Medicare Advantage Enrollees More Likely To Enter Lower-Quality Nursing Homes Compared To Fee-For-Service Enrollees

Medicare Advantage plan characteristics associated with sorting their beneficiaries to providers that generate fewer avoidable hospital stays

OBJECTIVE

To examine whether certain Medicare Advantage (MA) plan characteristics are associated with driving beneficiaries to providers that generate fewer avoidable hospital stays.

DATA SOURCES

This paper primarily used 2018-2019 MA encounter data and traditional Medicare (TM) claims data for a nationally representative 20% sample of Medicare beneficiaries.

STUDY DESIGN

For each plan design aspect-plan type, carrier, star rating, and network breadth-we estimated two adjusted Poisson regressions of avoidable hospital stays: one without clinician fixed effects and the other with. We calculated the difference between the coefficients to evaluate the extent to which patient sorting affected avoidable hospital stays relative to TM.

DATA EXTRACTION METHODS

Our sample included Medicare beneficiaries 65 years and older who were continuously enrolled in either MA or TM during 2018-2019. Beneficiaries in our sample had one or more chronic, ambulatory care-sensitive conditions.

PRINCIPAL FINDINGS

Patient sorting can be attributed to certain characteristics of plan design aspects. For plan type, HMOs account for 86%, with PPOs accounting for only 14%. For carriers, Humana and smaller carriers account for 89%. For star ratings, high-star contracts account for 94%, with other stars only accounting for 6%. By network design, narrow network plan-counties explained 20% of the patient sorting effect.

CONCLUSIONS

While MA plans were found to be associated with driving beneficiaries to providers that generate fewer avoidable hospital stays, the effect is not homogeneous across the characteristics of MA plans. HMOs and high-star contracts are drivers of this MA phenomenon.

Racial/Ethnic Disparities in Hospital Readmission and Frequent Hospitalizations Among Medicare Beneficiaries With Alzheimer's Disease and Related Dementia: Traditional Medicare Versus Medicare Advantage

OBJECTIVES

Examine racial/ethnic disparities in 30-day readmission and frequent hospitalizations among Medicare beneficiaries with dementia in traditional Medicare (TM) versus Medicare Advantage (MA).

METHODS

In this case-control study, we used 2018-2019 TM and MA claims data. Participants included individuals 65+ with 2 years of continuous enrollment, diagnosis of dementia, a minimum of 4 office visits in 2018, and at least 1 hospitalization in 2019, (cases: TM [n = 36,656]; controls: MA [n = 29,366]). We conducted matching based on health-need variables and applied generalized linear models adjusting for demographics, health-related variables, and healthcare encounters.

RESULTS

TM was associated with higher odds of 30-day readmission (OR = 1.07 [CI: 1.02 to 1.12]) and frequent hospitalizations (OR = 1.10 [CI: 1.06 to 1.14]) compared to MA. Hispanic and Black enrollees in TM had higher odds of frequent hospitalizations compared with Hispanic and Black enrollees in MA, respectively (OR = 1.35 [CI: 1.19 to 1.54]) and (OR = 1.26 [CI: 1.13 to 1.40]). MA was associated with lower Hispanic-White and Black-White disparities in frequent hospitalizations by 5.8 (CI: -0.09 to -0.03) and 4.4 percentage points (PP; CI: -0.07 to -0.02), respectively. For 30-day readmission, there was no significant difference between Black enrollees in TM and MA (OR = 1.04 [CI: 0.92 to 1.18]), but Hispanic enrollees in TM had higher odds of readmission than Hispanics in MA (OR = 1.23 [CI: 1.06 to 1.43]). MA was associated with a lower Hispanic-White disparity in readmission by 1.9 PP (CI: -0.004 to -0.01).

DISCUSSION

MA versus TM was associated with lower risks of 30-day readmission and frequent hospitalizations. Moreover, MA substantially reduced Hispanic-White and Black-White disparities in frequent hospitalizations compared with TM.

Medicare Advantage enrollment and outcomes of post-acute nursing home care among patients with dementia

Enrollment in Medicare Advantage (MA) has been rapidly growing. We examined whether MA enrollment affects the outcomes of post-acute nursing home care among patients with Alzheimer's disease and related dementias (ADRD). We exploited year-to-year changes in MA penetration rates within counties from 2012 through 2019. After adjusting for patient-level characteristics and county fixed effects, we found that MA enrollment was not associated with days spent at home, nursing home days, likelihood of becoming a long-stay resident, hospital days, hospital readmission, or 1-year mortality. There was a modest increase in successful discharge to the community by 0.73 percentage points (relative increase of 2.4%) associated with a 10-percentage-point increase in MA enrollment. The results are consistent among racial/ethnic subgroups and dual-eligible patients. These findings suggest an imperative need to monitor and improve quality of managed care among enrollees with ADRD.

Medicare Advantage and Home Health Care: A Systematic Review

OBJECTIVES

Home health care serves millions of Americans who are "Aging in Place," including the rapidly growing population of Medicare Advantage (MA) enrollees. This study systematically reviewed extant evidence illustrating home health care (HHC) services to MA enrollees.

METHODS

A comprehensive literature search was conducted in 6 electronic databases to identify eligible studies, which resulted in 386 articles. Following 2 rounds of screening, 30 eligible articles were identified. Each study was also assessed independently for study quality using a validated quality assessment checklist.

RESULTS

Of the 30 studies, nearly half (n=13) were recently published between January 1, 2017 - January 6, 2022. Among various issues related to HHC to MA enrollees examined, which were often compared with Traditional Medicare (TM) enrollees, the 2 most studied issues were HHC use rate (including access) and care dosage/intensity. Inconsistencies were common in findings across reviewed studies, with slight variations in the level of inconsistency by studied outcomes. Several critical issues, such as heterogeneity of MA plans, influence of MA-specific features, and program response to policy and quality improvement initiatives, were only examined by 1 or 2 studies. The depth and scope of scientific investigation were also limited by the scale and details available in MA data in addition to other methodological limits.

CONCLUSIONS

Wild variations and conflicting findings on HHC to MA beneficiaries exist across studies. More research with rigorous designs and robust MA encounter data is warranted to determine home health care for MA enrollees and the relevant outcomes.

United States' Nursing Home Finances: Spending, Profitability, and Capital Structure

Little is known about nursing home (NH) financial status in the United States even though most NH care is publicly funded. To address this gap, this descriptive study used 2019 Medicare cost reports to examine NH revenues, expenditures, net income, related-party expenses, expense categories, and capital structure. After a cleaning process for all free-standing NHs, a study population of 11,752 NHs was examined. NHs had total net revenues of US$126 billion and a profit of US$730 million (0.58%) in 2019. When US$6.4 billion in disallowed costs and US$3.9 billion in non-cash depreciation expenses were excluded, the profit margin was 8.84 percent. About 77 percent of NHs reported US$11 billion in payments to related-party organizations (9.54% of net revenues). Overall spending for direct care was 66 percent of net revenues, including 27 percent on nursing, in contrast to 34 percent spent on administration, capital, other, and profits. Finally, NHs had long-term debts that outweighed their total available financing. The study shows the value of analyzing cost reports. It indicates the need to ensure greater accuracy and completeness of cost reports, financial transparency, and accountability for government funding, with implications for policy changes to improve rate setting and spending limits.

