Multi-Payer Advanced Primary Care Practice Demonstration on quality of care

OBJECTIVES

We evaluated whether primary care practices in the Medicare Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration improved the quality of care and patient outcomes for beneficiaries.

STUDY DESIGN

For our quantitative analyses, we employed a pre-post study design with a comparison group using enrollment data, Medicare fee-for-service claims data, and Medicaid managed care and fee-for-service claims data, covering the period 2 to 4 years before Medicare joined the state patient-centered medical home initiatives through December 2014. We used difference-in-differences (DID) regression analysis to compare quality and outcomes in the period before and after the demonstration began.

METHODS

We examined the extent to which MAPCP and comparison group beneficiaries received up to 11 process and preventive care measures, as well as 4 measures of potentially avoidable hospitalizations to assess patient outcomes.

RESULTS

Analyses of Medicare and Medicaid data did not consistently reflect the positive impacts intended by the demonstration. Our descriptive and DID analysis found an inconsistent pattern among the process-of-care results, and there were some significant unfavorable associations between participation in MAPCP and avoidable hospitalizations.

CONCLUSIONS

Our analyses showed few statistically significant, favorable impacts on quality metrics among Medicare or Medicaid beneficiaries receiving care from MAPCP practices.

Changes in ambulatory utilization after switching from Medicaid fee-for-service to managed care

OBJECTIVES

To observe any change in ambulatory care utilization after switching from Medicaid fee-for-service (FFS) to Medicaid managed care (MC).

STUDY DESIGN

We conducted a statewide longitudinal study of 21,048 adult Medicaid beneficiaries in New York State who switched from FFS to MC in 2011 or 2012, with 2 sets of controls (n = 21,048 with continuous FFS; n = 21,048 with continuous MC) who were matched on age, gender, dual-eligible status, and number of chronic conditions.

METHODS

We measured ambulatory care utilization in the 12 months before and 12 months after the switch date, using regression to adjust for case mix and account for matching.

RESULTS

Overall, switching from Medicaid FFS to Medicaid MC was associated with greater absolute decreases over time in ambulatory visits and providers compared with controls (-1.49 visits vs continuous FFS and -1.60 visits vs continuous MC; each P <.0001; -0.10 providers vs continuous FFS and -0.12 providers vs continuous MC; each P <.0001). The subset of switchers with 5 or more chronic conditions had the greatest absolute decreases in visits (-5.88 visits vs continuous FFS and -5.98 visits vs continuous MC; each P <.0001) and providers (-1.37 providers vs continuous FFS and -1.39 providers vs continuous MC; each P <.0001). Significant decreases in visits and providers were also observed for switchers with 3 to 4 chronic conditions but not for those with 0 to 2 chronic conditions.

CONCLUSIONS

Switching from Medicaid FFS to Medicaid MC was associated with a decrease in ambulatory utilization, especially for the sickest patients.

Medicare Shared Savings Program ACO network comprehensiveness and patient panel stability

OBJECTIVES

The current Medicare Shared Savings Program (MSSP) accountable care organization (ACO) attribution methodology creates unpredictability for ACOs that are developing and deploying strategic initiatives aimed at improving value. The goal of this study is to determine if ACO network comprehensiveness is associated with the stability of assigned Medicare beneficiaries from 2013 to 2014.

STUDY DESIGN

We utilized a beneficiary-level logistic regression model to determine association of network comprehensiveness with stable attribution to an MSSP ACO.

METHODS

Using 2013 and 2014 Medicare fee-for-service beneficiary and provider files, we developed a measure of network comprehensiveness based on 2013 provider contracts, determined beneficiary attribution, and generated market-level measures. Additional population and quality measures were obtained from the US Census and the ACO Public Use File.

RESULTS

Of the 1,317,858 observed beneficiaries, 84.38% were attributed to the same ACO in 2013 and 2014, and mean (SD) ACO network comprehensiveness was 0.30 (0.20). We found that a 0.10 increase in network comprehensiveness score significantly increased the odds of remaining attributed to the same ACO by 4.5% (P = .001). Patient panel stability was significantly associated with improved diabetes (P = .01) and hypertension (P = .02) control, timely access to care (P = .001), and delivery of health education (P = .03) over the 2-year period.

CONCLUSIONS

The comprehensiveness of an MSSP ACO's contracted provider network is associated with stable patient assignment year to year. Patient panel stability may aid in the longitudinal management of some conditions.

Variation in Practice Patterns and Reimbursements Between Female and Male Urologists for Medicare Beneficiaries

Importance

Previous assessments of practice patterns and reimbursements for female urologists relied on surveys or board certification logs. A current evaluation of the geographic distribution and practice patterns by female urologists would reveal contemporary patterns of access for Medicare beneficiaries.

Objective

To characterize the variation in practice patterns and reimbursements by urologist sex and the regional deficiencies in care provided by female urologists.

