Uwe E. Reinhardt is an economics assistant at Princeton. He has some banking interests in the bloom affliction field.
My antecedent three posts on Medicare elicited able reactions on the affection of bloom affliction delivered beneath acceptable Medicare and beneath Medicare Advantage affairs that accomplish beneath Allotment C of Medicare. Two battling theories can be discerned in the commentary.
Theory II holds that Medicare Advantage affairs accept able incentives to advance the affection of the affliction they annex for patients, because the affairs are subjected to far added analytical affection ecology than is acceptable Medicare. Poor affection ratings aching them financially, because these ratings are fabricated accepted to patients who are chargeless to about-face affairs or acknowledgment to acceptable Medicare.
These theories arise to be based mainly on claimed adventures — that is, on anecdotal evidence. The catechism is what systematic, added able-bodied empiric affirmation ability afford ablaze on these two theories.A acceptable abode to alpha is the affirmation aggregate by the Medicare Payment Advisory Commission, accepted as Medpac, accustomed by Congress in 1997 to admonish it on affairs accompanying to Medicare. It is a anatomy of experts and stakeholders, accurate by an accomplished analysis staff.
In its latest anniversary address (in March 2012) to Congress, the agency adherent Chapter 12 to a array of issues apropos the Medicare Advantage program, including the affection of the affliction the affairs annex for patients and their own authoritative services. To my abruptness and disappointment, the address devotes no added than 173 words to a allegory of the affection of affliction in Medicare Advantage affairs and acceptable Medicare, forth with one table (see Table 12-8, Pages 327-8).
A added chase for abstract accurately addressed to this catechism yields bare after-effects as well. It is accordingly not hasty that claimed anecdotes or those in the media acquaint the prevailing ballad on the subject. I can anticipate of two affidavit for the absence of absolute analysis on this issue.
First, the characterization Medicare Advantage encompasses a array of plans. These accommodate accommodating affliction affairs (C.C.O.’s), like acceptable bloom aliment organizations (H.M.O.’s); bounded adopted provider organizations (P.P.O.’s); bounded P.P.O.’s, anniversary all-embracing several states, and special-needs affairs for patients with adapted medical needs. Medicare Advantage additionally includes clandestine fee-for-service affairs that action chargeless best of providers and unmanaged affliction aloof like acceptable fee-for-service Medicare.
As Medpac reports, the achievement on affection metrics amid these affairs varies systematically amid types, and it is apt to alter additionally aural plan types (see Table 12-4, Page 323). H.M.O.’s and bounded P.P.O.’s tend to rank accomplished in quality, clandestine fee-for-service affairs lowest.
Even if on boilerplate the affection of affliction beneath these affairs were begin to be good, the about-face amid affairs about that boilerplate can assuredly crop the affectionate of anecdotes that ammunition Theory I above. It is a botheration with any average, yet abstracts from amusing science are based on axial tendencies – averages or medians.
Second, as already noted, there is far added all-encompassing and accelerated ecology of affection in Medicare Advantage affairs than there is for the advancing acceptable Medicare.
Both acceptable Medicare and Medicare Advantage affairs are monitored annually through surveys of patients, application the Consumer Assessment of Bloom Affliction Providers and Systems, accepted in the barter as Cahps. The allegation from this analysis accomplish it accessible to analyze acceptable Medicare with Medicare Advantage affairs on quality. As Medpac letters in Table 12-8 of Chapter 12 of the March 2012 report, the agency begin little aberration in the almost few quality-performance array of the acceptable Medicare and Medicare Advantage plans.
In accession to the Cahps survey, Medicare Advantage affairs – but not acceptable Medicare – are monitored anxiously by two added analysis systems.
The aboriginal is the Bloom Effectiveness Abstracts and Advice Set, or Hedis. The Hedis array are based on advice from surveys of beneficiaries, from authoritative and claims data, and from patients’ analytic records. The array are taken actual actively by clandestine bloom affairs in both the clandestine and accessible area of bloom care.
The additional is the Medicare Bloom Outcomes Survey, or HOS. It retrieves self-reported advice on bloom cachet from Medicare beneficiaries in Medicare Advantage plans.
Finally, and actual importantly, the Affordable Affliction Act of 2010 accustomed a benefit arrangement for Medicare Advantage affairs angry to alleged brilliant ratings. These ratings are based on 53 metrics fatigued from the Cahps, Hedis and HOS systems, with 1 cogent “poor performance” and 5 cogent “excellent performance.”
Medicare’s brilliant arrangement sets aerial standards. In 2012, for example, alone 11 of about 500 bloom affairs becoming the accomplished score. Six of these were allotment of Kaiser Permanente, with addition Kaiser plan earning a 4.5. A aberration of one point in this appraisement arrangement can spell ample sums in the anatomy of becoming or absent benefit payments from Medicare.
As noted, a chase for abstract on the about achievement on affection by acceptable Medicare and Medicare Advantage affairs yields abbreviate pickings.
Several studies undertaken by or at the bidding of the American Bloom Allowance Plans, or AHIP, address that hospital readmission ante beneath Medicare Advantage are essentially lower than they are beneath acceptable Medicare. Although not all hospital readmissions aftereffect from poor analytic affliction during the aboriginal admission, lower readmission ante are broadly taken as apocalyptic of aloft quality.
Another abstraction appear by advisers from AHIP letters that hospital admissions for diabetes were begin lower in a Medicare Advantage plan apperception on special-needs patients than they were for a commensurable sample of patients in acceptable Medicare. These data, too, would be interpreted as aloft quality.
A abstraction by advisers absolute of the allowance industry begin that patients in Medicare Advantage affairs had beneath preventable hospital admissions than did commensurable patients in acceptable Medicare. That abstraction additionally focused on referrals by primary-care physicians to specialists, award alloyed results. It is not bright to me what that metric tells us anyhow, as a low barometer amount by primary-care physicians to specialists may be advised either acceptable or bad.
Another abstraction by absolute advisers comparing the analytic affection of affliction amid acceptable and Medicare Advantage affairs begin that “Medicare Advantage affairs denticulate essentially bigger (4-16 allotment points; median, 7.8 allotment points) on eight measures, hardly bigger (1.5 allotment points) on one admeasurement and worse than fee-for-service (2-5 allotment points; median, 4.1 allotment points) on two measures.”
Finally, yet addition absolute abstraction came to the anxiously belted abstracts that “overall, Medicare Advantage H.M.O. enrollees ability use beneath casework and be experiencing added adapted use of casework than enrollees in acceptable Medicare.”
In my chase of the literature, I may accept absent studies that appear to abstracts adverse to those appear here. If so, I aboveboard ambition to be acquainted of them.
Until I apprehend of such studies, I slouch against Theory II above, although accepting served on the lath of a Medicaid managed-care aggregation may accomplish my aspect doubtable in the eyes of some.
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