Managed care and the diffusion of endoscopy in fee-for-service Medicare

Healthcare Disparities Among Homeless Patients Hospitalized With Gastrointestinal Bleeding: A Propensity-Matched, State-Level Analysis

GOALS

Examine outcomes among homeless patients admitted with gastrointestinal (GI) bleeding, including all-cause mortality and endoscopic intervention rates.

BACKGROUND

Hospitalizations among homeless individuals have increased steadily since at least 2007 but little is known about GI outcomes in these patients.

STUDY

The 2010-2014 Healthcare Utilization Project (HCUP) State Inpatient Databases from New York and Florida were used to identify adults admitted with a primary diagnosis of acute upper or lower GI bleed. Homeless patients were 1:3 matched with nonhomeless patients using a propensity-score greedy-matched algorithm. The primary outcome (all-cause in-hospital mortality) and secondary outcomes (30-day readmission rates, endoscopy utilization, length of stay, and total hospitalization costs) were compared.

RESULTS

We matched 4074 homeless patients with 12,222 nonhomeless patients. Most hospitalizations for homeless individuals were concentrated in 113 (26.4%) of 428 hospitals. Homeless adults were more likely to be younger, male, African American or Hispanic, and on Medicaid. They experienced significantly higher odds of all-cause inpatient mortality compared with nonhomeless patients admitted with GI bleeding (OR 1.37, 95% CI 1.11-1.69). Endoscopy utilization rates were also lower for both upper (OR 0.62, 95% CI 0.55-0.71) and lower (OR 0.76, 95% CI 0.68-0.85) GI bleeding, though upper endoscopy rates within the first 24 hours were comparable (OR 1.11, 95% CI 1.00-1.23). Total hospitalization costs were lower ($9,715 vs. $12,173, P <0.001) while 30-day all-cause readmission rates were significantly higher in the homeless group (14.9% vs. 18.4%, P <0.001).

CONCLUSIONS

Homeless patients hospitalized for GI bleeding face disparities, including higher mortality rates and lower endoscopy utilization.

What Happened to Disparities in CRC Screening Among FFS Medicare Enrollees Following Medicare Modernization?

The Medicare Modernization Act of 2003, implemented in 2006, increased managed care options for seniors. It introduced insurance plans for prescription drug coverage for all Medicare beneficiaries, whether they were enrolled in FFS or managed care (Medicare Advantage) plans. The availability of drug coverage beginning in 2006 served to free up budgets for FFS Medicare enrollees that could be used to make copayments for colorectal cancer (CRC) screening using endoscopy (colonoscopy or sigmoidoscopy). In 2007, Medicare eliminated the copayments required by seniors for CRC screening by endoscopy. Later in 2008, CRC screening by colonoscopy became part of the gold standard for CRC screening. This legitimized its use and offered even further encouragement to seniors, who may have been reluctant to undergo the procedure because of the non-pecuniary risks associated with it. In addition, 37 CRC screening interventions occurred during this timeframe to enhance compliance with screening standards. Using multilevel analysis of individuals' endoscopy utilization, derived from 100% FFS Medicare claims, along with county-level market and contextual factors, we compare the periods before and after the MMA (2001-2005 to 2006-2009) to determine whether disparities in the utilization of endoscopic CRC screening occurred or changed over the decade. We examined Blacks, Asians, and Hispanics relative to Whites, and Females relative to Males (with race or ethnicity combined). We examined each state separately for evidence of disparities within states, to avoid confounding by geographic disparities. We expected that the net effect of the policy changes and the targeted interventions over the decade would be to increase CRC screening by endoscopy, reducing disparities. We saw improvements over time (reduced disparities relative to Whites) for Blacks and Hispanics residing in several states, and improvements over time for Females relative to Males in many states. For the vast majority of states, however, disparities persisted with Whites and Males exhibiting greater rates of utilization than other groups. States that undertook the interventions were more likely to have had improvements in disparities or positive disparities for women and minorities. While some gains were made over this time period, the gains were unevenly distributed across the USA and more work needs to be done to reduce remaining disparities.

Medicare modernization and diffusion of endoscopy in FFS medicare

OBJECTIVE

To examine how FFS Medicare utilization of endoscopy procedures for colorectal cancer (CRC) screening changed after implementation of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) in 2006, which provided subsidized drug coverage and expanded the geographic availability of Medicare managed care plans across the US.

DATA SOURCES/STUDY SETTING

Using secondary data from 100% FFS Medicare enrollees, we analyzed endoscopy utilization during two intervals, 2001-2005 and 2006-2009.

STUDY DESIGN

We examined change in predictors of county-level endoscopy utilization rates based on a conceptual model of market supply and demand with spillovers from managed care practices. The equations for each period were estimated jointly in a spatial lag regression model that properly accounts for both place and time effects, allowing robust assessment of changes over time.