Design, Setting, and Participants

This population-based cohort study used the publicly available Centers for Medicare & Medicaid Services Provider Payment database to evaluate payments for US urologists. The cohort (n = 8665) included urologists who provided and were paid for 11 or more services to Medicare beneficiaries in 2016. Data collection and analysis were performed from October 3, 2018, through June 19, 2019.

Main Outcomes and Measures

Proportion of female-specific services, payments per beneficiary, and payments per work relative value unit (wRVU) by urologist sex were assessed. Density of female urologists across hospital markets was also identified.

Results

Among the 8665 urologists who received payments in 2016, 7944 (91.7%) were men and 721 (8.3%) were women. Female urologists, compared with male urologists, saw a lower proportion of patients with cancer (mean [SD], 16.3% [9.2%] vs 22.7% [8.8%]; P < .001) and a greater proportion of female Medicare beneficiaries (mean [SD], 52.8% [23.2%] vs 24.4% [10.3%]; P < .001). Female urologists generated a greater proportion of wRVU from urodynamics (median [IQR], 2.88% [1.26%-4.84%] vs 1.07% [0.31%-2.26%]; P < .001) and gynecological operations (median [IQR], 0.68% [0.45%-1.07%] vs 0.41% [0.20%-0.81%]; P < .001) than male urologists. In addition, female urologists, compared with their male counterparts, received lower median payments per beneficiary seen ($70.12 [interquartile range (IQR), $60.00-$84.81] vs $72.37 [IQR, $59.63-$89.29]; P = .03) and lower payments per wRVU ($58.25 [IQR, $48.39-65.26] vs $60.04 [IQR, $51.93-$67.88]; P < .001). One-third (103 [33.7%]) of 306 hospital referral regions had 0 female urologists, and 80 (26.1%) had only 1 female urologist.

Conclusions and Relevance

Female urologists were more likely to provide care for female Medicare beneficiaries, to receive lower payments per wRVU generated and beneficiaries seen, and to be difficult to access in certain geographic areas; these findings have policy-related implications and highlight the regional deficiencies in urological care and reimbursement discrepancies according to urologist sex.

Racial Disparities in Readmission Rates among Patients Discharged to Skilled Nursing Facilities

OBJECTIVES

Prior studies have reported mixed findings about the existence of racial disparities in readmission rates among Medicare Advantage beneficiaries, but these studies used data from one state, focused on black-white disparities, and did not focus on patients discharged to skilled nursing facilities (SNFs). The objective of the study was to characterize racial and ethnic disparities in rates of 30-day rehospitalization directly from SNFs among fee-for-service and Medicare Advantage patients.

DESIGN

A cross-sectional study of admissions to SNFs in 2015 was conducted.

SETTING

SNFs across the United States.

PARTICIPANTS

The sample included 1 500 334 white, 213 848 African American, and 99 781 Hispanic Medicare patients who were admitted to 13 375 SNFs.

MEASUREMENTS

The main outcome of interest was readmission, identified as patients sent back to any hospital directly from the SNF within 30 days of admission, as indicated on the Minimum Data Set discharge assessment.

RESULTS

Overall readmission rates for fee-for-service patients were 16.7% (95% confidence interval [CI] = 16.7%-16.8%) for whites, 18.8% (95% CI = 18.7%-19.0%) for African Americans, and 17.4% (95% CI = 17.1%-17.7%) for Hispanics. Readmission rates in Medicare Advantage were 14.7% (95% CI = 14.5%-14.8%) for whites, 16.8% (95% CI = 16.6%-17.1%) for African Americans, and 15.3% (95% CI = 14.9%-15.6%) for Hispanics. We also found that African Americans had about 1% higher readmission rates than whites, even when they received care within the same SNF. No statistically significant differences were found in the magnitude of within-SNF racial disparities in Medicare Advantage compared with Medicare fee-for-service.

CONCLUSION

We found racial disparities in readmission rates even within the same facility for both Medicare Advantage and fee-for-service beneficiaries. Intervention to reduce disparities in readmission rates, as well as more comprehensive quality measures that incorporate outcomes for Medicare Advantage enrollees, are needed. J Am Geriatr Soc 67:1672-1679, 2019.

Contemporary Trends in Clinical Outcomes among Dialysis Patients with Medicare Coverage

BACKGROUND

The dialysis patient population in the United States continues to grow. Trends in rates of death and hospitalization among dialysis patients have important consequences for outpatient dialysis capacity and Medicare spending.

OBJECTIVES

To estimate contemporary trends in rates of death and hospitalization among dialysis patients in the United States, overall and within subgroups.

METHODS

We used Medicare Limited Data Sets (100% sample) in 2014-2017 to estimate trends in rates of death and hospitalization among dialysis patients with Medicare Parts A and B enrollment. We used seasonal autoregressive integrated moving average models to identify secular trends in the incidence of outcomes.

