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Anderson TS, Yeh RW, Herzig SJ, Marcantonio ER, Hatfield LA, Souza J, Landon BE. Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study. Ann Intern Med 2024; 177:1190-1198. [PMID: 39102715 DOI: 10.7326/m23-3475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024] Open
Abstract
BACKGROUND Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care. OBJECTIVE To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations. DESIGN Retrospective cohort study. SETTING Medicare. PARTICIPANTS Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019. MEASUREMENTS Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes. RESULTS The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF. LIMITATION Generalizability to other payers. CONCLUSION Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Timothy S Anderson
- Division of General Internal Medicine, University of Pittsburgh, and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (T.S.A.)
| | - Robert W Yeh
- Division of Cardiology and Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts (R.W.Y.)
| | - Shoshana J Herzig
- Harvard Medical School and Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (S.J.H., E.R.M.)
| | - Edward R Marcantonio
- Harvard Medical School and Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts (S.J.H., E.R.M.)
| | - Laura A Hatfield
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (L.A.H., J.S.)
| | - Jeffrey Souza
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (L.A.H., J.S.)
| | - Bruce E Landon
- Division of General Medicine, Beth Israel Deaconess Medical Center, and Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (B.E.L.)
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Jain SH. The Case for Continuing to Improve Medicare Advantage: Misplaced Nostalgia for Traditional Medicare. JAMA Intern Med 2024; 184:867-869. [PMID: 38857044 DOI: 10.1001/jamainternmed.2024.1865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Affiliation(s)
- Sachin H Jain
- SCAN Health Plan, Long Beach, California
- Stanford University School of Medicine, Stanford, California
- West Los Angeles VA Medical Center, Los Angeles, California
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Waitzman J, Sunkara PR, Lenze N, Brenner M, Cramer JD. Reply to Y. Kwon et al. JCO Oncol Pract 2024; 20:1141-1142. [PMID: 38810177 DOI: 10.1200/op.24.00286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 05/31/2024] Open
Affiliation(s)
- Jacob Waitzman
- Jacob Waitzman, BS, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI; Pranit R. Sunkara, MD, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI; Nicholas Lenze, MD, and Michael Brenner, MD, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI; and John D. Cramer, MD, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Pranit R Sunkara
- Jacob Waitzman, BS, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI; Pranit R. Sunkara, MD, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI; Nicholas Lenze, MD, and Michael Brenner, MD, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI; and John D. Cramer, MD, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Nicholas Lenze
- Jacob Waitzman, BS, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI; Pranit R. Sunkara, MD, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI; Nicholas Lenze, MD, and Michael Brenner, MD, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI; and John D. Cramer, MD, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Michael Brenner
- Jacob Waitzman, BS, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI; Pranit R. Sunkara, MD, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI; Nicholas Lenze, MD, and Michael Brenner, MD, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI; and John D. Cramer, MD, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - John D Cramer
- Jacob Waitzman, BS, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI; Pranit R. Sunkara, MD, Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI; Nicholas Lenze, MD, and Michael Brenner, MD, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI; and John D. Cramer, MD, Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
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Kyanko K, Sahay KM, Wang Y, Li SX, Schreiber M, Hager M, Myers R, Johnson W, Zhang J, Krumholz H, Suter LG, Triche EW. Incorporating Medicare Advantage Admissions Into the CMS Hospital-Wide Readmission Measure. JAMA Netw Open 2024; 7:e2414431. [PMID: 38829614 PMCID: PMC11148674 DOI: 10.1001/jamanetworkopen.2024.14431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/01/2024] [Indexed: 06/05/2024] Open
Abstract
