Care For Medicare Beneficiaries Research Articles

Association Between States' Certificate of Need Laws and Home Health Care Access in the US.

Home health care has a significant role in the care of Medicare beneficiaries. Certificate of Need (CON) laws for home health agencies limit their number in affected states. This study's objective was to evaluate the association of CON laws with the availability and service utilization of urban and rural home health agencies in CON states and non-CON states using the generalized estimating equations (GEE) method. The results from this study indicated that CON states have fewer home health agencies for their Medicare population than non-CON states, regardless of urbanicity or rurality. Home health agencies in CON states also have less service utilization in terms of care episodes and visits per patient. This study provides an understanding of the effects of CON laws on Medicare beneficiaries' home health access and experiences.

Increase Access, Reduce Disparities: Recommendations for Modifying Medicaid CGM Coverage Eligibility Criteria.

Numerous studies have demonstrated the clinical value of continuous glucose monitoring (CGM) in type 1 diabetes (T1D) and type 2 diabetes (T2D) populations. However, the eligibility criteria for CGM coverage required by the Centers for Medicare & Medicaid Services (CMS) ignore the conclusive evidence that supports CGM use in various diabetes populations that are currently deemed ineligible. In an earlier article, we discussed the limitations and inconsistencies of the agency's CGM eligibility criteria relative to current scientific evidence and proposed practice solutions to address this issue and improve the safety and care of Medicare beneficiaries with diabetes. Although Medicaid is administered through CMS, there is no consistent Medicaid policy for CGM coverage in the United States. This article presents a rationale for modifying and standardizing Medicaid CGM coverage eligibility across the United States.

921-P: Diabetes Preventive Care for Medicare Beneficiaries: Comparing Efficiency between the Diabetes Belt and Surrounding Areas

Objective: Evidence-based preventive care services are crucial for people with diabetes to improve their health outcomes, but the utilization of the services among older adults is suboptimal. Our objective is to compare relative performance of the Diabetes Belt and surrounding counties in the uptake of preventive services among Medicare beneficiaries with diabetes given available health care resources in the counties. The Diabetes Belt includes 644 counties in the Appalachian and deep south areas of the US that have high diabetes prevalence. Methods: We used data envelopment analysis (DEA) to compute technical efficiency of counties for 2009-2015. Technical efficiency measures how many outputs a decision-making unit produces given a set of inputs. Inputs included the number of physicians and nurses per 1000 adults in the counties, and outputs included the number of foot exams, a1c tests, and microalbumin tests per 1000 Medicare beneficiaries with diabetes. The Diabetes Belt includes counties in the Appalachian and deep south areas of the US that have high diabetes prevalence. We performed t-tests to compare efficiency between the Diabetes Belt and surrounding counties. We excluded counties with 0 doctors or 0 nurses for >1 year in 2009-2015. Results: Of 1057 counties, 861 (496 in the Belt and 365 in surrounding areas) were included. During the study period, the average technical efficiency of the counties ranged from 79% to 83%, with only 2.- 3.4% of counties achieving 100% technical efficiency. Diabetes Belt counties had consistently lower efficiency than surrounding counties during the study period (p <0.05) . The mean efficiency was 78-81% in the Diabetes Belt and 81-85% in the surrounding counties. Discussion: Our results suggest that the degree of inefficiencies was higher in the Diabetes Belt compared to surrounding counties. Given relatively low available resources in these areas, more attention to improve diabetes preventive care is needed. Disclosure H.Kang: None. S.Kim: None. J.M.Lobo: n/a. M.Sohn: None. Funding National Institutes of Health (1R01DK113295-01A1)

The impact of physician-hospital integration on spending and quality of oncology care.

