Summary: A national study of 2.2 million Medicare hospital admissions for heart attacks finds no clinical differences between Medicare Advantage and Traditional Medicare by 2018. At best, Medicare Advantage is providing equal outcomes at higher cost.
Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction, JAMA, December 6, 2022, by Bruce E. Landon, et al.
OBJECTIVE: To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018.
RESULTS: [statistical detail removed for clarity]
[Clinical] Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6%). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) … By 2018, there was no … significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare.
[Utilization] Rates of guideline-recommended medication prescriptions were … higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%)…. Medicare Advantage patients were … less likely to be admitted to an ICU than traditional Medicare patients (50.3% vs 51.2%) and more likely to be discharged to home rather than to a postacute facility (71.5% vs 70.2%). Adjusted 30-day readmission rates were lower in Medicare Advantage than in traditional Medicare (13.8% vs 15.2% and 11.2%vs 11.9%).
CONCLUSIONS AND RELEVANCE: Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018.
By Jim Kahn, M.D., M.P.H.
This impressive comparison of Medicare Advantage [MA] and Traditional Medicare [TM] in the management of acute myocardial infarctions (aka heart attacks) finds no differences in clinical outcomes and small differences in utilization. What are we to learn from this?
I’m not terribly interested in the utilization differences. They’re small, and may reflect MA plan cost control goals instead of clinical quality.
I prefer to focus on health results, as the authors did. Let’s look at these closely.
1) Clinical outcomes for heart attacks appear similar for MA and TM overall, by 2018. Thus, MA is not providing meaningful health advantages for this clinical situation. That leads to the question, why pay more, as MA forces us to?
2) An apparent MA advantage for 30-day mortality disappeared from 2009-2018. This makes sense, since the MA population evolved from very much healthier than TM to close in health status. However, there may still be a statistical bias making MA care look better than it is.
Geek detour: We know that MA plans aggressively upcode certain diagnoses to increase capitation rates. Once these clinical diagnoses are in the electronic health record, hospital doctors have the opportunity, and indeed a medical obligation, to assess and manage them. As a result, hospitalization summaries may list the added diagnoses as comorbidities. The TM patient doesn’t have this upcoding. In the analysis of clinical outcomes, it could look like the hospital did as well with similar MA and TM patients, when in fact the MA patients are a bit healthier than similarly coded TM patients. This introduces a bias that favors MA.
Summary in nearly normal speak: Small differences in hospital comorbidities due to diagnostic upcoding may make MA care look better than it is.
Summary in fully normal speak: MA care may not be as good as it appears.
3) Even if MA outcomes are about as good as TM overall, this doesn’t capture significant variation across MA plans. Beneficiaries have no way to determine which plans provide better care. It’s a crap shoot.
4) P.S., why are we using data that are four years old? Our healthcare data system is kludgy, due largely to the kludginess of our health care payment system. Single payer data would be streamlined and current.
Takeaway: It’s good that MA appears similar to TM in clinical outcomes, at least for heart attacks. I’m worried that the analysis is still biased. But even if MA is close on clinical outcomes, why is that good enough? We know that MA creates big cost problems – for CMS and for sick beneficiaries. Why would we pay more for something that’s not better?
With single payer, we’d pay less for medical care that’s superior.