1
|
Ernecoff NC, Anhang Price R, Klein DJ, Haviland AM, Saliba D, Orr N, Gildner J, Gaillot S, Elliott MN. Which medicare advantage enrollees are at highest one-year mortality risk? Arch Gerontol Geriatr 2024; 124:105454. [PMID: 38703702 DOI: 10.1016/j.archger.2024.105454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/05/2024] [Accepted: 04/20/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND While a number of tools exist to predict mortality among older adults, less research has described the characteristics of Medicare Advantage (MA) enrollees at higher risk for 1 year mortality. OBJECTIVES To describe the characteristics of MA enrollees at higher mortality risk using patient survey data. RESEARCH DESIGN Retrospective cohort. SUBJECTS MA enrollees completing the 2019 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. MEASURES Linked demographic, health, and mortality data from a sample of MA enrollees were used to predict 1-year mortality risk and describe enrollee characteristics across levels of predicted mortality risk. RESULTS The mortality model had a 0.80 c-statistic. Mortality risks were skewed: 6 % of enrollees had a ≥ 10 % 1-year mortality risk, while 45 % of enrollees had 1 % to < 5 % 1-year mortality risk. Among the high-risk (≥10 %) group, 47 % were age 85+ versus 12 % among those with mortality risk <5 %. 79 % were in fair or poor self-rated health versus 29 % among those with mortality risk of <5 %. 71 % reported needing urgent care in the prior 6 months versus 40 % among those with a mortality risk of 1 to<5 %. CONCLUSIONS Relatively few older adults enrolled in MA are at high 1-year mortality risk. Nonetheless, MA enrollees over age 85, in fair or poor health, or with recent urgent care needs are far more likely to be in a high mortality risk group.
Collapse
Affiliation(s)
- Natalie C Ernecoff
- RAND Corporation, 4570 Fifth Avenue Suite 600, Pittsburgh, PA 15213, United States
| | | | - David J Klein
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, United States
| | - Amelia M Haviland
- RAND Corporation and Carnegie Mellon University, 4800 Forbes Avenue, Hamburg Hall 2214, Pittsburgh, PA 15213, United States
| | - Debra Saliba
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, United States; University of California Los Angeles Borun Center, 10945 Le Conte Ave, Suite 2339, Los Angeles, CA 90095, United States; Los Angeles Veterans Administration GRECC, Los Angeles, CA, United States
| | - Nate Orr
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, United States
| | - Jennifer Gildner
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, United States
| | - Sarah Gaillot
- Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, United States
| | - Marc N Elliott
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, United States.
| |
Collapse
|
2
|
Wing JJ, Rajczyk JI, Burke JF. Geographic Variation of Prevalence of Alzheimer's Disease and Related Dementias in Central Appalachia. J Alzheimers Dis 2024:JAD240528. [PMID: 39121122 DOI: 10.3233/jad-240528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/11/2024]
Abstract
Background Alzheimer's disease and related dementias (ADRD) prevalence varies geographically in the United States. Objective To assess whether the geographic variation of ADRD in Central Appalachia is explained by county-level sociodemographics or access to care. Methods Centers for Medicare and Medicaid Services Public Use Files from 2015- 2018 were used to estimate county-level ADRD prevalence among all fee-for-service (FFS) beneficiaries with≥1 inpatient, skilled nursing facility, home health agency, hospital outpatient or Carrier claim with a valid ADRD ICD-9/10 code over three-years in Central Appalachia (Kentucky, North Carolina, Ohio, Tennessee, Virginia, and West Virginia). Negative binomial regression was used to estimate prevalence overall, by Appalachian/non-Appalachian designation, and by rural/urban classification. Models were then adjusted for county-level: 1) FFS demographics (age, gender, and Medicaid eligibility), comorbidities; 2) population sociodemographics (race/ethnicity, education, aging population distribution, and renter-occupied housing); and 3) diagnostic access (PCP visits, neurology visits, and imaging scans). Results Across the 591 counties in the Central Appalachian region, the average prevalence of ADRD from 2015- 2018 was 11.8%. ADRD prevalence was modestly higher for Appalachian counties both overall (PR: 1.03; 95% CI: 1.02, 1.04) and after adjustment (PR: 1.02; 95% CI: 1.00, 1.03) compared to non-Appalachian counties. This difference was similar among rural and urban counties (p = 0.326) but varied by state (p = 0.004). Conclusions The relative variation in ADRD prevalence in the Appalachian region was smaller than hypothesized. The case mixture of the dual eligible population, accuracy of the outcome measurement, and impact of educational attainment in this region may contribute to this observation.
Collapse
Affiliation(s)
- Jeffrey J Wing
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, OH, USA
| | - Jenna I Rajczyk
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, OH, USA
| | - James F Burke
- Department of Neurology, College of Medicine, Ohio State University, Columbus, OH, USA
| |
Collapse
|
3
|
Jain SH. The Case for Continuing to Improve Medicare Advantage: Misplaced Nostalgia for Traditional Medicare. JAMA Intern Med 2024; 184:867-869. [PMID: 38857044 DOI: 10.1001/jamainternmed.2024.1865] [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: 06/11/2024]
Affiliation(s)
- Sachin H Jain
- SCAN Health Plan, Long Beach, California
- Stanford University School of Medicine, Stanford, California
- West Los Angeles VA Medical Center, Los Angeles, California
| |
Collapse
|
4
|
Kyanko KA, Sahay KM, Wang Y, Schreiber M, Hager M, Myers R, Johnson W, Zhang J, Yen BJ, Suter LG, Triche EW, Li SX. Processing and validation of inpatient Medicare Advantage data for use in hospital outcome measures. Health Serv Res 2024. [PMID: 38961668 DOI: 10.1111/1475-6773.14350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
OBJECTIVE To determine the feasibility of integrating Medicare Advantage (MA) admissions into the Centers for Medicare & Medicaid Services (CMS) hospital outcome measures through combining Medicare Advantage Organization (MAO) encounter- and hospital-submitted inpatient claims. DATA SOURCES AND STUDY SETTING Beneficiary enrollment data and inpatient claims from the Integrated Data Repository for 2018 Medicare discharges. STUDY DESIGN We examined timeliness of MA claims, compared diagnosis and procedure codes for admissions with claims submitted both by the hospital and the MAO (overlapping claims), and compared demographic characteristics and principal diagnosis codes for admissions with overlapping claims versus admissions with a single claim. DATA COLLECTION/EXTRACTION METHODS We combined hospital- and MAO-submitted claims to capture MA admissions from all hospitals and identified overlapping claims. For admissions with only an MAO-submitted claim, we used provider history data to match the National Provider Identifier on the claim to the CMS Certification Number used for reporting purposes in CMS outcome measures. PRINCIPAL FINDINGS After removing void and duplicate claims, identifying overlapped claims between the hospital- and MAO-submitted datasets, restricting claims to acute care and critical access hospitals, and bundling same admission claims, we identified 5,078,611 MA admissions. Of these, 76.1% were submitted by both the hospital and MAO, 14.2% were submitted only by MAOs, and 9.7% were submitted only by hospitals. Nearly all (96.6%) hospital-submitted claims were submitted within 3 months after a one-year performance period, versus 85.2% of MAO-submitted claims. Among the 3,864,524 admissions with overlapping claims, 98.9% shared the same principal diagnosis code between the two datasets, and 97.5% shared the same first procedure code. CONCLUSIONS Inpatient MA data are feasible for use in CMS claims-based hospital outcome measures. We recommend prioritizing hospital-submitted over MAO-submitted claims for analyses. Monitoring, data audits, and ongoing policies to improve the quality of MA data are important approaches to address potential missing data and errors.
Collapse
Affiliation(s)
- Kelly A Kyanko
- Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Kashika M Sahay
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE), Yale School of Medicine, New Haven, Connecticut, USA
| | - Yongfei Wang
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE), Yale School of Medicine, New Haven, Connecticut, USA
| | - Michelle Schreiber
- Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards & Quality (CCSQ), Baltimore, Maryland, USA
| | - Melissa Hager
- Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards & Quality (CCSQ), Baltimore, Maryland, USA
| | - Raquel Myers
- Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards & Quality (CCSQ), Baltimore, Maryland, USA
| | - Wanda Johnson
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE), Yale School of Medicine, New Haven, Connecticut, USA
| | - Jing Zhang
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE), Yale School of Medicine, New Haven, Connecticut, USA
| | - Bing-Jie Yen
- Department of Applied Health Science, Indiana University Bloomington School of Public Health, Bloomington, Indiana, USA
| | - Lisa G Suter
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE), Yale School of Medicine, New Haven, Connecticut, USA
- Department of Internal Medicine, Section of Rheumatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Elizabeth W Triche
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE), Yale School of Medicine, New Haven, Connecticut, USA
| | - Shu-Xia Li
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation (YNHHSC/CORE), Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Gettel CJ, Salah W, Rothenberg C, Liang Y, Schwartz H, Scott KW, Hwang U, Hastings SN, Venkatesh AK. Total and Out-of-Pocket Costs Surrounding Emergency Department Care Among Older Adults Enrolled in Traditional Medicare and Medicare Advantage. Ann Emerg Med 2024:S0196-0644(24)00234-8. [PMID: 38864783 DOI: 10.1016/j.annemergmed.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 04/01/2024] [Accepted: 04/19/2024] [Indexed: 06/13/2024]
Abstract
STUDY OBJECTIVE We sought to quantify differences in total and out-of-pocket health care costs associated with treat-and-release emergency department (ED) visits among older adults with traditional Medicare and Medicare Advantage. METHODS We conducted a repeated cross-sectional analysis of treat-and-release ED visits using 2015 to 2020 data from the Medicare Current Beneficiary Survey. We measured total and out-of-pocket health care spending during 3 time periods: the 30 days prior to the ED visit, the treat-and-release ED visit itself, and the 30 days after the ED visit. Stratified by traditional Medicare or Medicare Advantage status, we determined median total costs and the proportion of costs that were out-of-pocket. RESULTS Among the 5,011 ED visits by those enrolled in traditional Medicare, the weighted median total (and % out-of-pocket) costs were $881.95 (13.3%) for the 30 days prior to the ED visit, $419.70 (10.1%) for the ED visit, and $809.00 (13.8%) for the 30 days after the ED visit. For the 2,595 ED visits by those enrolled in Medicare Advantage, the weighted median total (and % out-of-pocket) costs were $484.92 (24.0%) for the 30 days prior to the ED visit, $216.66 (21.9%) for the ED visit, and $439.13 (22.4%) for the 30 days after the ED visit. CONCLUSION Older adults insured by Medicare Advantage incur lower total health care costs and face similar overall out-of-pocket expenses in the time period surrounding emergency care. However, a higher proportion of expenses are out-of-pocket compared with those insured by traditional Medicare, providing evidence of greater cost sharing for Medicare Advantage plan enrollees.
Collapse
Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT.
| | - Wafa Salah
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | | | - Hope Schwartz
- University of California San Francisco School of Medicine, San Francisco, CA
| | - Kirstin W Scott
- Department of Emergency Medicine, University of Washington School of Medicine, Seattle, WA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT; Department of Emergency Medicine, New York University Grossman School of Medicine, New York, NY; Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC; Department of Medicine, Duke University School of Medicine, Durham, NC; Geriatric Research, Education, and Clinical Center, Durham VA Health Care System, Durham, NC; Center for the Study of Human Aging and Development, Duke University School of Medicine, Durham, NC; Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, CT
| |
Collapse
|
7
|
Kyanko K, Sahay KM, Wang Y, Li SX, Schreiber M, Hager M, Myers R, Johnson W, Zhang J, Krumholz H, Suter LG, Triche EW. Incorporating Medicare Advantage Admissions Into the CMS Hospital-Wide Readmission Measure. JAMA Netw Open 2024; 7:e2414431. [PMID: 38829614 PMCID: PMC11148674 DOI: 10.1001/jamanetworkopen.2024.14431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/01/2024] [Indexed: 06/05/2024] Open
Abstract
Importance Medicare Advantage (MA) enrollment is rapidly expanding, yet Centers for Medicare & Medicaid Services (CMS) claims-based hospital outcome measures, including readmission rates, have historically included only fee-for-service (FFS) beneficiaries. Objective To assess the outcomes of incorporating MA data into the CMS claims-based FFS Hospital-Wide All-Cause Unplanned Readmission (HWR) measure. Design, Setting, and Participants This cohort study assessed differences in 30-day unadjusted readmission rates and demographic and risk adjustment variables for MA vs FFS admissions. Inpatient FFS and MA administrative claims data were extracted from the Integrated Data Repository for all admissions for Medicare beneficiaries from July 1, 2018, to June 30, 2019. Measure reliability and risk-standardized readmission rates were calculated for the FFS and MA cohort vs the FFS-only cohort, overall and within specialty subgroups (cardiorespiratory, cardiovascular, medicine, surgery, neurology), then changes in hospital performance quintiles were assessed after adding MA admissions. Main Outcome and Measure Risk-standardized readmission rates. Results The cohort included 11 029 470 admissions (4 077 633 [37.0%] MA; 6 044 060 [54.8%] female; mean [SD] age, 77.7 [8.2] years). Unadjusted readmission rates were slightly higher for MA vs FFS admissions (15.7% vs 15.4%), yet comorbidities were generally lower among MA beneficiaries. Test-retest reliability for the FFS and MA cohort was higher than for the FFS-only cohort (0.78 vs 0.73) and signal-to-noise reliability increased in each specialty subgroup. Mean hospital risk-standardized readmission rates were similar for the FFS and MA cohort and FFS-only cohorts (15.5% vs 15.3%); this trend was consistent across the 5 specialty subgroups. After adding MA admissions to the FFS-only HWR measure, 1489 hospitals (33.1%) had their performance quintile ranking changed. As their proportion of MA admissions increased, more hospitals experienced a change in their performance quintile ranking (147 hospitals [16.3%] in the lowest quintile of percentage MA admissions; 408 [45.3%] in the highest). The combined cohort added 63 hospitals eligible for public reporting and more than 4 million admissions to the measure. Conclusions and Relevance In this cohort study, adding MA admissions to the HWR measure was associated with improved measure reliability and precision and enabled the inclusion of more hospitals and beneficiaries. After MA admissions were included, 1 in 3 hospitals had their performance quintile changed, with the greatest shifts among hospitals with a high percentage of MA admissions.
