A comparison of relative resource use and quality in Medicare Advantage health plans versus traditional Medicare.

OBJECTIVES: Prior analyses of Medicare health plans have examined either utilization of services or quality of care, but not both jointly. Our objective was to compare utilization and quality for Medicare Advantage (MA) enrollees with diabetes or cardiovascular disease to that for similarly defined traditional Medicare (TM) beneficiaries. STUDY
DESIGN: Cross-sectional matched observational study using data for 2007.
METHODS: We obtained individual-level Healthcare Effectiveness Data and Information Set (HEDIS) relative resource use (RRU) and quality data for patients enrolled in MA, and then developed comparable claims-based measures for matched samples of TM beneficiaries. MAIN OUTCOME MEASURES: utilization levels for inpatient care, evaluation and management services, and surgery; number of emergency department (ED) and inpatient visits; and quality of ambulatory care measures.
RESULTS: We studied approximately 680,000 MA health maintenance organization (HMO) enrollees with diabetes and 270,000 HMO enrollees with cardiovascular conditions. For both conditions and almost all major strata, the RRU was lower for those enrolled in MA than for those in TM. Spending for those with diabetes was $5223 for MA HMO enrollees compared with $6413 for those in TM (cost ratio, 0.81; P < .001). ED utilization rates were consistently lower in MA than TM (567 vs 719 visits/1000 enrollees; rate ratio, 0.79; P < .001). Health plans that are more established, nonprofit, and/or larger generally had lower resource use and better relative quality than did smaller, newer, for-profit HMOs or preferred provider organizations.
CONCLUSIONS: RRU for those with diabetes or cardiovascular disease is lower in MA, while quality of care is higher. Better MA plans may add value to the care of these major chronic medical conditions.