Medicare Enrollees Research Articles

Palliative Care Initiated in the Emergency Department: A Cluster Randomized Clinical Trial.

The emergency department (ED) offers an opportunity to initiate palliative care for older adults with serious, life-limiting illness. To assess the effect of a multicomponent intervention to initiate palliative care in the ED on hospital admission, subsequent health care use, and survival in older adults with serious, life-limiting illness. Cluster randomized, stepped-wedge, clinical trial including patients aged 66 years or older who visited 1 of 29 EDs across the US between May 1, 2018, and December 31, 2022, had 12 months of prior Medicare enrollment, and a Gagne comorbidity score greater than 6, representing a risk of short-term mortality greater than 30%. Nursing home patients were excluded. A multicomponent intervention (the Primary Palliative Care for Emergency Medicine intervention) included (1) evidence-based multidisciplinary education; (2) simulation-based workshops on serious illness communication; (3) clinical decision support; and (4) audit and feedback for ED clinical staff. The primary outcome was hospital admission. The secondary outcomes included subsequent health care use and survival at 6 months. There were 98 922 initial ED visits during the study period (median age, 77 years [IQR, 71-84 years]; 50% were female; 13% were Black and 78% were White; and the median Gagne comorbidity score was 8 [IQR, 7-10]). The rate of hospital admission was 64.4% during the preintervention period vs 61.3% during the postintervention period (absolute difference, -3.1% [95% CI, -3.7% to -2.5%]; adjusted odds ratio [OR], 1.03 [95% CI, 0.93 to 1.14]). There was no difference in the secondary outcomes before vs after the intervention. The rate of admission to an intensive care unit was 7.8% during the preintervention period vs 6.7% during the postintervention period (adjusted OR, 0.98 [95% CI, 0.83 to 1.15]). The rate of at least 1 revisit to the ED was 34.2% during the preintervention period vs 32.2% during the postintervention period (adjusted OR, 1.00 [95% CI, 0.91 to 1.09]). The rate of hospice use was 17.7% during the preintervention period vs 17.2% during the postintervention period (adjusted OR, 1.04 [95% CI, 0.93 to 1.16]). The rate of home health use was 42.0% during the preintervention period vs 38.1% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of at least 1 hospital readmission was 41.0% during the preintervention period vs 36.6% during the postintervention period (adjusted OR, 1.01 [95% CI, 0.92 to 1.10]). The rate of death was 28.1% during the preintervention period vs 28.7% during the postintervention period (adjusted OR, 1.07 [95% CI, 0.98 to 1.18]). This multicomponent intervention to initiate palliative care in the ED did not have an effect on hospital admission, subsequent health care use, or short-term mortality in older adults with serious, life-limiting illness. ClinicalTrials.gov Identifier: NCT03424109.

Out-Of-Network Utilization and Plan Selection Among Medicare Advantage Cost Plan Enrollees.

To understand how Medicare Advantage (MA) networks impact utilization patterns and plan choices, using the 2019 discontinuation of MA 1876 Cost plans as a natural experiment. We study 1876 Cost plans, MA plans for which out-of-network care is covered through traditional Medicare (TM) and many of which CMS discontinued in 2019. We characterize the proportion of Cost plan enrollees who utilized out-of-network care in 2018 from different types of medical specialties. We then study how enrollees in discontinued plans selected into new plans in 2019. We use regression analysis to characterize whether higher risk enrollees selected into TM at higher rates. We identify discontinued plans using public MA plan data. We employ administrative Medicare enrollment and TM claims data to identify 2018 enrollees of discontinued plans, their 2018 out-of-network utilization, and their subsequent 2019 enrollment decisions. Among Cost plan enrollees, 69% utilized non-emergency room related care out of network in 2018. Out-of-network utilization was distributed across several types of specialties: 43% of Cost plan enrollees had at least one out-of-network claim with a primary care physician and over 20% had a claim with a medical specialist, surgical specialist, or nurse practitioner. We find evidence of adverse selection among enrollees of discontinued Cost plans in 2019. Conditional on one's 2018 Cost plan and county of residence, a standard deviation increase in risk score was on average associated with a 26.35% (95% CI, 25.57%-27.12%) increased likelihood of enrolling in TM. The high rate of out-of-network utilization suggests that MA enrollees value access to care outside of standard MA networks. Subsequent selection patterns indicate that preferences for broader networks and subsequent enrollment in TM is highest among higher risk enrollees, suggesting limited networks may induce extensive margin selection.