Importance Medicare Advantage (MA) enrollment is rapidly expanding, yet Centers for Medicare & Medicaid Services (CMS) claims-based hospital outcome measures, including readmission rates, have historically included only fee-for-service (FFS) beneficiaries. Objective To assess the outcomes of incorporating MA data into the CMS claims-based FFS Hospital-Wide All-Cause Unplanned Readmission (HWR) measure. Design, Setting, and Participants This cohort study assessed differences in 30-day unadjusted readmission rates and demographic and risk adjustment variables for MA vs FFS admissions. Inpatient FFS and MA administrative claims data were extracted from the Integrated Data Repository for all admissions for Medicare beneficiaries from July 1, 2018, to June 30, 2019. Measure reliability and risk-standardized readmission rates were calculated for the FFS and MA cohort vs the FFS-only cohort, overall and within specialty subgroups (cardiorespiratory, cardiovascular, medicine, surgery, neurology), then changes in hospital performance quintiles were assessed after adding MA admissions. Main Outcome and Measure Risk-standardized readmission rates. Results The cohort included 11 029 470 admissions (4 077 633 [37.0%] MA; 6 044 060 [54.8%] female; mean [SD] age, 77.7 [8.2] years). Unadjusted readmission rates were slightly higher for MA vs FFS admissions (15.7% vs 15.4%), yet comorbidities were generally lower among MA beneficiaries. Test-retest reliability for the FFS and MA cohort was higher than for the FFS-only cohort (0.78 vs 0.73) and signal-to-noise reliability increased in each specialty subgroup. Mean hospital risk-standardized readmission rates were similar for the FFS and MA cohort and FFS-only cohorts (15.5% vs 15.3%); this trend was consistent across the 5 specialty subgroups. After adding MA admissions to the FFS-only HWR measure, 1489 hospitals (33.1%) had their performance quintile ranking changed. As their proportion of MA admissions increased, more hospitals experienced a change in their performance quintile ranking (147 hospitals [16.3%] in the lowest quintile of percentage MA admissions; 408 [45.3%] in the highest). The combined cohort added 63 hospitals eligible for public reporting and more than 4 million admissions to the measure. Conclusions and Relevance In this cohort study, adding MA admissions to the HWR measure was associated with improved measure reliability and precision and enabled the inclusion of more hospitals and beneficiaries. After MA admissions were included, 1 in 3 hospitals had their performance quintile changed, with the greatest shifts among hospitals with a high percentage of MA admissions.
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Affiliation(s)
- Kelly Kyanko
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Kashika M. Sahay
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Yongfei Wang
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Shu-Xia Li
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Michelle Schreiber
- Centers for Medicare & Medicaid Services, Center for Clinical Standards & Quality, Baltimore, Maryland
| | - Melissa Hager
- Centers for Medicare & Medicaid Services, Center for Clinical Standards & Quality, Baltimore, Maryland
| | - Raquel Myers
- Centers for Medicare & Medicaid Services, Center for Clinical Standards & Quality, Baltimore, Maryland
| | - Wanda Johnson
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Jing Zhang
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Harlan Krumholz
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Lisa G. Suter
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Elizabeth W. Triche
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
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5
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Sunkara PR, Waitzman J, Lenze NR, Brenner MJ, Cramer JD. Association of Medicaid Privatization With Patient Cancer Outcomes. JCO Oncol Pract 2024; 20:708-716. [PMID: 38295328 DOI: 10.1200/op.23.00297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 10/25/2023] [Accepted: 12/05/2023] [Indexed: 02/02/2024] Open
Abstract
PURPOSE Increasingly, states outsource administration of Medicaid insurance to privately administered Medicaid managed care organizations. However, on January 1, 2012, Connecticut transitioned from a privately to publicly administered Medicaid system. New Jersey retained a private model. METHODS Our objective was to assess rates of early-stage cancer diagnosis and cancer survival in two states with similar sociodemographic characteristics but differing exposures to Medicaid privatization. Using data from the SEER Program between 2007 and 2016, Connecticut and New Jersey Medicaid patients with 10 common solid cancers including breast, lung, colorectal, prostate, kidney, bladder, cervix, uterus, head and neck cancer, and melanoma were included. A difference-in-differences analysis of stage of cancer presentation and cancer survival in Connecticut (intervention) was compared with New Jersey (control). RESULTS Among 29,328 patients (14,424 patients from Connecticut and 14,904 patients from New Jersey) parallel trends were verified in early cancer diagnosis and survival for both states under privately administered Medicaid (pre-exposure). Connecticut's transition from privately to publicly administered Medicaid was associated with an adjusted 4.0% increase in overall early-stage cancer diagnosis (95% CI, +1.7% to +6.2%) and a 4.7% increase in early-stage cancer diagnosis for cancers with US Preventive Services Taskforce A/B recommendations for cancer screening (95% CI, 1.6% to 7.8%). Public administration of Medicaid was also associated with improved overall survival after cancer diagnosis (hazard ratio, 0.92 [95% CI, 0.85 to 0.99]). No changes were observed in New Jersey. CONCLUSION Transition from private to public administration of Medicaid in Connecticut was associated with earlier-stage cancer diagnosis and improved cancer survival.
