Disabled Beneficiaries Research Articles

Highly Stable Beneficiary Attribution in Medicare's Comprehensive Primary Care Plus Model.

Advanced primary care models are key in moving primary care practices toward greater accountability for the quality and cost of a beneficiary's care. One critical but often overlooked detail in model design is the beneficiary attribution methodology. Attribution results are key inputs in calculating practice payments. Stable attribution yields predictable practice payments, fostering longer-term investments in advanced primary care. We examine attribution stability for Medicare fee-for-service beneficiaries in Medicare's Comprehensive Primary Care Plus (CPC+) Model. To measure attribution stability, we calculate churn rates, which we define as the percentage of beneficiaries eligible for CPC+ who were not attributed to the same practice in a later period. Using 2017-2021 CPC+ program data and Medicare administrative data, we calculate churn rates for CPC+ overall and for beneficiary subgroups. To assess whether CPC+ attribution was responsive enough to changes in a beneficiary's practice, we calculate how long before attribution changes following a beneficiary's long-distance move. We find that for every 100 beneficiaries attributed to a CPC+ practice, 88 were still attributed to the same practice a year later (ie, churn rate of 12%), 79 were attributed 2 years later, 74 three years later, and 70 four years later. However, some vulnerable subgroups, such as disabled beneficiaries, had higher churn rates. Our analysis of long-distance movers reveals that only after 5 quarters did attribution change for more than half of these movers. Overall, high attribution stability may have encouraged CPC+ practices to make longer-term investments in advanced primary care.

Opportunities for Integration in the Dual Medicare-Medicaid Population: North Carolina Landscape Analysis.

NC Medicaid is amid a transformation to value-based care models. The transformation requires the consideration of models that may best serve the 1 in 5 NC Medicaid beneficiaries who are dually enrolled in Medicare. The lack of integration of Medicare and Medicaid administration, financing, and care may contribute to suboptimal health outcomes and care experiences. Integrating Medicare and Medicaid to improve care for dually enrolled individuals requires knowledge of the demographic, eligibility, and enrollment trends, as well as the medical needs of these individuals throughout North Carolina. We performed a cross-sectional analysis of 2019 NC Medicaid administrative enrollment data and 2015-2020 Medicare and Medicaid public use files. Nearly half of North Carolina's full-benefit dual-eligible (FBDE) population was eligible for Medicare due to disability. About one-third of the FBDE population lost full Medicaid benefits at some point during 2019; of these, 65% were under age 65. Most FBDE beneficiaries were enrolled in Medicaid fee-for-service, with 3.5% enrolled in Community Alternatives Program (CAP) waivers, 2% in Medicaid waivers for beneficiaries with behavioral health or intellectual and developmental disabilities (BH/IDD) or traumatic brain injury (TBI), and 1% in the Program of All-Inclusive Care for the Elderly (PACE). Enrollment in Medicare Duals Special Needs Plans (D-SNPs) increased from 7.3% of the FBDE population in 2015 to 32.5% in 2021. This descriptive, cross-sectional evaluation of North Carolina duals may not be generalizable to other time periods and contexts. Medicare-Medicaid integration presents an opportunity to improve the value of care for dual-eligible beneficiaries and aligns with the goals of NC Medicaid transformation. Integration strategies that leverage the current infrastructure may minimize disruption of services for beneficiaries and mitigate the impacts of unstable enrollment, particularly among working-age adults and disabled beneficiaries. The diversity within the dual-eligible populations requires a strategy designed to improve health equity across race, disability, eligibility, geography, and health care needs.

Updating the Chronic Illness and Disability Payment System.

