13 Areas of Low-Value Care Spending in Medicare Advantage Plans

Although many studies have touted Medicare Advantage plans’ successes in diminishing low-value care and pursuing high-value care, there are at least 13 areas of low-value care in which Medicare Advantage and Medicare alike are not reducing healthcare spending, according to a study published on JAMA Network Open.

“Low-value care is defined as a service that provides little to no clinical benefit but incurs health care costs,” the study began.

The study relied on six data sets from the 2006 to 2015 Medical Expenditure Panel Survey, in particular full-year consolidated data, longitudinal data, medical condition data, outpatient visit data, office-based clinical visit data, and prescription data.

The researchers observed 13 low-value services in four categories as well as a composite.    measure. Over 11,600 traditional Medicare beneficiaries and more than 5,100 Medicare Advantage beneficiaries were involved in this study. The mean age was 74.5 and over half of the participants were women.

The thirteen areas were as follows: cervical cancer screenings, colorectal cancer screenings, prostate cancer screenings, antibiotics for acute upper respiratory infection, antibiotics for influenza, anxiolytic, sedative, or hypnotic medication, benzodiazepine for depression, an opioid for headache, an opioid for back pain, nonsteroidal anti-inflammatory drug (NSAID) for hypertension, heart failure, or kidney disease, radiograph for back pain, and MRI or CT for back pain or for headaches.

Previous studies from 2016 to 2020 found that Medicare Advantage health plans offered less low-value care than traditional Medicare did. However, that was not the case in the present study.

“We found that use of low-value care in MA was as prevalent as in TM during the study period, suggesting that the structure of MA may not be associated with decreases in use of low-value care,” the researchers reported.

Two of the measures exhibited significant differences between traditional Medicare beneficiaries’ outcomes and Medicare Advantage beneficiaries’ outcomes.

The rate of low-value medication was statistically higher by 2.2 percentage points for Medicare Advantage beneficiaries. Similarly, the use of an NSAID for hypertension, heart failure, or kidney disease was 2.9 percentage points higher for Medicare Advantage beneficiaries.

While none of the other results were statistically significant, the Medicare Advantage population demonstrated a slightly higher rate of low-value care utilization than the traditional Medicare beneficiary population, with the sole exception of colorectal cancer screening.

Moreover, the overarching trend was not heading in a positive direction.

“Overall, there were no decreases in low-value composite measures in TM or MA over time except for the low-value cancer screening composite, which decreased in the two populations similarly over time,” the study found.

That being said, low-value imaging composite measures were higher for Medicare Advantage members from 2006 to 2007 before traditional Medicare rates of low-value imaging overtook Medicare Advantage plans’ rates from 2012 to 2013 and 2014 to 2015.

After years of studies demonstrating the positive impacts of Medicare Advantage against low-value care, what could be behind these results?

The researchers postulated that there could be three forces at work. Medicare Advantage plans may not see much gain in diminishing low-value care if the costs of such care are already low, they suggested. Alternatively, plans might not focus on these 13 areas of low-value care if these areas do not directly impact quality measures for quality scores and payments.

Finally, these results could reveal misalignment between Medicare Advantage plans and their providers.

“Some clinicians serving individuals enrolled in MA are still operating under volume-based incentives, which are associated with less leverage in decreasing low-value care,” the researchers explained. “These findings suggest the need to reconsider the design of financial incentives in the TM and MA programs.”

Medicare Advantage plans do boast success in other areas related to value-based care, however. For example, these plans have a 57 percent lower unnecessary hospitalization rate than traditional Medicare as well as a lower improper payment rate, according to data from the Alliance of Community Health Plans (ACHP).

Specific payers have reported success in using Medicare Advantage to continue their progress towards value-based care.

Humana’s latest Value-Based Care report found that Humana Medicare Advantage members leveraged preventive care services, with nearly 20 percent more colorectal cancer screenings and diabetic eye exams than traditional Medicare beneficiaries. Also, hospital admissions were lower among Medicare Advantage members than traditional Medicare beneficiaries.

Some experts have seen the coronavirus pandemic as an opportunity for Medicare Advantage plans and other types of health plans to reduce low-value care spending.

Nevertheless, the researchers challenged readers to revisit the financial incentives that exist across these 13 metrics and to determine whether payers’ and clinicians’ priorities are aligned.