Collapse
Affiliation(s)
- Kelly Kyanko
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Kashika M. Sahay
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Yongfei Wang
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Shu-Xia Li
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Michelle Schreiber
- Centers for Medicare & Medicaid Services, Center for Clinical Standards & Quality, Baltimore, Maryland
| | - Melissa Hager
- Centers for Medicare & Medicaid Services, Center for Clinical Standards & Quality, Baltimore, Maryland
| | - Raquel Myers
- Centers for Medicare & Medicaid Services, Center for Clinical Standards & Quality, Baltimore, Maryland
| | - Wanda Johnson
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Jing Zhang
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Harlan Krumholz
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Lisa G. Suter
- Yale School of Medicine, New Haven, Connecticut
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| | - Elizabeth W. Triche
- Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation, New Haven, Connecticut
| |
Collapse
|
8
|
Park S, Meyers DJ, Jimenez DE, Gualdrón N, Cook BL. Health Care Spending, Use, and Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With Mental Health Symptoms. Am J Geriatr Psychiatry 2024; 32:739-750. [PMID: 38267358 DOI: 10.1016/j.jagp.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/06/2024] [Accepted: 01/07/2024] [Indexed: 01/26/2024]
Abstract
OBJECTIVE We examined the differences in health care spending and utilization, and financial hardship between Traditional Medicare (TM) and Medicare Advantage (MA) enrollees with mental health symptoms. DESIGN Cross-sectional study. PARTICIPANTS We identified Medicare beneficiaries with mental health symptoms using the Patient Health Questionnaire-2 and the Kessler-6 Psychological Distress Scale in the 2015-2021 Medical Expenditure Panel Survey. MEASUREMENTS Outcomes included health care spending and utilization (both general and mental health services), and financial hardship. The primary independent variable was MA enrollment. RESULTS MA enrollees with mental health symptoms were 2.3 percentage points (95% CI: -3.4, -1.2; relative difference: 16.1%) less likely to have specialty mental health visits than TM enrollees with mental health symptoms. There were no significant differences in total health care spending, but annual out-of-pocket spending was $292 (95% CI: 152-432; 18.2%) higher among MA enrollees with mental health symptoms than TM enrollees with mental health symptoms. Additionally, MA enrollees with mental health symptoms were 5.0 (95% CI: 2.9-7.2; 22.3%) and 2.5 percentage points (95% CI: 0.8-4.2; 20.9%) more likely to have difficulty paying medical bills over time and to experience high financial burden than TM enrollees with mental health symptoms. CONCLUSION Our findings suggest that MA enrollees with mental health symptoms were more likely to experience limited access to mental health services and high financial hardship compared to TM enrollees with mental health symptoms. There is a need to develop policies aimed at improving access to mental health services while reducing financial burden for MA enrollees.
Collapse
Affiliation(s)
- Sungchul Park
- Department of Health Policy and Management (SP), College of Health Science, Korea University, Seoul, Republic of Korea; BK21 FOUR R&E Center for Learning Health Systems (SP), Korea University, Seoul, Republic of Korea.
| | - David J Meyers
- Department of Health Services, Policy, and Practice (DJM), School of Public Health, Brown University, Providence, RI, USA
| | - Daniel Enrique Jimenez
- Department of Psychiatry and Behavioral Sciences (DEJ), Miller School of Medicine, University of Miami, Coral Gables, FL, USA
| | - Nattalie Gualdrón
- Health Equity Research Lab (NG, BLC), Cambridge Health Alliance, Cambridge, MA, USA; Department of Community Health (NG), School of Arts and Sciences, Tufts University, Medford, MA, USA
| | - Benjamin Le Cook
- Health Equity Research Lab (NG, BLC), Cambridge Health Alliance, Cambridge, MA, USA; Center for Health Equity (BLC), Albert Einstein College of Medicine, Bronx, NY, USA; Department of Psychiatry (BLC), Harvard Medical School, Cambridge, MA, USA
| |
Collapse
|
9
|
Jacobson M, Ferido P, Zissimopoulos J. Health care utilization before and after a dementia diagnosis in Medicare Advantage versus traditional Medicare. J Am Geriatr Soc 2024; 72:1856-1866. [PMID: 37668467 PMCID: PMC10912367 DOI: 10.1111/jgs.18570] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/12/2023] [Accepted: 08/03/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Half of all Medicare beneficiaries are enrolled in Medicare Advantage (MA). Many studies document lower care utilization and mortality in MA than traditional Medicare (TM), but evidence for persons with Alzheimer's disease and related dementias (ADRD) is limited. METHODS We conducted a retrospective cohort study of 2015-2018 Medicare claims and encounter data for community-dwelling beneficiaries aged 65 and over in TM and MA with an incident ADRD diagnosis in 2017. We compared monthly hospitalization rates and outpatient visits 12 months before and after diagnosis and mortality 1 year from diagnosis. Models adjusted for sociodemographic characteristics and comorbidities. Sensitivity analyses addressed residual confounding using a control group with incident arthritis/glaucoma or excluding MA Special Needs Plans, and potential underreporting by restricting to MA plans with high data completeness. RESULTS Among 454,508 beneficiaries diagnosed with ADRD in 2017, 250,837 (55%) were in TM and 203,671 (45%) in MA. Four to 12 months before diagnosis, monthly hospitalizations and outpatient visits were similar in TM and MA. In the diagnosis month, 36.5% of beneficiaries in TM had a hospitalization compared with 25.4% in MA, an adjusted difference of 10.7 percentage points [95% CI: 10.3, 11.1]. Beneficiaries in TM averaged 10.5 outpatient visits in the diagnosis month compared with 8.4 in MA, an adjusted difference of 1.59 visits [95% CI: 1.47-1.70]. Utilization differences narrowed but remained higher in TM for many months. One-year mortality was 27.9% in TM and 22.2% in MA; an adjusted odds ratio of 1.152 [95% CI: 1.135-1.169] for those in TM compared with MA. Controlling for hospitalization in the diagnosis month substantially reduced the mortality difference. CONCLUSION Hospitalization rates and outpatient visits increased more after an ADRD diagnosis in TM than MA. One-year post-diagnosis, mortality was not higher in MA than TM but comparisons of quality of life and caregiver burden are needed.
Collapse
Affiliation(s)
- Mireille Jacobson
- Andrus School of Gerontology & Schaeffer Center, University of Southern California
| | - Patricia Ferido
- Price School of Public Policy & Schaeffer Center, University of Southern California
| | - Julie Zissimopoulos
- Price School of Public Policy & Schaeffer Center, University of Southern California
| |
Collapse
|
10
|
Hu J, Khan M, Chen X, Revere L, Hong YR. Comparison of Financial Hardship and Healthcare Utilizations Associated with Cancer in the United States Medicare Programs during the COVID-19 Pandemic. Healthcare (Basel) 2024; 12:1049. [PMID: 38786459 PMCID: PMC11121441 DOI: 10.3390/healthcare12101049] [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: 03/21/2024] [Revised: 04/27/2024] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND In the United States, Medicare beneficiaries diagnosed with cancer often face significant financial challenges due to the expensive nature of cancer treatments and increased cost-sharing responsibilities. However, there is limited knowledge regarding the financial hardships and healthcare utilizations faced by those enrolled in Medicare Advantage (MA) compared to those in traditional fee-for-service Medicare (TM) during the COVID-19 pandemic. Our study aims to investigate the subjective financial hardships experienced by individuals enrolled in TM and MA and to determine whether these two Medicare programs exhibit differences in healthcare utilization during the pandemic. METHODS We utilized data from the 2020-2022 National Health Interview Survey (NHIS), focusing on nationally representative samples of cancer survivors aged 65 or older. Financial hardship was categorized into three distinct groups: material (e.g., problems with medical bills), psychological (e.g., worry about paying), and behavioral (e.g., delayed care due to cost). Healthcare utilization included wellness visits (preventive care), emergency care services, hospitalizations, and telehealth. We used survey design-adjusted analysis to compare the study outcomes between MA and TM. RESULTS Among a weighted sample of 4.4 million Medicare beneficiaries with cancer (mean age: 74.9), 76% were enrolled in MA plans. Cancer survivors with a college degree (59.3% vs. 49.8%) and high family income (38.2% vs. 31.1%) were more likely to enroll in MA plans. There were no significant differences in any material, psychological, or behavioral financial hardship domains between beneficiaries with MA and TM plans except forgone counseling due to cost. For healthcare utilization measures, cancer survivors in MA were more likely than those in TM to have flu vaccination (77.2% vs. 70.1%) and experience lower hospitalizations (16.0% vs. 20.0%). However, there were no differences in other health service utilizations between MA and TM. CONCLUSION While no significant differences were observed in any materialized, psychological, or behavioral financial hardships, older cancer survivors enrolled in MA plans were more likely to receive vaccinations and lower hospitalization rates during COVID-19. Although other preventive or primary care visits (i.e., wellness visits) were higher, their difference did not reach statistical significance. As MA grows in popularity, it is essential to consistently monitor and evaluate the performance and outcomes of Medicare plans for cancer survivors as we navigate the post-pandemic landscape.
Collapse
Affiliation(s)
- Jiamin Hu
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL 32611, USA; (J.H.); (M.K.); (L.R.)
| | - Mishal Khan
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL 32611, USA; (J.H.); (M.K.); (L.R.)
| | - Xiaobei Chen
- College of Journalism and Communications, University of Florida, Gainesville, FL 32611, USA;
| | - Lee Revere
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL 32611, USA; (J.H.); (M.K.); (L.R.)
| | - Young-Rock Hong
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, Gainesville, FL 32611, USA; (J.H.); (M.K.); (L.R.)
| |
Collapse
|
11
|
Park S, Berkowitz SA. Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With and Without Food Insecurity. J Gen Intern Med 2024:10.1007/s11606-024-08798-4. [PMID: 38755470 DOI: 10.1007/s11606-024-08798-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Compared to traditional Medicare (TM), Medicare Advantage (MA) plans impose out-of-pocket cost limits and offer extra benefits, potentially providing financial relief for MA enrollees, especially for those with food insecurity. OBJECTIVE To examine whether the prevalence of food insecurity differs between TM and MA enrollees at baseline and then examine whether MA enrollment in a baseline year is associated with less financial hardships in the following year, relative to TM enrollment, especially for those experiencing food insecurity. DESIGN We conducted a retrospective longitudinal cohort study. PARTICIPANTS Our analysis included 2807 Medicare beneficiaries (weighted sample size, 23,963,947) who maintained continuous enrollment in either TM or MA in both 2020 and 2021 from the Medical Expenditure Panel Survey. MAIN MEASURES We assessed outcomes related to financial hardships in health care and non-health care domains (measured in 2021). Our primary independent variables were food insecurity and MA enrollment (measured in 2020). RESULTS The point estimate of food insecurity prevalence was greater among MA enrollees than TM enrollees, but the difference was not statistically significant (1.1 percentage points [95% CI, - 1.0, 3.4]). Furthermore, there is evidence that compared to TM enrollment, MA enrollment did not mitigate the risk of financial hardship, particularly for food-insecure enrollees. Rather, food-secure MA enrollees faced greater financial hardship in the following year than food-secure TM enrollees (11.2% [8.9-13.6] and 7.6% [6.9-8.3] for problems paying medical bills and 5.5% [4.6-6.4] and 2.8% [2.1-3.6] for paying medical bills over time). Moreover, the point estimate of financial hardship was higher among food-insecure MA enrollees than food-insecure TM enrollees (21.5% [5.4-37.5] and 11.2% [4.1-18.4] and 23.7% [9.6-37.9] and 6.9% [0.5-13.3]) despite the lack of statistical significance. CONCLUSION These findings suggest that the promise of financial protection offered by MA plans has not been fully realized, particularly for those with food insecurity.
