Comparison of Care Quality Metrics in 2-Sided Risk Medicare Advantage vs Fee-for-Service Medicare Programs

Abstract

ImportanceMedicare Advantage is associated with improved health outcomes, increased care efficiency, and lower out-of-pocket costs compared with fee-for-service (FFS) Medicare. When engaged in 2-sided risk arrangements, physicians are incented to offer high value for patients; however, no studies have explored the quality and efficiency outcomes in 2-sided risk Medicare Advantage models compared with FFS Medicare.ObjectiveTo compare quality and efficiency of care between physicians using a Medicare Advantage 2-sided risk model and FFS Medicare.Design, Setting, and ParticipantsThis retrospective cohort analysis with exact and propensity score–matched design used claims data from January 1, 2018, to December 31, 2019. Participants included beneficiaries enrolled in a Medicare Advantage 2-sided risk model (ie, physicians assumed the financial risk of total costs of care) and those in an FFS Medicare program in a 5% limited data set with part A and B coverage residing in 6 states (Arizona, California, Florida, Nevada, Texas, and Utah). Data were analyzed from February 1 to June 15, 2022.ExposuresMedicare Advantage 2-sided risk model seen in practices that are part of a nationwide health care delivery organization compared with traditional FFS Medicare.Main Outcomes and MeasuresComparative analysis of 8 quality and efficiency metrics in populations enrolled in a 2-sided risk-model Medicare Advantage program and 5% FFS Medicare.ResultsIn this analytic cohort of 316 312 individuals (158 156 in each group), 46.11% were men and 53.89% were women; 32.72% were aged 65-69 years, 29.44% were aged 70-74 years, 19.05% were aged 75-79 years, 10.84% were aged 80-85 years, and 7.95% were 85 years or older. The Medicare Advantage model was associated with care of higher quality and efficiency in all 8 metrics compared with the FFS model. This included lower odds of inpatient admission (−18%; odds ratio [OR], 0.82 [95% CI, 0.79-0.84]), inpatient admission through the emergency department (ED) (−6%; OR, 0.94 [95% CI, 0.91-0.97]), ED visits (−11%; OR, 0.89 [95% CI, 0.86-0.91]), avoidable ED visits (−14%; OR, 0.86 [95% CI, 0.82-0.89]), 30-day inpatient readmission (−9%; rate ratio, 0.91 [95% CI, 0.86-0.98]), admission for stroke or myocardial infarction (−10%; OR, 0.90 [95% CI, 0.83-0.98]), and hospitalization for chronic obstructive pulmonary disease or asthma exacerbation (−44%; OR, 0.56 [95% CI, 0.50-0.62]).Conclusions and RelevanceThe improvements observed in this study may be partly or fully attributed to the Medicare Advantage model. The Medicare Advantage risk adjustment system appears to be meeting its intended goal by aligning the capitation payments to the health care burden of the individual beneficiary and aggregate population served, thus providing revenue to develop infrastructure that supports improvements in quality and efficiency for the patients enrolled in Medicare Advantage models with 2-sided risk.

Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease: Medicine’s Best-kept Secret That Could Save Medicare a Billion Dollars a Year

“…Studies have shown that MA-enrolled patients have improved health outcomes across multiple metrics versus traditional Medicare beneficiaries. Importantly, the largest documented benefit is a reduction in COPD or asthma hospitalizations among beneficiaries whose physicians participated in a two-sided risk MA model compared with traditional Medicare ( 19 ). In a two-sided risk model, physicians may generate financial bonuses or incur penalties based on the quality and cost of care they provide.…”

Total Joint Arthroplasty Utilization in Persons Over 65 Years of Age

“…The first noteworthy finding (shown in Table I in the article by Anderson et al) is that MA enrollees are more likely to be Black, Hispanic, urban-based, Medicaid-eligible, and ‡70 years of age and to have a greater number of comorbidities but lower median income when compared with TM enrollees. These data suggest the potential for adverse selection into MA plans in this population and underscore the need for appropriate adjustment, as these demographic and clinical features are also associated with lower utilization of total joint arthroplasty (TJA) 3,12,13 . Given the stark differences in utilization of TJA between subjects in PPO and HMO plans, it would have also been useful to describe any differences in baseline demographic features between HMO and PPO beneficiaries.…”