Differences in Health Care Utilization, Process of Diabetes Care, Care Satisfaction, and Health Status in Patients With Diabetes in Medicare Advantage Versus Traditional Medicare

Evaluation of Low-Value Services Across Major Medicare Advantage Insurers and Traditional Medicare

Importance

Compared with traditional Medicare (TM), Medicare Advantage (MA) insurers have greater financial incentives to reduce the delivery of low-value services (LVS); however, there is limited evidence at a national level on the prevalence of LVS utilization among MA vs TM beneficiaries and whether LVS utilization rates vary among the largest MA insurers.

Objective

To determine whether there are differences in the rates of LVS delivered to Medicare beneficiaries enrolled in MA vs TM, overall and by the 7 largest MA insurers.

Design, Setting, and Participants

This cross-sectional study included Medicare beneficiaries aged 65 years and older residing in the US in 2018 with complete demographic information. Eligible TM beneficiaries were enrolled in Parts A, B, and D, and eligible MA beneficiaries were enrolled in Part C with Part D coverage. Data analysis was conducted between February 2022 and August 2024.

Exposures

Medicare plan type.

Main Outcomes and Measures

The primary outcome was utlization of 35 LVS defined by the Milliman Health Waste Calculator. An overdispersed Poisson regression model was used to calculate estimated margins comparing risk-adjusted rates of LVS in TM vs MA, overall and across the 7 largest MA insurers.

Results

The study sample included 3 671 364 unique TM beneficiaries (mean [SD] age, 75.7 [7.7] years; 1 502 631 female [40.9%]) and 2 299 618 unique MA beneficiaries (mean [SD] age, 75.3 [7.3] years; 983 592 female [42.8%]). LVS utilization was lower among those enrolled in MA compared with TM (50.02 vs 52.48 services per 100 beneficiary-years; adjusted absolute difference, -2.46 services per 100 beneficiary-years; 95% CI, -3.16 to -1.75 services per 100 beneficiary-years; P < .001). Within MA, LVS utilization was lower among beneficiaries enrolled in HMOs vs PPOs (48.03 vs 52.66 services per 100 beneficiary-years; adjusted absolute difference, -4.63 services per 100 beneficiary-years; 95% CI, -5.53 to -3.74 services per 100 beneficiary-years; P < .001). While MA beneficiaries enrolled in UnitedHealth, Humana, Centene, and smaller MA insurers had lower rates of LVS compared with those in TM, beneficiaries enrolled in CVS, Cigna, and Anthem showed no differences. Blue Cross Blue Shield Association plans had higher rates of LVS compared with TM.

Conclusions and Relevance

In this cross-sectional study of nearly 6 million Medicare beneficiaries, utilization of LVS was on average lower among MA beneficiaries compared with TM beneficiaries, possibly owing to stronger financial incentives in MA to reduce LVS; however, meaningful differences existed across some of the largest MA insurers, suggesting that MA insurers may have variable ability to influence LVS reduction.

Utilization of Diabetes Self-Management Education and Support Among Medicare Beneficiaries Newly Diagnosed With Diabetes in Arkansas, 12 Months Postdiagnosis (2015-2018)

PURPOSE

The purpose of the study was to determine the rate of diabetes self-management education and support (DSMES) utilization among Medicare fee-for-service (FFS) and Medicare Advantage (MA) populations with type 2 diabetes in Arkansas.

METHODS

The Arkansas All-Payer Claims Database was used to identify Medicare FFS and MA beneficiaries diagnosed with type 2 diabetes from 2015 to 2018. Claims from 2013 to 2020 were analyzed to determine newly diagnosed individuals from 2015 to 2018. The criteria included 1 outpatient diabetes claim in the index year and at least 1 inpatient or outpatient claim in the 2 years following the initial claim. A total of 15 648 Medicare FFS individuals and 7520 MA individuals with newly diagnosed type 2 diabetes were identified. The use of DSMES 1 year following the diagnosis dates for both Medicare FFS and MA populations was assessed. Descriptive statistics and multiple logistic regression analyses were conducted to understand the factors associated with DSMES utilization.

