1
|
Jung J, Ko H, Feldman R, Carlin CS, Song G. Gaps In Quality Of Care Not Consistent Between Traditional Medicare, Medicare Advantage For Racial And Ethnic Groups. Health Aff (Millwood) 2024; 43:381-390. [PMID: 38437614 DOI: 10.1377/hlthaff.2023.00428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
The quality of care experienced by members of racial and ethnic minority groups in Medicare Advantage, which is an increasingly important source of Medicare coverage for these groups, has critical implications for health equity. Comparing gaps in Medicare Advantage and traditional Medicare for three quality-of-care outcomes, measured by adverse health events, between minority and non-Hispanic White populations, we found that the relative magnitude of the gaps varied both by racial and ethnic minority group and by quality measure. Hispanic versus non-Hispanic White gaps were smaller in Medicare Advantage than in traditional Medicare for all outcomes: avoidable emergency department use, preventable hospitalizations, and thirty-day hospital readmissions. The gap between non-Hispanic Black and non-Hispanic White populations was larger in Medicare Advantage than in traditional Medicare for avoidable emergency department use but was no different for hospital readmissions and was smaller for preventable hospitalizations. The Asian versus non-Hispanic White gap was similar in Medicare Advantage and traditional Medicare for avoidable emergency department use and preventable hospitalizations but was larger in Medicare Advantage for hospital readmissions. As Medicare Advantage enrollment expands, monitoring the quality of care for enrollees who are members of racial and ethnic minority groups will remain important.
Collapse
Affiliation(s)
- Jeah Jung
- Jeah Jung , George Mason University, Fairfax, Virginia
| | | | - Roger Feldman
- Roger Feldman, University of Minnesota, Minneapolis, Minnesota
| | | | - Ge Song
- Ge Song, George Mason University
| |
Collapse
|
2
|
Jhumkhawala V, Lobaina D, Okwaraji G, Zerrouki Y, Burgoa S, Marciniak A, Densley S, Rao M, Diaz D, Knecht M, Sacca L. Social determinants of health and health inequities in breast cancer screening: a scoping review. Front Public Health 2024; 12:1354717. [PMID: 38375339 PMCID: PMC10875738 DOI: 10.3389/fpubh.2024.1354717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/18/2024] [Indexed: 02/21/2024] Open
Abstract
Introduction This scoping review aims to highlight key social determinants of health associated with breast cancer screening behavior in United States women aged ≥40 years old, identify public and private databases with SDOH data at city, state, and national levels, and share lessons learned from United States based observational studies in addressing SDOH in underserved women influencing breast cancer screening behaviors. Methods The Arksey and O'Malley York methodology was used as guidance for this review: (1) identifying research questions; (2) searching for relevant studies; (3) selecting studies relevant to the research questions; (4) charting the data; and (5) collating, summarizing, and reporting results. Results The 72 included studies were published between 2013 and 2023. Among the various SDOH identified, those related to socioeconomic status (n = 96) exhibited the highest frequency. The Health Care Access and Quality category was reported in the highest number of studies (n = 44; 61%), showing its statistical significance in relation to access to mammography. Insurance status was the most reported sub-categorical factor of Health Care Access and Quality. Discussion Results may inform future evidence-based interventions aiming to address the underlying factors contributing to low screening rates for breast cancer in the United States.
Collapse
Affiliation(s)
- Vama Jhumkhawala
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Diana Lobaina
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Goodness Okwaraji
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Yasmine Zerrouki
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Sara Burgoa
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Adeife Marciniak
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Sebastian Densley
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Meera Rao
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Daniella Diaz
- Charles E. Schmidt College of Science, Boca Raton, FL, United States
| | - Michelle Knecht
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| | - Lea Sacca
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, United States
| |
Collapse
|
3
|
Lee I, Luo Y, Carretta H, LeBlanc G, Sinha D, Rust G. Latent pathway-based Bayesian models to identify intervenable factors of racial disparities in breast cancer stage at diagnosis. Cancer Causes Control 2024; 35:253-263. [PMID: 37702967 DOI: 10.1007/s10552-023-01785-w] [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: 08/13/2021] [Accepted: 08/21/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE We built Bayesian Network (BN) models to explain roles of different patient-specific factors affecting racial differences in breast cancer stage at diagnosis, and to identify healthcare related factors that can be intervened to reduce racial health disparities. METHODS We studied women age 67-74 with initial diagnosis of breast cancer during 2006-2014 in the National Cancer Institute's SEER-Medicare dataset. Our models included four measured variables (tumor grade, hormone receptor status, screening utilization and biopsy delay) expressed through two latent pathways-a tumor biology path, and health-care access/utilization path. We used various Bayesian model assessment tools to evaluate these two latent pathways as well as each of the four measured variables in explaining racial disparities in stage-at-diagnosis. RESULTS Among 3,010 Black non-Hispanic (NH) and 30,310 White NH breast cancer patients, respectively 70.2% vs 76.9% were initially diagnosed at local stage, 25.3% vs 20.3% with regional stage, and 4.56% vs 2.80% with distant stage-at-diagnosis. Overall, BN performed approximately 4.7 times better than Classification And Regression Tree (CART) (Breiman L, Friedman JH, Stone CJ, Olshen RA. Classification and regression trees. CRC press; 1984) in predicting stage-at-diagnosis. The utilization of screening mammography is the most prominent contributor to the accuracy of the BN model. Hormone receptor (HR) status and tumor grade are useful for explaining racial disparity in stage-at diagnosis, while log-delay in biopsy impeded good prediction. CONCLUSIONS Mammography utilization had a significant effect on racial differences in breast cancer stage-at-diagnosis, while tumor biology factors had less impact. Biopsy delay also aided in predicting local and regional stages-at-diagnosis for Black NH women but not for white NH women.
Collapse
Affiliation(s)
- Inkoo Lee
- Department of Statistics, Rice University, Houston, USA
| | - Yi Luo
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, USA
| | - Henry Carretta
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, USA
| | - Gabrielle LeBlanc
- MD Class of 2023, Florida State University College of Medicine, Tallahassee, USA
| | - Debajyoti Sinha
- Department of Statistics, Florida State University, Tallahassee, USA
| | - George Rust
- Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, USA.
| |
Collapse
|
4
|
Gangopadhyaya A, Zuckerman S, Rao N. Assessing the difference in racial and ethnic disparities in access to and use of care between Traditional Medicare and Medicare Advantage. Health Serv Res 2023; 58:914-923. [PMID: 36894493 PMCID: PMC10315374 DOI: 10.1111/1475-6773.14150] [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] [Indexed: 03/11/2023] Open
Abstract
OBJECTIVE Test whether racial-ethnic disparities in the access and use of care differ between Traditional Medicare (TM) and Medicare Advantage (MA). DATA SOURCE Secondary data from the 2015-2018 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN Measure Black-White and Hispanic-White disparities in access to care and use of preventive services within TM, within MA, and assess the difference-in-disparities between the two programs with and without controls for factors that could influence enrollment, access, and use. DATA COLLECTION/EXTRACTION Pool 2015-2018 MCBS data and restrict to non-Hispanic Black, non-Hispanic White, or Hispanic respondents. PRINCIPAL FINDINGS Black enrollees have worse access to care relative to White enrollees in TM and MA, particularly for cost-related measures such as not having problems paying medical bills (11-13 pp. lower for Black enrollees; p < 0.05) and satisfaction with out-of-pocket costs (5-6 pp. lower; p < 0.05). We find no difference in Black-White disparities between TM and MA. Hispanic enrollees have worse access to care relative to White enrollees in TM but similar access relative to White enrollees in MA. Hispanic-White disparities in not delaying care due to cost and not reporting problems paying medical bills are narrower in MA relative to TM by about 4 pp (significant at the p < 0.05 level) each. We find no consistent evidence that Black-White or Hispanic-White differences in the use of preventive services differ between TM and MA. CONCLUSIONS Across the measures of access and use studied here, racial and ethnic disparities in MA are not substantially narrower than in TM for Black and Hispanic enrollees relative to White enrollees. For Black enrollees, this study suggests that system-wide reforms are required to reduce existing disparities. For Hispanic enrollees, MA does narrow some disparities in access to care relative to White enrollees but, in part, because White enrollees do not do as well in MA as they do in TM.
Collapse
Affiliation(s)
- Anuj Gangopadhyaya
- Health Policy CenterUrban Institute Health Policy Center500 L'Enfant Plaza SWWashingtonDC20024USA
| | - Stephen Zuckerman
- Health Policy CenterUrban Institute Health Policy Center500 L'Enfant Plaza SWWashingtonDC20024USA
| | - Nikhil Rao
- Health Policy CenterUrban Institute Health Policy Center500 L'Enfant Plaza SWWashingtonDC20024USA
| |
Collapse
|
5
|
Health inequities in mammography: A scoping review. Eur J Radiol 2023; 160:110693. [PMID: 36640712 DOI: 10.1016/j.ejrad.2023.110693] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 12/30/2022] [Accepted: 01/07/2023] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The objective of this scoping review is to chart the existing evidence on health inequities related to mammography and identify existing knowledge gaps to guide future research. METHODS This scoping review followed guidelines from the Joanna Briggs Institute and the PRISMA extension for scoping reviews. In July 2022, we searched PubMed and Ovid Embase for published articles on mammography screening, published between 2011 and 2021, written in English, and examining at least one health inequity as defined by the NIH. Screening and charting were both performed in a masked, duplicate manner. Frequencies of each health inequity examined were analyzed and main findings from each included study were summarized. RESULTS Following screening, our sample consisted of 128 studies. Our findings indicate that mammography screening was less likely in historically marginalized groups, patients who live in rural areas, and in women with low income status and education level. Significant research gaps were observed regarding the LGBTQ + community and sex and gender. No trends between inequities investigated over time were identified. DISCUSSION This scoping review highlights the gaps in inequities research regarding mammography, as well as the limited consensus across findings. To bridge existing research gaps, we recommend research into the following: 1) assessments of physician knowledge on the LGBTQ + community guidelines, 2) tools for health literacy, and 3) culturally competent screening models.
