Health outcomes under full-risk Medicare Advantage vs traditional Medicare

To compare quality and health resource utilization among beneficiaries under 2-sided risk Medicare Advantage (MA) payment arrangements (at-risk MA) vs traditional Medicare (TM).

Retrospective cross-sectional regression analyses of claims and enrollment data from 2016 to 2019 examining 20 performance measures. All patients were cared for by the same 17 physician groups and 15,488 physicians across 35 health insurers.

Logistic regressions adjusted for demographics, geography, and comorbidities for 20 quality and utilization measures across 4 domains of care. Estimates were reported using marginal risk and marginal risk difference per 1000 across the study period.

The sample comprised 6,564,538 person-years (30.3% at-risk MA and 69.7% TM). Sixteen of the 20 measures favored at-risk MA, including lower acute inpatient admissions, lower 30-day readmissions, avoidance of emergency department utilization across 4 measures, avoidance of disease-specific inpatient admissions in 7 of 9 measures, lower high-risk medication use and office visits, and higher medication adherence to renin-angiotensin system drugs. The other 4 measures were statistically equivalent.

Given the CMS goal of moving all beneficiaries to fully accountable care arrangements by 2030, it is critical to understand the differences in quality and health resource utilization between at-risk MA and fee-for-service TM to inform policies on payment and service delivery. Although the associations are not causal, in this cross-sectional study, at-risk MA relative to TM was associated with 11.3% to 54.0% higher quality and efficiency in 16 of 20 measures after adjusting for differences in demographics, comorbidities, and other health characteristics.