'Wake-up call': MA beneficiaries with certain conditions less likely to visit emergency room, report finds

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Dan Mendelson, CEO of Avalere Health
Dan Mendelson, CEO of Avalere Health

Medicare Advantage beneficiaries with hypertension, hyperlipidemia and diabetes are less likely to become hospital inpatients or visit the emergency room compared to traditional fee-for-service Medicare patients, a new analysis finds.

MA beneficiaires had 23% fewer inpatient stays and 33% fewer ER visits compared to fee-for-service beneficiaries, Avalere found. They also received more preventive physician tests.

“The report shows definitively that there are better outcomes associated with diabetes and cardiovascular disease in Medicare Advantage than fee-for-service,” Dan Mendelson, founder of Avalere, told McKnight's.

However, the report “also shows that the patients in Medicare Advantage are sicker than those that are in fee-for-service at this point. It is a compelling set of results. It should really be a wake-up call to fee-for-service providers to get their arms around these trends.”

Finding that MA patients are sicker is a new result, Mendelson said. Much of the previous data and conventional wisdom was based on earlier MA studies, when Medicare Advantage had fewer beneficiaires. Today, around 20 million people, or 35% of the Medicare population nationally, are in an MA plan.

“As the population has grown and become concentrated in urban areas, there are individuals who have complex conditions,” Mendelson said. For example, more than three-fourths of both MA and traditional beneficiaries have all three chronic conditions of hypertension, hyperlipidemia and diabetes.

Among dual-eligible beneficiaries, Avalere found Medicare Advantage outperformed FFS on utilization, cost and quality. Dual-eligible MA beneficiaires saw their primary care providers more often, had 33% fewer hospitalizations and 42% fewer ER visits compared to FFS Medicare, Avalere found.

“The findings show that for dual eligibles, MA can be compelling from an outcomes perspective,” Mendelson explained. It's an open question of how to facilitate coverage for more of this population in Medicare Advantage as “it's a population that's difficult to care for,” he said.