RESULTS

DSMES utilization consistently remained lower in the MA population compared to Medicare FFS (2.3% vs 4.9%). The adjusted analysis indicated that factors such as older age, living in a rural area, belonging to a racial group other than White, and MA enrollment were associated with a lower likelihood of receiving DSMES.

CONCLUSIONS

DSMES utilization in Arkansas, where the prevalence of diabetes is higher than the national average, is notably low. There is a need for coordinated efforts at various levels to enhance access to DSMES.

Health Care Spending, Use, and Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With Mental Health Symptoms

OBJECTIVE

We examined the differences in health care spending and utilization, and financial hardship between Traditional Medicare (TM) and Medicare Advantage (MA) enrollees with mental health symptoms.

DESIGN

Cross-sectional study.

PARTICIPANTS

We identified Medicare beneficiaries with mental health symptoms using the Patient Health Questionnaire-2 and the Kessler-6 Psychological Distress Scale in the 2015-2021 Medical Expenditure Panel Survey.

MEASUREMENTS

Outcomes included health care spending and utilization (both general and mental health services), and financial hardship. The primary independent variable was MA enrollment.

RESULTS

MA enrollees with mental health symptoms were 2.3 percentage points (95% CI: -3.4, -1.2; relative difference: 16.1%) less likely to have specialty mental health visits than TM enrollees with mental health symptoms. There were no significant differences in total health care spending, but annual out-of-pocket spending was $292 (95% CI: 152-432; 18.2%) higher among MA enrollees with mental health symptoms than TM enrollees with mental health symptoms. Additionally, MA enrollees with mental health symptoms were 5.0 (95% CI: 2.9-7.2; 22.3%) and 2.5 percentage points (95% CI: 0.8-4.2; 20.9%) more likely to have difficulty paying medical bills over time and to experience high financial burden than TM enrollees with mental health symptoms.

CONCLUSION

Our findings suggest that MA enrollees with mental health symptoms were more likely to experience limited access to mental health services and high financial hardship compared to TM enrollees with mental health symptoms. There is a need to develop policies aimed at improving access to mental health services while reducing financial burden for MA enrollees.

Comparison of Financial Hardship and Healthcare Utilizations Associated with Cancer in the United States Medicare Programs during the COVID-19 Pandemic

BACKGROUND

In the United States, Medicare beneficiaries diagnosed with cancer often face significant financial challenges due to the expensive nature of cancer treatments and increased cost-sharing responsibilities. However, there is limited knowledge regarding the financial hardships and healthcare utilizations faced by those enrolled in Medicare Advantage (MA) compared to those in traditional fee-for-service Medicare (TM) during the COVID-19 pandemic. Our study aims to investigate the subjective financial hardships experienced by individuals enrolled in TM and MA and to determine whether these two Medicare programs exhibit differences in healthcare utilization during the pandemic.

METHODS

We utilized data from the 2020-2022 National Health Interview Survey (NHIS), focusing on nationally representative samples of cancer survivors aged 65 or older. Financial hardship was categorized into three distinct groups: material (e.g., problems with medical bills), psychological (e.g., worry about paying), and behavioral (e.g., delayed care due to cost). Healthcare utilization included wellness visits (preventive care), emergency care services, hospitalizations, and telehealth. We used survey design-adjusted analysis to compare the study outcomes between MA and TM.

RESULTS

Among a weighted sample of 4.4 million Medicare beneficiaries with cancer (mean age: 74.9), 76% were enrolled in MA plans. Cancer survivors with a college degree (59.3% vs. 49.8%) and high family income (38.2% vs. 31.1%) were more likely to enroll in MA plans. There were no significant differences in any material, psychological, or behavioral financial hardship domains between beneficiaries with MA and TM plans except forgone counseling due to cost. For healthcare utilization measures, cancer survivors in MA were more likely than those in TM to have flu vaccination (77.2% vs. 70.1%) and experience lower hospitalizations (16.0% vs. 20.0%). However, there were no differences in other health service utilizations between MA and TM.

CONCLUSION

While no significant differences were observed in any materialized, psychological, or behavioral financial hardships, older cancer survivors enrolled in MA plans were more likely to receive vaccinations and lower hospitalization rates during COVID-19. Although other preventive or primary care visits (i.e., wellness visits) were higher, their difference did not reach statistical significance. As MA grows in popularity, it is essential to consistently monitor and evaluate the performance and outcomes of Medicare plans for cancer survivors as we navigate the post-pandemic landscape.

