Medicare Advantage Plans Losing Their Edge for Patient Outcomes

Amid years of Medicare Advantage's growing popularity, it was increasingly harder to argue that these private plans allow for better care over traditional Medicare, investigators found.

Within the model population of acute myocardial infarction (MI) patients, enrollment in Medicare Advantage was associated with a significant albeit modest reduction in adjusted 30-day mortality rates in 2009 as seen in, for example, people with ST-segment elevation MI (STEMI; 19.1% vs 20.6%).

However, a decade later, improved survival across the board meant that mortality rates no longer favored Medicare Advantage over traditional Medicare (e.g., 17.7% vs 17.8% in STEMI for 2018), according to Bruce Landon, MD, MBA, of Beth Israel Deaconess Medical Center and Harvard Medical School, both in Boston, and colleagues.

They reported in JAMA that a gap in 90-day revascularization rates had also narrowed to nonsignificance by 2018. Nevertheless, the study showed that small advantages remained for acute MI patients with Medicare Advantage in terms of:

• Greater postdischarge prescription fills (e.g., 91.7% vs 89.0% statin prescription fills after STEMI)
• Lower ICU admission
• Better odds of discharge to home rather than postacute facility
• Reduced adjusted 30-day readmission rates

"These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type," Landon and colleagues wrote.

They opted to assess the two Medicare programs using a relatively uniform population with established diagnostic criteria, and the analysis relied on a national sample of over 2.2 million acute MI patients with Medicare from 2009 to 2018.

Notably, the year 2012 saw the introduction of penalties, applied only to traditional Medicare, for high rates of acute MI readmissions under the Hospital Readmissions Reduction Program. Landon's group suggested that the growth of accountable care organizations and value-based payment in traditional Medicare since then could have factored into the convergence in care between Medicare Advantage and traditional Medicare.

Another explanation, according to the authors, could be unmeasured residual differences between patient populations that would narrow over time as opportunities for selection fall with growing enrollment in Medicare Advantage.

Medicare Advantage, also known as Part C, offers older Americans a private alternative to original Medicare. These plans can be appealing for offering lower out-of-pocket costs and coverage of additional benefits (e.g., dental and fitness) despite the downsides of a constrained network of available physicians, and care delays related to prior authorization and referral to specialists.

"How does this study fit into our greater understanding of the Medicare Advantage program? Much of the literature shows that enrollment in Medicare Advantage is associated with lower use of health care services, particularly postacute care, greater performance of recommended preventive services, and higher scores for some measures of patient experience," though "it is not clear whether these associations will persist as the program grows to represent a larger share of the overall Medicare program," according to David Meyers, PhD, MPH, and colleagues from Brown University's School of Public Health, Health Services, Policy, and Practice in Providence, Rhode Island.

"The study by Landon et al, along with research over the last decade, suggests that the association between Medicare Advantage and higher quality of care is modest at best. At the same time, extensive research suggests that Medicare Advantage plans are overpaid due to structural factors in the program design. These factors include risk-adjustment, plans' upcoding of disease severity, and inflated bonus payments for quality performance," they noted in an accompanying editorial.

Patients have also complained of deception in the aggressive sales pitches for Medicare Advantage plans.

For the retrospective cohort study, Landon and colleagues used the MedPAR files of adults, ages 66 and older, continuously enrolled in both Medicare Part A and Part B for at least 1 year prior to and following a hospitalization for acute MI. Posthospital medication use was assessed using a 20% random sample of enrollees with Part D coverage.

Across groups stratified by STEMI versus non-STEMI and Medicare type, patients were in their mid- to late-70s on average in 2018. That year, under 42% of patients were women.

Medicare Advantage patients were more frequently Black or Hispanic and had disproportionately more people with diabetes than traditional Medicare, the authors reported.

Study limitations included its reliance on coding being accurate in administrative claims and the lack of consideration of plan-level variation within Medicare Advantage.

"It is important to note that the discharge location variable in MedPAR data may be inaccurate for Medicare Advantage enrollees, the MedPAR data are not complete and may underreport readmissions, there may be differential enrollment in Part D plans between Medicare Advantage and traditional Medicare that could confound the association between Medicare Advantage enrollment and higher receipt of statins, and any reductions in spending may be offset by higher payments overall to Medicare Advantage plans," Meyers and colleagues warned.

They cited predictions that the majority of Medicare beneficiaries will be enrolled in a private Medicare Advantage plan in 2023 -- reaching nearly seven in 10 beneficiaries by 2030.

Meyers' group urged more research on how Medicare Advantage can be redesigned to reduce overpayments and deliver care of value.

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