CO2 Healthcare Utilization, Cost, and Quality Among High-Need, High-Cost Medicare Beneficiaries in Medicare Fee-for-Service Versus Medicare Advantage


      More than one-third of Medicare beneficiaries are enrolled in a managed Medicare Advantage (MA) plan, yet there is little data comparing outcomes among MA Beneficiaries (MAB) compared to traditional Medicare Fee-for-Service Beneficiaries (FFSB). The objective of this study was to identify high-need, high-cost cohorts of MAB and FFSB and compare their healthcare resource utilization, costs, and quality outcomes.


      This retrospective study used data from a national sample of MA encounter data and 100% Medicare Parts A, B, and D claims data from 2015-2017. A validated algorithm was applied to identify distinct clinical cohorts of high-need, high-cost beneficiaries in FFS and MA, including disabled under age 65, frail elderly, and major complex chronic patients. Propensity score matching was used to assure the populations had similar demographic and clinical characteristics; matching resulted in a study sample of 1,262,180 patients in both cohorts. We compared performance on a discrete set of health outcomes selected as relevant indicators of the impact of care management practices.


      Overall, MA performed better than FFS on 17 of 22 quality measures, including preventive care (e.g., 50% more likely to receive pneumonia vaccine; 18-27% more likely to be screened/treated for depression). MAB had 10% fewer inpatient stays, but higher use of outpatient and physician office visits. MAB were about 50% less likely to be hospitalized for potentially preventable complications. Total medical and pharmacy spend was 15% lower in MA.


      This study found significant differences in health outcomes of high-cost high-need MAB compared to similar FFSB. Enrollment in MA continues to rapidly expand, projected to reach 47% of Medicare by 2029. This study indicates the incentives in MA to better coordinate care and provide flexible medical/non-medical benefits are associated with better care at lower cost, which is the goal of value-based purchasing.