What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?

Introduction
  1. Henry J. Kaiser Family Foundation. “Medicare at a Glance.” September 2014.

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  2. Gold M, Jacobson G, Damico A, Neuman T. Medicare Advantage enrollment spotlight: 2014 enrollment update. Washington, DC: Kaiser Family Foundation, May 2014.

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  3. Miller RS, Luft HS. HMO plan performance update: an analysis of the literature, 1997-2001. Health Aff. 2002;21(4):63-86. Earlier reviews in this series came to similar conclusions, though authors note that studies specific to quality were even more limited then. (See Miller RH, Luft HS. Does managed care lead to better or worse quality? Health Aff. 1997;16(5):7-25; and Miller RH, Luft HS. Managed care plan performance since 1980: a literature analysis. JAMA. 1997;2271(19): 1512-29.)

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  4. Miller RH, Luft HS. Does managed care lead to better or worse quality? Health Aff. 1997;16(5):7-25.

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  5. Gold, M. “The Changing U.S. Health Care System: Challenges for Responsible Public Policy.” Milbank Quarterly, vol. 77, no. 1, 1999, pp. 3-37.

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  6. Medicare Payment Advisory Commission. Report to Congress: Medicare Payment policy. March 2014a; Chapter 13, The Medicare Advantage Program: a status report.

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  7. Jacobson G, Neuman T, Damico A, Huang J. “Medicare Advantage Plan Star Ratings and Bonus Payments in 2012” Washington DC: Kaiser Family Foundation, November 2011.

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  8. America’s Health Insurance Plans. What you need to know: Medicare Advantage: providing high quality, cost efficient care for Medicare Beneficiaries. Available at http://ahip.org/Issues/Medicare-Advantage.aspx. Accessed August 9, 2014.

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  9. Newhouse JP, McGuire TB. Review article: how successful is Medicare Advantage? Milbank Q. 2014;92(2):351-394. The three studies cited (Ayanian et al. 2013a, Ayanian et al. 2013b, and Landon et al. 2012) are included in the review in this paper. Citations are in the reference list.

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  10. Frakt A. “The UpShot: Medicare Advantage is More Expensive but It May Be Worth It” New York Times, August 18, 2014; and John Graham, “Are Medicare Advantage Plans Overpaid and Corrupt?” National Center for Policy Analysis, August 27, 2014, Available at http://healthblog.ncpa.org., Accessed August 27, 2014.

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Methods
  1. The search was conducted in spring 2014 by Stephanie Albier at Pinpoint Search Strategies LLC in Silver Spring, MD.

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  2. Our review techniques aimed to provide an objective analysis comparing access and quality in Medicare Advantage and traditional Medicare in policy-relevant terms within the constraints of available resources. These constraints limited our ability to incorporate all of the techniques recommended for systematic reviews (See for example, guidelines developed by the Institute of Medicine. Available from: http://www.iom.edu/~/media/Files/Report%20Files/2011/Finding-What-Works-in-Health-Care-Standards-for-Systematic-Reviews/Standards%20for%20Systematic%20Review%202010%20 Insert.pdf.) Despite this, we believe we have identified the major studies in this area, particularly on a national scope, and provided sufficient documentation of our analysis to allow users to judge the results.

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  3. America’s Health Insurance Plans. 2014. op. cit.

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  4. While we looked online for relevant research syntheses on this topic by the Cochrane Collaborative or a similar Canadian group that emphasizes health system studies, we found none directly on the topic.

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  5. McGlynn EA et al. The quality of health care delivered to adults in the United States. NJEM. 2003 June 26;348(26):2635-45.

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  6. Medicare Payment Advisory Commission. Report to Congress: Medicare and the health care delivery system. Washington, DC. June 2014b. Chapter 3, Measuring quality of care in Medicare.