Of the 38 Medicaid programs that risk adjust payments to Medicaid managed care organizations (MCOs), 33 of them use the Chronic Illness and Disability Payment System (CDPS). There has been recent interest in adding social determinants of health (SDH) into risk-adjustment models. To update the CDPS models using recent MCO data based on the International Classification of Diseases version 10 coding system and to explore whether indicators of SDH are predictive of expenditures. Data from 3 national Medicaid MCOs and 8 states are used to update the CDPS model. We test whether spending on Medicaid beneficiaries living in economically and socially deprived communities is greater than spending on similar beneficiaries in less deprived communities. Medicaid beneficiaries with full benefits and without dual eligibility under Medicare enrolled in Medicaid MCOs in 8 states during 2017-2019, including 1.4M disabled beneficiaries, 9.2M children, and 6.4M adults. Health care eligibility and claims records. Indicators based on the Social Deprivation Index were used to measure SDH. The revised CDPS model has 52 CDPS categories within 19 major categories. Six major categories of CDPS were revised: Psychiatric, Pulmonary, Renal, Cancer, Infectious Disease, and Hematological. We found no relationship between health care spending and the Social Deprivation Index. The revised CDPS models and regression weights reflect the updated International Classification of Diseases-10 coding system and recent managed care delivery. States should choose alternative payment strategies to address disparities in health and health outcomes.

The mortality experience of disabled persons in the United States during the COVID-19 pandemic.

New data from the Social Security Administration suggest there were 260 000 excess deaths in the United States among current or former disability beneficiaries during the first 22 months of the COVID-19 pandemic. These beneficiaries accounted for 26% of all excess deaths in the United States during this period. The pattern of deaths among disabled beneficiaries corresponds closely to known milestones in the pandemic's history. Disabled beneficiaries in New York, particularly those residing in institutions, had extremely elevated mortality with the onset of the pandemic in the spring of 2020. Across all regions in the United States, mortality among disability beneficiaries increased sharply with the onset of the winter of 2020-2021 and with the emergence of the Delta and Omicron variants in 2021. Elevated mortality was observed for persons with intellectual, mental, and physical impairments. Future public information campaigns about vaccines and other measures may be more successful if they include specific efforts to directly target disability beneficiaries. In addition, clinical trials and other research should consider including disabled persons as specific study groups as the severity of their underlying health impairments is likely comparable to that of persons of advanced age.

Adverse outcomes associated with concurrent gabapentin, opioid, and benzodiazepine utilization: A nested case-control study

Gabapentin, opioids, and/or benzodiazepines are commonly prescribed for a variety of pain and psychiatric conditions. Despite the high likelihood of co-prescription of these medications, little is known about co-utilization of gabapentin (GABA), opioids (OP), and benzodiazepines (BZD) and associated public health outcomes. Using Medicare CCW Data, 2013-2016, we conducted a nested case-control study to examine the association between concurrent utilization of GABA, OP, and BZD and respiratory depression, opioid, and substance-related overdose among Medicare disabled beneficiaries. Cases and controls were Fee-for-service disabled beneficiaries who had a diagnosis of acute pain (AP), chronic pain (CP) or mental health conditions (MH) and received GABA, OP or BZD. Cases with respiratory depression, opioid or substance-related overdose were matched with up to 4 controls on socio-demographics, year of cohort entry and disease risk score. Primary exposure was concurrent medication utilization defined as an overlap of at least one day in prescriptions for GABA, OP and BZD. Across all cohorts, the majority of cases and controls were under 65, female, dually eligible and had prior histories of pain and mental health conditions. GABA+OP+BZD use was associated with increased odds of respiratory depression [AOR(95%CI)-AP: 1.35 (1.19-1.52), CP:1.24 (1.11-1.38) and MH: 1.16 (1.02-1.32) vs. OP only], opioid-related overdose [AP: 1.43 (1.04-1.98), CP: 1.47 (1.07-2.00) and MH: 1.44 (1.04-2.00) vs. OP only], and substance-related overdose [AP: 1.77 (1.26-2.50), CP: 1.70 (1.24-2.34) and MH: 1.92 (1.31-2.82) vs. GABA only]. While there were cohort differences in the association between GABA+OP and both respiratory depression and opioid-related overdose, GABA+OP and GABA+BZD use were associated with significantly higher odds of substance-related overdose across all clinical cohorts. Among Medicare disabled beneficiaries, concurrent utilization of gabapentin, opioids, and benzodiazepines is associated with multiple adverse outcomes. Given this, it is imperative that the benefits and risks of co-prescribing these medications be comprehensively examined. None.