1584 Background: There has been increasing hospital and health system ownership of physician practices in recent years, particularly in oncology. However, relatively little is known about how this impacts care delivery for patients with cancer, who use many hospital-based services that may be impacted by integration. We evaluated the impact of physician-hospital integration in oncology on spending and quality of care for Medicare beneficiaries with cancer. Methods: We used Medicare Fee-for-Service claims from 2005-2019 linked with a unique Health System and Provider Database, developed by National Bureau of Economic Research and Harvard University researchers, to track practice ownership relationships over time. We used a stacked event study to assess outcomes for patients three years before and after oncologists move from independent practices to hospital- or system- owned practices. We compared outcomes to a control group with oncologists who shifted from independent to hospital- or system-owned practices in later years. We focused on two cohorts of patients. The first cohort included cancer patients with presumed incident or recurrent cancer based on ≥2 visits to an oncologist and no visit in the past year. For these patients, we evaluated the impact of physician-hospital integration on the likelihood of receiving chemotherapy following the visit. The second cohort included 6-month episodes for patients receiving chemotherapy. For these patients we evaluated the impact of physician-hospital integration on spending, utilization, and quality. Quality measures included receipt of timely chemotherapy (within 60 days) following surgery, inpatient readmissions, non-use of tamoxifen + strong CYPD26 inhibitors, and end-of-life intensity of care measures. Results: There was no change in the likelihood of receiving chemotherapy with an initial oncology consultation following an oncologist’s transition to hospital-based employment. Total spending during six-month chemotherapy episodes increased by $1391 (95%CI: $465, $2316). The primary contributors to this growth were increases in spending on inpatient care, chemotherapy administration, and office visits. Spending growth, where observed, was driven primarily by higher Medicare prices for care in hospital outpatient settings. We found no positive impact of physician-hospital integration on timeliness of chemotherapy initiation, readmissions, concurrent use of tamoxifen+strong CYPD26 inhibitors, or intensity of end-of-life care. Conclusions: Physician-hospital integration resulted in higher prices and thus higher spending, but had limited impact on utilization and no detectable impacts on measures of quality. These results suggest that claims of quality improvements and concerns regarding overuse associated with physician-hospital integration may be overstated. Our results also support continued movement towards site-neutral payments.

Disruptions in Care for Medicare Beneficiaries With Severe Mental Illness During the COVID-19 Pandemic

Little is known about changes in care for individuals with severe mental illness during the COVID-19 pandemic. To examine changes in mental health care during the pandemic and the use of telemedicine in outpatient care among Medicare beneficiaries with severe mental illness. This population-based cohort study included Medicare beneficiaries (age ≥18 years) diagnosed with schizophrenia and schizophrenia-related disorders or bipolar I disorder. Care patterns during January to September 2020 for a cohort defined in 2019 were compared with those during January to September 2019 for a cohort defined in 2018. Start of COVID-19 pandemic in the United States, defined as week 12 of 2020. Use of mental health-related outpatient visits, emergency department visits, inpatient care, and oral prescription fills for antipsychotics and mood stabilizers during 4-week intervals. Multivariable logistic regression analyses examined whether the pandemic was associated with differential changes in outpatient care across patient characteristics. The 2019 cohort of 686 214 individuals included 389 245 (53.8%) women, 114 073 (15.8%) Black and 526 301 (72.8%) White individuals, and 477 353 individuals (66.0%) younger than 65 years; the 2020 cohort of 723 045 individuals included 367 140 (53.5%) women, 106 699 (15.6%) Black and 497 885 (72.6%) White individuals, and 442 645 individuals (64.5%) younger than 65 years. Compared with 2019, there were large decreases during the pandemic's first month (calendar weeks 12-15) in individuals with outpatient visits (265 169 [36.7%] vs 200 590 [29.2%]; 20.3% decrease), with antipsychotic and mood stabilizer medication prescription fills (216 468 [29.9%] vs 163 796 [23.9%]; 20.3% decrease), with emergency department visits (12 383 [1.7%] vs 8503 [1.2%]; 27.7% decrease), and with hospital admissions (11 564 [1.6%] vs 7912 [1.2%]; 27.9% decrease). By weeks 32 to 35 of 2020, utilization rebounded but remained lower than in 2019, ranging from a relative decrease of 2.5% (outpatient visits) to 12.9% (admissions). During the full pandemic period (weeks 12-39) in 2020, 1 556 403 of 2 743 553 outpatient visits (56.7%) were provided via telemedicine. In multivariable analyses, outpatient visit use during weeks 12 to 25 of 2020 was lower among those with disability (odds ratio, 0.95; 95% CI, 0.93-0.96), and during weeks 26 to 39 of 2020, it was lower among Black vs non-Hispanic White individuals (OR, 0.97; 95% CI, 0.95-0.99) and those with dual Medicaid eligibility (OR, 0.96; 95% CI, 0.95-0.98). In this cohort study, despite greater use of telemedicine, individuals with severe mental illness experienced large disruptions in care early in the pandemic. These narrowed but persisted through September 2020. Disruptions were greater for several disadvantaged populations.

