Understanding the High‐Need Populations in Medicare Advantage: Evidence to Improve Quality of Care


Enrollment in the Medicare Advantage (MA) program is projected to grow from 30 percent to 40 percent of total Medicare enrollment over the next 10 years. Moreover, a recent study of Medicare Current Beneficiary Survey data suggests the prevalence of MA plan enrollees living with chronic conditions and reporting fair or poor health is now approaching that of traditional Medicare program enrollees. To date, however, research into Medicare beneficiaries’ health needs and interventions to improve their care have largely focused on the traditional fee‐for-service program—largely because public use files of MA claims‐level (encounter) data are lacking. With the Affordable Care Act mandating a substantial value‐based purchasing program for MA plans, policymakers will require more information about the exact prevalence and characteristics of MA enrollees with chronic and complex health needs to ensure the program encourages delivery of clinically optimal care. The University of Wisconsin research team will examine the prevalence and characteristics of high‐need, high‐cost Medicare beneficiaries enrolled in MA plans through analysis of self‐reported data from the Health Outcomes Survey (2013). The team will evaluate two approaches to segmenting the high‐need, high‐cost population, developed by researchers at Johns Hopkins and Harvard, to determine which fits best with the data. The project team will report the prevalence of high‐need enrollees in MA and describe characteristics of plans by prevalence of high‐need categories. Project findings will inform policymakers, providers, and health plans about the makeup of MA’s complex patient population and variation in their health outcomes. It also will yield recommendations that could help the MA quality bonus program better reflect its high‐need enrollees.

Grant Details

Grantee Organization:
Board of Regents of the University of Wisconsin System
Principal Investigator:
Eva DuGoff, Ph.D., M.P.P.
Award Amount:
Approval Date:
November 8, 2016

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