MA Beneficiaries Have Fewer Inpatient Stays, Emergency Department Visits Than FFS Beneficiaries

Despite having more clinical and social risk factors, Medicare Advantage (MA) beneficiaries have lower rates of high-cost services compared with fee-for-service (FFS) Medicare beneficiaries, according to a report by Avalere Health.

Looking at data from 1.5 million MA and 1.2 million FFS Medicare beneficiaries with hypertension, hyperlipidemia, and/or diabetes, researchers found that those enrolled in Medicare Advantage plans were less likely to have inpatient stays and emergency department visits.

“This study provides new evidence regarding the value of Medicare Advantage relative to FFS Medicare and demonstrates that Medicare Advantage plans’ focus on preventive services results in lower utilization of high-cost healthcare services, lower overall costs for high-need beneficiaries, and consistently better quality outcomes for similar groups of Medicare patients,” write the researchers in the report.

Although the groups were similar in demographic characteristics, age group distribution, chronic disease prevalence, and clinical complexity, MA beneficiaries had a higher prevalence of clinical and social risk factors. The MA group of patients had a 57.4% higher rate of serious mental illness and a 16.4% higher rate of alcohol/drug/substance abuse. They also had a higher proportion of social risk factors, with 15% more dual-eligible/low-income beneficiaries than FFS beneficiaries.

Even with these increased rates of clinical and social risk factors, MA beneficiaries had less utilization of costly healthcare services than FFS beneficiaries, including 23.1% fewer inpatient stays (249 vs 324 per 1000 beneficiaries, respectively) and 32.7% fewer emergency care services (511 vs 759 per 1000 beneficiaries). The population had slightly longer lengths of stay, on average (11 vs 10 days), and both groups had comparable rates of physician office visits.

Total spending per beneficiary was similar between the groups; however, the patterns of spending varied. Whereas FFS beneficiaries spent more on inpatient stays and outpatient/emergency care services, MA beneficiaries spent 21.4% more on preventive physician services and tests. These beneficiaries were 5.1% more likely to have completed low-density lipoprotein cholesterol testing and had a 13.4% higher rate of preventive breast cancer screenings. The authors noted that the focus on preventive services may be a driving factor in the lower rates of complications, hospitalizations, and emergency care services.

They added, “Given the social and clinical risk profile of the Medicare Advantage population studied, the finding that costs are the same or less indicates that the patterns of care observed in Medicare Advantage may result in more efficiencies relative to FFS.”

In the most clinically complex cohort of patients with diabetes—in which 75% of beneficiaries had all 3 chronic conditions—improved health outcomes and cost savings were more heavily associated with those enrolled in MA plans. Researchers observed a 52% lower rate of any complication and a 73% lower rate of serious complications. Concurrently, MA plans achieved a 6% lower average per beneficiary cost.