RESULTS

There were 631,075 unique patients; 222,924 deaths; and 1,876,779 hospital admissions. Weekly risks of both death and hospitalization exhibited strong seasonality. However, overall weekly risks of death were 34.9, 35.4, 35.2, and 35.7 deaths per 10,000 patients in 2014-2017, respectively (p = 0.47, from a likelihood ratio test of secular trend). The overall weekly risk of hospitalization was 3.08, 3.05, 3.11, and 3.11% in 2014, 2015, 2016, and 2017, respectively (p = 0.30). There were significant secular trends in risk of death in subgroups defined by black race and residency in South Atlantic states (p < 0.05). There were also secular trends in risk of hospitalization in subgroups defined by age 20-44 years, concurrent enrollment in Medicaid, and residency in South Central states.

CONCLUSION

For the first time since the beginning of this century, rates of both death and hospitalization among dialysis patients with Medicare fee-for-service coverage have stagnated. The reasons for this change are unknown and require detailed assessment. Persistent lack of change in clinical outcomes may alter the future expectations about dialysis patient population growth.

Cancer care spending and use by site of provider-administered chemotherapy in Medicare

OBJECTIVES

To compare cancer care spending and utilization by site of provider-administered chemotherapy in Medicare.

STUDY DESIGN

A retrospective analysis using 2010-2013 Medicare claims.

METHODS

The study population was a random sample of Medicare fee-for-service beneficiaries with cancer who initiated provider-administered chemotherapy in a hospital outpatient department (HOPD) or physician office (PO). We assessed the following outcomes during the 6-month follow-up period: (1) spending on cancer-related outpatient services excluding chemotherapy, (2) spending on cancer-related inpatient services, (3) utilization of select cancer-related outpatient services (evaluation and management, commonly used expensive billing codes, and radiation therapy sessions), and (4) the number of cancer-related hospitalizations. We used regression analyses to adjust for patient health risk factors and market characteristics.

RESULTS

During the 6-month follow-up period, risk-adjusted spending on nonchemotherapy outpatient services was slightly lower among patients receiving chemotherapy in HOPDs than in POs ($12,183 [95% CI, $12,008-$12,358] vs $12,444 [95% CI, $12,313-$12,575]; P <.05). Risk-adjusted cancer-related inpatient spending was higher in the HOPD group than in the PO group ($3996 [95% CI, $3837-$4156] vs $3168 [95% CI, $3067-$3268]; P <.01). The HOPD group had fewer visits in all select outpatient services but had a higher number of hospitalizations than the PO group.

CONCLUSIONS

Differences in cancer care spending by site of chemotherapy (HOPDs vs POs) vary by service type. Those differences are partially driven by utilization differences. As the site of chemotherapy shifts from POs to HOPDs, spending and utilization patterns in both settings need to be monitored.

Association of decision support for hospital discharge disposition with outcomes

OBJECTIVES

To assess the association of a clinical decision support (CDS) algorithm for hospital discharge disposition with spending, readmissions, and postdischarge emergency department (ED) use.

STUDY DESIGN

A retrospective study in a cohort of fee-for-service Medicare patients 65 years or older linked to a database of patients receiving CDS.

METHODS

We evaluated (1) patients whose discharge disposition was concordant with the CDS recommendation versus those whose disposition was not and (2) patients receiving CDS for discharge disposition versus those not receiving CDS, regardless of concordance. Outcomes were spending over a 90-day episode, 90-day readmissions, and postdischarge ED utilization not associated with a readmission.

RESULTS

Analysis of concordant versus discordant cases showed decreased spending for concordant cases ($860 savings; 95% CI, $162-$1558; P = .016), a decrease in readmissions (adjusted odds ratio [OR], 0.920; 95% CI, 0.850-0.995; P = .038), and no change in rate of postdischarge ED use (adjusted OR, 0.990; 95% CI, 0.882-1.110; P = .858). Analysis of patients receiving CDS versus not receiving CDS showed no significant difference in spending ($221 savings; 95% CI, -$115 to $557; P = .198), ED use (adjusted OR, 0.959; 95% CI, 0.908-1.012; P = .128), or readmission rate (adjusted OR, 1.004; 95% CI, 0.966-1.043; P = .840).

CONCLUSIONS

Following the recommendation of a CDS algorithm for hospital discharge disposition was associated with lower spending, fewer readmissions, and no change in ED use over a 90-day episode of care.

Health Care Fragmentation in Medicaid Managed Care vs. Fee for Service

Managed care plans often attempt to control health care costs through strategies designed to decrease health care utilization. However, the extent to which the resulting patterns of utilization represent high-quality care (compared to fee-for-service products) remains controversial. The authors sought to compare patterns of ambulatory care (including how diffuse or fragmented the care patterns were) for Medicaid fee-for-service beneficiaries vs. Medicaid managed care beneficiaries. A serial cross-sectional study of adults (≥18 years old) was conducted using statewide Medicaid claims from New York State for calendar years 2010-2013. Beneficiaries were required to be continuously enrolled and have ≥4 ambulatory visits for each year they contributed data, yielding a sample of more than 1 million beneficiaries per year. Beneficiaries were characterized by age, sex, and case mix. For each year, ambulatory care patterns were compared across subgroups of beneficiaries using Poisson models (for numbers of visits and providers) and bounded Tobit models (for fragmentation scores). In 2010, among those who were not dual eligible, managed care beneficiaries had on average fewer visits (10.9 visits vs. 11.4 visits [P < 0.0001]) but more providers (3.8 providers vs. 3.3 providers [P < 0.0001]) and therefore more fragmentation (0.58 vs. 0.51 [P < 0.0001]) than fee-for-service beneficiaries, adjusting for age, sex, and case mix. These patterns persisted throughout the follow-up period and in sensitivity analyses. Less utilization is not necessarily more efficient care; a smaller number of visits spread across a larger number of providers creates more challenges for care coordination.