Prevalence of Frailty in Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis: Data from a National Claims Dataset

ObjectiveFrailty is associated with disability and mortality independent of age. Although studies have evaluated frailty in rheumatoid arthritis (RA), information on the prevalence of frailty in ankylosing spondylitis (AS) and psoriatic arthritis (PsA) is limited. We aimed to determine the prevalence of frailty in AS and PsA and to evaluate whether characteristics known to be associated with frailty, including anxiety, differ among these three types of inflammatory arthritis.MethodsWe performed a cross sectional study of Centers for Medicare & Medicaid Services (CMS) beneficiaries aged 65 years or older with AS, PsA, or RA enrolled in 2014. We operationalized frailty using a validated claims‐based frailty index. We also explored the prevalence of frailty among CMS beneficiaries younger than age 65 years with work disability, a younger population that also may be at risk of frailty.ResultsThe prevalence of frailty in beneficiaries aged 65 years or older with AS and PsA was 45.2% and 46.7%, respectively, significantly lower than in RA (65.9%, P < 0.05). The prevalence of frailty in beneficiaries less than 65 years old was much lower overall, though still highest in RA; 11.7%, 4.4%, and 7.0% in RA, AS, and PsA, respectively (P < 0.05). Anxiety was significantly associated with frailty in subjects of all ages, particularly among those less than 65 years old (P < 0.05).ConclusionAlmost half of beneficiaries with AS or PsA aged 65 years old or older were frail, higher than in younger disabled beneficiaries. Further studies are needed to understand the risks of developing frailty in these diseases. Frailty was associated with anxiety, particularly in the younger age groups.

Patterns of opioid and benzodiazepine use with gabapentin among disabled Medicare beneficiaries – A retrospective cohort study

BackgroundOur goal was to describe specific patterns associated with co-prescriptions of gabapentin, opioids, and benzodiazepines among disabled Medicare beneficiaries. MethodsUsing 2013–2015 Medicare data, we conducted a retrospective cohort study among fee-for-service disabled beneficiaries continuously enrolled in Medicare Parts A, B, and D. The index date was defined as the earliest fill date for a gabapentin, opioid, or benzodiazepine prescription. Monotherapy, dual therapy, and tri-therapy were defined as utilization of one, two, and three medication classes, respectively. Augmentation was defined as a prescription for a different medication class in addition to prescription for initial medication; switching referred to a change in prescription for a different medication class with no subsequent fills of initial medication. We used descriptive statistics, Kaplan Meier analyses and Cox proportional hazards to examine the association between initial therapy and monotherapy, dual therapy, tri-therapy, switching and augmentation. ResultsAmong 151,552 disabled beneficiaries, gabapentin initiators were more likely to augment therapy (50.1%) when compared to opioid (28.7%) and benzodiazepine (38.7%) users. When compared to opioid initiators, the risk of augmentation (HR[95%CI]: 1.85[1.82–1.89]) and switching (1.62 [1.51–1.73]) was significantly higher among gabapentin initiators. Risk of augmentation was also significantly higher among beneficiaries with co-morbid pain and mental health conditions (p < 0.01). Overall, the majority of beneficiaries augmented and switched within 2-months and 4-months after initiating therapy, respectively. ConclusionsGiven safety concerns associated with gabapentin, opioids, and benzodiazepines, it is imperative that the benefits and risks of co-prescribing these medications be examined comprehensively, especially for those in vulnerable sub-groups.

Medicaid managed care in Iowa: Experiences of older adults and people with disabilities

BackgroundA growing number of states are turning to managed care arrangements to provide care to senior and disabled Medicaid beneficiaries. Despite their complex care needs, very little is known about the experience of these individuals in managed care. ObjectiveTo document experiences of a sample of aged and disabled Medicaid beneficiaries receiving long-term services and supports through managed care in Iowa and to assess whether these experiences changed over time. MethodsA purposive sample of 49 aged and disabled beneficiaries enrolled in one of seven HCBS waivers in Iowa was recruited in 2017. Telephone surveys were conducted in 2017 and 2019. A conventional content analysis was used to generate themes, which were then ranked by frequency proportions. Thematic frequencies were compared across waves among repeat respondents. ResultsContent analysis yielded seven themes in the following areas: system navigation; service approvals; provider relations; customer service; case management; perception of Iowa’s transition to managed care; and oversight. Concerns with service approvals was the most frequently reported theme and within this, issues related to changes in approved services or hours and quality of newly approved services comprised the largest number of references. Beneficiary concerns appeared to grow over time among respondents participating in both survey interview waves. ConclusionThe results of this study point to serious and persistent concerns related to access and quality of care under managed care for at least some HCBS waiver participants in Iowa, underscoring the need for a comprehensive evaluation of the program.

