Complex Patients and Quality of Care in Medicare Advantage

J Am Geriatr Soc. 2020 Feb;68(2):395-402. doi: 10.1111/jgs.16236. Epub 2019 Nov 1.


Objectives: New federal policies aim to focus Medicare Advantage (MA) plans on the needs of individuals with complex health conditions. Our objective was to examine enrollment patterns of MA beneficiaries with complex needs and the association of enrollment patterns with MA plan performance.

Design: Cross-sectional study.

Setting: The 2015 Medicare Health Outcome Survey baseline survey.

Participants: A total of 273 336 MA beneficiaries enrolled in 467 MA plans who lived in the community.

Measurements: Complex patients included individuals 65 years and older with multiple self-reported chronic conditions and functional limitations and all patients with disabilities younger than 65 years. Outcomes included 27 performance measures reported under the 5-Star Part C Star Rating. Linear probability regression was used to examine the association of concentration of complex patients and performance measures.

Results: Most complex patients were enrolled in general MA plans. Concentration of complex patients ranged from 25.9% in MA contracts in the lowest quintile to 68.9% in the top quintile. MA contract performance scores generally decreased as the concentration of complex patients increased. After adjusting for contract and enrollee characteristics, MA contracts with more complex patients performed less well on half of the Part C performance measures including patient experience, preventive care, and chronic care measures.

Conclusion: MA contracts with a high concentration of complex patients have lower performance scores on more than half of Part C measures. Further study is needed to understand whether these performance measures are capturing the delivery of poor care, deficiencies in the health plan's care systems, or whether some measures may not be appropriate for complex patients. J Am Geriatr Soc 68:395-402, 2020.

Keywords: Medicare Advantage; high-need functional limitation; multiple chronic conditions.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cross-Sectional Studies
  • Female
  • Humans
  • Male
  • Medicare Part C / standards
  • Medicare Part C / statistics & numerical data*
  • Multiple Chronic Conditions / epidemiology*
  • Program Evaluation
  • Quality Indicators, Health Care / standards*
  • United States / epidemiology