Collapse
|
6
|
Hanchate AD, Baker WE, Paasche-Orlow MK, Feldman J. Ambulance diversion and ED destination by race/ethnicity: evaluation of Massachusetts' ambulance diversion ban. BMC Health Serv Res 2022; 22:987. [PMID: 35918721 PMCID: PMC9347077 DOI: 10.1186/s12913-022-08358-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background The impact of ambulance diversion on potentially diverted patients, particularly racial/ethnic minority patients, is largely unknown. Treating Massachusetts’ 2009 ambulance diversion ban as a natural experiment, we examined if the ban was associated with increased concordance in Emergency Medical Services (EMS) patients of different race/ethnicity being transported to the same emergency department (ED). Methods We obtained Medicare Fee for Service claims records (2007–2012) for enrollees aged 66 and older. We stratified the country into patient zip codes and identified zip codes with sizable (non-Hispanic) White, (non-Hispanic) Black and Hispanic enrollees. For a stratified random sample of enrollees from all diverse zip codes in Massachusetts and 18 selected comparison states, we identified EMS transports to an ED. In each zip code, we identified the most frequent ED destination of White EMS-transported patients (“reference ED”). Our main outcome was a dichotomous indicator of patient EMS transport to the reference ED, and secondary outcome was transport to an ED serving lower-income patients (“safety-net ED”). Using a difference-in-differences regression specification, we contrasted the pre- to post-ban changes in each outcome in Massachusetts with the corresponding change in the comparison states. Results Our study cohort of 744,791 enrollees from 3331 zip codes experienced 361,006 EMS transports. At baseline, the proportion transported to the reference ED was higher among White patients in Massachusetts and comparison states (67.2 and 60.9%) than among Black (43.6 and 46.2%) and Hispanic (62.5 and 52.7%) patients. Massachusetts ambulance diversion ban was associated with a decreased proportion transported to the reference ED among White (− 2.7 percentage point; 95% CI, − 4.5 to − 1.0) and Black (− 4.1 percentage point; 95% CI, − 6.2 to − 1.9) patients and no change among Hispanic patients. The ban was associated with an increase in likelihood of transport to a safety-net ED among Hispanic patients (3.0 percentage points, 95% CI, 0.3 to 5.7) and a decreased likelihood among White patients (1.2 percentage points, 95% CI, − 2.3 to − 0.2). Conclusion Massachusetts ambulance diversion ban was associated with a reduction in the proportion of White and Black EMS patients being transported to the most frequent ED destination for White patients, highlighting the role of non-proximity factors in EMS transport destination. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08358-8.
Collapse
Affiliation(s)
- Amresh D Hanchate
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1063, USA. .,Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.
| | - William E Baker
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.,Boston Medical Center, Boston, MA, 02118, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.,Boston Medical Center, Boston, MA, 02118, USA
| | - James Feldman
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA, 02118, USA.,Boston Medical Center, Boston, MA, 02118, USA
| |
Collapse
|
7
|
Weeks WB, Cao SY, Smith J, Wang H, Weinstein JN. Trends in Characteristics of Adults Enrolled in Traditional Fee-for-Service Medicare and Medicare Advantage, 2011-2019. Med Care 2022; 60:227-231. [PMID: 34984991 DOI: 10.1097/mlr.0000000000001680] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While overall Medicare Part C (Medicare Advantage) enrollment has grown more rapidly than fee-for-service Medicare enrollment, changes in the growth and characteristics of different enrollee populations have not been examined. OBJECTIVES For 2011-2019, to compare changes in the growth and characteristics of younger (age younger than 65) and older (age 65 and older) Medicare beneficiaries enrolled in Medicare Part A only, Medicare Parts A & B, and Medicare Part C. RESEARCH DESIGN This was a retrospective, observational study. SUBJECTS Medicare beneficiaries who were alive and enrolled in Medicare Part A only, Medicare Parts A & B, or Medicare Part C on June 30 of each year and in no other plan that year. MEASURES For each plan type and age group the numbers and mean ages of enrollees and the proportion of enrollees who were: black, female, concurrently enrolled in Medicaid, and (for older enrollees), whose initial reason for eligibility was old age and survivors' benefits. RESULTS Between 2011 and 2019, Medicare Part C experienced rapid expansions of 85.0% among older and 109.5% among younger enrollees. Part C enrollees were increasingly likely to be dually enrolled in Medicaid, Black and, among younger enrollees, female. CONCLUSIONS Trends in demographic characteristics and changes in policy and growth in employer group plan offerings will likely continue to impact health care service utilization and costs in the Medicare population. Particularly as Medicare expansion to younger age groups is considered, future research should explore disparities in risk scores and care equity, quality, and costs across different Medicare enrollment options.
Collapse
Affiliation(s)
| | | | - Jeremy Smith
- White River Junction VA Outcomes Group, White River Junction, VT
| | | | - James N Weinstein
- Microsoft Corporation, Microsoft Research, Redmond, WA
- The Dartmouth Institute, Lebanon
- Tuck School of Business at Dartmouth, Hanover, NH
- Northwestern Kellogg School of Management, Evanston, IL
| |
Collapse
|
8
|
Moyo P, Bosco E, Bardenheier BH, Rivera-Hernandez M, van Aalst R, Chit A, Gravenstein S, Zullo AR. Variation in influenza vaccine assessment, receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes. Vaccine 2022; 40:1031-1037. [PMID: 35033387 PMCID: PMC8917469 DOI: 10.1016/j.vaccine.2021.12.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 12/22/2021] [Accepted: 12/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND More older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents. METHODS We analyzed 2014-2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination. RESULTS There were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.10 pp, 95% CL: -3.53 pp, -2.68 pp), or high (-4.63 pp, 95% CL: -5.11 pp, -4.15 pp) MA compared with NHs with the lowest prevalence of MA. CONCLUSION A higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings.
Collapse
Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA.
| | - Elliott Bosco
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA
| | - Barbara H Bardenheier
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA; Leslie Dan School of Pharmacy, University of Toronto, Ontario, Canada
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA
| | - Robertus van Aalst
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Modelling, Epidemiology, and Data Science, Sanofi Pasteur, Lyon, France; Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ayman Chit
- Sanofi Pasteur, Swiftwater, PA, USA; Leslie Dan School of Pharmacy, University of Toronto, Ontario, Canada
| | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| |
Collapse
|
9
|
Keshavarzi A, Asadi S, Asadollahi A, Mohammadkhah F, Khani Jeihooni A. Tendency to Breast Cancer Screening Among Rural Women in Southern Iran: A Structural Equation Modeling (SEM) Analysis of Theory of Planned Behavior. BREAST CANCER: BASIC AND CLINICAL RESEARCH 2022; 16:11782234221121001. [PMID: 36091183 PMCID: PMC9452820 DOI: 10.1177/11782234221121001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 08/08/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Early detection of breast cancer is a crucial factor in surviving the disease. This study aimed to investigate the mammography screening based on the theory of planned behavior (TPB) among rural women in Fasa and Shiraz cities, Iran. Methods: This study is a cross-sectional study performed on 800 female clients referring to rural health centers in Fasa and Shiraz cities in southern Iran in early 2021. The authors decided to send and distribute the electronic questionnaire form through the WhatsApp application in collaboration with the health staff of rural health centers for the people covered by these centers. Data gathering tools were a questionnaire on demographic characteristics, a questionnaire based on constructs of TPB, and behavior of mammography screening. Using the structural equation model (SEM), the TPB constructs and demographic variables were entered into the model. Data analysis was executed employing SPSS software version 26 and Amos version 24 (IBM Co., Ann Arbor, MI, USA). Analyzing the data was carried out using the 1-way analysis of variance (ANOVA), logistic regression, and structural equation analysis. During data analysis, various model indicators such as the goodness of fit, including comparative fit index (CFI), goodness-of-fit index (GFI), root mean square error of approximation (RMSEA), and chi-square index/df were evaluated. The significance level in all tests was considered 0.05. Results: The knowledge, attitude, and perceived behavioral control were the predictors of intention and behavior of mammography screening among the women. Among demographic variables, age, literacy, being menopausal, cancer in family, city, and ethnicity contribute more to the variance variation in TPB constructs. In this study, 7.2% of Persians, 8% of Qashqai Turks, and 4.5% of Arabs are contemplating going to mammography screening. In total, 6.8% (54 people) of all individuals intended to go mammography screening, and 5.4% (43 people) had a history of mammography screening. Goodness-of-fit indices (χ2 = 18.45, df = 10, n = 800, χ2/df = 1.845, RMSEA = 0.032, GFI = 0.90, non-normed fit index (NNFI) = 0.91) of conceptual model of this study indicate the suitability of the model. Conclusions: The results of the study indicated that the constructs of the TPB can predict mammography screening behaviors in rural women. It has also demonstrated that mammographic behavior can be improved in rural women using education based on the TPB model, emphasizing critical psychological factors of creating or changing behavior.
