change allows Medicare beneficiaries with AKI requiring dialysis to receive outpatient treatment in dialysis facilities. Outcomes for these patients have not been reported. We compare patient characteristics and mortality among patients with AKI requiring dialysis and patients without AKI requiring incident dialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We used a retrospective cohort design with 2017 Medicare claims to follow outpatients with AKI requiring dialysis and patients without AKI requiring incident dialysis up to 365 days. Outcomes are unadjusted and adjusted mortality using Kaplan-Meier estimation for unadjusted survival probability, Poisson regression for monthly mortality, and Cox proportional hazards modeling for adjusted mortality.

RESULTS

In total, 10,821 of 401,973 (3%) Medicare patients requiring dialysis had at least one AKI claim, and 52,626 patients were Medicare patients without AKI requiring incident dialysis. Patients with AKI requiring dialysis were more likely to be White (76% versus 70%), non-Hispanic (92% versus 87%), and age 60 or older (82% versus 72%) compared with patients without AKI requiring incident dialysis. Unadjusted mortality was markedly higher for patients with AKI requiring dialysis compared with patients without AKI requiring incident dialysis. Adjusted mortality differences between both cohorts persisted through month 4 of the follow-up period (all P=0.01), then, they declined and were no longer statistically significant. Adjusted monthly mortality stratified by Black and other race between patients with AKI requiring dialysis and patients without AKI requiring incident dialysis was lower throughout month 4 (1.5 versus 0.60, 1.20 versus 0.84, 1.00 versus 0.80, and 0.95 versus 0.74; all P<0.001), which persisted through month 7. Overall adjusted mortality risk was 22% higher for patients with AKI requiring dialysis (1.22; 95% confidence interval, 1.17 to 1.27).

CONCLUSIONS

In fully adjusted analyses, patients with AKI requiring dialysis had higher early mortality compared with patients without AKI requiring incident dialysis, but these differences declined after several months. Differences were also observed by age, race, and ethnicity within both patient cohorts.

Differences in Health Care Utilization, Process of Diabetes Care, Care Satisfaction, and Health Status in Patients With Diabetes in Medicare Advantage Versus Traditional Medicare

OBJECTIVE

The objective of this study was to determine differences in health care utilization, process of diabetes care, care satisfaction, and health status for Medicare Advantage (MA) and traditional Medicare (TM) beneficiaries with and without diabetes.

METHODS

Using the 2010-2016 Medicare Current Beneficiary Survey, we identified MA and TM beneficiaries with and without diabetes. To address the endogenous plan choice between MA and TM, we used an instrumental variable approach. Using marginal effects, we estimated differences in the outcomes between MA and TM beneficiaries with and without diabetes.

RESULTS

Our instrumental variable analysis showed that compared with TM beneficiaries with diabetes, MA beneficiaries with diabetes had less annual health care utilization, including -22.4 medical provider visits [95% confidence interval (CI): -23.6 to -21.1] and -3.4 outpatient hospital visits (95% CI: -3.8 to -3.0). A significant difference between MA and TM beneficiaries without diabetes was only observed in medical provider visits and the difference was greater among beneficiaries with diabetes than beneficiaries without diabetes (-12.5 medical provider visits; 95% CI: -15.9 to -9.2). While we did not detect significant differences in 5 measures of the process of diabetes care between MA and TM beneficiaries with diabetes, there were inconsistent results in the other 3 measures. There were no or marginal differences in care satisfaction and health status between MA and TM beneficiaries with and without diabetes.

CONCLUSIONS

MA enrollment was associated with lower health care utilization without compromising care satisfaction and health status, particularly for beneficiaries with diabetes. MA may have a more efficient care delivery system for beneficiaries with diabetes.

Health Care Utilization, Care Satisfaction, and Health Status for Medicare Advantage and Traditional Medicare Beneficiaries With and Without Alzheimer Disease and Related Dementias

Importance

Compared with traditional Medicare (TM) fee-for-service plans, Medicare Advantage (MA) plans may provide more-efficient care for beneficiaries with Alzheimer disease and related dementias (ADRD) without compromising care quality.

Objective

To determine differences in health care utilization, care satisfaction, and health status for MA and TM beneficiaries with and without ADRD.

Design, Setting, and Participants

A cohort study was conducted of MA and TM beneficiaries with and without ADRD from all publicly available years of the Medicare Current Beneficiary Survey between 2010 and 2016. To address advantageous selection into MA plans, county-level MA enrollment rate was used as an instrument. Data were analyzed between July 2019 and December 2019.

Exposures

Enrollment in MA.

Main Outcomes and Measures

Self-reported health care utilization, care satisfaction, and health status.