Effects of Medicare Advantage on preventive care use and health behavior

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on preventive care use and health behavior.

DATA SOURCES

The Medicare Current Beneficiary Survey, the Area Health Resources File, the Geographic Variation Public Use File, and the Centers for Medicare and Medicaid Services annual risk and ratebook files for 2012-2016.

STUDY DESIGN

Outcomes included 11 measures of preventive care use and six measures of health behavior. My primary independent variable was MA enrollment. For each outcome, I first conducted linear regression analysis while adjusting for individual-level and county-level characteristics. Then, I conducted the following alternative analyses to account for differences in observed and/or unobserved characteristics between MA and traditional Medicare (TM) enrollees: propensity score (PS) matching analysis and instrumental variable (IV) analysis.

DATA COLLECTION/EXTRACTION METHODS

I extracted 9399 MA enrollees and 15,543 TM enrollees.

FINDINGS

Linear regression and PS matching analyses showed that MA enrollment was statistically significantly associated with higher likelihood of having blood pressure measurement, cholesterol measurement, and influenza vaccine, lower likelihood of receiving an HbA1C test, and higher likelihood of currently smoking. However, the magnitude of the associations was small. There were no statistically significant associations in other measures. IV analyses also found no or limited evidence that MA enrollment led to statistically significant changes in preventive care use and health behavior. Specifically, MA enrollment led to statistically significant improvements in the likelihood of doing any physical activities (1.29 [95% CI: 0.51-2.07]) or doing muscle-strengthening activities (0.72 [95% CI: 0.03-1.41]). No statistically significant changes were observed in other measures.

CONCLUSIONS

MA plans may not necessarily increase the use of preventive services and improve health behaviors. As improvements in preventive services and health behavior may have the potential to achieve better outcomes while lowering costs, policy makers should consider developing targeted interventions for MA to achieve those improvements.

Comparison of Health Care Utilization by Medicare Advantage and Traditional Medicare Beneficiaries With Complex Care Needs

Importance

Medicare beneficiaries with co-occurring chronic conditions and complex care needs experience high rates of acute care utilization and poor outcomes. These patterns are well described among traditional Medicare (TM) beneficiaries, but less is known about outcomes among Medicare Advantage (MA) beneficiaries. Compared with TM, MA plans have additional levers to potentially address beneficiary needs, such as network design, care management, supplemental benefits, and value-based contracting.

Objective

To compare health care utilization for MA and TM beneficiaries with complex care needs.

Design, Setting, and Participants

This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. Beneficiaries were segmented into the following cohorts: frail elderly, major complex chronic, and minor complex chronic. Regression models estimated the association between MA enrollment and health care utilization in 2018, using inverse probability of treatment weighting to balance the MA and TM cohorts on observable characteristics. The study period was January 1, 2017, through December 31, 2018. All analyses were conducted from December 2020 to August 2022.

Exposures

Enrollment in MA vs TM.

Main Outcomes and Measures

Hospital stays (inpatient admissions and observation stays), emergency department (ED) visits, and 30-day readmissions.

Results

Among a study population of 1 844 326 Medicare beneficiaries (mean [SD] age, 75.6 [7.1] years; 1 021 479 [55.4%] women; 1 524 458 [82.7%] White; 223 377 [12.1%] with Medicare-Medicaid dual eligibility), 1 177 896 (63.9%) were enrolled in MA and 666 430 (36.1%) in TM. Beneficiary distribution across cohorts was as follows: frail elderly, 116 047 with MA (10.0% of the MA sample) and 104 036 with TM (15.6% of the TM sample); major complex chronic, 320 954 (27.2%) and 158 811 (23.8%), respectively; and minor complex chronic, 740 895 (62.9%) and 403 583 (60.6%), respectively. Beneficiaries enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions. The largest relative differences were observed for hospital stays, which ranged from -9.3% (95% CI, -10.9% to -7.7%) for the frail elderly cohort to -11.9% (95% CI, -13.2% to -10.7%) for the major complex chronic cohort.