Home Health Agencies With More Socially Vulnerable Patients Have Lower Experience-of-Care Ratings

Little is known about the disparities in patient experience of home health (HH) care related to social vulnerability. This study examined the relationships of patient Medicare-Medicaid dual eligible status and race and ethnicity with patient experience of HH care. We analyzed national data from the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS), Outcome and Assessment Information Set, Medicare claims and Area Health Resources File for 11,137 Medicare-certified HH agencies (HHA) that provided care for Medicare beneficiaries in 2017. Patient-reported experience of care star ratings (1-5) in HHCAHPS included 3 domains (professional care delivery, effective communication, and specific issues in direct patient care) with each dichotomized into high (4-5) and low (1-3) experience of care. The proportion of patients with dual eligibility and the proportion of racial/ethnic minorities were summarized at the HHA level. HHA with higher proportion of dual eligible patients were less likely to have high experience of care rating in professional care delivery (smallest Odds Ratio [OR]=0.514; 95% CI: 0.397, 0.665; p<0.001), effective communication (smallest OR=0.442, 95% CI: 0.336, 0.583; p<0.001), and specific direct care issues (smallest OR=0.697, 95% CI: 0.540, 0.899; p=0.006). HHA with higher proportion of racial/ethnic minorities were also less likely to have high patient experience of care rating across all three domains (smallest OR=0.265, 95% CI: 0.189, 0.370; p<0.001). Disparities in patient experience of HH care exist and they are associated with low income and racial/ethnic minority status, indicating substantial unmet needs among these socially vulnerable patients.

The Medicare Current Beneficiary Survey (MCBS): Providing Unique Access to Data on the Medicare Population

The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a nationally representative sample of the Medicare population, conducted by the Centers for Medicare & Medicaid Services (CMS). It collects data on demographics, health insurance, health status, health care expenditures, satisfaction with care, and access to care for Medicare beneficiaries. The MCBS provides a unique source of information regarding beneficiaries aged 65 and over and beneficiaries aged 64 and below with disabilities residing in the United States that cannot be obtained solely through CMS administrative sources. For researchers interested in issues of health care utilization and cost, CMS releases two Limited Data Set (LDS) files for each data year and a Public Use File (PUF) freely available for download and use. Also, special topic based PUFs have been released on the impact of COVID-19 on Medicare beneficiaries. This presentation will demonstrate the importance of the MCBS for research on the Medicare population, discuss how researchers can access the data, where researchers can find published MCBS estimates, what content areas have recently been added, such as food insecurity, limited English proficiency, and COVID-19 vaccination uptake and what new content is on the horizon. The presentation will also discuss the operational challenges posed by the COVID-19 pandemic, and the content enhancement opportunities created by the public health emergency. It will conclude with a review of the suite of materials and documentation available for data users to enhance their research and utilize more timely data.

