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Burke LG, Burke RC, Duggan CE, Figueroa JF, Boltz M, Fick D, Orav EJ, Marcantonio ER. Trends in observation stays for Medicare beneficiaries with and without Alzheimer's disease and related dementias. J Am Geriatr Soc 2024; 72:1442-1452. [PMID: 38546202 PMCID: PMC11090746 DOI: 10.1111/jgs.18890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/19/2024] [Accepted: 02/24/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown. METHODS Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-). RESULTS Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7). CONCLUSIONS Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Marie Boltz
- The Pennsylvania State University College of Nursing, University Park, PA, USA
| | - Donna Fick
- The Pennsylvania State University College of Nursing, University Park, PA, USA
| | - E. John Orav
- Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
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Sabbatini AK, Parrish C, Liao JM, Wright B, Basu A, Kreuter W, Joynt-Maddox KE. Hospital Performance Under Alternative Readmission Measures Incorporating Observation Stays. Med Care 2023; 61:779-786. [PMID: 37712715 PMCID: PMC10592134 DOI: 10.1097/mlr.0000000000001920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
OBJECTIVE To determine the extent to which counting observation stays changes hospital performance on 30-day readmission measures. METHODS This was a retrospective study of inpatient admissions and observation stays among fee-for-service Medicare enrollees in 2017. We generated 3 specifications of 30-day risk-standardized readmissions measures: the hospital-wide readmission (HWR) measure utilized by the Centers for Medicare and Medicaid Services, which captures inpatient readmissions within 30 days of inpatient discharge; an expanded HWR measure, which captures any unplanned hospitalization (inpatient admission or observation stay) within 30 days of inpatient discharge; an all-hospitalization readmission (AHR) measure, which captures any unplanned hospitalization following any hospital discharge (observation stays are included in both the numerator and denominator of the measure). Estimated excess readmissions for hospitals were compared across the 3 measures. High performers were defined as those with a lower-than-expected number of readmissions whereas low performers had higher-than-expected or excess readmissions. Multivariable logistic regression identified hospital characteristics associated with worse performance under the measures that included observation stays. RESULTS Our sample had 2586 hospitals with 5,749,779 hospitalizations. Observation stays ranged from 0% to 41.7% of total hospitalizations. Mean (SD) readmission rates were 16.6% (5.4) for the HWR, 18.5% (5.7) for the expanded HWR, and 17.9% (5.7) in the all-hospitalization readmission measure. Approximately 1 in 7 hospitals (14.9%) would switch from being classified as a high performer to a low performer or vice-versa if observation stays were fully included in the calculation of readmission rates. Safety-net hospitals and those with a higher propensity to use observation would perform significantly worse. CONCLUSIONS Fully incorporating observation stays in readmission measures would substantially change performance in value-based programs for safety-net hospitals and hospitals with high rates of observation stays.
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Affiliation(s)
- Amber K. Sabbatini
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, School of Public Health
| | - Canada Parrish
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, School of Public Health
| | - Joshua M. Liao
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
- Value System Science Lab, Department of Medicine, University of Washington, Seattle, WA
| | - Brad Wright
- Department of Health Services, Policy and Management University of South Carolina School of Public Health, Columbia, SC
| | - Anirban Basu
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle, WA
| | - William Kreuter
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle, WA
| | - Karen E. Joynt-Maddox
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
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Diamond J, Ayodele I, Fonarow GC, Joynt-Maddox KE, Yeh RW, Hammond G, Allen LA, Greene SJ, Chiswell K, DeVore AD, Yancy C, Wadhera RK. Quality of Care and Clinical Outcomes for Patients With Heart Failure at Hospitals Caring for a High Proportion of Black Adults: Get With The Guidelines-Heart Failure Registry. JAMA Cardiol 2023; 8:545-553. [PMID: 37074702 PMCID: PMC10116383 DOI: 10.1001/jamacardio.2023.0695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/26/2023] [Indexed: 04/20/2023]
Abstract
Importance Black adults with heart failure (HF) disproportionately experience higher population-level mortality than White adults with HF. Whether quality of care for HF differs at hospitals with high proportions of Black patients compared with other hospitals is unknown. Objective To compare quality and outcomes for patients with HF at hospitals with high proportions of Black patients vs other hospitals. Design, Setting, and Participants Patients hospitalized for HF at Get With The Guidelines (GWTG) HF sites from January 1, 2016, through December 1, 2019. These data were analyzed from May 2022 through November 2022. Exposures Hospitals caring for high proportions of Black patients. Main Outcomes and Measures Quality of HF care based on 14 evidence-based measures, overall defect-free HF care, and 30-day readmissions and mortality in Medicare patients. Results This study included 422 483 patients (224 