Quality of Care and Outcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized With Heart Failure

Abstract

MA), a private insurance plan option, now covers one-third of all Medicare beneficiaries. Although patients with cardiovascular disease enrolled in MA have been reported to receive higher quality of care in the ambulatory setting than patients enrolled in fee-for-service (FFS) Medicare, it is unclear whether MA is associated with higher quality in patients hospitalized with heart failure, or alternatively, if incentives to reduce utilization under MA plans may be associated with worse care. OBJECTIVE To determine whether there are differences in quality of care received and in-hospital outcomes among patients enrolled in MA vs FFS Medicare.DESIGN, SETTING, AND PARTICIPANTS Observational, retrospective cohort study of patients hospitalized with heart failure in hospitals participating in the Get With the Guidelines-Heart Failure registry.EXPOSURES Medicare Advantage enrollment. MAIN OUTCOMES AND MEASURESIn-hospital mortality, discharge disposition, length of stay, and 4 heart failure achievement measures. RESULTSOf 262 626 patients hospitalized with heart failure, 93 549 (35.6%) were enrolled in MA and 169 077 (64.4%) in FFS Medicare. The median (interquartile range) age was 78 (70-85) years for patients enrolled in MA and 78 (69-86) years for patients enrolled in FFS Medicare. Standard mean differences in age, sex, prevalence of comorbidities, or objective measures on admission, including vital signs and laboratory values, were less than 10%. After adjustment, there were no statistically significant differences in receipt of evidence-based β-blockers when indicated; angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, or angiotensin receptor-neprilysin inhibitors at discharge; measurement of left ventricular function; and postdischarge appointments by Medicare insurance type. Patients enrolled in MA, however, had higher odds of being discharged directly home (adjusted odds ratio [AOR], 1.16; 95% CI, 1.13-1.19; P < .001) relative to patients enrolled in FFS Medicare and lower odds of being discharged within 4 days (AOR, 0.97; 95% CI, 0.93-1.00; P = .04). There was no significant difference in in-hospital mortality between patients with MA and patients with FFS Medicare (AOR, 0.98; 95% CI, 0.92-1.03; P = .42).CONCLUSIONS AND RELEVANCE Among patients hospitalized with heart failure, no observable benefit was noted in quality of care or in-hospital mortality between those enrolled in MA vs FFS Medicare, except lower use of post-acute care facilities. As MA continues to grow, it will be important to ensure that participating private plans provide an added value to the patients they cover to justify the higher administrative costs compared with traditional FFS Medicare.

Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association

“…In a study of 262 626 patients hospitalized with HF included in GWTG-HF, inclusion in the Medicare Advantage program was compared with inclusion in the fee-for-service Medicare. 34 Patients included in the Medicare Advantage program were more likely to be discharged home (adjusted OR, 1.16 [95% CI, 1.13–1.19]; P <0.001) despite lower odds of discharge within 4 days (adjusted OR, 0.97 [95% CI, 0.93–1.00]; P =0.04). In addition, no difference was reported in in-hospital mortality.…”

Value of Discharging Heart Failure Patients Home

“…Figueroa and colleagues correctly point out that MA plans practice utilization management to help guide hospital discharge disposition, which may promote more appropriate home discharges and lower postacute costs, while also noting MA plans leverage additional care coordination services to support patients. Considering that the Centers for Medicare & Medicaid Services continues to regulate quality performance of both MA plans and hospitals, including all-cause readmissions, MA plans should continue partnering with hospitals and clinicians to support evidence-based inpatient management while studying and aligning benefit design for optimal patient outcomes along the continuum of care.…”

“…To the Editor Figueroa and colleagues reported that fee-for-service (FFS) Medicare and Medicare Advantage (MA) inpatients with heart failure shared similar complexity, clinical interventions, and outcomes but raised concerns that more MA inpatients were discharged home (adjusted odds ratio, 1.16; 95% CI, 1.13-1.19; P < .001) compared with a skilled nursing facility (SNF) as a quality difference driven mainly by MA plan cost interest. I would suggest clinically appropriate hospital-to-home discharge is a potential quality indicator aligned with Medicare patient interest.…”

Prognostic value of functional capacity after transitional rehabilitation in older patients hospitalized for heart failure

“…Currently, only a minimal proportion of elderly patients hospitalized for HF participate in CR. 18,19 A scientific statement from the American Heart Association emphasized the importance of prioritizing functional capacity as a principal end-point for therapies oriented to older adults with cardiovascular disease. 38 However, there is a dearth of research specifically addressing the diverse population of older patients hospitalized for HF.…”