Achieving Functional Goals During a Skilled Nursing Facility Stay: A National Study of Medicare Beneficiaries

OBJECTIVES

The aims of the study are to describe the frequency that functional goals are documented on the Minimum Data Set and to identify resident characteristics associated with meeting or exceeding discharge goals.

METHODS

We selected Medicare fee-for-service beneficiaries admitted to a skilled nursing facility within 3 days of hospital discharge from October 1, 2018, to December 31, 2019 ( N = 1,228,913). The admission Minimum Data Set was used to describe the discharge goal scores for seven self-care and 16 mobility items. We used the eight self-care and mobility items originally included in a publicly reported quality measure to calculate total scores for discharge goals, admission performance, and discharge performance ( n = 371,801).

RESULTS

For all self-care items, more than 70% of residents had a goal score of 1-6 points documented on the admission Minimum Data Set. Chair/bed-to-chair transfer had the highest percentage of residents with a score of 1-6 points (77.1%) and walking up/down 12 steps had the lowest (23.2%). Approximately 44% of residents had a discharge performance score that met or exceeded their goal score. Older age, urinary incontinence, and cognitive impairment had the lowest odds of meeting or exceeding discharge goals.

CONCLUSIONS

Assessing a resident's functional goals is important to providing patient-centered care. This information may help skilled nursing facilities determine whether a resident has made meaningful functional improvements.

Medicare advantage and dialysis facility choice

OBJECTIVE

To compare the characteristics of dialysis facilities used by traditional Medicare (TM) and Medicare advantage (MA) enrollees with end-stage kidney disease (ESKD).

DATA SOURCES

We used 20% TM claims and 100% MA encounter data from 2018 and publicly available data from the Centers for Medicare and Medicaid Services.

STUDY DESIGN

We compared the characteristics of the dialysis facilities treating TM and MA patients in the same ZIP code, adjusting for patient characteristics. The outcome variables were facility ownership, distance to the facility, and several measures of facility quality.

DATA COLLECTION/EXTRACTION

We identified point prevalent dialysis patients as of July 15, 2018.

PRINCIPAL FINDINGS

Compared to TM patients in the same ZIP code, MA patients were 1.84 percentage points more likely to be treated at facilities owned by the largest two dialysis organizations and 1.85 percentage points less likely to be treated at an independently owned facility. MA patients went to further and lower quality facilities than TM patients in the same ZIP code. However, these differences in facility quality were modest. For example, while the mean dialysis facility mortality rate was 21.85, the difference in mortality rates at facilities treating MA and TM patients in the same ZIP code was 0.67 deaths per 100 patient-years. Similarly, MA patients went to facilities that were, on average, 0.15 miles further than TM patients in the same ZIP code.

CONCLUSION

MA enrollees with ESKD were more likely than TM enrollees in the same ZIP code to use the dialysis facilities owned by the two largest chains, travel further for care, and receive care at lower quality facilities. While the magnitude of differences in facility distance and quality was modest, the direction of these results underscores the importance of monitoring dialysis network adequacy as ESKD MA enrollment continues to grow.

Postacute Care Services Use and Outcomes Among Traditional Medicare and Medicare Advantage Beneficiaries

Importance

Better evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes.

Objective

To compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees.

Design, Setting, and Participants

This cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design.

Exposures

Enrollment in MA and dual eligibility for Medicare and Medicaid.

Main Outcomes and Measures

Postacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services.

Results

Included in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility.

Conclusions and relevance

In this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.

Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter?

OBJECTIVE

To examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

The study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017.

METHODS

2010-2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a "choice" set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies.

RESULTS

Among the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01).

CONCLUSIONS AND IMPLICATIONS

Black individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.

Increased Medicare Advantage Penetration Is Associated With Lower Postacute Care Use For Traditional Medicare Patients

Medicare Advantage (MA) plans, which accounted for 45 percent of total Medicare enrollment in 2022, are incentivized to minimize spending on low-value services. Prior research indicates that MA plan enrollment is associated with reduced postacute care use without adverse impacts on patient outcomes. However, it is unclear whether a rising MA enrollment level is associated with a change in postacute care use in traditional Medicare, especially given growing participation in traditional Medicare Alternative Payment Models that have been found to be associated with lower postacute care spending. We hypothesize that market-level MA expansion is associated with reduced postacute care use among traditional Medicare beneficiaries-a "spillover" effect of providers modifying their practice patterns in response to MA plans' incentives. We found increased MA market penetration associated with reduced postacute care use among traditional Medicare beneficiaries, without a corresponding increase in hospital readmissions. This association was generally stronger in markets with a greater share of traditional Medicare beneficiaries attributed to accountable care organizations, suggesting that policy makers should account for MA penetration when evaluating potential savings in Alternative Payment Models within traditional Medicare.

Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare

Importance

Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care-sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges.

Objective

To determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare.

Design, Setting, and Participants

Cross-sectional study of US Medicare Advantage vs traditional Medicare beneficiaries from January 1 to December 31, 2018. Poisson regression models were used to compare risk-adjusted rates of Medicare Advantage vs traditional Medicare, controlling for patient demographic characteristics and clinical risk and including county fixed-effects. Data were analyzed between April 2021 and November 2022.

Main Outcomes and Measures

Hospitalizations, observation stays, and ED direct discharges for ACSCs.

Results

The study sample comprised 2 665 340 Medicare Advantage patients (mean [SD] age, 72.7 [9.8] years; 1 504 519 [56.4%] women; 1 859 067 [69.7%] White individuals) and 7 981 547 traditional Medicare patients (mean [SD] age, 71.2 [11.8] years; 4 232 201 [53.0%] women; 6 176 239 [77.4%] White individuals). Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94; 95% CI, 0.93-0.95), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44; 95% CI, 1.43-1.45) and observation stays (RR, 2.38; 95% CI, 2.34-2.41) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30; 95% CI, 1.30-1.31). Within the Medicare Advantage population, patients in health maintenance organizations (HMOs) were at lower risk of ACSC-related hospitalization compared with patients in its preferred provider organizations (RR, 0.96; 95% CI, 0.95-0.98); however, those in the HMOs had a higher risk of ED direct discharge (RR, 1.08; 95% CI, 1.07-1.09) and observation stay (overall RR, 1.10; 95% CI, 1.02-1.12).

Conclusions and Relevance

The findings of this cross-sectional study of Medicare Advantage and traditional Medicare patients with ACSCs indicate that apparent gains in lowering rates of potentially avoidable acute care have been associated with shifting inpatient care to settings such as ED direct discharges and observation stays.

Comparison of the Pathway to Hospice Enrollment Between Medicare Advantage and Traditional Medicare

Importance

Older adults in Medicare Advantage (MA) enroll in hospice at higher rates than those in traditional Medicare (TM), but it is unclear whether the pathway of care prior to hospice use differs between MA and TM.

Objective

To examine the site of care prior to hospice enrollment for MA beneficiaries compared with those in TM.

Design, Setting, and Participants

This population-based, retrospective cross-sectional study used Medicare claims data for decedents in calendar years 2011, 2013, 2016, and 2018 who enrolled in hospice in the last 90 days of life. Data were analyzed from February 11, 2022, to October 24, 2022.

Exposures

Enrollment in MA or TM in the last month of life.

