Health Affairs In HMOs Than In Traditional Medicare Medicare Beneficiaries More Likely To Receive Appropriate Ambulatory Services

With quality-of-care bonus payments now available for Medicare Advantage health maintenance organizations (HMOs) and for accountable care organizations in traditional Medicare, the need to understand the relative quality of care delivered to Medicare enrollees has increased. We compared the quality of ambulatory care from 2003 through 2009 between beneficiaries enrolled in Medicare Advantage HMOs and those enrolled in traditional Medicare, and we assessed how the performance of various types of Medicare HMOs differed from that of traditional Medicare for these same measures. We found that beneficiaries in Medicare HMOs were consistently more likely than those in traditional Medicare to receive appropriate breast cancer screening, diabetes care, and cholesterol testing for cardiovascular disease. We also found that Medicare HMO physicians were rated less favorably by their patients than were physicians in traditional Medicare in 2003; however, by 2009 the opposite was true. Not-for-profit, larger, and older Medicare HMOs performed consistently more favorably on clinical measures and ratings of care than for-profit, smaller, and newer HMOs. Our results suggest that the positive effects of more-integrated delivery systems on the quality of ambulatory care in Medicare HMOs may outweigh the potential incentives to restrict care under capitated payments. M edicare beneficiaries have had the option of joining private health maintenance organizations (HMOs) since 1976. Following the passage of the Medicare Prescription Drug, Improvement, andModernizationAct, enrollment in private health plans in theMedicare Advantage programgrew from5.3millionbeneficiaries in2003 to 14.4million in2013.HMOenrollees represent 65percentofMedicareAdvantageand18percent of all Medicare beneficiaries. As enrollment in Medicare Advantage grows, policy makers, health care providers, and beneficiaries have a correspondingly greater need to understand how the quality and costs of care in Medicare Advantage health plans compare to traditional fee-for-service Medicare. Whereas traditional Medicare has lacked explicit systems to improve the quality of care or limit costs, a major objective of Medicare HMOs has been to improve the integrationand coordinationof care in ways that could also improve the quality of care. However, because HMOs receive capitated payments fromMedicare, theyhave incentives to limit the volume of care, which could undermine doi: 10.1377/hlthaff.2012.0773