Prevention Care and Screening in Medicare Advantage

The Medicare Advantage program is committed to promoting the appropriate use of Medicare preventive benefits. Medicare Advantage plans cover a broad range of services to prevent disease and detect disease early when it is most treatable and curable, as well as manage disease so that complications and higher costs can be avoided. Implementing screening protocols across the Medicare Advantage population provides the ability to identify conditions, such as cancer, diabetes, cardiovascular disease and other chronic conditions that when diagnosed and treated early, give beneficiaries the ability to live longer and healthier lives.

Recognizing that screening and preventive services can help prevent Medicare beneficiaries from becoming unhealthy, the Medicare Advantage program began covering these critical services long before traditional Medicare. These services are particularly important for Medicare beneficiaries given the number of beneficiaries impacted by preventable and/or chronic disease, as well as the overall cost of related treatment to the Medicare program. For example, an estimated 17 percent of Medicare beneficiaries have been diagnosed with heart failure, resulting in $7.6 billion in spending in 2011, an average of $5,881 per beneficiary annually.[1]

Given the impact of the diseases outlined above and their exorbitant associated costs, preventive care and screening is vital among the Medicare population. As outlined below, evidence shows that Medicare Advantage continues to lead the way in screening and prevention in the Medicare program.

The Medicare Advantage Model

More than 16 million Medicare beneficiaries, or approximately 30 percent of the Medicare population, receive their health care services through the Medicare Advantage program. Medicare Advantage as a service delivery model is well suited to fulfilling prevention and screening goals for the Medicare population. Enrollees receive medical, prescription drug, vision, dental, fitness and wellness benefits as part of a combined benefit. Integrated service delivery systems, care coordination and new payment models that reward value over volume also facilitate prevention and timely screening. Involvement of providers in discharge planning and follow-up care after hospitalizations also allow for screening efforts that can prevent the recurrence of hospital admissions.

The Medicare Advantage program encourages preventive screenings through a multi-faceted approach. For example, plans participating in the Medicare Advantage program have engaged in an array of activities when screening for colorectal cancer, including:

  • Direct nurse calls to beneficiaries to provide education when a Medicare beneficiary’s screening has not been completed per national guidelines;
  • Educational mailings to beneficiaries with prevention calendars and recommended intervals for screening tests;
  • Collaboration with providers to review a physician’s panel of patients and provide customized patient lists for those meeting screening eligibility criteria;
  • Face-to-face education at health fairs; and
  • Innovative outreach programs, such as collaborating with physicians to mail testing kits directly to beneficiaries.

It is clear that the Medicare Advantage program is innovating around how care is delivered with an emphasis on preventing illness and detecting disease early. For example, many Medicare Advantage beneficiaries have received a free in-home clinical visit from a qualified practitioner, such as a physician or a nurse practitioner. These in-home clinical visits are proving vital to the effort to achieve improved clinical outcomes for Medicare beneficiaries. A recent study of beneficiaries with diabetes who received an in-home clinical visit demonstrated reduced hospitalizations by 9 percent, same quarter readmissions by 28 percent and hospital inpatient days by 19 percent, and also demonstrated increased physician office visits by 7 percent to address gaps in case as compared to beneficiaries in Medicare FFS.[2] Similarly, a study published in the Journal of American Geriatrics Society in July 2014 found that patients who received home-based primary care had 9 percent fewer hospitalizations, 20 percent fewer emergency department visits, 27 percent fewer skilled nursing facility stays and 23 percent fewer specialist visits. [3] It also found that home-based primary care saved an average of $8,477 per patient over two years.

Medicare Advantage versus Original Medicare

Data from a set of studies comparing Medicare Advantage with original Medicare illustrate the capacity of Medicare Advantage to provide better prevention and screening services than original Medicare.

An analysis of performance measures of breast cancer screening, diabetes care and cholesterol testing for cardiovascular disease, for example, found that HMOs consistently performed better on these screening and prevention measures than original Medicare. The authors note that these results may be due to the positive effects of these plans’ more integrated service delivery systems on the quality of ambulatory care and that the reliance on these types of service delivery systems may outweigh incentives to restrict care under capitated payment arrangements.[4] An analysis of 11 clinical quality measures also found that Medicare Advantage scored higher than original Medicare on 9 measures, with breast cancer screening approximately 15 percent higher and diabetes care 4 to 10 percent higher on the four measures studied.[5]

Another analysis of Healthcare Effectiveness Data and Information Set (HEDIS) measures – a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service – also demonstrated that Medicare Advantage outperformed, by a substantial margin, original Medicare on measures of breast cancer screening.[6] Moreover, rates of mammography were substantially higher among women enrolled in Medicare Advantage plans than in original Medicare and the pattern of statistically significant disparities in mammography screening for Black, Hispanic and Asian/Pacific Islander women relative to that of White women that is found in original Medicare did not occur in Medicare Advantage plans, leading the authors to suggest that minority women may have better access to mammography in Medicare Advantage than original Medicare.[7]