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Affiliation(s)
- Pranit R Sunkara
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Jacob Waitzman
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
| | - Nicholas R Lenze
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Michael J Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - John D Cramer
- Department of Otolaryngology-Head and Neck Surgery, Wayne State University School of Medicine, Detroit, MI
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [Citation(s) in RCA: 182] [Impact Index Per Article: 182.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Cifuentes P, Jaramillo M, Garrote F, Bravo D, Alvarez JC, Quintero RM, Mouhanna S, Nair RR. Impact of Insurance Type on Access to Pain Management Specialists for the Treatment of Lower Back Pain. Cureus 2024; 16:e51668. [PMID: 38313953 PMCID: PMC10838162 DOI: 10.7759/cureus.51668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
Background Low back pain is known to be one of the leading causes of disability among the young and elderly population. Low back pain can stem from multiple sources, including spinal degeneration, injury, herniated discs, sciatica, and other contributing causes. This symptom significantly influences the quality of life of affected individuals. Its implications include extensive social and economic costs. Economic considerations arise from the fact that not all healthcare facilities accept the insurance plans available to retired individuals under Medicare. This places an additional burden on patients who must bear the financial responsibility for healthcare services not covered by their insurance plan. Florida, renowned as a favored state for retirement, consists of a demographic composition wherein 21% of its residents are aged 65 or older. A significant proportion of this demographic qualifies for Traditional Medicare (TM) and/or Medicare Advantage (MA) plans. Thus, understanding the disparities in healthcare access between Medicare and Medicare Advantage plans is crucial. This study aims to evaluate different Medicare insurances available in the market and their impact on the ease of accessibility to pain management specialists for the treatment of lower back pain in Florida patients. Methods We analyzed the Florida Department of Health database to identify the four counties in Florida with the highest Medicare enrollment rates in 2022: Miami-Dade, Palm Beach, Broward, and Pinellas County. Using the U.S. News and Report directory, 25 Pain Management-trained anesthesiologists were randomly selected from each of the four counties. Each office was contacted four times via telephone by four different team members to assess appointment availability for a fictional 65-year-old grandfather seeking treatment for chronic low back pain. The study examined appointment availability and accepted insurance types, including Cigna (commercial insurance), TM, Humana Gold Plus HMO (Medicare Advantage plan), and Blue Medicare Select PPO (Medicare Advantage plan). Practices without contact information or retired physicians were excluded from the analysis. Time to appointment was measured in business days. Results Of the 100 Pain Management Physicians contacted, 44 fit the inclusion criteria of being non-retired physicians, still practicing in one of the four counties with open offices and valid contact information. Blue Medicare Select PPO was accepted by 47.73%, Humana Gold Plus HMO by 56.82%, TM by 93.18%, and Cigna by 93.18% of the encounters. Blue Medicare select PPO and Humana Gold Plus HMO were accepted at significantly lower rates when compared to Traditional Medicare and Cigna with P values of P < .00001 and P < .000176, respectively. There was no significant difference found in the time to appointment between insurances with P value < 7. Conclusion The study found that patients enrolled in Medicare Advantage plans have significantly decreased access to care when compared to those enrolled in TM or commercial insurance. Further research is needed to elucidate the reasons behind differences in access to care across different insurances, as identified in the study.
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Affiliation(s)
- Phillip Cifuentes
- Anesthesiology, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Manuela Jaramillo
- Anesthesiology, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Fabio Garrote
- Anesthesiology, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Daniel Bravo
- Internal Medicine, Albert Einstein College of Medicine, New York City, USA
| | - Juan C Alvarez
- Anesthesiology, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
| | - Ramon M Quintero
- Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, USA
| | | | - Rakesh R Nair
- Cellular Biology & Pharmacology, Florida International University, Herbert Wertheim College of Medicine, Miami, USA
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Oseran AS, Dong H, Wadhera RK. Cardiovascular hospitalizations for Medicare advantage beneficiaries in the United States, 2009 to 2019. Am Heart J 2023; 265:77-82. [PMID: 37451356 DOI: 10.1016/j.ahj.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/30/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Federal programs measuring hospital quality of care for acute cardiovascular conditions are based solely on Medicare fee-for-service (FFS) beneficiaries, and exclude Medicare Advantage (MA) beneficiaries. In this study we characterize the proportion of Medicare beneficiaries enrolled in MA at the time of acute myocardial infarction (AMI), heart failure (HF), and ischemic stroke hospitalization. METHODS Retrospective cross-sectional study of short-term acute care hospitals using Medicare claims in 2009 and 2019. RESULTS There were 2,653 hospitals in 2009 and 2,732 hospitals in 2019. Across hospitals, the proportion of Medicare beneficiaries hospitalized for AMI who were enrolled in MA increased between 2009 (hospital-level median 14.4% [IQR 5.1%-26.0%]) and 2019 (33.3% [IQR 20.6%-45.2%]), with substantial variation across hospitals. Similar patterns were observed for HF (13.0% [IQR 5.3%-24.3%] to 31.0% [IQR 20.2%-42.3%]) and ischemic stroke (14.6% [IQR 5.3%-26.7%] to 33.3% [IQR 20.9%-46.0%]). Within each hospital referral region, hospital size (large 36.3% vs small 24.5%; adjusted difference 6.7%, 95% CI, 4.5%-8.8%), teaching status (teaching 34.5% vs nonteaching 28.2%; 2.8%, 1.4%-4.1%), and ownership status (private nonprofit 32.3% vs public 24.5%; 5.2%, 3.5%-6.9%) were each associated with a higher hospital MA proportion. CONCLUSIONS The proportion of Medicare beneficiaries hospitalized for AMI, HF, and ischemic stroke enrolled in MA doubled between 2009 and 2019, with substantial variation across hospitals. These findings have implications for federal efforts to measure and improve quality, which currently focus only on FFS beneficiaries.