Main Outcomes and Measures

The main outcome was the site of care prior to hospice enrollment, defined as hospital, nursing home, and home with or without home health, dichotomized as community vs hospital in a logistic regression model. Covariates included decedent demographics, hospice primary diagnosis, and county-level MA penetration. Differences in hospice length of stay between MA beneficiaries and TM beneficiaries were assessed using linear and logistic regression models.

Results

In this study of 3 164 959 decedents, mean (SD) age was 83.1 (8.6) years, 55.8% were female, and 28.8% were enrolled in MA. Decedents in MA were more likely to enroll in hospice from a community setting than were those in TM, although the gap narrowed over time from an unadjusted 11.1% higher rate of community enrollment in MA vs TM in 2011 (50.1% vs 39.0%) to 8.1% in 2018 (46.4% vs 38.3%). In the primary adjusted analysis over the entire study period, MA enrollment was associated with an 8.09-percentage point (95% CI, 7.96-8.21 percentage points) higher rate of hospice enrollment from the community vs all other sites. This association remained in multiple sensitivity analyses to account for potential differences in the populations enrolled in MA vs TM. The mean overall hospice length of stay was 0.29 days (95% CI, 0.24-0.34 days) longer for MA decedents compared with TM decedents.

Conclusions and Relevance

Compared with TM beneficiaries, those in MA were more likely to enroll in hospice from community settings vs following inpatient stays. However, hospice length of stay was not substantially different between MA and TM. Further research is needed to understand how MA plans influence hospice use and the direct association with quality of end-of-life care as reported by older adults and their families.

Comparing the care experiences of Medicare Advantage beneficiaries with and without Alzheimer's disease and related dementias

BACKGROUND

The Medicare Advantage (MA) program is rapidly growing. Limited evidence exists about the care experiences of MA beneficiaries with Alzheimer's Disease and Related Dementia (ADRD). Our objective was to compare care experiences for MA beneficiaries with and without ADRD.

METHODS

We examined MA beneficiaries who completed the Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) and used inpatient, nursing home, or home health services in the past 3 years. We classified beneficiaries with ADRD using the presence of diagnosis codes in hospitals, nursing homes, and home health records. Our key measures included overall ratings of care and health plan, and indices of receiving timely care, care coordination, receiving needed care, and customer service. We compared differences between beneficiaries with and without ADRD using regression analysis adjusting for demographic, health, and plan characteristics, and stratifying by proxy response status.

RESULTS

Among beneficiaries sampled by CAHPS, 22.2% with ADRD completed the survey compared to 38.5% without ADRD. Among proxy responses, beneficiaries with ADRD were 4.2 (95% CI: 0.1-8.4) percentage points less likely to report a high score for receiving needed care, and 3.5 percentage points (95% CI: 0.2-6.9) less likely to report a high score for customer service. Among non-proxy responses, those with ADRD were 9.0 (95% CI: 5.5-12.5) percentage points less likely to report a high score for needed care, and 8.5 (95% CI: 5.4-11.5) percentage points less likely to report a high score for customer service.

CONCLUSIONS

ADRD respondents to the CAHPS were more likely to be excluded from CAHPS performance measures because they did not meet eligibility requirements and rates of non-response were higher. Among responders with or without a proxy, MA enrollees with an ADRD diagnosis reported worse care experiences in receiving needed care and in customer service than those without an ADRD diagnosis.

Variation in influenza vaccine assessment, receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes

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.

Association of Health Insurance Literacy With Enrollment in Traditional Medicare, Medicare Advantage, and Plan Characteristics Within Medicare Advantage

IMPORTANCE

Health insurance literacy helps individuals make informed choices. However, evidence suggests that Medicare beneficiaries experience low health insurance literacy, leading to high-cost or poor-quality coverage choices.

OBJECTIVE

To examine how health insurance literacy was associated with coverage choices between traditional Medicare (TM) and Medicare Advantage (MA), as well as within MA.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included 6627 TM and MA enrollees, using data from the 2015-2016 Medicare Current Beneficiary Survey. Data analyses were conducted between May 1 and June 30, 2021.

EXPOSURES

Three self-reported measures of health insurance literacy (presence of information to make an informed comparison, ease in reviewing and comparing coverage options, and annual review and comparison of coverage options).

MAIN OUTCOMES AND MEASURES

Enrollment in TM vs MA and enrollment in an MA plan with different characteristics (star rating, monthly plan premium, in-network maximum out-of-pocket limit, plan type, and provision of supplemental benefits).

RESULTS

We included 6627 Medicare beneficiaries (3578 women [54.0%]; mean [SD] age, 75.13 [7.12] years). A total of 77 individuals were Asian (1.2%), 696 were Black (10.5%), 488 were Hispanic (7.4%), 5277 were non-Hispanic White (79.6%), and 225 (3.4%) were single races not of Hispanic origin (including American Indian or Alaska Native and Native Hawaiian) or were 2 or more races. Medicare Advantage enrollment was higher among individuals with higher health insurance literacy than those with lower health insurance literacy, especially for those who reviewed or compared coverage options annually than among those who did not (38.0%; 95% CI, 36.0%-40.1% vs 27.8%; 95% CI, 25.8%-29.7%). Among MA beneficiaries, those who reviewed or compared coverage options annually were more likely to enroll in plans with 4 to 4.5 stars and plans with monthly premiums of $1 to $50 by 4.6 percentage points (95% CI, 0.1-9.2 percentage points) and 4.8 percentage points (95% CI, 0.6-9.0 percentage points), respectively. However, enrollment in plans with 5 stars was 3.8 percentage points lower (95% CI, -5.8 to -1.9 percentage points) among individuals who reviewed or compared coverage options annually than among those who did not. Among individuals with low socioeconomic status, the likelihood of reviewing or comparing coverage options annually was lower for those with Medicare and Medicaid dual eligibility than for those without it (odds ratio, 0.79; 95% CI, 0.63-0.99).

CONCLUSIONS AND RELEVANCE

Results of this study suggest that higher health insurance literacy-particularly, annual review and comparison of coverage choices-is associated with higher MA enrollment and choice of a particular MA plan. Policy makers should develop programs to encourage frequent review and comparison of coverage options for informed decision making.

Racial and ethnic differences in the improvement in daily activities during a nursing home stay

BACKGROUND

Improving independence in daily activities is an important outcome of postacute nursing home care. We investigated racial and ethnic differences in the improvement in activities of daily living (ADL) during a skilled nursing facility (SNF) stay among Medicare fee-for-service beneficiaries with a hip fracture, joint replacement, or stroke.

METHODS

This was a retrospective study of Medicare beneficiaries admitted to a SNF between 01/01/2013 and 9/30/2015. The final sample included 428,788 beneficiaries admitted to a SNF within 3 days of hospital discharge for a hip fracture (n = 118,790), joint replacement (n = 245,845), or stroke (n = 64,153). Data from residents' first and last Minimum Data Set were used to calculate ADL total scores for self-performance in dressing, personal hygiene, toileting, locomotion on the unit, transferring, bed mobility, and eating. Residents were dichotomized according to having had any improvement in the ADL total score. Multivariable logistic regression models that included a random intercept for the facility were used to estimate the adjusted odds ratios for any improvement in ADL function among black and Hispanic residents compared to white residents.

