Higher Quality and Lower Utilization in At-Risk Medicare Advantage for Dual-Eligible Beneficiaries

This study analyzed the impact of Medicare payment models on the quality and efficiency of care for dually eligible beneficiaries (Duals), who qualify for both Medicare and Medicaid and constitute 19% of Medicare beneficiaries but account for 35% of Medicare spending. It compared Duals managed under at-risk two-sided risk Medicare Advantage (MA), fee-for-service (FFS) MA, and traditional Medicare (TM) within the same physician groups, over the 2016-2019 period. The analysis covered 1,980,691 person-years from 17 provider groups and 15,488 primary care physicians. Results show that at-risk MA arrangements were associated with significantly higher quality and lower utilization across 17 of 20 measures compared to TM, including reductions of up to 32.7% in avoidable hospital readmissions and ED visits. Similarly, at-risk MA outperformed FFS MA in 18 of 20 measures, demonstrating better outcomes in hospitalization rates, emergency department visits, disease-specific admissions, and medication adherence. The study found that FFS MA also showed better quality and efficiency compared to TM but to a lesser extent than at-risk MA. Potential explanations for these differences include the care management infrastructure supported by at-risk MA plans, which facilitates integrated services such as social needs interventions and enhanced care coordination. Dual-eligible Special Needs Plans (D-SNPs) within at-risk MA displayed even greater improvements compared to other groups. The findings emphasize the importance of expanding accountable care arrangements that include at-risk MA models for Duals to address their increasing healthcare utilization and costs. The study controlled for patient demographic and clinical risk factors and accounted for provider-level influences by comparing cohorts treated by the same physicians. While the results demonstrate strong associations, the study does not establish causality. The implications support CMS initiatives promoting fully accountable care arrangements by 2030, highlighting opportunities to improve outcomes and address social determinants of health within the Duals population through at-risk MA payment structures.