270 male [53.1%] and 284 618 White [67.4%]) with a mean age of 73.0 years. Among 480 hospitals participating in GWTG-HF, 96 were classified as hospitals with high proportions of Black patients. Quality of care was similar between hospitals with high proportions of Black patients compared with other hospitals for 11 of 14 GWTG-HF measures, including use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors for left ventricle systolic dysfunction (high-proportion Black hospitals: 92.7% vs other hospitals: 92.4%; adjusted odds ratio [OR], 0.91; 95% CI, 0.65-1.27), evidence-based β-blockers (94.7% vs 93.7%; OR, 1.02; 95% CI, 0.82-1.28), angiotensin receptor neprilysin inhibitors at discharge (14.3% vs 16.8%; OR, 0.74; 95% CI, 0.54-1.02), anticoagulation for atrial fibrillation/flutter (88.8% vs 87.5%; OR, 1.05; 95% CI, 0.76-1.45), and implantable cardioverter-defibrillator counseling/placement/prescription at discharge (70.9% vs 71.0%; OR, 0.75; 95% CI, 0.50-1.13). Patients at high-proportion Black hospitals were less likely to be discharged with a follow-up visit made within 7 days or less (70.4% vs 80.1%; OR, 0.68; 95% CI, 0.53-0.86), receive cardiac resynchronization device placement/prescription (50.6% vs 53.8%; OR, 0.63; 95% CI, 0.42-0.95), or an aldosterone antagonist (50.4% vs 53.5%; OR, 0.69; 95% CI, 0.50-0.97). Overall defect-free HF care was similar between both groups of hospitals (82.6% vs 83.4%; OR, 0.89; 95% CI, 0.67-1.19) and there were no significant within-hospital differences in quality for Black patients vs White patients. Among Medicare beneficiaries, the risk-adjusted hazard ratio (HR) for 30-day readmissions was higher at high-proportion Black vs other hospitals (HR, 1.14; 95% CI, 1.02-1.26), but similar for 30-day mortality (HR 0.92; 95% CI,0.84-1.02). Conclusions and Relevance Quality of care for HF was similar across 11 of 14 measures at hospitals caring for high proportions of Black patients compared with other hospitals, as was overall defect-free HF care. There were no significant within-hospital differences in quality for Black patients vs White patients.
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Affiliation(s)
- Jamie Diamond
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | | | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles
| | - Karen E. Joynt-Maddox
- Center for Health Economics and Policy, Cardiovascular Division, Washington University School of Medicine, Washington University, St Louis, Missouri
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Gmerice Hammond
- Center for Health Economics and Policy, Cardiovascular Division, Washington University School of Medicine, Washington University, St Louis, Missouri
| | - Larry A. Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Stephen J. Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D. DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Clyde Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Smith LB, O'Brien C, Kenney GM, Tabb LP, Verdeflor A, Wei K, Lynch V, Waidmann T. Racialized economic segregation and potentially preventable hospitalizations among Medicaid/CHIP-enrolled children. Health Serv Res 2023; 58:599-611. [PMID: 36527452 PMCID: PMC10154153 DOI: 10.1111/1475-6773.14120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To examine geographic variation in preventable hospitalizations among Medicaid/CHIP-enrolled children and to test the association between preventable hospitalizations and a novel measure of racialized economic segregation, which captures residential segregation within ZIP codes based on race and income simultaneously. DATA SOURCES We supplement claims and enrollment data from the Transformed Medicaid Statistical Information System (T-MSIS) representing over 12 million Medicaid/CHIP enrollees in 24 states with data from the Public Health Disparities Geocoding Project measuring racialized economic segregation. STUDY DESIGN We measure preventable hospitalizations by ZIP code among children. We use logistic regression to estimate the association between ZIP code-level measures of racialized economic segregation and preventable hospitalizations, controlling for sex, age, rurality, eligibility group, managed care plan type, and state. DATA EXTRACTION METHODS We include children ages 0-17 continuously enrolled in Medicaid/CHIP throughout 2018. We use validated algorithms to identify preventable hospitalizations, which account for characteristics of the pediatric population and exclude children with certain underlying conditions. PRINCIPAL FINDINGS Preventable hospitalizations vary substantially across ZIP codes, and a quarter of ZIP codes have rates exceeding 150 hospitalizations per 100,000 Medicaid-enrolled children per year. Preventable hospitalization rates vary significantly by level of racialized economic segregation: children living in the ZIP codes that have the highest concentration of low-income, non-Hispanic Black residents have adjusted rates of 181 per 100,000 children, compared to 110 per 100,000 for children in ZIP codes that have the highest concentration of high-income, non-Hispanic white residents (p < 0.01). This pattern is driven by asthma-related preventable hospitalizations. CONCLUSIONS Medicaid-enrolled children's risk of preventable hospitalizations depends on where they live, and children in economically and racially segregated neighborhoods-specifically those with higher concentrations of low-income, non-Hispanic Black residents-are at particularly high risk. It will be important to identify and implement Medicaid/CHIP and other policies that increase access to high-quality preventive care and that address structural drivers of children's health inequities.
