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Original Investigation
September 2, 2020

Quality of Care and Outcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized With Heart Failure

Author Affiliations
  • 1Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 3VA Boston Healthcare System, Boston, Massachusetts
  • 4Boston University School of Public Health, Boston, Massachusetts
  • 5Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center
  • 6Section Editor, JAMA Cardiology
  • 7VA Palo Alto Health Care System, Palo Alto, California
  • 8Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
  • 9Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 10Deputy Editor, JAMA Cardiology
  • 11Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
  • 12Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
  • 13Center for Health Economics and Policy, Washington University Institute for Public Health, St Louis, Missouri
JAMA Cardiol. Published online September 2, 2020. doi:10.1001/jamacardio.2020.3638
Key Points

Question  Are there significant differences in the quality of care received by patients hospitalized with heart failure who are enrolled in Medicare Advantage vs fee-for-service Medicare?

Findings  In this cohort study, among 262 626 patients hospitalized with heart failure, no significant differences were noted in the quality of care received or in-hospital mortality between those enrolled in Medicare Advantage vs fee-for-service Medicare. Medicare Advantage patients had lower use of post–acute care facilities after discharge.

Meaning  Unlike care in the ambulatory setting, Medicare Advantage does not appear to be associated with the quality of care that Medicare patients receive when they are hospitalized with heart failure.

Abstract

Importance  Medicare Advantage (MA), a private insurance plan option, now covers one-third of all Medicare beneficiaries. Although patients with cardiovascular disease enrolled in MA have been reported to receive higher quality of care in the ambulatory setting than patients enrolled in fee-for-service (FFS) Medicare, it is unclear whether MA is associated with higher quality in patients hospitalized with heart failure, or alternatively, if incentives to reduce utilization under MA plans may be associated with worse care.

Objective  To determine whether there are differences in quality of care received and in-hospital outcomes among patients enrolled in MA vs FFS Medicare.

Design, Setting, and Participants  Observational, retrospective cohort study of patients hospitalized with heart failure in hospitals participating in the Get With the Guidelines—Heart Failure registry.

Exposures  Medicare Advantage enrollment.

Main Outcomes and Measures  In-hospital mortality, discharge disposition, length of stay, and 4 heart failure achievement measures.

Results  Of 262 626 patients hospitalized with heart failure, 93 549 (35.6%) were enrolled in MA and 169 077 (64.4%) in FFS Medicare. The median (interquartile range) age was 78 (70-85) years for patients enrolled in MA and 78 (69-86) years for patients enrolled in FFS Medicare. Standard mean differences in age, sex, prevalence of comorbidities, or objective measures on admission, including vital signs and laboratory values, were less than 10%. After adjustment, there were no statistically significant differences in receipt of evidence-based β-blockers when indicated; angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, or angiotensin receptor-neprilysin inhibitors at discharge; measurement of left ventricular function; and postdischarge appointments by Medicare insurance type. Patients enrolled in MA, however, had higher odds of being discharged directly home (adjusted odds ratio [AOR], 1.16; 95% CI, 1.13-1.19; P < .001) relative to patients enrolled in FFS Medicare and lower odds of being discharged within 4 days (AOR, 0.97; 95% CI, 0.93-1.00; P = .04). There was no significant difference in in-hospital mortality between patients with MA and patients with FFS Medicare (AOR, 0.98; 95% CI, 0.92-1.03; P = .42).

Conclusions and Relevance  Among patients hospitalized with heart failure, no observable benefit was noted in quality of care or in-hospital mortality between those enrolled in MA vs FFS Medicare, except lower use of post–acute care facilities. As MA continues to grow, it will be important to ensure that participating private plans provide an added value to the patients they cover to justify the higher administrative costs compared with traditional FFS Medicare.

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