Medicare Advantage vs. Traditional Medicare: How Do Beneficiaries’ Characteristics and Experiences Differ?

Abstract

• Issue: Enrollment in Medicare Advantage plans continues to increase rapidly. This has led to questions about which beneficiaries are enrolling in Medicare Advantage or in traditional Medicare and how their health care experiences compare.
• Goal: To assess the characteristics and experiences of beneficiaries in Medicare Advantage and traditional Medicare.
• Methods: Analysis of data from the 2018 Medicare Current Beneficiary Survey and the Commonwealth Fund 2021 International Health Policy Survey of Older Adults. Beneficiaries in Special Needs Plans (SNPs) were examined separately where sample sizes were sufficient.
• Key Findings: Medicare Advantage enrollees do not differ significantly from beneficiaries in traditional Medicare in terms of their age, race, income, chronic conditions, satisfaction with care, or access to care, after excluding SNP enrollees. Both groups reported waiting more than a month for physician office visits. Similar shares of Medicare Advantage and traditional Medicare enrollees report that their out-of-pocket costs make it difficult to obtain care.
• Conclusions: Medicare Advantage and traditional Medicare are serving similar populations, with beneficiaries having comparable health care experiences. The care management services provided by Medicare Advantage plans appear to neither impede access to care nor reduce concerns about costs. Overall, the analysis highlights substantial barriers to care that all beneficiaries seem to be experiencing.

Introduction

Medicare beneficiaries can choose whether to receive their benefits from traditional Medicare or Medicare Advantage plans, which are offered by private insurers. These plans have experienced a surge in enrollment over the past decade, and half of beneficiaries are projected to be enrolled in a private Medicare Advantage plan by 2025.¹ Medicare Advantage plans also have been paid more, on average, than what it costs to cover similar beneficiaries in traditional Medicare.² As Medicare Advantage enrollment continues to grow, it is critical to examine the experiences of beneficiaries to ensure equity among beneficiaries and value for the Medicare program.

Traditional Medicare and Medicare Advantage: A Historic Divide

Beneficiaries weigh considerable trade-offs when deciding whether to enroll in Medicare Advantage plans or traditional Medicare. Unlike the latter, Medicare Advantage plans are required to place limits on enrollees’ out-of-pocket spending and to maintain provider networks.³ The plans also can provide benefits not covered by traditional Medicare, such as eyeglasses, fitness benefits, and hearing aids. Medicare Advantage plans are intended to manage and coordinate beneficiaries’ care. Some Medicare Advantage plans specialize in care for people with diabetes and other common chronic conditions, including Special Needs Plans (SNPs); SNPs also focus on people who are eligible for both Medicare and Medicaid and those who require an institutional level of care.

Traditional Medicare and Medicare Advantage enrollees have historically had different characteristics, with Medicare Advantage enrollees somewhat healthier.⁴ Black and Hispanic beneficiaries and those with lower incomes have tended to enroll in Medicare Advantage plans at higher rates than others.⁵ Traditional Medicare has historically performed better on beneficiary-reported metrics, such as provider access, ease of getting needed care, and overall care experience.⁶

This issue brief examines the characteristics and experiences of Medicare Advantage enrollees relative to beneficiaries in traditional Medicare, using the most recent available data from the 2018 Medicare Current Beneficiary Survey fielded by the Centers for Medicare and Medicaid Services. It examines SNPs separately from other Medicare Advantage plans when sample sizes are sufficient, with an eye toward understanding how the experiences of SNP populations differ from those of other beneficiaries. The analysis also includes data from the Commonwealth Fund 2021 International Health Policy Survey of Older Adults, which surveyed a sample of 1,609 individuals over age 65 in the U.S. between March and May of 2021.⁷

Findings

Beneficiaries Enrolled in Medicare Advantage and Traditional Medicare Look Similar, After Separating Out SNPs

After excluding beneficiaries in SNPs, beneficiaries enrolled in traditional Medicare do not differ significantly from Medicare Advantage enrollees on age, income, or receipt of a Part D low-income subsidy (LIS), which helps low-income individuals pay for prescription drugs (Exhibit 1). However, beneficiaries in traditional Medicare are significantly more likely than Medicare Advantage enrollees to reside in a nonmetropolitan area, as well as more likely to live in a long-term-care or residential facility.

