Comparing Quality in Medicare FFS and Medicare Advantage

Mark ShepardHarvard 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

Antidepressant

Breast Cancer

Anti-Rheumatic

Persistent Meds

Persist. On BB

LDL Test

Beta Blockers*

Eye Exam

Nephro.

LDL Test

HbA1c

50% 60% 70% 80% 90% 100%

FFS

* 2006 Data

Dia

bete

sH

eart

D

isea

seO

ther

Results: FFS vs. MA Quality, 2007

Antidepressant

Breast Cancer

Anti-Rheumatic

Persistent Meds

Persist. On BB

LDL Test

Beta Blockers*

Eye Exam

Nephro.

LDL Test

HbA1c

50% 60% 70% 80% 90% 100%

FFSMA

* 2006 Data

Dia

bete

sH

eart

D

isea

seO

ther

+4.4%

+6.5%

+7.8%

+5.2%

Results: FFS vs. MA Quality, 2007

Antidepressant

Breast Cancer

Anti-Rheumatic

Persistent Meds

Persist. On BB

LDL Test

Beta Blockers*

Eye Exam

Nephro.

LDL Test

HbA1c

50% 60% 70% 80% 90% 100%

FFSMA

* 2006 Data

Dia

bete

sH

eart

D

isea

seO

ther

+4.4%

+6.5%

+7.8%

+5.2%

+6.8%

+7.3%

-5.0%

Results: FFS vs. MA Quality, 2007

Antidepressant

Breast Cancer

Anti-Rheumatic

Persistent Meds

Persist. On BB

LDL Test

Beta Blockers*

Eye Exam

Nephro.

LDL Test

HbA1c

50% 60% 70% 80% 90% 100%

FFSMA

* 2006 Data

Dia

bete

sH

eart

D

isea

seO

ther

+4.4%

+6.5%

+7.8%

+5.2%

+6.8%

+7.3%

-5.0%

-3.4%

+1.4%

+14.5%

+14.5%

Interpreting MA-FFS DifferencesMA Higher Quality (8)

• 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

FFS Higher/Close (3)

Suggested Explanation: MA “Learning Effect”

Older and Newer Measures in MA

2006 2007 2008 200972%

74%

76%

78%

80%

82%

Qua

lity

Rat

e

Avg. of 3 Newer Measures

Avg. of 8 Older Measures

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

Natl. FFS Avg. Natl. MA Avg.

05

1015

Per

cent

.4 .5 .6 .7 .8 .9 1Quality Rate

MA Plan Distribution: Breast Cancer Screening, 2007

Results: MA Distribution vs. FFS

Natl. FFS Avg. Natl. MA Avg.

05

10P

erce

nt

.2 .3 .4 .5 .6 .7 .8 .9 1Quality Rate

MA Plan Distribution: Diabetes Eye Exams, 2007

Results: MA Distribution vs. FFS

Natl. FFS Avg.Natl. MA Avg.

05

1015

Per

cent

.4 .5 .6 .7 .8 .9 1Quality Rate

MA Plan Distribution: Persistence of Beta Blockers, 2007

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