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Mahmoudi E, Margosian S, Lin P. Racial/Ethnic Disparities in Hospital Readmission and Frequent Hospitalizations Among Medicare Beneficiaries With Alzheimer's Disease and Related Dementia: Traditional Medicare Versus Medicare Advantage. J Gerontol B Psychol Sci Soc Sci 2024; 79:gbae078. [PMID: 38733162 PMCID: PMC11212310 DOI: 10.1093/geronb/gbae078] [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: 09/09/2023] [Indexed: 05/13/2024] Open
Abstract
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.
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Affiliation(s)
- Elham Mahmoudi
- Department of Family Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Sara Margosian
- Department of Family Medicine, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Prusynski RA, Gold LS, Rundell SD. Utilization and Potential Disparities in Access to Physical Therapy for Spine Pain in the Long-Term Care Population. Arch Phys Med Rehabil 2024:S0003-9993(24)01051-7. [PMID: 38866228 DOI: 10.1016/j.apmr.2024.05.032] [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: 05/02/2024] [Revised: 05/23/2024] [Accepted: 05/24/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE To determine the frequency of physical therapy (PT) services and potential disparities in receiving PT among Medicare fee-for-service beneficiaries with a history of spine pain who live in long-term care (LTC) settings. DESIGN Secondary cross-sectional analysis of Medicare administrative data on beneficiaries with a history of spine pain from 2017-2019. We identified LTC residents using a validated algorithm, then identified and described PT episodes that occurred after the LTC index date. To identify potential disparities in access to PT services, we performed multivariable logistic regression to determine resident demographic, clinical, and community factors associated with receiving PT. SETTING Not applicable. PARTICIPANTS Medicare fee-for-service LTC residents aged ≥65 years. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Receiving PT services. RESULTS Of the 999,495 LTC residents with a history of spine pain, 49.6% received PT. Only 12.1% of PT episodes specifically treated spine pain. The odds of receiving PT were higher for residents with pain in multiple spine regions or neuropathic pain (OR, 1.27; 95% confidence interval CI, 1.26-1.29) and for residents with inpatient admissions (OR, 1.76; 95% CI, 1.75-1.78). Odds of receiving PT were lower for residents from minoritized racial and ethnic groups, and for residents with dementia (OR, 0.89; 95% CI, 0.88-0.90), depression (OR, 0.95; 95% CI, 0.94-0.96), or who lived in urban or more socioeconomically deprived areas. CONCLUSIONS Although nearly half of LTC residents with histories of spine pain received PT services, most PT was not for spine pain. There are potential disparities in access to PT for LTC residents from minoritized groups living in urban and more deprived areas. Further work should examine PT outcomes and remove barriers to PT for LTC residents with histories of spine pain.
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Affiliation(s)
- Rachel A Prusynski
- Department of Rehabilitation Medicine, Division of Physical Therapy, University of Washington, Seattle WA; Department of Health Services and Population Health, University of Washington Seattle, WA.
| | - Laura S Gold
- Evidence and Research (CLEAR) Center for Musculoskeletal Disorders, the University of Washington Clinical Learning, Seattle, WA
| | - Sean D Rundell
- Department of Rehabilitation Medicine, Division of Physical Therapy, University of Washington, Seattle WA; Evidence and Research (CLEAR) Center for Musculoskeletal Disorders, the University of Washington Clinical Learning, Seattle, WA
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Ma C, Rajewski M, Smith JM. Medicare Advantage and Home Health Care: A Systematic Review. Med Care 2024; 62:333-345. [PMID: 38546388 PMCID: PMC10997464 DOI: 10.1097/mlr.0000000000001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
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.
