Medicare Prescription Drug Plan Enrollees Report Less Positive Experiences Than Their Medicare Advantage Counterparts

Use of High-Risk Medications Among Older Adults Enrolled in Medicare Advantage Plans vs Traditional Medicare

Importance

Limiting the use of high-risk medications (HRMs) among older adults is a national priority to provide a high quality of care for older beneficiaries of both Medicare Advantage and traditional fee-for-service Medicare Part D plans.

Objective

To evaluate the differences in the rate of HRM prescription fills among beneficiaries of traditional Medicare vs Medicare Advantage Part D plans and to examine the extent to which these differences change over time and the patient-level factors associated with higher rates of HRMs.

Design, Setting, and Participants

This cohort study used a 20% sample of Medicare Part D data on filled drug prescriptions from 2013 to 2017 and a 40% sample from 2018. The sample comprised Medicare beneficiaries aged 66 years or older who were enrolled in Medicare Advantage or traditional Medicare Part D plans. Data were analyzed between April 1, 2022, and April 15, 2023.

Main Outcomes and Measures

The primary outcome was the number of unique HRMs prescribed to older Medicare beneficiaries per 1000 beneficiaries. Linear regression models were used to model the primary outcome, adjusting for patient characteristics and county characteristics and including hospital referral region fixed effects.

Results

The sample included 5 595 361 unique Medicare Advantage beneficiaries who were propensity score-matched on a year-by-year basis to 6 578 126 unique traditional Medicare beneficiaries between 2013 and 2018, resulting in 13 704 348 matched pairs of beneficiary-years. The traditional Medicare vs Medicare Advantage cohorts were similar in age (mean [SD] age, 75.65 [7.53] years vs 75.60 [7.38] years), proportion of males (8 127 261 [59.3%] vs 8 137 834 [59.4%]; standardized mean difference [SMD] = 0.002), and predominant race and ethnicity (77.1% vs 77.4% non-Hispanic White; SMD = 0.05). On average in 2013, Medicare Advantage beneficiaries filled 135.1 (95% CI, 128.4-142.6) unique HRMs per 1000 beneficiaries compared with 165.6 (95% CI, 158.1-172.3) HRMs per 1000 beneficiaries for traditional Medicare. In 2018, the rate of HRMs had decreased to 41.5 (95% CI, 38.2-44.2) HRMs per 1000 beneficiaries in Medicare Advantage and to 56.9 (95% CI, 54.1-60.1) HRMs per 1000 beneficiaries in traditional Medicare. Across the study period, Medicare Advantage beneficiaries received 24.3 (95% CI, 20.2-28.3) fewer HRMs per 1000 beneficiaries per year compared with traditional Medicare beneficiaries. Female, American Indian or Alaska Native, and White populations were more likely to receive HRMs than other groups.

Conclusion and Relevance

Results of this study showed that HRM rates were consistently lower among Medicare Advantage than traditional Medicare beneficiaries. Higher use of HRMs among female, American Indian or Alaska Native, and White populations is a concerning disparity that requires further attention.

Physician-Peer Relationships and Patient Experiences With Specialist Care

IMPORTANCE

Peer relationships may motivate physicians to aspire to high professional standards but have not been a major focus of quality improvement efforts.

OBJECTIVE

To determine whether peer relationships between primary care physicians (PCPs) and specialists formed during training motivate improved specialist care for patients.

DESIGN, SETTING, AND PARTICIPANTS

In this quasi-experimental study, difference-in-differences analysis was used to estimate differences in experiences with specialist care reported by patients of the same PCP for specialists who did vs did not co-train with the PCP, controlling for any differences in patient ratings of the same specialists in the absence of co-training ties. Specialist visits resulting from PCP referrals from 2016 to 2019 in a large health system were analyzed, including a subset of undirected referrals in which PCPs did not specify a specialist. Data were collected from January 2016 to December 2019 and analyzed from March 2020 to October 2022.

EXPOSURE

The exposure was PCP-specialist overlap in training (medical school or postgraduate medical) at the same institution for at least 1 year (co-training).

MAIN OUTCOMES AND MEASURES

Composite patient experience rating of specialist care constructed from Press Ganey's Medical Practice Survey.