RESULTS

A total of 299,931 residents (69.9%) had any improvement in ADL function. Black residents (OR:0.94; 95% CI: 0.91-0.98) but not Hispanic residents (OR: 0.98; 95% CI: 0.94-1.03) had significantly lower odds to have any improvement in ADL function. Analyses stratified by the reason for prior hospitalization indicated that black residents discharged for hip fracture (OR: 0.87; 95% CI: 0.80-0.93) and stroke (OR: 0.87; 95% CI: 0.83-0.93), but not joint replacement (OR: 1.02; 95% CI: 0.97-1.06) had significantly lower odds for any ADL improvement compared to white residents.

CONCLUSIONS

Our findings are evidence for racial disparities in the improvement in ADL function during a SNF stay. Future research should investigate systemic factors that may contribute to disparities in the improvement in ADL function during a SNF stay.

The Relationship Between Medicare Advantage Star Ratings and Enrollee Experience

BACKGROUND

Medicare Advantage plans, private managed care plans that enrolled 34% of Medicare beneficiaries in 2019, received $6 billion in annual bonus payments on the basis of their performance on a 5-star rating system. Little is known, however, as to the extent these ratings adequately capture enrollee experience.

OBJECTIVES

To measure the effect of exposure to higher rated Medicare Advantage contracts on enrollee experience.

DESIGN

An instrumental variables analysis using MA contract consolidation as an exogenous shock to the quality of plan enrollees are exposed to.

PARTICIPANTS

A total of 345,897 MA enrollees enrolled in non-consolidated contracts and 21,405 enrollees who were consolidated.

MAIN MEASURES

The primary exposure was enrollee star rating, instrumented using contract consolidation. The primary outcomes were enrollee self-reported experience measures.

KEY RESULTS

There were no significant effects on increased star ratings on 23 of 27 outcomes. A one-star increase in contract star rating leads to a 5.4 percentage point increase in reporting that pain does not interfere with daily activities (95%CI 2.4, 8.4), and a 4.4 percentage reduction in the likelihood that a physician would talk to the enrollee about physical activity (95%CI: -7.8, -1.1, all p<0.05). A one-star increase in contract star rating led to an 8.4 percentage point reduction in achieving the top score on the received needed information index (95%CI: -16.4, -0.4), and a 1.8 percentage point reduction in responding with the lowest score for the overall rating of care (95%CI: -3.5, -0.1).

CONCLUSIONS

Exposure to a higher rated MA contract did not appreciably increase enrollee experience. Policymakers should consider reassessing how these ratings and associated bonus payments are currently calculated.

Prescribing of low- versus high-cost Part B drugs in Medicare Advantage and traditional Medicare

OBJECTIVE

Examine whether Medicare Advantage (MA) coverage is associated with more efficient prescribing of Part B drugs than traditional Medicare (TM) coverage.

DATA SOURCES

Twenty percent sample of 2016 outpatient and carrier TM claims and MA encounter records and Master Beneficiary Summary File data.

STUDY DESIGN

We analyzed whether MA enrollees compared to TM enrollees more often received the low-cost Part B drug in four clinical scenarios where multiple similarly effective drugs exist: (1) anti-VEGF agents to treat macular degeneration, (2) bone resorption inhibitors for osteoporosis, (3) bone resorption inhibitors for malignant neoplasms, and (4) intravenous iron for iron deficiency anemia. We then estimated differences in spending if TM prescribing aligned with MA prescribing. Finally, using linear probability models, we examined whether differences in MA and TM prescribing patterns were attributable to differences in the hospitals and clinician practices who treat MA and TM enrollees or differences in how these hospitals and clinician practices treat their MA versus TM patients.

DATA COLLECTION/EXTRACTION METHODS

Not applicable.

PRINCIPAL FINDINGS

In all cases, a larger share of MA enrollees received the low-cost drug compared to TM enrollees, ranging from 8 percentage points higher for anemia to 16 percentage points higher for macular degeneration in the unadjusted analysis. Results were similar in regression analyses controlling for enrollee characteristics and market factors (5-13 percentage points). If TM prescribing matched MA prescribing, we estimated savings ranging from 6% to 20% of TM spending for each scenario. Differences in prescribing patterns were driven both by MA enrollees receiving treatment at more efficient hospitals and clinician practices and hospitals and clinician practices more often prescribing low-cost drugs to their MA patients.

CONCLUSIONS

Our findings show MA enrollees were more likely than TM enrollees to receive low-cost Part B drugs in four clinical scenarios where multiple similarly or equally effective treatment options exist.

Relationship Between Nursing Home Compare Improvement in Function Quality Measure and Physical Recovery After Hip Replacement

OBJECTIVE

To determine whether patients with a total or partial hip replacement admitted to a skilled nursing facility (SNF) after the improvement in function quality measure was added to Nursing Home Compare in July 2016 have greater physical recovery than patients admitted before July 2016.

DESIGN

Pre (January 1, 2015-June 30, 2016) vs post (July 1, 2016-December 31, 2017) design.

SETTING

Skilled nursing facilities (n=12,829).

PARTICIPANTS

Medicare fee-for-service beneficiaries (N=106,832) discharged from acute hospitals to SNF after hip replacement between January 1, 2015 and December 31, 2017.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The 5- and 14-day minimum data set assessments were used to calculate total scores for the quality measure, self-care, mobility, and balance. We calculated the average adjusted change per 10 days and any improvement between the 5- and 14-day assessments.

RESULTS

The average adjusted change per 10 days for the quality measure total score for patients admitted before July 2016 and after July 2016 was 1.00 points (standard error, 0010) and 1.06 points (standard error, 0.010), respectively (P<.01). This was a relative increase of 6.0%. Among patients admitted to a SNF before July 2016, 44.4% (standard error, 0.06) had any improvement in the quality measure total score compared with 45.5% (standard error, 0.23) of patients admitted after July 2016 (P<.01). This was a relative increase of 2.5%. The adjusted change per 10 days and percentage of patients who had any improvement in the total scores for self-care, mobility, and balance were all significantly higher after July 2016.

CONCLUSIONS

Patients admitted to a SNF after a hip replacement after July 2016 had greater physical recovery than patients admitted before the improvement in function quality measure was added to Nursing Home Compare.

Comparing Medicare Advantage And Traditional Medicare: A Systematic Review

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.

Rural-urban differences in diagnostic incidence and prevalence of Alzheimer's disease and related dementias

INTRODUCTION

Understanding rural-urban variation in the diagnostic incidence and prevalence of Alzheimer's disease and related dementias (ADRD) will inform policies to improve timely diagnosis and access to supportive services for older adults in rural communities.

METHODS

Using 2008 to 2015 national claims data for fee-for-service Medicare beneficiaries (roughly 170 million person-years), we computed unadjusted and adjusted diagnostic incidence and prevalence estimates for ADRD in metropolitan, micropolitan, and rural counties, and examined differences in survival rates.

RESULTS

Risk-adjusted ADRD diagnostic incidence was higher in rural versus metropolitan counties despite lower prevalence. Among beneficiaries diagnosed with ADRD in 2008, metropolitan county residents experienced longer survival compared to residents in rural and micropolitan counties.

DISCUSSION

These data suggest that older adults in rural communities may be underdiagnosed with ADRD, and/or diagnosed at later stages of dementia. Further work is needed to develop strategies to reduce this disparity.