DATA COLLECTION/EXTRACTION METHODS

All Medicare FFS enrollees with both Parts A and B coverage who were age 65+, remained alive and living in the same state over the interval were included in the analyses. The later interval used a new cohort defined the same as the earlier interval. 100% Medicare denominator files were also used, providing county of address to use for county-level aggregation. The outcome variable was defined as county-level proportion of enrollees who ever used endoscopy over the interval.

PRINCIPAL FINDINGS

Endoscopy utilization by FFS Medicare increased, and became more accessible across the US. Medicare managed care plan spillovers onto FFS Medicare endoscopy utilization changed over time from a significant negative (restraining) effect in the early period to no significant effect by the later period.

CONCLUSIONS

The MMA eased budget constraints for seniors, making endoscopic CRC screening more affordable. The MMA policies also strengthened managed care business prospects, and enrollments in Medicare managed care escalated. The change in managed care spillover effects reflects the gradual acceptance of endoscopic CRC screening procedures, as they emerged as the gold standard during the period.

United States Health Policies and Late-stage Breast and colorectal cancer diagnosis: Why such disparities by age?

BACKGROUND

Colorectal and breast cancers are the second most common causes of cancer deaths in the US. Population cancer screening rates are suboptimal and many cancers are diagnosed at an advanced stage, which results in increased morbidity and mortality. Younger populations are more likely to be diagnosed at a later stage, and this age disparity is not well understood. We examine the associations between late-stage breast cancer (BC) and colorectal cancer (CRC) diagnoses and multilevel factors, focusing on individual state regulations of insurance and health practitioners, and interactions between such policies and age. We expect state-level regulations are significant predictors of the rates of late-stage diagnosis among younger adults.

METHODS

We included adults of all ages, with BC or CRC diagnosed between 2004 -2009, obtained from a newly available cancer population database covering 98 % of all known new cancer cases. We included personal characteristics, linked with a set of county and state-level predictors based on residence. We applied multilevel models to robustly examine differences in risk of late-stage cancer diagnosis across age groups (defined as age 65+ or < 65), focusing specifically on the effects of state regulatory factors and their interactions with age.

RESULTS

Late stage BC diagnoses range from 24 %-36 %, while CRC diagnoses range from 54 %-60 % of newly diagnosed BC or CRC cases across states. After controlling statistically for many confounding factors at three levels, age < 65 is the largest person-level predictor for CRC, while black race is the largest predictor for BC. State regulations of health markets exhibit significant interactions with age groups.

CONCLUSIONS

The state regulatory climate is an important predictor of late-stage BC and CRC diagnoses, especially among people younger than Medicare eligible age (65). State regulations can enhance the climate of access for younger, less well-insured or uninsured persons who fall outside normative screening guidelines.

Geographic and Demographic Disparities in Late-stage Breast and Colorectal Cancer Diagnoses Across the US

PROBLEM

In 2009, breast cancer was the most common cancer in women, and colorectal cancer was the third most common cancer in both men and women. Currently, the majority of colorectal and almost 1/3 of breast cancers are diagnosed at an advanced stage in the US, which results in higher morbidity and mortality than would obtain with earlier detection. The incidence of late-stage cancer diagnoses varies considerably across the US, and few analyses have examined the entire US.

PURPOSE

Using the newly available US Cancer Statistics database representing 98% of the US population, we perform multilevel analysis of the incidence of late-stage cancer diagnoses and translate the findings via bivariate mapping, answering questions related to both Why and Where demographic and geographic disparities in these diagnoses are observed.

METHODS

To answer questions related to Why disparities are observed, we utilize a three-level, random-intercepts model including person-, local area-, and region- specific levels of influence. To answer questions related to Where disparities are observed, we generate county level robust predictions of late-stage cancer diagnosis rates and map them, contrasting counties ranked in the upper and lower quantiles of all county predicted rates. Bivariate maps are used to spatially translate the geographic variation among US counties in the distribution of both BC and CRC late-stage diagnoses.

CONCLUSIONS

Empirical modeling results show demographic disparities, while the spatial translation of empirical results shows geographic disparities that may be quite useful for state cancer control planning. Late stage BC and CRC diagnosis rates are not spatially random, manifesting as place-specific patterns that compare counties in individual states to counties across all states. Providing a relative comparison that enables assessment of how results in one state compare with others, this paper is to be disseminated to all state cancer control and central cancer registry program officials.

Macro-level factors impacting geographic disparities in cancer screening

OBJECTIVES

Examine how differences in state regulatory environments predict geographic disparities in the utilization of cancer screening.

DATA SOURCES/SETTING

100% Medicare fee-for-service population data from 2001-2005 was developed as multi-year breast (BC) and colorectal cancer (CRC) screening utilization rates in each county in the US.

STUDY DESIGN

A comprehensive set of supply and demand predictors are used in a multilevel model of county-level cancer screening utilization in the context of state regulatory markets. States dictate insurance mandates/regulations and whether alternative providers (nurse practitioners) can provide preventive care services supplied by MDs. Controlling statistically for the supply of both types of providers, we study the joint effects of two private insurance regulations: one mandating that insureds with serious or chronic health conditions may receive continuity of care from their established physician(s) after changing health insurance plans, and another mandating that external grievance review is an option for all health plan coverage/denial decisions. These private insurance plan regulations are expected to affect the degree of beneficial spillovers from managed care practices, which may have increased area-wide cancer screening rates.