Beneficiaries in SNPs are different. Given the eligibility criteria for these plans, it is not surprising that enrollees tend to have significantly lower incomes and a greater likelihood of receiving Medicaid benefits or LIS than other Medicare beneficiaries. Enrollment in SNPs for people who require an institutional level of care has been growing rapidly, leading to a similar share of SNP enrollees and beneficiaries in traditional Medicare living in a long-term-care facility.⁸

Racial/ethnic distribution of enrollees. The racial and ethnic distribution of beneficiaries in traditional Medicare and Medicare Advantage is similar, after separating SNPs from other Medicare Advantage plans (Exhibit 2). Most beneficiaries in traditional Medicare and Medicare Advantage plans identify as white. However, SNP enrollees are significantly more likely to identify as Hispanic or Black.

When SNPs are included, about 13 percent of all Medicare Advantage enrollees identify as Black and approximately 10 percent identify as Hispanic, compared to 8 percent and 6 percent, respectively, of beneficiaries in traditional Medicare.

Chronic conditions. On average, the number of chronic conditions per beneficiary is relatively similar between traditional Medicare and non-SNP Medicare Advantage plans (Exhibit 3). Not surprisingly given eligibility criteria, the average number of chronic conditions is higher among beneficiaries in SNPs than among those with other types of Medicare coverage. Half of beneficiaries in SNPs have been diagnosed with six or more chronic conditions, compared with fewer than a third of beneficiaries in traditional Medicare and other types of Medicare Advantage plans.

After excluding SNPs, beneficiaries in traditional Medicare and Medicare Advantage do not differ with respect to the prevalence of chronic conditions (Exhibit 4). However, the prevalence of many chronic conditions is significantly higher among SNP enrollees, likely a reflection of the plans’ eligibility criteria. For example, more than half of SNP enrollees have diabetes, compared to about a third of enrollees in other Medicare Advantage plans or beneficiaries in traditional Medicare. Conversely, only about a quarter of SNP enrollees have been diagnosed with cancer versus more than a third of beneficiaries in other Medicare Advantage plans and in traditional Medicare.

Traditional Medicare and Medicare Advantage Enrollees Report Similar Difficulties Accessing Care

Cost as a barrier to care. A similar share of beneficiaries in traditional Medicare and Medicare Advantage plans report problems obtaining needed health care.

High cost is among the most frequently reported reasons for not getting needed care, followed by exclusion of a service from coverage (Exhibit 5). Relatively small shares of enrollees with either type of coverage reported problems with finding a specialist.

People with mental health conditions. A higher percentage of beneficiaries with a mental health condition than without one reported difficulty obtaining needed health care (11% vs. 4%, respectively) (data not shown). The proportion of beneficiaries with mental health conditions reporting access difficulties did not differ significantly by type of coverage.

Wait times. Wait times for hospital outpatient and physician office visits are similarly long for traditional Medicare and Medicare Advantage, averaging about three weeks for a hospital outpatient visit and over one month for a physician office appointment (data not shown). Waits were similar among those with mental health conditions and other common conditions.

Satisfaction with care. Regardless of coverage type, overwhelming majorities of Medicare beneficiaries in both traditional Medicare and Medicare Advantage report satisfaction with care (Exhibit 6).

Care Management Appears Somewhat Better for Beneficiaries in Medicare Advantage Plans Than for Beneficiaries in Traditional Medicare

Self-management of conditions. Across both types of Medicare coverage, most people age 65 and older said they felt confident they could manage and control their own health conditions (see Appendix). A somewhat larger share of people with diabetes in Medicare Advantage plans than people with diabetes in traditional Medicare felt confident they could manage their health conditions.

Among people age 65 and older with a health condition, a somewhat larger, though not statistically significantly different, share of those in Medicare Advantage plans than those in traditional Medicare that said they had a treatment plan for their condition. A larger share of Medicare Advantage enrollees said that a health care professional had given them clear instructions about symptoms to monitor and had discussed their priorities in caring for the condition (see Appendix).

Self-care among people with diabetes. Among beneficiaries with diabetes, no significant difference was observed by type of Medicare coverage in the proportion reporting their blood sugar was under control (Exhibit 7).⁹ While a larger share of SNP enrollees with diabetes engaged in self-care behaviors than their counterparts in other Medicare Advantage plans or traditional Medicare, the differences did not meet the statistical test for significance (Exhibit 8).