Results

The sample included 47 100 Medicare beneficiaries (25 900 women [54.9%]; mean [SD] age, 72.2 [11.4] years). Compared with TM beneficiaries with ADRD, MA beneficiaries with ADRD had lower utilization across the board, including a mean of -22.3 medical practitioner visits (95% CI, -24.9 to -19.8 medical practitioner visits), -2.3 outpatient hospital visits (95% CI, -3.6 to -1.1 outpatient hospital visits), -0.2 inpatient hospital admissions (95% CI, -0.3 to -0.1 inpatient hospital admissions), and -0.1 long-term care facility stays (95% CI, -0.2 to -0.1 long-term care facility stays). A similar trend was observed among beneficiaries without ADRD, but the difference was greater between MA and TM beneficiaries with ADRD than between MA and TM beneficiaries without ADRD (mean, -15.0 medical practitioner visits [95% CI, -18.7 to -11.3 medical practitioner visits], -1.7 outpatient hospital visits [95% CI, -3.0 to -0.3 outpatient hospital visits], and -0.1 inpatient hospital admissions [95% CI, -1.0 to 0.0 inpatient hospital admissions]). Overall, no or negligible differences were detected in care satisfaction and health status between MA and TM beneficiaries with and without ADRD.

Conclusions and Relevance

Compared with TM beneficiaries, MA beneficiaries had lower health care utilization without compromising care satisfaction and health status. This difference was more pronounced among beneficiaries with ADRD. These findings suggest that MA plans may be delivering health care more efficiently than TM, especially for beneficiaries with ADRD.

Hospital Readmission Rates in Medicare Advantage and Traditional Medicare: A Retrospective Population-Based Analysis

BACKGROUND

Medicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries.

OBJECTIVE

To compare readmission rates between Medicare Advantage and traditional Medicare.

DESIGN

Retrospective cohort study linking the Medicare Provider Analysis and Review (MedPAR) file with the Healthcare Effectiveness Data and Information Set (HEDIS).

SETTING

4748 U.S. acute care hospitals.

PATIENTS

Patients aged 65 years or older hospitalized for acute myocardial infarction (AMI) (n = 841 613), congestive heart failure (CHF) (n = 1 458 652), or pneumonia (n = 2 020 365) between 2011 and 2014.

MEASUREMENTS

30-day readmissions.

RESULTS

Among admissions for AMI, CHF, and pneumonia identified in MedPAR, 29.2%, 38.0%, and 37.2%, respectively, did not have a corresponding record in HEDIS. Of these, 18.9% for AMI, 23.7% for CHF, and 18.3% for pneumonia resulted in a readmission that was identified in MedPAR. However, among index admissions appearing in HEDIS, 14.4% for AMI, 18.4% for CHF, and 13.9% for pneumonia resulted in a readmission. Patients in Medicare Advantage had lower unadjusted readmission rates than those in traditional Medicare for all 3 conditions (16.6% vs. 17.1% for AMI, 21.4% vs. 21.7% for CHF, and 16.3% vs. 16.4% for pneumonia). However, after standardization, patients in Medicare Advantage had higher readmission rates than patients in traditional Medicare for AMI (17.2% vs. 16.9%; difference, 0.3 percentage point [95% CI, 0.1 to 0.5 percentage point]), CHF (21.7% vs. 21.4%; difference, 0.3 percentage point [CI, 0.2 to 0.5 percentage point]), and pneumonia (16.5% vs. 16.0%; difference, 0.5 percentage point [95% CI, 0.4 to 0.6 percentage point]). Rate differences increased between 2011 and 2014.

LIMITATION

Potential unobserved differences between populations.

CONCLUSION

The HEDIS data underreported hospital admissions for 3 common medical conditions, and readmission rates were higher among patients with underreported admissions. Medicare Advantage beneficiaries had higher risk-adjusted 30-day readmission rates than traditional Medicare beneficiaries.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Regional Variations: The Use Of Hospitals, Home Health, And Skilled Nursing In Traditional Medicare And Medicare Advantage

In the traditional Medicare program, the use of health care services-particularly postacute care-varies substantially across geographic regions. Less is known about such variations in Medicare Advantage (MA), which is growing rapidly. Insurers that are paid on a risk basis, as in MA, may have incentives and tools to restrain the use of services, which could attenuate geographic variations. In this study of fifty-four million Medicare beneficiaries in the period 2007-13, we found that geographic variations in the use of skilled nursing facility and hospital care in the MA population exceeded those in traditional Medicare, though variations in the use of home health care were greater in traditional Medicare. Within hospital referral regions, the correlations between the use of services in MA and traditional Medicare were moderate to strong. The findings suggest that regional variations in hospital and postacute care reflect local factors that influence beneficiaries' use of services irrespective of the way they obtain coverage.