Collapse
Affiliation(s)
- Ameneh Keshavarzi
- Department of Gynecology, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
| | - Saeedeh Asadi
- Department of Gynecology, School of Medicine, Fasa University of Medical Sciences, Fasa, Iran
| | - Abdolrahim Asadollahi
- Department of Health Promotion, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Mohammadkhah
- Department of Community Health, Child Nursing and Aging, Ramsar School of Nursing, Babol University of Medical Sciences, Babol, Iran
| | - Ali Khani Jeihooni
- Nutrition Research Center, Department of Public Health, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| |
Collapse
|
10
|
Schwartz AL, Zlaoui K, Foreman RP, Brennan TA, Newhouse JP. Health Care Utilization and Spending in Medicare Advantage vs Traditional Medicare. JAMA HEALTH FORUM 2021; 2:e214001. [PMID: 35977297 PMCID: PMC8796939 DOI: 10.1001/jamahealthforum.2021.4001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/12/2021] [Indexed: 11/14/2022] Open
Abstract
Question Findings Meaning Importance Objective Design, Setting, and Participants Main Outcomes and Measures Results Conclusions and Relevance
Collapse
Affiliation(s)
- Aaron L. Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | | | | | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| |
Collapse
|
11
|
Park S, Fishman P, Coe NB. Racial Disparities in Avoidable Hospitalizations in Traditional Medicare and Medicare Advantage. Med Care 2021; 59:989-996. [PMID: 34432767 PMCID: PMC8519483 DOI: 10.1097/mlr.0000000000001632] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IMPORTANCE Compared with traditional Medicare (TM), Medicare Advantage (MA) has the potential to reduce racial disparities in hospitalizations for ambulatory care sensitive conditions (ACSC). As racial disparities may be partly attributable to unequal treatment based on where people live, this suggests the need of examining geographic variations in racial disparities. OBJECTIVE The aim of this study was to examine differences in ACSC hospitalizations between White and Black beneficiaries in TM and MA and examine geographic variations in racial differences in ACSC hospitalizations in TM and MA. METHODS We analyzed the 2015-2016 Medicare Provider Analysis and Review files. We used propensity score matching to account for differences in characteristics between TM and MA beneficiaries. Then, we conducted linear regression and estimated adjusted outcomes for TM and MA beneficiaries by race. Also, we estimated racial differences in adjusted outcomes by insurance and hospital referral region (HRR). RESULTS While White beneficiaries in TM and MA had similar rates of ACSC hospitalizations (163.7 vs. 162.2/10,000 beneficiaries), Black beneficiaries in MA had higher rates of ACSC hospitalizations than Black beneficiaries in TM (221.2 vs. 209.3/10,000 beneficiaries). However, the racial differences were greater in MA than TM (59.0 vs. 45.6/10,000 beneficiaries). Racial differences in ACSC hospitalizations in MA were prevalent across almost all HRRs. 95.5% of HRRs had higher rates of ACSC hospitalizations among Black beneficiaries than White beneficiaries in MA relative to just 54.2% of HRRs in TM. CONCLUSION Our findings provide evidence of racial disparities in access to high-quality primary care, especially in MA.
Collapse
Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
12
|
Johnston KJ, Hammond G, Meyers DJ, Joynt Maddox KE. Association of Race and Ethnicity and Medicare Program Type With Ambulatory Care Access and Quality Measures. JAMA 2021; 326:628-636. [PMID: 34402828 PMCID: PMC8371568 DOI: 10.1001/jama.2021.10413] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE There are racial inequities in health care access and quality in the United States. It is unknown whether such differences for racial and ethnic minority beneficiaries differ between Medicare Advantage and traditional Medicare or whether access and quality are better for minority beneficiaries in 1 of the 2 programs. OBJECTIVE To compare differences in rates of enrollment, ambulatory care access, and ambulatory care quality by race and ethnicity in Medicare Advantage vs traditional Medicare. DESIGN, SETTING, AND PARTICIPANTS Exploratory observational cohort study of a nationally representative sample of 45 833 person-years (26 887 persons) in the Medicare Current Beneficiary Survey from 2015 to 2018, comparing differences in program enrollment and measures of access and quality by race and ethnicity. EXPOSURES Minority race and ethnicity (Black, Hispanic, Native American, or Asian/Pacific Islander) vs White or multiracial; Medicare Advantage vs traditional Medicare enrollment. MAIN OUTCOMES AND MEASURES Six patient-reported measures of ambulatory care access (whether a beneficiary had a usual source of care in the past year, had a primary care clinician usual source of care, or had a specialist visit) and quality (influenza vaccination, pneumonia vaccination, and colon cancer screening). RESULTS The final sample included 6023 persons (mean age, 68.9 [SD, 12.6] years; 57.3% women) from minority groups and 20 864 persons (mean age, 71.9 [SD, 10.8] years; 54.9% women) from White or multiracial groups, who accounted for 9816 and 36 017 person-years, respectively. Comparing Medicare Advantage vs traditional Medicare among minority beneficiaries, those in Medicare Advantage had significantly better rates of access to a primary care clinician usual source of care (79.1% vs 72.5%; adjusted marginal difference, 4.0%; 95% CI, 1.0%-6.9%), influenza vaccinations (67.3% vs 63.0%; adjusted marginal difference, 5.2%; 95% CI, 1.9%-8.5%), pneumonia vaccinations (70.7% vs 64.6%; adjusted marginal difference, 6.1%; 95% CI, 2.7%-9.4%), and colon cancer screenings (69.4% vs 61.1%; adjusted marginal difference, 7.1%; 95% CI, 3.8%-10.3%). Comparing minority vs White or multiracial beneficiaries across both programs, minority beneficiaries had significantly lower rates of access to a primary care clinician usual source of care (adjusted marginal difference, 4.7%; 95% CI, 2.5%-6.8%), specialist visits (adjusted marginal difference, 10.8%; 95% CI, 8.3%-13.3%), influenza vaccinations (adjusted marginal difference, 4.3%; 95% CI, 1.2%-7.4%), and pneumonia vaccinations (adjusted marginal difference, 6.4%; 95% CI, 3.9%-9.0%). The interaction of race and ethnicity with insurance type was not statistically significant for any of the 6 outcome measures. CONCLUSIONS AND RELEVANCE In this exploratory study of Medicare beneficiaries in 2015-2018, enrollment in Medicare Advantage vs traditional Medicare was significantly associated with better outcomes for access and quality among minority beneficiaries; however, minority beneficiaries were significantly more likely to experience worse outcomes for most access and quality measures than White or multiracial beneficiaries in both programs.
Collapse
Affiliation(s)
- Kenton J. Johnston
- Department of Health Management and Policy, Saint Louis University, St Louis, Missouri
| | - Gmerice Hammond
- Washington University School of Medicine, St Louis, Missouri
| | - David J. Meyers
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | | |
Collapse
|
13
|
Agarwal R, Connolly J, Gupta S, Navathe AS. Comparing Medicare Advantage And Traditional Medicare: A Systematic Review. Health Aff (Millwood) 2021; 40:937-944. [PMID: 34097516 DOI: 10.1377/hlthaff.2020.02149] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare Advantage enrollment has almost doubled since 2010 and now accounts for more than a third of all Medicare beneficiaries. We performed a systematic review to compare Medicare Advantage and traditional Medicare on key metrics. Evidence from forty-eight studies showed that in most or all comparisons, Medicare Advantage was associated with more preventive care visits, fewer hospital admissions and emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending. Medicare Advantage outperformed traditional Medicare in most studies comparing quality-of-care metrics. However, the evidence on patient experience, readmission rates, mortality, and racial/ethnic disparities did not show a trend of better performance in Medicare Advantage. Evidence to date might not fully account for selection bias, unobserved differences in social determinants of health, or risk adjustment challenges, in part because of differences in data quality that limit the comparability of outcomes between Medicare Advantage and traditional Medicare. With Medicare Advantage plans expected to grow in popularity, policy makers should support policies to improve data completeness and comparability, and health plans should focus on improving patient experience.
