OBJECTIVES

: As policymakers look to encourage value-driven, cost-effective, quality care delivery models, there is growing interest in comparing traditional Fee-for-Service (FFS) Medicare and Medicare Advantage (MA). To date, there is little comprehensive information on the performance of MA compared to FFS due in part to a lack of access to comparable MA encounter data. The objective of this study was to compare healthcare utilization, cost, and quality outcomes across 2 large national samples of dual eligible MA and FFS Medicare beneficiaries.

METHODS

: A descriptive cross-sectional cohort design was used to analyze 1,581,822 MA beneficiaries from a large national claims database and 1,212,698 FFS beneficiaries from Medicare Standard Analytic Files (SAF). Beneficiaries were required to be continuously enrolled with medical and pharmacy benefit coverage for the 12-month reporting year 2015.

RESULTS

: Dual eligible MA beneficiaries had 32.9% fewer inpatient stays and 42.1% fewer ER visits than FFS Medicare. Total cost of care for duals was 16.7% higher in FFS Medicare ($13,398 versus $11,159 in MA). MA duals experienced a 24.1% lower rate of potentially avoidable hospitalizations (19.2% versus 25.3% of FFS Medicare).

CONCLUSIONS

: Despite having a higher percentage of beneficiaries with clinical and social risk factors, the MA population had lower utilization of costly healthcare services. These findings support the notion that the flexibility MA plans have to provide coordinated care and additional benefits results in improved outcomes and lower costs. Starting in 2019, regulatory changes will expand the scope of supplemental benefits that MA plans can offer, including benefits that are not primarily health related. A better understanding of high-cost, high-need patients is essential to developing targeted and innovative benefit programs aimed at reducing costs and improving outcomes in this growing population.