Testing the myth of fee-for-service and overprovision in health care

Paying on the basis of fee-for-service (FFS) is often associated with a risk of overprovision. Policymakers are therefore increasingly looking to other payment schemes to ensure a more efficient delivery of health care. This study tests whether context plays a role for overprovision under FFS. Using a laboratory experiment involving medical students, we test the extent of overprovision under FFS when the subjects face different fee sizes, patient types, and market conditions. We observe that decreasing the fee size has an effect on overprovision under both market conditions. We also observe that patients who are harmed by excess treatment are at little risk of overprovision. Finally, when subjects face resource constraints but still have an incentive to overprovide high-profit services, they hesitate to do so, implying that the presence of opportunity costs in terms of reduced benefits to other patients protects against overprovision. Thus, this study provides evidence that the risk of overprovision under FFS depends on fee sizes, patients' health profiles, and market conditions.

Aggressive Care near the End of Life for Cancer Patients in Medicare Accountable Care Organizations

OBJECTIVES

To compare aggressiveness of end-of-life (EoL) care for older cancer patients attributed to Medicare Shared Savings Programs with that for similar fee for service (FFS) beneficiaries not in an accountable care organization (ACO) and examine whether observed differences in EoL care utilization vary across markets that differ in ACO penetration.

DESIGN

Cross-sectional observational study comparing ACO-attributed beneficiaries with propensity score-matched beneficiaries not attributed to an ACO.

SETTING

A total of 21 hospital referral regions (HRRs) in the United States.

PARTICIPANTS

Medicare FFS beneficiaries with a cancer diagnosis who were 66 years or older and died in 2013-2014.

MEASUREMENTS

Outcome measures were claims-based quality measures of aggressive EoL care: (1) one or more intensive care unit (ICU) admissions in the last month of life, (2) two or more hospitalizations in the last month of life, (3) two or more emergency department visits in the last month of life, (4) chemotherapy 2 weeks or less before death, and (5) no hospice enrollment or hospice enrollment within 3 days of death. Analyses were adjusted for demographic and clinical characteristics of beneficiaries and practice characteristics.

RESULTS

Compared with beneficiaries not in an ACO, ACO-attributed beneficiaries had a higher rate of ICU admission during the last month of life (37.7% vs 34.0%; adjusted difference = +2.8 percentage points; 95% confidence interval (CI) = 1.0-4.6) but fewer repeated hospitalizations (14.5% vs 15.2%; adjusted difference = -1.7 percentage points; CI = -3.1 to -.3). Other measures did not differ for the two groups. Although the ICU admission rates tended to decrease as ACO-penetration rates increased (P < .01), ACO patients had higher rates of ICU admission than non-ACO patients in both medium and high ACO-penetration HRRs.

CONCLUSION

Cancer patients attributed to ACOs had fewer repeated hospitalizations but more ICU admissions in the last month of life than non-ACO patients; they had similar rates of other measures of aggressive care at the EoL. This suggests opportunities for ACOs to improve EoL care for cancer patients. J Am Geriatr Soc 67:961-968, 2019.

The impact of integration on outpatient chemotherapy use and spending in Medicare

Hospital-physician integration has substantially grown in the United States for the past decade, particularly in certain medical specialties, such as oncology. Yet evidence is scarce on the relation between integration and outpatient specialty care use and spending. We analyzed the impact of oncologist integration on outpatient provider-administered chemotherapy use and spending in Medicare, where prices do not depend on providers' integration status or negotiating power. We addressed oncologists' selective integration and patients' nonrandom choice of oncologists using an instrumental variables method. We found that integrated oncologists reduced the quantity of outpatient chemotherapy drugs but used more expensive treatments. This led to an increase in chemotherapy-drug spending after integration. These findings suggest that changes in treatment patterns-treatment mix and quantity-may be an important mechanism by which integration increases spending. We also found that integration increased spending on chemotherapy administration (the act of injection). This is because integration shifted billing of chemotherapy to hospital outpatient departments, where Medicare payments for chemotherapy administration are higher than those in physician offices. As integration increases, efforts should continue to assess how integration influences patient care and explore policy options to ensure desirable outcomes from integration.

Design and effects of outcome-based payment models in healthcare: a systematic review

INTRODUCTION

Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.

METHODS

We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.

RESULTS

We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.