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Affiliation(s)
- Chenjuan Ma
- Rory Meyers College of Nursing, New York University, New York, NY
| | - Martha Rajewski
- Rory Meyers College of Nursing, New York University, New York, NY
| | - Jamie M Smith
- School of Nursing, Johns Hopkins University, Baltimore, MD
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Burgdorf JG, Ritchie CS, Reckrey JM, Liu B, McDonough C, Ornstein KA. Drivers of Community-Entry Home Health Care Utilization Among Older Adults. J Am Med Dir Assoc 2024; 25:697-703.e2. [PMID: 37931897 PMCID: PMC10990820 DOI: 10.1016/j.jamda.2023.09.031] [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: 07/13/2023] [Revised: 09/21/2023] [Accepted: 09/26/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVES A growing proportion of Medicare home health (HH) patients are "community-entry," meaning referred to HH without a preceding hospitalization. We sought to identify factors that predict community-entry HH use among older adults to provide foundational information regarding care needs and circumstances that may prompt community-entry HH referral. DESIGN Nationally representative cohort study. SETTING AND PARTICIPANTS Health and Retirement Study (HRS) respondents who were aged ≥65 years, community-living, and enrolled in Medicare between 2012 and 2018 (n = 11,425 unique individuals providing 27,026 two-year observation periods). METHODS HRS data were linked with standardized HH patient assessments. Community-entry HH utilization was defined as incurring one or more HH episode with no preceding hospitalization or institutional post-acute care stay (determined via assessment item indicating institutional care within 14 days of HH admission) within 2 years of HRS interview. Weighted, multivariable logistic regression was used to model community-entry HH use as a function of individual, social support, and community characteristics. RESULTS The overall rate of community-entry HH utilization across observation periods was 13.4%. Older adults had higher odds of community-entry HH use if they were Medicaid enrolled [adjusted odds ratio (aOR) = 1.49, P = .001], had fair or poor overall health (aOR = 1.48, P < .001), 3+ activities of daily living limitations (aOR = 1.47, P = .007), and had fallen in the past 2 years (aOR = 1.43, P < .001). Compared with those receiving no caregiver help, individuals were more likely to use community-entry HH if they received family or unpaid help only (aOR = 1.81, P < .001), both family and paid help (aOR = 2.79, P < .001), or paid help only (aOR: 3.46, P < .001). CONCLUSIONS AND IMPLICATIONS Findings indicate that community-entry HH serves a population with long-term care needs and coexisting clinical complexity, making this an important setting to provide skilled care and prevent avoidable health care utilization. Results highlight the need for ongoing monitoring of community-entry HH accessibility as this service is a key component of home-based care for a high-need subpopulation.
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Affiliation(s)
- Julia G Burgdorf
- Center for Home Care Policy & Research, VNS Health, New York, NY, USA
| | - Christine S Ritchie
- Mongan Institute Center for Aging and Serious Illness, Division of Palliative Care and Geriatric Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jennifer M Reckrey
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Catherine McDonough
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Katherine A Ornstein
- Center for Equity in Aging, Johns Hopkins School of Nursing, Baltimore, MD, USA.
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Prusynski RA, D’Alonzo A, Johnson MP, Mroz TM, Leland NE. Differences in Home Health Services and Outcomes Between Traditional Medicare and Medicare Advantage. JAMA HEALTH FORUM 2024; 5:e235454. [PMID: 38427341 PMCID: PMC10907922 DOI: 10.1001/jamahealthforum.2023.5454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024] Open
Abstract
Importance Private Medicare Advantage (MA) plans recently surpassed traditional Medicare (TM) in enrollment. However, MA plans are facing scrutiny for burdensome prior authorization and potential rationing of care, including home health. MA beneficiaries are less likely to receive home health, but recent evidence on differences in service intensity and outcomes among home health patients is lacking. Objective To examine differences in home health service intensity and patient outcomes between MA and TM. Design, Setting, and Participants This cross-sectional study was conducted from January 2019 to December 2022 in 102 home health locations in 19 states and included 178 195 TM and 107 102 MA patients 65 years or older with 2 or fewer 60-day home health episodes. It included a secondary analysis of standardized assessment and visit data. Inverse probability of treatment weighting regression compared service intensity and patient outcomes between MA and TM episodes, accounting for differences in demographic characteristics, medical complexity, functional and cognitive impairments, social environment, caregiver support, and local community factors. Models included office location, year, and reimbursement policy fixed effects. Data were analyzed between September 2023 and July 2024. Exposure TM vs MA plan. Main Outcomes and Measures Home health length of stay and number of visits from nursing, physical, occupational, and speech therapy, social work, and home health aides. Patient outcomes included improvement in self-care and mobility function, discharge to the community, and transfer to an inpatient facility during home health. Results Of 285 297 total patients, 180 283 (63.2%) were female; 586 (0.2%) were American Indian/Alaska Native, 8957 (3.1%) Asian, 28 694 (10.1%) Black, 7406 (2.6%) Hispanic, 1959 (0.7%) Native Hawaiian/Pacific Islander, 237 017 (83.1%) non-Hispanic White, and 678 (0.2%) multiracial individuals. MA patients had shorter home health length of stay by 1.62 days (95% CI, -1.82 to 1.42) and received fewer visits from all disciplines except social work. There were no differences in inpatient transfers. MA patients had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively (mobility odds ratio [OR], 0.97; 95% CI, 0.94-0.99; self-care OR, 0.96; 95% CI, 0.92-0.99). MA patients were 5% more likely to discharge to the community compared with TM (OR, 1.05; 95% CI, 1.01-1.08). Conclusions and Relevance The results of this cross-sectional study suggest that MA patients receive shorter and less intensive home health care vs TM patients with similar needs. Differences may be due to the administrative burden and cost-limiting incentives of MA plans. MA patients experienced slightly worse functional outcomes but were more likely to discharge to the community, which may have negative implications for MA patients, including reduced functional independence or increased caregiver burden.