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Affiliation(s)
- Andrew S Oseran
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiology, Massachusetts General Hospital, Boston, MA
| | - Huaying Dong
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA.
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de Oliveira Costa J, Pearson SA, Brieger D, Lujic S, Shawon MSR, Jorm LR, van Gool K, Falster MO. In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals. Int J Equity Health 2023; 22:226. [PMID: 37872627 PMCID: PMC10594777 DOI: 10.1186/s12939-023-02030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND International evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). METHODS We conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017-2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors. RESULTS Of 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45-0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients. CONCLUSION Our findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.
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Affiliation(s)
- Juliana de Oliveira Costa
- Medicines Intelligence Research Program, School of Population Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia.
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia.
| | - Sallie-Anne Pearson
- Medicines Intelligence Research Program, School of Population Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - David Brieger
- Concord Clinical School - The University of Sydney, Sydney, Australia
| | - Sanja Lujic
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Md Shajedur Rahman Shawon
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Kees van Gool
- Centre for Health Economics Research and Evaluation - University of Technology Sydney, Sydney, Australia
| | - Michael O Falster
- Medicines Intelligence Research Program, School of Population Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- Centre for Big Data Research in Health - Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
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Shortell SM, Toussaint JS, Halvorson GC, Kingsdale JM, Scheffler RM, Schwartz AY, Wadsworth PA, Wilensky G. The Better Care Plan: a blueprint for improving America's healthcare system. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad007. [PMID: 38756832 PMCID: PMC10986211 DOI: 10.1093/haschl/qxad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/30/2023] [Indexed: 05/18/2024]
Abstract
The United States falls far short of its potential for delivering care that is effective, efficient, safe, timely, patient-centered, and equitable. We put forward the Better Care Plan, an overarching blueprint to address the flaws in our current system. The plan calls for continuously improving care, moving all payers to risk-adjusted prospective payment, and creating national entities for collecting, analyzing, and reporting patient safety and quality-of-care outcomes data. A number of recommendations are made to achieve these goals.
