Why medicare advantage plans pay hospitals traditional medicare prices

Robert A. Berenson, Jonathan H. Sunshine, David Helms, Emily Lawton

Research output: Contribution to journalArticle

Abstract

The policy community generally has assumed Medicare Advantage (MA) plans negotiate hospital payment rates similar to those for commercial insurance products and well above those in traditional Medicare. After surveying senior hospital and health plan executives, we found, however, that MA plans nominally pay only 100-105 percent of traditional Medicare rates and, in real economic terms, possibly less. Respondents broadly identified three primary reasons for near-payment equivalence: statutory and regulatory provisions that limit out-of-network payments to traditional Medicare rates, de facto budget constraints that MA plans face because of the need to compete with traditional Medicare and other MA plans, and a market equilibrium that permits relatively lower MA rates as long as commercial rates remain well above the traditional Medicare rates. We explored a number of policy implications not only for the MA program but also for the problem of high and variable hospital prices in commercial insurance markets.

Original languageEnglish (US)
Pages (from-to)1289-1295
Number of pages7
JournalHealth Affairs
Volume34
Issue number8
DOIs
StatePublished - Jan 1 2015

ASJC Scopus subject areas

  • Health Policy

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