JAMA Netw Open. 2026 Mar 2;9(3):e261796. doi: 10.1001/jamanetworkopen.2026.1796.
ABSTRACT
IMPORTANCE: Failure to account for the full complexity and costs of high-need populations in the risk-adjusted capitated payment model for Medicare Advantage (MA) plans may create financial disincentives for plans to invest in comprehensive care for affected beneficiaries, potentially exacerbating health disparities.
OBJECTIVE: To evaluate the association of reinstatement of Alzheimer disease and related dementias (ADRD) hierarchical condition categories (HCCs) into the MA risk-adjusted payment model in 2020 with access, affordability, and quality of care for beneficiaries with ADRD.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study examined a nationally representative sample of MA beneficiaries from the Medicare Current Beneficiary Survey (2015-2022). Beneficiaries with ADRD and those without ADRD but with comparable neurological diseases (stroke, paralysis, or Parkinson disease) before and after 2020 were included. Data analyses were performed between January and December 2025.
EXPOSURES: Reinstatement of the ADRD HCC into the MA risk adjustment formula in 2020.
MAIN OUTCOMES AND MEASURES: Primary outcomes were accessibility of needed care, medical financial burden, satisfaction with specialist access, and satisfaction with quality of care. These outcomes were assessed using a difference-in-differences model to compare changes between the treatment and control group before and after the inclusion of ADRD HCCs in the MA risk adjustment model in 2020.
RESULTS: Among 5353 MA beneficiary observations (1239 [23.1%] aged 65-74 years; 3127 [58.4%] aged ≥75 years; 1785 male [33.3%]), 1629 (30.4%) reported a diagnosis of ADRD, and 3724 (69.6%) did not report an ADRD diagnosis. Compared with MA beneficiaries without ADRD, those with ADRD reported lower rates of difficulty accessing care (142 beneficiaries [8.7%] vs 394 beneficiaries [10.6%]) and medical financial burden (235 beneficiaries [19.3%] vs 740 beneficiaries [25.1%]), but slightly lower rates of satisfaction with specialist access (1384 beneficiaries [90.8%] vs 3267 [92.7%]) and care quality (1495 beneficiaries [92.8%] vs 3414 beneficiaries [93.0%]). Reintroducing ADRD HCCs into the MA risk-adjusted payment model was associated with a 6.62 percentage-point decrease in reporting any troubles accessing needed care (β = 0.06; 95% CI, -0.11 to -0.02; P = .005) and a 9.20 percentage-point decrease in reporting any medical financial burden (β = -0.09; 95% CI, -0.16 to -0.02; P = .009) among MA beneficiaries with ADRD. No significant association was observed for satisfaction with specialist access or with quality of care among MA beneficiaries with ADRD.
CONCLUSIONS AND RELEVANCE: In this cross-sectional study of MA beneficiaries, reintroducing ADRD HCCs into the MA risk adjustment model was associated with improved care access and reduced financial burden among MA beneficiaries with ADRD. These findings suggest that risk adjustment that better reflects the costs of chronic, complex conditions may better align MA plan incentives with the needs of high-need populations and promote care equity.
PMID:41823963 | DOI:10.1001/jamanetworkopen.2026.1796