Collapse
Affiliation(s)
- Sungchul Park
- Department of Health Policy and Management, College of Health Science, Korea University, Seoul, Republic of Korea.
- BK21 FOUR R&E Center for Learning Health Systems, Korea University, Seoul, Republic of Korea.
| | - Seth A Berkowitz
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
12
|
Mahmoudi E, Lin P, Rubenstein D, Guetterman T, Leggett A, Possin KL, Kamdar N. Use of preventive service and potentially preventable hospitalization among American adults with disability: Longitudinal analysis of Traditional Medicare and commercial insurance. Prev Med Rep 2024; 40:102663. [PMID: 38464419 PMCID: PMC10920729 DOI: 10.1016/j.pmedr.2024.102663] [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: 10/16/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/12/2024] Open
Abstract
Objective Examine the association between traditional Medicare (TM) vs. commercial insurance and the use of preventive care and potentially preventable hospitalization (PPH) among adults (18+) with disability [cerebral palsy/spina bifida (CP/SB); multiple sclerosis (MS); traumatic spinal cord injury (TSCI)] in the United States. Methods Using 2008-2016 Medicare and commercial claims data, we compared adults with the same disability enrolled in TM vs. commercial insurance [Medicare: n = 21,599 (CP/SB); n = 7,605 (MS); n = 4,802 (TSCI); commercial: n = 11,306 (CP/SB); n = 6,254 (MS); n = 5,265 (TSCI)]. We applied generalized estimating equations to address repeated measures, comparing cases with controls. All models were adjusted for age, sex, race/ethnicity, and comorbid conditions. Results Compared with commercial insurance, enrolling in TM reduced the odds of using preventive services. For example, adjusted odds ratios (OR) of annual wellness visits in TM vs. commercial insurance were 0.31 (95% confidence interval (CI): 0.28-0.34), 0.32 (95% CI: 0.28-0.37), and 0.19 (95% CI: 0.17-0.22) among adults with CP/SB, TSCI, and MS, respectively. Furthermore, PPH risks were higher in TM vs. commercial insurance. ORs of PPH in TM vs. commercial insurance were 1.50 (95% CI: 1.18-1.89), 1.83 (95% CI: 1.40-2.41), and 2.32 (95% CI: 1.66-3.22) among adults with CP/SB, TSCI, and MS, respectively. Moreover, dual-eligible adults had higher odds of PPH compared with non-dual-eligible adults [CP/SB: OR = 1.47 (95% CI: 1.25-1.72); TSCI: OR = 1.61 (95% CI: 1.35-1.92), and MS: OR = 1.80 (95% CI: 1.55-2.10)]. Conclusions TM, relative to commercial insurance, was associated with lower receipt of preventive care and higher PPH risk among adults with disability.
Collapse
Affiliation(s)
- Elham Mahmoudi
- Department of Family Medicine, Michigan Medicine, University of Michigan, USA
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Dana Rubenstein
- Clinical and Translational Science Institute, Duke University School of Medicine, 701 West Main Street, Durham, NC, USA
| | - Timothy Guetterman
- Department of Family Medicine, Michigan Medicine, University of Michigan, USA
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Amanda Leggett
- Institute of Gerontology & Department of Psychology, Wayne State University, Detroit, MI, USA
| | - Katherine L. Possin
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
13
|
Kwon Y, Roberts ET, Degenholtz HB, Jacobs BL, Sabik LM. Association of Medicare eligibility with access to and affordability of care among older cancer survivors. J Cancer Surviv 2024:10.1007/s11764-024-01562-x. [PMID: 38520599 DOI: 10.1007/s11764-024-01562-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 03/07/2024] [Indexed: 03/25/2024]
Abstract
PURPOSE Older cancer survivors have substantial needs for ongoing care, but they may encounter difficulties accessing care due to cost concerns. We examined whether near-universal insurance coverage through Medicare-a key source of health insurance coverage in this population-is associated with improvements in care access and affordability among older cancer survivors around age 65. METHODS In a nationally representative sample of cancer survivors (aged 50-80) from 2006-2018 National Health Interview Survey, we employed a quasi-experimental, regression discontinuity design to estimate changes in insurance coverage, delayed/skipped care due to cost, and worries about or problems paying medical bills at age 65. RESULTS Medicare coverage sharply increased from 8.3% at age 64 to 98.2% at age 65, ensuring near-universal insurance coverage (99.5%). Medicare eligibility at age 65 was associated with reductions in delayed/skipped care due to cost (discontinuity, - 5.7 percentage points or pp; 95% CI, - 8.1, - 3.3; P < .001), worries about paying for medical bills (- 7.7 pp; 95% CI, - 12.0, - 3.2; P = .001), and problems paying medical bills (- 3.2 pp; 95% CI, - 6.1, - 0.2; P = .036). However, a sizable proportion reported any access or affordability problems (29.7%) between ages 66 and 80. CONCLUSIONS Near-universal Medicare coverage at age 65 was associated with a reduction-but not elimination-of access and affordability problems among cancer survivors. IMPLICATIONS FOR CANCER SURVIVORS These findings reaffirm the role of Medicare in improving access and affordability for older cancer survivor and highlight opportunities for reforms to further alleviate financial burden of care in this population.
Collapse
Affiliation(s)
- Youngmin Kwon
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, A610 Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA.
| | - Eric T Roberts
- Department of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA, 19104, USA
| | - Howard B Degenholtz
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, A610 Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
| | - Bruce L Jacobs
- Department of Urology, Division of Health Services Research, University of Pittsburgh, School of Medicine, 3471 Fifth Ave, Suite 801, Pittsburgh, PA, 15213, USA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, A610 Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
| |
Collapse
|
14
|
Chen XT, Glasgow AE, Haberman EB, Heckmann ND, Callaghan JJ, Lewallen DG, Berry DJ, Bedard NA. Is the Rise of Medicare Advantage Impacting the Fidelity of Traditional Medicare Claims Data? Implications for Reporting of Long-Term Total Hip Arthroplasty Survivorship. J Arthroplasty 2024:S0883-5403(24)00230-4. [PMID: 38493968 DOI: 10.1016/j.arth.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Arthroplasty registries often utilize traditional Medicare (TM) claims data to report long-term total hip arthroplasty (THA) survivorship. The purpose of this study was to determine whether the large number of patients leaving TM for Medicare Advantage (MA) has compromised the fidelity of TM data. METHODS We identified 10,962 THAs in 9,333 Medicare-eligible patients who underwent primary THA from 2000 to 2020 at a single institution. Insurance type was analyzed, and 83% of patients had TM at the time of THA. Survivorship free from any revision or reoperation were calculated for patients who have TM. The same survivorship endpoints was re-calculated with censoring performed when a patient transitioned to a MA plan after their primary THA to model the impact of losing patients from the TM dataset. Differences in survivorship were compared. The mean follow-up was 7 years. RESULTS From 2000 to 2020, there was a decrease in TM insurance (93 to 73%) and a corresponding increase in MA insurance (0 to 19%) among THA patients. Following THA, 23% of TM patients switched to MA. For patients who had TM at the time of surgery, 15-year survivorship free from any reoperation or revision was 90 and 93%, respectively. When censoring patients upon transition from TM to MA, survivorship free from any reoperation became significantly higher (92 versus 90% at 15 years; hazard ratio (HR) = 1.16, P = 0.033), and there was a trend towards higher survivorship free from any revision (95 versus 93% at 15-years; HR = 1.16, P = 0.074). CONCLUSION Approximately 1 in 4 patients left TM for MA after primary THA, effectively making them lost to follow-up within TM datasets. The mass exodus of patients out of TM appears to have led to a slight overestimation of survivorship free from any reoperation and trended toward overestimating survivorship free from any revision. If MA continues to grow, efforts to obtain MA data will become even more important.
Collapse
Affiliation(s)
- Xiao T Chen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Elizabeth B Haberman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - John J Callaghan
- Department of Orthopedic Surgery, University of Iowa, Iowa City, IA
| | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
15
|
Brown C, Prusynski R, Baylor C, Humbert A, Mroz TM. Patient Characteristics and Treatment Patterns for Speech-Language Pathology Services in Skilled Nursing Facilities. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:912-936. [PMID: 38215225 DOI: 10.1044/2023_ajslp-23-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2024]
Abstract
PURPOSE Skilled nursing facility (SNF) care has historically been influenced by systemic issues that could impact speech-language pathology (SLP) service provision. However, there has been little study specifically on factors associated with SLP service provision in SNFs. Large administrative data sets are rarely analyzed in SLP research but can be used to understand real-world SLP services. This study investigated associations between patient and facility characteristics and SLP services. METHOD Mixed-effects logistic regression models were used to evaluate factors associated with SLP service provision in 2018 Medicare administrative data representing 833,653 beneficiaries. RESULTS Beneficiaries had higher odds of receiving SLP services when they had neurologic diagnosis (odds ratio [OR] = 3.32), had SLP-related functional impairments (ORs = 1.19-3.41), and received other rehabilitative services (ORs = 3.11-3.78). Beneficiaries had lower odds of receiving SLP services when they received care from SNFs located in hospitals versus freestanding (OR = 0.45), with need for interpreter services (OR = 0.76) and with thresholding (OR = 0.68), a financially motivated practice. Direction of association varied across racial and ethnic groups and measures of location. Odds of being provided SLP services decreased with increasing communication impairment severity. CONCLUSIONS The results suggest that clinicians are identifying patients with diagnoses most likely to warrant SLP services. However, association disparities and weakening association of service provision with increasing impairment severity have concerning clinical implications. Health services research methods can be used to further explore SLP practices in SNFs to support equitable service provision.
Collapse
Affiliation(s)
- Cait Brown
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Rachel Prusynski
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Carolyn Baylor
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Andrew Humbert
- Department of Rehabilitation Medicine, University of Washington, Seattle
| | - Tracy M Mroz
- Department of Rehabilitation Medicine, University of Washington, Seattle
| |
Collapse
|
16
|
Raver E, Xu WY, Jung J, Lee S. Breast cancer screening among Medicare Advantage enrollees with dementia. BMC Health Serv Res 2024; 24:283. [PMID: 38443911 PMCID: PMC10916275 DOI: 10.1186/s12913-024-10740-7] [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: 10/31/2023] [Accepted: 02/18/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The decision to screen for breast cancer among older adults with dementia is complex and must often be individualized, as these individuals have an elevated risk of harm from over-screening. Medicare beneficiaries with dementia are increasingly enrolling in Medicare Advantage plans, which typically promote receipt of preventive cancer screening among their enrollees. This study examined the utilization of breast cancer screening among Medicare enrollees with dementia, in Medicare Advantage and in fee-for-service Medicare. METHODS We conducted a pooled cross-sectional study of women with Alzheimer's disease and related dementias or cognitive impairment who were eligible for mammogram screening. We used Medicare Current Beneficiary Survey data to identify utilization of biennial mammogram screening between 2012 and 2019. Poisson regression models were used to estimate prevalence ratios of mammogram utilization and to calculate adjusted mammogram rates for Medicare Advantage and fee-for-service Medicare enrollees with dementia, and further stratified by rurality and by dual eligibility for Medicare and Medicaid. RESULTS Mammogram utilization was 16% higher (Prevalence Ratio [PR] 1.16; 95% CI: 1.05, 1.29) among Medicare Advantage enrollees with dementia, compared to their counterparts in fee-for-service Medicare. Rural enrollees experienced no significant difference (PR 0.99; 95% CI: 0.72, 1.37) in mammogram use between Medicare Advantage and fee-for-service Medicare enrollees. Among urban enrollees, Medicare Advantage enrollment was associated with a 21% higher mammogram rate (PR 1.21; 95% CI: 1.09, 1.35). Dual-eligible Medicare Advantage enrollees had a 34% higher mammogram rate (PR 1.34; 95% CI: 1.10, 1.63) than dual-eligible fee-for-service Medicare enrollees. Among non-dual-eligible enrollees, adjusted mammogram rates were not significantly different (PR 1.11; 95% CI: 0.99, 1.24) between Medicare Advantage and fee-for-service Medicare enrollees. CONCLUSIONS Medicare beneficiaries age 65-74 with Alzheimer's disease and related dementias or cognitive impairment had a higher mammogram use rate when they were enrolled in Medicare Advantage plans compared to fee-for-service Medicare, especially when they were dual-eligible or lived in urban areas. However, some Medicare Advantage enrollees with Alzheimer's disease and related dementias or cognitive impairment may have experienced over-screening for breast cancer.