Collapse
Affiliation(s)
- Rajender Agarwal
- Rajender Agarwal is director of the Center for Health Reform, in Southlake, Texas
| | - John Connolly
- John Connolly is a medical student in the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, in Philadelphia, Pennsylvania
| | - Shweta Gupta
- Shweta Gupta is the fellowship director of the Oncology Program, Department of Medicine, John H. Stroger Jr. Hospital of Cook County, in Chicago, Illinois
| | - Amol S Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center; an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine; and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, all in Philadelphia
| |
Collapse
|
14
|
Meyers DJ, Rahman M, Mor V, Wilson IB, Trivedi AN. Association of Medicare Advantage Star Ratings With Racial, Ethnic, and Socioeconomic Disparities in Quality of Care. JAMA HEALTH FORUM 2021; 2:e210793. [PMID: 35977175 PMCID: PMC8796982 DOI: 10.1001/jamahealthforum.2021.0793] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/06/2021] [Indexed: 01/25/2023] Open
Abstract
Importance Medicare Advantage (MA) plans, which disproportionately enroll racial/ethnic minorities and persons with socioeconomic disadvantage, receive bonus payments on the basis of overall performance on a 5-star rating scale. The association between plans' overall quality and disparities in quality is not well understood. Objective To examine the association between MA star ratings and disparities in care for racial/ethnic minorities and enrollees with lower income and educational attainment. Design Setting and Participants This cross-sectional study included 1 578 564 MA enrollees from 454 contracts across the 2015 and 2016 calendar years. Data analyses were conducted between June 2019 and June 2020. Exposures Self-reported race and ethnicity and low socioeconomic status (SES) (defined by low income or less than a high school education) vs high SES (neither low income nor low educational attainment). Main Outcomes and Measures Performance on 22 measures of quality and satisfaction determined at the individual enrollee level, aggregated into simulated star ratings (scale, 2-5) stratified by SES and race/ethnicity. Results A total of 1 578 564 enrollees were included in this analysis (55.8% female; mean [SD] age, 71.4 [11.3] years; 65.8% White; 12.3% Black; 14.6% Hispanic). Enrollees with low SES had simulated stratified star ratings 0.5 stars lower (95% CI, 0.4-0.6 stars) than individuals with high SES in the same contract. Black and Hispanic enrollees had simulated star ratings that were 0.3 stars (95% CI, 0.2-0.4 stars) and 0.1 stars (95% CI, -0.04 to 0.2 stars) lower than White enrollees within the same contracts. Black enrollees had a 0.4-star lower rating (95% CI, 0.1-0.7 stars) in 4.5- to 5-star contracts and a no statistical difference in 2.0- to 2.5-star-rated contracts (difference, 0.3 stars; 95% CI, -0.02 to 0.7 stars). Hispanic enrollees had a 0.6-star lower simulated rating (95% CI, 0.2-1.0 stars) in 4.5- to 5-star contracts and no statistical difference in 2- to 2.5-star contracts (difference, -0.01 stars; 95% CI, -0.5 to 0.4 stars). There was low correlation between simulated ratings for enrollees of low SES and high SES (difference, 0.2 stars; 95% CI, 0.03-0.4 stars) and between simulated ratings for White and Black enrollees (difference, 0.4 stars; 95% CI, 0.3-0.5 stars) and White and Hispanic enrollees (difference, 0.3 stars; 95% CI, 0.2-0.4 stars). As the proportion of Black and Hispanic enrollees increased in a contract, racial/ethnic disparities in ratings decreased. Conclusions and Relevance In this cross-sectional study, simulated MA star ratings were only weakly correlated with those for enrollees of low SES in the same contract, and contracts with higher star ratings had larger disparities in quality. Measures of equity in MA plans' quality of care may be needed.
Collapse
Affiliation(s)
- David J. Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| | - Ira B. Wilson
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Amal N. Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Providence VA Medical Center, Providence, Rhode Island
| |
Collapse
|
15
|
Landon BE, Zaslavsky AM, Souza J, Ayanian JZ. Use of diabetes medications in traditional Medicare and Medicare Advantage. THE AMERICAN JOURNAL OF MANAGED CARE 2021; 27:e80-e88. [PMID: 33720673 PMCID: PMC7967940 DOI: 10.37765/ajmc.2021.88602] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To compare use of diabetes medications between beneficiaries enrolled in Medicare Advantage (MA) and traditional Medicare (TM). STUDY DESIGN Retrospective cohort analysis of Medicare enrollment and Part D event claims during 2015-2016. METHODS Data came from 1,027,884 TM and 838,420 MA beneficiaries who received at least 1 prescription for an oral or injectable diabetes medication. After matching MA and TM enrollees by demographic characteristics and geography, we analyzed use of medication overall, choices of first diabetes medication for those new to medication, and patterns of adding medications. RESULTS Overall and for patients on 1, 2, or 3 diabetes medications, use of metformin was higher in MA by about 3 percentage points, but use of newer medication classes was 5.1 percentage points higher in TM overall (21.3% vs 16.2%). Use of guideline-recommended first-line agents was higher in MA. For those who started metformin first, use of a sulfonylurea as a second medication was 7.8 percentage points higher in MA than TM (61.5% vs 53.7%), whereas use of medications from newer classes was 7.7 percentage points lower (22.0% vs 29.7%). Mean total spending was $149 higher in TM for those taking 1 medication and $298 higher for those taking 2 medications. Differences in spending among MA plans were of similar magnitude to the MA-TM differences. CONCLUSIONS MA enrollees are more likely to be treated with metformin and sulfonylureas and less likely to receive costly newer medications than those in TM, but there also is substantial variation within MA. A limitation of the study is that we could not assess glucose control using glycated hemoglobin levels.
Collapse
Affiliation(s)
- Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02215.
| | | | | | | |
Collapse
|
16
|
Landon BE, Onnela JP, Meneades L, O’Malley AJ, Keating NL. Assessment of Racial Disparities in Primary Care Physician Specialty Referrals. JAMA Netw Open 2021; 4:e2029238. [PMID: 33492373 PMCID: PMC7835717 DOI: 10.1001/jamanetworkopen.2020.29238] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Disparities in quality of care according to patient race and socioeconomic status persist in the US. Differential referral patterns to specialist physicians might be associated with observed disparities. OBJECTIVE To examine whether differences exist between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians (PCPs) and physicians in the 6 specialties to which patients were most frequently referred. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional observational study of Black and White Medicare beneficiaries used claims data from 2009 to 2010 on 100% of traditional Medicare beneficiaries who were seen by PCPs and selected high-volume specialists in 12 health care markets with at least 10% of the population being Black. Statistical analyses were conducted from December 20, 2017, to September 30, 2020. EXPOSURES Differences in patterns of patient sharing among Black and White patients. MAIN OUTCOMES AND MEASURES Primary care physician and specialist degree (the number of other PCPs or specialists to whom each physician is connected) and strength (the number of shared patients per connection, overall, for Black patients and White patients and after equalizing the numbers of Black and White patients per PCP), as well as distance between PCP and patient and specialist zip code centroids. RESULTS The 12 selected markets ranged in size from Manhattan, New York (187 054 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 9794 total physicians), to Tallahassee, Florida (44 644 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% (Huntsville, Alabama) to 46.8% (Chicago, Illinois). The mean PCP-specialist degree (number of specialists with whom a PCP shares patients) was lower for Black patients than for White patients. For instance, the mean PCP-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. After sampling White patients to equalize the numbers of patients seen, the degree differences narrowed but were still not equivalent in many markets (eg, for all specialties in Baton Rouge, Louisiana: 4.5 for Black patients vs 5.7 for White patients). Specialist networks among White patients were much larger than those constructed based just on Black patients (eg, for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per PCP (123 for Black patients vs 211 for White patients). The overall test for differences in referral patterns was statistically significant for all 6 specialties examined in 7 of the 12 markets and in 5 specialties for another 3. CONCLUSIONS AND RELEVANCE This study suggests that differences exist in specialist referral patterns by race among Medicare beneficiaries. This is an observational study, and thus some differences might have resulted from patient-initiated visits to specialists.
Collapse
Affiliation(s)
- Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jukka-Pekka Onnela
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
| | - Laurie Meneades
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Nancy L. Keating
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
17
|
Figueroa JF, Wadhera RK, Frakt AB, Fonarow GC, Heidenreich PA, Xu H, Lytle B, DeVore AD, Matsouaka R, Yancy CW, Bhatt DL, Joynt Maddox KE. Quality of Care and Outcomes Among Medicare Advantage vs Fee-for-Service Medicare Patients Hospitalized With Heart Failure. JAMA Cardiol 2020; 5:1349-1357. [PMID: 32876650 DOI: 10.1001/jamacardio.2020.3638] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance Medicare Advantage (MA), a private insurance plan option, now covers one-third of all Medicare beneficiaries. Although patients with cardiovascular disease enrolled in MA have been reported to receive higher quality of care in the ambulatory setting than patients enrolled in fee-for-service (FFS) Medicare, it is unclear whether MA is associated with higher quality in patients hospitalized with heart failure, or alternatively, if incentives to reduce utilization under MA plans may be associated with worse care. Objective To determine whether there are differences in quality of care received and in-hospital outcomes among patients enrolled in MA vs FFS Medicare. Design, Setting, and Participants Observational, retrospective cohort study of patients hospitalized with heart failure in hospitals participating in the Get With the Guidelines-Heart Failure registry. Exposures Medicare Advantage enrollment. Main Outcomes and Measures In-hospital mortality, discharge disposition, length of stay, and 4 heart failure achievement measures. Results Of 262 626 patients hospitalized with heart failure, 93 549 (35.6%) were enrolled in MA and 169 077 (64.4%) in FFS Medicare. The median (interquartile range) age was 78 (70-85) years for patients enrolled in MA and 78 (69-86) years for patients enrolled in FFS Medicare. Standard mean differences in age, sex, prevalence of comorbidities, or objective measures on admission, including vital signs and laboratory values, were less than 10%. After adjustment, there were no statistically significant differences in receipt of evidence-based β-blockers when indicated; angiotensin-converting enzyme inhibitor, angiotensin II receptor blockers, or angiotensin receptor-neprilysin inhibitors at discharge; measurement of left ventricular function; and postdischarge appointments by Medicare insurance type. Patients enrolled in MA, however, had higher odds of being discharged directly home (adjusted odds ratio [AOR], 1.16; 95% CI, 1.13-1.19; P < .001) relative to patients enrolled in FFS Medicare and lower odds of being discharged within 4 days (AOR, 0.97; 95% CI, 0.93-1.00; P = .04). There was no significant difference in in-hospital mortality between patients with MA and patients with FFS Medicare (AOR, 0.98; 95% CI, 0.92-1.03; P = .42). Conclusions and Relevance Among patients hospitalized with heart failure, no observable benefit was noted in quality of care or in-hospital mortality between those enrolled in MA vs FFS Medicare, except lower use of post-acute care facilities. As MA continues to grow, it will be important to ensure that participating private plans provide an added value to the patients they cover to justify the higher administrative costs compared with traditional FFS Medicare.
