Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction

Abstract

ImportanceMedicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown.ObjectiveTo compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018.Design, Setting, and ParticipantsRetrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non–ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019).ExposuresEnrollment in Medicare Advantage vs traditional Medicare.Main Outcomes and MeasuresThe primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions).ResultsThe study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, −1.5 percentage points [95% CI, −2.2 to −0.7] and 12.0% vs 12.5% for NSTEMI; difference, −0.5 percentage points [95% CI, −0.9% to −0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, −0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, −0.2 percentage points [95% CI, −0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, −0.9 percentage points [95% CI, −1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, −1.3 percentage points [95% CI, −2.0 to −0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, −1.5 to 0.0]).Conclusions and RelevanceAmong Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.

Mindfulness Training and Exercise and Cognitive Function in Older Adults

“…Elena Salmoirago-Blotcher, MD, PhD Ronald Cohen, PhD In Reply We thank Drs Salmoirago-Blotcher and Cohen for their interest in the MEDEX study, 1 which showed that mindfulness training and/or exercise did not improve cognitive function in older adults with subjective cognitive concerns. However, we disagree with their concern that the negative findings "can be explained by…methodological limitations."…”

“…The Medicare Payment Advisory Commission (MedPAC) estimated that Medicare Advantage risk scores in 2021 were more than 10% higher than scores for similar beneficiaries in traditional Medicare . 1,2 To achieve these scores, Medicare Advantage plans rely on more intensive coding of diagnoses by their clinicians as well as chart audits and home visits to obtain additional diagnosis codes.…”

“…Morbidity outcomes in this study 1 were adjusted for multiple comorbidities including diabetes, peripheral vascular disease, and chronic obstructive pulmonary disease. The authors acknowledged that "the intensity of coding of comorbidities has increased, particularly in the Medicare Advantage program."…”

“…However, they also stated that in their study, the "measured comorbidities were obtained only from hospital claims" and "coding practices within hospitals would likely not vary by payer." 1 I am concerned that the more intensive coding of patients seen in the office setting in Medicare Advantage plans carried over to the hospital coding. For example, the diagnosis of chronic obstructive pulmonary disease was present in approximately 20% to 30% of the study population, depending on the year of hospitalization.…”

Medicare Advantage vs Traditional Medicare and 30-Day Mortality in Patients With AMI

“…To the Editor A recent study compared outcomes of 30-day mortality following myocardial infarction in patients with Medicare Advantage vs traditional Medicare. However, greater coding intensity occurs in Medicare Advantage plans, which makes reliable interpretation of outcome data difficult when comparing Medicare Advantage plans with traditional Medicare.…”