Humana Healthcare Research, Louisville, Kentucky.
Humana Inc, Louisville, Kentucky.
JAMA Health Forum. 2022 Oct 7;3(10):e223451. doi: 10.1001/jamahealthforum.2022.3451.
Medicare beneficiaries with co-occurring chronic conditions and complex care needs experience high rates of acute care utilization and poor outcomes. These patterns are well described among traditional Medicare (TM) beneficiaries, but less is known about outcomes among Medicare Advantage (MA) beneficiaries. Compared with TM, MA plans have additional levers to potentially address beneficiary needs, such as network design, care management, supplemental benefits, and value-based contracting.
To compare health care utilization for MA and TM beneficiaries with complex care needs.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. Beneficiaries were segmented into the following cohorts: frail elderly, major complex chronic, and minor complex chronic. Regression models estimated the association between MA enrollment and health care utilization in 2018, using inverse probability of treatment weighting to balance the MA and TM cohorts on observable characteristics. The study period was January 1, 2017, through December 31, 2018. All analyses were conducted from December 2020 to August 2022.
Enrollment in MA vs TM.
Hospital stays (inpatient admissions and observation stays), emergency department (ED) visits, and 30-day readmissions.
Among a study population of 1 844 326 Medicare beneficiaries (mean [SD] age, 75.6 [7.1] years; 1 021 479 [55.4%] women; 1 524 458 [82.7%] White; 223 377 [12.1%] with Medicare-Medicaid dual eligibility), 1 177 896 (63.9%) were enrolled in MA and 666 430 (36.1%) in TM. Beneficiary distribution across cohorts was as follows: frail elderly, 116 047 with MA (10.0% of the MA sample) and 104 036 with TM (15.6% of the TM sample); major complex chronic, 320 954 (27.2%) and 158 811 (23.8%), respectively; and minor complex chronic, 740 895 (62.9%) and 403 583 (60.6%), respectively. Beneficiaries enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions. The largest relative differences were observed for hospital stays, which ranged from -9.3% (95% CI, -10.9% to -7.7%) for the frail elderly cohort to -11.9% (95% CI, -13.2% to -10.7%) for the major complex chronic cohort.
In this cross-sectional study of Medicare beneficiaries with complex care needs, those enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions than similar beneficiaries enrolled in TM, suggesting that managed care activities in MA may influence the nature and quality of care provided to these beneficiaries.
同时患有慢性疾病和复杂护理需求的医疗保险受益人会出现高频率的急性护理利用和较差的治疗效果。这种模式在传统医疗保险（TM）受益人群中已有充分描述，但关于医疗保险优势（MA）受益人群的结果却鲜为人知。与 TM 相比，MA 计划有更多的手段来满足受益人的需求，例如网络设计、护理管理、补充福利和基于价值的合同。
比较具有复杂护理需求的 MA 和 TM 受益人的医疗保健利用情况。
设计、设置和参与者：本横断面研究使用来自一家大型全国性 MA 保险公司和 TM 随机 5%抽样的索赔数据，分析了 MA 和 TM 受益人的情况。将受益人群分为以下队列：体弱老年人、主要复杂慢性病和次要复杂慢性病。回归模型使用逆概率治疗加权法（inverse probability of treatment weighting），对可观察特征进行平衡，估计了 2018 年 MA 参保与医疗保健利用之间的关联。研究期间为 2017 年 1 月 1 日至 2018 年 12 月 31 日。所有分析均于 2020 年 12 月至 2022 年 8 月进行。
MA 与 TM 的参保情况。
住院（住院和观察住院）、急诊就诊和 30 天内再入院。
在 1844326 名医疗保险受益人（平均[SD]年龄，75.6[7.1]岁；1021479[55.4%]为女性；1524458[82.7%]为白人；223377[12.1%]为医疗保险-医疗补助双重资格）中，1177896 人（63.9%）参加了 MA，666430 人（36.1%）参加了 TM。受益人群在各队列中的分布情况如下：体弱老年人，MA 组有 116047 人（MA 样本的 10.0%），TM 组有 104036 人（TM 样本的 15.6%）；主要复杂慢性病，MA 组有 320954 人（27.2%），TM 组有 158811 人（23.8%）；次要复杂慢性病，MA 组有 740895 人（62.9%），TM 组有 403583 人（60.6%）。参加 MA 的受益人的住院、急诊就诊和 30 天内再入院的比例较低。观察到的最大相对差异是住院，从体弱老年人队列的 -9.3%（95%CI，-10.9%至-7.7%）到主要复杂慢性病队列的-11.9%（95%CI，-13.2%至-10.7%）。
在这项对具有复杂护理需求的医疗保险受益人的横断面研究中，与类似的 TM 参保受益人群相比，参加 MA 的受益人的住院、急诊就诊和 30 天内再入院比例较低，这表明 MA 中的管理式医疗活动可能会影响为这些受益人群提供的护理的性质和质量。
