Resource Use and Care Quality Differences Among Medicare Beneficiaries Undergoing Chemotherapy.

Importance: Medicare Advantage (MA) has grown significantly over the last decade; however, MA's performance for patients with serious conditions, such as cancer, remains unclear. Objective: To compare resource use and care quality between MA and traditional Medicare (TM) beneficiaries undergoing cancer chemotherapy. Design, Setting, and Participants: This cohort study used TM claims and MA encounter records from January 2015 to December 2019. Participants were MA and TM beneficiaries who initiated cancer chemotherapy between January 2016 and December 2019. Inverse probability of treatment weighting balanced characteristics between MA and TM beneficiaries, and regression estimation was used. The analysis was conducted between August 2023 and May 2024. Exposure: Chemotherapy initiation after a 1-year washout period. Main Outcomes and Measures: Resource use and care quality were measured during a 6-month period following chemotherapy initiation. Resource use was measured using standardized prices for services in both MA and TM, covering hospital inpatient services, outpatient care, Part D drugs, and hospice services. Chemotherapy utilization was examined for Part B chemotherapy, Part B supportive drugs, and Part D chemotherapy. Quality measures included chemotherapy-related emergency department (ED) visits and hospitalizations, avoidable ED visits, preventable hospitalizations during the 6-month episode, and survival days up to 18 months from chemotherapy initiation. Results: The study comprised 96 501 MA enrollees contributing to 98 872 episodes (mean [SD] age, 72.9 [7.6] years; 55 859 [56.5%] female; 7371 [7.5%] Hispanic, 14 778 [14.9%] non-Hispanic Black, and 75 130 [75.0%] non-Hispanic White participants) and 206 274 TM beneficiaries, contributing 212 969 episodes (mean [SD] age, 72.7 [8.3] years; 121 263 [56.9%] female; 8356 [3.9%] Hispanic, 16 693 [7.8%] non-Hispanic Black, and 182 228 [85.6%] non-Hispanic White participants). Adjusted total resource use per enrollee during the 6-month episode was $8718 (95% CI, $8343 to $9094) lower in MA than TM ($62 599 vs $71 317). Part B chemotherapy resource use accounted for most of the difference in total resource use, with MA enrollees having $5032 (95% CI, $4772 to $5293) lower use than TM beneficiaries. Lower resource use for Part B chemotherapy in MA was associated with both fewer chemotherapy visits (-1.06 visits; 95% CI, -1.10 to -1.02 visits) and less expensive chemotherapy per visit (-$277; 95% CI, -$275 to -$179). Findings on quality were mixed, but importantly, survival did not differ between MA and TM patients who initiated chemotherapy. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with cancer undergoing chemotherapy, MA enrollment was associated with lower resource use but not shorter survival.

County-Level Enrollment in Medicare Advantage Plans Offering Expanded Supplemental Benefits.

