Association of Medicare Advantage Premiums With Measures of Quality and Patient Experience

Abstract

ImportanceQuality of care varies substantially across Medicare Advantage plans. The price information that Medicare Advantage enrollees are most likely to consider when selecting a Medicare Advantage plan is the monthly premium. Enrollees may select plans to minimize premium or, alternatively, use premium as a proxy for quality and select plans with higher premiums; however, quality implications of these choices are unknown.ObjectiveTo determine the extent to which the quality of care offered by Medicare Advantage plans varies within vs across premium levels.Design, Setting, and ParticipantsThis was a retrospective cross-sectional study of the population enrolled in Medicare Advantage plans in 2016 to 2017 using clinical quality measures from the Healthcare Effectiveness Data and Information Set (HEDIS), patient experience measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and administrative data. Data were analyzed from March 2021 to March 2022.ExposuresMedicare Advantage monthly premium.Main Outcomes and MeasuresTen publicly reported 2017 HEDIS measures and 5 publicly reported 2017 CAHPS measures linearly transformed to a 0 to 100 scale.ResultsThe 168 968 Medicare Advantage CAHPS respondents were representative of the enrollee population (14% were <65 years old and eligible through disability; 24% ≥80 years old; sex and race/ethnicity data were not considered); 40% were in 591 plans with no monthly premiums and less than 6% were in 144 plans with monthly premiums of $120 or more. There were from 77 054 to 2 139 422 enrollees by HEDIS measure. Among all Medicare Advantage enrollees, 79% were in plans with either a $0 premium or a low monthly premium (≤$60); patient experience and clinical quality were generally similar in these 2 categories of plans. To a small extent, enrollees in moderately high ($60-$120) and high (≥$120) premium plans reported better patient experience (+1.4 [95% CI, 0.7-2.1] and 2.2 [95% CI, 1.5-2.9] points) and received better clinical care (1.4 [95% CI, 0.3-2.5] to 3.3 [5% CI, 2.1-4.5] percentage points on most measures than those with $0 and low-premium plans. Quality differences within each premium level category were substantial; the within-premium category plan-level SDs were 6.5 points and 7.2 percentage points for patient experience and clinical quality, respectively. A plan at the 50th percentile of clinical quality and patient experience in the high premium category would fall in the 65th and 62nd percentile within the $0-premium category, respectively.Conclusions and RelevanceThis population-based cross-sectional study found that although quality of care and patient experience were slightly higher with higher-premium plans, quality varied widely within each premium category. High-quality care and patient experience were found in each price category. Thus, paying higher premiums is not necessary for higher quality care in Medicare Advantage plans. Greater engagement of enrollees and advocates with quality of care and patient experience information for Medicare Advantage plan selection is recommended.

New Supplemental Benefits and Plan Ratings Among Medicare Advantage Enrollees

“…Similar to prior research using CAHPS data to evaluate patient experience, we applied the heuristic of 0.1 point to indicate a small, 0.3 points a medium, and 0.5 points a large difference in quality. 21,28 We found that the differences attributable to plans adopting both benefits were small to medium.…”

“…However, we found no statistically significant association between plans adopting only a PHRB or SSBCI and a change in mean enrollee plan ratings. Similar to prior research using CAHPS data to evaluate patient experience, we applied the heuristic of 0.1 point to indicate a small, 0.3 points a medium, and 0.5 points a large difference in quality . We found that the differences attributable to plans adopting both benefits were small to medium.…”

“…We included plan-level indicators for SNP status and plan type as binary variables and county-level enrollment, premium, maximum OOP spending, deductible, and changes in premium, deductible, and maximum OOP spending from the previous year as continuous variables. 17,21,22 We adjusted for plan size defined by 3 groups of plan enrollment. We adjusted for contract start year as before 2006,…”

Getting the Most From Payments to Medicare Advantage Health Plans—Thoughts on the Controversy

“…As the findings of Haviland and colleagues suggest, 1 the Medicare Advantage program could be improved by helping beneficiaries to choose better plans for themselves. Broader strategic reforms will likely be needed as well.…”

“…For this reason, many scholars studying the US system examine aspects of how well the market system works. One strand of this research explores the associations between price and quality, and the study by Haviland and colleagues in this issue of JAMA Health Forum exemplifies this research . Specifically, the authors analyze the associations between premiums and quality in the Medicare Advantage market, which is composed of private health plans that served almost half of eligible Medicare beneficiaries in 2021.…”