As Medicare Advantage (MA) eclipses more and more of the Medicare market, it is critical to understand how MA plans are able to save costs and provide quality care to recipients.
One recent study published in JAMA Network found MA has fewer instances of low-value care––such as tests, treatments and procedures that provide little to no clinical benefit––compared to traditional Medicare. The cross-sectional study of more than 2.4 million Medicare beneficiaries found that MA beneficiaries received 9.2% fewer low-value services compared to traditional Medicare beneficiaries in 2019.
In general, low-value care is a big money-waster across the healthcare industry, as well as a cause of inefficiency and even potential harm. As many as one-third of Medicare beneficiaries receive low-value services annually, the study noted. The study was conducted by researchers from Humana, which is one of the top MA providers in the U.S., with 5 million enrollees, according to the Kaiser Family Foundation. It is also notable that the study is published as the ongoing discussion about prior authorization creating burdens and delayed care, as MA plans can require prior authorization before beneficiaries can receive care. Traditional Medicare does not require prior authorization for most services, in contrast.
While low-value services are prevalent––and costly––not much progress has been made to limit it, and efforts to reduce low-value care have been primarily dedicated to raising awareness of it, the researchers noted. MA plans may be better suited to reduce low-value services thanks to their abilities to create their own networks, incentivize in-network care and review tests, treatments and procedures.
“Despite considerable research and policy attention to low-value care in TM, to our knowledge comparatively little is known about low-value care in the MA program,” wrote first author Emily Boudreau, PhD, MPhil, of Humana, et al.
Researchers analyzed a sample of MA beneficiaries from enrollees in plans offered by a large, national insurer, and the study was reviewed by the Humana Healthcare Research Human Subject Protection Office. The study looked at 26 low-value services relevant to the Medicare population, finding the 9.2% lower rate of low-value services among MA beneficiaries compared to traditional Medicare.
“Our findings have several implications for efforts to reduce low-value care,” researchers wrote. “Within the [traditional Medicare] program, in which low-value care has remained prevalent despite policy and research attention, it may be possible to leverage elements of insurance design to encourage the de-adoption of low-value services.”
One such solution is to expand value-based payment models, as well as create preferred networks. Outside of traditional Medicare, researchers saw opportunities to “optimize network design, product design, utilization management, value-based payment and other elements of insurance design to reduce the prevalence of low-value care.”
Amy joined TriMed Media as a Senior Writer for HealthExec after covering home care for three years. When not writing about all things healthcare, she fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."