Conclusions and Relevance

In this cross-sectional study of Medicare beneficiaries with complex care needs, those enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions than similar beneficiaries enrolled in TM, suggesting that managed care activities in MA may influence the nature and quality of care provided to these beneficiaries.

Effect of Medicare Advantage on health care use and care dissatisfaction in mental illness

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on health care use and dissatisfaction with care received among Medicare beneficiaries with mental illness.

DATA SOURCES

I identified traditional Medicare (TM) and MA beneficiaries with mental illness using the Medicare Current Beneficiary Survey for 2012-2016.

STUDY DESIGN

I included two types of outcomes: four measures of health care use and 10 measures of care dissatisfaction. My primary independent variable was enrollment in TM versus MA. To address selective enrollment into MA, I used an instrumental variable (IV) approach. Following prior research, I decomposed the MA benchmark into exogenous and endogenous components and then used the exogenous component as my instrument.

DATA COLLECTION/EXTRACTION METHODS

Not Applicable.

PRINCIPAL FINDINGS

IV analyses showed that compared with TM enrollment, MA enrollment significantly decreased outpatient hospital visits and medical provider visits by 6.73 (95% CI: -12.10 to -1.36) and 36.48 (95% CI: -52.67 to -20.28). However, there were no significant changes in inpatient hospital admissions and prescription drug purchases. Compared with TM enrollment, MA enrollment significantly increased dissatisfaction with out-of-pocket expenses by 25.51 percentage points (95% CI: 0.43 to 50.60). However, there were no significant changes in other measures of care dissatisfaction in terms of access to care, quality of care, and prescription medication.

CONCLUSIONS

These findings suggest that MA enrollment may lead to low health care use among those with mental illness, indicating efficient care delivery. Also, MA enrollment may not preclude those with mental illness from accessing needed care. However, high dissatisfaction with out-of-pocket expenses among MA beneficiaries may imply the use of out-of-network providers. Further research is warranted to investigate whether high dissatisfaction with out-of-pocket expenses may be attributable to MA's narrow networks for mental services.

Effects of Medicare advantage on patterns of end-of-life care among Medicare decedents

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on patterns of end-of-life care.

DATA SOURCES

We used data from the Master Beneficiary Summary File, the Medicare Provider Analysis and Review, hospice claims, the Minimum Data Set, the Outcome and Assessment Information Set, the Area Health Resources File, and Geographic Variation Public Use File for 2012-2014.

STUDY DESIGN

To address selective enrollment into MA, we exploited a discontinuity in payment rates by county population (urban floor payments) as an instrument.

DATA COLLECTION/EXTRACTION METHODS

We identified Medicare beneficiaries continuously enrolled in MA or TM during their last year of life between 2012 and 2014 using Medicare administrative data.

PRINCIPAL FINDINGS

We did not find evidence that MA enrollment led to a change in hospital admissions in the last 30 days of life, but MA enrollment decreased hospital as the site of death by 11.0 (95% CI: -13.9 to -8.1) percentage points. Once hospitalized, however, MA enrollment increased use of intensive care by 6.7 (95% CI: 0.3 to 13.1) percentage points and non-invasive mechanical ventilation by 9.2 (95% CI: 5.5 to 12.9) percentage points. MA enrollment increased hospice use by 6.2 (95% CI: 2.3 to 10.1) percentage points at time of death and 7.7 (95% CI: 3.8 to 11.6) percentage points in the last 30 days of life. Particularly, MA enrollment increased hospice admissions among those who were admitted to the hospital within 30 days prior to hospice admission by 18.8 (95% CI: 13.8 to 23.8) percentage points. However, MA enrollment decreased hospice admissions among those who were admitted to home health within 30 days prior to hospice admission by 18.6 (95% CI: -21.9 to -15.2) percentage points.

CONCLUSIONS

MA plans may improve end-of-life care by reducing hospital death while also improving access to hospice, especially among recently hospitalized persons.

Diabetes Care Among Older Adults Enrolled in Medicare Advantage Versus Traditional Medicare Fee-For-Service Plans: The Diabetes Collaborative Registry

OBJECTIVE

Medicare Advantage (MA), Medicare's managed care program, is quickly expanding, yet little is known about diabetes care quality delivered under MA compared with traditional fee-for-service (FFS) Medicare.

