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
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