Importance: Since 2019 and 2020, Medicare Advantage (MA) plans have been able to offer supplemental benefits that address long-term services and supports (LTSS) and social determinants of health (SDOH). Objective: To examine the temporal trends and geographic variation in enrollment in MA plans offering LTSS and SDOH benefits. Design, Setting, and Participants: This cross-sectional study used publicly available data to examine changes in beneficiary enrollment and plan offerings of LTSS and SDOH benefits from the benefits data from the second quarter of each year and other data from April of each year except 2024, for which the first quarter was the latest for benefits data and January the latest for other data at the time of analysis. Multivariable linear regression models for each type of benefit were used to investigate associations between county characteristics and enrollment in 2024. Analyses were stratified for (1) Dual Eligible Special Needs Plans (D-SNPs) that exclusively enroll dual-eligible beneficiaries and (2) non-D-SNPs. Main Outcomes and Measures: The percentage of MA enrollees in plans offering LTSS or SDOH benefits at the county level. Results: This study included 2 631 697 D-SNP and 20 114 506 non-D-SNP enrollees in 2020, which increased to 5 494 426 and 25 561 455, respectively, in 2024. From 2020 to 2024, the percentage of D-SNP enrollees in plans offering SDOH benefits increased from 9% to 46%, whereas the percentage fluctuated between 23% and 39% for LTSS benefits. There was an increase in non-D-SNP enrollees with LTSS (from 9% to 22%) and SDOH (from 4% to 20%) benefits from 2020 to 2023, which decreased in 2024. In 2024, the most offered LTSS benefit was in-home support services, and the most offered SDOH benefit was food and produce. The percentage of enrollees with these benefits varied across counties in 2024. In multivariable linear regression models, among D-SNPs, enrollment in plans offering any SDOH benefits was higher in counties with greater MA penetration (coefficient, 5.0 percentage points [pp] per 10-pp change; 95% CI, 2.1-7.9 pp), in urban counties (coefficient, 7.2 pp vs rural counties; 95% CI, 3.8-10.6 pp), in counties with greater enrollment in fully integrated D-SNPs (coefficient, 3.0 pp per 10-pp change; 95% CI, 2.2-3.9 pp), and in counties in states with approved Medicaid home- and community-based services waivers for individuals 65 years or older or those with disabilities (coefficient, 10.8 pp; 95% CI, 4.0-17.6 pp). Enrollment in D-SNPs offering LTSS benefits was also higher in counties with greater MA penetration (coefficient, 5.9 pp per 10-pp change; 95% CI, 2.4-9.5 pp), urban vs rural counties (coefficient, 4.6 pp; 95% CI, 1.1-8.1 pp), and counties with greater enrollment in fully integrated D-SNPs (coefficient, 3.0 pp per 10-pp change; 95% CI, 2.1-3.9 pp) in addition to counties with greater social vulnerability scores (coefficient, 1.4 pp per 10-pp change; 95% CI, 0.3-2.5 pp). Conclusions and Relevance: In this cross-sectional study of MA plans and enrollees, an increase in enrollment was most consistent in D-SNPs offering SDOH benefits compared with LTSS benefits and in D-SNPs compared with non-D-SNPs. Geographic variation in enrollment patterns highlights potential gaps in access to LTSS and SDOH benefits for rural MA beneficiaries and dual-eligible enrollees living in counties with lower enrollment in fully integrated D-SNPs and states with more limited Medicaid home- and community-based services coverage.

Medicare Advantage Enrollment Following the 21st Century Cures Act in Adults With End-Stage Renal Disease.

Importance: In January 2021, under the 21st Century Cures Act, Medicare beneficiaries with end-stage renal disease (ESRD) were permitted to enroll in private Medicare Advantage (MA) plans for the first time. In the first year of the Cures Act, there was a 51% increase in MA enrollment among beneficiaries with ESRD. Objective: To examine changes in MA enrollment among Medicare beneficiaries with ESRD in the first 2 years of the Cures Act and, among beneficiaries newly enrolled in MA in 2021, to assess the proportion of beneficiaries who switched MA contracts and how the characteristics of contracts changed. Design, Setting, and Participants: This cross-sectional, population-based time-trend study was conducted from January 2020 to December 2022. Eligible participants included Medicare beneficiaries with ESRD. Data analysis was conducted from August 2023 to March 2024. Exposure: Enrollment in Medicare during the first 2 years of the 21st Century Cures Act. Main Outcomes and Measures: The primary outcomes were enrollment in MA, switching between traditional Medicare (TM) and MA, and switching between MA contracts from 2021 to 2022. Results: There were 718 252 unique Medicare beneficiaries with ESRD between 2020 and 2022 (1 659 652 beneficiary-years). In 2022, there were 583 203 beneficiaries with ESRD (mean [SD] age, 64.9 [14.1] years, 245 153 female (42.0%); 197 988 Black [34.0%]; 47 912 Hispanic [8.2%]). The proportion of beneficiaries with ESRD who were enrolled in MA increased from 25.1% (118 601 of 472 234 beneficiaries) in January 2020 to 43.1% (211 896 of 491 611 beneficiaries) in December 2022. Increases in MA enrollment were larger in the first year of the Cures Act (12.6 percentage points [pp]; 95% CI 12.3-12.8 pp) compared with the second year (5.7 pp; 95% CI, 5.5-5.9 pp). Changes between December 2020 and December 2022 ranged between 49.3% for Asian or Pacific Islander beneficiaries (difference = 13.0 pp; 95% CI, 12.2-13.8 pp) and 207.2% for American Indian or Alaska Native beneficiaries (difference = 17.0 pp; 95% CI, 15.3-18.7 pp). Changes were high among partial dual-eligible (difference = 35.5 pp; 95% CI, 34.9-36.1 pp; 134.7% increase) and fully dual-eligible beneficiaries (difference = 22.8 pp, 95% CI, 22.5-23.1 pp; 98.0% increase). Among 53 366 beneficiaries enrolled in MA in 2021, 37 439 (70.2%) remained in their contract, 11 730 (22.0%) switched contracts, and 4197 (7.9%) switched to TM in 2022. Compared with the characteristics of MA enrollees with ESRD in 2021, those in 2022 were more likely to be in contracts with lower premiums and with a rating of 4.5 stars or higher. Conclusions and Relevance: In this cross-sectional time-trend study of Medicare beneficiaries with ESRD, MA enrollment continued to increase in the second year of the Cures Act, particularly among racially or ethnically minoritized individuals and dual eligible populations. These findings suggest need to monitor the equity of care for beneficiaries with ESRD as they enroll in managed care plans.

