February 26, 2025
Contact: Erin Hemlin, Vice President of Communications, APG
Email: ehemlin@apg.org
Tel: 202-770-1901
Patients cared for by physician groups operating under accountable relationships with Medicare Advantage (MA) plans experience superior health outcomes even when they are not enrolled in MA but are in traditional Medicare, a new study[1] shows. The study is the first to demonstrate that positive health outcomes made possible through accountable care can “spill over” from patients enrolled in Medicare Advantage to other Medicare patients, who can benefit from the advanced care practices adopted by these physician groups and made possible through MA.
The study examined the care outcomes achieved by two groups of traditional Medicare patients who were cared for by physicians with different levels of experience in providing accountable care through Medicare Advantage – high and low. Compared to patients cared for by physician groups with low levels of experience in accountable care, the traditional Medicare patients cared for by physician groups with high levels of experience in accountable care were:
- 10 percent less likely to undergo acute hospital admissions, one of the costliest forms of health care;
- 12 percent less likely to be readmitted to a hospital within 30 days of a previous hospital stay;
- 21 percent less likely to use emergency departments;
- 82 percent more likely to have annual wellness visits; and
- 9-13 percent more likely to be adherent to their medications for hypertension, diabetes, and high cholesterol.
The study was published in the March 2025 issue of the American Journal of Managed Care, the leading peer-reviewed journal dedicated to issues in managed care. An APG infographic explains more about the import of the study and its findings. The study was conducted by APG; Optum Health Translational Science; and CareJourney, a division of Arcadia, which provided extensive data compilation and analysis.
Background: Many of the patients whose care was examined in the study were cared for by nine large physician groups – all members of America’s Physician Groups — and their more than 5,000 primary care physicians. These physician groups were engaged in value-based, accountable, “two-sided risk” relationships with MA plans, in which MA plans transfer much of the payment they receive from the government to the physician groups in the form of capitated payments. The physician groups are then accountable for the quality and costs of care that they provide to their MA patients and stand to make money if they hit quality and cost targets and lose money if they do not.
The payments that these physician groups receive from the MA plans exceed what they would normally be paid under traditional fee-for-service Medicare. The extra payments enable them to develop advanced care practices including preventive care, intensive case management, care coordination, behavioral health services, pharmacy support and other services that keep patients as healthy as possible and out of the hospital. These groups then extend these services to other patients for whom they deliver care – not just MA patients, but patients in the traditional Medicare program as well.
“The results of the study show that advanced care practices made possible through two-sided risk in Medicare Advantage lead the way for the Medicare program,” said the lead researcher on the study, Ken Cohen, MD, a longtime physician with APG member Optum Colorado Physician Group and executive director of translational research at Optum. “The superior care outcomes for quality and cost achieved by physician groups participating in at-risk MA payment arrangements clearly “spill over” to patients in traditional Medicare, who also benefit from a care model focused more on coordination and prevention.”
“These results should send a strong signal to policymakers about the importance of building on the positive elements of MA,” said Susan Dentzer, president and chief executive officer of America’s Physician Groups. “Medicare Advantage is not a zero-sum arrangement in which only MA enrollees obtain the benefits of the program and traditional Medicare patients are somehow disadvantaged by it. In fact, it’s the opposite: Our groups’ results show that all Medicare patients can benefit from the types of advanced care practices that the resources channeled through MA allow.”
The new study builds on an earlier study[2] that demonstrated superior results achieved by physician groups operating under two-sided risk arrangements with MA plans, compared to when the groups were paid under conventional fee-for-service arrangements by MA plans. The studies are part of a suite of studies examining the effects on patients of being cared for by highly accountable APG physician practices operating under two-sided risk arrangements with MA plans.
About America’s Physician Groups
APG’s approximately 360 physician groups comprise 170,000 physicians, as well as thousands of other clinicians, providing care to nearly 90 million patients, including about 1 in 3 Medicare Advantage enrollees. APG’s motto, ‘Taking Responsibility for America’s Health,’ represents our members’ commitment to clinically integrated, coordinated, value-based health care in which physician groups are accountable for the costs and quality of patient care. Visit us at www.apg.org.##
[1] Vabson B, Cohen K, Ameli O, et al. Potential spillover effects on traditional Medicare when physicians bear Medicare Advantage risk. Am J Manag Care. Published online February 26, 2025. doi:10.37765/ajmc.2025.89686.
[2] Cohen KR et al, Medicare Risk Arrangement and Use and Outcomes Among Physician Groups. JAMA Netw Open. 2025; 8(1):e2456074. 10.1001/jamanetworkopen.2024.56074