Collapse
Affiliation(s)
- Jose F Figueroa
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rishi K Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Austin B Frakt
- VA Boston Healthcare System, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center.,Section Editor, JAMA Cardiology
| | | | - Haolin Xu
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Barbara Lytle
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Adam D DeVore
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Roland Matsouaka
- Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina
| | - Clyde W Yancy
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois.,Deputy Editor, JAMA Cardiology
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.,Center for Health Economics and Policy, Washington University Institute for Public Health, St Louis, Missouri
| |
Collapse
|
18
|
Timbie JW, Kranz AM, DeYoreo M, Eshete-Roesler B, Elliott MN, Escarce JJ, Totten ME, Damberg CL. Racial and ethnic disparities in care for health system-affiliated physician organizations and non-affiliated physician organizations. Health Serv Res 2020; 55 Suppl 3:1107-1117. [PMID: 33094846 DOI: 10.1111/1475-6773.13581] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To assess racial and ethnic disparities in care for Medicare fee-for-service (FFS) beneficiaries and whether disparities differ between health system-affiliated physician organizations (POs) and nonaffiliated POs. DATA SOURCES We used Medicare Data on Provider Practice and Specialty (MD-PPAS), Medicare Provider Enrollment, Chain, and Ownership System (PECOS), IRS Form 990, 100% Medicare FFS claims, and race/ethnicity estimated using the Medicare Bayesian Improved Surname Geocoding 2.0 algorithm. STUDY DESIGN Using a sample of 16 007 POs providing primary care in 2015, we assessed racial/ethnic disparities on 12 measures derived from claims (2 cancer screenings; diabetic eye examinations; continuity of care; two medication adherence measures; three measures of follow-up visits after acute care; all-cause emergency department (ED) visits, all-cause readmissions, and ambulatory care-sensitive admissions). We decomposed these "total" disparities into within-PO and between-PO components using models with PO random effects. We then pair-matched 1853 of these POs that were affiliated with health systems to similar nonaffiliated POs. We examined differences in within-PO disparities by affiliation status by interacting each nonwhite race/ethnicity with an affiliation indicator. DATA COLLECTION/EXTRACTION METHODS Medicare Data on Provider Practice and Specialty identified POs billing Medicare; PECOS and IRS Form 990 identified health system affiliations. Beneficiaries age 18 and older were attributed to POs using a plurality visit rule. PRINCIPAL FINDINGS We observed total disparities in 12 of 36 comparisons between white and nonwhite beneficiaries; nonwhites received worse care in 10. Within-PO disparities exceeded between-PO disparities and were substantively important (>=5 percentage points or>=0.2 standardized differences) in nine of the 12 comparisons. Among these 12, nonaffiliated POs had smaller disparities than affiliated POs in two comparisons (P < .05): 1.6 percentage points smaller black-white disparities in follow-up after ED visits and 0.6 percentage points smaller Hispanic-white disparities in breast cancer screening. CONCLUSIONS We find no evidence that system-affiliated POs have smaller racial and ethnic disparities than nonaffiliated POs. Where differences existed, disparities were slightly larger in affiliated POs.
Collapse
Affiliation(s)
| | | | | | | | | | - José J Escarce
- David Geffen School of Medicine at UCLA and UCLA Fielding School of Public Health, Los Angeles, California, USA
| | | | | |
Collapse
|
19
|
Elewonibi B, Nkwonta C. The association of chronic diseases and mammography among Medicare beneficiaries living in Appalachia. ACTA ACUST UNITED AC 2020; 16:1745506520933020. [PMID: 32538325 PMCID: PMC7297020 DOI: 10.1177/1745506520933020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study assessed the relationship between presence and number of chronic disease and reception of mammogram in women 65 years and older, and how this relationship is influenced by primary care provider visits. METHODS A total of 3306 women diagnosed with breast cancer from 2006 to 2008 from cancer registries in four Appalachian states were analyzed. RESULTS Having a mammogram within the past 2 years was associated with having at least one chronic disease. The presence of a chronic disease was associated with an increased likelihood of breast cancer screening adherence but was not a strong predictor when demographic variables were added. CONCLUSION This study supports the findings that women with more primary care provider visits were more likely to adhere to breast cancer screening guidelines but having several chronic diseases presents a barrier to achieving guideline-concordant mammography screening, highlighting the importance of preventive screening for patients managing chronic diseases.
Collapse
Affiliation(s)
- Bilikisu Elewonibi
- Department of Health Policy and Administration, Pennsylvania State University, University Park, PA, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Chigozie Nkwonta
- Smart State Center for Heathcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| |
Collapse
|
20
|
Figueroa JF, Blumenthal DM, Feyman Y, Frakt AB, Turchin A, Doros G, Gao Q, Song Y, Joynt Maddox KE. Differences in Management of Coronary Artery Disease in Patients With Medicare Advantage vs Traditional Fee-for-Service Medicare Among Cardiology Practices. JAMA Cardiol 2020; 4:265-271. [PMID: 30785590 DOI: 10.1001/jamacardio.2019.0007] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance One-third of Medicare beneficiaries are enrolled in Medicare Advantage (MA), Medicare's private plan option. Medicare Advantage incentivizes performance on evidence-based care, but limited information exists using reliable clinical data to determine whether this translates into better quality for patients with coronary artery disease (CAD) enrolled in MA compared with those enrolled in traditional fee-for-service (FFS) Medicare. Objective To determine differences in evidence-based secondary prevention treatments and intermediate outcomes among patients with CAD enrolled in MA vs FFS Medicare. Design, Setting, and Participants In this observational, retrospective, cohort study, deidentified data from patients 18 years or older diagnosed as having CAD between January 1, 2013, and May 1, 2014, at cardiology practices participating in the Practice Innovation and Clinical Excellence (PINNACLE) registry were studied, including 35 563 patients enrolled in MA and 172 732 enrolled in FFS Medicare. Data were analyzed from March to July 2018. Exposures Medicare Advantage enrollment. Main Outcomes and Measures Medication prescription patterns among eligible patients and intermediate outcomes, including blood pressure and low-density lipoprotein cholesterol. Results Of the 35 563 patients with CAD enrolled in MA, 20 193 (56.8%) were male, and the mean (SD) age was 76.7 (7.6) years; of the 172 732 patients with CAD enrolled in FFS Medicare, 100 025 (57.9%) were male, and the mean (SD) age was 77.5 (8.0) years. Patients enrolled in MA were younger, less likely to be white, and more likely to be female and to have heart failure, diabetes, and chronic kidney disease compared with those enrolled in FFS Medicare. Compared with FFS Medicare beneficiaries, MA beneficiaries were more likely to receive secondary prevention treatments, including β-blockers (80.6% vs 78.8%; P < .001), angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (70.7% vs 65.1%; P < .001), and statins (68.4% vs 64.5%; P < .001). Patients enrolled in MA were also more likely to receive all 3 medications when eligible (48.9% vs 40.4%; P < .001). After adjustment, MA beneficiaries had higher odds of receiving guideline-recommended therapy compared with FFS Medicare beneficiaries for β-blockers (odds ratio, 1.10; 95% CI, 1.04-1.17; P = .002), angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (odds ratio, 1.13; 95% CI, 1.08-1.19; P < .001), and all 3 medications (odds ratio, 1.23; 95% CI, 1.001-1.50; P = .047). There were no significant differences in intermediate outcomes between those enrolled in MA and FFS Medicare, including systolic and diastolic blood pressure and low-density lipoprotein cholesterol levels. Conclusions and Relevance Among patients with CAD in the PINNACLE registry, MA beneficiaries had more comorbidities than FFS Medicare beneficiaries and were more likely to receive secondary prevention treatments. However, this did not translate into differences in intermediate outcomes. These findings suggest that MA plans may drive improvements in process-based quality measures for Medicare beneficiaries, although this may have a limited effect on improving patient outcomes over FFS Medicare.
