Medicare Advantage and Disparities in the Era of Pay for Performance

Background: In 2012 Medicare introduced the Quality Bonus Program, a pay for performance (P4P) initiative, to reward high quality Medicare Advantage plans. While P4P is intended to improve care for all patients, there is concern it may exacerbate health disparities. While previous studies have reported substantial disparities in the receipt of clinically recommended care in MA, there have been no subsequent studies since the introduction of the Quality Bonus Program. This study addresses this gap in the literature.

Method: This is a cross-sectional study of 303,512 MA enrollees who completed the Medicare Health Outcome Survey in 2013. Multivariate logistic regression was used to examine the association between the individual characteristics (race and education) and three performance measures (improving bladder control, monitoring physical activity, and reducing the risk of falling).

Results: Overall, receipt of recommended care ranged from 61% for reducing risk of falling to 35% for improving bladder control. In multivariate analyses, the relationship between race and education and receipt of services varied. Black enrollees were significantly less likely to receive services reducing fall risk, and more likely to receive monitoring of physical activity. We observe similar patterns by education. Individuals with chronic conditions and/or disability had higher odds of receiving clinically recommended services.

Conclusion: Too few MA beneficiaries receive clinically recommended health services. There are persistent gaps in the quality of care by race and education for some services. Policymakers and health plans should consider intervention to increase these services to reduce disparities and improve population health.