Promises and Pitfalls of Health Information Technology for Home- and Community-Based Services.

Background: Health information technology (HIT) use in home- and community-based services (HCBS) has been hindered by inadequate resources and incentives to support modernization. We sought to understand the ways the Medicaid Balancing Incentive Program (BIP) facilitated increased use of HIT to increase access to HCBS. Method: Qualitative analysis of interviews with 30 Medicaid administrators, service agency providers, and consumer advocates. Results: Although stakeholders perceived several benefits to greater HIT use, they highlighted critical challenges to effective adoption within the long-term services and supports (LTSS) system, including lack of extant expertise/knowledge about HIT, the limited reach of HIT among rural and disabled beneficiaries, burdensome procurement processes, and the ongoing resources required to maintain up-to-date HIT solutions. Conclusion: The structural reforms required by BIP gave states an opportunity to modernize their HCBS systems through use of HIT. However, barriers to HIT adoption persist, underscoring the need for continued support as part of future rebalancing efforts.

Understanding risk in accountable care organisations

The US healthcare system is in the midst of a transition from reimbursement based on the volume of services to that based on the value and quality of services provided to patients. Accountable care organisations (ACOs), or groups of providers that come together to meet certain financial and care quality goals, are illustrative of this movement. This paper presents two prerequisites for a successful Medicare ACO, which serves aged and disabled beneficiaries. First, an ACO makes strategic use of population health techniques, including advanced primary care and nurse-led services such as annual wellness visits (AWV) and data-driven chronic care management (CCM). Second, an ACO must achieve significant scale to avoid unexplained swings in year-to-year savings and losses. The paper demonstrates that, in spite of early success, rural ACOs face additional challenges, including a strong aversion to risk in light of their economic fragility and community-based governance and random pricing inaccuracies created by cost-based reimbursement.

Exploring the Valley of Savings: Minimizing Part D Costs and Optimizing Drug Therapy Outcomes in Medicare Beneficiaries With Developmental Disability.

Nonelderly disabled Medicare beneficiaries have a higher prevalence of chronic conditions, higher utilization of prescription medications, and increased demand for clinical services when compared to beneficiaries 65 years of age and older who are not disabled. Out-of-pocket costs and medication-related problems are major barriers to medication compliance and achievement of therapeutic goals. A school of pharmacy partnered with a nonprofit organization that provides care to individuals with developmental disabilities. The present study highlights outcomes resulting from (a) providing Medicare Part D plan optimization services to lower prescription drug costs and (b) Medication Therapy Management services to evaluate safe and effective medication use in this beneficiary population. Provided interventions were shown to reduce overall medication costs and identify significant medication-related problems.

Performance in the Medicare Shared Savings Program by Accountable Care Organizations Disproportionately Serving Dual and Disabled Populations.