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Affiliation(s)
| | | | | | - Tracy M. Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Natalie E. Leland
- Department of Occupational Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
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Jacobson G, Blumenthal D. The Predominance of Medicare Advantage. N Engl J Med 2023; 389:2291-2298. [PMID: 38091536 DOI: 10.1056/nejmhpr2302315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Gretchen Jacobson
- From the Commonwealth Fund, New York (G.J.); and Harvard T.H. Chan School of Public Health, Boston (D.B.)
| | - David Blumenthal
- From the Commonwealth Fund, New York (G.J.); and Harvard T.H. Chan School of Public Health, Boston (D.B.)
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Leff B, Ritchie C, Ciemins E, Dunning S. Prevalence of use and characteristics of users of home-based medical care in Medicare Advantage. J Am Geriatr Soc 2023; 71:455-462. [PMID: 36222194 PMCID: PMC11226183 DOI: 10.1111/jgs.18085] [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: 03/31/2022] [Revised: 09/07/2022] [Accepted: 09/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND/OBJECTIVES Home-based medical care (HBMC) is longitudinal medical care provided by physicians, advanced practice providers, and, often, inter-professional care teams to patients in their homes. Our objective is to determine the prevalence of HBMC among older adults (≥65) insured by a Medicare Advantage (MA) plan and compare characteristics of those who receive HBMC to those who do not. METHODS Study used de-identified medical claims and enrollment records for MA beneficiaries during calendar years 2017 and 2018 linked with socioeconomic status data in the OptumLabs Data Warehouse. We defined a cohort of MA beneficiaries age ≥65 receiving HBMC for at least 2 months during 2017-2018, described the cohort using demographic, utilization, and comorbidity data and compared it to a 5% random sample of a population of MA beneficiaries age ≥65 not receiving HBMC (No HBMC). RESULTS Overall, 1.45% of the study cohort age ≥65 received HBMC. Compared to No HBMC (n = 132,147), those receiving HBMC (n = 38,800) were more likely to be: older (46.6% vs. 11.9% age 85+); female (70.8% vs. 58.5%); Black (12.3% vs. 11.3%); urban (90.3% vs. 81.3%); experience hospitalization (38.0% vs. 13.3%), emergency department visit (58.3% vs. 26.9%), ambulance trip (44.1% vs. 9.6%), skilled nursing facility (37.6% vs. 6.4%), or hospice care admission (21.1% vs. 3.5%). They also were more likely to experience a wide range of chronic conditions including dementia (58.1% vs. 5.2%), morbidity burden (Charlson score 3.4 vs. 1.8), and serious illness (77.1% vs. 29.5%). All comparisons p < 0.0001. CONCLUSIONS MA beneficiaries who received HBMC are older, experience greater chronic and serious illness burden, and higher levels of facility-based care than those who did not receive HBMC. MA plans need strategies to identify patients that would benefit from HBMC and develop approaches to deliver such care to this impactful, often invisible population.
