Health Outcomes Are Superior in Fill-Risk Medicare Advantage vs Traditional Medicare
Medicare Advantage (MA) plans with 2-sided risk arrangements consistently outperform traditional Medicare (TM) on measures of quality and efficiency, according to a study published in The American Journal of Managed Care.
“A prior study observed that 2-sided MA risk arrangements were associated with higher quality and efficiency in the inpatient setting compared with TM,” explained Kenneth Cohen, MD, and coauthors. “We expand this previous work by including a larger array of quality and efficiency measures across 4 domains of patient care,” they added.
In a comprehensive analysis of more than 6.5 million person-years across 17 physician groups, patients enrolled in at-risk MA plans had better outcomes than their peers in TM on 16 of 20 measures. These included significantly lower rates of hospitalizations, emergency department (ED) visits, and admissions for chronic disease complications, as well as safer prescribing practices.
Unlike traditional Medicare, which generally reimburses providers based on volume, many MA plans use delegated 2-sided risk contracts. These arrangements shift financial responsibility for patient care to physician groups, incentivizing them to invest in population health tools and avoid costly complications. Researchers compared outcomes among MA and TM patients treated by the same providers from 2016 to 2019.
Patients in at-risk MA were 20% less likely to have an acute hospital admission and nearly 39% less likely to be readmitted within 30 days. ED utilization was consistently lower, with MA patients 11% to 22% less likely to experience unnecessary visits. Seven of 9 disease-specific inpatient admission rates, including those for chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, and urinary tract infections, were significantly lower in the MA group, with reductions ranging from 32% to 54%.
In the outpatient setting, MA patients were 23% less likely to be prescribed high-risk medications and slightly more adherent to hypertension treatments, though other medication adherence outcomes were similar. Office visit counts were slightly lower in MA, suggesting more efficient care delivery.
“These findings, although not causal, suggest that 2-sided–risk MA payment arrangements deliver higher quality and more efficient use of health care resources,” concluded the study authors.
Reference
Cohen K, Vabson B, Podulka J, et al. Health outcomes under full-risk Medicare Advantage vs traditional Medicare. Am J Manag Care. 2025;31(10):In Press.