The growth of accountable care organizations (ACOs) and other alternative payment models has prompted concern about whether these models will disadvantage providers who serve vulnerable populations, particularly those living in poverty or with a disability. To examine performance by ACOs in the top quintile of their proportion of beneficiaries dually enrolled in Medicare and Medicaid (high-dual) and the top quintile of disabled beneficiaries (high-disabled). This is a retrospective cohort study. The 333 ACOs in the Medicare Shared Savings Program in 2014, followed through 2016. Quality scores, savings per beneficiary, whether or not the ACO shared savings, and amount of shared savings. High-dual and high-disabled ACOs had slightly lower quality and similar or higher baseline spending than other ACOs, but achieved greater savings per beneficiary than other ACOs ($212 vs. $51 for high-dual ACOs, P=0.04; $241 vs. $44 for high-disabled ACOs, P=0.012). Further, these ACOs were equally or more likely to earn shared savings; just over 30% of high-dual ACOs earned shared savings compared with 25% of non-high-dual ACOs (P=0.35) and 38% of high-disabled ACOs earned shared savings compared with 23% of non-high-disabled ACOs (P=0.013). In longitudinal analyses, we found a decrease in the differences in quality between high-social risk and other ACOs over time. Savings remained higher for high-dual and high-disabled ACOs relative to other ACOs over 2014-2016 though the gap narrowed over time. High-dual and high-disabled ACOs had similar or higher spending than other ACOs at baseline, but achieved greater savings and were equally or more likely to earn shared savings, suggesting that alternative payment models can have positive financial outcomes for providers who serve vulnerable populations.

Relating through differences: disability, affective relationality, and the U.S. public healthcare assemblage

Using affect theory and disability theory, this article theorizes relationality as it emerges between disabled people who require daily assistance and their paid care providers. In response to the question of how people relate when not only their social identities but also their embodied capacities are different, the concept of affective relationality is developed. Using the work of Deleuze and Guattari, Spinoza, as well as Harney and Moten, I describe how such relationality emerges based on the ontological, haptic connection of bodies that develops through recursive practices of a task co-conducted by and between those bodies, and is co-capacitative. As this study takes place in the U.S. neoliberal public healthcare assemblage—which involves mainly lower- or no-income disabled beneficiaries and their paid workers who are disproportionately lower-income, non/immigrant women of color—the concept of affective relationality is brought into the political arena by contemplating what the relationality does in such assemblage.

Offsetting the Effects of Medical Expenses on Older Adults' Household Food Budgets: An Analysis of the Standard Medical Expense Deduction.

The Supplemental Nutrition Assistance Program (SNAP) provides critical nutrition assistance to over 40 million Americans each month. Low-income older adults (60 and older) and disabled participants experience additional budgetary constraints because of high out-of-pocket medical expenses. In recent years, some states have adopted a "Standard Medical Expense Deduction" (SMED) for senior and disabled beneficiaries, making it easier to report medical expenses in the SNAP application process. We conduct a descriptive national analysis that shows increases in benefit levels and reporting of medical expenses for states that have implemented SMED. We then present descriptive findings from Medicare claims data among a sample of low-income older adults in need of food assistance in Georgia. Average medical expenses among this sample approach $200 per month, whereas those for persons diagnosed with multiple chronic conditions exceed $300 per month. Policy implications of this analysis include the need for more states to consider adoption of SMED or alternative estimating approaches, leading to increases in benefit levels for the neediest beneficiaries and decreases in administrative burden among state agencies. We present two possible policy approaches states might take to receive approval for these changes from U.S. Department of Agriculture.

State Legal Restrictions and Prescription-Opioid Use among Disabled Adults

BackgroundIn response to rising rates of opioid abuse and overdose, U.S. states enacted laws to restrict the prescribing and dispensing of controlled substances. The effect of these laws on opioid use is unclear.MethodsWe tested associations between prescription-opioid receipt and state controlled-substances laws. Using Medicare administrative data for fee-for-service disabled beneficiaries 21 to 64 years of age who were alive throughout the calendar year (8.7 million person-years from 2006 through 2012) and an original data set of laws (e.g., prescription-drug monitoring programs), we examined the annual prevalence of beneficiaries with four or more opioid prescribers, prescriptions yielding a daily morphine-equivalent dose (MED) of more than 120 mg, and treatment for nonfatal prescription-opioid overdose. We estimated how opioid outcomes varied according to eight types of laws.ResultsFrom 2006 through 2012, states added 81 controlled-substance laws. Opioid receipt and potentially hazardous prescription patterns were common. In 2012 alone, 47% of beneficiaries filled opioid prescriptions (25% in one to three calendar quarters and 22% in every calendar quarter); 8% had four or more opioid prescribers; 5% had prescriptions yielding a daily MED of more than 120 mg in any calendar quarter; and 0.3% were treated for a nonfatal prescription-opioid overdose. We observed no significant associations between opioid outcomes and specific types of laws or the number of types enacted. For example, the percentage of beneficiaries with a prescription yielding a daily MED of more than 120 mg did not decline after adoption of a prescription-drug monitoring program (0.27 percentage points; 95% confidence interval, −0.05 to 0.59).ConclusionsAdoption of controlled-substance laws was not associated with reductions in potentially hazardous use of opioids or overdose among disabled Medicare beneficiaries, a population particularly at risk. (Funded by the National Institute on Aging and others.)