EARLY PALLIATIVE CARE UTILIZATION AMONG OLDER ADULTS WITH METASTATIC CANCER IN A MEDICARE COHORT

Abstract Meta-analytic data have found early palliative care (EPC) to be associated with better outcomes among older adults with cancers. EPC is now recommended for all people with advanced cancers. Ideally, the resources required to appropriately treat referred patients would reflect the needs of the patient population. We are aware of no prior attempts to characterize patients receiving EPC. To address this gap, we used a 20% random sample of fee-for-service Medicare enrollees from 2008-2016 to identify predictors of EPC use within 8 weeks of a new diagnosis of metastatic cancer. Logistic regression modeling adjusted for demographics, cancer site, indicators for a variety of physical and behavioral health diagnoses, the Elixhauser comorbidity index, and several indicators for past-year health service use. 525,936 individuals were included, with 4.9% (25,982) receiving EPC. Several behavioral health diagnoses were associated with increased odds of EPC, including both active and remitted alcohol use disorder; active drug use disorder; major depression; and schizophrenia. These findings suggest that the caseloads of palliative care clinicians may disproportionately include persons with histories of significant psychiatric disorders and behavioral health disorders. Though palliative care clinicians may effectively manage some psychological symptoms, such interventions fail to consistently do so. Moreover, few palliative care teams include psychologists or psychiatrists, potentially leading to significant gaps in clinical expertise. Models of palliative care should integrate specialty mental health clinicians to meet the demand for EPC services and manage the spectrum of needs among older adults with advanced cancers.

Enrollment in Medicare is associated with fewer outpatient mental healthcare visits among those with mental health symptoms.

To test whether enrolling in traditional Medicare (TM) or Medicare Advantage (MA) at age 65 reduces mental healthcare utilization among individuals with mental health symptoms and low or moderate family incomes. We employ a fuzzy regression discontinuity design, comparing the likelihood of having an outpatient mental health visit or a psychotropic drug fill among individuals younger than or older than the age 65 Medicare eligibility threshold. We analyze 2014-2021 Medical Expenditure Panel Survey data. Our primary sample is restricted to individuals with probable mental health symptoms as indicated by their score on the Kessler K6 psychological distress scale (K6) and Patient Health Questionnaire-2 instrument (PHQ-2) and who have incomes less than 400% of the federal poverty level. Among individuals with probable mental health symptoms and low or moderate incomes, enrolling in Medicare (combining the effect of MA and TM) is associated with a 24.9 percentage point reduction (95% CI -49.1 to -0.8; p = 0.043) in the likelihood of having any type of outpatient mental health visit and a 31.3 percentage point reduction (95% CI -54.2 to -8.4; p = 0.008) in the likelihood of having a prescription drug fill for a psychotropic drug. Effects of MA and TM on mental healthcare utilization are not statistically different from each other. We observe no impact of enrolling in Medicare on the likelihood of having a visit to a primary care provider, having a visit to a non-mental healthcare specialist, or having a fill for a prescribed non-psychotropic drug. Enrolling in Medicare is associated with a reduction in the use of mental healthcare among individuals with probable mental health symptoms and low or moderate family incomes. Our findings suggest that the program poses access barriers specific to mental healthcare.

Utilization and Outcomes Associated With Intravascular Ultrasound during Abdominal and Thoracic Endovascular Aortic Interventions in the United States in the Contemporary Era (2016-2023).

