Study Finds Mortality, Utilization Benefits CareMore ESRD Special Needs Plan

Amol Navathe, M.D., Ph.D., says you can think about Medicare Advantage plans as a form of accountable care.

“Medicare Advantage plans are capitated, meaning get a fixed budget for each Medicare beneficiary who elects to enroll them. They are at risk for both quality and cost outcomes,” explained Navathe, an assistant professor of health policy and medicine at the University of Pennsylvania, in a recent video interview with Managed Healthcare Executive.®

“It is version of accountable care, if you will, that is different than the alternative, which is the traditional fee-for-service system, which is great, in some senses. It [traditional fee-for-service Medicare] provides great coverage. Almost every physician and hospital out there take Medicare. So it gives people a lot of choice. But oftentimes there is a lot less coordination of care and coordination of benefits (than in Medicare Advantage plan).”

Navathe, along with six other colleagues, set out recently to compare a Special Needs Plans for Medicare beneficiaries with end-stage renal disease (ESRD) sponsored by CareMore, a subsidiary of Anthem, with traditional Medicare fee for service. They reported their results in the September issue of Health Affairs. The study was supported by grant from the Anthem

Amol Navathe

Public Policy Institute.

“We really wanted to explore, so are there benefits here (to the Special Needs Plan). Is it really worth it?” Navathe said. In the Health Affairs article, Navathe and his colleagues say their study is the first evaluation of Special Needs Plan for ESRD Medicare beneficiaries since the plans got started in 2003.

Special Needs Plans are a subset of Medicare Advantage plans for beneficiaries who are dually eligible for Medicare and Medicaid, in nursing homes or have a chronic, disabling disease, such as ESRD. About 3 million Medicare beneficiaries are enrolled in Special Needs Plans, according to the Kaiser Family Foundation, and last year they accounted for about 13% of the Medicare Advantage enrollment. Americans with ESRD have been eligible for Medicare, regardless of age, since the early 1970s, partly out of recognition that hemodialysis would be a major obstacle to employment.

For the mortality rate comparison, Navathe and his colleagues compared 441 beneficiaries enrolled in the CareMore Special Needs Plan with 8,519 matched controls in traditional Medicare for service. The numbers were slightly slower when it came to comparing utilization of healthcare services, such as the number of inpatient days. The federal government supports a database on ESRD patients called the United States Renal Data System, and the amount of clinical information in that database allowed for very careful matching, which strengthened this study, Navathe explained in the interview. “We were able to make these credible comparisons that probably would not have been possible otherwise,” he said.

Navathe said the most striking finding was the lower mortality rate of the beneficiaries in the CareMore Special Needs Plan during the three-year study period. The adjusted average hazard ratio for those enrollees was .51 compared with the fee-for-service controls, which, roughly speaking, means that the CareMore enrollees were half as less likely to have died at the end of thee-year study period than the fee-for-service controls.

The utilization comparisons also tallied up in the Special Needs Plan Care favor with CareMore having fewer inpatient days (4.6 per year vs. 12.5), skilled nursing facility days, and home health days than the fee-for-service controls. Results also show more dialysis days among the CareMore enrollees than the fee-for-service controls and fewer hospital admissions for ESRD complications.

Navathe and his co-authors did not report any of the cost comparisons that are commonly included in research published in Health Affairs, but Navathe noted that inpatient days and some of the other utilization measures have a large effect on spending, so if they are lower, healthcare spending is likely to be also, although the greater number of dialysis days would likely offsetssome of the savings.

Navathe’s co-authors include Brian W. Powers, deputy chief medical officer for Humana; Sachin H. Jain, the former president and CEO of CareMore; and Jennifer Kowalski, vice president of the Anthem Public Policy Institute.