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Affiliation(s)
| | - John S Toussaint
- Catalysis, Inc. 3825 East Calumet Street, Suite 400-114, Appleton, WI 54915, United States
| | - George C Halvorson
- The Institute for Intergroup Understanding, 1300 Bracketts Point Road, Wayzata, MN 55391, United States
| | | | | | | | - Peter A Wadsworth
- Amory Associates, 1310 Norwest Drive, Norwood, MA 02062, United States
| | - Gail Wilensky
- Project Hope, 1220 19th Street, Washington, DC 20036, United States
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Schwartz AL, Kim S, Navathe AS, Gupta A. Growth of Medicare Advantage After Plan Payment Reductions. JAMA HEALTH FORUM 2023; 4:e231744. [PMID: 37354538 DOI: 10.1001/jamahealthforum.2023.1744] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2023] Open
Abstract
Importance Various policy proposals would reduce federal payments to Medicare Advantage (MA) plans. However, it is unclear whether payment reductions would compromise beneficiary access to the MA program. Objective To quantify the association between MA payment reductions under the Affordable Care Act (ACA) and MA enrollment growth. Design, Setting, and Participants This retrospective cohort study examined the MA market before and after the ACA, which mandated cuts to MA benchmark payment rates. Using 2008 to 2019 county-level enrollment and payment data, a difference-in-differences analysis was conducted comparing MA enrollment changes between counties with larger vs smaller benchmark reductions, before vs after the ACA. Main Outcomes and Measures The primary outcome was the MA enrollment rate, defined as the proportion of a county's Medicare beneficiaries enrolled in MA. A secondary analysis examined MA plan payments per member per month. Results Among 3138 counties with 37 639 county-year observations, ACA-induced benchmark cuts were sizeable and varied, ranging from 0% to 42.9% (mean [SD], 5.9% [6.6%]). Counties with benchmark cuts above the 75th percentile had population-weighted average benchmark cuts of 14.9% compared with 4.4% in other counties. In the 8 years following the ACA, there was no differential change in MA enrollment between counties with larger vs smaller benchmark cuts (difference-in-differences estimate, 0.02 [95% CI, -1.18 to 1.21] percentage points; P = .98). Plan payments differentially fell in counties with larger benchmark cuts by $78.35 (95% CI, $62.21-$94.48) per member per month (P < .001). Conclusion and Relevance This cohort study found no evidence that the MA benchmark and ensuing payment cuts imposed by the ACA were associated with reduced MA enrollment, compromising access to MA. This evidence can inform ongoing policy debates regarding the growth of MA, concerns about excess payments to MA plans, and proposed Medicare reforms, including further reductions in MA payments.
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Affiliation(s)
- Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, US Department of Veterans Affairs, Philadelphia, Pennsylvania
| | - Seyoun Kim
- The Wharton School, University of Pennsylvania, Philadelphia
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, US Department of Veterans Affairs, Philadelphia, Pennsylvania
| | - Atul Gupta
- The Wharton School, University of Pennsylvania, Philadelphia
- National Bureau of Economic Research, Cambridge, Massachusetts
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Diamantidis CJ, Storfer-Isser A, Fishman E, Wang V, Zepel L, Maciejewski ML. Costs Associated With Progression of Mildly Reduced Kidney Function Among Medicare Advantage Enrollees. Kidney Med 2023; 5:100636. [PMID: 37250500 PMCID: PMC10220400 DOI: 10.1016/j.xkme.2023.100636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Abstract
Rationale & Objective The prevalence of early chronic kidney disease (CKD) in older adults has increased in the past 2 decades, yet CKD disease progression, overall, is variable. It is unclear whether health care costs differ by progression trajectory. The purpose of this study was to estimate the trajectories of CKD progression and examine Medicare Advantage (MA) health care costs of each trajectory over a 3-year period in a large cohort of MA enrollees with mildly reduced kidney function. Study Design Cohort study. Setting & Population 421,187 MA enrollees with stage G2 CKD in 2014-2017. Outcomes We identified 5 trajectories of kidney function over time. Model Perspective & Timeframe Mean total health care costs for each of the trajectories were described in each of the following 3 years from a payer perspective: 1 year before and 2 years after the index date establishing stage G2 CKD (study entry). Results The mean estimated glomerular filtration rate (eGFR) at study entry was 75.9 mL/min/1.73 m2 and the median (interquartile range) follow-up period was 2.6 (1.6, 3.7) years. The cohort had a mean age of 72.6 years and had predominantly female participants (57.2%), and White (71.2%). We identified the following 5 distinct trajectories of kidney function: a stable eGFR (22.3%); slow eGFR decline with a mean eGFR at study entry of 78.6 (30.2%); slow eGFR decline with an eGFR at study entry of 70.9 (28.4%); steep eGFR decline (16.3%); and accelerated eGFR decline (2.8%). Mean costs of enrollees with accelerated eGFR decline were double the MA enrollees' mean costs in each of the other 4 trajectories in every year ($27,738 vs $13,498 for a stable eGFR 1 year after study entry). Limitations Results may not generalized beyond MA and a lack of albumin values. Conclusions The small fraction of MA enrollees with accelerated eGFR decline has disproportionately higher costs than other enrollees with mildly reduced kidney function.
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Affiliation(s)
- Clarissa J. Diamantidis
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Ezra Fishman
- National Committee for Quality Assurance, Washington DC
- Optum Labs, Minneapolis, Minnesota
| | - Virginia Wang
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
| | - Lindsay Zepel
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Optum Labs, Minneapolis, Minnesota
| | - Matthew L. Maciejewski
- Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Duke-Margolis Center for Health Policy, Duke University, Durham, North Carolina
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