Quality of CAD care higher for Medicare Advantage patients

Patients with coronary artery disease (CAD) enrolled in private insurance plans through Medicare Advantage (MA) are more likely to receive guideline-recommended medications for secondary prevention than those in fee-for-service Medicare, according to a new analysis in JAMA Cardiology. But that wasn't tied to improvements in blood pressure or cholesterol levels.

“As MA continues to enroll a higher proportion of beneficiaries each year, it will be important to monitor both quality and outcomes of care to determine whether these patterns ultimately lead to better outcomes in Medicare,” lead author Jose F. Figueroa, MD, MPH, of Harvard Medical School, and colleagues wrote.

MA plans covered 33 percent of Medicare beneficiaries in 2017, up from 22 percent in 2008, according to Figueroa et al. That percentage is expected to climb even higher as MA plans continue to add more benefits.

The researchers studied more than 205,000 patients from the PINNACLE registry, a national outpatient-based quality improvement registry of patients seen in cardiology practices across the U.S. About 35,000 were enrolled in MA plans while 172,732 were in fee-for-service (FFS) Medicare. All patients were diagnosed with CAD between January 2013 and May 2014 through a history of myocardial infarction, percutaneous coronary intervention or coronary artery bypass grafting.

After multivariable adjustment, MA beneficiaries were 10 percent more likely to receive beta-blockers, 13 percent more likely to receive either angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and 23 percent more likely to receive a statin plus those two types of medications, when eligible. The rates of statin use alone or referral to cardiac rehab weren’t significantly different between groups.

Likewise, blood pressure levels and LDL cholesterol levels were similar between MA beneficiaries and FFS enrollees.

The authors suggested the higher uptake of guideline-recommended therapy among the MA patients could be because managed care plans often directly incentivize providing those evidence-based medicines as part of quality improvement initiatives.

“Other reasons for better performance on process measures may include the additional benefits offered by MA plans (eg, disease management programs and pharmacist medication reconciliation services) or simply that a greater share of MA beneficiaries are enrolled in Part D drug benefits compared with FFS Medicare beneficiaries and therefore may be better able to access and afford any prescribed medications,” they wrote. “These findings may be of interest to policymakers hoping to use more market-driven strategies, such as private insurance coverage, to drive improvements in quality in Medicare.”

On the other hand, the lack of a meaningful impact on blood pressure and cholesterol may be a signal that incremental improvements in process measures don’t always translate to significantly better outcomes in an older Medicare population, a group that is typically underrepresented in CAD drug trials.

“Policymakers might temper their expectations on using MA plans, especially as enrollment continues to grow, as a means for improving patient outcomes for Medicare-enrolled patients,” Figueroa et al. wrote. “However, since MA plans outperformed FFS Medicare on process measures, one strategy the U.S. Centers for Medicare and Medicaid Services could pursue is revising the measures it focuses on for financial incentives under MA to ones that are more closely tied to outcomes in the Medicare population.”

The researchers acknowledged practices participating in the voluntary PINNACLE registry may not be reflective of all practices; given their willingness to participate in a quality improvement registry, they may be more likely to provide guideline-recommended care than other facilities. They were also unable to determine how long patients had been prescribed therapies to treat CAD, which would have an impact on the outcomes that were studied.