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Affiliation(s)
| | | | | | - Loni Philip Tabb
- Drexel UniversityDornsife School of Public HealthPhiladelphiaPennsylvaniaUSA
| | | | - Keqin Wei
- Health Policy CenterUrban InstituteWashingtonDCUSA
- Urban InstituteOffice of Technology and Data ScienceWashingtonDCUSA
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Anderson A, Mukashev N, Zhou D, Bigler W. The Costs Of Disparities In Preventable Heart Failure Hospitalizations In The US South, 2015-17. Health Aff (Millwood) 2023; 42:693-701. [PMID: 37126750 DOI: 10.1377/hlthaff.2022.01314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Black Americans in the US South have high rates of preventable heart failure hospitalizations, which reflects systemic inequities that also produce economic costs. We measured the direct medical costs of disparities in preventable heart failure admissions (that is, excess admissions) among Medicare beneficiaries living in six states in the US South (Kentucky, Arkansas, Florida, Georgia, Mississippi, and North Carolina). We used 2015-17 data from the Healthcare Cost and Utilization Project and constructed negative binomial models with state-level fixed effects to calculate adjusted admission rates with heart failure as the principal diagnosis. We calculated the number of these admissions that would have been avoided if Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native Medicare beneficiaries had the same admission rates as White beneficiaries. We found 28,213 excess admissions (48 percent excess) with $60,845,855 annual costs among Black beneficiaries, 3,499 (14 percent excess) with $8,179,381 annual costs among Hispanic beneficiaries, and 550 (51 percent excess) with $1,093,472 in annual costs among American Indian/Alaska Native beneficiaries. Failure to address heart failure treatment inequities in the community has a high opportunity cost.
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Oseran AS, Wadhera RK, Orav EJ, Figueroa JF. Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings. Ann Intern Med 2023; 176:480-488. [PMID: 36972544 DOI: 10.7326/m22-3165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown. OBJECTIVE To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures. DESIGN Cross-sectional. SETTING Population-based. PARTICIPANTS Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. MEASUREMENTS Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated. RESULTS Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings. LIMITATION Hospital performance measurement and risk adjustment differed slightly from those used by Medicare. CONCLUSION Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. PRIMARY FUNDING SOURCE Laura and John Arnold Foundation.
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Affiliation(s)
- Andrew S Oseran
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, and Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts (A.S.O.)
| | - Rishi K Wadhera
- Section of Health Policy and Equity at the Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts (R.K.W.)
| | - E John Orav
- Harvard T.H. Chan School of Public Health and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (E.J.O., J.F.F.)
| | - Jose F Figueroa
- Harvard T.H. Chan School of Public Health and Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (E.J.O., J.F.F.)
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Beckman AL, Frakt AB, Duggan C, Zheng J, Orav EJ, Tsai TC, Figueroa JF. Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare. JAMA HEALTH FORUM 2023; 4:e225530. [PMID: 36826828 PMCID: PMC9958527 DOI: 10.1001/jamahealthforum.2022.5530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
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.
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Affiliation(s)
- Adam L. Beckman
- Harvard Medical School, Boston, Massachusetts,Harvard Business School, Boston, Massachusetts
| | - Austin B. Frakt
- US Department of Veterans Affairs, Boston Healthcare System, Boston University School of Public Health, Boston, Massachusetts,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Ciara Duggan
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas C. Tsai
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Himmelstein G, Ceasar JN, Himmelstein KE. Hospitals That Serve Many Black Patients Have Lower Revenues and Profits: Structural Racism in Hospital Financing. J Gen Intern Med 2023; 38:586-591. [PMID: 35931911 PMCID: PMC9361904 DOI: 10.1007/s11606-022-07562-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/30/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND Care for Black patients is concentrated at a relatively small proportion of all US hospitals. Some previous studies have documented quality deficits at Black-serving hospitals, which may be due to inequities in financial resources for care. OBJECTIVE To assess disparities in funding between hospitals associated with the proportion of Black patients that they serve. PARTICIPANTS All Medicare-participating hospitals, 2016-2018. MAIN MEASURES Patient care revenues and profits per patient day at Black-serving hospitals (the top 10% of hospitals ranked by the share of Black patients among all Medicare inpatients) and at other hospitals, unadjusted and adjusted for differences in case mix and hospital characteristics. KEY RESULTS Among the 574 Black-serving hospitals, an average of 43.7% of Medicare inpatients were Black, vs. 5.2% at the 5,166 other hospitals. Black-serving hospitals were slightly larger, and were more often urban, teaching, and for-profit or government (vs. non-profit) owned. Patient care revenues and profits averaged $1,736 and $-17 per patient day respectively at Black-serving hospitals vs. $2,213 and $126 per patient day at other hospitals (p<.001 for both comparisons). Adjusted for patient case mix and hospital characteristics, mean revenues were $283 lower/patient day (p<.001) and mean profits were $111/patient day lower (p<.001) at Black-serving hospitals. Equalizing reimbursement levels would have required $14 billion in additional payments to Black-serving hospitals in 2018, a mean of approximately $26 million per Black-serving hospital. CONCLUSIONS US hospital financing effectively assigns a lower dollar value to the care of Black patients. To reduce disparities in care, health financing reforms should eliminate the underpayment of hospitals serving a large share of Black patients.