RESEARCH DESIGN AND METHODS

This was a retrospective cohort study of Medicare beneficiaries ≥65 years old enrolled in the Diabetes Collaborative Registry from 2014 to 2019 with type 2 diabetes treated with one or more antihyperglycemic therapies. Quality measures, cardiometabolic risk factor control, and antihyperglycemic prescription patterns were compared between Medicare plan groups, adjusted for sociodemographic and clinical factors.

RESULTS

Among 345,911 Medicare beneficiaries, 229,598 (66%) were enrolled in FFS and 116,313 (34%) in MA plans (for ≥1 month). MA beneficiaries were more likely to receive ACE inhibitors/angiotensin receptor blockers for coronary artery disease, tobacco cessation counseling, and screening for retinopathy, foot care, and kidney disease (adjusted P ≤ 0.001 for all). MA beneficiaries had modestly but significantly higher systolic blood pressure (+0.2 mmHg), LDL cholesterol (+2.6 mg/dL), and HbA1c (+0.1%) (adjusted P < 0.01 for all). MA beneficiaries were independently less likely to receive glucagon-like peptide 1 receptor agonists (6.9% vs. 9.0%; adjusted odds ratio 0.80, 95% CI 0.77-0.84) and sodium-glucose cotransporter 2 inhibitors (5.4% vs. 6.7%; adjusted odds ratio 0.91, 95% CI 0.87-0.95). When integrating Centers for Medicare and Medicaid Services-linked data from 2014 to 2017 and more recent unlinked data from the Diabetes Collaborative Registry through 2019 (total N = 411,465), these therapeutic differences persisted, including among subgroups with established cardiovascular and kidney disease.

CONCLUSIONS

While MA plans enable greater access to preventive care, this may not translate to improved intermediate health outcomes. MA beneficiaries are also less likely to receive newer antihyperglycemic therapies with proven outcome benefits in high-risk individuals. Long-term health outcomes under various Medicare plans requires surveillance.

Medication Use for Obesity-Related Comorbidities After Sleeve Gastrectomy or Gastric Bypass

IMPORTANCE

Sleeve gastrectomy and gastric bypass are the most common bariatric surgical procedures in the world; however, their long-term medication discontinuation and comorbidity resolution remain unclear.

OBJECTIVE

To compare the incidence of medication discontinuation and restart of diabetes, hypertension, and hyperlipidemia medications up to 5 years after sleeve gastrectomy or gastric bypass.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study of adult Medicare beneficiaries who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between January 1, 2012, to December 31, 2018, and had a claim for diabetes, hypertension, or hyperlipidemia medication in the 6 months before surgery with a corresponding diagnosis used instrumental-variable survival analysis to estimate the cumulative incidence of medication discontinuation and restart. Data analyses were performed from February to June 2021.

EXPOSURES

Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

MAIN OUTCOMES AND MEASURES

The primary outcome was discontinuation of diabetes, hypertension, and hyperlipidemia medication for any reason. Among patients who discontinued medication, the adjusted cumulative incidence of restarting medication was calculated up to 5 years after discontinuation.

RESULTS

Of the 95 405 patients included, 71 348 (74.8%) were women and the mean (SD) age was 56.6 (11.8) years. Gastric bypass compared with sleeve gastrectomy was associated with a slightly higher 5-year cumulative incidence of medication discontinuation among 30 588 patients with diabetes medication use and diagnosis at the time of surgery (74.7% [95% CI, 74.6%-74.9%] vs 72.0% [95% CI, 71.8%-72.2%]), 52 081 patients with antihypertensive medication use and diagnosis at the time of surgery (53.3% [95% CI, 53.2%-53.4%] vs 49.4% [95% CI, 49.3%-49.5%]), and 35 055 patients with lipid-lowering medication use and diagnosis at the time of surgery (64.6% [95% CI, 64.5%-64.8%] vs 61.2% [95% CI, 61.1%-61.3%]). Among the subset of patients who discontinued medication, gastric bypass was also associated with a slightly lower incidence of medication restart up to 5 years after discontinuation. Specifically, the 5-year cumulative incidence of medication restart was lower after gastric bypass compared with sleeve gastrectomy among 19 599 patients who discontinued their diabetes medication after surgery (30.4% [95% CI, 30.2%-30.5%] vs 35.6% [95% CI, 35.4%-35.9%]), 21 611 patients who discontinued their antihypertensive medication after surgery (67.2% [95% CI, 66.9%-67.4%] vs 70.6% [95% CI, 70.3%-70.9%]), and 18 546 patients who discontinued their lipid-lowering medication after surgery (46.2% [95% CI, 46.2%-46.3%] vs 52.5% [95% CI, 52.2%-52.7%]).

