Examining access to care for younger vs. older dual-eligible adults living in the community

Health Center Characteristics Associated With Hospital Care Among Medicare-Medicaid Dual Enrollees

Using 2012-2018 Medicare claims and health center data, we identified factors associated with variation in rates of hospital care among Medicare-Medicaid dual enrollees receiving primary care at health centers. In our sample (n = 5961 health center-years), we found no evidence that patient-centered medical home designation or other modifiable health center characteristics were associated with reductions in hospital care use, which depends more on health center patient mix. Thus, policymakers should target efforts to health centers serving the most disadvantaged and marginalized communities.

Unmet need for medical care among Medicare beneficiaries by health insurance literacy and disability

BACKGROUND

Navigating the US healthcare system requires considerable health insurance literacy, especially for adults with disabilities. Limited health insurance literacy may lead to suboptimal treatment, leading to unmet need for medical care.

OBJECTIVE

We examined whether unmet need for medical care among Medicare beneficiaries differs by health insurance literacy and disability status.

METHODS

Using data from the 2010-2019 Medicare Current Beneficiary Survey, we identified 48,989 Medicare beneficiaries, including those in traditional Medicare and Medicare Advantage. Our outcomes were three measures of unmet need for medical care. Our key independent variables were health insurance literacy and disability status. For each outcome, we estimated the adjusted rates of reporting unmet need for medical care by health insurance literacy and disability while controlling for individual-level characteristics.

RESULTS

Unmet need for medical care was higher among Medicare beneficiaries with disabilities across all outcomes, but the highest rates were among those with disabilities and limited health insurance literacy (27.4% [95% CI: 24.9-29.9] for experiencing delayed care, 17.7% [95% CI: 15.6-19.9] for experiencing trouble in getting needed care, and 20.8% [95% CI: 18.5-23.1] for not seeing a doctor despite medical need). Notably, there was an increasing trend in experiencing delayed care and trouble getting needed care among Medicare beneficiaries with disabilities over time, especially for those with limited health insurance literacy.

CONCLUSIONS

Medicare beneficiaries with disabilities and limited health insurance literacy face disproportionate unmet need for medical care. Policies are needed to ensure that these beneficiaries have access to clear and accessible health insurance information.

On the road to retirement: Predicting nighttime driving difficulty and cessation using self-reported health factors

Introduction

Older drivers now expect to drive longer than previous cohorts and will make up about 25% of licensed U.S. drivers by 2050. Identifying early predictors of nighttime driving difficulty, a precursor to driving retirement, can inform screening procedures and timely linkage to interventions supporting driving or transitioning to driving cessation.

Methods

We examined self-reported physical and mental health baseline predictors of greater nighttime driving difficulty in five and ten years using weighted multivariate logistic analyses of 2261 drivers, aged 57 to 85, from the National Social Life, Health, and Aging Project (NSHAP). Transition matrix models describe probabilities of having greater, lesser, or the same nighttime driving difficulty after five years based on baseline driving conditions and the significant logistic model factors. We built a transition matrix tool that offers users the ability to calculate expected probabilities of change in nighttime driving difficulty based on the identified salient factors.

Results

Five-year predictors of greater nighttime driving difficulty included perceived poor physical health (OR = 3.75), limitations to activities of daily living (ADLs; OR = 1.97), and clinical levels of depressive and anxiety symptoms (OR = 1.63; OR = 1.71). Excellent physical health (OR = 0.52), mental health (OR = 0.60), and any frequency of physical activity compared to 'never' were protective (OR = 0.37-0.51). Physical health, walking pain, and limitations to ADLs were predictive at ten-years. Transition models showed physical health and anxiety were most indicative of greater nighttime driving difficulty at 5-years for those reporting no difficulty at baseline, but limitations to ADLs were more predictive otherwise.

Conclusions

Lay practitioners could capitalize on the use of self-report screening measures to identify older adults who may experience near-term nighttime driving difficulty. Earlier identification may better guide long-term driving retirement planning or engagement in appropriate health interventions. The transition matrix modeling tool is freely available to facilitate development and validation of related measures.

