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Regional associations between Medicare Advantage penetration and administrative claims-based measures of hospital
Vivek T Kulkarni1, Sachin J Shah, Susannah M Bernheim
1Yale University School of Medicine, New Haven, CT 06510, USA.
Background:
Risk-standardized measures of hospital outcomes reported by the Centers for Medicare and Medicaid Services include Medicare fee-for-service (FFS) patients and exclude Medicare Advantage (MA) patients due to data availability. MA penetration varies greatly nationwide and seems to be associated with increased FFS population risk. Whether variation in MA penetration affects the performance on the Centers for Medicare and Medicaid Service measures is unknown.
Objective:
To determine whether the MA penetration rate is associated with outcomes measures based on FFS patients.
Research Design:
In this retrospective study, 2008 MA penetration was estimated at the Hospital Referral Region (HRR) level. Risk-standardized mortality rates and risk-standardized readmission rates for heart failure, acute myocardial infarction, and pneumonia from 2006 to 2008 were estimated among HRRs, along with several markers of FFS population risk. Weighted linear regression was used to test the association between each of these variables and MA penetration among HRRs.
Results:
Among 304 HRRs, MA penetration varied greatly (median, 17.0%; range, 2.1%-56.6%). Although MA penetration was significantly (P<0.05) associated with 5 of the 6 markers of FFS population risk, MA penetration was insignificantly (P≥0.05) associated with 5 of 6 hospital outcome measures.
Conclusion:
Risk-standardized mortality rates and risk-standardized readmission rates for heart failure, acute myocardial infarction, and pneumonia do not seem to differ systematically with MA penetration, lending support to the widespread use of these measures even in areas of high MA penetration.
Insights
Medicare Advantage penetration does not significantly impact hospital outcome measures for fee-for-service patients. These risk-standardized measures remain reliable, even in areas with high Medicare Advantage enrollment.
Area of Science:
- Healthcare policy
- Health services research
- Quality measurement
Background:
- Centers for Medicare and Medicaid Services (CMS) hospital outcome measures exclude Medicare Advantage (MA) patients due to data limitations.
- MA enrollment varies geographically and may influence the risk profile of the remaining fee-for-service (FFS) population.
- The impact of varying MA penetration on the validity of CMS performance measures is not well understood.
Purpose of the Study:
- To investigate the association between Medicare Advantage (MA) penetration rates and hospital outcome measures derived from fee-for-service (FFS) patients.
- To assess whether higher MA penetration influences the risk-standardized performance metrics reported by CMS.
Main Methods:
- Retrospective analysis using 2008 Medicare Advantage (MA) penetration data at the Hospital Referral Region (HRR) level.
- Estimation of risk-standardized mortality and readmission rates for heart failure, acute myocardial infarction, and pneumonia (2006-2008).
- Weighted linear regression to examine the relationship between MA penetration and FFS population risk markers and hospital outcome measures.
Main Results:
- Medicare Advantage (MA) penetration varied widely across 304 Hospital Referral Regions (HRRs), with a median of 17.0%.
- MA penetration was significantly associated with 5 out of 6 markers of fee-for-service (FFS) population risk.
- However, MA penetration showed no significant association with 5 out of 6 hospital outcome measures (risk-standardized mortality and readmission rates).
Conclusions:
- Risk-standardized mortality and readmission rates for major conditions do not appear to be systematically affected by Medicare Advantage (MA) penetration.
- These findings support the continued use of current CMS hospital performance measures, even in regions with substantial MA enrollment.
- The study suggests that existing risk-standardized measures are robust despite variations in MA market share.
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