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Affiliation(s)
- Bruce Leff
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Transformative Geriatrics Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Community and Public Health, Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth Ciemins
- Analytics Department, AMGA (American Medical Group Association), Alexandria, Virginia, USA
| | - Stephan Dunning
- Outset Medical, Health Economics and Market Access, San Jose, California, USA
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Casebeer AW, Ronning D, Schwartz R, Long C, Bhattacharya R, Uribe C, Brown CR, Cameron J, Painter P, Sharma A, Spitale S, Powers B, Stemple C, Shrank W. A Comparison of Home Health Utilization, Outcomes, and Cost Between Medicare Advantage and Traditional Medicare. Med Care 2022; 60:66-74. [PMID: 34739413 DOI: 10.1097/mlr.0000000000001661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Home health use is rising rapidly in the United States as the population ages, the prevalence of chronic disease increases, and older Americans express their desire to age at home. Enrollment in Medicare Advantage (MA) plans rather than Traditional Medicare (TM) has grown as well, from 13% of total Medicare enrollment in 2004 to 39% in 2020. Despite these shifts, little is known about outcomes and costs following home health in MA as compared with TM. OBJECTIVE The objective of this study was to measure the association of MA enrollment with outcomes and costs for patients using home health. DESIGN This was a retrospective cohort study. PARTICIPANTS Patients enrolled in plans offered by 1 large, national MA organization and patients enrolled in TM, with at least 1 home health visit between January 1, 2017, and June 30, 2018. EXPOSURE MA enrollment. MAIN MEASURES We compared the intensity of home health services and types of care delivered. The main outcome measures were hospitalization, the proportion of days in the home, and total allowed costs during the 180-day period following the first qualifying home health visit during the study period. KEY RESULTS Among patients who used home health, our models demonstrated enrollment in MA was associated with 14%, and 6% decreased odds of 60- and 180-day hospitalization, respectively, a 12.8% and 14.7% decrease in medical costs exclusive and inclusive of home health costs, respectively, and a 0.27% increase in the proportion of days at home during the 180-day follow-up, equivalent to an additional half-day at home. There were few differences in home health care delivered for MA and TM [mean number of visits in the first episode of care (17.1 vs. 17.3) and mean visits per week (3.2 vs. 3.3)]. The mean number of visits by visit type and percent of patients with each type was similar between MA and TM as well. CONCLUSIONS Compared with enrollment in TM, enrollment in MA was associated with improved patient-centered outcomes and lower cost and utilization, despite few differences in the way home health was delivered. These findings might be explained by structural components of MA that encourage better care management, but further investigation is needed to clarify the mechanisms by which MA enrollment may lead to higher value home health care.
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Sood N, Yang Z, Huckfeldt P, Escarce J, Popescu I, Nuckols T. Geographic Variation in Medicare Fee-for-Service Health Care Expenditures Before and After the Passage of the Affordable Care Act. JAMA HEALTH FORUM 2021; 2:e214122. [PMID: 35977300 PMCID: PMC8796890 DOI: 10.1001/jamahealthforum.2021.4122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/18/2021] [Indexed: 12/01/2022] Open
Abstract
Question Which categories of spending were associated with reductions in geographic variation of Medicare per-beneficiary spending across the US after the passage of the Affordable Care Act? Findings In this cross-sectional study of Medicare enrollees aged 65 years or older, geographic variation in Medicare fee-for-service spending per beneficiary was stable from 2007 to 2011 and then declined steadily from 2012 to 2018. A key factor associated with reduced geographic variation in spending was reduced variation in postacute care spending, specifically home health spending. Meaning These findings suggest that antifraud enforcement efforts and payment reforms that were instituted as part of the Affordable Care Act may have reduced geographic variation in Medicare fee-for-service per-beneficiary spending, although significant geographic variation remains. Importance Geographic variation in Medicare spending is often used as a measure of wasteful spending. A 2013 Institute of Medicine report found that postacute care was a key contributor of geographic variation from 2007 to 2009. However, payment reforms and antifraud efforts implemented after the passage of the Affordable Care Act (ACA) may have reduced geographic variation in spending, especially postacute care spending. Objective To investigate how geographic variation in Medicare fee-for-service per-beneficiary spending changed from 2007 to 2018 before and after