5 Findings From the September 2019 Issue of AJMC®

The September issue of The American Journal of Managed Care^® featured research on federal healthcare reform that detailed innovative ideas in Medicare, Medicaid, and the Veterans Affairs (VA) health system. Here are 5 findings from research published in the issue.

1. Payment cuts to Medicare Advantage did not affect affordability or access

When the Affordable Care Act enacted payment cuts to Medicare Advantage (MA), it prompted concerns that the cuts would make the program less attractive to plans, which might then implement narrower networks or higher cost sharing. The results of this analysis help to allay those concerns, as not only did enrollment in MA grow between 2009 to 2017, but also access and affordability remained stable for beneficiaries.

MA enrollees reported similar levels of access to care as traditional Medicare enrollees, and changes in rates of cost-related care delays were not significantly different between the groups. The study authors wrote that MA plans reduced their costs while preserving room for rebates, possibly by increasing their quality scores or through the risk adjustment system. “Access and affordability have remained relatively stable despite overall payment reductions, making those payment changes largely invisible to beneficiaries,” they concluded.

2. Education program reduced rates of potentially inappropriate prescriptions for veterans

Participation in the VA Geriatric Scholars Program course on geriatric medicine was associated with reduced prescribing of potentially dangerous or inappropriate medications for older veterans in VA primary care, according to this study. The multiday course emphasizes the teaching of best practices on appropriate prescribing and alternatives to potentially inappropriate medications.

Researchers found that the prescribing rate for potentially inappropriate medications decreased from 6.68% before the course to 6.51% after. In particular, there were significant postintervention slope changes in prescribing of insulin and nonbenzodiazepine hypnotics. These results indicate that primary care providers participating in the program “are taking the knowledge gained…and modifying how they prescribe medication to older veterans,” the study authors wrote.

3. Switching to Medicaid managed care associated with less ambulatory utilization

A statewide longitudinal study found that after some New York Medicaid beneficiaries switched from fee-for-service (FFS) to managed care, those who switched had larger decreases in ambulatory visits and providers than those who were continuously enrolled in either FFS or managed care. These patterns were primarily driven by changes among beneficiaries with 5 or more chronic conditions, who experienced average absolute decreases of 8 visits and 2 providers per beneficiary per year.

According to the study authors, these findings support the assertion that managed care “can reduce ambulatory utilization for the sickest beneficiaries.” They suggested further research onto how the switch from FFS to managed care can affect decision-making processes among beneficiaries, care providers, and plan administrators.

4. MA Institutional Special Needs Plans linked to changing patterns of care utilization in nursing homes

Compared with Medicare FFS beneficiaries, nursing home residents in MA Institutional Special Needs Plans (I-SNPs) had different patterns of healthcare use across various settings, according to the results of an observational analysis. The I-SNP members had 51% lower emergency department use, 38% fewer hospital admissions, and 45% fewer readmissions, but their skilled nursing facility use was 112% higher.

The authors attributed the changes to the I-SNP model’s use of advanced on-site clinicians in nursing homes and plans’ financial accountability for nursing home and medical care costs, which could discourage costly transfers to the hospital. “Our findings suggest that the I-SNP model studied here is a potential payment and delivery innovation that can overcome these misaligned incentives to encourage increased clinical investment in the care of residents in the nursing home,” they asserted.

5. Multistate CMS demonstration had mixed impacts on quality of care

The Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration was intended to improve care by facilitating the transformation to a patient-centered medical home, but this pre—post study of claims and enrollment data found that there were few significant improvements in quality after the demonstration period across 8 participating states. For instance, MAPCP Medicare beneficiaries in New York and Minnesota were more likely to receive recommended diabetes care than the comparison group, but those in Minnesota and Michigan had lower likelihoods of lipid panel assessment.

Despite these mixed results, the MAPCP Demonstration has still produced useful insights, the authors noted. “Knowing what processes MAPCP practices opted to put in place to improve quality has informed CMS’ thinking on how to structure supports to help participants in these newer models,” they wrote, and lessons from the demonstration can help set expectations around quality measures in innovative demonstrations.