Post-Acute Care for Medicare Beneficiaries in Accountable Care Organizations

Post-acute care (PAC) is a component of health-care utilization and spending that is subject to the discretion of providers. Prior research has demonstrated that Accountable Care Organizations (ACOs) recognize PAC as a logical target for increased efficiency and cost savings. As part of the evaluation of the Centers for Medicare & Medicaid Services (CMS) Next Generation ACO (NGACO) Model, we investigated NGACOs’ approaches to PAC services and the impact of these efforts on utilization and cost using a mixed-methods study design. We conducted interviews and surveys with NGACO leadership and providers and performed a difference-in-differences analysis of utilization and spending based on Medicare claims data. We found that NGACOs focused specifically on establishing partnerships with skilled nursing facilities (SNF) to facilitate transitions in care by establishing new channels of communication, sharing performance data, embedding staff in SNFs, and (in some cases) sharing financial risk. We observed a statistically significant decrease in SNF spending, a trend toward fewer SNF days, and statistically significantly lower expenditures for other PAC settings (e.g., inpatient rehabilitation and long-term acute care facilities). These findings suggest that NGACOs have contributed to improving transitions in care and diverting beneficiaries from intensive PAC settings. Nonetheless, the reduction in PAC spending alone did not translate to a decline in total cost of care. Future ACOs may need to expand their focus to the inpatient utilization and spending that precedes PAC in order to impact total cost of care.

Differences by Rurality in Satisfaction with Care Among Medicare Beneficiaries.

There are stark differences between rural and urban areas in demographic characteristics, health status, and health care, yet less is known about rural-urban differences in Medicare beneficiaries' satisfaction with care. We seek to identify rural-urban differences in satisfaction with care for Medicare beneficiaries and whether those differences are explained by differences in beneficiary characteristics. We used data from the 2016 Medicare Current Beneficiary Survey (n = 10,625), in which beneficiaries indicated their level of satisfaction for 9 measures related to quality and access/affordability of care. We first assessed bivariate differences in satisfaction with care by rural-urban location (metropolitan, rural micropolitan, and rural noncore) across each measure. We then used logistic regression to assess whether differences remained after adjusting for sociodemographic and health characteristics. For nearly all measures, satisfaction with care decreased with increasing rurality. Differences in satisfaction persisted for satisfaction with ease of getting to the doctor from home (adjusted odds ratio [AOR] micropolitan: 0.63, P = .037; AOR noncore: 0.61, P = .023) and availability of care by specialists (AOR micropolitan: 0.51, P = .001; AOR noncore: 0.61, P < .001) after adjusting for sociodemographic and health characteristics. Rural Medicare beneficiaries reported lower satisfaction with care than their urban counterparts across a variety of measures, and some of these differences remained after adjustments were made for sociodemographic and health characteristics. These findings may have implications for access to and quality of care that rural Medicare beneficiaries receive and their subsequent health outcomes.

Low-Value Back Imaging in the Care of Medicare Beneficiaries: A Comparison of Nurse Practitioners and Physician Assistants

Little is known about practice pattern differences between nurse practitioners (NPs) and physician assistants (PAs). We compared the rates of low-value back images ordered by NPs and PAs. For this comparison, we used 2012-2013 Medicare Part B claims for all beneficiaries in 18 hospital referral regions and a measure of low-value back imaging from the Choosing Wisely recommendations. Models included a random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician type, the emergency department setting, and region. NPs (N = 234) order low-value back images significantly less than PAs (N = 204) (NPs 25.5% vs. PAs 39.2%, p < .0001). Controlling for relevant factors, NPs are 10.0 percentage points (p < .0001) less likely to order a low-value back image than PAs. NPs and PAs have distinct patterns of low-value back imaging, which is likely a reflection of their different practice settings.

Let’s Talk Legislation: How Diabetes Educators Can Work to Improve Access to Diabetes Care for Medicare Beneficiaries

Let’s Talk Legislation: How Diabetes Educators Can Work to Improve Access to Diabetes Care for Medicare Beneficiaries

Wednesday, September 26, 2018 9:00 AM – 10:00 AM Best Papers: 7. Predictors of total hospital resource cost during 1- or 2-level lumbar spinal fusion among Medicare beneficiaries