Contract Termination and Insurance Enrollment Among Medicare Advantage Beneficiaries.

Importance: Approximately one-fifth of Medicare Advantage (MA) contracts terminated their participation in the MA program between 2011 and 2020. Little is known about subsequent insurance choices following a termination. Objective: To examine the insurance destinations of MA enrollees and the characteristics of enrollees who switch into traditional Medicare (TM) after a contract termination. Design, Setting, and Participants: This cross-sectional study examined MA program data of MA beneficiaries in the Medicare Master Beneficiary File from 2016 to 2018. Statistical analysis was performed from June 2023 to April 2024. Exposures: Beneficiary characteristics, including age, sex, race and ethnicity, dual eligibility; hospital, nursing home, and home health utilization; and contract characteristics, including plan type, vertical integration, premium, and MA star rating. Main Outcome and Measures: The main outcome was switching to TM in the year immediately after termination. We also evaluated the characteristics of contracts among those who remained in MA. Results: A total of 117 681 beneficiaries were included in this analysis (64 654 [54.9%] female; 409 [0.4%] American Indian or Alaska Native; 2817 [2.4%] Asian; 76 725 [16.8%] Black; 11 131 [9.5%] Hispanic; 81 226 [69.0%] White; and 2373 [2.0%] other race or ethnicity; 27 078 [23.0%] dual-eligible; mean [SD] age, 71.2 [10.4] years). Following a contract termination, 20.1% (95% CI, 19.9%-20.4%) of enrollees switched to TM, including 32.7% (95% CI, 32.4%-33.1%) of dual-eligible beneficiaries and 16.4% (95% CI, 16.2%-16.5%) of non-dual-eligible beneficiaries. In nonterminated contracts, the concurrent switch rate was 6.2% (95% CI, 6.2%-6.2%) for all, 10.4% (95% CI, 10.4%-10.4%) for dual-eligible beneficiaries and 5.1% (95% CI, 5.1%-5.1%) for non-dual-eligible enrollees. The highest switch rates to TM were among Black enrollees (32.3% [95% CI, 31.7%-32.8%]) and those with prior use of hospital (31.3% [95% CI, 30.7%-31.9%], nursing home, 41.4% [95% CI, 40.4%-42.4%], or home health care (28.3% [95% CI, 27.4%-29.2%]). Beneficiaries who stayed in MA selected higher-rated star plans (mean posttermination contract star rating of 3.8 [95% CI, 3.8-3.8] stars compared with 3.3 [95% CI, 3.3-3.3] stars in the terminated year), but did not pay more in monthly premiums with 66.5% (95% CI, 66.2%-66.8%) paying the same or lower premiums. Conclusions and Relevance: In this cross-sectional study, 1 in 5 MA beneficiaries switched to TM after a contract termination, with Black beneficiaries and those with more intensive health needs having the highest switch rates. These findings highlight the need to examine consequences of contract terminations and subsequent insurance destinations on access to care and health outcomes, especially among those with marginalized race and ethnicity, those who are dual-eligible, and beneficiaries with higher health care needs.