Collapse
Affiliation(s)
- Jose F Figueroa
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel M Blumenthal
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of Cardiology, Massachusetts General Hospital, Boston
| | - Yevgeniy Feyman
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Austin B Frakt
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts.,Boston University School of Public Health, Boston, Massachusetts
| | - Alexander Turchin
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.,Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Baim Clinical Research Institute, Boston, Massachusetts
| | - Gheorghe Doros
- Baim Clinical Research Institute, Boston, Massachusetts.,Department of Biostatistics, Boston University, Boston, Massachusetts
| | - Qi Gao
- Department of Biostatistics, Boston University, Boston, Massachusetts
| | - Yang Song
- Department of Biostatistics, Boston University, Boston, Massachusetts
| | - Karen E Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri
| |
Collapse
|
21
|
Hanchate AD, Paasche-Orlow MK, Baker WE, Lin MY, Banerjee S, Feldman J. Association of Race/Ethnicity With Emergency Department Destination of Emergency Medical Services Transport. JAMA Netw Open 2019; 2:e1910816. [PMID: 31490537 PMCID: PMC6735492 DOI: 10.1001/jamanetworkopen.2019.10816] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Evidence from national studies indicates systematic differences in hospitals in which racial/ethnic minorities receive care, with most care obtained in a small proportion of hospitals. Little is known about the source of these differences. OBJECTIVES To examine the patterns of emergency department (ED) destination of emergency medical services (EMS) transport according to patient race/ethnicity, and to compare the patterns between those transported by EMS and those who did not use EMS. DESIGN, SETTING, AND PARTICIPANTS This cohort study of US EMS and EDs used Medicare claims data from January 1, 2006, to December 31, 2012. Enrollees aged 66 years or older with continuous fee-for-service Medicare coverage (N = 864 750) were selected for the sample. Zip codes with a sizable count (>10) of Hispanic, non-Hispanic black, and non-Hispanic white enrollees were used for comparison of EMS use across racial/ethnic subgroups. Data on all ED visits, with and without EMS use, were obtained. Data analysis was performed from December 18, 2018, to July 7, 2019. MAIN OUTCOMES AND MEASURES The main outcome measure was whether an EMS transport destination was the most frequent ED destination among white patients (reference ED). The secondary outcomes were (1) whether the ED destination was a safety-net hospital and (2) the distance of EMS transport from the ED destination. RESULTS The study cohort comprised 864 750 Medicare enrollees from 4175 selected zip codes who had 458 701 ED visits using EMS transport. Of these EMS-transported enrollees, 26.1% (127 555) were younger than 75 years, and most were women (302 430 [66.8%]). Overall, the proportion of white patients transported to the reference ED was 61.3% (95% CI, 61.0% to 61.7%); this rate was lower among black enrollees (difference of -5.3%; 95% CI, -6.0% to -4.6%) and Hispanic enrollees (difference of -2.5%; 95% CI, -3.2% to -1.7%). A similar pattern was found among patients with high-risk acute conditions; the proportion transported to the reference ED was 61.5% (95% CI, 60.7% to 62.2%) among white enrollees, whereas this proportion was lower among black enrollees (difference of -6.7%; 95% CI, -8.3% to -5.0%) and Hispanic enrollees (difference of -2.6%; 95% CI, -4.5% to -0.7%). In major US cities, a larger black-white discordance in ED destination was observed (-9.3%; 95% CI, -10.9% to -7.7%). Black and Hispanic patients were more likely to be transported to a safety-net ED compared with their white counterparts; the proportion transported to a safety-net ED among white enrollees (18.5%; 95% CI, 18.1% to 18.7%) was lower compared with that among black enrollees (difference of 2.7%; 95% CI, 2.2% to 3.2%) and Hispanic enrollees (difference of 1.9%; 95% CI, 1.3% to 2.4%). Concordance rates of non-EMS-transported ED visits were statistically significantly lower than for EMS-transported ED visits; the concordance rate among white enrollees of 52.9% (95% CI, 52.1% to 53.6%) was higher compared with that among black enrollees (difference of -4.8%; 95% CI, -6.4% to -3.3%) and Hispanic enrollees (difference of -3.0%; 95% CI, -4.7% to -1.3%). CONCLUSIONS AND RELEVANCE This study found race/ethnicity variation in ED destination for patients using EMS transport, with black and Hispanic patients more likely to be transported to a safety-net hospital ED compared with white patients living in the same zip code.
Collapse
Affiliation(s)
- Amresh D. Hanchate
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
- Boston Medical Center, Boston, Massachusetts
| | - William E. Baker
- Boston Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Meng-Yun Lin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Souvik Banerjee
- Disparities Research Unit, The Mongan Institute, Massachusetts General Hospital, Boston
| | - James Feldman
- Boston Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
22
|
Tran L, Tran P. US urban-rural disparities in breast cancer-screening practices at the national, regional, and state level, 2012-2016. Cancer Causes Control 2019; 30:1045-1055. [PMID: 31428890 DOI: 10.1007/s10552-019-01217-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 08/09/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Previous studies suggesting that rural US women may be less likely to have a recent mammogram than urban women are limited in either scope or granularity. This study explored urban-rural disparities in US breast cancer-screening practices at the national, regional, and state levels. METHODS We used data from the 2012, 2014, and 2016 Behavioral Risk Factor Surveillance Systems surveys. Logistic models were utilized to examine the impact of living in an urban/rural area on mammogram screening at three geographic levels while adjusting for covariates. We then calculated average adjusted predictions (AAPs) and average marginal effects (AMEs) to isolate the association between breast cancer screening and the urban/rural factor. RESULTS At all geographic levels, AAPs of breast cancer screening were similar among urban, suburban, and rural residents. Regarding "ever having a mammogram" and "having a recent mammogram," urban women had small but significantly higher adjusted probabilities (AAP: 94.6%, 81.1%) compared to rural women (AAP: 93.5%, 80.2%). CONCLUSIONS While urban-rural differences in breast cancer screening are small, they can translate into tens of thousands of rural women not receiving mammograms. Hence, there is a need to continue screening initiatives in these areas to reduce the number of breast cancer deaths.
Collapse
Affiliation(s)
- Lam Tran
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA.
| | - Phoebe Tran
- Department of Chronic Disease Epidemiology, Yale University, New Haven, CT, USA
| |
Collapse
|
23
|
Fazeli Dehkordy S, Fendrick AM, Bell S, Kamdar N, Kobernik E, Dalton VK, Carlos RC. Breast Screening Utilization and Cost Sharing Among Employed Insured Women Following the Affordable Care Act: Impact of Race and Income. J Womens Health (Larchmt) 2019; 28:1529-1537. [PMID: 30985249 DOI: 10.1089/jwh.2018.7403] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: We assessed changes in screening mammography cost sharing and utilization before and after the Affordable Care Act (ACA) and the revised U.S. Preventive Services Task Force (USPSTF) recommendations by race and income. Methods: We used Optum™© Clinformatics™® Data Mart deidentified patient-level analytic files between 2004 and 2014. We first visually inspected trends for screening mammography utilization and cost-sharing elimination over time by race and income. We then specifically calculated the slopes and compared trends before and after 2009 and 2010 to assess the impact of ACA implementation and USPSTF recommendation revisions on screening mammography cost-sharing elimination and utilization. All analyses were conducted in 2018. Results: A total of 1,763,959 commercially insured women, ages 40-74, were included. Comparing trends for cost-sharing elimination before and after the 2010 ACA implementation, a statistically significant but small upward trend was found among all races and income levels with no racial or income disparities evident. However, screening utilization plateaued or showed a significant decline after the 2009 USPSTF recommendation revision in all income and racial groups except for African Americans in whom screening rates continued to increase after 2009. Conclusions: Impact of ACA cost-sharing elimination did not differ among various racial and income groups. Among our population of employer-based insured women, the racial gap in screening mammography use appeared to have closed and potentially reversed among African American women. Continued monitoring of screening utilization as health care policies and recommendations evolve is required, as these changes may affect race- and income-based disparities.
Collapse
Affiliation(s)
| | - A Mark Fendrick
- Program for Women's Health Effectiveness Research, University of Michigan, Ann Arbor, Michigan.,Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Division of General Internal Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.,Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, Michigan
| | - Sarah Bell
- Program for Women's Health Effectiveness Research, University of Michigan, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Neil Kamdar
- Program for Women's Health Effectiveness Research, University of Michigan, Ann Arbor, Michigan.,Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Emily Kobernik
- Program for Women's Health Effectiveness Research, University of Michigan, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Vanessa K Dalton
- Program for Women's Health Effectiveness Research, University of Michigan, Ann Arbor, Michigan.,Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Ruth C Carlos
- Program for Women's Health Effectiveness Research, University of Michigan, Ann Arbor, Michigan.,Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, Michigan.,Department of Radiology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
24
|
Disparities in Emergency Department Visits Among Collocated Racial/Ethnic Medicare Enrollees. Ann Emerg Med 2019; 73:225-235. [PMID: 30798793 DOI: 10.1016/j.annemergmed.2018.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/28/2018] [Accepted: 09/05/2018] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE We estimate emergency department (ED) use differences across Medicare enrollees of different race/ethnicity who are residing in the same zip codes. METHODS In this retrospective cohort study, we stratified all Medicare fee-for-service beneficiaries aged 66 years and older (2006 to 2012) by residence zip code and identified zip codes with racial/ethnic diversity, defined as containing at least 1 enrollee from each of 3 racial/ethnic groups: Hispanics, (non-Hispanic) blacks, and (non-Hispanic) whites. Our primary study population consisted of a stratified random sample of approximately equal number of each racial/ethnic group from each zip code with racial/ethnic diversity (N=1,563,631). We identified ED visits, comorbidities, primary-care-treatable status, and patient disposition. We characterized socioeconomic status by zip code poverty rate. The main outcome measure was the ratio of ED visit rate (number of visits/100 person-years) between each minority group and whites. RESULTS Of 38,423 zip codes nationally, 41% met the racial/ethnic diversity criterion; these zip codes contained 85% of the Medicare fee-for-service beneficiaries. Among enrollees from zip codes with racial/ethnic diversity, the ED visit rate among whites was 45.4 (95% confidence interval 45.1 to 45.6), and the ED visit rate ratio was 1.34 (95% confidence interval 1.33 to 1.36) among blacks and 1.23 (95% confidence interval 1.22 to 1.24) among Hispanics. ED visit rate ratios for both minority groups were greater than 1.00 among all subgroups by age, comorbidity, zip code poverty rate, urban/rural area, and primary-care-treatable and disposition status. CONCLUSION Among Medicare enrollees, blacks and Hispanics had higher ED use rates than whites overall and among subgroups by demographics and socioeconomic status.