PRINCIPAL FINDINGS

The two private insurance regulations under study were significant predictors impacted by local market conditions. Managed care spillovers in local markets were significantly associated with higher BC screening rates, but only in states lacking the two forms of regulation under study. Spillovers were significantly associated with higher CRC cancer screening rates everywhere, but much higher in the unregulated states. Area poverty dampened screening rates, but less so for CRC screening in the states with these regulations.

CONCLUSIONS

Two state insurance regulations that empowered consumers with more autonomy to make informed utilization decisions varied across states, and exhibited significant associations with screening rates, which varied with the degree of managed care penetration or poverty in the state's counties. Beneficial spillover effects from managed care practices and negative influences from area poverty are not uniform across the United States. Both variables had stronger associations with CRC than BC screening utilization, as did state regulatory variables. CRC screening by endoscopy was more subject to market and regulatory factors than BC screening.

Breast cancer screening, area deprivation, and later-stage breast cancer in Appalachia: does geography matter?

OBJECTIVE

To model the relationship of an area-based measure of a breast cancer screening and geographic area deprivation on the incidence of later stage breast cancer (LSBC) across a diverse region of Appalachia.

DATA SOURCE

Central cancer registry data (2006-2008) from three Appalachian states were linked to Medicare claims and census data.

STUDY DESIGN

Exploratory spatial analysis preceded the statistical model based on negative binomial regression to model predictors and effect modification by geographic subregions.

PRINCIPAL FINDINGS

Exploratory spatial analysis revealed geographically varying effects of area deprivation and screening on LSBC. In the negative binomial regression model, predictors of LSBC included receipt of screening, area deprivation, supply of mammography centers, and female population aged>75 years. The most deprived counties had a 3.31 times greater rate of LSBC compared to the least deprived. Effect of screening on LSBC was significantly stronger in northern Appalachia than elsewhere in the study region, found mostly for high-population counties.

CONCLUSIONS

Breast cancer screening and area deprivation are strongly associated with disparity in LBSC in Appalachia. The presence of geographically varying predictors of later stage tumors in Appalachia suggests the importance of place-based health care access and risk.

Spatial Sufficiency of 5% Medicare Standard Analytic Files

The 5% Medicare Standard Analytic Files (SAF) are random samples used to analyze national trends in medical treatments, expenditures, and outcomes. Their utility in small-area or multilevel analyses is unknown. To demonstrate possible limitations of the 5% SAF for analysis of health behaviors in small areas. We use descriptive Chi-square goodness-of-fit tests and mapping to explore consistency in the 5% representation of the 100% population in states and counties. We conduct multilevel modeling of individual utilization of mammography or endoscopy services for cancer screening and contrast findings across the 5% and 100% files. Subjects are enrolled in both parts A and B Medicare coverage and ages 65-104, alive and residing in the same state, with no gaps in coverage during the study period. Identically defined groups are drawn from the 5% SAF and 100% population claims and denominator files. The Chi-square tests of homogeneous population subgroups in 5% and 100% files exhibit significant differences in 7 of 8 states. Maps confirm this among states' counties and find that one state is generally under-represented by the 5% SAF, while others show areas with variable representation. Multilevel modeling results are largely consistent across the partitions of the data, but 5% sample models have much lower statistical power. Area-level covariate effect estimates show some differences across the two datasets. Multilevel modeling with contextual variables may be misleading in small area analyses conducted using 5% Medicare SAFs. Provider supply and market characteristics show inconsistent results. Disparities research may benefit from 100% files to provide statistical power needed to detect meaningful differences. This is significant because the Centers for Medicare and Medicaid Services have recently curtailed permissions to use the 100% files. These 100% files are one of few sources of population data available in the U.S. that are representative of small areas in the U.S.. In times of constrained budgets, using population data files is essential so that resources can be targeted to areas robustly identified as having greatest need or gaps in outcomes.

Geographic disparities in late-stage cancer diagnosis: multilevel factors and spatial interactions

In 2009 in the United States, breast cancer was the most common cancer in women, and colorectal cancer was the third most common cancer in both men and women. Currently, over 40% of these cancers are diagnosed at an advanced stage, which results in higher morbidity and mortality than would obtain with optimal cancer screening utilization. To provide information that might improve these cancer outcomes we use spatial analysis to answer questions related to both Why and Where disparities in late-stage cancer diagnoses are observed. In examining Why, we include state level characteristics reflecting characteristics of states' cancer control planning, insurance markets and managed care environments to help model the spatial heterogeneity from place to place. To answer questions related to Where disparities are observed, we generate county level predictions of late-stage cancer rates from a random-intercept multilevel model estimated on the population data from 11 pooled SEER Registries. The findings allow for comparisons across states that reveal logical starting points for a national effort to control cancer.