Collapse
Affiliation(s)
- Eli Raver
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Wendy Y Xu
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Jeah Jung
- Department of Health Administration and Policy, College of Public Health, George Mason University, Fairfax, VA, USA
| | - Sunmin Lee
- Department of Medicine, School of Medicine & Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, CA, USA.
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Jung J, Ko H, Feldman R, Carlin CS, Song G. Gaps In Quality Of Care Not Consistent Between Traditional Medicare, Medicare Advantage For Racial And Ethnic Groups. Health Aff (Millwood) 2024; 43:381-390. [PMID: 38437614 DOI: 10.1377/hlthaff.2023.00428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
The quality of care experienced by members of racial and ethnic minority groups in Medicare Advantage, which is an increasingly important source of Medicare coverage for these groups, has critical implications for health equity. Comparing gaps in Medicare Advantage and traditional Medicare for three quality-of-care outcomes, measured by adverse health events, between minority and non-Hispanic White populations, we found that the relative magnitude of the gaps varied both by racial and ethnic minority group and by quality measure. Hispanic versus non-Hispanic White gaps were smaller in Medicare Advantage than in traditional Medicare for all outcomes: avoidable emergency department use, preventable hospitalizations, and thirty-day hospital readmissions. The gap between non-Hispanic Black and non-Hispanic White populations was larger in Medicare Advantage than in traditional Medicare for avoidable emergency department use but was no different for hospital readmissions and was smaller for preventable hospitalizations. The Asian versus non-Hispanic White gap was similar in Medicare Advantage and traditional Medicare for avoidable emergency department use and preventable hospitalizations but was larger in Medicare Advantage for hospital readmissions. As Medicare Advantage enrollment expands, monitoring the quality of care for enrollees who are members of racial and ethnic minority groups will remain important.
Collapse
Affiliation(s)
- Jeah Jung
- Jeah Jung , George Mason University, Fairfax, Virginia
| | | | - Roger Feldman
- Roger Feldman, University of Minnesota, Minneapolis, Minnesota
| | | | - Ge Song
- Ge Song, George Mason University
| |
Collapse
|
19
|
Anderson KE, Wu RJ, Darden M, Jain A. Medicare Advantage Is Associated with Lower Utilization of Total Joint Arthroplasty. J Bone Joint Surg Am 2024; 106:198-205. [PMID: 37973049 DOI: 10.2106/jbjs.23.00507] [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] [Indexed: 11/19/2023]
Abstract
BACKGROUND Medicare Advantage (MA) insurers use managed care techniques to review the utilization of medical services and control costs. It is unclear if MA enrollees have a lower utilization of elective surgical procedures such as inpatient hip and knee total joint arthroplasty (TJA), which have traditionally been covered by traditional Medicare (TM) without restrictions. METHODS We conducted a cross-sectional study using a 20% sample of 2018 TM claims and MA encounter records for 5,300,188 TM enrollees and 1,970,032 MA enrollees who were 65 to 85 years of age. We calculated unadjusted and adjusted differences (controlling for beneficiary and market characteristics) in the incidence of TJA for MA compared with TM, and by MA plan type. Finally, we calculated differences in the time to contact with an orthopaedic surgeon and time to the surgical procedure among enrollees with an osteoarthritis diagnosis. RESULTS After controlling for observable characteristics, there was a 15.6% lower incidence of TJA in MA enrollees compared with TM enrollees (p < 0.001). Compared with TM enrollees, health maintenance organization (HMO) enrollees were 28.1% less likely to undergo TJA, controlling for observable characteristics (p < 0.001). From the initial diagnosis, the time to contact with an orthopaedic surgeon and the time to the surgical procedure were also lower among TM enrollees compared with MA enrollees. At 2 years after an osteoarthritis diagnosis, 10.4% of TM enrollees, 7.9% of preferred provider organization (PPO) enrollees, and 5.7% of HMO enrollees had undergone inpatient TJA. CONCLUSIONS MA coverage was associated with a lower utilization of elective, inpatient hip and knee TJA. MA was also associated with a longer time to orthopaedic surgeon evaluation and surgical procedure. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
Collapse
Affiliation(s)
- Kelly E Anderson
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, Colorado
- Hopkins Business of Health Initiative, Baltimore, Maryland
| | - Rachel J Wu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Michael Darden
- Hopkins Business of Health Initiative, Baltimore, Maryland
- Carey Business School, Johns Hopkins University, Baltimore, Maryland
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Amit Jain
- Hopkins Business of Health Initiative, Baltimore, Maryland
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
20
|
Liu A, Xuan A, Socal M, Anderson G, Anderson KE. Filgrastim and infliximab biosimilar uptake in Medicare Advantage compared with Traditional Medicare, 2016-2019. J Manag Care Spec Pharm 2024; 30:15-21. [PMID: 38153867 PMCID: PMC10775772 DOI: 10.18553/jmcp.2024.30.1.15] [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: 12/30/2023]
Abstract
BACKGROUND Medicare Advantage (MA) and Traditional Medicare face different financing structures and incentives and may implement different strategies to encourage biosimilar uptake. Strategies used by health insurers can influence biosimilar uptake, which can in turn promote savings to insurers and patients. OBJECTIVE To compare filgrastim and infliximab biosimilar uptake between MA and Traditional Medicare from 2016 to 2019 and examine biosimilar uptake by different MA carriers and plan types (Health Maintenance Organization [HMO] or Preferred Provider Organization). METHODS We use a 2016-2019 nationally representative random 20% sample of the carrier (physician) and outpatient paid claims for Traditional Medicare data and final-action carrier and outpatient records for MA data. We compare quarterly biosimilar uptake from 2016 to 2019 for the first 2 drugs with biosimilar competition: (1) filgrastim, (Neupogen, originator), and biosimilars tbo-filgrastim (GRANIX) and filgrastim-sndz (ZARXIO), and (2) infliximab (Remicade, originator), and biosimilars infliximab-dyyb (Inflectra) and infliximab-abda (Renflexis). RESULTS From their introduction, there was consistently greater uptake of filgrastim and infliximab biosimilars in MA compared with Traditional Medicare. By Q4 2019, filgrastim biosimilar uptake was 7.6 percentage points higher in MA (80.3%) than Traditional Medicare (72.7%). By Q4 2019, infliximab biosimilar uptake was 28.7% and 15.4% in MA and Traditional Medicare, respectively. Kaiser HMO plans were primarily responsible for the higher uptake of biosimilars in MA; in Q4 2019, filgrastim and infliximab biosimilar uptake was 98.8% and 78.8%, respectively. CONCLUSIONS Our findings suggest that filgrastim and infliximab biosimilar uptake is greater in MA compared with Traditional Medicare, which is driven in part by particularly high uptake of biosimilars in MA Kaiser HMO plans. This highlights the need for future work to examine specific strategies and levers employed by MA Kaiser HMO plans and other insurers to increase biosimilar uptake, which can lead to cost savings for physician-administered drugs.
Collapse
Affiliation(s)
- Angela Liu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrew Xuan
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Mariana Socal
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gerard Anderson
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kelly E. Anderson
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora
| |
Collapse
|
21
|
Magnuson JA, Hobbs J, Yakkanti R, Gold PA, Courtney PM, Krueger CA. Lower Revenue Surplus in Medicare Advantage Versus Private Commercial Insurance for Total Joint Arthroplasty: An Analysis of a Single Payor Source at One Institution. J Arthroplasty 2024; 39:26-31.e1. [PMID: 37380139 DOI: 10.1016/j.arth.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Since the Affordable Care Act was passed in 2010, reductions in Medicare reimbursement have led to larger discrepancies between the relative cost of Medicare patients and privately insured patients. The purpose of this study was to compare reimbursement between Medicare Advantage and other insurance plans in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS Patients of a single commercial payor source who underwent primary unilateral TKA or THA at 1 institution between the dates of January 4 and June 30, 2021, were included (n = 833). Variables included insurance type, medical comorbidities, total costs, and surplus amounts. The primary outcome measure was revenue surplus between Medicare Advantage and Private Commercial plans. t-tests, Analyses of Variance, and Chi-Squared tests were used for analysis. A THA represented 47% of cases and a TKA 53%. Of these patients, 31.5% had Medicare Advantage and 68.5% had Private Commercial insurance. Medicare Advantage patients were older and had higher medical comorbidity risk for both TKA and THA. RESULTS Significant differences were observed in medical costs between Medicare Advantage and Private Commercial insurance for THA ($17,148 versus $31,260, P < .001) and TKA ($16,723 versus $33,593, P < .001). Additionally, differences were seen in surplus amounts between Medicare Advantage and Private Commercial insurance for THA ($3,504 versus $7,128, P < .001) and TKA ($5,581 versus $10,477, P < .001). Deficits were higher in Private Commercial patients undergoing TKA (15.2 versus 6%, P = .001). CONCLUSION The lower average surplus associated with Medicare Advantage plans may lead to financial strain on provider groups who care for these patients and face additional overhead costs.
Collapse
Affiliation(s)
- Justin A Magnuson
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - John Hobbs
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ramakanth Yakkanti
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Peter A Gold
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Chad A Krueger
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| |
Collapse
|
22
|
Schmutte T, Olfson M, Xie M, Marcus SC. Association of 7-Day Follow-Up With 6-Month Suicide Mortality Following Hospitalization for Suicidal Thoughts or Behaviors Among Older Adults. Am J Geriatr Psychiatry 2024; 32:128-134. [PMID: 37690981 PMCID: PMC10841311 DOI: 10.1016/j.jagp.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE To evaluate whether timely follow-up outpatient mental health care is associated with reduced short-term suicide risk following hospitalization for suicidal thoughts or behaviors. METHODS Retrospective cohort analysis using 2015 Medicare data for adults aged ≥ 65 years who were hospitalized for suicidal ideation or behaviors (n = 36,557) linked with the National Death Index. Adjusted risk ratios (ARR) estimated the association between 7-day follow-up and suicide risk at 30-, 90-, and 180-days, adjusted for confounding by indication using inverse probability of treatment weights of observable covariates. RESULTS Overall, 39.3% of patients received 7-day follow-up, which was associated with 41% higher risk of suicide within 180 days. Follow-up care was associated with higher suicide risk for Medicare Advantage enrollees, patients with no recent prior mental health care, and those admitted for suicidal behaviors. CONCLUSION Results suggest 7-day follow-up care was not associated with lower post-discharge suicide risk. For this high-risk group, suicide-specific interventions may be needed during the critical postdischarge period.
Collapse
Affiliation(s)
- Timothy Schmutte
- Department of Psychiatry (TS), Program for Recovery and Community Health, Yale University, New Haven, CT.
| | - Mark Olfson
- Department of Psychiatry and the New York State Psychiatric Institute (MO), Columbia University, New York, NY
| | - Ming Xie
- Department of Psychiatry (MX), University of Pennsylvania, Philadelphia, PA
| | - Steven C Marcus
- School of Social Policy & Practice (SCM), University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
23
|
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.)
| |
Collapse
|
24
|
Xu J(F, Anderson KE, Liu A, Miller BJ, Polsky D. Role of Patient Sorting in Avoidable Hospital Stays in Medicare Advantage vs Traditional Medicare. JAMA HEALTH FORUM 2023; 4:e233931. [PMID: 37948062 PMCID: PMC10638641 DOI: 10.1001/jamahealthforum.2023.3931] [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: 05/25/2023] [Accepted: 09/19/2023] [Indexed: 11/12/2023] Open
Abstract
Importance Unlike traditional Medicare (TM), Medicare Advantage (MA) plans limit in-network care to a specific network of Medicare clinicians. MA plans thus play a role in sorting patients to a subset of clinicians. It is unknown whether the performance of physicians who treat MA and TM beneficiaries is different. Objective To examine whether avoidable hospital stay differences between MA and TM can be explained by the primary care clinicians who treat MA and TM beneficiaries. Design, Setting, and Participants This was a cross-sectional study of a nationally representative sample of MA and TM beneficiaries in 2019 with any of 5 chronic ambulatory care-sensitive conditions (ACSCs). The relative risk (RR) of avoidable hospital stays in MA compared with TM was estimated with inverse probability of treatment-weighted Poisson regression, both without and with clinician fixed effects. The degree to which the estimated MA vs TM difference could be explained by patient sorting was calculated by comparing the 2 RR estimates. Data were analyzed between February 2022 and April 2023. Exposure Enrollment in MA. Main Outcome and Measures Whether a beneficiary had avoidable hospital stays in 2019 due to any of the ACSCs. Avoidable hospital stays included both hospitalizations and observation stays. Results The study sample comprised 1 323 481 MA beneficiaries (mean [SD] age, 75.4 [7.0] years; 56.9% women; 69.3% White) and 1 965 863 TM beneficiaries (mean [SD] age, 75.9 [7.4] years; 57.1% women; 82.5% White). When controlling for the primary care clinician, the RR of avoidable hospital stays in MA vs TM changed by 2.6 percentage points (95% CI, 1.72-3.50; P < .001), suggesting that compared with TM beneficiaries, MA beneficiaries saw clinicians with lower rates of avoidable hospital stays. This effect size was statistically significant to explain the 2% lower rate of avoidable hospital stays in MA than in TM. Conclusions and Relevance In this cross-sectional study of MA and TM beneficiaries, the lower rate of avoidable hospital stays among MA beneficiaries than TM beneficiaries was attributable to MA beneficiaries visiting clinicians with lower rates of avoidable hospital stays. The patient sorting that occurs in MA plays a critical role in the lower rates of avoidable hospital stays compared with TM.