CONCLUSIONS AND RELEVANCE

Findings of this study suggest that, compared with sleeve gastrectomy, gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart among patients who discontinued medication. Long-term trials are needed to explain the mechanisms and factors associated with differences in medication discontinuation and comorbidity resolution after bariatric surgery.

Comparison of Ambulatory Care Access and Quality for Beneficiaries With Disabilities Covered by Medicare Advantage vs Traditional Medicare Insurance

Question

Do Medicare beneficiaries aged 18 to 64 years with disability entitlement have different rates of enrollment in Medicare Advantage (MA) vs traditional Medicare (TM) compared with other beneficiaries, and how do the 2 programs compare on rates of ambulatory care access and quality for beneficiaries with disabilities?

Findings

In this cohort study of a nationally representative sample of 7201 person-years for Medicare beneficiaries in 2015 through 2018, beneficiaries with disability entitlement were significantly less likely to enroll in MA compared with those without disability entitlement. However, enrollment in MA vs TM was associated with better outcomes on 2 of 3 access measures and 3 of 3 quality measures for beneficiaries with disabilities.

Meaning

Although Medicare beneficiaries with disabilities enrolled in MA at lower rates than other beneficiaries in this study, MA appeared to compare favorably with TM in meeting key ambulatory care access and quality measures for beneficiaries with disabilities.

Importance

Medicare beneficiaries with disabilities aged 18 to 64 years face barriers accessing ambulatory care. Past studies comparing Medicare Advantage (MA) with traditional Medicare (TM) have not assessed how well these programs meet the needs of beneficiaries with disabilities.

Objective

To compare differences in enrollment rates, ambulatory care access, and ambulatory care quality for beneficiaries with disabilities in MA vs TM.

Design, Setting, and Participants

This cohort study included a nationally representative, weighted sample of 7201 person-years for beneficiaries aged 18 to 64 years with disability entitlement in the Medicare Current Beneficiary Survey from 2015 through 2018. Differences in program enrollment and in measures of access and quality by program enrollment were compared after adjusting for demographic, insurance, social, health, and area characteristics and after reweighting the sample by propensity to enroll in MA as estimated by observed confounders. Data analyses were conducted between November 1, 2020, and November 11, 2021.

Exposures

Medicare Advantage vs TM program enrollment.

Main Outcomes and Measures

Six patient-reported measures of ambulatory care access (usual source of care, primary care usual source of care, specialist visit) and quality (cholesterol screening, influenza vaccination, colon cancer screening).

Results

The mean (SD) age of the overall study population was 52.1 (11.0) years; 49.5% were female and 50.5% were male; 1.6% were Asian/Pacific Islander; 17.4%, Black; 10.2% Hispanic; 1.4%, Native American; 65.1%, White, and 4.2%, multiracial. Among all beneficiaries living in the community, individuals with disability entitlement were less likely to enroll in MA than other beneficiaries (34.8% vs 41.2%). The final sample of beneficiaries with disabilities included 2444 person-years in MA and 4757 person-years in TM. Beneficiaries with disabilities in MA vs TM were more likely to be of a minority race or ethnicity (35.7% vs 27.6%) and less likely to be enrolled in private insurance (11.9% vs 25.0%). Comparing MA with TM among beneficiaries with disabilities, those in MA had significantly better rates of access to a usual source of care (90.2% vs 84.9%; adjusted propensity-weighted marginal difference [APWMD], 2.9%; 95% CI, 0.2%-5.7%), access to specialist visits (53.2% vs 44.8%; APWMD, 5.5%; 95% CI, 0.6%-10.5%), cholesterol screenings (91.1% vs 86.4%; APWMD, 3.8%; 95% CI, 0.9%-6.7%), influenza vaccinations (61.4% vs 51.5%; APWMD, 10.4%; 95% CI, 5.3%-15.5%), and colon cancer screenings (68.4% vs 54.6%; APWMD, 10.3%; 95% CI, 4.8%-15.8%).