DISCUSSION

Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

Health Care Spending Slowed After Rhode Island Applied Affordability Standards To Commercial Insurers

States are introducing regulations to slow health care spending growth, but which of these successfully reduce spending growth remains unclear. We studied Rhode Island's 2010 affordability standards, which imposed price controls-particularly inflation caps and diagnosis-based payments-on contracts between commercial insurers and hospitals and clinics and required commercial insurers to increase their spending on primary care and care coordination services. Using a difference-in-differences design, we compared spending among 38,001 commercially insured adults in Rhode Island to that among 38,001 matched adults in other states in the period 2007-16. Relative to quarterly fee-for-service (FFS) spending among the control group, quarterly FFS spending among the Rhode Island group decreased by $76 per enrollee after implementation of the policy, or a decline of 8.1 percent from 2009 spending. Quarterly non-FFS primary care coordination spending increased by $21 per enrollee. Total spending growth decreased, driven by lower prices concordant with the adoption of price controls. Quality measures were unaffected or improved. The Rhode Island experience indicates that states may be able to slow total commercial health care spending growth through price controls while maintaining quality.

Comparison of medication adherence between type 2 diabetes mellitus patients who pay for their medications and those who receive it free: a rural Asian experience

BACKGROUND

Treatment plans fail if patients have poor medication adherence. Our aim was to compare medication adherence, reasons for non-adherence, and satisfaction with community support among type 2 diabetes mellitus patients who pay for their medications and those who receive it free.

METHODS

A descriptive cross-sectional study was conducted at Anuradhapura, Sri Lanka, among patients who were on oral anti-diabetic drugs for at least 3 months. They were grouped into two: universal-free group and fee-paying group. Three different scales were used to score medication adherence, reasons for non-adherence, and satisfaction with community support. Fisher's exact test was performed to determine if there was a significant difference between the two groups (p < 0.05) concerning medication adherence and satisfaction with community support.

RESULTS

The median (IQR) medication adherence scores for fee-paying group and universal-free group were 3 (2-3) and 3 (3-3), respectively; the median (IQR) scores for satisfaction with community support were 5 (2-6) and 4 (4-6), respectively. Both the adherence and the satisfaction failed to show a significant difference between the two groups. Forgetfulness, being away from home, complex drug regime, and willingness to avoid side effects were common reasons of non-adherence for both the groups.

CONCLUSIONS

There was no significant difference in medication adherence between the universal-free group and fee-paying group, despite of having a significantly different income. The universal-free health service would be a probable reason.

The Prevalence and Cost of Medicare Beneficiaries Diagnosed and At Risk for Opioid Abuse, Dependence, and Poisoning

BACKGROUND

Reliance on prescription opioids to manage pain has been associated with increases in diversion, overdose, and addiction. Prevalence of misuse and abuse has been shown to be higher among government-insured populations than commercially insured populations. However, the prevalence and costs of misuse/abuse among the Medicare fee-for-service (FFS) population has not been studied.

OBJECTIVES

To (a) determine the prevalence and costs of prescription opioid misuse/abuse and (b) evaluate the prevalence and costs associated with those identified as at risk for opioid misuse/abuse in Medicare FFS beneficiaries.

METHODS

This retrospective case-control study used Medicare claims data for the calendar years of 2010 and 2011 and included Medicare beneficiaries aged at least 18 years. The index date was the date of first diagnosed misuse/abuse or at risk for abuse and had to occur between July 1, 2010, and June 30, 2011, and beneficiaries had to have at least 6 months continuous eligibility before and after the index date. Matching (1:1) was used for comparing opioid misusers/abusers with nonabuser controls, as well as comparing patients at risk for opioid abuse with controls not at risk for abuse. Controls were matched to cases by gender, age, disability, and geographic region. The index date of the control patient was set equal to the index date of the matched case.

RESULTS

Prevalence of misuse/abuse in the Medicare FFS population was 13.1 per 1,000 persons, with the majority among patients receiving Medicare based on disability (76.2%). The prevalence of at risk for misuse/abuse was 117.4 per 1,000 persons. Approximately half of the Medicare FFS patients used an opioid. Overall total annual unadjusted mean costs of health care resources were significantly greater for abusers than for matched controls ($46,194 vs. $21,964; P < 0.0001), with a mean annual excess cost of $24,230. The overall total adjusted 6-month post-index mean costs of health care resources for abusers was significantly greater than that of matched controls ($33,942 vs. $10,754; P < 0.0001), with a mean excess cost of $23,188.

CONCLUSIONS

The prevalence of diagnosed abuse among Medicare FFS population (13.1 per 1,000 persons) was higher than other payer groups studied using similar ICD-9-CM codes, and the majority of abuse was among those receiving Medicare based on disability (76.2%). The prevalence of at-risk abuse was 9 times higher than the prevalence of diagnosed abuse. As with other studies, health care resource utilization and costs were significantly greater for diagnosed abuse than matched controls.

