Chronic Condition Prevalence Similar in Medicare Advantage, Traditional Medicare Beneficiaries

In part 2 of this interview, Andrew S. Oseran, MD, MBA, MSc, advanced heart failure and transplant cardiologist at Beth Israel Deaconess Medical Center, explores the similarities in chronic condition prevalence between Medicare Advantage (MA) and traditional Medicare beneficiaries. He also reveals the key limitations of his study, "Prevalence of Chronic Medical Conditions Among Medicare Advantage and Traditional Medicare Beneficiaries."

Watch part 1 to learn more about the criticism surrounding MA and Oseran's inspiration behind the study.

This transcript has been lightly edited for clarity; captions were auto-generated.

Transcript

Your study found similar prevalence rates for 4 out of 5 chronic conditions in Medicare Advantage (MA) and fee-for-service Medicare beneficiaries. What implications do these findings have for the ongoing MA payment structure debate?

That's exactly right. We found that MA beneficiaries really did not have a higher prevalence of obesity, hyperlipidemia, hypertension, or chronic kidney disease when we compared them with traditional Medicare beneficiaries. In fact, after standardizing for age and sex, the prevalence of these conditions differed by less than 1 percentage point in the case of obesity and hypertension and less than 3 percentage points in the cases of hyperlipidemia and chronic kidney disease.

While we were only able to evaluate a handful of conditions that had physical exam and lab data from NHANES [the National Health and Nutrition Examination Survey], on the whole, our findings substantiate these concerns that the excess payments that MA plans are receiving for higher risk scores may be driven more by differences in coding practices rather than actual differences in disease burden between these 2 populations.

The only significant difference found was a higher prevalence of diabetes in MA beneficiaries. What factors might explain this disparity?

I think the main driver of this observation is probably that racial and ethnic minority groups, like Black, Hispanic, and Asian populations, all are known to have a higher prevalence of diabetes, and these populations are also disproportionately enrolling in MA plans. In our study, about 30% of the MA beneficiaries between 2015 and 2018 were non-White, compared with just 20% in traditional Medicare.

It's also possible that this difference in diabetes prevalence could be explained by some specific features of MA plans. Some MA plans offer supplemental benefits, things like chronic disease management coaching, nutrition counseling, meal benefits; they often market to specific populations. It's possible that some of these features, and some of these business strategies, are attracting more patients with diabetes to enroll.

What were the key limitations of your study? How might they have impacted your findings?

There are definitely several important limitations that we discuss in our paper more fully, and I'll highlight a couple of them now. First, we weren't able to characterize differences in the severity of medical conditions between groups.

Even though we found that, for example, the prevalence of hypertension was similar between MA and fee-for-service populations, it's possible that individuals with more refractory hypertension, or more difficult-to-treat hypertension, disproportionately enrolled in traditional Medicare, or vice versa. Even though we found the prevalence was similar between the 2, it's theoretically possible that a more complex patient population is still enrolled in one plan vs the other.

Second, we obviously only estimated the prevalence of 5 conditions that actually had physical exam and lab data in NHANES, and we're sort of using those 5 conditions to extrapolate about overall patient complexity. It's possible that there are differences in medical complexity between MA and fee-for-service if we were to assess these populations based on the prevalence of other conditions, a broader array of conditions, or different conditions.