Abstract

Medicare Advantage (MA) enrollment is increasing, with one-third of Medicare beneficiaries currently selecting MA. Despite this growth, it is difficult to assess the quality of the health care professionals and organizations that serve MA beneficiaries or to compare them with health care professionals and organizations serving traditional Medicare (TM) beneficiaries. Elderly individuals served by home health agencies (HHAs) may be particularly susceptible to the negative outcomes associated with low-quality care. To compare the quality of HHAs that serve TM and MA beneficiaries. This cross-sectional, admission-level analysis used data from 4 391 980 home health admissions identified using the Outcome and Assessment Information Set (most commonly known as OASIS) admission assessments of Medicare beneficiaries in 2015 from Medicare-certified HHAs. A multinomial logistic regression model was used to assess whether an association existed between the Medicare plan type and HHA quality. The model was adjusted for patient demographics, acuity, and characteristics of the zip codes. Sensitivity analyses controlled for zip code fixed effects. The present analysis was conducted between October 2018 and March 2019. Home health users were classified as TM or MA beneficiaries using the Master Beneficiary Summary File. The MA beneficiaries were further classified as enrolled in a high- or low-quality MA plan on the basis of publicly reported MA star ratings. Quality of HHA derived from the publicly reported patient care star ratings: low quality (1.0-2.5 stars), average quality (3.0-3.5 stars), or high quality (≥4.0 stars). Of 4 391 980 admissions, most (75.5%) were for TM beneficiaries (mean [SD] age, 76.1 [12.2] years), with 16.6% of beneficiaries enrolled in high-quality MA plans (mean [SD] age, 77.8 [10.0] years) and 7.9% in low-quality MA plans (mean [SD] age, 74.4 [11.4] years). Individuals enrolled in low-rated MA plans were most likely to be nonwhite (percentages of nonwhite individuals in TM, 14.3%; in high-quality MA, 19.8%; and in low-quality MA, 36.5%) and dual Medicare-Medicaid eligible (percentages for dual eligible in TM, 30.5%; in high-quality MA, 19.5%; and in low-quality MA, 43.3%). Among TM beneficiaries, 30.4% received care from high-quality HHAs, whereas 17.0% received care from low-quality HHAs. Compared with TM beneficiaries, those in a low-quality MA plan were 3.0 percentage points (95% CI, 2.6%-3.4%) more likely to be treated by a low-quality HHA and 4.9 percentage points (95% CI, -5.4% to -4.3%) less likely to be treated by a high-quality HHA. The MA beneficiaries in high-quality plans were also less likely to receive care from high-quality vs low-quality HHAs (-2.8% [95% CI, -3.1% to -2.2%] vs 1.0% [95% CI, 0.7%-1.3%]). Compared with TM beneficiaries, MA beneficiaries residing in the same zip code enrolled in either high- or low-quality MA plans may receive treatment from lower-quality HHAs. Policy makers may consider incentivizing MA plans to include higher-quality HHAs in their networks and improving patient education regarding HHA quality.

Highlights

  • The proportion of Medicare beneficiaries enrolled in Medicare Advantage (MA) increased from 13% in 2004 to 33% in 2017.1 Despite this growth, we know little about the quality of health care professionals serving MA beneficiaries compared with those serving traditional Medicare (TM) beneficiaries because of the incompleteness of MA claims data.Both MA and TM beneficiaries use Medicare-certified home health (HH) services more than in the past

  • Compared with TM beneficiaries, those in a low-quality MA plan were 3.0 percentage points more likely to be treated by a low-quality Health Agency (HHA) and 4.9 percentage points less likely to be treated by a high-quality HHA

  • Compared with TM beneficiaries, MA beneficiaries residing in the same zip code enrolled in either high- or low-quality MA plans may receive treatment from lowerquality HHAs

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Summary

Introduction

The proportion of Medicare beneficiaries enrolled in Medicare Advantage (MA) increased from 13% in 2004 to 33% in 2017.1 Despite this growth, we know little about the quality of health care professionals serving MA beneficiaries compared with those serving traditional Medicare (TM) beneficiaries because of the incompleteness of MA claims data. Both MA and TM beneficiaries use Medicare-certified home health (HH) services more than in the past. The high risk of adverse outcomes in this vulnerable population[4] may be exacerbated by receiving care from low-quality home health agencies (HHAs). Similar to what has been observed in the private insurance market,[5,6,7] MA plans may form networks with lower-quality HHAs that are willing to accept lower prices

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