Medicare Advantage Beneficiaries Research Articles

Medicare Advantage Health Risk Assessments Contribute Up To $12 Billion Per Year To Risk-Adjusted Payments.

With Medicare Advantage (MA) enrollment surpassing 50percent of Medicare beneficiaries, accurate risk-adjusted plan payment rates are essential. However, artificially exaggerated coding intensity, where plans seek to enhance measured health risk through the addition or inflation of diagnoses, may threaten payment rate integrity. One factor that may play a role in escalating coding intensity is health risk assessments (HRAs)-typically in-home reviews of enrollees' health status-that enable plans to capture information about their enrollees. In this study, we evaluated the impact of HRAs on Hierarchical Condition Categories (HCC) risk scores, variation in this impact across contracts, and the aggregate payment impact of HRAs, using 2019 MA encounter data. We found that 44.4percent of MA beneficiaries had at least one HRA. Among those with at least one HRA, HCC scores increased by 12.8percent, on average, as a result of HRAs. More than one in five enrollees had at least one additional HRA-captured diagnosis, which raised their HCC score. Potential scenarios restricting the risk-score impact of HRAs correspond with $4.5-$12.3billion in reduced Medicare spending in 2020. Addressing increased coding intensity due to HRAs will improve the value of Medicare spending and ensure appropriate payment in the MA program.

Long-term outcomes after rehabilitation in Medicare Advantage and fee-for-service beneficiaries.

Financial incentives in capitated Medicare Advantage (MA) plans may lead to inadequate rehabilitation. We therefore investigated if MA enrollees had worse long-term physical performance and functional outcomes after rehabilitation. We conducted a retrospective cohort study of Medicare beneficiaries in the nationally representative National Health and Aging Trends Study. We compared MA and fee-for-service (FFS) beneficiaries reporting rehabilitation between 2014 and 2017 by change in (1) Short Physical Performance Battery (SPPB) and (2) NHATS-derived Functional Independence Measure (FIM) from the previous year, using t-tests incorporating inverse-probability weighting and complex survey design. Secondary outcomes were self-reported: (1) improved function during rehabilitation, (2) worse function since rehabilitation ended, (3) meeting rehabilitation goals, and (4) meeting insurance limits. Among 738 MA and 1488 FFS participants, weighted mean age was 76 years (SD 7.0), 59% were female, and 9% had probable dementia. MA beneficiaries were more likely to be Black (9% vs. 6%) or Hispanic/other race (15% vs. 10%), be on Medicaid (14% vs. 10%), have lower income (median $35,000 vs. $48,000), and receive <1 month of rehabilitation (30% vs. 23%). MA beneficiaries had a similar decline in SPPB (-0.46 [SD 1.8] vs. -0.21 [SD 2.7], p-value 0.069) and adapted FIM (-1.05 [SD 3.7] vs. -1.13 [SD 5.45], p-value 0.764) compared to FFS. MA beneficiaries were less likely to report improved function during rehabilitation (61% [95% CI 56-67] vs. 70% [95% CI 67-74], p-value 0.006). Other outcomes and analyses restricted to inpatient rehabilitation participants were non-significant. MA enrollment was associated with lower likelihood of self-reported functional improvement during rehabilitation but no clinically or statistically significant differences in annual changes of physical performance or function. As MA expands, future studies must monitor implications on rehabilitation coverage and older adults' independence.

Restrictiveness of Medicare Advantage provider networks across physician specialties.