Collapse
Affiliation(s)
- Jianhui (Frank) Xu
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Kelly E. Anderson
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora
| | - Angela Liu
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Brian J. Miller
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- American Enterprise Institute, Washington, DC
| | - Daniel Polsky
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
- Carey Business School, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
25
|
Kurth L, Casey ML, Mazurek JM, Blackley DJ. Pneumoconiosis incidence and prevalence among US Medicare beneficiaries, 1999-2019. Am J Ind Med 2023; 66:831-841. [PMID: 37482966 PMCID: PMC10924676 DOI: 10.1002/ajim.23519] [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: 05/15/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND Pneumoconiosis is a group of occupational lung diseases caused by dust and fiber exposure. This study analyzes Medicare claims to estimate the burden of pneumoconiosis among fee-for-service (FFS; Medicare Parts A and B) Medicare beneficiaries during 1999-2019 in the United States. METHODS Claim and enrollment information from 81 million continuously enrolled FFS Medicare beneficiaries were analyzed. Beneficiaries with any pneumoconiosis and cause-specific pneumoconiosis (e.g., asbestosis, silicosis) were identified using three case definitions (broad, intermediate, and narrow) with varying diagnostic criteria based on claim International Classification of Diseases, Clinical Modification (ICD-CM) diagnosis codes and Healthcare Common Procedure Coding System codes. Results are presented as ranges of values for the three case definitions. RESULTS The 21-year prevalence range for any pneumoconiosis was 345,383-677,361 (412-833 per 100,000 beneficiaries) using the three case definitions. The highest prevalence was among those ≥75 years of age, males, Whites, and North American Natives. Most claims (70.0%-72.5%) included an ICD-CM diagnosis code for asbestosis. The broad pneumoconiosis prevalence rate increased significantly (p < 0.001) during 2002-2009 by 3%-10% annually and declined significantly by 3%-5% annually starting in 2009. The average annual broad incidence rate declined significantly by 7% annually during 2009-2019. CONCLUSIONS Despite the decline in rate for any pneumoconiosis among Medicare beneficiaries, which is primarily attributed to a decline in asbestosis, pneumoconiosis is prevalent among FFS Medicare beneficiaries.
Collapse
Affiliation(s)
- Laura Kurth
- Surveillance Branch, Centers for Disease Control and Prevention, Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia, USA
| | - Megan L. Casey
- National Personal Protective Technology Laboratory, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Morgantown, West Virginia, USA
| | - Jacek M. Mazurek
- Surveillance Branch, Centers for Disease Control and Prevention, Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia, USA
| | - David J. Blackley
- Surveillance Branch, Centers for Disease Control and Prevention, Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia, USA
| |
Collapse
|
26
|
DiPaolo N, Hulsebos IF, Yu J, Gillenwater TJ, Yenikomshian HA. Race and Ethnicity Influences Outcomes of Adult Burn Patients. J Burn Care Res 2023; 44:1223-1230. [PMID: 36881674 PMCID: PMC10480350 DOI: 10.1093/jbcr/irad033] [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: 12/03/2022] [Indexed: 03/09/2023]
Abstract
Outcomes of burn survivors is a growing field of interest; however, there is little data comparing the outcomes of burn survivors by ethnicity. This study seeks to identify any inequities in burn outcomes by racial and ethnic groups. A retrospective chart review of an ABA Certified burn center at a large urban safety net hospital identified adult inpatient admissions from 2015 to 2019. A total of 1142 patients were categorized by primary ethnicity: 142 black or African American, 72 Asian, 479 Hispanic or Latino, 90 white, 215 other, and 144 patients whose race or ethnicity was unrecorded. Multivariable analyses evaluated the relationship between race and ethnicity and outcomes. Covariate confounders were controlled by adjustment of demographic, social, and prehospital clinical factors to isolate differences that might not be explained by other factors. After controlling for covariates, black patients had 29% longer hospital stays (P = .043). Hispanic patients were more likely to be discharged to home or to hospice care (P = .005). Hispanic ethnicity was associated with a 44% decrease in the odds of discharge to acute care, inpatient rehabilitation, or a ward outside the burn unit (P = .022). Black and Hispanic patients had a higher relative chance of having publicly assisted insurance, versus private insurance, than their white counterparts (P = .041, P = .011 respectively). The causes of these inequities are indeterminate. They may stem from socioeconomic status not entirely accounted for, ethnic differences in comorbidity related to stressors, or inequity in health care delivery.
Collapse
Affiliation(s)
- Nicola DiPaolo
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ian F Hulsebos
- Department of Surgery, Hospital Corporation of America Medical City North Texas Hospitals, Plano, Texas, USA
| | - Jeremy Yu
- Clinical and Translational Science Institute, University of Southern California, Los Angeles, California, USA
| | - Timothy Justin Gillenwater
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Haig A Yenikomshian
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
27
|
Jung J, Carlin CS, Feldman R, Song G. Wide Variation In Differences In Resource Use Seen Across Conditions Between Medicare Advantage, Traditional Medicare. Health Aff (Millwood) 2023; 42:1212-1220. [PMID: 37669492 DOI: 10.1377/hlthaff.2023.00448] [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: 09/07/2023]
Abstract
Medicare Advantage (MA) is a rapidly growing source of coverage for Medicare beneficiaries. Examining how MA performs compared with traditional Medicare is an important policy issue. We analyzed national MA encounter data and found that the adjusted differences in resource use between MA and traditional Medicare varied widely across medical conditions in 2019. Total resource use in MA was generally lower than in traditional Medicare but by varying amounts across conditions, and it was not significantly different from traditional Medicare for some conditions. This variation was explained by resource use for hospital inpatient services in MA relative to traditional Medicare. Resource use for treatments was considerably lower in MA than in traditional Medicare across all conditions, whereas resource use for imaging and testing was consistently higher in MA for all conditions. As MA grows, efforts are needed to identify mechanisms driving differences in resource use between MA and traditional Medicare and to assess their implications for patient care.
Collapse
Affiliation(s)
- Jeah Jung
- Jeah Jung , George Mason University, Fairfax, Virginia
| | | | | | - Ge Song
- Ge Song, George Mason University
| |
Collapse
|
28
|
Jafri FI, Patel VR, Xu J, Polsky D, Gupta A, Hussaini SMQ. Association of Medicare Program Type with Health Care Access, Utilization, and Affordability among Cancer Survivors. Cancers (Basel) 2023; 15:3964. [PMID: 37568779 PMCID: PMC10417052 DOI: 10.3390/cancers15153964] [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: 06/19/2023] [Revised: 07/17/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The Medicare Advantage program provides care to nearly half of Medicare beneficiaries, including a rapidly growing population of cancer survivors. Despite its increased adoption, it is still unknown whether or not the program improves healthcare access, outcomes, and affordability for cancer survivors. METHODS We performed a cross-sectional study of Medicare beneficiaries aged ≥ 65 years with a self-reported history of cancer from the 2019 National Health Interview Survey. We used multivariable logistic regression to evaluate the association between Medicare program type (Medicare Advantage vs. traditional Medicare) and measures of healthcare access, acute care utilization, and affordability. RESULTS We identified 4451 beneficiaries with a history of cancer, corresponding to 26.6 million weighted cancer survivors in 2019. Of the beneficiaries, 35.8% were enrolled in Medicare Advantage, whereas 64.2% were enrolled in traditional Medicare. The age, sex, racial and ethnic composition, household income, primary site of cancer, and comorbidity burden of Medicare Advantage and traditional Medicare beneficiaries were similar. In the adjusted analysis, there were no differences in healthcare access or acute care utilization between traditional Medicare and Medicare Advantage beneficiaries. However, cancer survivors enrolled in Medicare Advantage were more likely to worry about (34.3% vs. 29.4%; aOR, 1.3 (95% CI, 1.1-1.5)) or have problems paying (13.6% vs. 11.1%; aOR, 1.4 (95% CI, 1.1-1.8)) medical bills. CONCLUSIONS We found no evidence that Medicare Advantage beneficiaries with cancer had better healthcare access, affordability, or acute care utilization than traditional Medicare beneficiaries did. Furthermore, Medicare Advantage beneficiaries were more likely to report financial strain and have difficulty paying for their medical bills than were those with traditional Medicare. Despite the generous benefits and attractive incentives, Medicare Advantage plans may not be more cost-effective than traditional Medicare is for cancer survivors. Our study informs ongoing congressional deliberations to re-evaluate the role of Medicare Advantage in promoting equity among beneficiaries with cancer.
Collapse
Affiliation(s)
- Faraz I. Jafri
- Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA;
| | - Vishal R. Patel
- Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA;
| | - Jianhui Xu
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (J.X.); (D.P.)
| | - Daniel Polsky
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (J.X.); (D.P.)
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD 21224, USA
- Carey Business School, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Arjun Gupta
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA;
| | | |
Collapse
|
29
|
Cao B, Hogan SL, Derebail VK, Ehlert A, Thorpe CT. Polypharmacy in US Medicare beneficiaries with antineutrophil cytoplasmic antibody vasculitis. J Manag Care Spec Pharm 2023; 29:770-781. [PMID: 37404075 PMCID: PMC10387912 DOI: 10.18553/jmcp.2023.29.7.770] [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: 07/06/2023]
Abstract
BACKGROUND: Treatment requirements of antineutrophil cytoplasmic autoantibody vasculitis (AV) and high comorbidity burden among patients with AV may lead to higher potential for polypharmacy and its associated adverse outcomes, including adverse drug events, nonadherence, drug-drug interactions, and higher costs. Medication burden and risk factors associated with polypharmacy in patients with AV have not been well-characterized. OBJECTIVE: To characterize medication burden and examine prevalence of and risk factors for polypharmacy in the first year after diagnosis with AV. METHODS: We conducted a retrospective cohort study using 2015-2017 Medicare claims to identify incident cases of AV. We counted the number of unique generic products dispensed to patients in each of the 4 quarters after diagnosis and categorized medication count as high (≥10 medications), moderate (5-9 medications), or minimal or no polypharmacy (<5 medications). We used multinomial logistic regression to examine associations of predisposing, enabling, and medical need factors with having high or moderate polypharmacy. RESULTS: In 1,239 Medicare beneficiaries with AV, high or moderate polypharmacy was most common in the first quarter after diagnosis (83.7%), with 43.2% taking 5 - 9 medications and 40.5% taking at least 10. The odds of high polypharmacy were greater in all quarters for patients with eosinophilic granulomatosis with polyangiitis compared with granulomatosis with polyangiitis, ranging from 2.02 (95% CI = 1.18 - 3.46) in the third quarter to 2.96 (95% CI = 1.64-5.33) in the second quarter. Older age, diabetes, chronic kidney disease, obesity, a higher Charlson Comorbidity Index score, coverage with Medicaid/Part D low-income subsidy, and living in areas with low education or persistent poverty were risk factors for high or moderate polypharmacy. CONCLUSIONS: Medicare beneficiaries with newly diagnosed AV experienced a high medication burden, with more than 40% taking at least 10 medications and the highest rates among those with eosinophilic granulomatosis with polyangiitis. Patients with AV may benefit from medication therapy management interventions to manage complex drug regimens and reduce risks associated with polypharmacy. DISCLOSURES: Dr Derebail receives personal fees from Travere Therapeutics, Pfizer, Bayer, Forma Therapeutics, UpToDate, outside of the submitted work. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health or the Department of Veterans Affairs. Dr Thorpe receives royalties from SAGE Publishing for activities unrelated to the submitted work. This research is supported by internal funds from the University of North Carolina, as well as the National Institute of Allergy and Infectious Diseases of the National Institutes of Health under award number R21AI160606 (PI: C. Thorpe).