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Affiliation(s)
- Gracie Himmelstein
- Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Joniqua N Ceasar
- Departments of Medicine and Pediatrics, The Johns Hopkins Hospital and The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathryn Ew Himmelstein
- Division of Infectious Diseases, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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9
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Park S, Werner RM, Coe NB. Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions. Med Care 2022; 60:872-879. [PMID: 36356289 PMCID: PMC9668368 DOI: 10.1097/mlr.0000000000001770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Enrollment in high-quality Medicare Advantage (MA) plans, measured by a 5-star quality rating system, was lower among racial and ethnic minority enrollees than White enrollees partly due to fewer high-quality plans available in their counties of residence. This may contribute to racial and ethnic disparities in ambulatory care sensitive condition (ACSC) hospitalizations. OBJECTIVE We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating. METHODS Using the Medicare enrollment and claims data for 2016, we identified White, Black, Hispanic, and Asian/Pacific Islander enrollees in MA plans. We estimated racial and ethnic disparities in ACSC hospitalizations (per 10,000 enrollees) overall and by star rating. RESULTS We found that the adjusted rates of ACSC hospitalizations were significantly higher among Black enrollees than White enrollees overall [39.4 (95% confidence interval: 36.3-42.5)]. However, no significant disparities were found among Hispanic and Asian/Pacific Islander enrollees. The adjusted rates of ACSC hospitalizations were higher in lower-rated plans than higher-rated plans in all racial and ethnic groups. The significant disparities in ACSC hospitalizations by star rating were the most pronounced between White and Black enrollees. We found suggestive evidence that enrollment in lower-rated plans was associated with higher disparities in ACSC hospitalizations between White and Black enrollees. CONCLUSIONS Substantial disparities in ACSC hospitalizations exist between White and Black enrollees in MA plans, especially for lower-rated plans. Policies aimed at reducing racial disparities in ACSC hospitalizations could include improving access to high-rated plans.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA
- Department of Health Policy and Management, College of Health Science, Korea University, Seoul, South Korea
| | - Rachel M Werner
- Department of Medicine, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennsylvania
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center
| | - Norma B Coe
- Leonard Davis Institute of Health Economics, University of Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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10
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Sabbatini AK, Joynt-Maddox KE, Liao J, Basu A, Parrish C, Kreuter W, Wright B. Accounting for the Growth of Observation Stays in the Assessment of Medicare's Hospital Readmissions Reduction Program. JAMA Netw Open 2022; 5:e2242587. [PMID: 36394872 PMCID: PMC9672971 DOI: 10.1001/jamanetworkopen.2022.42587] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
IMPORTANCE Decreases in 30-day readmissions following the implementation of the Medicare Hospital Readmissions Reduction Program (HRRP) have occurred against the backdrop of increasing hospital observation stay use, yet observation stays are not captured in readmission measures. OBJECTIVE To examine whether the HRRP was associated with decreases in 30-day readmissions after accounting for observation stays. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included a 20% sample of inpatient admissions and observation stays among Medicare fee-for-service beneficiaries from January 1, 2009, to December 31, 2015. Data analysis was performed from November 2021 to June 2022. A differences-in-differences analysis assessed changes in 30-day readmissions after the announcement of the HRRP and implementation of penalties for target conditions (heart failure, acute myocardial infarction, and pneumonia) vs nontarget conditions under scenarios that excluded and included observation stays. MAIN OUTCOMES AND MEASURES Thirty-day inpatient admissions and observation stays. RESULTS The study included 8 944 295 hospitalizations (mean [SD] age, 78.7 [8.2] years; 58.6% were female; 1.3% Asian; 10.0% Black; 2.0% Hispanic; 0.5% North American Native; 85.0% White; and 1.2% other or unknown). Observation stays increased from 2.3% to 4.4% (91.3% relative increase) of index hospitalizations among target conditions and 14.1% to 21.3% (51.1% relative increase) of index hospitalizations for nontarget conditions. Readmission rates decreased significantly after the announcement of the HRRP and returned to baseline by the time penalties were implemented for both target and nontarget conditions regardless of whether observation stays were included. When only inpatient hospitalizations were counted, decreasing readmissions accrued into a -1.48 percentage point (95% CI, -1.65 to -1.31 percentage points) absolute reduction in readmission rates by the postpenalty period for target conditions and -1.13 percentage point (95% CI, -1.30 to -0.96 percentage points) absolute reduction in readmission rates by the postpenalty period for nontarget conditions. This reduction corresponded to a statistically significant differential change of -0.35 percentage points (95% CI, -0.59 to -0.11 percentage points). Accounting for observation stays more than halved the absolute decrease in readmission rates for target conditions (-0.66 percentage points; 95% CI, -0.83 to -0.49 percentage points). Nontarget conditions showed an overall greater decrease during the same period (-0.76 percentage points; 95% CI, -0.92 to -0.59 percentage points), corresponding to a differential change in readmission rates of 0.10 percentage points (95% CI, -0.14 to 0.33 percentage points) that was not statistically significant. CONCLUSIONS AND RELEVANCE The findings of this study suggest that the reduction of readmissions associated with the implementation of the HRRP was smaller than originally reported. More than half of the decrease in readmissions for target conditions appears to be attributable to the reclassification of inpatient admission to observation stays.