The objective was to measure specialty provider networks in Medicare Advantage (MA) and examine associations with market factors. We relied on traditional Medicare (TM) and MA prescription drug event data from 2011 to 2017 for all Medicare beneficiaries in the United States as well as data from the Area Health Resources File. Relying on a recently developed and validated prediction model, we calculated the provider network restrictiveness of MA contracts for nine high-prescribing specialties. We characterized network restrictiveness through an observed-to-expected ratio, calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based on the prediction model. We assessed the relationship between network restrictiveness and market factors across specialties with multivariable linear regression. Prescription drug event data for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017. Provider networks in MA varied in restrictiveness. OB-Gynecology was the most restrictive with enrollees seeing 34.5% (95% CI: 34.3%-34.7%) as many providers as they would absent network restrictions; cardiology was the least restrictive with enrollees seeing 58.6% (95% CI: 58.4%-58.8%) as many providers as they otherwise would. Factors associated with less restrictive networks included the county-level TM average hierarchical condition category score (0.06; 95% CI: 0.04-0.07), the county-level number of doctors per 1000 population (0.04; 95% CI: 0.02-0.05), the natural log of local median household income (0.03; 95% CI: 0.007-0.05), and the parent company's market share in the county (0.16; 95% CI: 0.13-0.18). Rurality was a major predictor of more restrictive networks (-0.28; 95% CI: -0.32 to -0.24). Our findings suggest that rural beneficiaries may face disproportionately reduced access in these networks and that efforts to improve access should vary by specialty.

Trajectories of adherence to ACEI/ARB medications following a motivational interviewing intervention among Medicare Advantage beneficiaries in Texas

Trajectories of adherence to ACEI/ARB medications following a motivational interviewing intervention among Medicare Advantage beneficiaries in Texas

Differences in Home Health Services and Outcomes Between Traditional Medicare and Medicare Advantage

Private Medicare Advantage (MA) plans recently surpassed traditional Medicare (TM) in enrollment. However, MA plans are facing scrutiny for burdensome prior authorization and potential rationing of care, including home health. MA beneficiaries are less likely to receive home health, but recent evidence on differences in service intensity and outcomes among home health patients is lacking. To examine differences in home health service intensity and patient outcomes between MA and TM. This cross-sectional study was conducted from January 2019 to December 2022 in 102 home health locations in 19 states and included 178 195 TM and 107 102 MA patients 65 years or older with 2 or fewer 60-day home health episodes. It included a secondary analysis of standardized assessment and visit data. Inverse probability of treatment weighting regression compared service intensity and patient outcomes between MA and TM episodes, accounting for differences in demographic characteristics, medical complexity, functional and cognitive impairments, social environment, caregiver support, and local community factors. Models included office location, year, and reimbursement policy fixed effects. Data were analyzed between September 2023 and July 2024. TM vs MA plan. Home health length of stay and number of visits from nursing, physical, occupational, and speech therapy, social work, and home health aides. Patient outcomes included improvement in self-care and mobility function, discharge to the community, and transfer to an inpatient facility during home health. Of 285 297 total patients, 180 283 (63.2%) were female; 586 (0.2%) were American Indian/Alaska Native, 8957 (3.1%) Asian, 28 694 (10.1%) Black, 7406 (2.6%) Hispanic, 1959 (0.7%) Native Hawaiian/Pacific Islander, 237 017 (83.1%) non-Hispanic White, and 678 (0.2%) multiracial individuals. MA patients had shorter home health length of stay by 1.62 days (95% CI, -1.82 to 1.42) and received fewer visits from all disciplines except social work. There were no differences in inpatient transfers. MA patients had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively (mobility odds ratio [OR], 0.97; 95% CI, 0.94-0.99; self-care OR, 0.96; 95% CI, 0.92-0.99). MA patients were 5% more likely to discharge to the community compared with TM (OR, 1.05; 95% CI, 1.01-1.08). The results of this cross-sectional study suggest that MA patients receive shorter and less intensive home health care vs TM patients with similar needs. Differences may be due to the administrative burden and cost-limiting incentives of MA plans. MA patients experienced slightly worse functional outcomes but were more likely to discharge to the community, which may have negative implications for MA patients, including reduced functional independence or increased caregiver burden.

