• Diabetes Management – Is Medicare Advantage really Advantageous?

    Stuart Figueroa, MSW, is a policy analyst at Boston University School of Public Health. He tweets at @RealStuTweets.

    Turn on the TV to your favorite mid-day programming and there is a good chance you’ll see Joe Namath gracing the screen, selling Medicare Advantage. Far removed from gridiron glory with the New York Jets, 78-year-old Namath is less ‘Broadway Joe’, and a little more Medicare Joe. The question begs – what exactly is he selling and who actually benefits?

    Background on Medicare Advantage

    Medicare Advantage, also known as Medicare Part C, is a program that allows Medicare eligible beneficiaries to enroll in health plans offered by private insurers. These plans contract with Medicare and receive a capitated payment based on enrollment. Aside from its payment structure, MA differs from traditional Medicare (TM) in several important ways.

    First, MA enrollees tend to have fewer health care provider options; this differs substantially from TM beneficiaries who have access to a broader network. From a benefits standpoint though, many MA plans offer more expansive benefits. For example, plans may include dental coverage, audiology, and other perks such as fitness programs and gym memberships. There are also significant differences when it comes to enrollee cost burden. In particular, MA plans cap out-of-pocket costs; such a cap does not exist under traditional Medicare.

    As of June 2021, more than 26 million persons, approximately 42 percent of all Medicare enrollees, were enrolled in MA plans. Current enrollment projections anticipate that the proportion of beneficiaries participating in MA plans will increase to nearly 50% of all enrollees by 2029. Recent growth in MA enrollment has been disproportionately higher among racial/ethnic minorities and other traditionally marginalized groups, though the reasons why are not entirely clear.

    But how do the two differ in treating chronic disease? And how about across racial and ethnic subpopulations? As the nation’s population ages, there is an urgent need to understand how well MA serves beneficiaries with chronic disease, and whether MA participation translates into improved disease management and health outcomes when compared to traditional Medicare.

    Background on Diabetes

    Let’s take diabetes. It is estimated that one in four dollars spent on health care is spent on diabetes related costs. Diabetes is a progressive disease that if untreated or mismanaged leads to serious complications such as stroke, cardiovascular disease, nerve issues, and kidney and liver problems. The risk of developing diabetes and experiencing complications increases dramatically with age, and those affected by the disease and its comorbid conditions are likely to require escalated care including more frequent and longer hospitalizations, increased outpatient care, and prescriptions.

    Health Disparities in Diabetes Management

    Racial and ethnic health disparities have been found to exist both between different MA plans and between TM and MA. Studies have documented differences in the management of blood pressure, cholesterol, and glucose, as well as hospital readmission following complications from surgery. When it comes to diabetes management, it is difficult but important to ascertain the extent that racial and ethnic disparities in health outcomes exist in MA.

    In TM, numerous studies have explored the racial and ethnic health disparities associated with diabetes. Early studies found that, even as TM improved preventative care practices overall, non-White beneficiaries, especially Black beneficiaries, were less likely to receive preventative services. This resulted in a higher likelihood of both short- and long-term complications.

    A 2019 study in Health Equity found that among traditional Medicare beneficiaries with diabetes, Hispanic beneficiaries fared significantly poorer across a number of health metrics when compared with their non-Hispanic White counterparts. The economic manifestation of this disparity was increased costs, utilization of acute care, and longer inpatient hospitalizations.

    When considering the long arc of diabetes management under MA, the results are mixed. When the MA program was still in its infancy, many of the same issues found in TM were prevalent in MA. A 2007 study examining racial and gender differences on process of care and intermediate outcome measures (e.g., A1C screenings, cholesterol screenings, eye exams) found that, when compared to White beneficiaries, Black MA enrollees consistently fared poorer on five of six measures. This disparate performance relative to race and ethnicity and diabetes outcomes has been observed repeatedly. Complicating the picture further, MA plans are not created equal and significant variation in outcomes has been found both between and within plans.

    More recent efforts comparing diabetes management more broadly between MA to TM have found improvements in the quality of diabetes care as well as reduced costs for MA beneficiaries. Studies found decreased utilization of diabetes services in MA health plans, as well as higher quality of care than in TM. In addition, MA plans tend to manage diabetes care with less expensive medications than TM, resulting in lower out-of-pocket costs for enrollees. (Caveat: as with all studies of MA, there’s a thorny issue of the extent to which beneficiary risk is adequately controlled for or reflects coding differences between MA and TM or in MA over time.)

    Looking at diabetes care as a whole, MA would appear to be trending in the right direction. It is not clear, however, that the racial and ethnic health disparities previously identified have been eliminated.

    Conclusion

    Medicare Advantage has its…advantages. It reduces enrollees’ costs while offering greater benefits, and recent studies show improved quality, at least for diabetes management. These are among the arguments used by private health plans who are looking to expand their MA lines of business.

    However, traditionally underserved populations continue to lag behind White beneficiaries in both care and access. As is the case with almost every facet of the healthcare system, MA plans still have a lot of work to do in addressing health equity. For this reason, non-White beneficiaries will want to evaluate their MA options carefully before taking Medicare Joe at his word.

    Research for this piece was supported by Arnold Ventures.

     
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