Healthcare Utilization Lower for MA Beneficiaries with Complex Care Needs

October 13, 2022 - Among Medicare beneficiaries with complex care needs, those enrolled in Medicare Advantage had lower acute healthcare utilization than traditional Medicare beneficiaries, including lower rates of hospital stays and emergency department visits, a study published in JAMA Health Forum found.

Medicare beneficiaries with complex, co-occurring, chronic conditions tend to experience high acute care utilization rates and poor health outcomes. Medicare Advantage plans have components that may help address the needs of these beneficiaries, such as care management, supplemental benefits, and value-based contracting.

Researchers used claims data from January 1, 2017, to December 31, 2018, to determine how healthcare utilization differed between Medicare Advantage and traditional Medicare beneficiaries.

The study population included over 1.8 million Medicare beneficiaries, 1,177,896 of whom were enrolled in Medicare Advantage and 666,430 who were enrolled in traditional Medicare.

Researchers separated the sample into different cohorts. The frail elderly cohort included 116,047 Medicare advantage beneficiaries and 104,036 traditional Medicare beneficiaries. The major complex chronic cohort consisted of 320,954 individuals enrolled in Medicare Advantage and 158,811 enrolled in traditional Medicare. Finally, the minor complex chronic cohort included 740,895 people enrolled in Medicare Advantage and 403,583 traditional Medicare beneficiaries.

Overall, Medicare Advantage beneficiaries had lower healthcare utilization rates, including lower rates of hospital stays, emergency department visits, and 30-day readmissions. The most significant differences were in hospital stays.

Hospital stay rates were 9.3 percent lower for Medicare Advantage beneficiaries in the frail elderly cohort than traditional Medicare beneficiaries in the same cohort. Similarly, among the major complex chronic cohort, the rates of hospital stays were 11.9 percent lower for Medicare Advantage beneficiaries.

The adjusted differences per 1,000 beneficiaries in hospital stays were -65.46 for the frail elderly cohort, -64.27 for the major complex chronic cohort, and -29.28 for the minor complex cohort.

Among beneficiaries who experienced a hospital stay, 30-day readmissions were less frequent for Medicare Advantage beneficiaries in the major complex chronic and minor complex chronic cohorts.

The adjusted differences in emergency department visits per 1,000 beneficiaries were -29.43 for the frail elderly cohort, -39.12 for the major complex chronic cohort, and -28.71 for the minor complex chronic cohort.

Medicare Advantage beneficiaries with health maintenance organization (HMO) and preferred provider organization (PPO) plans had lower hospitalization and emergency department visit rates than traditional Medicare beneficiaries. The differences were more pronounced for Medicare Advantage members in HMOs, the study noted.

“This difference could be explained by the fact that HMO plans place a greater incentive on in-network care and an accountable primary care relationship,” researchers wrote.

Additionally, across different primary care payment arrangements, individuals enrolled in Medicare Advantage had lower rates of hospital stays and emergency department visits in most cohorts. The most significant difference was observed for Medicare Advantage beneficiaries who were part of primary care organizations reimbursed under two-sided risk arrangements.

While the use of value-based payment models in traditional Medicare has helped mitigate acute care utilization for beneficiaries with frailty, it did not reduce utilization for those with complex care needs. This suggests that differences in the design and implementation of value-based payment models may influence healthcare utilization, researchers said.

“Although we were not able to assess the influence of other potential levers, previous research has suggested that the disease management and care management programs used by MA plans may reduce acute care utilization and improve outcomes for beneficiaries with chronic illnesses.”

Past research has detailed the differences between Medicare Advantage and traditional Medicare.

For example, data from the Kaiser Family Foundation (KFF) found that Medicare Advantage beneficiaries were more likely to have a usual source of care and utilize preventive care services, while traditional Medicare beneficiaries experienced fewer cost-related issues.

Another study found that low-value care services were less common for Medicare Advantage beneficiaries than those enrolled in traditional Medicare.