PURPOSE The purpose of this study is to identify demographic factors, comorbid conditions, and procedure approaches associated with higher total hospital resources consumed by Medicare beneficiaries (MBs) during a primary 1- or 2-level lumbar spinal fusion (1-2 LLF). METHODS This retrospective study examined the calendar year 2014 Medicare inpatient standard analytical files (IPSAF) linked data for hospital claims. There were 43,117 hospitalizations where a Medicare beneficiary survived for at least 90 days following a 1-2 LLF hospitalization during the first three quarters of 2014. Multi-variable regression cost equations were estimated controlling for 8 demographic characteristics, the presence of 31 comorbid conditions, and the fusion approach or a combination of fusion approaches used during the 1-2 LLF procedures. Control variables were considered a statistically significant predictor of hospital resource use if the associated p-value was less than .01. RESULTS Overall, the majority of MBs undergoing a 1-2 LLF were white (89.5%), female (59.1%) and between 65 and 74 years of age (53.2%). Average total cost of hospital resources consumed during the initial hospitalization was $27,182±$15,569. The regression results estimated that the y-intercept for total hospital resource cost to be $21,881. The resource cost equation indicates that, compared to MBs age 80 and older, hospital costs were significantly higher (between $1,529 and $2,238) in each of the other four age groups. In addition, MBs who were non-white had significant higher estimated index hospital cost. Furthermore, 14 comorbid conditions were associated with higher incremental hospital cost and four comorbid conditions had estimated incremental cost exceeding $10,000 [malnutrition ($19,243), malignant tumor ($14,780), bone infection ($13,025), and benign tumor ($11,875)]. On the other hand, six comorbid conditions were estimated to be associated with lower hospital resource utilization. The lowest hospital resource utilization was associated with a posterior column/posterior approach technique. All other fusion approaches and combinations thereof significantly increased the estimated incremental hospital resource utilization with the anterior/posterior/anterior column/posterior approach being the most costly with an incremental increase of $26,515. CONCLUSIONS There is increasing interest in understanding the resources utilized during the hospitalization for high volume Medicare procedures such and 1-2 LLF. This study identifies 22 demographic, comorbid conditions, and fusion approaches estimated to increase incremental hospital cost by over 5% during the MBs index hospitalization. As the Medicare program continues to place hospitals at risk for the care MBs receive post discharge, it will become increasingly important to determine if care paths can be developed for MBs with selected comorbid conditions that reduce the incremental resources they are currently consuming during the initial procedure. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Trends in hospital-SNF relationships in the care of Medicare beneficiaries

Improving the value of post-acute care at skilled nursing facilities (SNFs) has become a Medicare policy priority. Anecdotally, hospitals have responded by formally acquiring or pursuing tighter informal connections with SNFs. We evaluated the trend in connections between US acute care hospitals and Medicare-certified SNFs between 2000 and 2013 using vertical integration and two novel network-based measures (number of SNF partners, and discharge concentration). Among 4441 hospitals and 17,215 SNFs, hospitals with weaker connections with SNFs were more often non-profit, major teaching hospitals with a larger number of discharges and beds. We found an apparent weakening of hospital-SNF connections over time for all three measures. Over one-third (39%) of hospitals were vertically integrated in 2000 compared to 8.2% in 2013. The number of SNF partners increased between 2000 and 2013, while hospitals’ discharge concentration declined steadily. Additional work is needed to understand the implications of these trends.

High costs of wound care for Medicare beneficiaries

High costs of wound care for Medicare beneficiaries

Audiologist's Role Within the Changing Climate of Fall Prevention: Are We Ready?

This article is aimed to address the vestibular audiologist's role in assessing patient fall risk as tasked by Medicare. With implementation of the Physician's Quality Reporting System (PQRS), audiologists performing standard measures of the vestibular battery must report on measures #154: Falls: Risk assessment and #155: Falls: Plan of care for Medicare beneficiaries. Mandated reporting of this measure includes vestibular audiologists in the multidisciplinary medical management of fall prevention in older adults. In order for audiologists to provide the most relevant care, it is important to evaluate the current fall risk assessments in medical settings, how the implementation of these measures can be structured within the audiology clinic, and challenges audiologist may face with implementation.

Community-based wellness and prevention programs: the role of medicare.

Community-based wellness and prevention programs: the role of medicare.

Relationships between Medicare Advantage contract characteristics and quality-of-care ratings: an observational analysis of Medicare Advantage star ratings.

