Medicare Advantage members who experienced acute ambulatory care-sensitive conditions were less likely to be hospitalized than traditional Medicare beneficiaries, according to a study in JAMA Health Forum.1
The findings, based on data from more than 10 million beneficiaries between January and December 2018, also showed MA members with both acute and chronic ACSCs were more likely to be discharged directly from the emergency department and to stay in the ED for observation, compared with those in traditional Medicare.1
Ambulatory care-sensitive conditions are those that are potentially preventable with access to outpatient care. The “apparent differences in potentially avoidable hospitalizations among Medicare Advantage plans may be explained by shifting inpatient care to other settings,” the authors write.2 They add that this may be because MA plans are more likely to prioritize finding the most cost-effective care for members.
In 2021, hospital adjusted expenses per inpatient day were about $2,883 on average in the US.3 In addition to unnecessary costs for both plans and members, preventable hospital stays can also bring additional health risks for members, such as hospital-acquired infections.
The authors suggest that if shifting care to more cost-effective settings does not hurt quality or outcomes, it could be an important cost-savings strategy. They call for further research into the effect, if any, on long-term patient outcomes.
They also suggest using caution in “relying on hospitalizations for ACSCs to serve as an indicator of higher-quality care in ambulatory settings.” It is currently a quality measure for assessing performance in value-based care models, but the study results underscore the importance of monitoring observation stays and direct discharge from emergency departments for the same conditions, the authors wrote.
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References
- Wilson, R. Medicare Advantage members less likely to be hospitalized, more likely to be shifted to other care: Study. Becker’s Payer Issues. Feb. 27, 2023. https://www.beckerspayer.com/payer/medicare-advantage-members-less-likely-to-be-hospitalized-more-likely-to-be-shifted-to-other-care-study.html
- Beckman, A., Frakt, A., Duggan, C. Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare. JAMA Health Forum. Feb. 24, 2023. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2801779
- Hospital adjusted expenses per inpatient day. KFF. https://www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day/