Conclusions and Relevance

In this cohort study, Medicare beneficiaries with disabilities were enrolled in MA at significantly lower rates than those without disabilities. However, MA was associated with significantly better ambulatory care access and quality for these beneficiaries on 5 of 6 measures compared with TM.

Disparities in Chronic Kidney Disease Progression by Medicare Advantage Enrollees

INTRODUCTION

The prevalence of chronic kidney disease (CKD) in Medicare beneficiaries has quadrupled in the past 2 decades, but little is known about risk factors affecting the progression of CKD. This study aims to understand the progression in Medicare Advantage enrollees and whether it differs by provider recognition of CKD, race and ethnicity, or geographic location. In a large cohort of Medicare Advantage (MA) enrollees, we examined whether CKD progression, up to 5 years after study entry, differed by demographic and clinical factors and identified additional risk factors of CKD progression.

METHODS

In a cohort of 1,002,388 MA enrollees with CKD stages 1-4 based on 2013-2018 labs, progression was estimated using a mixed-effects model that adjusted for demographics, geographic location, comorbidity, urine albumin-to-creatinine ratio, clinical recognition via diagnosed CKD, and time-fixed effects. Race and ethnicity, geographic location, and clinical recognition of CKD were interacted with time in 3 separate regression models.

RESULTS

Mean (median) follow-up was 3.1 (3.0) years. Black and Hispanic MA enrollees had greater kidney function at study entry than other beneficiaries, but their kidney function declined faster. MA enrollees with clinically recognized CKD had estimated glomerular filtration rate levels that were 18.6 units (95% confidence interval [CI]: 18.5-18.7) lower than levels of unrecognized patients, but kidney function declined more slowly in enrollees with clinical recognition. There were no differences in CKD progression by geography. After removal of the race coefficient from the eGFR equation in a sensitivity analysis, kidney function was much lower in all years among Black MA enrollees, but patterns of progression remained the same.

DISCUSSION/CONCLUSIONS

These results suggest that patients with clinically recognized CKD and racial and ethnic minorities merit closer surveillance and management to reduce their risk of faster progression.

The relationship between insurance and health outcomes of diabetes mellitus patients in Maryland: a retrospective archival record study

Background

Past studies examining the health outcomes of diabetes mellitus (DM) patients found that social determinants of health disparities were associated with variabilities in health outcomes. However, improving access to healthcare, such as health insurance, should mitigate negative health outcomes. The aim of the study was to explore the association between four types of health insurance, namely, Medicare Fee-For-Service (FFS), Medicare Managed Care (MC), Private FFS, and Private MC plans, and the health outcomes of DM patients, controlling for patients’ social determinants of health.

Methods

This is a retrospective cross-sectional archival record study to explore the relationships between types of health insurance and health outcomes of DM patients who were at least 65 years old, or the elderly. Data was drawn from the 2012 Maryland Clinical Public Use Data and received an exempt status from our Institutional Review Board. Elderly Maryland residents with chronic DM were included in the study, resulting in a sample size of 43,519 individuals. Predictor variables were four types of insurance and health outcome variables were length of hospital stay (LOS), 30-day readmission, and end-stage renal disease (ESRD). Control variables included hospital characteristics, patient characteristics, and social determinants of health. Student’s t-tests determined the statistical differences for the control variables between the types of insurance. Multiple hierarchical regression analysis was applied to test the association between insurance plans and LOS, while logistic regression analyses were applied to test the association between insurance plans with 30-day readmission and ESRD. Statistical significance was set at p < 0.05.

Results

t-test results indicated minimal statistical differences between the health statuses of patients enrolled in different insurance plans. After factoring out the control variables, regression analyses indicated that Medicare FFS patients had the worst outcome for LOS, 30-day readmission, and ESRD rates. Although patients on Medicare MC plans had lower LOS, 30-day readmission, and ESRD rates compared to those on Medicare FFS, patients enrolled in Private MC plans had the lowest odds of a 30-day readmission and patients enrolled in Private FFS had the lowest odds of an ESRD.