passage of the ACA. Design, Setting, and Participants This cross-sectional study included all fee-for-service Medicare enrollees 65 years or older from January 1, 2007, to December 31, 2018. The fee-for-service Medicare Geographic Variation Public Use File was used to group hospital referral regions (HRRs) in each year into deciles (10 equal groups) based on per-beneficiary total spending. The difference between the per-beneficiary monthly spending in each decile and the national mean, as well as the ratio of per-beneficiary total spending in the top deciles to that of the bottom decile, were reported. Data analysis occurred from July 22, 2019, to October 21, 2021. Main Outcomes and Measures Per-beneficiary spending on hospital inpatient, hospital outpatient, physician, and postacute care (and type of postacute care). Results There were 27.2 million fee-for-service beneficiaries in 2007 (58.0% women) and 28.3 million beneficiaries in 2018 (55.9% women). Per-beneficiary Medicare spending was $9691 in 2007 and $9847 in 2018 (using inflation-adjusted 2018 dollars). Geographic variation in Medicare spending was stable from 2007 to 2011 and then declined steadily from 2012 to 2018. The ratio of per-beneficiary total Medicare spending in the HRRs in the top decile to the bottom decile was 1.68 in 2007 ($415 monthly difference in spending) but only 1.56 ($361 monthly difference in spending) in 2018 (estimated change, −0.12 [95% CI, −0.21 to −0.02]; P = .01). Focusing on specific spending categories, the only statistically significant reductions in geographic variation were found for home health; the ratio of home health spending among HRRs in the top to bottom deciles of total Medicare spending fell from 5.14 in 2007 to 3.45 in 2018 (change, −1.69 [95% CI, −3.30 to −0.09]; P = .04). Conclusions and Relevance Geographic variation in total per-beneficiary Medicare spending fell from 2007 to 2018, with home health spending being a key factor associated with geographic variation. The ACA’s value-based payment programs and enhanced integrity efforts in home health provide a possible explanation for the decrease.
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Affiliation(s)
- Neeraj Sood
- Sol Price School of Public Policy, University of Southern California, Los Angeles
| | - Zhiyou Yang
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Boston
| | - Peter Huckfeldt
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis
| | - José Escarce
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA (University of California, Los Angeles)
- Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Ioana Popescu
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA (University of California, Los Angeles)
| | - Teryl Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Comparing Receipt of Prescribed Post-acute Home Health Care Between Medicare Advantage and Traditional Medicare Beneficiaries: an Observational Study. J Gen Intern Med 2021; 36:2323-2331. [PMID: 33051838 PMCID: PMC8342740 DOI: 10.1007/s11606-020-06282-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Medicare Advantage (MA) covers more than 1/3rd of all Medicare beneficiaries. MA plans are required to provide the same benefits as Traditional Medicare (TM), but can impose utilization management tools to control costs. OBJECTIVE To assess differences between TM and MA enrollees in the probability of receiving prescribed post-acute home health (HH) care and to describe MA plan characteristics associated with HH receipt. DESIGN Retrospective cross-sectional analysis of claims data, HH patient assessment data, and MA plan data from 2011 to 2017. PARTICIPANTS Medicare beneficiaries aged 66 and older with an incident hospitalization for joint replacement, pneumonia, chronic obstructive pulmonary disease, stroke, urinary tract infection, septicemia, acute renal failure, or congestive heart failure. MAIN MEASURES Receipt of prescribed HH as indicated by a HH discharge code and corresponding HH patient assessment within 14 days of hospital discharge. KEY RESULTS There were 2,723,245 beneficiaries prescribed HH at discharge (68% TM, 32% MA). About 75% of TM enrollees and 62% of MA enrollees received prescribed post-acute HH. In adjusted analyses, MA enrollees had an -11.7 percentage point (pp) (95% confidence interval (CI): -16.8, -6.5) lower probability of receiving HH compared with TM enrollees. In adjusted analyses, HMO enrollees in plans with cost sharing (- 8.4 pp; 95% CI: - 14.3, - 2.5), referrals (- 3.7 pp; 95% CI: - 6.1, - 1.2), and pre-authorization (- 5.1 pp; 95% CI: - 8.3, - 2.0) were less likely to receive prescribed HH. In adjusted analyses, PPO enrollees in plans with cost sharing were -7.0 pp (95% CI: - 12.7, - 1.4) less likely to receive HH, but there was no difference for those with referrals (1.1 pp; 95% CI, - 1.5, 3.7) or pre-authorization (1.6 pp; 95% CI: - 0.6, - 3.9). CONCLUSIONS Among Medicare beneficiaries, MA enrollees were less likely to receive prescribed post-acute HH compared with TM. As enrollment in MA continues to grow, it is important to examine how differences in utilization relate to outcomes.