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Affiliation(s)
- Amber K. Sabbatini
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle
| | - Karen E. Joynt-Maddox
- Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri
- Division of Cardiology, Washington University School of Medicine, St Louis, Missouri
| | - Josh Liao
- Department of Medicine, University of Washington School of Medicine, Seattle
- Value System Science Lab, Department of Medicine, University of Washington, Seattle
| | - Anirban Basu
- The Comparative Health Outcomes, Policy, and Economics Institute, University of Washington School of Pharmacy, Seattle
| | - Canada Parrish
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle
| | - William Kreuter
- The Comparative Health Outcomes, Policy, and Economics Institute, University of Washington School of Pharmacy, Seattle
| | - Brad Wright
- Department of Health Services, Policy and Management University of South Carolina School of Public Health, Columbia
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11
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Surbhi S, Chen M, Shuvo SA, Price-Haywood E, Shi L, Mann J, Lin Y, Le PL, Burton JH, Bailey JE. Effect of continuity of care on emergency department and hospital visits for obesity-associated chronic conditions: A federated cohort meta-analysis. J Natl Med Assoc 2022; 114:525-533. [PMID: 35977848 DOI: 10.1016/j.jnma.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 05/09/2022] [Accepted: 07/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Obesity-associated chronic conditions (OCC) are prevalent in medically underserved areas of the Southern US. Continuity of care with a primary care provider is associated with reduced preventable healthcare utilization, yet little is known regarding the impact of continuity of care among populations with OCC. This study aimed to examine whether continuity of care protects patients living with OCC and the subgroup with type 2 diabetes (OCC+T2D) from emergency department (ED) and hospitalizations, and whether these effects are modified by race and patient residence in health professional shortage areas (HPSA) METHODS: We conducted a retrospective federated cohort meta-analysis of 2015-2018 data from four large practice-based research networks in the Southern U.S. among adult patients with obesity and one more more additional diagnosed OCC. The outcomes included overall and preventable ED visits and hospitalizations. Continuity of care was assessed at the clinic-level using the Bice-Boxerman Continuity of Care Index RESULTS: A total of 111,437 patients with OCC and 47,071 patients with OCC+T2D from the four large practice-based research networks in the South were included in the meta-analysis. Continuity of Care index varied among sites from a mean (SD) of 0.6 (0.4) to 0.9 (0.2). Meta-analysis demonstrated that, regardless of race or residence in HPSA, continuity of care significantly protected OCC patients from preventable ED visits (IRR:0.95; CI:0.92-0.98) and protected OCC+T2D patients from overall ED visits (IRR:0.92; CI:0.85-0.99), preventable ED visits (IRR:0.95; CI:0.91-0.99), and overall hospitalizations (IRR:0.96; CI:0.93-0.98) CONCLUSION: Improving continuity of care may reduce ED and hospital use for patients with OCC and particularly those with OCC+T2D.
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Affiliation(s)
- Satya Surbhi
- Center for Health System Improvement, College of Medicine, University of Tennessee Health Science Center, 956 Court Ave, Coleman D224 A, Memphis, TN 38163, USA.
| | - Ming Chen
- Center for Health System Improvement, College of Medicine, University of Tennessee Health Science Center, 956 Court Ave, Coleman D224 A, Memphis, TN 38163, USA
| | - Sohul A Shuvo
- Center for Health System Improvement, College of Medicine, University of Tennessee Health Science Center, 956 Court Ave, Coleman D224 A, Memphis, TN 38163, USA
| | - Eboni Price-Haywood
- Ochsner Xavier Institute for Health Equity and Research, Ochsner Health System, New Orleans, LA, USA
| | - Lizheng Shi
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Joshua Mann
- Department of Preventive Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Yilu Lin
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Phi L Le
- Department of Preventive Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jeffrey H Burton
- Ochsner Xavier Institute for Health Equity and Research, Ochsner Health System, New Orleans, LA, USA
| | - James E Bailey
- Center for Health System Improvement, College of Medicine, University of Tennessee Health Science Center, 956 Court Ave, Coleman D224 A, Memphis, TN 38163, USA
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12
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Oh NL, Potter AJ, Sabik LM, Trivedi AN, Wolinsky F, Wright B. The association between primary care use and potentially-preventable hospitalization among dual eligibles age 65 and over. BMC Health Serv Res 2022; 22:927. [PMID: 35854303 PMCID: PMC9295296 DOI: 10.1186/s12913-022-08326-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022] Open
Abstract
Background Individuals dually-enrolled in Medicare and Medicaid (dual eligibles) are disproportionately sicker, have higher health care costs, and are hospitalized more often for ambulatory care sensitive conditions (ACSCs) than other Medicare beneficiaries. Primary care may reduce ACSC hospitalizations, but this has not been well studied among dual eligibles. We examined the relationship between primary care and ACSC hospitalization among dual eligibles age 65 and older. Methods In this observational study, we used 100% Medicare claims data for dual eligibles ages 65 and over from 2012 to 2018 to estimate the likelihood of ACSC hospitalization as a function of primary care visits and other factors. We used linear probability models stratified by rurality, with subgroup analyses for dual eligibles with diabetes or congestive heart failure. Results Each additional primary care visit was associated with an 0.05 and 0.09 percentage point decrease in the probability of ACSC hospitalization among urban (95% CI: − 0.059, − 0.044) and rural (95% CI: − 0.10, − 0.08) dual eligibles, respectively. Among dual eligibles with CHF, the relationship was even stronger with decreases of 0.09 percentage points (95% CI: − 0.10, − 0.08) and 0.15 percentage points (95% CI: − 0.17, − 0.13) among urban and rural residents, respectively. Conclusions Increased primary care use is associated with lower rates of preventable hospitalizations for dual eligibles age 65 and older, especially for dual eligibles with diabetes and congestive heart failure. In turn, efforts to reduce preventable hospitalizations for this dual-eligible population should consider how to increase access to and use of primary care. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08326-2.