The Medicare Advantage program’s successes in prevention and screening also may help to explain lower rates of hospitalization and readmissions than those in original Medicare. An analysis of Medicare Advantage versus original Medicare found that, during the 2003-2009 period, emergency room visits were approximately 20-25 percent lower among Medicare Advantage enrollees, inpatient medical days were 25-35 percent lower, and ambulatory surgery and procedure use were also substantially lower, leading the authors to conclude that Medicare Advantage enrollees may be experiencing more appropriate use of services than those in original Medicare.[8] In a three-state study (California, Florida, New York), researchers found that the odds of preventable hospital admissions were lower for Medicare Advantage enrollees compared to original Medicare enrollees by 22 percent, 16 percent and 9 percent, respectively. [9] In another study, the risk-adjusted 30-day readmission rate among Medicare Advantage enrollees was 13-20 percent lower than those in original Medicare. [10]

These empirical results consistently demonstrate the significant role that Medicare Advantage has in ensuring that prevention and screening goals for its enrollees are achieved, and also point to the growing impact that Medicare Advantage will have on the health of the Medicare population in the future as enrollment continues to grow.

Gold and Casillas note that more recent analyses of Medicare Advantage plans versus original Medicare, along with studies that control for geographic variation and beneficiaries’ socio-demographic characteristics, will shed more light on the difference between the two models of Medicare service delivery.[11] They note, in particular, that the requirement for Medicare Advantage plans to report an expanded set of HEDIS measures in 2014 may aid in this effort.[12]


The Better Medicare Alliance is developing a short and long-term research agenda designed to respond to these recommendations and demonstrate the value proposition for enrollees in Medicare Advantage. The research agenda will analyze key topics such as the impact Medicare Advantage is having on seniors’ access to preventive care, wellness, and chronic condition management.

[1] Center for Medicare & Medicaid Services, Chronic Conditions Among Medicare Beneficiaries, 2012 Edition Chartbook. See also Whitaker, S., Richardson, A., Cardiovascular Disease Risk Factors Among Medicare Beneficiaries: Review of Disparities and Opportunities, Delmarva Foundation for Medicare Care (April 2014).

[2] Cohen, R. and Lemieux, J. and Schoenborn, J. and Mulligan, T. (2012) Medicare Advantage Chronic Special Needs Plan Boosted Primary Care, Reduced Hospital Use Among Diabetes Patients. Health Affairs, 31:1 (January 2012).

[3] De Jonge, K. Eric, Jamshed, N., Gilden, D., Kubisiak, J., Bruce, S.R., and Taler, G., Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders, Journal of American Geriatrics Society, 62:10 (October 2014).

[4] Guran, J., and Moffit, R., The Medicare Advantage Success Story- Looking beyond the Cost Difference, N.Eng. J. Med. 366:13 (Mar.29, 2012). A 2013 Health Affairs article (See n. 4) also cites these findings, noting specifically that mammography rates were 13 percenthigher, eye tests for individuals with diabetes were 17 percent higher and cholesterol testing for cardiovascular disease were 7 to 9 percent higher in Medicare Advantage plans than original Medicare.

[5] Brennan, N. and Shepard, M., Comparing Quality of Care in the Medicare Program, The American Journal of Managed Care, 11: 841-8 (Nov. 19, 2010).

[6] Ayanian, J.Z. Landon, B.E., Zaslavsky, A.M., et al., Medicare Beneficiaries More Likely To Receive Appropriate Ambulatory Services In HMOs Than In Traditional Medicare, Health Affairs 32:7 (2013).

[7] Ayanian, J.E., Landon, B.E., Zaslavsky, A.M., and Newhouse, J.P., Racial and Ethnic Differences in Use of Mammography Between Medicare Advantage and Traditional Medicare, J. Natl. Cancer Insti., 105:1891-1896 (2013).

[8] Landon, B.E., Zaslavsky, A.M., Saunders, R.C. Pawlson, G. et al., Analysis of Medicare Advantage HMOs Compared With Traditional Medicare Shows Lower Use of Many Services During 2003-2009, Health Affairs, 31:12 (2012).

[9] Basu, J., Mobley, L.R., Medicare Managed Care plan Performance: A Comparison across Hospitalization Types, Medicare & Medicaid Research Review, 2:1 (2012).

[10] Lemieux, J., Sennett, C., Wang, R., Mulligan, T. and Bumbaugh, J., Hospital Readmission Rates in Medicare Advantage Plans, The American Journal of Managed Care, 18:2 (Feb. 27, 2012). Available at:….

[11] Gold, M. and Casillas, G., What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?, Report to the Henry J. Kaiser Family Foundation, (Nov. 2014).

[12] Id. at 3.

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