EMTALA Turns 30: Unconstitutional from Birth

The Emergency Medical Treatment and Active Labor Act (“EMTALA”) requires every Medicare-contracting hospital with an emergency department (“ED”) to screen and stabilize anyone with an emergency condition, regardless of ability to pay. Enacted in 1986, EMTALA vastly expanded Medicare’s initial focus on elderly and disabled beneficiaries and imposed enormous financial liabilities. Neither the Supreme Court nor any Circuits have addressed EMTALA’s constitutionality.This Article proposes that EMTALA violates the Fifth Amendment’s Takings Clause. First, it imposes a host of individual takings as the government forces one private party — the hospital — to transfer personal property to another private party — the patient. Here, violations depend on whether the hospital is justly compensated.Second, EMTALA as a whole is an “unconstitutional condition” imposed on hospitals’ participation in Medicare. Although the government can properly attach “strings” to ensure public funds are spent as Congress intended, the government cannot with impunity require persons to waive fundamental constitutional rights as a condition for receiving a government benefit. This Article shows that, as EMTALA forces hospitals to abdicate their Fifth Amendment right against uncompensated takings, it exceeds the Supreme Court’s boundaries on federal spending.In the final analysis, EMTALA’s mandate that hospitals care for emergency patients should remain, but hospitals must be justly compensated.

Clozapine for Schizophrenia: State Variation in Evidence-Based Practice

Clozapine is the only antipsychoticwith known efficacy in treatment-resistant schizophrenia. Although 20% to 30% of individuals with schizophrenia have treatment-resistant conditions, clozapine accounts for only about 5% of their antipsychotic starts (1).We updated our previous analysis (2001–2005) by examining more recent (2006–2009) trends and patterns across 46 state Medicaid programs. Overall, clozapine accounted for 4.8% (95% confidence interval [CI]54.8%–4.9%) of antipsychotic use in schizophrenia, with a slight decline during this period: 5.7% (CI55.6%–5.8%) in 2006; 4.9% (CI54.8%–5.0%) in 2007; 4.6% (CI54.5%–4.6%) in 2008; and 4.3% (CI54.2%–4.4%) in 2009. Figure 1 shows substantial interstate variation. Clozapine was least commonly used in the Deep South and more commonly used in New England, the Rocky Mountain West, and Washington. The highest rate was in SouthDakota (15.6%, CI514.0%–17.2%) and the lowest in Louisiana (2.0%, CI51.9%–2.2%). Fiscal stress has been linked to lower clozapine use (2), as has inadequate staffing to monitor clozapine (3). The state variations are broadly consistent with known variations in overall Medicaid spending for disabled beneficiaries. Patient reluctance about blood monitoring and concerns over tolerability are unlikely to explain the variation. These findings underscore the need to determine the extent to which state variation can be explained by local practice environments or state policy factors. Interventions and policies are needed to promote appropriate clozapine treatment of Medicaid-insured patients with treatment-resistant schizophrenia.

Capsule Commentary on Zallman et al., Unauthorized Immigrants Prolong the Life of Medicare's Trust Fund.