National Estimates of Short- and Longer-Term Hospital Readmissions After Major Surgery Among Community-Living Older Adults

Nationally representative estimates of hospital readmissions within 30 and 180 days after major surgery, including both fee-for-service and Medicare Advantage beneficiaries, are lacking. To provide population-based estimates of hospital readmission within 30 and 180 days after major surgery in community-living older US residents and examine whether these estimates differ according to key demographic, surgical, and geriatric characteristics. A prospective longitudinal cohort study of National Health and Aging Trends Study data (calendar years 2011-2018), linked to records from the Centers for Medicare & Medicaid Services (CMS). Data analysis was conducted from April to August 2023. Participants included community-living US residents of the contiguous US aged 65 years or older who had at least 1 major surgery from 2011 to 2018. Data analysis was conducted from April 10 to August 28, 2023. Major operations and hospital readmissions within 30 and 180 days were identified through data linkages with CMS files that included both fee-for-service and Medicare Advantage beneficiaries. Data on frailty and dementia were obtained from the annual National Health and Aging Trends Study assessments. A total of 1780 major operations (representing 9 556 171 survey-weighted operations nationally) were identified from 1477 community-living participants; mean (SD) age was 79.5 (7.0) years, with 56% being female. The weighted rates of hospital readmission were 11.6% (95% CI, 9.8%-13.6%) for 30 days and 27.6% (95% CI, 24.7%-30.7%) for 180 days. The highest readmission rates within 180 days were observed among participants aged 90 years or older (36.8%; 95% CI, 28.3%-46.3%), those undergoing vascular surgery (45.8%; 95% CI, 37.7%-54.1%), and persons with frailty (36.9%; 95% CI, 30.8%-43.5%) or probable dementia (39.0%; 95% CI, 30.7%-48.1%). In age- and sex-adjusted models with death as a competing risk, the hazard ratios for hospital readmission within 180 days were 2.29 (95% CI, 1.70-3.09) for frailty and 1.58 (95% CI, 1.15-2.18) for probable dementia. In this nationally representative cohort study of community-living older US residents, the likelihood of hospital readmissions within 180 days after major surgery was increased among older persons who were frail or had probable dementia, highlighting the potential value of these geriatric conditions in identifying those at increased risk.

Dental Use and Spending in Medicare Advantage and Traditional Medicare, 2010-2021

This cross-sectional study examines Medicare Advantage and traditional Medicare beneficiaries’ use of and spending for dental services.

Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization.

Sickle cell disease (SCD) has a history of health inequity, as patients with SCD are primarily Black and often marginalized from the health care system. Although recent health care and treatment advancements have prolonged life expectancy, it may be insufficient to support the complex needs of the growing population of older adults with SCD. This retrospective study used a cohort (N = 812) of Medicare Advantage beneficiaries 45 years and older (ages: 45-54, 55-64, 65-74, 75-89) with SCD to identify associations of SCD-related complications and comorbidities with emergency department (ED) visits, potentially avoidable ED visits, all-cause hospitalization, and potentially avoidable hospitalizations, 2018-2020. The 75-89 age group had lower odds of an ED visit (OR 0.56; 95% CI 0.32-1.00), 65-74 age group had lower odds of an ED visit (OR 0.49; 95% CI 0.31-0.78) and hospitalization (OR 0.50; 95% CI 0.31-0.79), compared with the 45-54 age group. Acute chest syndrome was associated with increased odds of an ED visit (OR 2.02; 95% CI 1.10-3.71), avoidable ED visit (OR 1.87; 95% CI 1.14-3.06), and hospitalization (OR 3.61; 95% CI 2.06-6.31). Pain was associated with increased odds of an ED visit (OR 2.64; 95% CI 1.85-3.76), an avoidable ED visit (OR 3.08; 95% CI 1.90-4.98), hospitalization (OR 1.51; 95% CI 1.02-2.24), and avoidable hospitalization (OR 6.42; 95% CI 1.74-23.74). Older adults with SCD have been living with SCD for decades, often while managing pain crises and complications associated increased incidence of an ED visit and hospitalization. The characteristics and needs of this population must continue to be examined to increase preventative care and reduce costly emergent health care resource utilization.

Disparities in Acute and Chronic Complications of Diabetes Along the U.S. Rural-Urban Continuum.

