Study Finds At-Risk Medicare Advantage Plans Lead in Quality and Efficiency
A recent study published in JAMA Network Open provides evidence that at-risk Medicare Advantage(MA) payment arrangements lead to superior quality and efficiency in health care delivery compared with fee-for-service (FFS) MA models. This cross-sectional study analyzed claims and enrollment data from 2016 to 2019, covering over 5.2 million person-years, to evaluate 20 quality and health resource use measures across 4 domains of patient care: hospital care, avoidance of emergency department (ED) visits, avoidance of disease-specific admissions, and outpatient care.
Findings indicate that physician groups operating under at-risk MA arrangements—where financial risk is transferred to the provider group—achieved better outcomes in 18 of the 20 evaluated measures. Specifically, inpatient admissions and 30-day readmissions per 1000 beneficiaries were 10.03 and 1.95 lower, respectively, in at-risk MA than in FFS MA. Similarly, ED visits per 1000 beneficiaries were 26.02 lower overall and 2.95 lower for avoidable ED visits. Avoidance of disease-specific hospitalizations was also more favorable in at-risk MA, with diabetes-related admissions reduced by 0.24 per 1000 beneficiaries and chronic disease-related admissions reduced by 2.18 per 1000 beneficiaries. Additionally, at-risk MA showed lower high-risk drug use and improved medication adherence for statins and antihypertensives.
These results suggest that at-risk MA payment structures foster care models that emphasize preventive care, efficient care coordination, and reduction of unnecessary utilization. The ability of physician groups in at-risk MA arrangements to invest in population health infrastructure—such as case management, social worker support, and integrated behavioral health services—may contribute to these improved outcomes. Furthermore, the study controlled for potential confounders, such as demographic differences, health risk scores, and variations in physician group practices, ensuring the robustness of the findings.
“While this study was not designed to assess causality, the results provide further evidence for the benefits associated with at-risk payment models and the possibility that they lead to higher quality and more efficient use of health care resources,” the researchers stated. “These findings support the vision of a health care system where particular physician payment arrangements incentivize care that results in higher quality and more efficient use of health care resources.”
Reference
Cohen KR, Vasbon B, Podulka J, et al. Medicare risk arrangement and use and outcomes among physician groups. JAMA Netw Open. 2025;8(1):e2456074. doi:10.1001/jamanetworkopen.2024.56074