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Smith JM, Lin H, Thomas-Hawkins C, Tsui J, Jarrín OF. Timing of Home Health Care Initiation and 30-Day Rehospitalizations among Medicare Beneficiaries with Diabetes by Race and Ethnicity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:5623. [PMID: 34070282 PMCID: PMC8197411 DOI: 10.3390/ijerph18115623] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 01/02/2023]
Abstract
Older adults with diabetes are at elevated risk of complications following hospitalization. Home health care services mitigate the risk of adverse events and facilitate a safe transition home. In the United States, when home health care services are prescribed, federal guidelines require they begin within two days of hospital discharge. This study examined the association between timing of home health care initiation and 30-day rehospitalization outcomes in a cohort of 786,734 Medicare beneficiaries following a diabetes-related index hospitalization admission during 2015. Of these patients, 26.6% were discharged to home health care. To evaluate the association between timing of home health care initiation and 30-day rehospitalizations, multivariate logistic regression models including patient demographics, clinical and geographic variables, and neighborhood socioeconomic variables were used. Inverse probability-weighted propensity scores were incorporated into the analysis to account for potential confounding between the timing of home health care initiation and the outcome in the cohort. Compared to the patients who received home health care within the recommended first two days, the patients who received delayed services (3-7 days after discharge) had higher odds of rehospitalization (OR, 1.28; 95% CI, 1.25-1.32). Among the patients who received late services (8-14 days after discharge), the odds of rehospitalization were four times greater than among the patients receiving services within two days (OR, 4.12; 95% CI, 3.97-4.28). Timely initiation of home health care following diabetes-related hospitalizations is one strategy to improve outcomes.
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Affiliation(s)
- Jamie M. Smith
- College of Nursing, Thomas Jefferson University, Philadelphia, PA 19107, USA;
- School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07108, USA; (H.L.); (C.T.-H.)
| | - Haiqun Lin
- School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07108, USA; (H.L.); (C.T.-H.)
- School of Public Health, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA
| | - Charlotte Thomas-Hawkins
- School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07108, USA; (H.L.); (C.T.-H.)
| | - Jennifer Tsui
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA 90033, USA;
| | - Olga F. Jarrín
- School of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07108, USA; (H.L.); (C.T.-H.)
- Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey, New Brunswick, NJ 08901, USA
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Racial Disparities in Post-Acute Home Health Care Referral and Utilization among Older Adults with Diabetes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18063196. [PMID: 33808769 PMCID: PMC8003472 DOI: 10.3390/ijerph18063196] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 01/02/2023]
Abstract
Racial and ethnic disparities exist in diabetes prevalence, health services utilization, and outcomes including disabling and life-threatening complications among patients with diabetes. Home health care may especially benefit older adults with diabetes through individualized education, advocacy, care coordination, and psychosocial support for patients and their caregivers. The purpose of this study was to examine the association between race/ethnicity and hospital discharge to home health care and subsequent utilization of home health care among a cohort of adults (age 50 and older) who experienced a diabetes-related hospitalization. The study was limited to patients who were continuously enrolled in Medicare for at least 12 months and in the United States. The cohort (n = 786,758) was followed for 14 days after their diabetes-related index hospitalization, using linked Medicare administrative, claims, and assessment data (2014–2016). Multivariate logistic regression models included patient demographics, comorbidities, hospital length of stay, geographic region, neighborhood deprivation, and rural/urban setting. In fully adjusted models, hospital discharge to home health care was significantly less likely among Hispanic (OR 0.8, 95% CI 0.8–0.8) and American Indian (OR 0.8, CI 0.8–0.8) patients compared to White patients. Among those discharged to home health care, all non-white racial/ethnic minority patients were less likely to receive services within 14-days. Future efforts to reduce racial/ethnic disparities in post-acute care outcomes among patients with a diabetes-related hospitalization should include policies and practice guidelines that address structural racism and systemic barriers to accessing home health care services.
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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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