Association of Medicare Advantage Premiums With Measures of Quality and Patient Experience

Abstract

Importance: Quality of care varies substantially across Medicare Advantage plans. The price information that Medicare Advantage enrollees are most likely to consider when selecting a Medicare Advantage plan is the monthly premium. Enrollees may select plans to minimize premium or, alternatively, use premium as a proxy for quality and select plans with higher premiums; however, quality implications of these choices are unknown.

Objective: To determine the extent to which the quality of care offered by Medicare Advantage plans varies within vs across premium levels.

Design, setting, and participants: This was a retrospective cross-sectional study of the population enrolled in Medicare Advantage plans in 2016 to 2017 using clinical quality measures from the Healthcare Effectiveness Data and Information Set (HEDIS), patient experience measures from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and administrative data. Data were analyzed from March 2021 to March 2022.

Exposures: Medicare Advantage monthly premium.

Main outcomes and measures: Ten publicly reported 2017 HEDIS measures and 5 publicly reported 2017 CAHPS measures linearly transformed to a 0 to 100 scale.

Results: The 168 968 Medicare Advantage CAHPS respondents were representative of the enrollee population (14% were <65 years old and eligible through disability; 24% ≥80 years old; sex and race/ethnicity data were not considered); 40% were in 591 plans with no monthly premiums and less than 6% were in 144 plans with monthly premiums of $120 or more. There were from 77 054 to 2 139 422 enrollees by HEDIS measure. Among all Medicare Advantage enrollees, 79% were in plans with either a $0 premium or a low monthly premium (≤$60); patient experience and clinical quality were generally similar in these 2 categories of plans. To a small extent, enrollees in moderately high ($60-$120) and high (≥$120) premium plans reported better patient experience (+1.4 [95% CI, 0.7-2.1] and 2.2 [95% CI, 1.5-2.9] points) and received better clinical care (1.4 [95% CI, 0.3-2.5] to 3.3 [5% CI, 2.1-4.5] percentage points on most measures than those with $0 and low-premium plans. Quality differences within each premium level category were substantial; the within-premium category plan-level SDs were 6.5 points and 7.2 percentage points for patient experience and clinical quality, respectively. A plan at the 50th percentile of clinical quality and patient experience in the high premium category would fall in the 65th and 62nd percentile within the $0-premium category, respectively.

Conclusions and relevance: This population-based cross-sectional study found that although quality of care and patient experience were slightly higher with higher-premium plans, quality varied widely within each premium category. High-quality care and patient experience were found in each price category. Thus, paying higher premiums is not necessary for higher quality care in Medicare Advantage plans. Greater engagement of enrollees and advocates with quality of care and patient experience information for Medicare Advantage plan selection is recommended.

Figure 1.. Differences in Patient Experiences Within and Between Plan Premium Categories (CAHPS composite, 0-100 scale)

The gray box indicates 1 SD (67%) of plans, the whiskers indicate 2 SD (95%) of plans, and the dark line shows the mean quality. Mean quality at each premium level from Table 2 (see also eTables 2A and 2B in the Supplement); plan SDs from models in eAppendix A in the Supplement; and CAHPS indicates Consumer Assessment of Healthcare Providers and Systems.

Figure 2.. Differences in Clinical Quality Within and Between Plan Premium Categories (HEDIS composite, 0-100 scale)

The gray box indicates 1 SD (67%) of plans, the whiskers indicate 2 SD (95%) of plans, and the dark line shows the mean quality. Mean quality at each premium level from Table 2 (see also eTables 2A and 2B in the Supplement); plan SDs from models in eAppendix A in the Supplement; and HEDIS indicates Healthcare Effectiveness Data and Information Set.