New Analysis: Medicare Advantage Achieves Better Outcomes for High Need, High Cost Beneficiaries

Washington, D.C. – Better Medicare Alliance’s Center for Innovation in Medicare Advantage (CIMA) today unveiled new research offering a first-of-its-kind comprehensive comparison of health care utilization, outcomes, and costs for high-need, high-cost populations in Medicare Advantage as compared to Traditional Medicare.

The report, with analysis conducted by Avalere Health, examined data on more than 1.4 million Medicare Advantage beneficiaries and 7.9 million Traditional Medicare beneficiaries, finding that Medicare Advantage outperforms Traditional Medicare on a broad range of quality measures – ranging from pneumonia and flu vaccines to diabetic eye exams, post-acute care, and avoidable hospitalizations.

Study populations included the frail elderly, those with complex chronic conditions, and those individuals under 65 years old who are in Medicare due to a disability. These high-need beneficiaries were matched using new analytic tools not previously used for such studies.

“This research paints a compelling picture of how Medicare Advantage’s high-quality, value-based care and care management offers earlier clinical interventions and more frequent use of primary care services and preventive screenings. In turn, beneficiaries stay out of the hospital and avoid costlier settings of care,” said Allyson Y. Schwartz, President and CEO of the Better Medicare Alliance. “Medicare Advantage beneficiaries had 49% and 11% higher rates of vaccination for pneumonia and the flu and the contrasts are even more pronounced among high-need, high-cost beneficiaries. For example, beneficiaries with major complex chronic conditions had 57% lower rates of avoidable hospitalizations for acute conditions in Medicare Advantage than in Traditional Medicare, while frail elderly beneficiaries had 45% lower rates of avoidable hospitalizations for acute conditions.”

“Our report provides meaningful evidence that Medicare Advantage’s use of care management and focus on prevention, outpatient visits, and primary care is making a real difference in the lives of the most vulnerable seniors and under age 65 disabled beneficiaries,” concluded Schwartz.  “As we look to the future, these findings offer evidence to policymakers that achieving better outcomes at better cost is not only possible, but it is happening in Medicare Advantage for millions of Medicare beneficiaries.”

“Medicare Advantage is growing faster than ever, and plans are enrolling more members with social needs who are also more clinically complex,” said Christie Teigland, PhD, Principal at Avalere Health. “Our research shows that Medicare Advantage plans are stepping up to these challenges and outperforming Traditional Medicare Fee-for-Service in providing higher quality care and lower costs to these increasingly vulnerable Medicare beneficiaries.”  

• Read the full report
• Read a text fact sheet
• Read an infographic fact sheet

Key findings from the report include:

More Preventive and Primary Care:

• Overall, beneficiaries in Medicare Advantage received a pneumonia vaccine 49% more often and a flu vaccine 11% more often than those in Traditional Medicare.
• Across all high-need, high-cost beneficiary populations (frail elderly, under age 65 disabled, and major complex chronic conditions), Medicare Advantage beneficiaries experienced higher rates of screening for depression, breast cancer, and prostate cancer as well as higher rates of receiving a risk falls assessment than those in Traditional Medicare.
• Costs for primary care services and tests are 41% higher for major complex chronic beneficiaries in Medicare Advantage than those in Traditional Medicare, suggesting higher utilization of primary care services.
• Among under age 65 disabled beneficiaries with diabetes, 79% of beneficiaries in Medicare Advantage received an eye exam – used to detect conditions such as diabetic retinopathy – as compared to 51% in Traditional Medicare.

Fewer Avoidable Hospitalizations:

• Frail elderly beneficiaries in Medicare Advantage had a 66% higher rate of outpatient visits as compared to similar beneficiaries in Traditional Medicare, showing greater use of lower-cost sites of care.
• Likewise, under age 65 disabled beneficiaries in Medicare Advantage saw 46% higher rates of outpatient visits than those in Traditional Medicare.
• Major complex chronic Medicare Advantage beneficiaries had 57% lower rates of avoidable hospitalizations for acute conditions than those in Traditional Medicare.
• Frail elderly Medicare Advantage beneficiaries had 45% lower rates of avoidable hospitalizations for acute conditions than those in Traditional Medicare.
• 74% of frail elderly Medicare Advantage beneficiaries had a visit with their doctor within 14 days of a hospital discharge, as compared to 52% of Traditional Medicare beneficiaries.

Post-Acute Care:

• Medicare Advantage achieved 44% lower costs for long term acute care hospitals for the under age 65 disabled and frail elderly populations.
• Major complex chronic Medicare Advantage beneficiaries have 16% lower rates of skilled nursing facility (SNF) stays than those in Traditional Medicare.

Lower Prescription Costs, Less High-Risk Medications:  

• Overall, beneficiaries in Medicare Advantage had 30% lower rates of being concurrently prescribed opioids and benzodiazepines.
• Major complex chronic beneficiaries in Medicare Advantage were prescribed high-risk medications 16% less often than those in Traditional FFS Medicare.
• Prescription drug costs were 41% lower in Medicare Advantage than Traditional Medicare.

Definitions: “Under age 65 Disabled” describes Medicare beneficiaries who are not yet Medicare age but receive Medicare benefits due to a disability or diagnosis of End-Stage Renal Disease. “Frail elderly” describes anyone aged 65 or older with two or more frailty conditions. “Major complex chronic” is defined as anyone aged 65 or older with two or more complex chronic conditions or six or more non-complex chronic conditions.

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