Epidemiology of Homebound Population Among Beneficiaries of a Large National Medicare Advantage Plan.

BACKGROUND: Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown. OBJECTIVE: To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan. DESIGN: Cross-sectional. SETTING: National MA plan. PARTICIPANTS: Humana MA beneficiaries in 2022 (n = 2 435 519). MEASUREMENTS: Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status. RESULTS: In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58]). LIMITATION: The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability. CONCLUSION: Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries. PRIMARY FUNDING SOURCE: Humana, under a collaborative research agreement with Johns Hopkins University.

Addressing the Marketing Practices of Medicare Advantage Plans.

The Medicare Advantage (MA) Program, home to nearly half of the eligible Medicare population, has recently come under increased scrutiny. Recent investigations conducted by the United States Senate Committee on Finance and Centers for Medicare & Medicaid Services (CMS) have uncovered marketing practices of MA insurance agents that "were not complying with current regulation and unduly pressuring beneficiaries, as well as failing to provide accurate or enough information to assist a beneficiary in making an informed enrollment decision." These findings come at a time in which MA programs are under investigation for denials of prior authorization requests that fall within Medicare guidelines for covered health services. In this Commentary we consider the backdrop for the growing scrutiny of the MA program and the implications thereof to its future trajectory.

Medicare Advantage customer service is used most by higher-need patients.

OBJECTIVES: To examine characteristics of Medicare Advantage (MA) enrollees who use their plan's customer service to help plans understand how to better meet members' needs. STUDY DESIGN: National sample of 259,533 respondents to MA Consumer Assessment of Healthcare Providers and Systems survey enrolled in any of the 559 MA contracts in 2022. METHODS: We assessed the association between self-reported customer service use in the prior 6 months and enrollee demographic, coverage, health, and health care utilization characteristics. We used weighted linear regression models to test for bivariate and multivariate associations between customer service use and enrollee characteristics. RESULTS: Forty-two percent of MA enrollees reported using customer service in the prior 6 months. Use was 20 percentage points (PP) higher for those in poor vs excellent/very good general health, 13 PP higher for those in poor vs excellent/very good mental health, and 14 PP higher for those reporting 3 or more vs no chronic conditions. Those using customer service more often had lower educational attainment, had limited income and assets, preferred another language to English, and had greater health care utilization. CONCLUSIONS: MA customer service supports a less healthy, higher-need population with greater-than-average barriers to health care, and so should be designed and staffed to effectively serve medically complex, high-need patients. Commercial plan evidence suggests that continuity in customer service support for a member or a given issue may be helpful. Customer service is an important mechanism for improving quality and addressing health equity.

Frailty in Medicare Advantage Beneficiaries and Traditional Medicare Beneficiaries.