Plan switching among Medicare Advantage beneficiaries with Alzheimer's disease and other dementias

INTRODUCTION

Patients with Alzheimer's disease and related dementias (ADRD) face substantial challenges in selecting, and remaining enrolled in, health insurance. Little is known about how patients with ADRD experience the Medicare Advantage (MA) program.

METHODS

We used, hospital, outpatient, and post-acute care data to identify MA beneficiaries with and without ADRD in 2014. Multinomial logit models estimated the percentage of people who disenrolled to traditional Medicare (TM) or switched to a different MA plan in 2015.

RESULTS

Among non-dually eligible beneficiaries, 9.0% (95% confidence interval [CI]: 8.0, 9.1) with ADRD disenrolled while 19.7% (95% CI: 19.6, 19.9) switched plans within MA compared to a disenrollment rate of 4.2% (95% CI: 4.2, 4.2) and switching rate of 22.8% (95% CI: 22.9, 22.8) for persons without ADRD.

DISCUSSION

MA enrollees with ADRD tend to disenroll at substantially higher rates than those without ADRD. This may be indicative of their care needs not being met in the program.

Higher Medicare Advantage Star Ratings Are Associated With Improvements In Patient Outcomes

Little is known about how well the Centers for Medicare and Medicaid Services' five-star rating system for the overall quality of Medicare Advantage (MA) contracts captures quality of care. Leveraging contract consolidation as a natural experiment to study the association between outcomes and insurer-initiated enrollee shifts to plans with higher-rated contracts, we found that enrollees experiencing a one-star MA rating increase were 20.8 percent less likely to voluntarily leave their plan to enroll in another plan or traditional Medicare. When hospitalized, they were 3.4 percent more likely to use a higher-quality hospital and 2.6 percent less likely to be readmitted within ninety days. Our findings suggest that MA star ratings may capture key domains of an MA plan's quality; however, the differences in outcomes that they capture might not all be clinically meaningful.

Nearly One In Five Skilled Nursing Facilities Awarded Positive Incentives Under Value-Based Purchasing

Medicare's Skilled Nursing Facility Value-Based Purchasing Program, which awards value-based incentive payments based on hospital readmissions, distributed its first two rounds of incentives during fiscal years 2019 and 2020. Incentive payments were based on achievement or improvement scores-whichever was better. Incentive payments were as low as -2.0 percent in both program years and as high as +1.6 percent in FY 2019 and +3.1 percent in FY 2020. In FY 2019, 26 percent of facilities earned positive incentives and 72 percent earned negative incentives, compared with 19 percent positive and 65 percent negative incentives in FY 2020. Larger, rural, and not-for-profit facilities were more likely to earn positive incentives, as were those with the highest registered nurse staffing levels. Although these findings indicate the potential to reward high-quality care at skilled nursing facilities, intended and unintended outcomes of this new value-based purchasing program should be monitored closely for possible program refinements, particularly in light of the disproportionate impacts of coronavirus disease 2019 (COVID-19) on nursing facilities.

Quality of Post-Acute Care in Skilled Nursing Facilities That Disproportionately Serve Hispanics With Dementia

OBJECTIVES

As the number of Hispanics with dementia continues to increase, greater use of post-acute care in nursing home settings will be required. Little is known about the quality of skilled nursing facilities (SNFs) that disproportionately serve Hispanic patients with dementia and whether the quality of SNF care varies by the concentration of Medicare Advantage (MA) patients with dementia admitted to these SNFs.

DESIGN

Cross-sectional study using 2016 data from Medicare certified providers.

SETTING AND PARTICIPANTS

Our cohort included 177,396 beneficiaries with probable dementia from 8884 SNFs.

METHODS

We examined facility-level quality of care among facilities with high and low proportions of Hispanic beneficiaries with probable dementia enrolled in MA and fee-for-service (FFS) using data from Medicare-certified providers. Three facility-level measures were used to assess quality of care: (1) 30-day rehospitalization rate; (2) successful discharge from the facility to the community; and (3) Medicare 5-star quality ratings.

RESULTS

About 20% of residents were admitted to 1615 facilities with a resident population that was more than 15% Hispanic. Facilities with a higher share of Hispanic residents had a lower proportion of 4- or 5-star facilities by an average of 14% to 15% compared with facilities with little to no Hispanics. In addition, these facilities had a 1% higher readmission rate. There were also some differences in the quality of facilities with high (>26.5%) and low (<26.5%) proportions of MA beneficiaries. On average, SNFs with a high concentration of MA patients have lower readmission rates and higher successful discharge, but lower star ratings.

CONCLUSIONS AND IMPLICATIONS

Achieving better quality of care for people with dementia may require efforts to improve the quality of care among facilities with a high concentration of Hispanic residents.

Family and Friend Perceptions of Quality of End-of-Life Care in Medicare Advantage vs Traditional Medicare

IMPORTANCE

Medicare Advantage (MA) insures an increasing proportion of Medicare beneficiaries, but evidence is lacking on patient or family perceptions of the quality of end-of-life care in MA vs traditional Medicare.

OBJECTIVE

To determine if there is a difference in quality of care reported by family and friends of individuals who died while insured by MA vs traditional Medicare at the end of life.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used the 2011 to 2017 Medicare-linked National Health and Aging Trends Study to conduct population-based survey research representing 8 668 829 Medicare enrollees. Included individuals were 2119 enrollees who died when aged 65 years or older, with quality of care reported by a family member or close friend familiar with the individual's last month of life. Analysis was conducted in July 2020.

EXPOSURES

MA enrollment at the time of death or before hospice enrollment.

MAIN OUTCOMES AND MEASURES

Perception of end-of-life care was measured with 9 validated items, with the primary outcome variable being overall care rated not excellent. We conducted a propensity score-weighted multivariable model to examine the association of each item with MA vs traditional Medicare enrollment. The propensity score and multivariable model included covariates capturing demographic and socioeconomic factors, function and health, and relationship of the respondent to the individual who died. The sample was then stratified by hospice enrollment and setting of care in the last month.

RESULTS

Of 2119 people in the sample, 670 individuals were enrolled in MA at the time of death or prior to hospice (32.7%) and 1449 were enrolled in traditional Medicare (67.3%). In survey-weighted percentages, 53.6% (95% CI, 51.0% to 56.1%) were women and 43.4% (95% CI, 41.5% to 45.3%) were older than 85 years at the time of death. In the adjusted model, family and friends of individuals in MA were more likely to report that care was not excellent (odds ratio, 1.28; 95% CI, 1.01 to 1.61; P = .04) and that they were not kept informed (odds ratio, 1.48; 95% CI, 1.06 to 2.05; P = .02). For those in nursing homes, there was an estimated probability of 57.2% of respondents reporting that care was not excellent for individuals with traditional Medicare, compared with 77.9% of respondents for individuals with MA (marginal increase for those in MA, 0.21; 95% CI, 0.08 to 0.32; P = .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of people who died while enrolled in Medicare, friends and family of those in MA reported lower-quality end-of-life care compared with friends and family of those enrolled in traditional Medicare. These findings suggest that, given the rapid growth of MA, Medicare should take steps to ensure that MA plans are held accountable for quality of care at the end of life.

Assessment of Rural-Urban Differences in Health Care Use and Survival Among Medicare Beneficiaries With Alzheimer Disease and Related Dementia

IMPORTANCE

There is poor understanding as to how survival and health care use varies among older adults living with Alzheimer disease and related dementia (ADRD) in rural vs urban areas of the United States.

