Comparison of Health Care Utilization by Medicare Advantage and Traditional Medicare Beneficiaries With Complex Care Needs

Key PointsQuestionDo rates of health care utilization for beneficiaries with complex care needs differ between traditional Medicare and Medicare Advantage (MA)? FindingsIn this cross-sectional study of 1844326 Medicare beneficiaries, those enrolled in MA had lower rates of hospital stays, emergency department visits, and 30-day readmissions. The largest relative differences were observed for hospital stays, which ranged from -9.3% to -11.9% across different cohorts of beneficiaries with complex care needs. MeaningAmong Medicare beneficiaries with complex care needs, those enrolled in MA had lower rates of acute care utilization, suggesting that managed care activities in MA may influence the nature and quality of care provided to these beneficiaries. This cross-sectional study uses claims data to compare patterns of health care utilization between Medicare Advantage and traditional Medicare beneficiaries with complex care needs. ImportanceMedicare 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. ObjectiveTo compare health care utilization for MA and TM beneficiaries with complex care needs. Design, Setting, and ParticipantsThis 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. ExposuresEnrollment in MA vs TM. Main Outcomes and MeasuresHospital stays (inpatient admissions and observation stays), emergency department (ED) visits, and 30-day readmissions. ResultsAmong a study population of 1844326 Medicare beneficiaries (mean [SD] age, 75.6 [7.1] years; 1021479 [55.4%] women; 1524458 [82.7%] White; 223377 [12.1%] with Medicare-Medicaid dual eligibility), 1177896 (63.9%) were enrolled in MA and 666430 (36.1%) in TM. Beneficiary distribution across cohorts was as follows: frail elderly, 116047 with MA (10.0% of the MA sample) and 104036 with TM (15.6% of the TM sample); major complex chronic, 320954 (27.2%) and 158811 (23.8%), respectively; and minor complex chronic, 740895 (62.9%) and 403583 (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. Conclusions and RelevanceIn 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.