Call them bundled payments, medical homes, capitation or accountable care, new versions of managed care (think HMOs in the 1990s) are health care’s great cost control hope. Researchers publishing in the latest JAMA tested that idea by counting procedures in one of the biggest managed care programs of all: Medicare Advantage plans for seniors. One finding they expected. The other they didn’t.
Patients in Medicare Advantage plans got expensive balloons and stenting to clear coronary arteries at a rate 31 percent lower than patients in traditional Medicare, according to the study published in the Journal of the American Medical Association by Dr. Daniel Matlock and colleagues.
Medicare Advantage offers incentives to insurers and caregivers to limit costs. In classic, “fee for service” Medicare, the more procedures providers perform, the more money they collect. So the scholars had assumed utilization would be lower among Medicare Advantage patients. They got similar results for diagnostic heart scans. Angiography procedures were 36 percent lower among Medicare Advantage patients, adjusted for age, sex and the other usual variables.
What they didn’t expect were enormous differences in utilization rates among Medicare Advantage patients from one city to another. They figured cost-control incentives would smooth out the notorious regional swings in how often procedures are administered under traditional Medicare. They didn’t. In some regions Medicare Advantage patients in non-emergency situations had coronary arteries propped open by balloons or scaffolds at five times the rate of others. In some places patients were four times as likely to get a diagnostic heart scan as in others.
“There is this policy in this country to push to more capitated reimbursement,” or paying fixed amounts per member, as Medicare Advantage does, Matlock said in an interview. “At least in our study, that hasn’t done anything to address this wide variation in health care. There is something going on beyond incentives that causes a patient to be five times more likely to get a procedure in one place than in another part of the country.”
One possible factor: A boom in some regions in cardiac catheterization labs that deliver the procedures, as recounted in a new study in the journal Circulation. Numerous studies show that the mere existence of medical facilities drives up utilization whether it’s needed or not.
Matlock and colleagues didn’t test to see if heart patients’ health results differed between Medicare Advantage and traditional Medicare or between regions. That’s part of the next study, he said.