Importance: A growing proportion of the population is enrolling in Medicare Advantage (MA), which typically offers additional benefits compared with traditional Medicare (TM). Objective: To determine whether frailty and frailty trajectories differ between MA enrollees and TM enrollees. Design, Setting, and Participants: This retrospective cohort study used data from the National Health and Aging Trends Study (2015-2016). Analyses were conducted from August 2023 to March 2024. Participants were community-dwelling Medicare beneficiaries aged 65 years and older. Exposure: Enrollment in MA vs TM. Main Outcomes and Measures: Frailty was calculated by a frailty index (FI) (range, 0-1, with higher values indicating greater frailty) and the Fried Frailty Phenotype (FFP) score (range, 0-5, with higher values indicating greater frailty). Physical performance, including Short Physical Performance Battery (SPPB) score (range, 0-12, with higher values indicating better performance), and gait speed (meters per second) were measured. The primary outcome was the difference in FI and FFP scores from the 2015 baseline assessment to the 2016 follow-up assessment. Secondary outcomes include the 1-year changes in SPPB and gait speed. Results: The final cohort consisted of 7063 participants (2775 [23.1%] aged >80 years; 4040 [54.7%] female), representing a sample of the 38.8 million beneficiaries. There were 2583 (35.0%) MA enrollees (13.6 million) and 4480 (65.0%) TM enrollees (25.2 million). At baseline, the FI score was similar between MA and TM enrollees (mean [SD], 0.22 [0.15] vs 0.21 [0.14]), although MA enrollees had worse phenotypic frailty (496 participants [15.2%] vs 811 participants [13.7%] considered frail by FFP score), SPPB scores (mean [SD], 6.91 [3.34] vs 7.21 [3.27]), and gait speed (0.79 [0.24] m/s vs 0.82 [0.23] m/s) than TM enrollees. One year later, there were no differences between MA and TM enrollees in the 1-year change in FI score (mean [SD], 0.016 [0.071] vs 0.014 [0.066]; adjusted mean difference, 0.001 [95% CI, -0.004 to 0.005]), FFP score (mean [SD], 0.017 [1.004] vs 0.007 [0.958]; adjusted mean difference, -0.009 [95% CI, -0.067 to 0.049]), SPPB score (mean [SD], -0.144 [2.064] vs -0.211 [1.968]; adjusted mean difference, 0.068 [95% CI, -0.076 to 0.212]), and gait speed (mean [SD], -0.0160 [0.148] m/s vs -0.007 [0.148] m/s; adjusted mean difference, -0.010 m/s [95% CI, -0.067 to 0.049 m/s]). Conclusions and Relevance: In this cohort study of Medicare beneficiaries from 2015, MA enrollees experienced similar declines in frailty over 1 year compared with TM enrollees. Future work should examine whether the specific types of services covered by health insurance can impact frailty and health trajectories for older adults.

Medicare Advantage Plan Star Ratings and County Social Vulnerability.

Importance: The star rating of a Medicare Advantage (MA) plan is meant to represent plan performance, and it determines the size of quality bonuses. Consumer access to MA plans with a high star rating may vary by the extent of social vulnerability in geographic regions. Objective: To examine the association between a county's Social Vulnerability Index (SVI) and the star rating of a county's MA plans. Design, Setting, and Participants: This cross-sectional study used 2023 Centers for Medicare & Medicaid Services data for all MA plans linked to 2020 county-level SVI data from the Centers for Disease Control and Prevention. Data were analyzed from March to October 2023. Exposure: Quintile rank of county based on composite and theme-specific SVI scores, with quartile 1 (Q1) representing the least vulnerable counties and Q5, the most vulnerable counties. The SVI is a multidimensional measure of a county's social vulnerability across 4 themes: socioeconomic status, household characteristics (such as disability, age, and language), racial and ethnic minority status, and housing type and transportation. Main Outcomes and Measures: County-level mean star rating and the number of MA plans with low-rated (<3.5 stars), high-rated (3.5 or 4.0 stars), and highest-rated (≥4.5 stars) plans. Results: Across 3075 counties, the median county-level star rating was 4.1 (IQR, 3.9-4.3) in Q1 counties and 3.8 (IQR, 3.6-4.0) in Q5 counties (P < .001). The mean star rating of MA plans was lower (difference, -0.24 points; 95% CI, -0.28 to -0.21 points; P < .001), the number of low-rated plans was higher (incidence rate ratio, 1.81; 95% CI, 1.61-2.06; P < .001), and the number of highest-rated plans was lower (incidence rate ratio, 0.75; 95% CI, 0.70-0.81; P < .001) in Q5 counties compared with Q1 counties. Similar patterns were found across theme-specific SVI score quintiles and for 2022 star ratings. Conclusions and Relevance: In this cross-sectional study, the most socially vulnerable counties were found to have the fewest highest-rated plans for MA beneficiaries. As MA enrollment grows in socially vulnerable regions, this may exacerbate regional differences in health outcomes for Medicare beneficiaries.