To determine the relative hazards of acute and chronic diabetes complications among people with diabetes across the U.S. rural-urban continuum. This retrospective cohort study used the OptumLabs Data Warehouse, a deidentified data set of U.S. commercial and Medicare Advantage beneficiaries, to follow 2,901,563 adults (age ≥18 years) with diabetes between 1 January 2012 and 31 December 2021. We compared adjusted hazard ratios (HRs) of diabetes complications in remote areas (population <2,500), small towns (population 2,500-50,000), and cities (population >50,000). Compared with residents of cities, residents of remote areas had greater hazards of myocardial infarction (HR 1.06 [95% CI 1.02-1.10]) and revascularization (HR 1.04 [1.02-1.06]) but lower hazards of hyperglycemia (HR 0.90 [0.83-0.98]) and stroke (HR 0.91 [0.88-0.95]). Compared with cities, residents of small towns had greater hazards of hyperglycemia (HR 1.06 [1.02-1.10]), hypoglycemia (HR 1.15 [1.12-1.18]), end-stage kidney disease (HR 1.04 [1.03-1.06]), myocardial infarction (HR 1.10 [1.08-1.12]), heart failure (HR 1.05 [1.03-1.06]), amputation (HR 1.05 [1.02-1.09]), other lower-extremity complications (HR 1.02 [1.01-1.03]), and revascularization (HR 1.05 [1.04-1.06]) but a smaller hazard of stroke (HR 0.95 [0.94-0.97]). Compared with small towns, residents of remote areas had lower hazards of hyperglycemia (HR 0.85 [0.78-0.93]), hypoglycemia (HR 0.92 [0.87-0.97]), and heart failure (HR 0.94 [0.91-0.97]). Hazards of retinopathy and atrial fibrillation/flutter did not vary geographically. Adults in small towns are disproportionately impacted by complications of diabetes. Future studies should probe for the reasons underlying these disparities.

Short term exposure to low level ambient fine particulate matter and natural cause, cardiovascular, and respiratory morbidity among US adults with health insurance: case time series study

ObjectiveTo estimate the excess relative and absolute risks of hospital admissions and emergency department visits for natural causes, cardiovascular disease, and respiratory disease associated with daily exposure to fine particulate...

Abstract TP80: Differences in Access to Post Acute Care Services Between Traditional Medicare and Medicare Advantage Beneficiaries in Michigan

Introduction: In recent years, Medicare Advantage (MA) enrollment in the US has increased dramatically relative to traditional Medicare (TM). There is evidence to suggest that MA stroke patients are less likely to receive inpatient rehabilitation facility (IRF) based care in favor of home health. To evaluate potential gaps in quality of care, we compared post-acute care use patterns following hospitalization for acute stroke between TM and MA populations. Methods: We probabilistically linked data from Michigan’s Get With The Guidelines-Stroke registry and Michigan Value Collaborative multipayer claims data registry for 16,231 TM and MA beneficiaries discharged alive following acute stroke (ICD-10 I61-I63) between 2016-2020. We used discharge claims to identify the initial discharge destination classified as home, home health, IRF, skilled nursing facility (SNF) or other. Unadjusted differences in proportions and time trends between TM and MA populations were assessed using chi square statistical tests. Results: TM and MA-insured patients constituted 75.1% and 24.9% of the 16,231 stroke discharges, respectively. Compared with TM, MA beneficiaries were older (77.4 vs 75.8, P &lt;0.001), less likely to be female (50.3% vs 55.3%, P &lt;0.001), and more likely to be white (87.0% vs 82.4%, P &lt;0.001). Over the study period, the proportion of MA patients increased from 21.2% in 2016 to 32.4% in 2020 ( P &lt;0.001) (Table). Overall, significant differences in discharge destination were due to more MA patients discharged to home and home health ( P &lt;0.001). Despite significant differences between MA and TM populations, there were no consistent time trends in discharge patterns. However, the exception was in 2020 where increased utilization of home health was accompanied by decreases in IRF and SNF discharge. Conclusions: We did not find clinically meaningful differences in discharge patterns between TM and MA populations. Changes in 2020 were likely attributed to COVID-19.

Social Risk Factors and Racial and Ethnic Disparities in Health Care Resource Utilization Among Medicare Advantage Beneficiaries With Psychiatric Disorders.

