COMPARING HEALTH CARE UTILIZATION AND EXPENDITURES BETWEEN VALUE-BASED PAYMENT AND NON-VALUE-BASED PAYMENT IN MEDICARE ADVANTAGE
Author(s)
Eleanor Beltz, PhD1, Wei Xin, PhD1, Amanda Zaleski, PhD1, Elyse Pegler, MPH2, Kelly Thomas Craig, PhD1;
1CVS Health, Clinical Evidence Development, Wellesley, MA, USA, 2Aetna, CVS Health, Value-Based Solutions, Wellesley, MA, USA
1CVS Health, Clinical Evidence Development, Wellesley, MA, USA, 2Aetna, CVS Health, Value-Based Solutions, Wellesley, MA, USA
OBJECTIVES: Value-based payment (VBP) for primary care can improve quality outcomes, but less is known regarding the impact on utilization and expenditures. This study compared utilization and expenditures between VBP and non-VBP in Medicare Advantage (MA).
METHODS: Retrospective analyses of 2023 claims data from a large, national payor examined differences in utilization and expenditures for MA members with primary care providers in VBP or non-VBP arrangements. Utilization, reported per thousand members per month (PTPM), included emergency department (ED), inpatient, and skilled nursing facility visits, IP days, and 30-day same- and all-cause readmissions. Expenditures, reported per member per month (PMPM), included ED, inpatient, outpatient, total medical, total pharmacy, and total cost of care. Propensity score matching balanced member covariates. Generalized linear modeling with Bonferroni correction examined group differences. Means with 95% confidence intervals reported unless otherwise noted.
RESULTS: There were 1,375,027 members per cohort (VBP: 56.5% female, mean [standard deviation] age 72.4 [9.1]; non-VBP: 55.6% female, mean [standard deviation] age 72.2 [9.4]). All outcome measures were lower for VBP than non-VBP (all P<.0001). Specifically, the VBP cohort had 1.8 (1.6, 2.0) PTPM fewer ED, 1.1 (1.0, 1.2) PTPM fewer IP, and 8.2 (7.0, 9.4) PTPM fewer outpatient visits, and 0.3 (0.3, 0.4) PTPM fewer 30-day all-cause readmissions. Total cost of care was $47.74 (43.91, 51.57) PMPM less in VBP than non-VBP.
CONCLUSIONS: This real-world analysis of ~2.8 million MA members supports lower utilization and expenditures with VBP compared to non-VBP. VBP was associated with approximately 30,000 fewer ED, 18,000 fewer inpatient, and 135,000 fewer outpatient visits, and 5000 fewer 30-day all-cause readmissions. Estimated annual savings with VBP was $572.88 per member, translating to approximately $790 million for the VBP cohort. This study adds to the body of evidence demonstrating that VBP can achieve it’s aim of improving health care quality, utilization eficciency, and affordability.
METHODS: Retrospective analyses of 2023 claims data from a large, national payor examined differences in utilization and expenditures for MA members with primary care providers in VBP or non-VBP arrangements. Utilization, reported per thousand members per month (PTPM), included emergency department (ED), inpatient, and skilled nursing facility visits, IP days, and 30-day same- and all-cause readmissions. Expenditures, reported per member per month (PMPM), included ED, inpatient, outpatient, total medical, total pharmacy, and total cost of care. Propensity score matching balanced member covariates. Generalized linear modeling with Bonferroni correction examined group differences. Means with 95% confidence intervals reported unless otherwise noted.
RESULTS: There were 1,375,027 members per cohort (VBP: 56.5% female, mean [standard deviation] age 72.4 [9.1]; non-VBP: 55.6% female, mean [standard deviation] age 72.2 [9.4]). All outcome measures were lower for VBP than non-VBP (all P<.0001). Specifically, the VBP cohort had 1.8 (1.6, 2.0) PTPM fewer ED, 1.1 (1.0, 1.2) PTPM fewer IP, and 8.2 (7.0, 9.4) PTPM fewer outpatient visits, and 0.3 (0.3, 0.4) PTPM fewer 30-day all-cause readmissions. Total cost of care was $47.74 (43.91, 51.57) PMPM less in VBP than non-VBP.
CONCLUSIONS: This real-world analysis of ~2.8 million MA members supports lower utilization and expenditures with VBP compared to non-VBP. VBP was associated with approximately 30,000 fewer ED, 18,000 fewer inpatient, and 135,000 fewer outpatient visits, and 5000 fewer 30-day all-cause readmissions. Estimated annual savings with VBP was $572.88 per member, translating to approximately $790 million for the VBP cohort. This study adds to the body of evidence demonstrating that VBP can achieve it’s aim of improving health care quality, utilization eficciency, and affordability.
Conference/Value in Health Info
2026-05, ISPOR 2026, Philadelphia, PA, USA
Value in Health, Volume 29, Issue S6
Code
CO197
Topic
Clinical Outcomes
Topic Subcategory
Performance-based Outcomes
Disease
No Additional Disease & Conditions/Specialized Treatment Areas