Medicare-Covered Services Near the End of Life in Medicare Advantage vs Traditional Medicare.

Importance: Financial incentives in Medicare Advantage (MA), the managed care alternative to traditional Medicare (TM), were designed to reduce overutilization. For patients near the end of life (EOL), MA incentives may reduce potentially burdensome care and encourage hospice but could also restrict access to costly but necessary services. Objective: To compare receipt of potentially burdensome treatments and transfers and potentially necessary postacute services in the last 6 months of life in individuals with MA vs TM. Design, Setting, and Participants: A retrospective analysis of Medicare claims data among older Medicare beneficiaries who died between 2016 and 2018. The study included Medicare decedents aged 66 years or older covered by TM (n = 659 135) or MA (n = 360 430). All decedents and the subset of decedents with 1 or more emergent hospitalizations with a life-limiting condition (cancer, dementia, end-stage organ failure) that would likely qualify for hospice care were included. Exposure: MA enrollment. Main Outcomes: Receipt of potentially burdensome hospitalizations and treatments; receipt of postdischarge home and facility care. Results: The study included 659 135 TM enrollees (mean [SD] age at death, 83.3 [9.0] years, 54% female, 15.1% non-White, 55% with 1 or more life-limiting condition) and 360 430 MA enrollees (mean [SD] age at death 82.5 [8.7] years, 53% female, 19.3% non-White, 49% with 1 or more life-limiting condition). After regression adjustment, MA enrollees were less likely to receive potentially burdensome treatments (-1.6 percentage points (pp); 95% CI, -2.1 to -1.1) and less likely to die in a hospital (-3.3 pp; 95% CI, -4.0 to -2.7) compared with TM. However, when hospitalized, MA enrollees were more likely to die in the hospital (adjusted difference, 1.3 pp; 95% CI, 1.1-1.5) and less likely to be transferred to rehabilitative or skilled nursing facilities (-5.2 pp; 95% CI, -5.7 to -4.6). Higher rates of home health and home hospice among those discharged home offset half of the decline in facility use. Results were unchanged in the life-limiting conditions sample. Conclusions: MA enrollment was associated with lower rates of potentially burdensome and facility-based care near the EOL. Greater use of home-based care may improve quality of care but may also leave patients without adequate assistance after hospitalization.

Medicare Advantage Plan and Health System Vertical Integration, 2011-2020.

This cross-sectional study compares the beneficiary and plan characteristics and trends in enrollment, premiums, star ratings, and benefits of nonintegrated, non­legacy-integrated, and legacy-integrated Medicare Advantage plans between 2011 and 2020.

Prevalence of Independence at Home-Qualifying Beneficiaries in Traditional Medicare, 2014-2021.

Importance: The Centers for Medicare & Medicaid Services Innovation Center Independence at Home (IAH) demonstration, a test of home-based primary care operating in a value-based shared-savings payment model, ended December 2023 after a decade of consistently showing savings to Medicare. It is important to assess whether high-need, IAH-qualified beneficiaries continue to pose a growing challenge to traditional Medicare (TM) or if Medicare Advantage (MA), with programmatic features favorable to caring for this subset of the general Medicare population, can disproportionately provide such care. Objective: To examine the size and share of IAH-qualified beneficiaries in TM and MA. Design, Setting, and Participants: This cohort study used all Medicare claims data and MA encounter data for 2014 and 2021. IAH qualifying criteria were applied to the TM populations enrolled in Parts A and B in 2014 and 2021, and to MA enrollees in 2021. Growth in the number of IAH-qualified TM beneficiaries from 2014 to 2021 was calculated, and the proportions and numbers of IAH-qualified enrollees in the total 2021 TM and MA populations were compared. Data were analyzed between April and June 2023. Main Outcomes and Measures: The number and share of beneficiaries meeting IAH criteria in TM and MA; the share of TM spending among IAH-qualified beneficiaries. Results: Among 64 million Medicare beneficiaries in 2021, there were 30.55 million beneficiaries in TM with Parts A and B coverage, down from 33.82 million in 2014. The number of IAH-qualified beneficiaries in TM grew 51%, from 2.16 million to 3.27 million, while their proportionate share in TM grew 67% from 6.4% to 10.7% of TM between 2014 and 2021. IAH-qualified beneficiaries represented $155 billion in 2021 Medicare Parts A and B spending, 44% of all TM spending, up from 29% of total spending in 2014. In 2021, 2.15 million IAH-qualified beneficiaries represented 8.0% of Medicare Advantage enrollees. Combining TM and MA, 5.42 million IAH-qualified beneficiaries represented 9.3% of all Medicare beneficiaries, with 3.27 million (60.3%) being insured by TM. Conclusions and Relevance: In this cohort study of IAH-qualified Medicare beneficiaries, the share of IAH-qualified beneficiaries in TM grew between 2014 and 2021, with 60% of Medicare high-need beneficiaries accounting for 44% of TM spending. The Centers for Medicare & Medicaid Services should continue to operate value-based programs like IAH that are specifically designed for these high-needs individuals.