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Affiliation(s)
- N Loren Oh
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.,Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Andrew J Potter
- Department of Political Science & Criminal Justice, California State University, Chico, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Amal N Trivedi
- Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, USA
| | - Fredric Wolinsky
- Department of Health Management and Policy, College of Public Health, University of Iowa, Iowa City, USA
| | - Brad Wright
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA. .,Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, 590 Manning Dr. CB 7595, Chapel Hill, NC, 27599, USA.
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13
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Dickman SL, Gaffney A, McGregor A, Himmelstein DU, McCormick D, Bor DH, Woolhandler S. Trends in Health Care Use Among Black and White Persons in the US, 1963-2019. JAMA Netw Open 2022; 5:e2217383. [PMID: 35699954 PMCID: PMC9198752 DOI: 10.1001/jamanetworkopen.2022.17383] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
IMPORTANCE In the US, Black people receive less health care than White people. Data on long-term trends in these disparities, which provide historical context for interpreting contemporary inequalities, are lacking. OBJECTIVE To assess trends in Black-White disparities in health care use since 1963. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study analyzed 29 US surveys conducted between 1963 and 2019 of noninstitutionalized Black and non-Hispanic White civilians. EXPOSURES Self-reported race and ethnicity. MAIN OUTCOMES AND MEASURES Annual per capita visit rates (for ambulatory, dental, and emergency department care), inpatient hospitalization rates, and total per capita medical expenditures. RESULTS Data from 154 859 Black and 446 944 White (non-Hispanic) individuals surveyed from 1963 to 2019 were analyzed (316 503 [52.6%] female; mean [SD] age, 37.0 [23.3] years). Disparities narrowed in the 1970s in the wake of landmark civil rights legislation and the implementation of Medicare and Medicaid but subsequently widened. For instance, the White-Black gap in ambulatory care visits decreased from 1.2 (95% CI, 1.0-1.4) visits per year in 1963 to 0.8 (95% CI, 0.6-1.0) visits per year in the 1970s and then increased, reaching 3.2 (95% CI, 3.0-3.4) visits per year in 2014 to 2019. Even among privately insured adults aged 18 to 64 years, White individuals used far more ambulatory care (2.6 [95% CI, 2.4-2.8] more visits per year) than Black individuals in 2014 to 2019. Similarly, White peoples' overall health care use, measured in dollars per capita, exceeded that of Black people in every year. After narrowing from 1.96 in the 1960s to 1.26 in the 1970s, the White-Black expenditure ratio began widening in the 1980s, reaching 1.46 in the 1990s; it remained between 1.31 and 1.39 in subsequent periods. CONCLUSIONS AND RELEVANCE This study's findings indicate that racial inequities in care have persisted for 6 decades and widened in recent years, suggesting the persistence and even fortification of structural racism in health care access. Reform efforts should include training more Black health care professionals, investments in Black-serving health facilities, and implementing universal health coverage that eliminates cost barriers.
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Affiliation(s)
- Samuel L. Dickman
- Texas Policy Evaluation Project, The University of Texas at Austin, Austin
- Planned Parenthood South Texas, San Antonio, Texas
| | - Adam Gaffney
- Division of Pulmonary and Critical Care Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
| | - Alecia McGregor
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David U. Himmelstein
- City University of New York at Hunter College, New York, New York
- Department of Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
- Public Citizen Health Research Group, Washington, DC
| | - Danny McCormick
- Department of Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
| | - David H. Bor
- Department of Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, New York
- Department of Medicine, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts
- Public Citizen Health Research Group, Washington, DC
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14
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Underlying Factors of Health Insurance Use Among Blacks and Hispanics With Ambulatory Care-Sensitive Conditions. J Ambul Care Manage 2022; 45:114-125. [PMID: 35202028 DOI: 10.1097/jac.0000000000000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study examined satisfaction with and confidence in understanding health insurance use among Blacks and Hispanic Americans with ambulatory care-sensitive conditions. Using the 2013-2016 Health Reform Monitoring Survey data sets, descriptive statistics and ordinary least-square regressions estimated the association between satisfaction and confidence scores and racial or ethnic groups with ambulatory care-sensitive conditions. Compared with their White counterparts, Black (β = -.13; 95% confidence interval [CI], -0.19 to -0.06) and Hispanic (β = -0.41; 95% CI, -0.48 to -0.33) participants' standardized confidence scores were significantly lower. Research is needed to identify factors that may enhance this population's confidence level.
