News: Medicare Advantage patients less likely to be hospitalized than Medicare members, study says

CDI Strategies - Volume 17, Issue 10

Medicare Advantage (MA) beneficiaries have a lower risk of hospitalization for ambulatory care sensitive conditions (ACSC) than traditional Medicare members, according to a study recently published in JAMA Health Forum. The research also found that MA beneficiaries are more likely to be directly discharged from the emergency department (ED) or stay for observation, however, indicating this tendency may be due to moving MA patients to other care settings, HealthLeaders reported.

The study used administrative claims and encounter data for patients enrolled in MA and traditional Medicare in 2018 to compare utilization of hospitalizes, observations, and ED direct discharges with ACSCs. “Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for [ACSCs],” the researchers stated.

The study’s findings leave it unclear if MA plans lower acute care use compared to traditional Medicare, or if they shift patients to other settings of care, however. Site shifting can save on out-of-pocket costs, but can result in lower care quality, which could mean higher costs from other care settings for MA members. Such plans are known to use tools like prior authorization to treat patients at the lowest cost site of care allowed, with 70% of MA enrollees being in a plan that required prior authorization for inpatient stays in 2018.

“Additionally these findings suggest the need for caution in relying on hospitalizations for ACSCs to serve as an indicator of higher-quality care in ambulatory settings,” the researchers said.

Editor’s note: To read HealthLeaders’ coverage of this story, click here. To read the JAMA study, click here.

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