Unfulfilled home health referrals lead to higher mortality among Medicare Advantage members.

OBJECTIVES: Medicare Advantage (MA) members referred to home health after inpatient hospitalization may or may not receive these services for a variety of member- and health care system-related reasons. Our objective was to compare outcomes among MA members referred to home health following hospitalization who receive home health services vs those who do not. STUDY DESIGN: Retrospective quasi-experimental study. METHODS: Following acute hospitalization, members with discharge orders to receive home health services between January 2021 and October 2022 were identified in a medical claims database consisting of MA beneficiaries. Members who received services within 30 days of discharge were balanced using inverse propensity score weighting on member- and admission-related covariates with a comparator group of members who did not receive services. Primary outcomes included mortality and readmissions in the ensuing 30, 90, and 180 days. Secondary outcomes included emergency department visits, primary care visits, and per-member per-month costs. RESULTS: The home health-treated group consisted of 2115 discharges, and the untreated group consisted of 761 discharges. The treated group experienced lower mortality at 30 days (2% vs 3%, respectively; OR, 0.58; 95% CI, 0.36-0.92), 90 days (8% vs 10%; OR, 0.77; 95% CI, 0.60-0.98), and 180 days (11% vs 14%; OR, 0.81; 95% CI, 0.65-0.99). The treated group also experienced higher readmissions at 30 days (13% vs 10%; OR, 1.26; 95% CI, 1.01-1.60), 90 days (24% vs 16%; OR, 1.69; 95% CI, 1.39-2.05), and 180 days (33% vs 24%; OR, 1.52; 95% CI, 1.29-1.79). CONCLUSION: MA members referred to home health after acute hospitalization who did not receive home health services had higher mortality.

The impacts of supplemental benefits on Medicare Advantage plan composition.

OBJECTIVES: In 2019 and 2020, Medicare Advantage (MA) plans received historic flexibility to begin to address members' nonmedical and social needs through a set of primarily health-related benefits (PHRBs) and Special Supplemental Benefits for the Chronically Ill (SSBCIs). We aimed to evaluate the impact of adoption on the number and composition of new MA plan enrollees. STUDY DESIGN: A difference-in-differences design of retrospective Medicare enrollment data linked to publicly available plan and county-level data. METHODS: We linked individual-level Medicare enrollment data to publicly available, plan-level MA benefit, crosswalk, and penetration files from 2016 to 2020. We compared the number of new enrollees and the proportion of new enrollees who were Black, Hispanic, younger than 65 years, partially and fully Medicare and Medicaid dual eligible, and disabled in plans that adopted a PHRB or SSBCI vs a set of matched control plans that did not. RESULTS: In fully adjusted models, PHRB adoption was associated with a 2.2% decrease in the proportion of fully dual-eligible new members (95% CI, -4.0% to -0.5%). SSBCI adoption was associated with a 2.3% decrease in the proportion of new members younger than 65 years (95% CI, -3.6% to -0.9%). After accounting for multiple comparisons, these results were no longer statistically significant. CONCLUSION: We determined that supplemental benefit adoption was not associated with demographic shifts in MA plan enrollment.