Was Unstable Medicaid Coverage Among Older Medicare Beneficiaries Associated With Worse Clinical Outcomes? Evidence From the Delivery of Breast Cancer Care

BACKGROUND

Medicare and Medicaid dually eligible beneficiaries (duals) could experience Medicaid coverage changes without losing Medicaid. It is unknown whether health care use and clinical outcomes among elderly duals with coverage changes would be like those among duals without coverage changes or duals ever lost Medicaid and whether various types of unstable coverage due to income/asset changes are associated with worse clinical outcomes.

OBJECTIVES

Examine the associations of unstable Medicaid coverage with clinical outcomes among older Medicare beneficiaries.

RESEARCH DESIGN

Population-based cohort study.

SUBJECTS

A total of 131,202 women newly diagnosed with breast cancer at 65 years and older between 2007 and 2015 were identified from the Surveillance, Epidemiology, and End Results-Medicare linked database.

MEASURES

We examined 2 types of unstable Medicaid coverage: (1) those who had changes in the types of Medicaid support they received and (2) those who ever lost Medicaid. We examined outcomes that predict better cancer survival and involve the use of inpatient and outpatient services and prescription drugs: early diagnosis, receiving surgery, receiving radiation, hormonal therapy adherence, and discontinuation. We used logistic regressions to estimate the predicted probabilities of outcomes for dual groups.

RESULTS

Duals had poorer outcomes than those who were "never dual." Women with the 2 types of unstable Medicaid coverage had similarly worse outcomes than those with stable coverage. Those with stable coverage had similar outcomes regardless of the generosity of Medicaid support.

CONCLUSIONS

These patterns are concerning and, in the context of well-defined clinical guidelines for beneficial treatments that extend survival, point to the importance of stable insurance coverage and income.

Difficulties in accessing health services among the elderly in the city of São Paulo-Brazil

To identify difficulties in accessing health services by the elderly in the city of São Paulo/Brazil and the contributory factors that reflect inequalities. This is a cross-sectional study that used data from the Health, Well-being and Aging Study (SABE). The population is composed of elderly ≥ 60 years old, of both sexes, living in the urban area of São Paulo. For this analysis, we used data from the 2015 cohort of the SABE study, containing a sample of 1,221 individuals. The proportions of access difficulty and, through logistic regression, the associated factors were verified, based on Andersen's Behavioral Model, which considers factors of predisposition, enabling and need as individual determinants of access to health care. It was observed that 37.0% of the elderly reported difficulty accessing health services when they needed it. This difficulty was greatest among females (42.3%), aged 60 to 69 years (40.9%), black race/color (58.8%), illiterate (44.5%), single/separated/divorced (44.3%), with income slower than one salary minimum (46.8%), without health insurance (51.9%), with poor/very poor self-assessment of health (54.7%), with multimorbidity (40.1%), frail (47.2%) and among those who used polypharmacy (40.8%). After multivariate analysis, in the final model, there was a positive association between difficulty of access and predisposing factors (female gender, age group 60 to 69 years, black race/color, illiterate), enabling factors (possession of health insurance) and need factors (regular and poor/very poor self-assessment of health and pre-fragility and frailty condition). The presence of difficulty in access associated with predisposing, enabling and need factors reflect the existence of inequalities caused by barriers that point to weaknesses in the organization of services. The identification of these barriers that hinder access highlights important points that can have an impact on the equity and resolution of care.

Use of Connected Technologies to Assess Barriers and Stressors for Age and Disability-Friendly Communities

Background: The benefits of engaging in outdoor physical activity are numerous for older adults. However, previous work on outdoor monitoring of physical activities did not sufficiently identify how older adults characterize and respond to diverse elements of urban built environments, including structural characteristics, safety attributes, and aesthetics.

Objective: To synthesize emerging multidisciplinary trends on the use of connected technologies to assess environmental barriers and stressors among older adults and for persons with disability.

