Covid-19 and excess mortality in medicare beneficiaries.

Scott D Greenwald,Nassib G Chamoun,Josh Gray,Kamal Maheshwari,David Clain,Daniel I Sessler,Paul J Manberg,Satya Surbhi

doi:10.1371/journal.pone.0262264

Abstract

We estimated excess mortality in Medicare recipients in the United States with probable and confirmed Covid-19 infections in the general community and amongst residents of long-term care (LTC) facilities. We considered 28,389,098 Medicare and dual-eligible recipients from one year before February 29, 2020 through September 30, 2020, with mortality followed through November 30th, 2020. Probable and confirmed Covid-19 diagnoses, presumably mostly symptomatic, were determined from ICD-10 codes. We developed a Risk Stratification Index (RSI) mortality model which was applied prospectively to establish baseline mortality risk. Excess deaths attributable to Covid-19 were estimated by comparing actual-to-expected deaths based on historical (2017–2019) comparisons and in closely matched concurrent (2020) cohorts with and without Covid-19. Overall, 677,100 (2.4%) beneficiaries had confirmed Covid-19 and 2,917,604 (10.3%) had probable Covid-19. A total of 472,329 confirmed cases were community living and 204,771 were in LTC. Mortality following a probable or confirmed diagnosis in the community increased from an expected incidence of about 4.0% to actual incidence of 7.5%. In long-term care facilities, the corresponding increase was from 20.3% to 24.6%. The absolute increase was therefore similar at 3–4% in the community and in LTC residents. The percentage increase was far greater in the community (89.5%) than among patients in chronic care facilities (21.1%) who had higher baseline risk of mortality. The LTC population without probable or confirmed Covid-19 diagnoses experienced 38,932 excess deaths (34.8%) compared to historical estimates. Limitations in access to Covid-19 testing and disease under-reporting in LTC patients probably were important factors, although social isolation and disruption in usual care presumably also contributed. Remarkably, there were 31,360 (5.4%) fewer deaths than expected in community dwellers without probable or confirmed Covid-19 diagnoses. Disruptions to the healthcare system and avoided medical care were thus apparently offset by other factors, representing overall benefit. The Covid-19 pandemic had marked effects on mortality, but the effects were highly context-dependent.

Highlights

The Covid-19 pandemic has profoundly influenced US healthcare, especially among Medicare recipients who are mostly at least 65 years old
In long-term care facilities, the corresponding increase was from 20.3% to 24.6%
The results demonstrate that, within the Medicare population, Covid-19 had a considerable impact by increasing mortality well above what would have been expected based on age and co-morbidities alone. 677,100 (2.4%) beneficiaries had confirmed Covid-19 and 2,917,604 (10.3%) had probable Covid-19. 472,329 confirmed cases were community living and 204,771 were in Long-Term Care (LTC)

Summary

Introduction

The Covid-19 pandemic has profoundly influenced US healthcare, especially among Medicare recipients who are mostly at least 65 years old. By March 1, 2021, SARS-CoV-2, the virus responsible for Covid-19, had already infected more than 29 million US-Americans and more than 500,000 deaths associated with infection [1]. Many people infected with Covid are never tested or have false-negative test results; the true toll of Covid-19 remains uncertain. Early in the pandemic, due to limited testing availability, it was difficult to differentiate deaths caused by Covid-19 from those that may have occurred naturally due to underlying health conditions. It is evident that many people who died consequent to Covid-19 infections may not have been diagnosed with the condition or may have died due to underlying causes

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Discussion

Conclusion