Studies comparing Medicare Advantage, traditional Medicare don't capture enough racial, ethnic data: analysis

Enrollees in Medicare Advantage (MA) and in traditional Medicare appear to receive similar care in terms of quality, accessibility to providers and affordability, according to a review of 62 studies about the two systems by the Kaiser Family Foundation (KFF).

However, what wasn’t captured in the studies published since 2016 was how well racial and ethnic minorities fared in MA and Medicare supplemental plans compared to traditional Medicare.

“When possible, we highlight findings for specific subgroups of interest, such as beneficiaries from communities of color, living in rural areas, or dually eligible for Medicare and Medicaid,” the literature review stated. “Notably, relatively few studies specifically examine these population subgroups, so it is difficult to assess the strength of the findings or how broadly they apply.”

And some of what they did find about Medicare coverage for minority groups didn’t go far enough.

“For example, one study found that black Medicare beneficiaries had higher rates of potentially avoidable hospitalizations in Medicare Advantage than in traditional Medicare,” the literature review said. “While important, we could not identify additional analyses that compared the rate of potentially avoidable hospitalizations between Medicare Advantage and traditional Medicare among Hispanic and other beneficiaries of color, beneficiaries living in rural areas, or beneficiaries dually eligible for Medicare and Medicaid.”

The underrepresentation of racial and ethnic minorities can foster wariness about just how broadly applicable findings can be. As Fierce Healthcare reported about a study in Health Affairs, many algorithms used in studies do not reveal the race or ethnicity of individuals in an attempt to remove bias, but that method may be misguided because “knowledge, not ignorance, of race and ethnicity helps combat bias.”

The authors of the KFF study, policy analysts Nancy Ochieng and Jeannie Fuglesten Biniek, told Fierce Healthcare in an email that though they were not surprised, they were disappointed that the studies for the most part did not capture differences in quality of care for MA and traditional Medicare along racial and ethnic lines.

Several possible explanations might explain this gap, the pair said.

“One key barrier is lack of complete, reliable data that captures race/ethnicity and other key demographic data for both Medicare Advantage and traditional Medicare beneficiaries,” Ochieng and Biniek told Fierce Healthcare. “For example, Medicare Advantage encounter data, which can be used to look at utilization patterns within the Medicare Advantage population by race/ethnicity, has been criticized for being incomplete.”

Studies that did contain racial and ethnic data did so for the most part for only Black, white and Hispanic beneficiaries, and that limits what might be learned about the experiences of other beneficiaries of color.

“It’s possible, researchers may not feel comfortable presenting data that excludes other racial/ethnic groups (e.g., Asian, Native Hawaiian, and Other Pacific Islanders), and so have opted not to break out findings by race/ethnicity at all,” Ochieng and Biniek said. “Other researchers have combined multiple racial/ethnic groups into one category in an effort to address sample size issues, but this approach has limitations as well, by obscuring any differences across the groups.”

Another possible explanation, said Ochieng and Biniek, might be “racism itself,” which they argue “is the key driver of health inequities and extends to academia itself. Researchers and their funders may not view this as a salient issue to focus on.”

KFF, they said, strives to stratify by as many demographic groups as possible, if the data are available and can shed light at the level of subgroup analysis. They cite a KFF report published last year in which Ochieng was a co-author that specifically examines racial and health inequalities in Medicare.

As of last year, Medicare covers about 62 million people, and 48% of those enrollees chose MA over traditional Medicare, according to KFF

In their literature review, Ochieng and Biniek did find some differences along racial and ethnic lines. For instance, there was not much switching between the two, although slightly more beneficiaries switched from MA to traditional Medicare, rather than vice versa.

“Additionally, rates of switching from Medicare Advantage to traditional Medicare were relatively higher among beneficiaries who are dually eligible for Medicare and Medicaid, beneficiaries of color, beneficiaries in rural areas, and following the onset of a functional impairment,” the literature review said

In terms of affordability, fewer beneficiaries in traditional Medicare supplemental coverage reported cost concerns than enrollees in MA, and “similar findings were observed among black beneficiaries, beneficiaries under the age of 65, and beneficiaries in fair or poor self-assessed health.”

MA enrollees were more likely to utilize preventive services than those in traditional Medicare such as flu vaccines, checkups and screenings, and the findings were similar “for people of color and beneficiaries under age 65.”

Twelve of the studies examined hospital readmissions, finding that MA enrollees were less likely to be readmitted than enrollees in traditional Medicare. In two of the studies, researchers found that Black beneficiaries had higher hospital readmission rates in both MA and traditional Medicare. One study found that Black beneficiaries in MA had higher rates for potentially avoidable readmissions than Black beneficiaries in traditional Medicare.

However, the studies did not account for racial and ethnic differences in several categories, including hospital services, post-acute care, prescription drugs, emergency department visits and chronic disease management.

While noting these data gaps, the literature review “found few differences between Medicare Advantage and traditional Medicare that are supported by strong evidence or have been replicated across multiple studies. Both Medicare Advantage and traditional Medicare beneficiaries reported similar rates of satisfaction with their care and overall measures of care coordination.”

MA outperformed traditional Medicare when it comes to beneficiaries’ use of preventive services, having a usual source of care and hospital readmission rates. Traditional Medicare outperformed MA on beneficiaries receiving care in “the highest-rated hospitals for cancer care or in the highest-quality skilled nursing facilities and home health agencies.”