OBJECTIVE

To describe survival and trajectories of hospital, hospice, nursing home, and home health care use among rural and urban Medicare beneficiaries with ADRD in the 6 years after diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study linked Medicare claims data from January 1, 2009, to December 31, 2016, with nursing home and home health assessment data from all US counties. A total of 555 333 Medicare fee-for-service beneficiaries newly diagnosed with ADRD in 2010 were included. A total of 424 561 individuals (76.5%) resided in metropolitan counties, 75 001 (13.5%) in micropolitan counties, and 55 771 (10.0%) in rural counties.

EXPOSURES

Rurality of beneficiary's county of residence.

MAIN OUTCOMES AND MEASURES

Number of days survived after initial ADRD diagnosis; percent of survived days per month spent in the hospital, hospice nursing home, community with home health care services, and community without home health care services.

RESULTS

A total of 555 333 Medicare beneficiaries (mean [SD] age, 82.0 [7.5] years; 345 294 women [62.2%]; 480 286 White [86.5%]) were evaluated. Compared with metropolitan county residents, rural beneficiaries were younger (mean [SD] age, 81.6 [7.6] vs 82.1 [7.5] years), were less likely to be women (34 100 [61.1%] vs 264 688 [62.3%]), were more likely to be White (50 886 [91.2%] vs 361 205 [85.1%]) and Medicaid-eligible (14 264 [25.6%] vs 71 656 [16.9%]), and had fewer preexisting chronic conditions (mean [SD], 6.9 [2.8] vs 7.4 [2.9]). Medicare beneficiaries residing in metropolitan counties survived a mean (SD) of 1183.5 (826.0) days after diagnosis. Adjusting for individual demographic and clinical characteristics, rural and micropolitan county residents survived approximately 1.5 months less than metropolitan residents. The adjusted share of survived days spent in nursing homes was 5.7 (95% CI, 4.0-7.5) percentage points higher for rural vs metropolitan residents. The adjusted share of days in hospitals was 0.7 (95% CI, -0.9 to -0.4) percentage points lower, and the share of days in community without home health care was 4.6 (95% CI, -6.1 to -3.1) percentage points lower for rural vs metropolitan county residents. There were no statistically significant differences in home health or hospice use. Similar patterns were found for micropolitan vs metropolitan residents as for rural vs metropolitan residents, although the magnitude of the differences were smaller. Differences in time spent in community and nursing homes between rural vs metropolitan beneficiaries became more pronounced with further time from diagnosis.

CONCLUSIONS AND RELEVANCE

Study results suggest that, after diagnosis, rural Medicare beneficiaries with ADRD spend more time in nursing homes and less time in the community, receive less home health care, and have shorter survival than their urban counterparts.

The Effect of Physical and Cognitive Impairments on Caregiving

BACKGROUND

Many older adults receive caregiving; however, less is known about how a change in a care recipient's functional activity limitations [instrumental activities of daily living (IADL) and basic activities of daily living (ADL)] as well as their cognitive impairment influence the amount of caregiving received.

METHODS

Using the Health and Retirement Study (2002-2014) we identified community-dwelling respondents with Alzheimer disease and related dementias (ADRD; n=674), cognitive impairment no dementia (CIND; n=530), and no cognitive impairment (n=6126). We estimated a series of two-part regression models to identify the association between care recipients' level of cognitive impairment, change in total number of IADL/ADL limitations and amount of caregiving received.

RESULTS

Persons with ADRD received 235.8 (SD=265.6) monthly hours of care compared with 26.0 (SD=92.6) and 6.0 (SD=40.7) for persons with CIND and no cognitive impairment, respectively. An increase in one IADL/ADL limitation resulted in persons with ADRD and CIND receiving 4.90 (95% confidence interval: 3.40-6.39) and 1.43 (95% confidence interval: 0.17-2.69) more hours of caregiving than persons with no cognitive impairment. Increases in total IADL/ADL limitations were associated with persons with ADRD, but not CIND, receiving more days of caregiving and having more caregivers than persons with no cognitive impairment.

CONCLUSIONS

Compared with persons with no cognitive impairment, increases in IADL/ADL limitations disproportionally increases the caregiving received for persons with ADRD. Policies and programs must pay attention to functional impairments among those living with ADRD.

Switching Between Medicare Advantage And Traditional Medicare Before And After The Onset Of Functional Disability

Medicare Advantage (MA) plans have increasing flexibility to provide nonmedical services to support older adults aging in place in the community. However, prior research has suggested that enrollees with functional disability (hereafter, "disability") were more likely than those without disability to leave MA plans. This indicates that MA plans might not meet the needs of older adults with disability. We used data for 2011-16 from the National Health and Aging Trends Study linked to Medicare claims to measure and characterize switches in either direction between Medicare Advantage and traditional Medicare in the twelve months before and after onset of disability. While the rate of switches from Medicare Advantage to traditional Medicare increased slightly after disability onset, people with greater levels of disability were more likely to switch to traditional Medicare, compared to those with lower levels: 36 percent of those who switched from Medicare Advantage to traditional Medicare needed help with two or more activities of daily living, compared to 14.3 percent of those who switched from traditional Medicare to Medicare Advantage. This indicates the potential benefit of including functional measures in MA plan risk adjustment and quality measures. Furthermore, the highest-need older adults with disability may experience lower-quality care in Medicare Advantage and thus leave before accessing the program's expanded benefits.

Home Health Use Following a Cancer Diagnosis Among Patients Enrolled in Medicare Advantage and Traditional Medicare: Findings From the Newly Linked SEER-Medicare and Home Health OASIS Data

BACKGROUND

This article describes characteristics of patients receiving home health following an initial cancer diagnosis, comparing those enrolled in Medicare Advantage (MA) and Traditional Medicare (TM), using the newly linked 2010-2014 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare and home health Outcome and Assessment Information Set (OASIS) data.

METHODS

We identified SEER-Medicare beneficiaries with at least one OASIS assessment within 3 months of cancer diagnosis in 2010-2014, and summarized their demographic and clinical characteristics. Demographic and diagnostic data were obtained from the SEER-Medicare data, while further details about cognitive status, mood, function, and medical history were obtained from OASIS. We assessed differences between MA and TM beneficiaries using chi-square tests for independence, t-tests, and Kruskal-Wallis tests.

RESUTLS

We identified 104 023 patients who received home health within 3 months of cancer diagnosis: 81 587 enrolled in TM and 22 436 enrolled in MA. TM cancer patients had higher unadjusted rates of home health use than MA patients (16.3% vs 10.3%, P < .001). TM cancer patients receiving home health had more limitations in their cognitive function than their MA counterparts and longer lengths of service (mean = 42.2 days vs 39.4 days, P < .001; median = 27 vs 26 days, interquartile range = 42).

CONCLUSION

This study demonstrates the large number of cancer patients in the SEER-Medicare-OASIS data and describes characteristics for TM and MA patients. These newly linked data can be used to assess home health care among older patients with cancer.

Comparison of the Quality of Hospitals That Admit Medicare Advantage Patients vs Traditional Medicare Patients

IMPORTANCE

In the Medicare Advantage (MA) program, Medicare enrollees may be steered by their health plan to specific hospitals. Little is known about the quality of hospitals that serve MA enrollees.