DISCLOSURES

This study was sponsored by Pfizer. Roland is a Pfizer employee and stockholder and was involved in all aspects of the study as part of a mid-career fellowship in pharmacoeconomics with the University of Utah. Ye and Stevens are employees of University of Utah, and Oderda was an employee of University of Utah, which received financial support from Pfizer in connection with the development of this manuscript. Oderda also reports consulting fees from Pfizer, Trevena, and Pacira, unrelated to this study. The results of this study were presented at the Academy of Managed Care Pharmacy Nexus 2015; October 26-29, 2015; Orlando, FL, and the AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016; April 19-22, 2016; San Francisco, CA.

Racial and ethnic estimates of Alzheimer's disease and related dementias in the United States (2015-2060) in adults aged ≥65 years

INTRODUCTION

Alzheimer's disease and related dementias (ADRD) cause a high burden of morbidity and mortality in the United States. Age, race, and ethnicity are important risk factors for ADRD.

METHODS

We estimated the future US burden of ADRD by age, sex, and race and ethnicity by applying subgroup-specific prevalence among Medicare Fee-for-Service beneficiaries aged ≥65 years in 2014 to subgroup-specific population estimates for 2014 and population projection data from the United States Census Bureau for 2015 to 2060.

RESULTS

The burden of ADRD in 2014 was an estimated 5.0 million adults aged ≥65 years or 1.6% of the population, and there are significant disparities in ADRD prevalence among population subgroups defined by race and ethnicity. ADRD burden will double to 3.3% by 2060 when 13.9 million Americans are projected to have the disease.

DISCUSSION

These estimates can be used to guide planning and interventions related to caring for the ADRD population and supporting caregivers.

Fee-for-Service Medicare-Enrolled Elderly Veterans Are Increasingly Voting with Their Feet to Use More VA and Less Medicare, 2003-2014

OBJECTIVE

To examine the long-term reliance on outpatient care at the population (i.e., system) level among fee-for-service Medicare-enrolled elderly veterans in the Department of Veterans Affairs (VA) health care system and Medicare from 2003 to 2014.

DATA SOURCES/STUDY SETTING

We analyzed a 5 percent random sample, stratified by facility, age, gender, and race, of Medicare-enrolled veterans enrolled in a VA primary care panel using VA administrative data and Medicare claims.

STUDY DESIGN

We performed a repeated cross-sectional analysis over 48 quarters. VA reliance was defined at the system level as the proportion of total visits (VA + Medicare) that occurred in VA. We examined four visit types and seven high-volume medical subspecialties. We applied direct standardization adjusting for age, gender, and race using the 2010 population distribution of Medicare-enrolled veterans.

PRINCIPAL FINDINGS

Over the 12-year period, VA provided the vast majority of mental health care. Conversely, veterans received slightly more than half of their primary care and most of their specialty care, surgical care, and seven high-volume medical subspecialties through Medicare. However, reliance on VA outpatient care steadily increased over time for all categories of care.

CONCLUSIONS

Despite the controversies about VA access to care, Medicare-enrolled veterans, who have a choice of using VA or Medicare providers, appear to increase their use of VA care prior to the Choice Act.

Geographic Variation in Cystoscopy Rates for Suspected Bladder Cancer between Female and Male Medicare Beneficiaries

OBJECTIVE

To assess geographic variation in cystoscopy rates among women vs men with suspected bladder cancer, lending insight into gender-specific differences in cystoscopic evaluation.

METHODS

We conducted a cross-sectional study of all fee-for-service Medicare beneficiaries within 306 Hospital Referral Regions (HRRs) who received care in 2014. For each HRR, we calculated the age- and race-adjusted cystoscopy rate for women and men as our primary outcome. The rate was the number of beneficiaries who underwent cystoscopy for bladder cancer symptoms (using procedure and ICD-9 diagnosis codes) divided by all beneficiaries in the HRR. We used the coefficient of variation to compare relative variability of cystoscopy rates.

RESULTS

Overall, 173,551 women (n = 14.8 million) and 286,090 men (n = 11.5 million) underwent cystoscopy in 2014. While women received less cystoscopies compared to men (mean 11.0 vs 23.5 per 1000, P < .001), there was greater variation in cystoscopy rates among women (coefficient of variation 27.5 vs 23.5, P = .010). When restricting to ICD-9 codes for hematuria only, women continued to demonstrate greater variation in cystoscopy rates (coefficient of variation 27.8 vs 24.2, P = .022). Findings were robust across larger HRR sizes-thereby removing some random variation seen in smaller HRRs-as well as across years 2010, 2011, 2012, and 2013.

CONCLUSION

Cystoscopy rates are lower in women than men, likely due to their lower bladder cancer incidence. However, there is greater variation in cystoscopy rates among women with symptoms of bladder cancer. This may reflect increased provider uncertainty whether to refer and work-up women with suspected bladder cancer.

Effects of a community-based care management model for super-utilizers

OBJECTIVES

Medicare, Medicaid, and commercial plans have all explored ways to improve outcomes for patients with high costs and complex medical and social needs. The purpose of this study was to test the effectiveness of a high-intensity care management program that the Rutgers University Center for State Health Policy (CSHP) implemented as an adaptation of a promising model developed by the Camden Coalition of Healthcare Providers.