The intersection of social risk and race and ethnicity on mental health care utilization is understudied. This study examined disparities in health care treatment, adjusting for clinical need, among 25,780 Medicare Advantage beneficiaries with a diagnosis of a psychiatric disorder. We assessed contributions to disparities from racial and ethnic differences in the composition and returns of social risk variables. Black and Hispanic beneficiaries had lower rates of mental health outpatient visits than Whites. Assessing composition, Black and Hispanic beneficiaries experienced greater financial, food, and housing insecurity than White beneficiaries, factors associated with greater mental health treatment. Assessing returns, food insecurity was associated with an exacerbation of Hispanic-White disparities. Health care systems need to address the financial, food and housing insecurity of racial and ethnic minority groups with psychiatric disorder. Accounting for racial and ethnic differences in social risk adjustment-based payment reforms has significant implications for provider reimbursement and outcomes.

Impact of a Pharmacy Care Management Service on Medically Complex Medicare Advantage Members

Summary Medicare Advantage (MA) programs have grown rapidly, and a shift toward more medically complex beneficiaries has implications for health care utilization, costs, and quality in the MA program. Ensuring safe and effective medication use in this population has been identified as a priority, yet there is limited evidence to guide MA plans’ pharmacy care management (PCM) efforts. The goal of this study was to investigate the impact of an integrated PCM program for MA beneficiaries taking multiple chronic medications, including a subset with high predicted cost savings from improved medication adherence, assessed using the Value of Future Adherence (VFA) score. Using adjudicated administrative claims data from a regional Medicare Advantage and Part D (MAPD) plan, a retrospective matched cohort study was designed. A total of 724 members receiving PCM services were matched to 3,620 control members who received usual pharmacy care. From these two cohorts, 196 of 724 PCM participant members and 980 of 3,620 control group members were defined as having a high VFA score. PCM program enrollees underwent monthly medication reviews, reconciliation, and synchronization of refills, which were dispensed and delivered to the home in adherence packaging by a specially equipped pharmacy. Members were contacted monthly and received, as needed, education, referral to health care providers, consultation with prescribers on changes to medication regimens, and referral to social support or case management programs. Primary outcomes of interest were per enrollee per month (PEPM) costs, resource utilization, and medication adherence for three MAPD Star Ratings measures — Medication Adherence for Diabetes Medications, Medication Adherence for Hypertension (renin-angiotensin system antagonists [RASAs]), and Medication Adherence for Cholesterol (statins) — over 12 months for all members and for the subgroup with a high VFA score. The authors found that among all PCM program enrollees, there was a $50 (95% confidence interval [CI], $15 to $86; P = 0.005) PEPM increase in average pharmacy spending compared with control members and an offsetting $158 (95% CI, −$265 to −$51; P = 0.004) PEPM decrease in medical spending, resulting in PCM participants having $108 (95% CI, −$221 to $5; P = 0.062) lower PEPM total cost of care. Compared with the control group, PCM enrollees had 15% (P = 0.008) fewer inpatient stays and improvements in medication adherence of 7.3% among members taking oral antidiabetic agents, 9.4% among members taking statins, and 12.9% among members taking RASA antihypertensive agents (P < .001 for all three measures). These effects were driven by the patients in the subgroup with a high VFA score, for whom PEPM total cost of care was $406 (95% CI, −$645 to −$161; P < 0.001) lower than control members. These findings support the potential value of an integrated PCM program for MAPD beneficiaries on multiple medications, particularly when targeted to those members predicted to benefit most.

Enrollment Patterns of Medicare Advantage Beneficiaries by Dental, Vision, and Hearing Benefits