New Supplemental Benefits and Plan Ratings Among Medicare Advantage Enrollees.

Importance: In 2018, the US Congress gave Medicare Advantage (MA) historic flexibility to address members' social needs with a set of Special Supplemental Benefits for the Chronically Ill (SSBCIs). In response, the Centers for Medicare & Medicaid Services expanded the definition of primarily health-related benefits (PHRBs) to include nonmedical services in 2019. Uptake has been modest; MA plans cited a lack of evidence as a limiting factor. Objective: To evaluate the association between adopting the expanded supplemental benefits designed to address MA enrollees' nonmedical and social needs and enrollees' plan ratings. Design, Setting, and Participants: This cohort study compared the plan ratings of MA enrollees in plans that adopted an expanded PHRB, SSBCI, or both using difference-in-differences estimators with MA Consumer Assessment of Health Care Providers and Systems survey data from March to June 2017, 2018, 2019, and 2021 linked to Medicare administrative claims and publicly available benefits and enrollment data. Data analysis was performed between April 2023 and March 2024. Exposure: Enrollees in MA plans that adopted a PHRB and/or SSBCI in 2021. Main Outcomes and Measures: Enrollee plan rating on a 0- to 10-point scale, with 0 indicating the worst health plan possible and 10 indicating the best health plan possible. Results: The study sample included 388 356 responses representing 467 MA contracts and 2558 plans in 2021. Within the weighted population of responders, the mean (SD) age was 74.6 (8.7) years, 57.2% were female, 8.9% were fully Medicare-Medicaid dual eligible, 74.6% had at least 1 chronic medical condition, 13.7% had not graduated high school, 9.7% were helped by a proxy, 45.1% reported fair or poor physical health, and 15.6% were entitled to Medicare due to disability. Adopting both a new PHRB and SSBCI benefit in 2021 was associated with an increase of 0.22 out of 10 points (95% CI, 0.4-4.0 points) in mean enrollee plan ratings. There was no association between adoption of only a PHRB (adjusted difference, -0.12 points; 95% CI, -0.26 to 0.02 points) or SSBCI (adjusted difference, 0.09 points; 95% CI, -0.03 to 0.21 points) and plan rating. Conclusions and Relevance: Medicare Advantage plans that adopted both benefits saw modest increases in mean enrollee plan ratings. This evidence suggests that more investments in supplemental benefits were associated with improved plan experiences, which could contribute to improved plan quality ratings.

Primary care visit cadence and hospital admissions in high-risk patients.

OBJECTIVES: Most Medicare beneficiaries obtain supplemental insurance or enroll in Medicare Advantage (MA) to protect against potentially high cost sharing in traditional Medicare (TM). We examined changes in Medicare supplemental insurance coverage in the context of MA growth. STUDY DESIGN: Repeated cross-sectional analysis of the Medicare Current Beneficiary Survey from 2005 to 2019. METHODS: We determined whether Medicare beneficiaries 65 years and older were enrolled in MA (without Medicaid), TM without supplemental coverage, TM with employer-sponsored supplemental coverage, TM with Medigap, or Medicaid (in TM or MA). RESULTS: From 2005 to 2019, beneficiaries with TM and supplemental insurance provided by their former (or current) employer declined by approximately half (31.8% to 15.5%) while the share in MA (without Medicaid) more than doubled (13.4% to 35.1%). The decline in supplemental employer-sponsored insurance use was greater for White and for higher-income beneficiaries. Over the same period, beneficiaries in TM without supplemental coverage declined by more than a quarter (13.9% to 10.1%). This decline was largest for Black, Hispanic, and lower-income beneficiaries. CONCLUSIONS: The rapid rise in MA enrollment from 2005 to 2019 was accompanied by substantial changes in supplemental insurance with TM. Our results emphasize the interconnectedness of different insurance choices made by Medicare beneficiaries.