STUDY DESIGN

We estimated the impact of the program on 6 utilization and spending outcomes for a subgroup of beneficiaries enrolled in Medicare fee-for-service (n = 149) and a matched comparison group (n = 1130).

METHODS

We used Medicare claims for all analyses. We used propensity score matching to construct a comparison group of beneficiaries with baseline characteristics similar to those of program participants. We employed regression models to test the relationship between program enrollment and outcomes over a 12-month period while controlling for baseline characteristics.

RESULTS

A test of joint significance across all outcomes showed that the CSHP program reduced service use and spending in aggregate (P = .012), although estimates for most of the individual measures were not statistically significant. Participants had 37% fewer unplanned readmissions (P = .086) than did comparison beneficiaries. Although we did not find statistically significant results for the other 5 outcomes, the CIs for these outcomes spanned substantively large effects.

CONCLUSIONS

Although these findings are mixed, they suggest that adaptations of the Camden model hold promise for reducing short-term service use and spending for Medicare super-utilizers.

The impact of the 2008/2009 financial crisis on specialist physician activity in Canada

Fee-for-service physicians are responsible for planning for their retirements, and there is no mandated retirement age. Changes in financial markets may influence how long they remain in practice and how much they choose to work. The 2008 crisis provides a natural experiment to analyze elasticity in physician service supply in response to dramatic financial market changes. We examined quarterly fee-for-service data for specialist physicians over the period from 1999/2000 to 2013/2014 in Canada. We used segmented regression to estimate changes in the number of physicians receiving payments, per-physician service counts, and per-physician payments following the 2008 financial crisis and explored whether patterns differed by physician age. The number of specialist physicians increased more rapidly in the period since 2008 than in earlier years, but increases were largest within the youngest age group, and we observed no evidence of delayed retirement among older physicians. Where changes in service volume and payments were observed, they occurred across all ages and not immediately following the 2008 financial crisis. We conclude that any response to the financial crisis was small compared with demographic shifts in the physician population and changes in payments per service over the same time period.

Differences Between Skilled Nursing Facilities in Risk of Subsequent Long-Term Care Placement

OBJECTIVES

To determine how the risk of subsequent long-term care (LTC) placement varies between skilled nursing facilities (SNFs) and the SNF characteristics associated with this risk.

DESIGN

Population-based national cohort study with participants nested in SNFs and hospitals in a cross-classified multilevel model.

SETTING

SNFs (N=6,680).

PARTICIPANTS

Fee-for-service Medicare beneficiaries (N=552,414) discharged from a hospital to a SNF in 2013.

MEASUREMENTS

Participant characteristics from Medicare data and the Minimum Data Set. SNF characteristics from Medicare and Nursing Home Compare. Outcome was a stay of 90 days or longer in a LTC nursing home within 6 months of SNF admission.

RESULTS

Within 6 months of SNF admission, 10.4% of participants resided in LTC. After adjustments for participant characteristics, the SNF where a participant received care explained 7.9% of the variance in risk of LTC, whereas the prior hospital explained 1.0%. Individuals in SNFs with excellent quality ratings had 22% lower odds of transitioning to LTC than those in SNFs with poor ratings (odds ratio=0.78, 95% confidence interval=0.74-0.84). Variation between SNFs and associations with quality markers were greater in sensitivity analyses limited to individuals least likely to require LTC. Results were essentially the same in a number of other sensitivity analyses designed to reduce potential confounding.

CONCLUSION

Risk of subsequent LTC placement, an important and negatively viewed outcome for older adults, varies substantially between SNFs. Individuals in higher-quality SNFs are at lower risk.

Preventive visit among older adults with Medicare's introduction of Annual Wellness Visit: Closing gaps in underutilization

Preventive visit rates are low among older adults in the United States. We evaluated changes in preventive visit utilization with Medicare's introduction of Annual Wellness Visits (AWVs) in 2011. We further assessed how coverage expansion differentially affected older adults who were previously underutilizing the service. The study included Medicare beneficiaries aged 65 to 85 from a mixed-payer multispecialty outpatient healthcare organization in northern California between 2007 and 2016. Data from the electronic health records were used, and the unit of analysis was patient-year (N = 456,281). Multivariable logistic regression models were used to assess determinants of "any preventive visit" use. Prior to the AWV coverage (2007-2010), Medicare beneficiaries who were older, with serious chronic conditions, and with a fee-for-services (FFS) plan underutilized preventive visits such that odds ratio (OR) for age groups (vs. age 65-69) ranges from 0.826 (age 70-74) to 0.522 (age 80-85); for Charlson comorbidity index (CCI) (vs. 0 CCI) ranges from 0.77 (1 CCI) to 0.65 (≥2 CCI); and for FFS (vs. HMO) is 0.236. With the Medicare coverage (2011-2016), the age-based gap reduced substantially, but the difference persisted, e.g., OR for age 80-85 (vs. 65-69) is 0.628, and FFS (vs. HMO) beneficiaries still have far lower odds of using a preventive visit (OR = 0.278). The gap based on comorbidity was not reduced. Medicare's coverage expansion facilitated the use of preventive visit particularly for older adults with more advanced age or with FFS, thereby reducing disparities in preventive visit use.

