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Medicare Advantage beneficiaries run higher risk of readmission compared with traditional Medicare

HEDIS data underreported hospital admissions for at least three medical conditions, and the excluded admissions had higher readmission rates.

Jeff Lagasse, Associate Editor

Medicare Advantage users had higher risk-adjusted 30-day hospital readmission rates compared to traditional Medicare beneficiaries, according to findings from a retrospective population-based analysis published in Annals of Internal Medicine.

Hospital readmissions are not only common -- they cost Medicare $26 billion annually. Reducing readmission rates has become a priority for clinicians, hospitals and payers, particularly Medicare.

As such, the Medicare Hospital Readmissions Reduction Program penalizes hospitals with worse-than-expected 30-day-readmission rates. But readmission rates are calculated using data for traditional Medicare beneficiaries only, and not from those enrolled in the rapidly growing Medicare Advantage program.

Hospital admissions in the analysis were compared for three common medical conditions: heart failure, pneumonia and acute myocardial infarction.


Researchers from Brown University School of Public Health linked data from the Medicare Provider Analysis and Review (MedPAR) file with the Healthcare Effectiveness Data and Information Set (HEDIS) to investigate whether Medicare Advantage enrollees hospitalized for the three conditions in question had lower readmission rates than traditional Medicare enrollees.

They found that, between 2011 and 2014, HEDIS data underreported hospital admissions for those conditions, and admissions that were incorrectly excluded had higher readmission rates than those that appeared in HEDIS data.

Despite this, in analyses using the linkage of HEDIS and MedPAR, Medicare Advantage beneficiaries had higher 30-day risk-adjusted readmission rates than did traditional Medicare beneficiaries.

Citing policy observers who have suggested that Medicare Advantage beneficiaries have better post-acute care outcomes than traditional Medicare beneficiaries, the authors said they found no evidence that this happens with regard to readmission rates.


The authors of an accompanying editorial from the University of Minnesota School of Public Health suggest that while the study methodology is rigorous, the results should be interpreted with caution. The diagnosis codes on hospital claims were used for case-mix adjustment and may be subject to variation.

In addition, the study included a cross-sectional comparison of Medicare Advantage versus traditional Medicare enrollees. If there were differences in the attributes between the enrollees in both programs that were related to both the choice of program coverage and hospital readmissions that are not captured by case-mix adjustment, then the estimates in the study may not capture the causal effect of Medicare Advantage enrollment.


Seniors in particular are more likely to switch their Medicare Advantage plans, a Welltok survey found this year.

Nearly six in 10 seniors said they would consider switching their current Medicare Advantage plan in the near future. Low out-of-pocket costs, prescription drug coverage and in-network access to providers were cited as primary factors that could influence a plan change.

Seniors also said it's important for their insurance provider to offer programs and resources that address their total health and wellbeing. Roughly half feel their current plan isn't offering relevant or personalized support.

Twitter: @JELagasse

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