Collapse
Affiliation(s)
- Binxin Cao
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Susan L Hogan
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill
| | - Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill
| | - Alexa Ehlert
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Carolyn T Thorpe
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
- Veterans Affairs Pittsburgh Healthcare System, PA
| |
Collapse
|
30
|
Shortell SM, Toussaint JS, Halvorson GC, Kingsdale JM, Scheffler RM, Schwartz AY, Wadsworth PA, Wilensky G. The Better Care Plan: a blueprint for improving America's healthcare system. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad007. [PMID: 38756832 PMCID: PMC10986211 DOI: 10.1093/haschl/qxad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/30/2023] [Indexed: 05/18/2024]
Abstract
The United States falls far short of its potential for delivering care that is effective, efficient, safe, timely, patient-centered, and equitable. We put forward the Better Care Plan, an overarching blueprint to address the flaws in our current system. The plan calls for continuously improving care, moving all payers to risk-adjusted prospective payment, and creating national entities for collecting, analyzing, and reporting patient safety and quality-of-care outcomes data. A number of recommendations are made to achieve these goals.
Collapse
Affiliation(s)
| | - John S Toussaint
- Catalysis, Inc. 3825 East Calumet Street, Suite 400-114, Appleton, WI 54915, United States
| | - George C Halvorson
- The Institute for Intergroup Understanding, 1300 Bracketts Point Road, Wayzata, MN 55391, United States
| | | | | | | | - Peter A Wadsworth
- Amory Associates, 1310 Norwest Drive, Norwood, MA 02062, United States
| | - Gail Wilensky
- Project Hope, 1220 19th Street, Washington, DC 20036, United States
| |
Collapse
|
31
|
Miller BJ, Grabert LM, Hargan ED. Medicare Modernization-The Urgent Need for Fiscal Solvency. JAMA HEALTH FORUM 2023; 4:e231571. [PMID: 37327006 DOI: 10.1001/jamahealthforum.2023.1571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
This Viewpoint describes how reforms to Medicare built around a transition from volume to value may be helpful for improving fiscal solvency.
Collapse
Affiliation(s)
- Brian J Miller
- Division of Hospital Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- American Enterprise Institute, Washington, DC
| | - Lisa M Grabert
- College of Nursing, Marquette University, Milwaukee, Wisconsin
| | - Eric D Hargan
- Carlson School of Management, University of Minnesota, Minneapolis, Minnesota
- The Hargan Group, Arlington, Virginia
| |
Collapse
|
32
|
Schwartz AL, Kim S, Navathe AS, Gupta A. Growth of Medicare Advantage After Plan Payment Reductions. JAMA HEALTH FORUM 2023; 4:e231744. [PMID: 37354538 DOI: 10.1001/jamahealthforum.2023.1744] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2023] Open
Abstract
Importance Various policy proposals would reduce federal payments to Medicare Advantage (MA) plans. However, it is unclear whether payment reductions would compromise beneficiary access to the MA program. Objective To quantify the association between MA payment reductions under the Affordable Care Act (ACA) and MA enrollment growth. Design, Setting, and Participants This retrospective cohort study examined the MA market before and after the ACA, which mandated cuts to MA benchmark payment rates. Using 2008 to 2019 county-level enrollment and payment data, a difference-in-differences analysis was conducted comparing MA enrollment changes between counties with larger vs smaller benchmark reductions, before vs after the ACA. Main Outcomes and Measures The primary outcome was the MA enrollment rate, defined as the proportion of a county's Medicare beneficiaries enrolled in MA. A secondary analysis examined MA plan payments per member per month. Results Among 3138 counties with 37 639 county-year observations, ACA-induced benchmark cuts were sizeable and varied, ranging from 0% to 42.9% (mean [SD], 5.9% [6.6%]). Counties with benchmark cuts above the 75th percentile had population-weighted average benchmark cuts of 14.9% compared with 4.4% in other counties. In the 8 years following the ACA, there was no differential change in MA enrollment between counties with larger vs smaller benchmark cuts (difference-in-differences estimate, 0.02 [95% CI, -1.18 to 1.21] percentage points; P = .98). Plan payments differentially fell in counties with larger benchmark cuts by $78.35 (95% CI, $62.21-$94.48) per member per month (P < .001). Conclusion and Relevance This cohort study found no evidence that the MA benchmark and ensuing payment cuts imposed by the ACA were associated with reduced MA enrollment, compromising access to MA. This evidence can inform ongoing policy debates regarding the growth of MA, concerns about excess payments to MA plans, and proposed Medicare reforms, including further reductions in MA payments.
Collapse
Affiliation(s)
- Aaron L Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, US Department of Veterans Affairs, Philadelphia, Pennsylvania
| | - Seyoun Kim
- The Wharton School, University of Pennsylvania, Philadelphia
| | - Amol S Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, US Department of Veterans Affairs, Philadelphia, Pennsylvania
| | - Atul Gupta
- The Wharton School, University of Pennsylvania, Philadelphia
- National Bureau of Economic Research, Cambridge, Massachusetts
| |
Collapse
|
33
|
Cao YJ, Luo D. Post-Acute Care in Inpatient Rehabilitation Facilities Between Traditional Medicare and Medicare Advantage Plans Before and During the COVID-19 Pandemic. J Am Med Dir Assoc 2023; 24:868-875.e5. [PMID: 37148906 PMCID: PMC10073583 DOI: 10.1016/j.jamda.2023.03.030] [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: 12/28/2022] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVES Compare post-acute care (PAC) utilization and outcomes in inpatient rehabilitation facilities (IRF) between beneficiaries covered by Traditional Medicare (TM) and Medicare Advantage (MA) plans during the COVID-19 pandemic relative to the previous year. DESIGN This multiyear cross-sectional study used Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) data to assess PAC delivery from January 2019 to December 2020. SETTING AND PARTICIPANTS Inpatient rehabilitation for stroke, hip fracture, joint replacement, and cardiac and pulmonary conditions among Medicare beneficiaries 65 years or older. METHODS Patient-level multivariate regression models with difference-in-differences approach were used to compare TM and MA plans in length of stay (LOS), payment per episode, functional improvements, and discharge locations. RESULTS A total of 271,188 patients were analyzed [women (57.1%), mean (SD) age 77.8 (0.06) years], among whom 138,277 were admitted for stroke, 68,488 hip fracture, 19,020 joint replacement, and 35,334 cardiac and 10,069 pulmonary conditions. Before the pandemic, MA beneficiaries had longer LOS (+0.22 days; 95% CI: 0.15-0.29), lower payment per episode (-$361.05; 95% CI: -573.38 to -148.72), more discharges to home with a home health agency (HHA) (48.9% vs 46.6%), and less to a skilled nursing facility (SNF) (15.7% vs 20.2%) than TM beneficiaries. During the pandemic, both plan types had shorter LOS (-0.68 day; 95% CI: 0.54-0.84), higher payment (+$798; 95% CI: 558-1036), increased discharges to home with an HHA (52.8% vs 46.6%), and decreased discharges to an SNF (14.5% vs 20.2%) than before. Differences between TM and MA beneficiaries in these outcomes became smaller and less significant. All results were adjusted for beneficiary and facility characteristics. CONCLUSIONS AND IMPLICATIONS Although the COVID-19 pandemic affected PAC delivery in IRF in the same directions for both TM and MA plans, the timing, time duration, and magnitude of the impacts were different across measures and admission conditions. Differences between the 2 plan types shrank and performance across all dimensions became more comparable over time.
Collapse
Affiliation(s)
- Ying Jessica Cao
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA.
| | - Dian Luo
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
| |
Collapse
|
34
|
Landon BE, Zaslavsky AM, Anderson TS, Souza J, Curto V, Ayanian JZ. Differences In Use Of Services And Quality Of Care In Medicare Advantage And Traditional Medicare, 2010 And 2017. Health Aff (Millwood) 2023; 42:459-469. [PMID: 37011314 PMCID: PMC10171780 DOI: 10.1377/hlthaff.2022.00891] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Medicare Advantage (MA) enrollment growth could make it difficult for MA plans to maintain their track record of limiting discretionary utilization while delivering higher-quality care than traditional Medicare. We compared quality and utilization measures in Medicare Advantage and traditional Medicare in 2010 and 2017. Clinical quality performance was higher in MA health maintenance organizations (HMOs) and preferred provider organizations (PPOs) than in traditional Medicare for almost all measures in both years. MA HMOs outperformed traditional Medicare on all measures in 2017. MA HMOs' performance on nearly all seven patient-reported quality measures improved, and MA HMOs outperformed traditional Medicare on five of those measures in 2017. MA PPOs performed the same as or better than traditional Medicare on all but one patient-reported quality measure in 2010 and 2017. The number of emergency department visits was 30 percent lower, the number of elective hip and knee replacements was approximately 10 percent lower, and the number of back surgeries was almost 30 percent lower in MA HMOs than in traditional Medicare in 2017. Utilization trends were similar in MA PPOs, but differences from traditional Medicare were narrower. Despite increased enrollment, overall utilization remains lower in Medicare Advantage than in traditional Medicare, whereas quality performance is the same or higher.
Collapse
Affiliation(s)
- Bruce E Landon
- Bruce E. Landon , Harvard University and Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - John Z Ayanian
- John Z. Ayanian, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
35
|
Koma JW, Fuglesten Biniek J, Cubanski J, Neuman T. Access Problems And Cost Concerns Of Younger Medicare Beneficiaries Exceeded Those Of Older Beneficiaries In 2019. Health Aff (Millwood) 2023; 42:470-478. [PMID: 37011311 DOI: 10.1377/hlthaff.2022.00501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Medicare is a primary source of health insurance coverage for several million people younger than age sixty-five who have long-term disabilities. This analysis compared measures of access to care, cost concerns, and satisfaction with care for beneficiaries younger than age sixty-five versus those ages sixty-five and older, using the 2019 Medicare Current Beneficiary Survey. We also compared beneficiaries in traditional Medicare with those in Medicare Advantage, given that a growing share of younger beneficiaries with disabilities are enrolled in private plans. We found that Medicare beneficiaries younger than age sixty-five reported worse access to care, more cost concerns, and lower satisfaction with care than beneficiaries ages sixty-five and older, regardless of their type of Medicare coverage. Among beneficiaries younger than age sixty-five in traditional Medicare, the share reporting cost concerns was highest among those without supplemental coverage. All of these differences were statistically significant. Addressing gaps in coverage for people with disabilities could improve experiences for this often-overlooked segment of the Medicare population.
Collapse
Affiliation(s)
- J Wyatt Koma
- J. Wyatt Koma, Henry J. Kaiser Family Foundation (KFF), San Francisco, California
| | | | | | | |
Collapse
|
36
|
Gupta A, Hu J, Huang S, Diaz L, Gore R, Levy N, Bergman M, Tanner M, Sherman SE, Islam N, Schwartz MD. Implementation fidelity to a behavioral diabetes prevention intervention in two New York City safety net primary care practices. BMC Public Health 2023; 23:575. [PMID: 36978071 PMCID: PMC10045092 DOI: 10.1186/s12889-023-15477-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND It is critical to assess implementation fidelity of evidence-based interventions and factors moderating fidelity, to understand the reasons for their success or failure. However, fidelity and fidelity moderators are seldom systematically reported. The study objective was to conduct a concurrent implementation fidelity evaluation and examine fidelity moderators of CHORD (Community Health Outreach to Reduce Diabetes), a pragmatic, cluster-randomized, controlled trial to test the impact of a Community Health Workers (CHW)-led health coaching intervention to prevent incident type 2 Diabetes Mellitus in New York (NY). METHODS We applied the Conceptual Framework for Implementation Fidelity to assess implementation fidelity and factors moderating it across the four core intervention components: patient goal setting, education topic coaching, primary care (PC) visits, and referrals to address social determinants of health (SDH), using descriptive statistics and regression models. PC patients with prediabetes receiving care from safety-net patient-centered medical homes (PCMHs) at either, VA NY Harbor or at Bellevue Hospital (BH) were eligible to be randomized into the CHW-led CHORD intervention or usual care. Among 559 patients randomized and enrolled in the intervention group, 79.4% completed the intake survey and were included in the analytic sample for fidelity assessment. Fidelity was measured as coverage, content adherence and frequency of each core component, and the moderators assessed were implementation site and patient activation measure. RESULTS Content adherence was high for three components with nearly 80.0% of patients setting ≥ 1 goal, having ≥ 1 PC visit and receiving ≥ 1 education session. Only 45.0% patients received ≥ 1 SDH referral. After adjusting for patient gender, language, race, ethnicity, and age, the implementation site moderated adherence to goal setting (77.4% BH vs. 87.7% VA), educational coaching (78.9% BH vs. 88.3% VA), number of successful CHW-patient encounters (6 BH vs 4 VA) and percent of patients receiving all four components (41.1% BH vs. 25.7% VA). CONCLUSIONS The fidelity to the four CHORD intervention components differed between the two implementation sites, demonstrating the challenges in implementing complex evidence-based interventions in different settings. Our findings underscore the importance of measuring implementation fidelity in contextualizing the outcomes of randomized trials of complex multi-site behavioral interventions. TRIAL REGISTRATION The trial was registered with ClinicalTrials.gov on 30/12/2016 and the registration number is NCT03006666 .