RESULTS

Of 9920 specialist visits for 8655 patients (62.9% female; mean age, 57.4 years) with 502 specialists in 13 specialties, 3.1% (306) involved PCP-specialist dyads with a co-training tie. Co-training ties between PCPs and specialists were associated with a 9.0 percentage point higher adjusted composite patient rating of specialist care (95% CI, 5.6-12.4 percentage points; P < .001), analogous to improvement from the median to the 91st percentile of specialist performance. This association was stronger for PCP-specialist dyads with full temporal overlap in training (same class or cohort) and consistently strong for 9 of 10 patient experience items, including clarity of communication and engagement in shared decision-making. In secondary analyses of objective markers of altered specialist practice in an expanded sample of visits not limited by the availability of patient experience data, co-training was associated with changes in medication prescribing, suggesting behavioral changes beyond interpersonal communication. Patient characteristics varied minimally by co-training status of PCP-specialist dyads. Results were similar in analyses restricted to undirected referrals (in which PCPs did not specify a specialist). Concordance between PCPs and specialists in physician age, sex, medical school graduation year, and training institution (without requiring temporal overlap) was not associated with better care experiences.

CONCLUSIONS AND RELEVANCE

In this quasi-experimental study, PCP-specialist co-training elicited changes in specialist care that substantially improved patient experiences, suggesting potential gains from strategies encouraging the formation of stronger physician-peer relationships.

Comparison of oral anticoagulation use and adherence among Medicare beneficiaries enrolled in stand-alone prescription drug plans vs Medicare Advantage prescription drug plans

BACKGROUND: For atrial fibrillation (AF) patients, oral anticoagulants (OACs) can reduce the risk of stroke by 60%; however, nearly 50% of patients recommended to receive OACs do not receive therapy. Integrated insurers that cover pharmacy and medical benefits may be incentivized to improve OAC use and adherence because they benefit from offsets in medical costs associated with prevented strokes. OBJECTIVE: To compare OAC use and adherence between AF patients enrolled in Medicare stand-alone prescription drug plans (PDPs), which only cover pharmacy benefits, and those enrolled in Medicare Advantage prescription drug (MAPD) plans, which cover medical and pharmacy benefits. METHODS: This was a retrospective cohort study, conducted using 2014-2016 Medicare claims data from the Centers for Medicare & Medicaid Services and a large regional health plan in Pennsylvania. Primary outcomes included OAC use and OAC adherence. OAC use was measured as filling at least 1 prescription for an OAC after AF diagnosis. OAC adherence was defined as having greater than or equal to 80% of days covered with an OAC. We constructed conditional logistic regression models in propensity score-matched samples to test the association between enrollment in PDPs or MAPD plans and outcomes. RESULTS: There were 2,551 AF patients enrolled in PDPs and 4,502 in MAPD plans before propensity score matching. The propensity score-matched sample included 2,537 patients in each group. OAC use was higher among MAPD beneficiaries (74%-76%) compared with PDP beneficiaries (70%; P < 0.001), and 41%-42% of MAPD beneficiaries were adherent to OACs, compared with 34% of PDP beneficiaries (P < 0.001). In adjusted analyses among propensity score-matched samples, PDP enrollment was associated with lower odds of OAC use (OR = 0.67, 95% CI = 0.56-0.81) and adherence (OR = 0.68, 95% CI = 0.59-0.78) compared with MAPD enrollment. CONCLUSIONS: AF patients enrolled in MAPD plans were more likely to use and adhere to OACs compared with PDP enrollees. These results may reflect the financial incentives of MAPD plans to improve guideline-recommended OAC use, since MAPD insurers bear the risk of pharmacy and medical costs and thus may benefit from cost savings associated with averted stroke events. As efforts to improve use and adherence of OACs in AF patients increase, focus should be given to how insurance benefit designs can affect medication use. DISCLOSURES: No outside funding supported this study. Hernandez has received personal fees from BMS and Pfizer, unrelated to this study. The other authors have nothing to disclose.

Are care experiences associated with survival among cancer patients? An analysis of the SEER-CAHPS data resource

PURPOSE

Cancer patients' care experiences encompass the range of interactions with the health care system and are an important indicator of care quality, which may influence survival outcomes. This study evaluates relationships between care experiences and survival using a large, nationally representative sample of cancer patients.

