In this week’s JAMA Health Forums, Xu et al* assessed the role of provider networks in Medicare Advantage against non-network Traditional Medicare on the rate of plausibly preventable hospital admissions. Medicare Advantage insurers are allowed to build networks. These networks are a subset of clinicians in a region. Traditional Medicare does not place cost-sharing restrictions or incentives to steer patients to any particular Medicare participating clinician. The key question is whether or not this matters. They measure admission rates for five disease categories and find that it likely does matter (although more and better causal work is needed!) as going to the hospital is both expensive and quality of life lowering if it the admission was avoidable.
What do they find?
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.
The controlling for physician is important. They look at clinicians who are serving both TM and MA patients and find that the physician does not appear to treat those patients differently. Instead there seems to be selection occurring in who the MA plans contract with:
The first decile in the graph are the doctors who send the fewest patients to the hospital for avoidable conditions. These docs have a Medicare panel (we can’t see their Medicaid, ACA, uninsured or commerical patient counts in these data) that is heavy on MA patients and lighter on TM patients. The worst performing docs in the 10th decile treat comparatively more TM patients than MA patients by a substantial margin.
This is suggestive that MA is doing a decent job of contracting with docs who keep patients out of hospitals and/or steering patients to docs who keep patients out of the hospital when possible. We know from other contexts that there is usually a lot of value of chopping off the worst 5% to 10% of a distribution for outcome measures and it seems that MA does this. However, we need to think about what this would mean for access to care, equity and workforce development as MA is now over 50% of all Medicare covered lives.
* Disclosures: I am on an R01 grant application with Dan Polsky that is currently under review. I am playing e-mail ping pong this morning with Kelly Anderson (no relation) and others on a preliminary data/feasibility grant application. If our idea is feasible, we will turn the concept into a big grant and a lot of writing together over the second half of this decade.
mskitty
Oh good! An argument better than “I like mine” to use in the running knife fight over MA vs TM at dkos. Now if you could only quantify increase in health per MA dollar …
Tabbed to cite, and thank you.
David Anderson
@mskitty: That question is really tough to evaluate. I think the current evidence is that without spillovers MA gets paid about the same as TM, but there is solid and enduring evidence that MA (once market share gets above ~18% in a county) changes practice patterns that produce both savings and health improvements. The biggest challenge is that we strongly suspect Medicare Advantage is really good at picking the healthier/cheaper people within each disease state category https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2022.01525) so we’re comparing Red Delicious Apples to JonaGold Apples at best and apples to pineapples at worst.
Barbara
@David Anderson: That phenomenon might explain why MA plans are incurring increased medical expenses as MA share of overall Medicare beneficiaries approaches and in some markets exceeds 50%.
Barbara
@David Anderson: Just another thought, almost all MA marketing is now focused on “extra” benefits. Those who prioritize extra benefits (vision, dental, OTC products) are probably measurably different in health status from those who are trying to assess core service coverage. IMO, this is a weakness in the MA structure — that the plan selection process pushes plans to reduce spending for core services in order to have more money to throw at “extra” services. CMS has tried to reduce the impact of this phenomenon through the use of star ratings but that doesn’t really seem to be helping much.
gene108
@David Anderson:
My anecdotal experience with people I know in my mom’s generation is that less healthy people with high usage prefer TM. Seniors without serious chronic health issues gravitate to MA.
Adam Lang
So how do we find these first decile doctors ourselves?
rikyrah
OT:
Will you do a post about Amazon’s entry into the healthcare marketplace?
People are freaking out on TikTok.
And, all I can see is ..
Unless you’re telling me that Bezos bought Kaiser-Permanente and Humana
Amazon policies are no better than those phony ones the religious groups are peddling.
They have to deal with healthcare networks like anyone else.
Am I right or wrong about that?
dnfree
When I went on Medicare after retiring at 65, I attended an informational session with the one and only MA plan in my area at the time (2012). The presenter even said, “IF you have known health issues and IF you can afford supplemental insurance, you’re probably better off with traditional Medicare.” Not sure if he was just being honest or if he was steering sicker people away from his plan.
I did already have a known chronic condition and I’m risk-averse, so I took TM with a supplement plan (F then, now G). Since then I had a heart attack, and now I can’t even switch insurance companies for the supplement because no one else wants me. People may get locked in to whatever they initially chose because of health changes.
Ohio Mom
@dnfree: Long before I reached Medicare age, I mistakenly believed that pre-existing conditions held no sway for the over 65 crowd. Finally, our health histories would not be held against us.
Now, three years into my Medicare enrollment, I can only shake my head at my naïveté.
Odie Hugh Manatee
Good luck with your grant application, David. I don’t comment often but I read everything you write and am better educated for doing so.
Thank you for your work and sharing it here!
SW
Since MA is a model that generates profits by limiting care an area where they should be expected to do better than TM is in cases where additional care is actually detrimental.
Prescott Cactus
David,
Thank you and all your commenters on each and every post you write.
May the “Grant be with you” !