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Medicare Advantage (MA) patients with coronary heart disease were slightly sicker than those receiving Medicare Paid (FFS) benefits and were more likely to receive appropriate secondary prevention treatments, a new observational study found.
After adjusting for co-morbidities and patient characteristics, AM-eligible patients were 23% more likely to receive beta-blockers, angiotensin-converting enzyme inhibitors, or antagonists. angiotensin II receptors (ACEi / ARB) and a statin compared to those enrolled in FFS Medicare (probability ratio 1.23; P = .047). They were not, however, more likely to be referred to cardiac rehabilitation.
"When we sought to find out if the medications they needed were supported by Medicare, patients enrolled in private Medicare Advantage plans were more likely to receive these medications than Medicare-paid patients at the time", Lead author, Jose Figueroa, MD, MPH, Brigham & Women's Hospital, Harvard Medical School, Boston, said theheart.org | Medscape Cardiology.
The study was published online on February 20 in JAMA Cardiology.
However, despite the increased use of evidence-based care, there was no difference in systolic and diastolic blood pressure or low-density lipoprotein cholesterol levels between the two groups.
To counter concerns that MA is considering choosing healthier patients over FFS Medicare, these patients were significantly younger, had a somewhat heavier burden of comorbidities, and were more likely to be eligible for both Medicare and Medicaid. These differences, however, were small, noted Figueroa.
The researchers used data from the national PINNACLE (Practice Innovation and Clinical Excellence) registry, based on outpatient consultations, to identify patients with coronary artery disease. They then selected patients with Medicare MA coverage (n = 35,563) or FFS coverage (n = 172,732). PINNACLE is a cardiac quality improvement registry run by the American College of Cardiology.
Figueroa noted that the study was limited by its nature of observation and by its inability to know how long patients were following a prescribed treatment. "We only know that the drug has been prescribed for them and that we know the blood pressure and cholesterol levels, but we do not necessarily know when the drug was started or if the rates have increased over time."
Medicare Advantage pays a monthly lump sum for patient treatment and provides performance-based evidence-based care with financial awards for high adherence to guideline-based care. The program has grown in popularity; in 2008, about 22% of Medicare eligible Americans had chosen to enroll in a private drug plan, but in 2017 this proportion was 33%.
The MA plans include drug coverage but require prior approvals for expensive drugs, making them more convenient and potentially more restrictive than FFS Medicare, explained Figueroa during an interview.
"Under Medicare Advantage, there are financial incentives to do some of the things we've measured – these same incentives do not exist in FFS Medicare," he noted.
The numerical differences in the prescription were small but significant. Compared to FFS Medicare recipients, AM patients were more likely to receive beta-blockers (80.6% vs. 78.8%; P <0.001), ACEi / ARA (70.7% vs 65.1%; P <0.001) and statins (68.4% vs. 64.5%; P <001).
Patients enrolled in AM were also more likely to receive all three medications when they were eligible (48.9% vs. 40.4%; P<0.001).
Prioritize the process or results?
In an editorial comment, Paul Heidenreich, MD, MS, Palo Alto Health Care System, Department of Veterans Affairs, California, warned against placing too much weight on lack of difference in outcome measures .
"It would be great if you could also show an badociation with the results, but … we should not let this lack of difference distract us from better health care," he said. theheart.org | Medscape Cardiology, especially because these improved care metrics have already been shown in randomized clinical trials to improve both positive and negative outcomes.
Given the "rather low" drug use differences observed by Figueroa et al., The poor signal-to-noise ratio for the outcome measures of observation and the "enormous size of the" "sample" that would be needed to show a difference in results, he warned against being distracted by the results of null results.
"We certainly do not want to misinterpret that there is no significant difference in the results that means zero profit, which I think is an incorrect interpretation," Heidenreich said.
Figueroa is partially funded by a grant from national Center to advance the translational sciences. Heidenreich has not reported any conflicts of interest.
JAMA Cardiology. Posted online 20 February 2019. Full text, Editorial
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