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  7. See NCQA’s Summary Table of Measures, Product Lines, and Changes in HEDIS 2014. Available from: http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2014/List_of_HEDIS_ 2014_ Measures.pdf (Accessed 8/4/2014). Effectiveness metrics include the following: adult BMI assessment, breast cancer screening, colorectal cancer screening, glaucoma screening for older adults, spirometry testing for COPD, pharmacotherapy for COPD, cholesterol management for CVD, hypertension control, beta blocker after a heart attack, comprehensive diabetes care, disease-modifying anti-rheumatic drug therapy for rheumatoid arthritis, osteoporosis management, anti-depression medication management, follow-up care after hospitalization for mental illness, annual monitoring of patients on persistent medications, potentially harmful drug interactions, use of high-risk medications in the elderly, health outcomes survey, fall risk management, urinary incontinence management, osteoporosis testing in older women, physician activity in older adults, flu vaccinations for 65+, medical assistance with smoking and tobacco cessation, and pneumonia vaccination for 65+. Access/availability of care measures includes adult access to preventive ambulatory services, initial and engagement of alcohol and other drug dependence treatment, and call-answer timeliness.

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  8. Medicare Payment Advisory Commission. Report to Congress: Medical Payment Policy. March 2010; Chapter 6, Report on comparing quality among Medicare Advantage plans and between the Medicare Advantage and fee-for-service Medicare; and Medicare Payment Advisory Commission. Report to Congress: Medicare Payment policy. March 2012; Chapter 12, The Medicare Advantage Program: a status report, p. 326.

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  9. Medicare Payment Advisory Commission, June 2014b and March 2010, op. cit.

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  10. Additional information on the survey is posted on these two web sites: http://www.ma-pdpcahps.org/content/homepage.aspx and https://cahps.ahrq.gov/surveys-guidance/hp/ about/ Medicares-CAHPS-HP-Survey.html, accessed August 4, 2014. Beginning in 2011, Medicare replaced its survey of traditional Medicare beneficiaries with a requirement that freestanding prescription drug plans (PDPs) collect CAHPS data.

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Findings
  1. Almost all studies focused only on a single type of metric because of the data sources they employed. (Ayanian 2013a is an exception). Where more than one source is used, we classify the study based on its predominant method but discuss findings wherever they are relevant.

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  2. For additional information on the Medicare Modernization Act of 2003 and the evolution of the Medicare Advantage program over the first few years, see Gold, Marsha. “Medicare’s Private Plans: A Report Card on Medicare Advantage.” Health Affairs Web Exclusive, November 24, 2008.

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  3. See, for example, Gold, Marsha R., Gretchen A. Jacobson, and Rachel L. Garfield. “There Is Little Experience and Limited Data to Support Policy Making on Integrated Care for Dual Eligibles.” Health Affairs, vol. 312, no. 6, June 2012, pp. 1176-1187.

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  4. See National Quality Forum “Prioritizing Measures. Available at http://www.qualityforum.org/prioritizing_measures/ (accessed 10/9/2014).

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  5. MedPAC 2014a, op site.

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  6. Miller and Luft, 2002, op. cit.

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  7. Bundorf MK, Choudhry K, Baker L. Health plan performance measurement: does it affect quality of care for Medicare managed care enrollees? Inquiry. 2008;45:1658‒183. This period was before payment was tied to such metrics.

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  8. Medicare Payment Advisory Commission. Report to Congress: Medicare Payment policy, March 2011; Chapter 12, The Medicare Advantage program: a status update, p. 295.

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  9. Jencks SF. “Rehospitalizations among Patients in the Medicare Fee-for-Service Program” New England J. of Medicine 360:1418-1428, April 2, 2009.

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  10. Patrizi P, Thompson E, and Spector A. “Improving Care at the End of Life: How the Robert Wood Johnson Foundation and Its Grantees Built the Field,” Retrospective evaluation prepared for the Robert Wood Johnson Foundation, March 2011.

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  11.  See the Medicare Payment Advisory Commission’s March 2013 Report to Congress, including both Chapter 12 (Hospice Services) and Chapter 13 (Medicare Advantage). Washington DC.

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Works Cited
    Appendix