Conclusions

The data suggests that insurance plans were related to the health outcomes of elderly DM patients after considering their social determinants of health. Specifically, DM patients enrolled in managed care and private insurance plans had better health outcomes compared to those on Medicare FFS plans.

Rural Enrollees In Medicare Advantage Have Substantial Rates Of Switching To Traditional Medicare

Medicare beneficiaries in rural areas may face challenges to gaining access to care, particularly if enrolled in Medicare Advantage (MA) plans with limited benefits and restrictive provider networks. These barriers to care may, in turn, increase switching to traditional fee-for-service Medicare among rural MA enrollees. Using 2010-16 Medicare Current Beneficiary Survey data, we found that switching from traditional Medicare to Medicare Advantage was uncommon among enrollees, both rural (1.7 percent) and nonrural (2.2 percent). Switching from Medicare Advantage to traditional Medicare was more common in both settings, especially for rural enrollees (10.5 percent) compared with nonrural enrollees (5.0 percent). The differential was even greater among rural enrollees who were high cost or high need. Of eleven care satisfaction variables we examined, dissatisfaction with care access had the strongest association with switching from Medicare Advantage to traditional Medicare among rural enrollees. Our findings point to the importance of developing policies targeted at improving care access for rural MA enrollees.

Trends in Use of Low-Value Care in Traditional Fee-for-Service Medicare and Medicare Advantage

IMPORTANCE

Decreasing use of low-value care is a major goal for Medicare given the potential to decrease costs and harms. Compared with traditional fee-for-service Medicare (TM), Medicare Advantage (MA) is more strongly financially incentivized to decrease use of low-value care.

OBJECTIVES

To compare use of low-value care among individuals enrolled in TM and those enrolled in MA overall and to examine trends in use of low-value care in both programs from 2006 to 2015.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed individuals enrolled in TM and MA using data from the 2006 to 2015 Medical Expenditure Panel Survey. To account for differences in characteristics between individuals enrolled in TM and those enrolled in MA, a propensity score-based approach was used. Data were analyzed from August 2020 through January 2021.

EXPOSURES

Being enrolled in MA or TM.

MAIN OUTCOMES AND MEASURES

Binary measures of use were collected for 13 low-value services in 4 categories (ie, [1] cancer screening: cervical, colorectal, and prostate cancer screening in older adults; [2] antibiotic use: antibiotic for acute upper respiratory infection and antibiotic for influenza; [3] medication: anxiolytic, sedative, or hypnotic in an adult older than 65 years; benzodiazepine for depression; opioid for headache; opioid for back pain; and nonsteroidal anti-inflammatory drug [NSAID] for hypertension, heart failure, or chronic kidney disease; and [4] imaging: magnetic resonance imaging [MRI] or computed tomography [CT] for back pain, radiograph for back pain, and MRI or CT for headache) and 4 low-value composites corresponding to the categories (ie, cancer screening composite, antibiotic use composite, medication composite, and imaging composite).

RESULTS

Among 11 677 individuals enrolled in TM and 5164 individuals enrolled in MA, 9429 (56.0%) were women and the mean (SD) age was 74.5 (6.3) years. Of 13 low-value services and 4 low-value composites, statistically significant differences were found in 2 measures. For the low-value medication composite, 2054 of 11 636 eligible individuals enrolled in TM (adjusted mean, 17.6%; 95% CI, 16.8%-18.3%) received the care, and 981 of 5141 eligible individuals enrolled in MA (adjusted mean, 19.7%; 95% CI, 18.3%-21.2%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.2 percentage points (95% CI, 0.5-3.8 percentage points; P = .02). For the NSAID use for hypertension, heart failure, or kidney disease metric, 807 of 7832 individuals enrolled in TM (adjusted mean, 10.0%; 95% CI, 9.2%-10.8%) received the care, and 447 of 3566 individuals enrolled in MA (adjusted mean, 12.9%; 95% CI, 19.7%-27.1%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.9 percentage points (95% CI, 1.3-4.6 percentage points; P = .001). Overall, there were no decreases in use of low-value care in TM or MA over time.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that use of low-value care was similarly prevalent in MA and TM, suggesting that MA enrollment was not associated with decreased provision of low-value care compared with TM.