Methods: A multidisciplinary overview and literature synthesis.

Results: First, we review measurement and monitoring of outdoor physical activity in community environments and during transport using wearable sensing technologies, their contextualization and using smartphone-based applications. We describe physiological responses (e.g., gait patterns, electrodermal activity, brain activity, and heart rate), stressors and physical barriers during outdoor physical activity. Second, we review the use of visual data (e.g., Google street images, Street score) and machine learning algorithms to assess physical (e.g., walkability) and emotional stressors (e.g., stress) in community environments and their impact on human perception. Third, we synthesize the challenges and limitations of using real-time smartphone-based data on driving behavior, incompatibility with software data platforms, and the potential for such data to be confounded by environmental signals in older adults. Lastly, we summarize alternative modes of transport for older adults and for persons with disability.

Conclusion: Environmental design for connected technologies, interventions to promote independence and mobility, and to reduce barriers and stressors, likely requires smart connected age and disability-friendly communities and cities.

Healthcare Decision-Making Among Dual-Eligible Immigrants: Implications from a Study of an Integrated Medicare-Medicaid Demonstration Program in California

To improve the coordination of long-term services and supports for dual-eligibles (those with both Medicare and Medicaid), California created Cal MediConnect (CMC), an Affordable Care Act-authorized managed care demonstration program. Beneficiaries were "passively enrolled" into CMC, meaning they were automatically enrolled unless they actively opted out. The aim of this study was to examine differences in factors influencing the enrollment decisions of U.S. born and immigrant dual-eligible beneficiaries. To explore differences in decision-making processes, we conducted in-depth interviews with dual-eligible consumers (39 native and 14 immigrant) in Los Angeles County. Interviews were analyzed using a constructivist grounded theory approach. Our findings illustrate a heightened sense of vulnerability and disempowerment experienced by immigrant participants. Immigrant participants also faced greater challenges in accessing healthcare and eliciting healthcare information compared to U.S.-born participants. Understanding the diverse perspectives of dual-eligible immigrant healthcare decision-making has implications for health care reform strategies aimed at ameliorating disparities for vulnerable immigrant populations.

Outcomes after peripheral artery disease intervention among Medicare-Medicaid dual-eligible patients compared with the general medicare population in the Vascular Quality Initiative registry

Objective

To determine whether patients from the Vascular Quality Initiative (VQI) registry who are Medicare–Medicaid dual-eligible have outcomes after surgical intervention with medical devices such as stents for peripheral artery disease comparable to the outcomes of those eligible for Medicare alone.

Methods

The study cohort included fee-for-service Medicare beneficiaries from 2010 to 2015 who underwent peripheral vascular intervention as determined by the VQI. We performed propensity matching between the dual-eligible and non-dual-eligible cohorts. Postintervention use, including imaging, amputation and death, was determined using Medicare claims data.

Results

Rates of major amputation were higher among dual-eligible patients (13.0% vs 10.5%, p<0.001), while time to amputation by disease severity was similar (p=0.443). For patients with more advanced disease (critical limb ischaemia (CLI) vs claudication), dual-eligible patients have significantly faster times to any amputation and death (p<0.001). For of postoperative imaging, 48.4% of dual-eligible patients receive at least one postoperative image, while the percentage for non-dual-eligible patients is 47.2% (p=0.187).

Conclusions

Patients with mild forms of peripheral artery disease (PAD), such as claudication, demonstrated similar outcomes regardless of dual-eligibility status. However, those with severe PAD, such as CLI, who were also dual-eligible had both inferior overall survival and amputation-free survival. Minimal differences were observed in process-driven aspects of care between dual-eligible and non-dual-eligible patients, including postoperative imaging. These findings indicate that despite receiving similar care, dual-eligible patients with severe PAD have inferior long-term outcomes, suggesting the Medicaid safety net is not timely enough to benefit from long-term outcomes for these patients.

