Literature indicates favorable selection among Medicare Advantage (MA) enrollees compared with fee-for-service (FFS) enrollees. This study examined whether favorable selection into MA affected readmission rates among Medicare-eligible veterans following hospitalization for congestive heart failure in the Veterans Affairs Health System (VA). We measured total (VA + Medicare FFS) 30-day all-cause readmission rates across hospitals and all of VA. We used Heckman’s correction to adjust readmission rates to be representative of all Medicare-eligible veterans, not just FFS-enrolled veterans. The adjusted all-cause readmission rate among FFS veterans was 27.1% (95% confidence interval [CI] = 26.5% to 27.7%), while the adjusted readmission rate among Medicare-eligible veterans was 25.3% (95% CI = 23.6% to 27.1%) after correcting for favorable selection. Readmission rate estimates among FFS veterans generalize to all Medicare-eligible veterans only after accounting for favorable selection into MA. Estimation of quality metrics should carefully consider sample selection to produce valid policy inferences.
AjmeraM.WilkinsT. L.SambamoorthiU. (2011). Dual Medicare and Veteran Health Administration use and ambulatory care sensitive hospitalizations. Journal of General Internal Medicine, 26(Suppl. 2), 669-675.
2.
AmarasinghamR.MooreB. J.TabakY. P.DraznerM. H.ClarkC. A.ZhangS.. . .HalmE. A. (2010). An automated model to identify heart failure patients at risk for 30-day readmission or death using electronic medical record data. Medical Care, 48, 981-988.
3.
ArmitageP.ColtonT. (2005). Encyclopedia of Biostatistics (2nd ed.). Hoboken, NJ: John Wiley.
4.
AtherlyA.HebertP. L.MaciejewskiM. L. (2005). An analysis of disenrollment from Medicare managed care plans by Medicare beneficiaries with diabetes. Medical Care, 43, 500-506.
5.
CallK. T.DowdB. E.FeldmanR.LurieN.McBeanM. A.MaciejewskiM. (2001). Disenrollment from Medicare HMOs. American Journal of Managed Care, 7, 37-51.
6.
CallK. T.DowdB.FeldmanR.MaciejewskiM. (1999). Selection experiences in Medicare HMOs: Pre-enrollment expenditures. Health Care Financial Review, 20, 197-209.
DowdB.MaciejewskiM. L.O’ConnorH.RileyG.GengY. (2011). Health plan enrollment and mortality in the Medicare program. Health Economics, 20, 645-659.
10.
FischerM. J.StroupeK. T.KaufmanJ. S.O’HareA. M.BrowningM. M.HuoZ.HynesD. M. (2010). Predialysis nephrology care among older veterans using Department of Veterans Affairs or Medicare-covered services. American Journal of Managed Care, 16, e57-e66.
11.
GreenwaldL. M.LevyJ. M.IngberM. J. (2000). Favorable selection in the Medicare+Choice program: New evidence. Health Care Finance Review, 21, 127-134.
12.
HeckmanJ. (1979). Sample selection bias as a specification error. Econometrica, 47, 153-161.
13.
HellingerF. J. (1995). Selection bias in HMOs and PPOs: A review of the evidence. Inquiry, 32, 135-142.
14.
HellingerF. J.WongH. S. (2000). Selection bias in HMOs: A review of the evidence. Medical Care Research and Review, 57, 405-439.
15.
KeatingN. L.LandrumM. B.LamontE. B.EarleC. C.BozemanS. R.McNeilB. J. (2010). End-of-life care for older cancer patients in the Veterans Health Administration versus the private sector. Cancer, 116, 3732-3739.
16.
KeenanP. S.NormandS. L.LinZ.DryeE. E.BhatK. R.RossJ. S.. . .KrumholzH. M. (2008). An administrative claims measure suitable for profiling hospital performance on the basis of 30-day all-cause readmission rates among patients with heart failure. Circulation: Cardiovascular Quality and Outcomes, 1, 29-37.
17.
KizerK. W. (2012). Veterans and the Affordable Care Act. Journal of the American Medical Association, 307, 789-790.
18.
LiuC. F.BrysonC. L.BurgessJ. F.Jr.SharpN.PerkinsM.MaciejewskiM. L. (2012). Use of outpatient care in VA and Medicare among disability-eligible and age-eligible veteran patients. BMC Health Services Research, 12, 51.
19.
MaciejewskiM. L.BirkenS.PerkinsM.BurgessJ. F.Jr.SharpN.LiuC. F. (2009). Medicare managed care enrollment by disability-eligible and age-eligible veterans. Medical Care, 47, 1180-1185.
20.
MelloM. M.StearnsS. C.NortonE. C. (2002). Do Medicare HMOs still reduce health services use after controlling for selection bias?Health Economics, 11, 323-340.
21.
MirandaA.Rabe-HeskethS. (2006). Maximum likelihood estimation of endogenous switching and sample selection models for binary, ordinal, and count variables. Stata Journal, 6, 285-308.
22.
PetersenL. A.ByrneM. M.DawC. N.HascheJ.ReisB.PietzK. (2010). Relationship between clinical conditions and use of Veterans Affairs health care among Medicare-enrolled veterans. Health Services Research, 45, 762-791.
23.
PetersenL. A.NormandS. L.DaleyJ.McNeilB. J. (2000). Outcome of myocardial infarction in Veterans Health Administration patients as compared with Medicare patients. New England Journal of Medicine, 343, 1934-1941.
24.
PizerS. D.FraktA. B. (2002). Payment policy and competition in the Medicare+Choice program. Health Care Financial Review, 24, 83-94.
RossJ. S.ChenJ.LinZ.BuenoH.CurtisJ. P.KeenanP. S.. . .KrumholzH. M. (2010). Recent national trends in readmission rates after heart failure hospitalization. Circulation: Heart Failure, 3, 97-103.
27.
ShimadaS. L.ZaslavskyA. M.ZaborskiL. B.O’MalleyA. J.HellerA.ClearyP. D. (2009). Market and beneficiary characteristics associated with enrollment in Medicare managed care plans and fee-for-service. Medical Care, 47, 517-523.
28.
StockJ. H.WrightJ. H.YogoM. (2002). A survey of weak instruments and weak identification in generalized method of moments. Journal of Business and Economic Statistics, 20, 518-529.
29.
TrivediA. N.GreblaR. C.JiangL.YoonJ.MorV.KizerK. W. (2012). Duplicate federal payments for dual enrollees in Medicare Advantage plans and the Veterans Affairs health care system. Journal of the American Medical Association, 308, 67-72.
30.
Van de VenW. P. M. M.Van PraggB. M. S. (1981). The demand for deductibles in private health insurance: A probit model with sample selection. Journal of Econometrics, 17, 229-252.