U nauthorized immigrants have become the modern day pariahs. They are barred from programs like Medicare, Medicaid, and even the newHealth InsuranceMarketplace, no matter how long they have lived in the U.S., how sick or how impoverished. Paradoxically, they make payments into Medicare, but are prohibited from eventually receiving Medicare benefits. Part A of Medicare (the hospital component) is f inanced by workers ’— including undocumented workers’—payroll taxes, reserved in the Medicare Trust Fund and paid out as Medicare benefits to elderly or disabled beneficiaries. The government has acknowledged that undocumented immigrants’ untapped contributions to the Social Security Trust Fund, the counterpart to the Medicare fund, prolong its solvency and sustain Social Security benefits for retired citizens. Leah Zallman and her associates have estimated that unauthorized immigrants contributed a net surplus of $35 billion to the Medicare Trust Fund, extending its solvency. They also find that proposals to offer a pathway to citizenship for a portion of the undocumented would continue to create a generous surplus. Even though the new citizens could eventually become eligible for Medicare, legalization would increase their earning power, thereby boosting their tax contributions to the Medicare Trust Fund. It has long been known that immigrants, including the unauthorized, use medical services sparingly and, contrary to popular misconceptions, even use emergency departments less than citizens, so tend to be less costly even when they are insured. But ideological barriers have made it almost impossible to overcome the political challenges needed to improve the conditions for the undocumented, whether through legislation or executive action. For now, unauthorized immigrants are likely to remain in the shadows and reliant on the health care safety net.

Persistent medication affordability problems among disabled Medicare beneficiaries after Part D, 2006-2011.

Disabled Americans who qualify for Medicare coverage typically have multiple chronic conditions, are highly dependent on effective drug therapy, and have limited financial resources, putting them at risk for cost-related medication nonadherence (CRN). Since 2006, the Part D benefit has helped Medicare beneficiaries afford medications. To investigate recent national trends in medication affordability among this vulnerable population, stratified by morbidity burden. We estimated annual rates of medication affordability among nonelderly disabled participants in a nationally representative survey (2006-2011, n=14,091 person-years) using multivariate logistic regression analyses. Survey-reported CRN and spending less on other basic needs to afford medicines. In the 6 years following Part D implementation, the proportion of disabled Medicare beneficiaries reporting CRN ranged from 31.6% to 35.6%, while the reported prevalence of spending less on other basic needs to afford medicines ranged from 17.7% to 21.8%. Across study years, those with multiple chronic conditions had consistently worse affordability problems. In 2011, the prevalence of CRN was 37.3% among disabled beneficiaries with ≥ 3 morbidities as compared with 28.1% among those with fewer morbidities; for spending less on basic needs, the prevalence was 25.4% versus 15.7%, respectively. There were no statistically detectable changes in either measure when comparing 2011 with 2007. Disabled Medicare beneficiaries continue to struggle to afford prescription medications. There is an urgent need for focused policy attention on this vulnerable population, which has inadequate financial access to drug treatments, despite having drug coverage under Medicare Part D.

Using Medicare data to assess nurse practitioner–provided care

BackgroundTo mitigate shortages of primary care physicians and ensure access to health care services for a growing number of Medicare beneficiaries, some policy makers have recommended expanding the supply and roles of nurse practitioners (NPs). Little is known about the number of NPs billing Medicare or their practice patterns. PurposeThis study examines the geographic distribution and county characteristics of NPs billing Medicare, compares the types and quantities of primary care services provided to Medicare beneficiaries by NPs and primary care physicians, and analyzes the characteristics of beneficiaries receiving primary care from each type of clinician. MethodsWe performed a cross-sectional analysis of 2008 Medicare administrative data from 959,848 aged and/or disabled beneficiaries continuously enrolled in fee-for-service Medicare during the study period. Outcome measures included geographic distribution of NPs measured by the rate of NPs per 1,000 Medicare beneficiaries by state, average utilization, and patient characteristics. DiscussionStates with the highest rate of NPs billing were rural. Over 80% of the payments received by both NPs and primary care physicians were for evaluation and management services. Beneficiaries assigned to an NP were more likely to be female, to be dually eligible for Medicare and Medicaid, and to have qualified for Medicare because of a disability. NPs with assigned beneficiaries were significantly more likely than similar primary care physicians to practice in federally designated primary care shortage areas. ConclusionsApproximately 45,000 NPs were providing services to beneficiaries and billing under their own provider numbers in 2008. Aspects of NP practice patterns were different from primary care physicians, and NPs appeared more likely to provide services to disadvantaged Medicare beneficiaries.