Prescription drug review. Older adults taking multiple medications may be susceptible to medication-related problems; having a health care professional review their medications can prevent harmful interactions and reduce the number of drugs prescribed. Among adults age 65 and older, a somewhat larger share of Medicare Advantage enrollees than beneficiaries in traditional Medicare reported having a health care professional review their medications in the past year. However, among beneficiaries with cancer and those with high needs and high costs — people who often take many medications — the share who had their medications reviewed did not significantly differ by type of coverage (see Appendix).

Usual source of care. Having a usual source of care has been found to improve quality and reduce unnecessary care. The majority of people age 65 and older reported having a usual provider or place where they receive care, with slightly higher rates among people in Medicare Advantage plans, people with diabetes, and people with high needs (see Appendix).

Providers coordinating care and responding to medical concerns. People age 65 and older with diabetes in Medicare Advantage plans were slightly more likely than those in the same group in traditional Medicare to report that their doctor’s practice always or often helped them coordinate or arrange their care with other providers. There were not statistically significant differences in the share of older adults in Medicare Advantage plans reporting that they would always or often receive an answer about a medical concern the same day they contacted their usual source of care compared to those in traditional Medicare (see Appendix). A larger share of older adults in Medicare Advantage plans had a health care professional they could easily contact in between doctor visits for advice about their health condition (data not shown).

Hospital discharge information. Hospitalization rates in the previous two years for people age 65 and older were similar by type of Medicare coverage (28% for Medicare Advantage vs. 27% for traditional Medicare) (data not shown). A somewhat larger share of Medicare Advantage enrollees than beneficiaries in traditional Medicare received written information on what to do and what symptoms to watch when they returned home (see Appendix).

Management of emergency department use. The percentage of people age 65 and older who had an emergency department visit in the previous two years did not differ by type of Medicare coverage (34% for both Medicare Advantage and traditional Medicare) (data not shown). The share of older adults who reported their emergency department visit could have been treated by their usual source of care did not differ by type of coverage (see Appendix).

Policy Implications

Historically, Medicare Advantage beneficiaries have been healthier than those in the traditional program, but this seems to be changing: beneficiaries now have similar characteristics and experiences regardless of coverage. Our analysis also shows that SNPs are serving a disproportionately larger share of lower-income beneficiaries who are Black or Hispanic.

These findings highlight the importance of separating SNPs from other Medicare Advantage plans when evaluating plan performance and considering policy changes. SNPs serve a particularly vulnerable population, including many people with serious health conditions or low incomes. Analyses by the Medicare Payment Advisory Commission (MedPAC) have shown that, on average, these plans have lower medical loss ratios (suggesting higher profits) than other types of Medicare Advantage plans.¹⁰ This indicates that insurers’ interest in serving these populations will likely continue to grow. The findings also raises the imperative to examine these plans separately from other Medicare Advantage plans in order to ensure high-quality, equitable care.

There are some areas in which Medicare Advantage plans appear to perform better than traditional Medicare. In particular, Medicare Advantage enrollees are more likely than those in traditional Medicare to have a treatment plan, to have someone who reviews their prescriptions, and to have a regular doctor or place of care. By providing this additional help, Medicare Advantage plans are making it easier for enrollees to get the help they need to manage their health care conditions. Medicare experts have suggested providing a similar service to beneficiaries in traditional Medicare through care coordinators.¹¹

The survey results also raise questions about whether Medicare Advantage plans are receiving appropriate payments. MedPAC estimates that plans are paid 4 percent more than it would cost to cover similar people in traditional Medicare.¹² On the one hand, Medicare Advantage plans seem to be providing services that help their enrollees manage their care, and this added care management could be of significant value to both plan enrollees and the Medicare program. On the other hand, rates of hospitalizations and emergency room visits are similar for beneficiaries in Medicare Advantage plans and traditional Medicare — outcomes that call into question the impact of the added services on health care use, spending, and outcomes.

Paying Medicare Advantage plans appropriately and fairly is important not only to their enrollees but also to beneficiaries in traditional Medicare, since higher payments to plans raise Part B premiums for all beneficiaries and erode the solvency of the Medicare Hospital Insurance Trust Fund.¹³ With Medicare Advantage enrollment projected to overtake traditional Medicare enrollment over the next decade, maintaining sufficient coverage choices and facilitating innovation — while also ensuring that Medicare Advantage plans provide efficient, effective, and equitable care — will remain a challenging balancing act.