Intravascular ultrasound (IVUS) use in aortic endovascular interventions, including thoracic endovascular aneurysm repair (TEVAR) and endovascular aneurysm repair (EVAR), may have similar benefits to those seen in coronary and peripheral interventions, but limited utilization and outcome data exist. Centers for Medicare and Medicaid Services claims data were used to identify patients undergoing TEVAR and EVAR from 2016 to 2023. Utilization trends were stratified by region, urbanicity, distressed communities index, community versus academic center, Medicare versus dual enrollment status, indication, urgency, and presence of dissection with malperfusion. Inverse probability weighting was used to assess the impact of IVUS on a composite outcome of repeat aortic intervention or death. Cox regression was used to estimate weighted hazard ratios. A total of 136 540 patients underwent TEVAR and EVAR, of which 9.8% (13 364) used IVUS. IVUS use increased slightly from 2016 to 2023, driven more by use in TEVAR compared with EVAR, and was higher in academic settings, with Medicare and Medicaid dual enrollment, in the West, with dissections, with malperfusion and for elective procedures. IVUS was associated with a lower risk of the primary outcome at 30-days (hazard ratio, 0.80 [95% CI, 0.73-0.89]; P<0.001) and 6-months (hazard ratio, 0.93 [95% CI, 0.87-0.99]; P=0.022) for all-comers. Subgroup analysis suggested lower risks of the primary outcome with IVUS use for aneurysm driven by the abdominal segment, malperfusion, thoracoabdominal dissection with malperfusion, thoracoabdominal repair, and chronic kidney disease. IVUS use has increased slightly in TEVAR and EVAR with heterogeneity in use. IVUS implementation during TEVAR and EVAR was associated with improved early and mid-term outcomes, particularly in certain subsets.

Private-Sector Readmissions for Inpatient Surgery in Veterans Health Administration Hospitals

The Veterans Health Administration (VHA) reports multiple indicators of hospital surgical performance, including hospital risk-standardized 30-day readmission rates (RSRRs). Currently, most routinely reported measures do not include readmissions that occur outside VHA hospitals. The impact of readmissions outside the VHA on hospital RSRR is not known. To measure the impact of including non-VHA readmissions on VHA hospital performance rankings for 30-day readmission. This retrospective cohort study included patients aged at least 65 years from 2013 to 2019 from the Veterans Affairs Surgical Quality Improvement Program linked to patient-level data from the VHA and Medicare. Data were limited to patients with VHA and Medicare enrollment during the year prior to surgery. Data were analyzed from November 2023 through July 2024. The main outcome was readmissions to acute care VHA or non-VHA hospitals within 30 days of discharge. VHA hospital-level RSRRs were estimated using separate generalized linear mixed-effects risk adjustment models that alternatively included VHA-only or VHA plus non-VHA readmissions. VHA hospitals were then stratified into quintiles based on RSRRs derived using VHA-only or VHA plus non-VHA readmissions. Changes in hospital performance quintiles with the addition of non-VHA readmissions were calculated, and characteristics of VHA hospitals most impacted by including non-VHA readmissions were evaluated. The eligible cohort included 108 265 patients (mean [SD] age, 72.2 [6.5] years; 105 661 [97.6%] male) who underwent surgery in 104 VHA hospitals. The combined readmission rate was 14.0%. The proportion of readmissions occurring outside the VHA ranged from 0% to 55.3% across the 104 VHA hospitals (median, 20.9%). Using VHA and non-VHA readmissions, 24 VHA hospitals (23.1%) improved performance and 23 hospitals (22.1%) worsened performance, defined as a decrease or increase, respectively, of 1 or more RSRR quintiles. Improvements in hospital performance rank were associated with larger surgical volume (-7.48; 95% CI, -11.33 to 03.64; P < .001), urban location, greater surgical complexity (-9.86; 95% CI, -16.61 to -3.11; P = .005), and lower proportion of readmissions outside the VHA (-8.15; 95% CI, -12.75 to -3.55; P < .001). In this cohort study, VHA hospitals whose readmission performance metric improved by including non-VHA readmissions had higher patient volume, higher complexity, and lower proportion of care outside the VHA. Thus, improving continuity of care may have a paradoxical effect of worsening VHA performance metrics.