The Centers for Medicare & Medicaid Services (CMS) publishes star ratings on Medicare Advantage (MA) contracts to measure plan quality of care with implications for reimbursement and bonuses. To investigate whether MA contract characteristics are associated with quality of care through the Medicare plan star ratings. Retrospective study of MA star ratings in 2010. Unadjusted and adjusted multivariable linear regression models assessed the relationship between 5-star rating summary scores and plan characteristics. CMS MA contracts nationally. 409 (71%) of a total of 575 MA contracts, covering 10.56 million Medicare beneficiaries (90% of the MA population) in the United States in 2010. The MA quality ratings summary score (stars range from 1 to 5) is a quality measure based on 36 indicators related to processes of care, health outcomes, access to care, and beneficiary satisfaction. Nonprofit, larger, and older MA contracts were more likely to receive higher star ratings. Star ratings ranged from 2 to 5. Nonprofit contracts received an average 0.55 (95% CI, 0.42 to 0.67) higher star ratings than for-profit contracts (P <0.001) after controls were set for contract characteristics. The study focused on persons aged 65 years or older covered by MA. In 2010, nonprofit MA contracts received significantly higher star ratings than for-profit contracts. When comparing health plans in the future, the CMS should give increasing attention to for-profit plans with lower quality ratings and consider developing programs to assist newer and smaller plans in improving their care for Medicare beneficiaries. None.

Care coordination for people with complex care needs in the U.S.: A policy analysis

The U.S. boomer population reaching the age of Medicare eligibility and the rising cost of healthcare are putting pressure on the sustainability of the federal Medicare fund. As a result people over 65 with complex care needs risk spending more out of pocket on their healthcare or becoming eligible for Medicaid as their personal resources are depleted. A number of recent initiatives have been developed to improve coordination of care for Medicare beneficiaries with complex care needs and to address the disjointed provision of care for patients who are eligible for Medicare and Medicaid. In order to improve care and reduce the financial burden on patients with complex care needs in the U.S., policy makers must take a system-wide approach, strengthening primary care systems, tackling those at highest risk, increasing care at home and in the community instead of institutions, ensuring better financial protection for patients, and offering healthcare providers financial incentives.

Quality of care and racial disparities in medicare among potential ACOs.

The Medicare Accountable Care Organization (ACO) programs encourage integration of providers into large groups and reward provider groups for improving quality, but not explicitly for reducing health care disparities. Larger group size and better overall quality may or may not be associated with smaller disparities. To examine differences in patient characteristics between provider groups sufficiently large to participate in ACO programs and smaller groups; the association between group size and racial disparities in quality; and the association between quality and disparities among larger groups. Using 2009 Medicare claims for 3.1 million beneficiaries with cardiovascular disease or diabetes and linked data on provider groups, we compared racial differences in quality by provider group size, adjusting for patient characteristics. Among larger groups, we used multilevel models to estimate correlations between group performance on quality measures for white beneficiaries and black-white disparities within groups. Four process measures of quality, hospitalization for ambulatory care-sensitive conditions (ACSCs) related to cardiovascular disease or diabetes, and hospitalization for any ACSC. Beneficiaries served by larger groups were more likely to be white and live in areas with less poverty and more education. Larger group size was associated with smaller disparities in low-density lipoprotein (LDL) cholesterol testing and retinal exams, but not in other process measures or hospitalization for ACSCs. Among larger groups, better quality for white beneficiaries in one measure (hospitalization for ACSCs related to cardiovascular disease or diabetes) was correlated with smaller racial disparities (r = 0.28; P = 0.02), but quality was not correlated with disparities in other measures. Larger provider group size and better performance on quality measures were not consistently associated with smaller racial disparities in care for Medicare beneficiaries with cardiovascular disease or diabetes. ACO incentives rewarding better quality for minority groups and payment arrangements supporting ACO development in disadvantaged communities may be required for ACOs to promote greater equity in care.

Spending and Quality of Care for Medicare Beneficiaries in Massachusetts

Spending and Quality of Care for Medicare Beneficiaries in Massachusetts