A study shows that Medicare Advantage beneficiaries with complex care needs have lower acute healthcare utilization than those in original Medicare, including lower rates of hospital stays, emergency department visits and 30-day readmissions.
Hospital stay rates saw the largest differences, ranging from 9.3% lower for the study’s frail elderly cohort and 11.9% lower for the major complex chronic cohort, compared with traditional Medicare.1 For beneficiaries who experienced a hospital stay, 30-day readmissions were significantly less frequent for MA beneficiaries in the minor complex chronic and major complex chronic cohorts.
Adjusted differences in ED 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.
MA managed care activities “may influence the nature and quality of care provided,” according to the authors.1 “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.”
They noted that MA plans have additional features to address beneficiary needs, including:
- Care management
- Supplemental benefits
- Value-based contracting
Other factors may be at play as well. For hospital stays and ED visits, the most significant difference was observed for MA beneficiaries in primary care organizations that are reimbursed under two-sided risk arrangements, compared with those being treated under “less advanced” value-based payment models.
Plan design also affected the link between MA enrollment and acute care utilization, with greater differences seen for MA beneficiaries enrolled in HMO plans compared with PPO plans. “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,” the authors said.
MA plans that provide high-quality care management, supplemental benefits and appropriate payment models will likely see less acute care utilization among their members, as they receive care that meets their needs sooner and keeps them as healthy as possible.
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- Antol, D., Schwartz, R., Caplan, A. Comparison of Health Care Utilization by Medicare Advantage and Traditional Medicare Beneficiaries With Complex Care Needs. JAMA Health Forum. Oct. 7, 2022. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2797081
- Bailey, V. Healthcare Utilization Lower for MA Beneficiaries with Complex Care Needs. HealthPayer Intelligence. Oct. 13, 2022. https://healthpayerintelligence.com/news/healthcare-utilization-lower-for-ma-beneficiaries-with-complex-care-needs