Identifying Gaps in Care Quality for Seriously Ill Medicare Advantage Enrollees

Objectives

Increasingly, seriously ill Americans are ensured by Medicare Advantage (MA). However, standardized assessments of MA care quality do not highlight their unique experiences and needs. We adapted a previously validated survey to describe care experiences of seriously ill MA enrollees and highlight areas of unmet need for quality improvement.

Study Design

This is a cross-sectional study.

Methods

We sampled 3500 MA enrollees with the highest Hierarchical Condition Category (HCC) scores within one MA organization and administered a validated patient Serious Illness Survey for Home-Based Programs assessing communication, care coordination, symptom management, and planning for care in July and August 2023. We calculated top-box scores for all respondents and used linear regressions to calculate adjusted scores for subgroups of respondents meeting alternate serious illness definitions.

Results

Of 1412 respondents, 84.6% had three or more chronic conditions. Responses indicated substantial room for improvement across quality measures assessed, with just 59.6% and 56.9% of respondents reporting that their communication and care coordination needs were met, respectively; 52.8% reporting that they “definitely” got the help they wanted for their symptoms; and 38.8% indicating that they had “definitely” discussed planning for care with their health care professionals. Respondents with HCC risk scores of ≥3 plus recent health care utilization also reported considerable unmet needs.

Conclusions

Seriously ill MA enrollees have important unmet needs for care planning, care coordination, communication, and symptom management that are not highlighted by existing quality measures, but can be addressed through evidence-based interventions. Assessing care quality for seriously ill enrollees using standardized, survey-based measures can help to identify actionable improvement targets for this high-need, high-cost group.