Most Medicare beneficiaries now choose to enroll in Medicare Advantage (MA) plans. Racial and ethnic minority group and low-income beneficiaries are increasingly enrolling in MA plans. To examine whether dental, vision, and hearing supplemental benefits offered in MA plans are associated with the plan choices of traditionally underserved Medicare beneficiaries. This exploratory observational cross-sectional study used data from the 2018 to 2020 Medicare Current Beneficiary Survey linked to MA plan benefits. The nationally representative sample comprised primarily community-dwelling MA beneficiaries enrolled in general enrollment MA plans. Data analysis was performed between April and October 2023. Beneficiary self-identified race and ethnicity and combined individual and spouse income and educational attainment. Binary indicators were developed to determine whether beneficiaries were enrolled in a plan offering any dental, comprehensive dental, any vision, eyewear, any hearing, or hearing aid benefit. Mixed-effects logistic regression models were estimated to report average marginal effects adjusted for beneficiary-level demographic and health characteristics, plan attributes, and plan availability. This study included 8139 (weighted N = 31 million) eligible MA beneficiaries, with a mean (SD) age of 77.7 (7.5) years. More than half of beneficiaries (54.9%) were women; 9.8% self-identified as Black, 2.0% as Hispanic, 83.9% as White, and 4.2% as other or multiple races or ethnicities. Plan choices by dental benefits were examined among 7516 beneficiaries who were not enrolled in any dental standalone plan, by vision benefits for 8026 beneficiaries not enrolled in any vision standalone plan, and by hearing benefits for 8131 beneficiaries not enrolled in any hearing standalone plan. Black beneficiaries were more likely to enroll in plans with any dental benefit (9.0 percentage points [95% CI, 3.4-14.4]; P < .001), any comprehensive dental benefit (11.2 percentage points [95% CI, 5.7-16.7]; P < .001), any eye benefit (3.0 percentage points [95% CI, 1.0 to 5.0]; P = .004), or any eyewear benefit (6.0 percentage points [95% CI, 0.6-11.5]; P = .03) compared with White beneficiaries. Lower-income individuals (earning ≤200% of the federal poverty level) were more likely to enroll in a plan with a comprehensive dental benefit (4.4 percentage-point difference [95% CI, 0.1-7.9]; P = .01) compared with higher-income beneficiaries. Beneficiaries without a college degree were more likely to enroll in a plan with a comprehensive dental benefit (4.7 percentage-point difference [95% CI, 1.4-8.0]; P = .005) compared with those with higher educational attainment. The results of this study suggest that racial and ethnic minority individuals and those with lower income or educational attainment are more likely to choose MA plans with dental or vision benefits. As the federal government prepares to adjust MA plan star ratings for health equity, implements MA payment cuts, and allows increasing flexibility in supplemental benefit offerings, these findings may inform benefit monitoring for MA.

Association Between the Medicare Advantage Quartile Adjustment System and Plan Behavior and Enrollment

Medicare Advantage (MA) has grown in popularity, but critics believe that insurers are overpaid, partially due to the quartile adjustment system that determines plan benchmarks. However, elimination of the quartile adjustments may be associated with less generous benefits and fewer plan offerings, which could slow MA enrollment growth. To examine whether the quartile adjustment system is associated with differences in county-level benefits, insurer offerings, and MA enrollment. The quartile adjustments create discontinuous jumps in county-level base payments based on historical traditional Medicare spending. Data from January 2017 to December 2021 and a regression discontinuity design were used to examine changes in insurer behavior and MA enrollment between quartiles. The analytic sample included 1557 county observations. Study outcomes included monthly premiums, the share of plans charging premiums, primary care copayments, the share of plans using rebates to reduce Part B premiums, supplemental benefits, plan and contract availability, and MA enrollment. Discontinuities were found in the quartile adjustments and benchmarks. A 1-percentage point (pp) increase in the quartile adjustment was associated with a $6.36 increase in monthly benchmarks (95% CI, 5.10-7.62), a $0.51 decrease in monthly premiums (95% CI, -0.96 to -0.07), and a 0.68 pp decrease in the share of plans charging premiums (95% CI, -1.25 to -0.10). Significant changes were not found in primary care copayments (-$0.04; 95% CI, -0.17 to 0.09), the share of plans using rebates to reduce Part B premiums (-0.17 pp; 95% CI, -0.34 to 0.01), supplemental benefits (eg, preventive dental coverage; 0.17 pp; 95% CI, -0.25 to 0.0), the number of plans (1.06; 95% CI, -3.44 to 5.57) or contracts (0.31; 95% CI, -0.18 to 0.81), or the MA enrollment rate (0.16 pp; 95% CI, -0.61 to 0.94). The study results suggest that MA plans are not very sensitive to modest changes in payment rates. Modifications to the quartile adjustment system may generate savings without substantially affecting MA beneficiaries.