METHODS

We used linked SEER (Surveillance Epidemiology and End Results)-CAHPS (Consumer Assessment of Healthcare Providers and Systems) data to identify people diagnosed 8/2006-12/2013, focusing on 10 solid tumor cancer sites with the highest mortality rates among those > 65. CAHPS measures included 5 global ratings and 3 composite scores. We used survey-weighted Cox proportional hazard models comparing survival time for those who had lower (0-8) vs higher ratings (9-10) and lower (0-89) vs higher (90-100) composite scores, adjusting for case-mix and additional covariates.

RESULTS

We identified 2,263 eligible people; 26% died by 5-year post-survey completion or end of follow-up (12/31/2017). We found lower Prescription Drug Plan (PDP) ratings were significantly associated with lower mortality (adjusted HR = 0.67, p = 0.03). Lower Getting Needed Care scores were also significantly associated with lower mortality (adjusted HR = 0.79, p = 0.04). For other care experience measures, general health status, cancer stage, and comorbidities were more predictive of survival (p < .05).

CONCLUSIONS

Except for PDP and Getting Needed Care, survival was similar for those with worse versus better care experiences. Patients with poorer cancer prognoses may perceive better services from their drug plan and more responsive care from clinical providers compared to those with better prognoses. Further research is needed examining processes underlying perceptions of care experiences and survival.

Do dual eligible beneficiaries experience better health care in special needs plans?

OBJECTIVE

Dual Eligible Special Needs Plans (D-SNPs) were intended to provide better care for beneficiaries eligible for both Medicare and Medicaid through better coordination of these two programs.

DATA SOURCES

671 913 dual eligible (DE) respondents to the 2009-2019 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.

STUDY DESIGN

We compared the 2015-2019 experiences of DE beneficiaries in D-SNPs relative to fee-for-service Medicare (FFS) and non-SNP Medicare Advantage (MA) using propensity-score weighted linear regression. Comparisons were made to 2009-2014. 12 patient experience measures were considered.

DATA COLLECTION METHODS

Annual mail survey with telephone follow-up of non-respondents.

PRINCIPAL FINDINGS

More than 65% of DE beneficiaries enrolled in FFS. Of 12 measures, D-SNP performance was higher than non-SNP MA on two (P < .05), lower than non-SNP MA on two (P < .05), and higher than FFS on four (P < .01). DE beneficiaries did not report better coordination of care in D-SNPs. D-SNP performance was often worse than other coverage types in prior periods.

CONCLUSIONS

Relative to FFS Medicare, DE beneficiaries report higher immunization rates in D-SNPs, but slight or no better performance on other dimensions of patient experience. New requirements in 2021 may help D-SNPs attain their goal of better care coordination.

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.

Psychometric evaluation of the Medicare Advantage and prescription drug plan disenrollment reasons survey

OBJECTIVES

To develop and assess the reliability and validity of composite measures of reasons for disenrollment from Medicare Advantage (MA) and prescription drug plans (PDPs).

DATA SOURCE

Medicare beneficiaries who responded to the Medicare Advantage and Prescription Drug Plan Disenrollment Reasons Survey.

STUDY DESIGN

Separate multilevel factor analyses of MA and PDP data suggested groupings of survey items to form composite measures, for which internal consistency and interunit reliability were estimated. The association of each composite with an overall plan rating was examined to evaluate criterion validity.

PRINCIPAL FINDINGS

Five composites were identified: financial reasons for disenrollment; problems with prescription drug benefits and coverage; problems getting information and help from the plan; problems getting needed care, coverage, and cost information; and problems with coverage of doctors and hospitals. Beneficiary-level internal consistency reliability exceeded 0.70 for all but one composite (financial reasons); plan-level internal consistency reliability exceeded 0.80 for all composites; average interunit reliability for plans with ≥ 30 survey completes exceeded 0.75 for 3 of 5 composites. As expected, greater endorsement of reasons for disenrollment was associated with lower overall plan ratings.

CONCLUSIONS

The Disenrollment Reasons Survey provides a reliable and valid assessment of beneficiaries' reasons for leaving their plans. Multiple reasons for disenrollment may indicate especially poor experiences.

Getting What We Pay For: How Do Risk-Based Payments to Medicare Advantage Plans Compare with Alternative Measures of Beneficiary Health Risk?

