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. 2022 Sep 2;3(9):e222935.
doi: 10.1001/jamahealthforum.2022.2935.

Comparison of Low-Value Services Among Medicare Advantage and Traditional Medicare Beneficiaries

Emily Boudreau  1 , Richard Schwartz  1 , Aaron L Schwartz  2   3   4 , Amol S Navathe  2   4 , Ariel Caplan  1 , Yong Li  1 , Andy Blink  1 , Patrick Racsa  1 , Dana Drzayich Antol  1 , C Jo Erwin  1 , William H Shrank  1 , Brian W Powers  1   5
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Comparison of Low-Value Services Among Medicare Advantage and Traditional Medicare Beneficiaries

Emily Boudreau et al. JAMA Health Forum. .

Abstract

Importance: Low-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care.

Objectives: To compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care.

Design, setting, and participants: This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022.

Exposures: Enrollment in MA vs TM.

Main outcomes and measures: Low-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries.

Results: Among a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements.

Conclusions and relevance: In this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.

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Conflict of interest statement

Conflict of Interest Disclosures: Messrs R. Schwartz and Caplan reported personal fees, employment with, and equity holdings in Humana Inc outside the submitted work. Dr A. Schwartz reported grants from Arnold Ventures and personal fees from Tufts School of Medicine, CVS Health, Lown Institute, and MedPAC outside the submitted work. Dr Navathe reported grants from the Hawaii Medical Service Association, Commonwealth Fund, Robert Wood Johnson Foundation, Donaghue Foundation, Pennsylvania Department of Health, Veterans Affairs Administration, Ochsner Health System, United Healthcare, Blue Cross Blue Shield of NC, Blue Shield of CA, and Humana; personal fees from Navvis Healthcare, Avahealth Equity, YNHHSC/CORE, Maine Health Accountable Care Organization, Singapore Ministry of Health, Elsevier Press, Medicare Payment Advisory Commission, Cleveland Clinic, Analysis Group, VBID Health, Advocate Physician Partners, Federal Trade Commission, and Catholic Health Services Long Island; and board service for Clarify Health Equity, and Integrated Services, Inc during the conduct of the study. Ms Drzayich Antol reported employment and equity holdings with Humana. Ms Erwin reported employment with and stock ownership in Humana, Inc. Dr Shrank reported being an employee of Humana Inc during the conduct of the study and board service with GetWell outside the submitted work. Dr Powers reported employment and equity holdings with Humana and prior employment by Anthem and Fidelity Investments. No other disclosures were reported.

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