OBJECTIVE

To compare the quality of hospitals that admit MA enrollees with the quality of those that admit traditional Medicare enrollees.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the 2012 to 2016 Medicare Provider Analysis and Review to compare quality of care, as measured by the star rating given by the Centers for Medicare and Medicaid Services and readmission rates, in hospitals that serve MA enrollees and traditional Medicare enrollees using multinomial logit models. Participants were 7 130 610 Medicare beneficiaries admitted to 2994 acute care hospitals across the United States in 2016. Data were analyzed between August 2018 and August 2019.

EXPOSURES

The exposure was MA enrollment. Adjusters included demographic and clinical characteristics and zip code fixed effects.

MAIN OUTCOMES AND MEASURES

Hospital Compare star ratings and quintiles of performance in 30-day readmission rates.

RESULTS

The sample included 7 130 610 Medicare beneficiaries in 2016 (54.3% female; mean [SD] age, 72.7 [13.2] years). Of 12 190 270 total hospitalizations, 1 211 293 traditional Medicare and 494 352 MA patients were admitted to 718 low-readmission hospitals and 1 205 586 traditional Medicare and 526 955 MA patients were admitted to 597 high-readmission hospitals. Accounting for observed patient characteristics, MA enrollees less often entered either low- or high-quality hospitals and were more often admitted to average-quality hospitals. For nonemergent hospitalizations, MA enrollees were 1.9 percentage points (95% CI, 1.5-2.2 percentage points) less likely to enter a low-readmissions hospital, 5.1 percentage points (95% CI, 4.6-5.6 percentage points) more likely to enter an average-readmissions hospital, and 3.2 percentage points (95% CI, 2.9-3.5 percentage points) less likely to enter a high-readmissions hospital compared with traditional Medicare enrollees. Patients with MA were also 2.6 percentage points (95% CI, 2.2-2.9 percentage points) less likely to enter a 1- to 2-star hospital, 5.5 percentage points (95% CI, 4.9-5.9 percentage points) more likely to enter a 3-star hospital, and 2.8 percentage points (95% CI, 2.5-3.2 percentage points) less likely to enter a 4- to 5-star hospital compared with traditional Medicare enrollees. The differences were less pronounced for emergency admissions.

CONCLUSIONS AND RELEVANCE

This study found that enrollees in MA plans were more likely to be admitted to average-quality hospitals instead of either high- or low-quality hospitals, suggesting that MA plans may be steering their enrollees to specific hospitals.

Quality of Home Health Agencies Serving Traditional Medicare vs Medicare Advantage Beneficiaries

IMPORTANCE

Medicare Advantage (MA) enrollment is increasing, with one-third of Medicare beneficiaries currently selecting MA. Despite this growth, it is difficult to assess the quality of the health care professionals and organizations that serve MA beneficiaries or to compare them with health care professionals and organizations serving traditional Medicare (TM) beneficiaries. Elderly individuals served by home health agencies (HHAs) may be particularly susceptible to the negative outcomes associated with low-quality care.

OBJECTIVE

To compare the quality of HHAs that serve TM and MA beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional, admission-level analysis used data from 4 391 980 home health admissions identified using the Outcome and Assessment Information Set (most commonly known as OASIS) admission assessments of Medicare beneficiaries in 2015 from Medicare-certified HHAs. A multinomial logistic regression model was used to assess whether an association existed between the Medicare plan type and HHA quality. The model was adjusted for patient demographics, acuity, and characteristics of the zip codes. Sensitivity analyses controlled for zip code fixed effects. The present analysis was conducted between October 2018 and March 2019.

EXPOSURES

Home health users were classified as TM or MA beneficiaries using the Master Beneficiary Summary File. The MA beneficiaries were further classified as enrolled in a high- or low-quality MA plan on the basis of publicly reported MA star ratings.

MAIN OUTCOMES AND MEASURES

Quality of HHA derived from the publicly reported patient care star ratings: low quality (1.0-2.5 stars), average quality (3.0-3.5 stars), or high quality (≥4.0 stars).

RESULTS

Of 4 391 980 admissions, most (75.5%) were for TM beneficiaries (mean [SD] age, 76.1 [12.2] years), with 16.6% of beneficiaries enrolled in high-quality MA plans (mean [SD] age, 77.8 [10.0] years) and 7.9% in low-quality MA plans (mean [SD] age, 74.4 [11.4] years). Individuals enrolled in low-rated MA plans were most likely to be nonwhite (percentages of nonwhite individuals in TM, 14.3%; in high-quality MA, 19.8%; and in low-quality MA, 36.5%) and dual Medicare-Medicaid eligible (percentages for dual eligible in TM, 30.5%; in high-quality MA, 19.5%; and in low-quality MA, 43.3%). Among TM beneficiaries, 30.4% received care from high-quality HHAs, whereas 17.0% received care from low-quality HHAs. Compared with TM beneficiaries, those in a low-quality MA plan were 3.0 percentage points (95% CI, 2.6%-3.4%) more likely to be treated by a low-quality HHA and 4.9 percentage points (95% CI, -5.4% to -4.3%) less likely to be treated by a high-quality HHA. The MA beneficiaries in high-quality plans were also less likely to receive care from high-quality vs low-quality HHAs (-2.8% [95% CI, -3.1% to -2.2%] vs 1.0% [95% CI, 0.7%-1.3%]).

CONCLUSIONS AND RELEVANCE

Compared with TM beneficiaries, MA beneficiaries residing in the same zip code enrolled in either high- or low-quality MA plans may receive treatment from lower-quality HHAs. Policy makers may consider incentivizing MA plans to include higher-quality HHAs in their networks and improving patient education regarding HHA quality.

Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries

IMPORTANCE

How often enrollees with complex care needs leave the Medicare Advantage (MA) program and what might drive their decisions remain unknown.

OBJECTIVE

To characterize trends in switching to and from MA among high-need beneficiaries and to evaluate the drivers of disenrollment decisions.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of MA and traditional Medicare (TM) enrollees from January 1, 2014, through December 31, 2015, used a multinomial logit regression stratified by Medicare-Medicaid eligibility status. All 14 589 645 non-high-need MA enrollees and 1 302 470 high-need enrollees in the United States who survived until the end of 2014 were eligible for the analysis. Data were analyzed from November 1, 2017, through August 1, 2018.

EXPOSURES

Enrollee dual eligibility and high-need status (based on complex chronic conditions, multiple morbidities, use of health care services, functional impairment, and frailty indicators), MA plan star rating, and cost sharing.

MAIN OUTCOMES AND MEASURES

The proportion of enrollees who disenrolled into TM, remained in the same MA plan, or who switched plans within the MA program.