BIAS AND GENERALIZABILITY IN MEDICARE-BASED ANALYSES ACROSS THREE POLICY PERIODS

Abstract Administrative Big Health data such as that drawn from the Medicare program is an invaluable resource for the study of population health. Although the Medicare program provides near universal health coverage for older U.S. adults age 65+, for most types of care data is collected only for individuals enrolled in traditional Medicare (TM) plans, with those enrolled in private Medicare Advantage (MA) plans being effectively censored in terms of the extent of available data. This presents two potential problems for health outcomes research: bias and generalizability. In this study we use Health and Retirement Study data (1998-2015) to assess the presence and magnitude of group-specific differences between MA and TM beneficiaries as well as plan switchers across three policy-specific periods (Balanced Budget Act; Medicare Modernization Act; Affordable Care Act). We found that the MA population was characterized by higher diversity, adverse behavioral habits, lower education, and economic disadvantage. Initially, lower morbidity levels converged with the TM average over time. Individuals, switching into MA after TM had much larger morbidity levels and mortality risk than any other Medicare group. We found significant loss of generalizability with respect to the Hispanic population; such estimates could be further biased to the extent that MA Hispanics differ from TM Hispanics. Of great concern is the combination of low education and low economic status in MA beneficiaries – a combination also found in many disadvantaged minorities. Care is needed in the design of TM-based studies, especially those focused on ethnic differences.

Estimates of diagnosed dementia prevalence and incidence among diverse beneficiaries in Traditional Medicare and Medicare Advantage

AbstractBackgroundApproximately half of Medicare beneficiaries are enrolled in Medicare Advantage (MA) ‐ a private plan alternative to Traditional Medicare (TM). Yet little is known about diagnosed dementia rates among Medicare Advantage enrollees, limiting population estimates.Methods100% claims of Medicare beneficiaries using Encounter data for MA and claims for TM were used to quantify diagnosed dementia prevalence and incidence rates in MA, compare rates to TM, and provide estimates for the entire Medicare population and for different racial/ethnic populations.ResultDementia incidence and prevalence among MA beneficiaries was 2.54% (95%CI 2.53‐2.55) and 7.04% (95%CI 7.03‐7.06). Comparison to TM adjusted for sociodemographic and health differences among beneficiaries in MA and TM; the prevalence of diagnosed dementia among beneficiaries in MA was lower (7.1%; 95%CI 7.12‐7.13) than in TM (8.7%; 95%CI 8.71‐8.72). Diagnosed dementia incidence rate was also lower in MA (2.50%; 95%CI 2.50‐2.50) compared to TM (2.99%; 95%CI 2.99‐2.99). There were lower rates in MA compared to TM for men and women and White, Black, Hispanic, Asian, American Indian/Alaska Native persons. Diagnosed dementia prevalence and incidence for the entire Medicare population was 7.9% (95%CI: 7.91‐7.93) and 2.8% (95%CI: 2.77‐2.78).ConclusionLower diagnosed dementia rates in MA compared to TM may exacerbate racial/ethnic disparities in diagnosed dementia. Rates tracked over time will provide understanding of impact on dementia diagnosis of 2020 MA risk adjustment for dementia.

Trajectories of adherence to ACEI/ARB medications following a motivational interviewing intervention among Medicare Advantage beneficiaries in Texas

ObjectivesTo assess the impact of student telephone motivational interviewing intervention on angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACEI/ARBs) adherence trajectories and identify predictors of each trajectory. MethodsThe intervention group included continuously enrolled Medicare Advantage Plan patients non-adherent to ACEI/ARBs vs the control group (1:2 ratio). The intervention was tailored by pre-intervention trajectories and included an initial and five follow-up calls. Adherence was measured 6 months after initial calls using the proportion of days covered (PDC). Monthly PDCs were integrated into a group-based trajectory model and categorized patients into 4-groups. A multinomial logistic regression model was used to evaluate trajectory predictors. ResultsThe study comprised 240 intervention patients and 480 controls with four trajectories: adherent trajectory 44.2%, gradual improvement in adherence 13.4%, slow decline in adherence 24.1%, and discontinuation 18.3%. Patients with the intervention were less likely to experience a slow decline in adherence than controls (OR: 0.627 [0.401–0.981]). Patients with specialty prescribers’ visits, ≥ 1 previous hospitalization, rapid decline in adherence as pre-intervention trajectory, and higher CMS risk score were associated with discontinuation trajectory. ConclusionIntervention patients vs controls had a lower likelihood of following a slow decline in adherence pattern. Practice implicationsThis study underscores the importance of individualized interventions and the association between past adherence patterns and post-intervention trajectories.

