SHM Converge Scientific Abstract ePoster Gallery-Potentially Avoidable Acute Care Use: Medicare Advantage Versus Traditional Medicare

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This 2023 JAMA Health Forum study examined potentially avoidable acute care use for ambulatory care sensitive conditions (ACSCs) among Medicare Advantage (MA) and Traditional Medicare (TM) beneficiaries in 2018. The study compared hospitalizations, emergency department (ED) direct discharges, and observation stays, and also compared MA health maintenance organizations (HMOs) with MA preferred provider organizations (PPOs).<br /><br />After adjusting for patient characteristics and county fixed effects, MA patients had a slightly lower risk of hospitalization for ACSCs than TM patients (RR 0.94), driven mainly by fewer hospitalizations for acute conditions such as pneumonia and urinary tract infection. However, MA patients had higher risk of ED direct discharges (RR 1.44) and observation stays (RR 2.38) for ACSCs. Overall, MA patients were at higher risk of receiving some form of acute care for an ACSC when all episode types were considered together.<br /><br />Within Medicare Advantage, HMO patients had lower risk of ACSC-related hospitalization than PPO patients, but higher risk of ED direct discharge and observation stay. The authors suggest that MA plans, especially HMOs, may be using management tools such as prior authorization and narrower networks to steer patients toward lower-cost sites of care rather than eliminating care entirely.<br /><br />The study cautions that it is observational, so it cannot determine whether reductions in hospitalizations reflect better efficiency or shifting to cheaper care settings. It also notes possible differences in coding intensity between MA and TM, though sensitivity analyses were reassuring. The authors call for further research on how these utilization patterns affect care quality, patient out-of-pocket costs, and health outcomes.

Asset Subtitle

Adam L. Beckman

Meta Tag

Author List Adam L. Beckman, Austin Frakt, Ciara E. Duggan, E. John Orav, Jie Zheng, Jose F. Figueroa, Tom Tsai

Category Research

Concept Medicare Advantage

Concept Traditional Medicare

Concept Ambulatory Care Sensitive Condition

Concept Acute Care Utilization

Concept Hospitalization

Distinguished Finalist

Presenter Organization Harvard Medical School & Harvard Business School

Presenting Author Adam L. Beckman

Track Value in Hospital Medicine

Keywords

Medicare Advantage

Traditional Medicare

ambulatory care sensitive conditions

acute care use

hospitalization

emergency department

observation stays

HMO

PPO

healthcare utilization

Medicare Advantage

Traditional Medicare

Ambulatory Care Sensitive Condition

Acute Care Utilization

Hospitalization