Collapse
|
25
|
Sabatino SA, Thompson TD, Miller JW, Breen N, White MC, Breslau E, Shoemaker ML. Prevalence of Out-Of-Pocket Payments for Mammography Screening Among Recently Screened Women. J Womens Health (Larchmt) 2018; 28:910-918. [PMID: 30265611 DOI: 10.1089/jwh.2018.6973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Because cost may be a barrier to receiving mammography screening, cost sharing for "in-network" screening mammograms was eliminated in many insurance plans with implementation of the Affordable Care Act. We examined prevalence of out-of-pocket payments for screening mammography after elimination in many plans. Materials and Methods: Using 2015 National Health Interview Survey data, we examined whether women aged 50-74 years who had screening mammography within the previous year (n = 3,278) reported paying any cost for mammograms. Logistic regression models stratified by age (50-64 and 65-74 years) examined out-of-pocket payment by demographics and insurance (ages 50-64 years: private, Medicaid, other, and uninsured; ages 65-74 years: private ± Medicare, Medicare+Medicaid, Medicare Advantage, Medicare only, and other). Results: Of women aged 50-64 years, 23.5% reported payment, including 39.1% of uninsured women. Compared with that of privately insured women, payment was less likely for women with Medicaid (adjusted OR 0.17 [95% CI 0.07-0.41]) or other insurance (0.49 [0.25-0.96]) and more likely for uninsured women (1.99 [0.99-4.02]) (p < 0.001 across groups). For women aged 65-74 years, 11.9% reported payment, including 22.5% of Medicare-only beneficiaries. Compared with private ± Medicare beneficiaries, payment was less likely for Medicare+Medicaid beneficiaries (adjusted OR 0.21 [95% CI 0.06-0.73]) and more likely for Medicare-only beneficiaries (1.83 [1.01-3.32]) (p = 0.005 across groups). Conclusions: Although most women reported no payment for their most recent screening mammogram in 2015, some payment was reported by >20% of women aged 50-64 years or aged 65-74 years with Medicare only, and by almost 40% of uninsured women aged 50-64 years. Efforts are needed to understand why many women in some groups report paying out of pocket for mammograms and whether this impacts screening use.
Collapse
Affiliation(s)
- Susan A Sabatino
- 1Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Trevor D Thompson
- 1Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jacqueline W Miller
- 1Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nancy Breen
- 2National Institute on Minority Health and Health Disparities, Bethesda, Maryland
| | - Mary C White
- 1Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erica Breslau
- 3Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Meredith L Shoemaker
- 1Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
26
|
Temkin SM, Rimel BJ, Bruegl AS, Gunderson CC, Beavis AL, Doll KM. A contemporary framework of health equity applied to gynecologic cancer care: A Society of Gynecologic Oncology evidenced-based review. Gynecol Oncol 2018; 149:70-77. [PMID: 29605053 DOI: 10.1016/j.ygyno.2017.11.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 10/19/2017] [Accepted: 11/07/2017] [Indexed: 01/21/2023]
Abstract
Health disparities are defined as the preventable difference in the burden of disease, injury, and violence, or opportunity to achieve optimal health that socially disadvantaged populations experience compared to the population as a whole. Disparities in incidence and cancer outcomes for women with gynecologic malignancies have been well described particularly for American women of Black race. The etiology of these disparities has been tied to socio-economics, cultural, educational and genetic factors. While access to high quality treatment has been primarily linked to survival from cervical and ovarian cancer, innate biologic distinctions have been principally cited as reasons for differences in incidence and mortality in cancers of the uterine corpus. This article will update the framework of disparities to incorporate a broader understanding of the social determinants of health and how they affect health equity by addressing the root causes of disparities within the health care system. Special populations are identified who are at risk for health inequities which include but are not limited to Black race, underserved racial and ethnic minorities (e.g. indigenous peoples, low English fluency), trans/gender nonconforming people and rural populations. Each of these populations at risk have unique structural barriers within the healthcare system impacting gynecologic cancer outcomes. The authors provide practical recommendations for practitioners aimed at eliminating cancer related outcome disparities.
Collapse
Affiliation(s)
- Sarah M Temkin
- Virginia Commonwealth University, Massey Cancer Center, Richmond, VA, USA
| | - B J Rimel
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Camille C Gunderson
- Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma city, OK, USA
| | | | | |
Collapse
|
27
|
Rosenkrantz AB, Fleming M, Duszak R. Variation in Screening Mammography Rates Among Medicare Advantage Plans. J Am Coll Radiol 2017; 14:1013-1019. [DOI: 10.1016/j.jacr.2017.01.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 01/09/2017] [Accepted: 01/18/2017] [Indexed: 10/19/2022]
|
28
|
Beveridge RA, Mendes SM, Caplan A, Rogstad TL, Olson V, Williams MC, McRae JM, Vargas S. Mortality Differences Between Traditional Medicare and Medicare Advantage: A Risk-Adjusted Assessment Using Claims Data. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2017; 54:46958017709103. [PMID: 28578605 PMCID: PMC5798747 DOI: 10.1177/0046958017709103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Medicare Advantage (MA) has grown rapidly since the Affordable Care Act; nearly one-third of Medicare beneficiaries now choose MA. An assessment of the comparative value of the 2 options is confounded by an apparent selection bias favoring MA, as reflected in mortality differences. Previous assessments have been hampered by lack of access to claims diagnosis data for the MA population. An indirect comparison of mortality as an outcome variable was conducted by modeling mortality on a traditional fee-for-service (FFS) Medicare data set, applying the model to an MA data set, and then evaluating the ratio of actual-to-predicted mortality in the MA data set. The mortality model adjusted for clinical conditions and demographic factors. Model development considered the effect of potentially greater coding intensity in the MA population. Further analysis calculated ratios for subpopulations. Predicted, risk-adjusted mortality was lower in the MA population than in FFS Medicare. However, the ratio of actual-to-predicted mortality (0.80) suggested that the individuals in the MA data set were less likely to die than would be predicted had those individuals been enrolled in FFS Medicare. Differences between actual and predicted mortality were particularly pronounced in low income (dual eligibility), nonwhite race, high morbidity, and Health Maintenance Organization (HMO) subgroups. After controlling for baseline clinical risk as represented by claims diagnosis data, mortality differences favoring MA over FFS Medicare persisted, particularly in vulnerable subgroups and HMO plans. These findings suggest that differences in morbidity do not fully explain differences in mortality between the 2 programs.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Stefan Vargas
- 2 Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
29
|
Potential impact of the Affordable Care Act's preventive services provision on breast cancer stage: A preliminary assessment. Cancer Epidemiol 2017; 49:108-111. [PMID: 28601783 DOI: 10.1016/j.canep.2017.05.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 05/17/2017] [Accepted: 05/30/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The Affordable Care Act's (ACA) preventive services provision (PSP) removes copayments for preventive services such as cancer screening. We examined: 1) whether a shift in breast cancer stage occurred, and 2) the impact of the provision on racial/ethnic disparities in stage. MATERIALS AND METHODS Data from the National Cancer Database were used. The pre- and post-PSP periods were identified as 2007-2009 and 2011-2013, respectively. Proportion differences (PDs) and 95% confidence Intervals (CIs) were calculated. RESULTS All three racial/ethnic groups experienced a statistically significant shift toward Stage I breast cancer. Pre-PSP, the black:white disparity in Stage I cancer was -9.5 (95% CI: -8.9, -10.4) and the Latina:white disparity was -5.2 (95% CI: -4.0, -6.1). Post-PSP, the disparities improved slightly. DISCUSSION Preliminary data suggest that the ACA's PSP may have a meaningful impact on cancer stage overall and by race/ethnicity. However, more time may be needed to see reductions in disparities.
Collapse
|
30
|
Hanchate AD, Paasche-Orlow MK, Dyer KS, Baker WE, Feng C, Feldman J. Geographic Variation in Use of Ambulance Transport to the Emergency Department. Ann Emerg Med 2017; 70:533-543.e7. [PMID: 28559039 DOI: 10.1016/j.annemergmed.2017.03.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 02/23/2017] [Accepted: 03/16/2017] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Evidence on variability in emergency medical services use is limited. We obtain national evidence on geographic variation in the use of ambulance transport to the emergency department (ED) among Medicare enrollees and assess the role of health status, socioeconomic status, and provider availability. METHODS We used 2010 Medicare claims data for a random sample of 999,999 enrollees aged 66 years and older, and identified ambulance transport and ED use. The main outcome measures were number of ambulance transports to the ED per 100 person-years (ambulance transport rate) and proportion (percentage) of ED visits by ambulance transport by hospital referral regions. RESULTS The national ambulance transport rate was 22.2 and the overall proportion of ED visits by ambulance was 36.7%. Relative to hospital referral regions in the lowest rate quartile, those in the highest quartile had a 75% higher ambulance transport rate (incidence rate ratio [IRR] 1.75; 95% confidence interval [CI] 1.69 to 1.81) and a 15.5% higher proportion of ED visits by ambulance (IRR 1.155; 95% CI 1.146 to 1.164). Adjusting for health status, socioeconomic status, and provider availability reduced quartile 1 versus quartile 4 difference in ambulance transport rate by 43% (IRR 1.43; 95% CI 1.38 to 1.48) and proportion of ED visits by ambulance by 7% (IRR 1.145; 95% CI 1.135 to 1.155). Among the 3 covariate domains, health status was associated with the largest variability in ambulance transport rate (30.1%), followed by socioeconomic status (12.8%) and provider availability (2.9%). CONCLUSION Geographic variability in ambulance use is large and associated with variation in patient health status and socioeconomic status.
Collapse
Affiliation(s)
- Amresh D Hanchate
- VA Boston Healthcare System, Boston, MA; Section of General Internal Medicine, Boston University School of Medicine, Boston, MA.