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15
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Park S, Fishman P, Coe NB. Racial Disparities in Avoidable Hospitalizations in Traditional Medicare and Medicare Advantage. Med Care 2021; 59:989-996. [PMID: 34432767 PMCID: PMC8519483 DOI: 10.1097/mlr.0000000000001632] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IMPORTANCE Compared with traditional Medicare (TM), Medicare Advantage (MA) has the potential to reduce racial disparities in hospitalizations for ambulatory care sensitive conditions (ACSC). As racial disparities may be partly attributable to unequal treatment based on where people live, this suggests the need of examining geographic variations in racial disparities. OBJECTIVE The aim of this study was to examine differences in ACSC hospitalizations between White and Black beneficiaries in TM and MA and examine geographic variations in racial differences in ACSC hospitalizations in TM and MA. METHODS We analyzed the 2015-2016 Medicare Provider Analysis and Review files. We used propensity score matching to account for differences in characteristics between TM and MA beneficiaries. Then, we conducted linear regression and estimated adjusted outcomes for TM and MA beneficiaries by race. Also, we estimated racial differences in adjusted outcomes by insurance and hospital referral region (HRR). RESULTS While White beneficiaries in TM and MA had similar rates of ACSC hospitalizations (163.7 vs. 162.2/10,000 beneficiaries), Black beneficiaries in MA had higher rates of ACSC hospitalizations than Black beneficiaries in TM (221.2 vs. 209.3/10,000 beneficiaries). However, the racial differences were greater in MA than TM (59.0 vs. 45.6/10,000 beneficiaries). Racial differences in ACSC hospitalizations in MA were prevalent across almost all HRRs. 95.5% of HRRs had higher rates of ACSC hospitalizations among Black beneficiaries than White beneficiaries in MA relative to just 54.2% of HRRs in TM. CONCLUSION Our findings provide evidence of racial disparities in access to high-quality primary care, especially in MA.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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16
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Johnston KJ, Hammond G, Meyers DJ, Joynt Maddox KE. Association of Race and Ethnicity and Medicare Program Type With Ambulatory Care Access and Quality Measures. JAMA 2021; 326:628-636. [PMID: 34402828 PMCID: PMC8371568 DOI: 10.1001/jama.2021.10413] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE There are racial inequities in health care access and quality in the United States. It is unknown whether such differences for racial and ethnic minority beneficiaries differ between Medicare Advantage and traditional Medicare or whether access and quality are better for minority beneficiaries in 1 of the 2 programs. OBJECTIVE To compare differences in rates of enrollment, ambulatory care access, and ambulatory care quality by race and ethnicity in Medicare Advantage vs traditional Medicare. DESIGN, SETTING, AND PARTICIPANTS Exploratory observational cohort study of a nationally representative sample of 45 833 person-years (26 887 persons) in the Medicare Current Beneficiary Survey from 2015 to 2018, comparing differences in program enrollment and measures of access and quality by race and ethnicity. EXPOSURES Minority race and ethnicity (Black, Hispanic, Native American, or Asian/Pacific Islander) vs White or multiracial; Medicare Advantage vs traditional Medicare enrollment. MAIN OUTCOMES AND MEASURES Six patient-reported measures of ambulatory care access (whether a beneficiary had a usual source of care in the past year, had a primary care clinician usual source of care, or had a specialist visit) and quality (influenza vaccination, pneumonia vaccination, and colon cancer screening). RESULTS The final sample included 6023 persons (mean age, 68.9 [SD, 12.6] years; 57.3% women) from minority groups and 20 864 persons (mean age, 71.9 [SD, 10.8] years; 54.9% women) from White or multiracial groups, who accounted for 9816 and 36 017 person-years, respectively. Comparing Medicare Advantage vs traditional Medicare among minority beneficiaries, those in Medicare Advantage had significantly better rates of access to a primary care clinician usual source of care (79.1% vs 72.5%; adjusted marginal difference, 4.0%; 95% CI, 1.0%-6.9%), influenza vaccinations (67.3% vs 63.0%; adjusted marginal difference, 5.2%; 95% CI, 1.9%-8.5%), pneumonia vaccinations (70.7% vs 64.6%; adjusted marginal difference, 6.1%; 95% CI, 2.7%-9.4%), and colon cancer screenings (69.4% vs 61.1%; adjusted marginal difference, 7.1%; 95% CI, 3.8%-10.3%). Comparing minority vs White or multiracial beneficiaries across both programs, minority beneficiaries had significantly lower rates of access to a primary care clinician usual source of care (adjusted marginal difference, 4.7%; 95% CI, 2.5%-6.8%), specialist visits (adjusted marginal difference, 10.8%; 95% CI, 8.3%-13.3%), influenza vaccinations (adjusted marginal difference, 4.3%; 95% CI, 1.2%-7.4%), and pneumonia vaccinations (adjusted marginal difference, 6.4%; 95% CI, 3.9%-9.0%). The interaction of race and ethnicity with insurance type was not statistically significant for any of the 6 outcome measures. CONCLUSIONS AND RELEVANCE In this exploratory study of Medicare beneficiaries in 2015-2018, enrollment in Medicare Advantage vs traditional Medicare was significantly associated with better outcomes for access and quality among minority beneficiaries; however, minority beneficiaries were significantly more likely to experience worse outcomes for most access and quality measures than White or multiracial beneficiaries in both programs.