Collapse
Affiliation(s)
- Avni Gupta
- School of Global Public Health, New York University, 708 Broadway, New York, NY, 10003, USA.
| | - Jiyuan Hu
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Ave 2F Rm 222, New York, NY, 10016, USA
| | - Shengnan Huang
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Ave, 2Nd Floor, New York, NY, 10016, USA
| | - Laura Diaz
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Ave, 9-43A, New York, NY, 10016, USA
| | - Radhika Gore
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Ave, New York, NY, 10016, USA
| | - Natalie Levy
- Department of Medicine, NYU Grossman School of Medicine, 462 First Avenue, Area 2d, New York, NY, 10016, USA
| | - Michael Bergman
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Ave, 2Nd Floor, New York, NY, 10016, USA
- Department of Medicine, NYU Grossman School of Medicine, 423 East 23Rd Street, Room 16049C, New York, NY, 10010, USA
- VA New York Harbor Healthcare System, 423 East 23Rd Street, Room 16049C, New York, NY, 10010, USA
| | - Michael Tanner
- Department of Medicine, NYU Grossman School of Medicine, 462 1St Ave, New York, NY, 10016, USA
| | - Scott E Sherman
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, 180 Madison Avenue, New York, NY, 10016, USA
| | - Nadia Islam
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, New York, NY, 10016, USA
| | - Mark D Schwartz
- Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, Suite 955, New York, NY, 10016, USA
- VA New York Harbor Healthcare System, 180 Madison Avenue, Suite 955, New York, NY, 10016, USA
| |
Collapse
|
37
|
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.
Collapse
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.)
| |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Xu H, Li S, Mehta HB, Hommel EL, Goodwin JS. Excess deaths from COVID-19 among Medicare beneficiaries with psychiatric diagnoses: Community versus nursing home. J Am Geriatr Soc 2023; 71:167-177. [PMID: 36137264 PMCID: PMC9537955 DOI: 10.1111/jgs.18062] [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: 03/07/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Psychiatric illness may pose an additional risk of death for older adults during the COVID-19 pandemic. Older adults in the community versus institutions might be influenced by the pandemic differently. This study examines excess deaths during the COVID-19 pandemic among Medicare beneficiaries with and without psychiatric diagnoses (depression, anxiety, bipolar disorder, and schizophrenia) in the community versus nursing homes. METHODS This is a retrospective cohort study of a 20% random sample of 15,229,713 fee-for-service Medicare beneficiaries, from January 2019 through December 2021. Unadjusted monthly mortality risks, COVID-19 infection rates, and case-fatality rates after COVID-19 diagnosis were calculated. Excess deaths in 2020, compared to 2019 were estimated from multivariable logistic regressions. RESULTS Of all included Medicare beneficiaries in 2020 (N = 5,140,619), 28.9% had a psychiatric diagnosis; 1.7% lived in nursing homes. In 2020, there were 246,422 observed deaths, compared to 215,264 expected, representing a 14.5% increase over expected. Patients with psychiatric diagnoses had more excess deaths than those without psychiatric diagnoses (1,107 vs. 403 excess deaths per 100,000 beneficiaries, p < 0.01). The largest increases in mortality risks were observed among patients with schizophrenia (32.4% increase) and bipolar disorder (25.4% increase). The pandemic-associated increase in deaths with psychiatric diagnoses was only found in the community, not in nursing homes. The increased mortality for patients with psychiatric diagnoses was limited to those with medical comorbidities. The increase in mortality for psychiatric diagnoses was associated with higher COVID-19 infection rates (1-year infection rate = 7.9% vs. 4.2% in 2020), rather than excess case fatality. CONCLUSIONS Excess deaths during the COVID-19 pandemic were disproportionally greater in beneficiaries with psychiatric diagnoses, at least in part due to higher infection rates. Policy interventions should focus on preventing COVID-19 infections and deaths among community-dwelling patients with major psychiatric disorders in addition to those living the nursing homes.
Collapse
Affiliation(s)
- Huiwen Xu
- School of Public and Population Health, University of Texas Medical Branch, Galveston, TX;,Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX;,Corresponding author: Huiwen Xu, PhD, School of Public and Population Health and Sealy Center on Aging, University of Texas Medical Branch. 301 University Blvd., Galveston, TX 77555-1150. Phone: +1 409-772-5899; ; Twitter handle: @Dr_HuiwenXu
| | - Shuang Li
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX
| | - Hemalkumar B. Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Erin L. Hommel
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX;,Department of Medicine, University of Texas Medical Branch, Galveston, TX
| | - James S. Goodwin
- Sealy Center on Aging, University of Texas Medical Branch, Galveston, TX;,Department of Medicine, University of Texas Medical Branch, Galveston, TX
| |
Collapse
|
40
|
Affiliation(s)
- David J Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Andrew M Ryan
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Amal N Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| |
Collapse
|
41
|
Cohen K, Ameli O, Chaisson CE, Catlett K, Chiang J, Kwong A, Kamrudin S, Vabson B. Comparison of Care Quality Metrics in 2-Sided Risk Medicare Advantage vs Fee-for-Service Medicare Programs. JAMA Netw Open 2022; 5:e2246064. [PMID: 36508218 PMCID: PMC9856238 DOI: 10.1001/jamanetworkopen.2022.46064] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Medicare Advantage is associated with improved health outcomes, increased care efficiency, and lower out-of-pocket costs compared with fee-for-service (FFS) Medicare. When engaged in 2-sided risk arrangements, physicians are incented to offer high value for patients; however, no studies have explored the quality and efficiency outcomes in 2-sided risk Medicare Advantage models compared with FFS Medicare. OBJECTIVE To compare quality and efficiency of care between physicians using a Medicare Advantage 2-sided risk model and FFS Medicare. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort analysis with exact and propensity score-matched design used claims data from January 1, 2018, to December 31, 2019. Participants included beneficiaries enrolled in a Medicare Advantage 2-sided risk model (ie, physicians assumed the financial risk of total costs of care) and those in an FFS Medicare program in a 5% limited data set with part A and B coverage residing in 6 states (Arizona, California, Florida, Nevada, Texas, and Utah). Data were analyzed from February 1 to June 15, 2022. EXPOSURES Medicare Advantage 2-sided risk model seen in practices that are part of a nationwide health care delivery organization compared with traditional FFS Medicare. MAIN OUTCOMES AND MEASURES Comparative analysis of 8 quality and efficiency metrics in populations enrolled in a 2-sided risk-model Medicare Advantage program and 5% FFS Medicare. RESULTS In this analytic cohort of 316 312 individuals (158 156 in each group), 46.11% were men and 53.89% were women; 32.72% were aged 65-69 years, 29.44% were aged 70-74 years, 19.05% were aged 75-79 years, 10.84% were aged 80-85 years, and 7.95% were 85 years or older. The Medicare Advantage model was associated with care of higher quality and efficiency in all 8 metrics compared with the FFS model. This included lower odds of inpatient admission (-18%; odds ratio [OR], 0.82 [95% CI, 0.79-0.84]), inpatient admission through the emergency department (ED) (-6%; OR, 0.94 [95% CI, 0.91-0.97]), ED visits (-11%; OR, 0.89 [95% CI, 0.86-0.91]), avoidable ED visits (-14%; OR, 0.86 [95% CI, 0.82-0.89]), 30-day inpatient readmission (-9%; rate ratio, 0.91 [95% CI, 0.86-0.98]), admission for stroke or myocardial infarction (-10%; OR, 0.90 [95% CI, 0.83-0.98]), and hospitalization for chronic obstructive pulmonary disease or asthma exacerbation (-44%; OR, 0.56 [95% CI, 0.50-0.62]). CONCLUSIONS AND RELEVANCE The improvements observed in this study may be partly or fully attributed to the Medicare Advantage model. The Medicare Advantage risk adjustment system appears to be meeting its intended goal by aligning the capitation payments to the health care burden of the individual beneficiary and aggregate population served, thus providing revenue to develop infrastructure that supports improvements in quality and efficiency for the patients enrolled in Medicare Advantage models with 2-sided risk.
Collapse
Affiliation(s)
- Kenneth Cohen
- Optum Center for Research and Innovation, Minnetonka, Minnesota
| | - Omid Ameli
- Optum Center for Research and Innovation, Minnetonka, Minnesota
| | | | | | | | | | | | - Boris Vabson
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| |
Collapse
|
42
|
Drzayich Antol D, Schwartz R, Caplan A, Casebeer A, Erwin CJ, Shrank WH, Powers BW. Comparison of Health Care Utilization by Medicare Advantage and Traditional Medicare Beneficiaries With Complex Care Needs. JAMA HEALTH FORUM 2022; 3:e223451. [PMID: 36206006 PMCID: PMC9547312 DOI: 10.1001/jamahealthforum.2022.3451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Importance Medicare beneficiaries with co-occurring chronic conditions and complex care needs experience high rates of acute care utilization and poor outcomes. These patterns are well described among traditional Medicare (TM) beneficiaries, but less is known about outcomes among Medicare Advantage (MA) beneficiaries. Compared with TM, MA plans have additional levers to potentially address beneficiary needs, such as network design, care management, supplemental benefits, and value-based contracting. Objective To compare health care utilization for MA and TM beneficiaries with complex care needs. Design, Setting, and Participants This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. Beneficiaries were segmented into the following cohorts: frail elderly, major complex chronic, and minor complex chronic. Regression models estimated the association between MA enrollment and health care utilization in 2018, using inverse probability of treatment weighting to balance the MA and TM cohorts on observable characteristics. The study period was January 1, 2017, through December 31, 2018. All analyses were conducted from December 2020 to August 2022. Exposures Enrollment in MA vs TM. Main Outcomes and Measures Hospital stays (inpatient admissions and observation stays), emergency department (ED) visits, and 30-day readmissions. Results Among a study population of 1 844 326 Medicare beneficiaries (mean [SD] age, 75.6 [7.1] years; 1 021 479 [55.4%] women; 1 524 458 [82.7%] White; 223 377 [12.1%] with Medicare-Medicaid dual eligibility), 1 177 896 (63.9%) were enrolled in MA and 666 430 (36.1%) in TM. Beneficiary distribution across cohorts was as follows: frail elderly, 116 047 with MA (10.0% of the MA sample) and 104 036 with TM (15.6% of the TM sample); major complex chronic, 320 954 (27.2%) and 158 811 (23.8%), respectively; and minor complex chronic, 740 895 (62.9%) and 403 583 (60.6%), respectively. Beneficiaries enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions. The largest relative differences were observed for hospital stays, which ranged from -9.3% (95% CI, -10.9% to -7.7%) for the frail elderly cohort to -11.9% (95% CI, -13.2% to -10.7%) for the major complex chronic cohort. Conclusions and Relevance In this cross-sectional study of Medicare beneficiaries with complex care needs, those enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions than similar beneficiaries enrolled in TM, suggesting that managed care activities in MA may influence the nature and quality of care provided to these beneficiaries.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Brian W. Powers
- Humana Inc, Louisville, Kentucky,Mass General Brigham, Boston, Massachusetts,Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
| |
Collapse
|
43
|
Oseran AS, Sun T, Aggarwal R, Kyalwazi A, Yeh RW, Wadhera RK. Association Between Medicare Program Type and Health Care Access, Acute Care Utilization, and Affordability Among Adults With Cardiovascular Disease. Circ Cardiovasc Qual Outcomes 2022; 15:e008762. [PMID: 36052688 PMCID: PMC9489621 DOI: 10.1161/circoutcomes.121.008762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medicare Advantage plans now provide health insurance coverage to >24 million older adults in the United States, and enrollment is increasing among individuals with cardiovascular disease (CVD). Whether Medicare Advantage enrollment is associated with similar health care access, acute care utilization, and financial strain for adults with CVD compared with traditional Medicare is unknown. METHODS We performed a cross-sectional study of Medicare beneficiaries 65 years or older with CVD using the 2019 National Health Interview Survey. We fit multivariable logistic regression models to examine the association of Medicare program type (Medicare Advantage versus traditional Medicare) with measures of health care access, acute care utilization, and affordability. RESULTS The weighted population included 11 013 437 Medicare beneficiaries, of whom 3 922 104 (35.6%) were enrolled in Medicare Advantage, and 7 091 334 (64.4%) were enrolled in traditional Medicare. Medicare Advantage and traditional Medicare enrollees were similar with respect to age, sex, racial/ethnic distribution, and household income; however, Medicare Advantage beneficiaries were more likely to live in an urban setting (82.7% versus 76.0%; P=0.01) and to be college educated (24.2% versus 19.0%; P=0.01). Medicare Advantage beneficiaries were more likely to have a usual source of care (93.5% versus 88.9%; OR, 1.99 [95% CI, 1.33-2.98)]; however, there were no other differences in health care access or utilization. Medicare Advantage beneficiaries were more likely to have problems paying medical bills (16.5% versus 11.6%; OR, 1.68 [1.17-2.40]) and to worry about paying medical bills (40.1% versus 33.8%; OR, 1.37 [1.07-1.76]) compared with those enrolled in traditional Medicare. CONCLUSIONS Adults with CVD in Medicare Advantage were more likely to experience financial strain related to their medical bills compared with those in traditional Medicare. As enrollment in Medicare Advantage grows, policy efforts should focus on ensuring care is affordable for patients with CVD.
