Comparing Quality in Medicare FFS and Medicare Advantage Mark Shepard Harvard University Heritage Foundation Briefing June 28, 2011

Context for MA-FFS Comparison Mandate in MIPPA to compare quality in MA and FFS starting this year. Quality comparisons are a potential tool for beneficiaries making enrollment choices. Build on quality comparisons among plans when select MA plan on Medicare Plan Finder website. Little previous work comparing the programs on quality of care because of data availability. Goal: Compare MA and FFS nationally using identical measures, constructed as similarly as possible.

Data and Methods MA: HEDIS data publicly reported for 2006-07, pooled to form national quality rate Exclude PFFS plans due to data availability FFS: National measures for 2006-07 calculated from Medicare claims by CMS (GEM project) Based on administrative HEDIS specifications Statistically adjust for different geographic distribution of MA and FFS beneficiaries

Quality Measures 11 HEDIS measures of appropriate preventive screenings and medication management Diabetes HbA1c tests Eye exams LDL testing Nephropathy screening/ med. attention Heart Disease LDL Testing Beta Blockers After Heart Attack Persistence on Beta Blockers for 6 months Other Breast Cancer Screening Antidepressant Management Anti-Rheumatic Drug Therapy Monitoring for persistent meds.

Results: FFS vs. MA Quality, 2007

Results: FFS vs. MA Quality, 2007

Results: FFS vs. MA Quality, 2007

Results: FFS vs. MA Quality, 2007

Interpreting MA-FFS Differences MA Higher Quality (8) FFS Higher/Close (3) All “well-established” in HEDIS: since 1990s Declined in quality in MA from 2006 to 2007 All newer in HEDIS: introduced 2004-2005 Improved rapidly in MA from 2006 to 2007; also in 2008-2009 Suggested Explanation: MA “Learning Effect”

Older and Newer Measures in MA Averages calculated from NCQA, State of Health Care Quality, 2010

Limitations of MA-FFS Comparison Population Differences Beneficiaries who choose MA may be easier/ harder to deliver appropriate care. Measurement Differences FFS has only claims data, while MA plans can also use chart review (hybrid measures). Additional research needed to address these limitations.

Results: MA Distribution vs. FFS

Results: MA Distribution vs. FFS

Results: MA Distribution vs. FFS

Conclusions MA better on 9 of 11 measures Much better on 8 measures, slightly better or worse than FFS on 3 measures MA performed best on older HEDIS measures, worst on the newer measures. Suggested explanation: MA plan learning effect Substantial differences in absolute terms, but even larger variation across MA plans