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Affiliation(s)
- Kenton J. Johnston
- Department of Health Management and Policy, Saint Louis University, St Louis, Missouri
| | - Gmerice Hammond
- Washington University School of Medicine, St Louis, Missouri
| | - David J. Meyers
- Department of Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
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17
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Leuchter RK, Villaflores CWA, Norris KC, Sorensen A, Vangala S, Sarkisian CA. Racial Disparities in Potentially Avoidable Hospitalizations During the COVID-19 Pandemic. Am J Prev Med 2021; 61:235-239. [PMID: 33820665 PMCID: PMC8319069 DOI: 10.1016/j.amepre.2021.01.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/22/2021] [Accepted: 01/29/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Potentially avoidable hospitalizations are disproportionately experienced by racial and ethnic minorities and expose these groups to unnecessary iatrogenic harm (including the risk of nosocomial COVID-19) and undue financial burden. In working toward an overarching goal of eliminating racial and ethnic health disparities, it is important to understand whether and to what extent potentially avoidable hospitalizations have changed by race and ethnicity during the COVID-19 pandemic. METHODS This single-center pre-post study included patients admitted to any UCLA Health hospital for an ambulatory care-sensitive condition between March-August 2019 (prepandemic period) and March-August 2020 (postpandemic period). Investigators measured the change in the number of potentially avoidable hospitalizations (defined per the Agency for Healthcare Research and Quality guidelines) stratified by race and ethnicity and calculated the 95% CIs for these hospitalizations using a cluster bootstrap procedure. RESULTS Between March 1, 2020 and August 31, 2020, 347 of 4,838 hospitalizations (7.2%) were potentially avoidable, compared with 557 of 6,248 (8.9%) during the same 6-month period in 2019. Potentially avoidable hospitalizations decreased by 50.3% (95% CI=41.2, 60.9) among non-Hispanic Whites but only by 8.0% (95% CI= -16.2, 39.9) among African Americans (50.3% vs 8.0%, p=0.015). CONCLUSIONS Racial disparities in potentially avoidable hospitalizations increased during the COVID-19 pandemic at a large urban health system. Given that the prepandemic rates of potentially avoidable hospitalizations were already higher among racial and ethnic minorities, especially among African Americans, this finding should cause alarm and lead to further exploration of the complex factors contributing to these disparities.
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Affiliation(s)
- Richard K Leuchter
- Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California.
| | - Chad Wes A Villaflores
- Division of Geriatric Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Keith C Norris
- Division of General Internal Medicine & Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Andrea Sorensen
- Division of Geriatric Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Sitaram Vangala
- Department of Medicine Statistics Core, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Catherine A Sarkisian
- Division of Geriatric Medicine, Department of Medicine, David Geffen School of Medicine, UCLA, Los Angeles, California; Greater Los Angeles VA Healthcare System Geriatrics Research Education and Clinical Center (GRECC), Los Angeles, California
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18
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Mehtsun WT, Orav EJ, Phelan J, Lipa SA, Dimick JB, Jha AK, Figueroa JF. Disparities in Surgical Readmissions and Use of Observation Status in Hip and Knee Replacements: A Retrospective Cohort Study. Ann Surg 2021; 274:e90-e91. [PMID: 33630446 PMCID: PMC8928569 DOI: 10.1097/sla.0000000000004806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Winta T Mehtsun
- Department of Surgery, Dana Farber Cancer Institute, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts
| | - E John Orav
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jessica Phelan
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ashish K Jha
- Brown University School of Public Health, Providence, Rhode Island
| | - Jose F Figueroa
- Department of Health Policy & Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Himmelstein DU, Woolhandler S. Health Care Crisis Unabated: A Review of Recent Data on Health Care in the United States. INTERNATIONAL JOURNAL OF HEALTH SERVICES 2020; 51:182-187. [PMID: 33334224 DOI: 10.1177/0020731420981497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We review recently published studies of US health policy and the nation's health care system. Even prior to the COVID-19 pandemic, health inequalities were widening and care was inequitably distributed. Although the Affordable Care Act's coverage expansion improved access to care and timely cancer diagnoses, a large proportion of US residents continued to avoid medical care due to concerns about costs, and access to mental health services remains particularly inadequate. Yet more evidence of private insurers' profit-driven misbehaviors and of corruption among medical leaders continues to emerge. Misguided incentives and lax regulation encourages nominally nonprofit health care providers to mimic for-profits' misconduct, and rapacious investors own and control an increasing share of physicians' practices. Pharmaceutical firms wield outsize political influence and devote far more funds to rewarding investors than to research and development effort. Yet despite vigorous efforts by pharma and other commercial interests to denigrate national health insurance, polls indicate that the COVID-19 pandemic has led to increasing support for such reform.
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Affiliation(s)
- David U Himmelstein
- School of Urban Public Health, City University of New York at Hunter College, New York, NY, USA
| | - Steffie Woolhandler
- School of Urban Public Health, City University of New York at Hunter College, New York, NY, USA
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