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. 2015 Oct;34(10):1675-81.
doi: 10.1377/hlthaff.2015.0272.

High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare

Momotazur Rahman  1 , Laura Keohane  2 , Amal N Trivedi  3 , Vincent Mor  4
Affiliations

High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare

Momotazur Rahman et al. Health Aff (Millwood). 2015 Oct.

Abstract

Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending.

Keywords: Health Reform; Home Care; Long-Term Care; Managed Care - Medicare < Managed Care.

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Figures

Exhibit 1
Exhibit 1. Beneficiaries’ Adjusted Rates Of Switching In 2011 Between Medicare Advantage And Traditional Medicare, By Use Of Acute Hospital Care In 2010
SOURCE Authors’ analysis of data from the Medicare enrollment files, Minimum Data Set, Outcome and Assessment Information Set, Healthcare Effectiveness Data and Information Set, and Medicare claims. NOTE Rates and 95% confidence intervals (represented by the whiskers) were estimated using an ordinary least squares regression of switching onto age, sex, race, other types of care use, and state fixed effects.
Exhibit 2
Exhibit 2. Beneficiaries’ Adjusted Rates Of Switching In 2011 Between Medicare Advantage And Traditional Medicare, By Use Of Home Health Care In 2010
SOURCE Authors’ analysis of data from the Medicare enrollment files, Minimum Data Set, Outcome and Assessment Information Set, Healthcare Effectiveness Data and Information Set, and Medicare claims. NOTE Rates and 95% confidence intervals (represented by the whiskers) were estimated using an ordinary least squares regression of switching onto age, sex, race, other types of care use, and state fixed effects.
Exhibit 3
Exhibit 3. Beneficiaries’ Adjusted Rates Of Switching In 2011 Between Medicare Advantage And Traditional Medicare, By Use Of Nursing Home Care In 2010
SOURCE Authors’ analysis of data from the Medicare enrollment files, Minimum Data Set, Outcome and Assessment Information Set, Healthcare Effectiveness Data and Information Set, and Medicare claims. NOTE Rates and 95% confidence intervals (represented by the whiskers) were estimated using an ordinary least squares regression of switching onto age, sex, race, other types of care use, and state fixed effects.
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