Health Services Utilization Among Fee-for-Service Medicare and Medicaid Patients Under Age 65 with Behavioral Health Illness at an Urban Safety Net Hospital

BACKGROUND

In 2011, fee-for-service patients with both Medicare and Medicaid (dual eligible) sustained $319.5 billion in health care costs.

OBJECTIVE

To describe the emergency department (ED) use and hospital admissions of adult dual eligible patients aged under 65 years who used an urban safety net hospital.

METHODS

This was a retrospective database analysis of patients aged between 18 and 65 years with Medicare and Medicaid, who used an urban safety net academic health center between January 1, 2011, and December 31, 2011. We compared patients with and without behavioral health illness. The main outcome measures were hospital admission and ED use. Chi-square and Wilcoxon rank-sum tests were used for descriptive statistics on categorical and continuous variables, respectively. Greedy propensity score matching was used to control for confounding factors. Rate ratios (RR) and 95% confidence intervals (CI) were determined after matching and after adjusting for those variables that remained significantly different after matching.

RESULTS

In 2011, 10% of all fee-for-service dual eligible patients aged less than 65 years in Massachusetts were seen at Boston Medical Center. Data before propensity score matching showed significant differences in age, sex, race/ethnicity, marital status, education, employment, physical comorbidities, and Charlson Comorbidity Index score between patients with and without behavioral health illness. Analysis after propensity score matching found significant differences in sex, Hispanic race, and other education and employment status. Compared with patients without behavioral health illness, patients with behavioral health illness had a higher RR for hospital admissions (RR = 2.07; 95% CI = 1.81-2.38; P < 0.001) and ED use (RR = 1.61; 95% CI = 1.46-1.77; P < 0.001). Results were robust after adjusting for characteristics that remained statistically significantly different after propensity score matching.

CONCLUSIONS

Adult dual eligible patients aged less than 65 years with behavioral health illness in the Medicaid fee-for-service plan had significantly higher rates of hospital admission and ED use compared with dual eligible patients without behavioral health illness at the largest urban safety net medical center in New England. Safety net hospitals care for a large proportion of dual eligible patients with behavioral health illness. Further research is needed to elucidate the systems-related and patient-centered factors contributing to the utilization behaviors of this patient population.

DISCLOSURES

This research was funded in part by a National Research Service Award (T3HP10028-14-01). The authors have no conflicts of interests to disclose. Cancino had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Cancino, Jack, and Burgess, with assistance from Cremieux. Cancino and Cremieux took the lead in data collection, along with Jack and Burgess, and data interpretation was performed by Jarvis, Cummings, and Cooper, along with the other authors. The manuscript was written primarily by Cancino, along with Jack and Burgess, and revised primarily by Cancino, along with the other authors.

Identifying adults aging with disability using existing data: The case of the Health and Retirement Study

BACKGROUND

The population of persons aging with disabilities is growing. Being able to segment aging with disability sub-populations within national data sets is becoming increasingly important in order to understand the relationship of aging with disability to a range of outcomes in later life including health and wellness, economic security, and health and long-term service and support need and use.

OBJECTIVE

The purpose of this study was to identify viable sub-samples of adults aging with disabilities within the Health and Retirement Study, one of the most used secondary data sets to study aging and older adults.

METHOD

Samples used in this research are drawn from wave 11 (2012) of the HRS. Five operationalizations of disability were used: childhood disability (n = 719), childhood chronic condition (n = 3070), adult chronic condition (n = 13,723), functional limitation in adulthood (n = 4448) and work disability (n = 5632).

RESULTS

These subsamples are not mutually exclusive. Among respondents that reported having a childhood disability, 87% also report having at least one chronic disease in adulthood, 50% report having functional limitations in adulthood and 38% report interruption in their ability to work due to a disability. Compared to the childhood disability samples, rates of reporting fair/poor health are nearly double among adults with functional limitations or those with work disruptions because of disability.

CONCLUSION

Work disability and functional limitation appeared to be the most viable sub-sample options to consider when using the HRS to study experiences of adults aging with disability. Overall, age at onset is unclear.