Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare

Abstract

ImportanceMedicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care−sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges.ObjectiveTo determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare.Design, Setting, and ParticipantsCross-sectional study of US Medicare Advantage vs traditional Medicare beneficiaries from January 1 to December 31, 2018. Poisson regression models were used to compare risk-adjusted rates of Medicare Advantage vs traditional Medicare, controlling for patient demographic characteristics and clinical risk and including county fixed-effects. Data were analyzed between April 2021 and November 2022.Main Outcomes and MeasuresHospitalizations, observation stays, and ED direct discharges for ACSCs.ResultsThe study sample comprised 2 665 340 Medicare Advantage patients (mean [SD] age, 72.7 [9.8] years; 1 504 519 [56.4%] women; 1 859 067 [69.7%] White individuals) and 7 981 547 traditional Medicare patients (mean [SD] age, 71.2 [11.8] years; 4 232 201 [53.0%] women; 6 176 239 [77.4%] White individuals). Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94; 95% CI, 0.93-0.95), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44; 95% CI, 1.43-1.45) and observation stays (RR, 2.38; 95% CI, 2.34-2.41) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30; 95% CI, 1.30-1.31). Within the Medicare Advantage population, patients in health maintenance organizations (HMOs) were at lower risk of ACSC-related hospitalization compared with patients in its preferred provider organizations (RR, 0.96; 95% CI, 0.95-0.98); however, those in the HMOs had a higher risk of ED direct discharge (RR, 1.08; 95% CI, 1.07-1.09) and observation stay (overall RR, 1.10; 95% CI, 1.02-1.12).Conclusions and RelevanceThe findings of this cross-sectional study of Medicare Advantage and traditional Medicare patients with ACSCs indicate that apparent gains in lowering rates of potentially avoidable acute care have been associated with shifting inpatient care to settings such as ED direct discharges and observation stays.

Inequities in Definitive Treatment for Localized Prostate Cancer Among Those With Clinically Significant Mental Health Disorders

“…The exclusion of Medicare 15, which was necessary to avoid issues related to care outside of traditional Medicare, may confound our results as these patients are more likely to be older and from minoritized population. 24 Another limitation of this analysis is the use of census-tract estimates of social and economic factors such as poverty, which may not capture individual risk in our cohort and sometimes oversimplify complex relationships between social, political, and geographic factors. Lastly, this sample is restricted to those over the age of 65 who were insured, and the associations we describe may not be generalizable.…”

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

“…We defined avoidable hospital stays to include both hospitalizations and observation stays. This broader definition was used to allow for more balanced MA vs TM comparisons because the rules and incentives governing hospitalizations differ between MA and TM, 7 and patients in outpatient observation status often receive similar services on the same hospital ward as those in inpatient status. In additional analyses, we separately evaluated the rates of these 2 types of stays in MA and TM.…”

“…Hospitalizations due to ambulatory care–sensitive conditions (ACSCs), such as diabetes and hypertension, are potentially avoidable with appropriate primary care and are often used as a measure of primary care quality 4 and the overall performance of MA relative to TM. 5 , 6 , 7 We test whether avoidable hospitalization differences between MA and TM can be explained by the primary care clinicians seen by MA and TM beneficiaries to examine the role of patient sorting.…”

Margin notes from the COVID-19 pandemic for the future of healthcare innovation

“…Whether and to what extent “value-based care” (Medicare advantage and accountable care organizations among others in the US; complexity-modified capitated and bundled funding in Canada) will constitute disruption or diversification remains unclear. 52,53 As a funding model designed to incentivize outcomes, while value-based care may risk significant payor upcode gaming 54 and opportunities for significant profit-margin expansion within corporate owned primary care practices, 55 it better enables distributed integrated health and social care than fee-for-service payment. 56 The competitive advantage of distributed integrated health and social care models depend on the implementation of tight controls of code gaming, improved complexity modification, and accounting for the time horizon of impact for different types of interventions.…”