RESULTS

A total of 13 901 816 enrollees were included in the analysis (56.2% women; mean [SD] age, 70.9 [9.9] years). Among the 1 302 470 high-need enrollees, an adjusted 4.6% (95% CI, 4.5%-4.6%) of Medicare-only and 14.8% (95% CI, 14.5%-15.0%) of Medicare-Medicaid members switched from MA to TM compared with 3.3% (95% CI, 3.3%-3.3%) and 4.6% (95% CI, 4.5%-4.7%), respectively, among non-high-need enrollees. Among enrollees in low-quality plans, 23.0% (95% CI, 22.3%-23.9%) of Medicare and 42.8% (95% CI, 40.5%-45.1%) of dual-eligible high-need enrollees left MA. Even in high-quality plans, high-need members disenrolled at higher rates than non-high-need members (4.9% [95% CI, 4.6%-5.2%] vs 1.8% [95% CI, 1.8%-1.9%] for Medicare-only enrollees and 11.3% vs 2.4% dual eligible enrollees). Enrollment in a 5.0-star rated plan was associated with a 30.1-percentage point reduction (95% CI, -31.7 to -28.4 percentage points) in the probability of disenrollment among high-need individuals. A $100 increase in monthly premiums was associated with a 33.9-percentage point increase (95% CI, -34.9 to -33.0 percentage points) in the likelihood of switching plans, and a small reduction in the likelihood of disenrolling (-2.7 percentage points; 95% CI, -3.2 to -2.2 percentage points). Among Medicare-Medicaid eligible participants, 14.1% (95% CI, 14.0%-14.2%) of high-need and 16.7% (95% CI, 16.6%-16.7%) of non-high-need enrollees switched from TM to MA.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that substantially higher disenrollment from MA plans occurs among high-need and Medicare-Medicaid eligible enrollees. This study's findings suggest that star ratings have the strongest association with disenrollment trends, whereas increases in monthly premiums are associated with greater likelihood of switching plans.

Examination of the New Short-Stay Nursing Home Quality Measures: Rehospitalizations, Emergency Department Visits, and Successful Returns to the Community

In 2016, the Centers for Medicare & Medicaid Services (CMS) introduced 3 new quality measures (QMs) to its report card, Nursing Home Compare (NHC). These measures—rehospitalizations, emergency department visits, and successful discharges to the community—focus on short-stay residents. We offer a first analysis of nursing homes’ performance in terms of these new measures. We examined their properties and distribution across nursing homes using descriptive statistics and regression models. We found that, similar to other QMs, performance varies across the country, and that there is very minimal correlation between these 3 new QMs as well as between these QMs and other NHC QMs. Regression models reveal that better performance on these QMs tends to be associated with fewer deficiencies, higher staffing and more skilled staffing, nonprofit ownership, and lower proportion of Medicaid residents. Other characteristics are associated with better performance for some but not all 3 QMs. We also found improvement in all 3 QMs in the second year of publication. This study contributes to the validity of these measures by demonstrating their relationship to these structural QMs. It also suggests that these QMs are important by demonstrating their large variation across the country, suggesting substantial room for improvement, and finding that nursing homes are already responding to the incentives created by publication of these QMs.

Medicare Advantage control of postacute costs: perspectives from stakeholders

OBJECTIVES

Medicare Advantage (MA) plans have strong incentives to control costs, including postacute spending; however, to our knowledge, no research has examined the methods that MA plans use to control or reduce postacute costs. This study aimed to understand such MA plan efforts and the possible unintended consequences.

STUDY DESIGN

A multiple case study method was used.

METHODS

We conducted 154 interviews with administrative and clinical staff working in 10 MA plans, 16 hospitals, and 25 skilled nursing facilities (SNFs) in 8 geographically diverse markets across the United States.

RESULTS

Participants discussed how MA plans attempted to reduce postacute care spending by controlling the SNF to which patients are discharged and SNF length of stay (LOS). Plans typically influenced SNF selection by providing patients with a list of facilities in which their care would be covered. To influence LOS, MA plans most commonly authorized patient stays in SNFs for a certain number of days and required that SNFs adhere to this limitation, but they did not provide guidance or assistance in ensuring that the LOS goals were met. Hospital and SNF responses to the largely authorization-based system were frequently negative, and participants expressed concerns about potential unintended consequences.

CONCLUSIONS

In their interactions with hospitals and SNFs, MA plans attempted to influence the choice of SNF and LOS to control postacute spending. However, exerting too much influence over hospitals and SNFs, as these results seem to indicate, may have the negative consequences of delayed hospital discharge and SNFs' avoidance of burdensome plans.

The Effects of Medicare Advantage Contract Concentration on Patients' Nursing Home Outcomes

OBJECTIVE

The Medicare Modernization Act of 2004 allowed Medicare Advantage (MA) contracts to form provider networks in order to concentrate their patients among preferred providers. We focus on the skilled nursing facility (SNF) industry to assess patients' health when treating SNFs concentrate more patients from the same MA contract.

DATA SOURCES/STUDY SETTING

We use Medicare Beneficiary Summary File and Health, HEDIS, and the Minimum Data Set for patient attributes and OSCAR, LTCfocus.org, and Nursing Home Compare for SNF attributes. We include 1,069,436 MA enrollees newly admitted to SNF between 2012 and 2014.

STUDY DESIGN

Using a MA contract fixed-effect model, we examine the effect of prevalence of a patient's MA contract in the treating SNF on patient's health outcomes including 180-day survival, 30-day hospital readmission, 30-day home discharge, and nursing home length of stay. We use an Instrumental Variable (IV), the expected share of admissions in a SNF from patient's MA contract calculated using a McFadden choice model.

PRINCIPAL FINDINGS

We find no relationship between SNF contract concentration and patients' outcomes after applying the IV.

CONCLUSIONS

While MA plans appear to steer patients to specific SNFs, we do not observe significant returns to patient outcomes related to concentration.

Assessing the Quality of Nursing Homes in Managed Care Organizations: Integrating LTSS for Dually Eligible Beneficiaries

Little is known about the quality of nursing homes in managed care organizations (MCOs) networks. This study (1) described decision-making criteria for selecting nursing home networks and (2) compared selected quality indicators of network and nonnetwork nursing homes. The sample was 17 MCOs participating in a California demonstration that provided integrated long-term services and supports to dually eligible enrollees in 2017. The findings showed that the MCOs established a broad network of nursing homes, with only limited attention to using quality criteria. Network nursing homes (602) scored significantly lower on 6 selected quality measures than nonnetwork (117) nursing homes. Low registered nurse and total nurse staffing were strong predictors of network nursing homes controlling for facility characteristics. Managed care organizations should consider greater transparency about the quality of their nursing homes and use specific quality criteria to improve the quality of their networks.

Comparing post-acute rehabilitation use, length of stay, and outcomes experienced by Medicare fee-for-service and Medicare Advantage beneficiaries with hip fracture in the United States: A secondary analysis of administrative data

BACKGROUND

Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees.

METHODS AND FINDINGS

This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation.

CONCLUSIONS

Compared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs.

Preferred Provider Relationships Between Medicare Advantage Plans and Skilled Nursing Facilities Reduce Switching Out of Plans: An Observational Analysis

Unlike traditional Medicare, Medicare Advantage (MA) plans contract with specific skilled nursing facilities (SNFs). Patients treated in an MA plan's preferred SNF may benefit from enhanced coordination and have a lower likelihood of switching out of their plan. Using 2011-2014 Medicare enrollment data, the Medicare Healthcare Effectiveness Data and Information Set, and the Minimum Data Set, we examined Medicare enrollees who were newly admitted to SNFs in 2012-2013. We used the Centers for Medicare & Medicaid Services star rating to distinguish between MA plans and show how SNF concentration experienced by patients varies between patients in plans with different star ratings. We found that highly rated MA plans steer their patients to a smaller number of SNFs, and these patients are less likely to switch out of their plans. Strengthening the MA plan-SNF relationship may lower disenrollment rates for SNF beneficiaries, imparting benefits to both patients and payers.