Association between physician US News & World Report medical school ranking and patient outcomes and costs of care: observational study

OBJECTIVE

To investigate whether the US News & World Report (USNWR) ranking of the medical school a physician attended is associated with patient outcomes and healthcare spending.

DESIGN

Observational study.

SETTING

Medicare, 2011-15.

PARTICIPANTS

20% random sample of Medicare fee-for-service beneficiaries aged 65 years or older (n=996 212), who were admitted as an emergency to hospital with a medical condition and treated by general internists.

MAIN OUTCOME MEASURES

Association between the USNWR ranking of the medical school a physician attended and the physician's patient outcomes (30 day mortality and 30 day readmission rates) and Medicare Part B spending, adjusted for patient and physician characteristics and hospital fixed effects (which effectively compared physicians practicing within the same hospital). A sensitivity analysis employed a natural experiment by focusing on patients treated by hospitalists, because patients are plausibly randomly assigned to hospitalists based on their specific work schedules. Alternative rankings of medical schools based on social mission score or National Institute of Health (NIH) funding were also investigated.

RESULTS

996 212 admissions treated by 30 322 physicians were examined for the analysis of mortality. When using USNWR primary care rankings, physicians who graduated from higher ranked schools had slightly lower 30 day readmission rates (adjusted rate 15.7% for top 10 schools v 16.1% for schools ranked ≥50; adjusted risk difference 0.4%, 95% confidence interval 0.1% to 0.8%; P for trend=0.005) and lower spending (adjusted Part B spending $1029 (£790; €881) v $1066; adjusted difference $36, 95% confidence interval $20 to $52; P for trend <0.001) compared with graduates of lower ranked schools, but no difference in 30 day mortality. When using USNWR research rankings, physicians graduating from higher ranked schools had slightly lower healthcare spending than graduates from lower ranked schools, but no differences in patient mortality or readmissions. A sensitivity analysis restricted to patients treated by hospitalists yielded similar findings. Little or no relation was found between alternative rankings (based on social mission score or NIH funding) and patient outcomes or costs of care.

CONCLUSIONS

Overall, little or no relation was found between the USNWR ranking of the medical school from which a physician graduated and subsequent patient mortality or readmission rates. Physicians who graduated from highly ranked medical schools had slightly lower spending than graduates of lower ranked schools.

Association of the Overall Well-being of a Population With Health Care Spending for People 65 Years of Age or Older

IMPORTANCE

New US health care payment models have increasingly incentivized health care systems to promote health and reduce health care spending at the population level, with Medicare beneficiaries representing one of the largest populations affected by new payment models. Identifying novel strategies to promote health and reduce health care spending is necessary.

OBJECTIVE

To assess whether the overall well-being of a population is associated with health care spending for people 65 years of age or older.

DESIGN, SETTING, AND PARTICIPANTS

This US national, population-based cross-sectional study examined the association between county well-being and Medicare fee-for-service (FFS) spending. Population well-being, a holistic assessment of the overall health of the population comprising interrelated domains, including physical, mental, and social health, as measured by the Gallup-Sharecare Well-Being Index (2010), was linked to the mean spending per Medicare FFS beneficiary (2010) and county characteristics data for all US counties assessed. The data were adjusted for prevalence of 4 low-variation conditions (hip fracture, stroke, colorectal cancer, and acute myocardial infarction) and regional penetration of Medicare Advantage. Data analyses were conducted October 13, 2016, to October 31, 2017.

MAIN OUTCOMES AND MEASURES

Mean spending per Medicare FFS beneficiary per county.

RESULTS

In total, 2998 counties were assessed using county-level mean values, with 4 to 7317 participants (mean [SD] number of participants, 755 [1220]) per county. The mean (SD) values of the demographic characteristics of the participants were 50.8% (1.3%) female, 74.9% (16.5%) white, 12.1% (13.0%) black, 4.0% (5.3%) Asian, and 13.7% (14.8%) Hispanic with a mean (SD) of the median county age of 38.2 (4.4) years. Medicare spent a mean (SE) of $992 ($110) less per Medicare FFS beneficiary in counties in the highest quintile of well-being compared with counties in the lowest well-being quintile. This inverse association persisted after accounting for key population characteristics such as median household income and contextual factors such as urbanicity and health care system capacity. Medicare spent a mean (SE) of $1233 ($104) less per Medicare FFS beneficiary in counties with the greatest access to basic needs than in those with the lowest access.

CONCLUSIONS AND RELEVANCE

In this US national study, the overall well-being of a geographically defined population was inversely associated with its health care spending for people 65 years and older. Identifying this association between well-being and health care spending at the population level may help to lay the foundation for further study to first illuminate the mechanisms underlying the association and to second study interventions aimed at creating greater well-being and lower health care spending at the population level.