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From Health Law Daily, November 7, 2014

How do access and quality of care differ between traditional Medicare and Part C? We don’t really know

By Michelle L. Oxman, JD, LLM

The authors of a study that reviewed the literature on access to care and quality of care in Medicare found that there is some evidence that members of Medicare Advantage (MA) organizations use more preventive care and may have fewer hospital admissions and less intensive procedures than enrollees in traditional Medicare. The study did not lead to any definite conclusions about quality or access that could be generalized on a national scale. Enrollment in MA plans has grown significantly since 2006. The types of plans available also have changed, so that studies of health maintenance organizations (HMOs) from the early 2000s involved a different model than the MA organizations available today, but most of the available literature covers earlier time periods.

Types of data available. The authors, Marcia Gold of Mathematica Research and Giselle Casillas of the Kaiser Family Foundation, discussed more than 40 studies published between 2000 and early 2014 that had formal comparison groups, described the data and methodology used, and measured some aspect of access or quality in Medicare. They grouped the studies according to the measures used, including reported utilization or claims data, beneficiary surveys, quality metrics concerning hospitalizations, and other measures that are related to appropriate utilization or access, as well as mortality and healthcare outcomes.

MA plans must report Healthcare Effectiveness Data and Information Set (HEDIS) data to CMS. This data measures services furnished along five dimensions of care and is used to determine quality by the National Committee on Quality Assurance (NCQA). Utilization data for traditional Medicare comes from the claims data. Several studies compared HEDIS measures to claims data to consider utilization of resources. Some older studies, in particular, showed that MA members receive better care. Then again, the HEDIS measures emphasize use of preventive services, an area where MA plans and HMOs are particularly strong. The difference is also more marked in areas with mature HMO markets, and some of these studies cover the period when HMOs were primarily nonprofit organizations.

Consumer opinion. Other studies examined beneficiaries’ experience and opinion of the care they received, primarily using the Consumer Assessment of Healthcare Providers and Systems (CAHPS). In general, beneficiaries rated traditional Medicare more highly than MA plans. The differences have narrowed as to some measures of satisfaction, but not overall. Beneficiaries with chronic illnesses or who are very sick are more dissatisfied with their care, but beneficiaries with similar health status still tended to rate traditional Medicare more positively with respect to access and quality than the MA members did.

There is some evidence that members of MA plans have fewer avoidable hospital admissions and fewer readmissions than traditional Medicare beneficiaries. However, one of these studies was funded by an association of health plans, and there is little information on which plans submitted data or what adjustments were made. Another study found that after controlling for health status, traditional Medicare beneficiaries were less likely to be readmitted.

There are wide differences among and within plans, however, as well as wide differences depending on location. In addition, there are few national studies. Therefore, it is not possible to generalize and reach any firm conclusions about quality or access throughout the country.

Utilization. Some studies addressed specific procedures or services that are often overused, while others measured overall use of doctor visits, inpatient and outpatient services. One study showed that traditional Medicare beneficiaries were more likely to undergo aggressive treatment for prostate or colorectal cancer than members of HMOs. There was no evidence that their outcomes were better or worse than patients who underwent less invasive treatments. There was some evidence that the MA plan members used less discretionary care. There was insufficient information to determine whether the care used was appropriate, however.

Cancer patients who were members of MA plans were likely to have had their cancer discovered at an earlier stage than traditional Medicare beneficiaries. This study also compared the uninsured and people with Medicaid, and found that the uninsured fared worst, followed by the Medicaid beneficiaries; these groups sought care later and were likely to have poorer outcomes.

Summary. The authors found that there is little information available about the extent to which one group or the other receives better or more appropriate care or has better outcomes, except that members of managed care plans in mature markets may fare better than traditional Medicare beneficiaries. The wide variation within and among plans and among geographic locations makes it difficult to draw firm conclusions.

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