Measuring restrictiveness of Medicare Advantage networks: A claims-based approach.

To develop and validate a measure of provider network restrictiveness in the Medicare Advantage (MA) population. Prescription drug event data and beneficiary information for Part D enrollees from the Center for Medicare and Medicaid Services, along with prescriber identifiers; geographic variables from the Area Health Resources Files. A prediction model was used to predict the unique number of primary care providers that would have been seen by MA beneficiaries absent network restrictions. The model was trained and validated on Traditional Medicare (TM) beneficiaries. A pseudo-Poisson and a random forest model were evaluated. An observed-to-expected (O/E) ratio was calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based the TM prediction model. Multivariable linear models were used to assess the relationship between network restrictiveness and plan and market factors. Prescription drug event data were obtained for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017. Health Maintenance Organization plans were more restrictive (O/E = 55.5%; 95% CI 55.3%-55.7%) than Health Maintenance Organization-Point of Service plans (67.2%; 95% CI 66.7%-67.8%) or Preferred Provider Organization plans (74.7%; 95% CI 74.3%-75.1%), and rural areas had more restrictive networks (31.6%; 95% CI 29.0%-34.2%) than metropolitan areas (61.5%; 95% CI 61.3%-61.7%). Multivariable results confirmed these findings, and also indicated that increased provider supply was associated with less restrictive networks. We developed a means of estimating provider network restrictiveness in MA from claims data. Our results validate the approach, providing confidence for wider application (e.g., for other markets and specialties) and use for regulation.

Role of Patient Sorting in Avoidable Hospital Stays in Medicare Advantage vs Traditional Medicare

Unlike traditional Medicare (TM), Medicare Advantage (MA) plans limit in-network care to a specific network of Medicare clinicians. MA plans thus play a role in sorting patients to a subset of clinicians. It is unknown whether the performance of physicians who treat MA and TM beneficiaries is different. To examine whether avoidable hospital stay differences between MA and TM can be explained by the primary care clinicians who treat MA and TM beneficiaries. This was a cross-sectional study of a nationally representative sample of MA and TM beneficiaries in 2019 with any of 5 chronic ambulatory care-sensitive conditions (ACSCs). The relative risk (RR) of avoidable hospital stays in MA compared with TM was estimated with inverse probability of treatment-weighted Poisson regression, both without and with clinician fixed effects. The degree to which the estimated MA vs TM difference could be explained by patient sorting was calculated by comparing the 2 RR estimates. Data were analyzed between February 2022 and April 2023. Enrollment in MA. Whether a beneficiary had avoidable hospital stays in 2019 due to any of the ACSCs. Avoidable hospital stays included both hospitalizations and observation stays. The study sample comprised 1 323 481 MA beneficiaries (mean [SD] age, 75.4 [7.0] years; 56.9% women; 69.3% White) and 1 965 863 TM beneficiaries (mean [SD] age, 75.9 [7.4] years; 57.1% women; 82.5% White). When controlling for the primary care clinician, the RR of avoidable hospital stays in MA vs TM changed by 2.6 percentage points (95% CI, 1.72-3.50; P < .001), suggesting that compared with TM beneficiaries, MA beneficiaries saw clinicians with lower rates of avoidable hospital stays. This effect size was statistically significant to explain the 2% lower rate of avoidable hospital stays in MA than in TM. In this cross-sectional study of MA and TM beneficiaries, the lower rate of avoidable hospital stays among MA beneficiaries than TM beneficiaries was attributable to MA beneficiaries visiting clinicians with lower rates of avoidable hospital stays. The patient sorting that occurs in MA plays a critical role in the lower rates of avoidable hospital stays compared with TM.