Are Medicare Advantage plans more or less effective at reducing hospital readmissions for patients with multiple chronic conditions?
Discussant: Keaton Miller
Medicare Advantage (MA) plans and providers have been increasingly focused on the needs of high-risk, high-need individuals through Special Needs Plans, disease management programs, and better care coordination for vulnerable, expensive populations. We aim to compare relative readmission risks for beneficiaries enrolled in MA and traditional Medicare (TM) and highlight how changes in those measures can serve as evidence of care coordination and changes in practice outcomes in a high-risk cohort of patients admitted with multiple chronic conditions (MCC). We compare MA patients with those in TM for all Medicare enrollees as well as their MCC subgroup, using multivariate models with selection adjustment including propensity score matching. While many studies find unadjusted readmissions rates are lower for MA than TM enrollees, the evidence is limited for MCC patients and less clear after accounting for the differing health risk of the two groups.
We use the Agency for Healthcare Research and Quality’s (AHRQ) 2014 HCUP-SID data for Medicare enrollees aged 65 years or older having traditional Medicare or Medicare Advantage insurance in 4 states: California, Florida, New York, and Tennessee. Hospital discharge data from HCUP is combined with HRSA data to obtain information on patient’s area of residence and with AHA data to obtain hospital characteristics. We define MCC subgroup as those admitted with 6 or more chronic conditions. The outcome of interest is the patient’s risk of 30-day all-cause hospital readmission, defined as the probability of a hospital readmission within 30 days of discharge from an index hospital admission of any type. We use propensity score analysis to address the issue of self-selection, matching enrollees through a large number of patient and area characteristics including an extensive set of secondary comorbidities and selected medical surgical diagnoses.
Overall in 4 states, MA enrollees in MCC subgroup had 11% lower odds (OR=0.908, p<0.01) of readmissions than corresponding TM enrollees. This is similar to findings for all Medicare enrollees in those states (OR=0.90, p<0.01). The results by state reveal variations: the adjusted odds of readmissions for MCC patients were 16% (CA) to 2% (FL) less for MA compared to TM enrollees after selection adjustment. The findings were consistent with those for all Medicare enrollees in respective states.
MA enrollment is associated with significantly lower all-cause readmission risk relative to TM enrollment, both overall as well as for the MCC subgroup. We do not find evidence that the performance of MA plans in reducing readmissions was significantly different for MCC patients compared to all Medicare patients. Our findings are also robust to a variety of alternative methods for controlling for health status.
Implications for Policy or Practice
The study topic is highly relevant in light of the growing importance of MA plans, and the growing debate surrounding MA versus TM delivery systems. Our study provides suggestive evidence regarding the success of MA plans in achieving better care transitions and improving care delivery and practice relative to traditional Medicare both in overall Medicare population as well as in its high-risk subgroup.