OBJECTIVE

To estimate the relative health risk of Medicare Advantage (MA) beneficiaries compared to those in Traditional Medicare (TM).

DATA SOURCES/STUDY SETTING

Medicare claims and enrollment records for the sample of beneficiaries enrolled in Part D between 2008 and 2015.

STUDY DESIGN

We assigned therapeutic classes to Medicare beneficiaries based on their prescription drug utilization. We then regressed nondrug health spending for TM beneficiaries in 2015 on demographic and therapeutic class identifiers for 2014 and used coefficients from this regression to predict relative risk of both MA and TM beneficiaries.

PRINCIPAL FINDINGS

Based on prescription drug utilization data, beneficiaries enrolled in MA in 2015 had 6.9 percent lower health risk than beneficiaries in TM, but differences based on coded diagnoses suggested MA beneficiaries were 6.2 percent higher risk. The relative health risk based on drug usage of MA beneficiaries compared to those in TM increased by 3.4 p.p. from 2008 to 2015, while the relative risk using diagnoses increased 9.8 p.p.

CONCLUSIONS

Our results add to a growing body of evidence suggesting MA receives favorable, or, at worst, neutral selection. If MA beneficiaries are no healthier and no sicker than similar beneficiaries in TM, then payments to MA plans exceed what is warranted based on their health status.

Validation of New Care Coordination Quality Measures for Children with Medical Complexity

OBJECTIVES

To validate new caregiver-reported quality measures assessing care coordination services for children with medical complexity (CMC).

METHODS

A cross-sectional analysis of the associations between 20 newly developed Family Experiences with Coordination of Care (FECC) quality measures and 3 validation measures among 1209 caregivers who responded to a telephone or mailed survey from August to November 2013 in Minnesota and Washington. Validation measures included an access composite, a provider rating item, and a care coordination outcome measure, all derived from Consumer Assessments of Healthcare Providers and Systems (CAHPS) survey items. Multivariate regression was used to examine associations between the 3 validation measures and each of the 20 FECC quality measures.

RESULTS

Nineteen of the 20 FECC quality measures were significantly and positively associated with ≥1 of the validation measures. The components of care coordination demonstrating the strongest positive association with provider ratings included: 1) having a care coordinator who was knowledgeable and supportive and advocated for the child's needs (β = 26.4; 95% confidence interval [CI], 20.0-32.8, scaled to reflect change associated with a 0-100 change in the FECC measure score); and 2) receiving a written visit summary that was useful and easy to understand (β = 22.0; 95% CI, 17.1-27.0).

CONCLUSIONS

Nineteen newly developed FECC quality measures demonstrated convergent validity with previously validated CAHPS measures. These new measures are valid for assessing the quality of care coordination services provided to CMC and may be useful for evaluating new models of care focused on improving these services.

Medicare Advantage and Fee-for-Service Performance on Clinical Quality and Patient Experience Measures: Comparisons from Three Large States

OBJECTIVE

To compare performance between Medicare Advantage (MA) and Fee-for-Service (FFS) Medicare during a time of policy changes affecting both programs.

DATA SOURCES/STUDY SETTING

Performance data for 16 clinical quality measures and 6 patient experience measures for 9.9 million beneficiaries living in California, New York, and Florida.

STUDY DESIGN

We compared MA and FFS performance overall, by plan type, and within service areas associated with contracts between CMS and MA organizations. Case mix-adjusted analyses (for measures not typically adjusted) were used to explore the effect of case mix on MA/FFS differences.

DATA COLLECTION/EXTRACTION METHODS

Performance measures were submitted by MA organizations, obtained from the nationwide fielding of the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) Survey, or derived from claims.

PRINCIPAL FINDINGS

Overall, MA outperformed FFS on all 16 clinical quality measures. Differences were large for HEDIS measures and small for Part D measures and remained after case mix adjustment. MA enrollees reported better experiences overall, but FFS beneficiaries reported better access to care. Relative to FFS, performance gaps were much wider for HMOs than PPOs. Excluding HEDIS measures, MA/FFS differences were much smaller in contract-level comparisons.

CONCLUSIONS

Medicare Advantage/Fee-for-Service differences are often large but vary in important ways across types of measures and contracts.