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA
| | - K Sophia Dyer
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA; Boston EMS, City of Boston, Boston, MA
| | - William E Baker
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA
| | - Chen Feng
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA
| | - James Feldman
- Department of Emergency Medicine, Boston University School of Medicine, Boston, MA; Boston Medical Center, Boston, MA
| |
Collapse
|
31
|
Chang E, Ruder T, Setodji C, Saliba D, Hanson M, Zingmond DS, Wenger NS, Ganz DA. Differences in Nursing Home Quality Between Medicare Advantage and Traditional Medicare Patients. J Am Med Dir Assoc 2016; 17:960.e9-960.e14. [DOI: 10.1016/j.jamda.2016.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 07/18/2016] [Accepted: 07/21/2016] [Indexed: 11/26/2022]
|
32
|
Abstract
BACKGROUND We examined mammography use before and after Medicare eliminated cost sharing for screening mammography in January 2011. METHODS Using National Health Interview Survey data, we examined changes in mammography use between 2010 and 2013 among Medicare beneficiaries aged 65-74 years. Logistic regression and predictive margins were used to examine changes in use after adjusting for covariates. RESULTS In 2013, 74.7% of women reported a mammogram within 2 years, a 3.5 percentage point increase (95% confidence interval, -0.3, 7.2) compared with 2010. Increases occurred among women aged 65-69 years, unmarried women, and women with usual sources of care and 2-5 physician visits in the prior year. After adjustment, mammography use increased in 2013 versus 2010 (74.8% vs. 71.3%, P=0.039). Interactions between year and income, insurance, race, or ethnicity were not significant. CONCLUSIONS There was a modest increase in mammography use from 2010 to 2013 among Medicare beneficiaries aged 65-74 years, possibly consistent with an effect of eliminating Medicare cost sharing during this time. Findings suggest that eliminating cost sharing might increase use of recommended screening services.
Collapse
|
33
|
Curtis JR, Xie F, Yun H, Bernatsky S, Winthrop KL. Real-world comparative risks of herpes virus infections in tofacitinib and biologic-treated patients with rheumatoid arthritis. Ann Rheum Dis 2016; 75:1843-7. [PMID: 27113415 DOI: 10.1136/annrheumdis-2016-209131] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/03/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To evaluate the risks of herpes zoster (HZ) and herpes simplex virus (HSV) infection associated with tofacitinib compared with biologic agents among patients with rheumatoid arthritis (RA). METHODS Using health plan data from 2010 to 2014, patients with RA initiating tofacitinib or biologics with no history of HZ or HSV were identified, as were incident cases of HZ or HSV. Crude incidence rates were calculated by drug exposure. Cox proportional hazards models evaluated the adjusted association between tofacitinib and HZ, and a composite outcome of HZ or HSV. RESULTS A total of 2526 patients initiating tofacitinib were compared with initiations of other biologics: anti-tumour necrosis factor (TNF) (n=42 850), abatacept (n=12 305), rituximab (n=5078) and tocilizumab (n=6967). Patients receiving tofacitinib were somewhat younger (mean age 55 years) versus those on other biologics, and somewhat less likely to use concomitant methotrexate (MTX) (39% vs 43%-56%, depending on drug). Crude incidence of HZ associated with tofacitinib was 3.87/100 patient-years (py). After multivariable adjustment, HZ risk was significantly elevated, HR 2.01 (95% CI 1.40 to 2.88) compared with abatacept. Rates and adjusted HRs for all other RA biologics were comparable with each other and abatacept. Older age, female sex, prednisone >7.5 mg/day, prior outpatient infection and greater number of hospitalisations were also associated with increased HZ risk. Incidence rates for the combined outcome were greatest for tofacitinib (7.61/100 py) and also significantly elevated after adjustment (HR=1.40, 95% CI 1.09 to 1.81). CONCLUSIONS The rate of zoster associated with tofacitinib was approximately double that observed in patients using biologics.
Collapse
Affiliation(s)
- Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Fenglong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Huifeng Yun
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sasha Bernatsky
- Division of Clinical Epidemiology McGill University Health Centre, Montreal, Quebec, Canada
| | - Kevin L Winthrop
- Divisions of Infectious Diseases, Public Health, and Preventive Medicine, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
34
|
Abstract
The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.
Collapse
Affiliation(s)
- Kevin Fiscella
- Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, Rochester, New York 14620;
| | - Mechelle R Sanders
- Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, Rochester, New York 14620;
| |
Collapse
|
35
|
Ayanian JZ, Landon BE, Newhouse JP, Zaslavsky AM. Racial and ethnic disparities among enrollees in Medicare Advantage plans. N Engl J Med 2014; 371:2288-97. [PMID: 25494268 PMCID: PMC4381536 DOI: 10.1056/nejmsa1407273] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Differences in the control of blood pressure, cholesterol, and glucose among the various racial and ethnic groups of Medicare enrollees may contribute to persistent disparities in health outcomes. METHODS Among elderly enrollees in Medicare Advantage health plans in 2011 who had hypertension (94,171 persons), cardiovascular disease (112,039), or diabetes (105,848), we compared the respective age-and-sex-adjusted proportions with blood pressure lower than 140/90 mm Hg, low-density lipoprotein cholesterol levels below 100 mg per deciliter (2.6 mmol per liter), and a glycated hemoglobin value of 9.0% or lower, according to race or ethnic group. Comparisons were made nationally and within regions and health plans, and changes since 2006 were assessed. RESULTS Black enrollees in 2006 and 2011 were substantially less likely than white enrollees to have adequate control of blood pressure (adjusted absolute differences in proportions of enrollees in the 2 years, 7.9 percentage points and 10.3 percentage points, respectively), cholesterol (11.4 percentage points and 10.2 percentage points, respectively), and glycated hemoglobin (10.1 percentage points and 9.4 percentage points, respectively) (P<0.001 for all comparisons). Differing distributions of enrollees among health plans accounted for 39 to 59% of observed disparities in 2011. These differences persisted in 2011 in the Northeast, Midwest, and South (6.9 to 14.1 percentage points, P<0.001 for all comparisons) but were eliminated in the West for all three measures (<1.5 percentage points, P≥0.15). Hispanic enrollees were less likely than whites in 2011 to have adequate control of blood pressure (adjusted difference, 1.6 percentage points), cholesterol (adjusted difference, 1.0 percentage points), and glycated hemoglobin (adjusted difference, 3.4 percentage points) (P≤0.02 for all comparisons). Asians and Pacific Islanders were more likely than whites to have adequate control of blood pressure (difference, 4.4 percentage points; P<0.001) and cholesterol (5.5 percentage points, P<0.001) and had similar control of glycated hemoglobin (0.3 percentage points, P=0.63). CONCLUSIONS Disparities in control of blood pressure, cholesterol, and glucose have not improved nationally for blacks in Medicare Advantage plans, but these disparities were eliminated in the West in 2011. (Funded by the National Institute on Aging.).
Collapse
Affiliation(s)
- John Z Ayanian
- From the Institute for Healthcare Policy and Innovation, the Division of General Medicine, University of Michigan Medical School, the Department of Health Management and Policy, University of Michigan School of Public Health, and the Gerald R. Ford School of Public Policy, University of Michigan - all in Ann Arbor (J.Z.A.); the Department of Health Care Policy, Harvard Medical School (J.Z.A., B.E.L., J.P.N., A.M.Z.), the Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School (B.E.L.), and the Department of Health Policy and Management, Harvard School of Public Health (J.P.N.) - all in Boston; and the Harvard Kennedy School and the National Bureau of Economic Research - both in Cambridge, MA (J.P.N.)
| | | | | | | |
Collapse
|
36
|
Abstract
CONTEXT Medicare Part C, or Medicare Advantage (MA), now almost 30 years old, has generally been viewed as a policy disappointment. Enrollment has vacillated but has never come close to the penetration of managed care plans in the commercial insurance market or in Medicaid, and because of payment policy decisions and selection, the MA program is viewed as having added to cost rather than saving funds for the Medicare program. Recent changes in Medicare policy, including improved risk adjustment, however, may have changed this picture. METHODS This article summarizes findings from our group's work evaluating MA's recent performance and investigating payment options for improving its performance even more. We studied the behavior of both beneficiaries and plans, as well as the effects of Medicare policy. FINDINGS Beneficiaries make "mistakes" in their choice of MA plan options that can be explained by behavioral economics. Few beneficiaries make an active choice after they enroll in Medicare. The high prevalence of "zero-premium" plans signals inefficiency in plan design and in the market's functioning. That is, Medicare premium policies interfere with economically efficient choices. The adverse selection problem, in which healthier, lower-cost beneficiaries tend to join MA, appears much diminished. The available measures, while limited, suggest that, on average, MA plans offer care of equal or higher quality and for less cost than traditional Medicare (TM). In counties, greater MA penetration appears to improve TM's performance. CONCLUSIONS Medicare policies regarding lock-in provisions and risk adjustment that were adopted in the mid-2000s have mitigated the adverse selection problem previously plaguing MA. On average, MA plans appear to offer higher value than TM, and positive spillovers from MA into TM imply that reimbursement should not necessarily be neutral. Policy changes in Medicare that reform the way that beneficiaries are charged for MA plan membership are warranted to move more beneficiaries into MA.
Collapse
Affiliation(s)
- Joseph P Newhouse
- Harvard Medical School; Harvard School of Public Health; Harvard University, John F. Kennedy School of Government; National Bureau of Economic Research
| | | |
Collapse
|