Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program

Abstract

IMPORTANCEThe 2 primary efforts of Medicare to advance value-based care are Medicare Advantage (MA) and the fee-for-service-based Medicare Shared Savings Program (MSSP). It is unknown how spending differs between the 2 programs after accounting for differences in patient clinical risk. OBJECTIVE To examine how spending and utilization differ between MA and MSSP beneficiaries after accounting for differences in clinical risk using data from administrative claims and electronic health records. DESIGN, SETTING, AND PARTICIPANTS This retrospective economic evaluation used data from 15 763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022. EXPOSURES Enrollment in MA or attribution to an accountable care organization in the MSSP program. MAIN OUTCOMES AND MEASURES Per-beneficiary annual total spending and subcomponents, including inpatient hospital, outpatient hospital, skilled nursing facility, emergency department, primary care, and specialist spending. RESULTS The sample of 15 763 participants included 12 720 (81%) MA and 3043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). The mean unadjusted per-member per-year spending difference between MSSP and

Accountable Care Organization Leader Perspectives on the Medicare Shared Savings Program

“…Some leaders reported that these and other trends have introduced difficulties in maintaining participation and engagement in MSSP. The implications of this shift are unclear: a decade after the implementation of ACOs, evidence of their effectiveness remains mixed relative to both traditional fee-for-service payment and the Medicare Advantage program . More research is needed to evaluate outcomes for patients attributed to ACOs vs those in other value-based payment programs, and CMS may also want to devote greater attention to facilitating multipayer ACO models…”

A Retrospective Multi-site Examination of Chronic Kidney Disease Using Longitudinal Laboratory Results and Metadata to Identify Clinical and Financial Risk

“…Medicare utilizes capitation risk-adjusted payments within the Medicare Advantage program as a pivotal strategy for determining accurate financial arrangements, promoting payment accuracy, and assessing cost control (20). A comparative analysis of spending patterns between Medicare Advantage and the Medicare Shared Savings Program revealed that spending within the latter was 30% higher than in Medicare Advantage (37). This finding assumes added importance when considering projections that the Medicare Advantage program, which has grown from 19% in 2007 to 51% in 2023, is anticipated to encompass over 60% of Medicare beneficiaries by 2030 (38).…”

Is there an advantage? Considerations for researchers studying the effects of the type of Medicare coverage

“…While the TM program is still largely paid Fee‐for‐Service and is administered by CMS, the proliferation of alternative payment models (APMs) such as accountable care organizations (ACOs) ACOs and bundled payment programs make it so that the TM program is also not one single exposure. When comparing outcomes between MA and TM, a researcher may find different results when comparing TM beneficiaries attributed to one of these programs, compared to TM beneficiaries not attributed to an APM 19 . For example, several prior studies have found differences in outcomes when comparing MA to TM without ACO attribution to TM with ACO attribution 20 .…”

“…When comparing outcomes between MA and TM, a researcher may find different results when comparing TM beneficiaries attributed to one of these programs, compared to TM beneficiaries not attributed to an APM. 19 For example, several prior studies have found differences in outcomes when comparing MA to TM without ACO attribution to TM with ACO attribution. 20 Beyond attribution to APMs in TM, TM beneficiaries do actually have some differences in coverage choices that may also be subject to selection bias.…”