Collapse
Affiliation(s)
- Andrew S. Oseran
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiology, Massachusetts General Hospital, Boston
| | | | - Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ashley Kyalwazi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA
| |
Collapse
|
44
|
Aggarwal R, Gondi S, Wadhera RK. Comparison of Medicare Advantage vs Traditional Medicare for Health Care Access, Affordability, and Use of Preventive Services Among Adults With Low Income. JAMA Netw Open 2022; 5:e2215227. [PMID: 35671058 PMCID: PMC9175080 DOI: 10.1001/jamanetworkopen.2022.15227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE The Medicare Advantage (MA) program has doubled in size during the past decade, and enrollment among adults with low income has increased rapidly. Such adults face significant barriers in accessing care, leading to poorer health outcomes. Therefore, understanding how health care access, preventive care, and care affordability compare for adults with low income who are enrolled in MA vs traditional Medicare (TM) is critically important. OBJECTIVE To compare measures of health care access, preventive care use, and affordability of care between adults with low income who are enrolled in MA vs TM. DESIGN, SETTING, AND PARTICIPANTS This nationally representative cross-sectional study used the 2019 National Health Interview Survey to compare 2622 adults aged 65 years or older with low income who were enrolled in MA vs TM. Data were analyzed from December 5, 2021, to April 10, 2022. MAIN OUTCOMES AND MEASURES Measures of health care access, preventive care use, and health care affordability. RESULTS The study cohort included 2622 adults aged 65 years or older with low income, resulting in a weighted cohort of 14 222 243 adults, of whom 5 641 049 (39.7%) were enrolled in MA and 8 581 194 (60.3%) in TM. The overall age of the cohort was 74.6 years (95% CI, 74.3-74.9). Between the MA and TM groups, the mean age (74.5 years [95% CI, 74.1-75.0] vs 74.7 years [95% CI, 74.3-75.1]; P = .63) and sex distribution (63.6% women [95% CI, 59.8%-67.3%] vs 60.4% women [95% CI, 57.4%-63.3%]; P = .17) were similar, but adults with low income in MA were more likely to be non-Hispanic Asian (7.6% [95% CI, 5.0%-10.1%] vs 3.8% [95% CI, 2.4%-5.3%]; P = .01) or Hispanic (18.1% [95% CI, 14.3%-21.9%] vs 9.4% [95% CI, 7.2%-11.7%]; P < .001). Adults with low income in MA compared with those enrolled in TM were more likely to have a usual place of care (97.7% vs 94.9%; adjusted odds ratio [aOR], 2.37 [95% CI, 1.38-4.07]), but similarly likely to have a recent physician visit (95.5% vs 93.5%; aOR, 1.39 [95% CI, 0.88-2.17]) and to delay medical care (5.3% vs 5.7%; aOR, 0.83 [95% CI, 0.56-1.24]) or not seek medical care (5.6% vs 5.9%; aOR, 0.86 [95% CI, 0.56-1.30]) due to costs. For preventive care measures, adults with low income in MA were more likely than those in TM to have undergone a recent cholesterol screening (98.7% vs 96.6%; aOR, 2.58 [95% CI, 1.27-5.22]). However, there were no significant differences between the MA and TM groups in the likelihood of diabetes screening (90.6% vs 87.6%; aOR, 1.21 [95% CI, 0.87-1.66]), blood pressure screening (96.8% vs 95.2%; aOR, 1.37 [95% CI, 0.84-2.23]), or receipt of an influenza vaccination in the past year (66.3% vs 63.8%; aOR, 1.16 [95% CI, 0.93-1.45]). Adults with low income in MA or TM were similarly likely to be concerned about paying medical bills (47.3% vs 44.2%; aOR, 1.09 [95% CI, 0.88-1.35]) or have problems paying medical bills (17.1% vs 17.2%; aOR, 0.94 [95% CI, 0.69-1.27]) and were also similarly likely to delay filling prescriptions (7.4% vs 6.2%; aOR, 1.22 [95% CI, 0.78-1.92]) or to not fill prescriptions (7.8% vs 7.4%; aOR, 1.01 [95% CI, 0.70-1.45]) due to costs. CONCLUSIONS AND RELEVANCE In this study of Medicare beneficiaries with low income, key measures of health care access, preventive care use, and health care affordability generally did not differ between those enrolled in MA vs TM.
Collapse
Affiliation(s)
- Rahul Aggarwal
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Suhas Gondi
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| |
Collapse
|
45
|
Wilensky GR. The Future of Medicare Advantage. JAMA HEALTH FORUM 2022; 3:e221684. [DOI: 10.1001/jamahealthforum.2022.1684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
46
|
Weeks WB, Cao SY, Smith J, Wang H, Weinstein JN. Trends in Characteristics of Adults Enrolled in Traditional Fee-for-Service Medicare and Medicare Advantage, 2011-2019. Med Care 2022; 60:227-231. [PMID: 34984991 DOI: 10.1097/mlr.0000000000001680] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While overall Medicare Part C (Medicare Advantage) enrollment has grown more rapidly than fee-for-service Medicare enrollment, changes in the growth and characteristics of different enrollee populations have not been examined. OBJECTIVES For 2011-2019, to compare changes in the growth and characteristics of younger (age younger than 65) and older (age 65 and older) Medicare beneficiaries enrolled in Medicare Part A only, Medicare Parts A & B, and Medicare Part C. RESEARCH DESIGN This was a retrospective, observational study. SUBJECTS Medicare beneficiaries who were alive and enrolled in Medicare Part A only, Medicare Parts A & B, or Medicare Part C on June 30 of each year and in no other plan that year. MEASURES For each plan type and age group the numbers and mean ages of enrollees and the proportion of enrollees who were: black, female, concurrently enrolled in Medicaid, and (for older enrollees), whose initial reason for eligibility was old age and survivors' benefits. RESULTS Between 2011 and 2019, Medicare Part C experienced rapid expansions of 85.0% among older and 109.5% among younger enrollees. Part C enrollees were increasingly likely to be dually enrolled in Medicaid, Black and, among younger enrollees, female. CONCLUSIONS Trends in demographic characteristics and changes in policy and growth in employer group plan offerings will likely continue to impact health care service utilization and costs in the Medicare population. Particularly as Medicare expansion to younger age groups is considered, future research should explore disparities in risk scores and care equity, quality, and costs across different Medicare enrollment options.
Collapse
Affiliation(s)
| | | | - Jeremy Smith
- White River Junction VA Outcomes Group, White River Junction, VT
| | | | - James N Weinstein
- Microsoft Corporation, Microsoft Research, Redmond, WA
- The Dartmouth Institute, Lebanon
- Tuck School of Business at Dartmouth, Hanover, NH
- Northwestern Kellogg School of Management, Evanston, IL
| |
Collapse
|
47
|
Johnston KJ, Wen H, Pollack HA. Comparison of Ambulatory Care Access and Quality for Beneficiaries With Disabilities Covered by Medicare Advantage vs Traditional Medicare Insurance. JAMA HEALTH FORUM 2022; 3:e214562. [PMID: 35977235 PMCID: PMC8903104 DOI: 10.1001/jamahealthforum.2021.4562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/11/2021] [Indexed: 11/16/2022] Open
Abstract
Question Do Medicare beneficiaries aged 18 to 64 years with disability entitlement have different rates of enrollment in Medicare Advantage (MA) vs traditional Medicare (TM) compared with other beneficiaries, and how do the 2 programs compare on rates of ambulatory care access and quality for beneficiaries with disabilities? Findings In this cohort study of a nationally representative sample of 7201 person-years for Medicare beneficiaries in 2015 through 2018, beneficiaries with disability entitlement were significantly less likely to enroll in MA compared with those without disability entitlement. However, enrollment in MA vs TM was associated with better outcomes on 2 of 3 access measures and 3 of 3 quality measures for beneficiaries with disabilities. Meaning Although Medicare beneficiaries with disabilities enrolled in MA at lower rates than other beneficiaries in this study, MA appeared to compare favorably with TM in meeting key ambulatory care access and quality measures for beneficiaries with disabilities. Importance Medicare beneficiaries with disabilities aged 18 to 64 years face barriers accessing ambulatory care. Past studies comparing Medicare Advantage (MA) with traditional Medicare (TM) have not assessed how well these programs meet the needs of beneficiaries with disabilities. Objective To compare differences in enrollment rates, ambulatory care access, and ambulatory care quality for beneficiaries with disabilities in MA vs TM. Design, Setting, and Participants This cohort study included a nationally representative, weighted sample of 7201 person-years for beneficiaries aged 18 to 64 years with disability entitlement in the Medicare Current Beneficiary Survey from 2015 through 2018. Differences in program enrollment and in measures of access and quality by program enrollment were compared after adjusting for demographic, insurance, social, health, and area characteristics and after reweighting the sample by propensity to enroll in MA as estimated by observed confounders. Data analyses were conducted between November 1, 2020, and November 11, 2021. Exposures Medicare Advantage vs TM program enrollment. Main Outcomes and Measures Six patient-reported measures of ambulatory care access (usual source of care, primary care usual source of care, specialist visit) and quality (cholesterol screening, influenza vaccination, colon cancer screening). Results The mean (SD) age of the overall study population was 52.1 (11.0) years; 49.5% were female and 50.5% were male; 1.6% were Asian/Pacific Islander; 17.4%, Black; 10.2% Hispanic; 1.4%, Native American; 65.1%, White, and 4.2%, multiracial. Among all beneficiaries living in the community, individuals with disability entitlement were less likely to enroll in MA than other beneficiaries (34.8% vs 41.2%). The final sample of beneficiaries with disabilities included 2444 person-years in MA and 4757 person-years in TM. Beneficiaries with disabilities in MA vs TM were more likely to be of a minority race or ethnicity (35.7% vs 27.6%) and less likely to be enrolled in private insurance (11.9% vs 25.0%). Comparing MA with TM among beneficiaries with disabilities, those in MA had significantly better rates of access to a usual source of care (90.2% vs 84.9%; adjusted propensity-weighted marginal difference [APWMD], 2.9%; 95% CI, 0.2%-5.7%), access to specialist visits (53.2% vs 44.8%; APWMD, 5.5%; 95% CI, 0.6%-10.5%), cholesterol screenings (91.1% vs 86.4%; APWMD, 3.8%; 95% CI, 0.9%-6.7%), influenza vaccinations (61.4% vs 51.5%; APWMD, 10.4%; 95% CI, 5.3%-15.5%), and colon cancer screenings (68.4% vs 54.6%; APWMD, 10.3%; 95% CI, 4.8%-15.8%). Conclusions and Relevance In this cohort study, Medicare beneficiaries with disabilities were enrolled in MA at significantly lower rates than those without disabilities. However, MA was associated with significantly better ambulatory care access and quality for these beneficiaries on 5 of 6 measures compared with TM.
Collapse
Affiliation(s)
- Kenton J. Johnston
- Department of Health Management and Policy, Saint Louis University, St. Louis, Missouri
| | - Hefei Wen
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School & Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Harold A. Pollack
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, Illinois
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois
- Urban Health Lab, University of Chicago, Chicago, Illinois
| |
Collapse
|
48
|
Schwartz AL, Zlaoui K, Foreman RP, Brennan TA, Newhouse JP. Health Care Utilization and Spending in Medicare Advantage vs Traditional Medicare. JAMA HEALTH FORUM 2021; 2:e214001. [PMID: 35977297 PMCID: PMC8796939 DOI: 10.1001/jamahealthforum.2021.4001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/12/2021] [Indexed: 11/14/2022] Open
Abstract
Question Findings Meaning Importance Objective Design, Setting, and Participants Main Outcomes and Measures Results Conclusions and Relevance
Collapse
Affiliation(s)
- Aaron L. Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | | | | | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| |
Collapse
|
49
|
Ly DP. Association of Patient Race and Ethnicity With Differences in Opioid Prescribing by Primary Care Physicians for Older Adults With New Low Back Pain. JAMA HEALTH FORUM 2021; 2:e212333. [PMID: 35977182 PMCID: PMC8796941 DOI: 10.1001/jamahealthforum.2021.2333] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/01/2021] [Indexed: 01/30/2023] Open
Abstract
Question Finding Meaning Importance Objective Design, Setting, and Participants Main Outcomes and Measures Results Conclusions and Relevance
Collapse
Affiliation(s)
- Dan P. Ly
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- VA Greater Los Angeles Healthcare System, Department of Veterans Affairs, Los Angeles, California
| |
Collapse
|