Frailty and Long-Term Health Care Utilization After Elective General and Vascular Surgery

Surgical quality improvement efforts have largely focused on 30-day outcomes, such as readmissions and complications. Surgery may have a sustained impact on the health and quality of life of patients considered frail, yet data are lacking on the long-term health care utilization of patients with frailty following surgery. To examine the independent association of preoperative frailty on long-term health care utilization (up to 24 months) following surgery. This retrospective, observational cohort study included patients undergoing elective general and vascular surgery performed in the Veterans Affairs (VA) Surgical Quality Improvement Program with study entry from October 1, 2013, to September 30, 2018. Patients were followed up for 24 months. Patients with nursing home visits prior to surgery, emergent cases, and in-hospital deaths were excluded. Data analysis was conducted from September 2022 to May 2024. Preoperative frailty as assessed by the Risk Analysis Index (RAI-A) score: robust, less than 20; normal, 20 to 29; frail, 30 to 39; and very frail, 40 or more. The primary outcome was health care utilization through 24 months, defined as inpatient admissions, outpatient visits, emergency department (ED) visits, and nursing home or rehabilitation services collected via Corporate Data Warehouse and Centers for Medicare & Medicaid Services data. χ2 Tests and analysis of variance were used to assess preoperative frailty status, and a Cox proportional hazards model was used to calculate the adjusted association of preoperative frailty on each postdischarge health care utilization outcome. This study identified 183 343 elective general (80.5%) and vascular (19.5%) procedures (mean [SD] age, 62 [12.7] years; 12 915 females [7.0%]; 28 671 Black patients [16.0]; 138 323 White patients [77.3%]; 94 451 Medicare enrollees [51.5%]) with mean (SD) RAI-A score of 22.2 (7.0). After adjustment for baseline characteristics and preoperative use of health care services, frailty was associated with higher inpatient admissions (frail: hazard ratio [HR], 1.75; 95% CI, 1.70-1.79; very frail: HR, 2.33; 95% CI, 2.25-2.42), ED visits (frail: HR, 1.39; 95% CI, 1.36-1.41; very frail: HR, 1.70; 95% CI, 1.65-1.75), and nursing home or rehabilitation encounters (frail: HR, 4.97; 95% CI, 4.36-5.67; very frail: HR, 7.44; 95% CI, 6.34-8.73). For patients considered frail and very frail, health care utilization was higher after surgery and remained significant through 24 months for all outcomes (using piecewise Cox proportional hazards modeling). In this study, frailty was a significant risk factor for high long-term health care utilization after surgery. This may have quality of life implications for patients and policy implications for health care systems and payers.

Quality of Hospices Used by Medicare Advantage and Traditional Fee-for-Service Beneficiaries

Although enrollment in both hospice care and Medicare Advantage (MA) have grown substantially, little is known about the quality of hospice care received by MA beneficiaries relative to traditional Medicare fee-for-service (FFS) beneficiaries. To compare hospice enrollment and the quality of hospices serving MA and FFS beneficiaries. This population-based cross-sectional study used Medicare enrollment and claims data from January 1, 2018, through December 31, 2019, and Hospice Quality Reporting Program (HQRP) data released between November 1, 2020, and August 30, 2022, to compare the probability of enrolling in hospice before death and the probability of using high- vs low-quality hospices between MA and FFS beneficiaries. Two sample populations were assessed: (1) all Medicare beneficiaries who died in 2018 or 2019, and (2) all Medicare hospice enrollees in 2018 and 2019, excluding beneficiaries with hospice use in 2017. Data were analyzed between April 1, 2023, and April 30, 2024. MA enrollment was assessed 6 months prior to death for decedents and in the month of hospice admission for hospice enrollees. MA beneficiaries were further classified by plan type: regular MA, special needs plan (SNP), and Medicare-Medicaid plan (MMP). For decedents, the outcome of interest was the prevalence of any hospice use in the last 6 months of life. For hospice enrollees, the outcome of interest was 9 HQRP measures of hospice quality. Data from 4 215 648 decedents (51.6% female; mean [SD] age, 80.1 [11.6] years) and 2 211 826 hospice enrollees (56.6% female; mean [SD] age, 82.4 [10.5] years) were included. In the decedent sample, beneficiaries enrolled in every type of MA plan were significantly more likely than beneficiaries enrolled in FFS to use hospice care in the last 6 months of life (regular MA beneficiaries were 3.4 percentage points more likely to use hospice; MA SNP beneficiaries, 2.4 percentage points; and MA MMP beneficiaries, 3.6 percentage points). Regular MA and FFS beneficiaries enrolled in hospices of similar quality. However, beneficiaries in SNPs and MMPs were significantly more likely than FFS beneficiaries to use hospices with inferior quality (eg, MA SNP beneficiaries were 4.3 [95% CI, 3.9-4.7] percentage points more likely to use a hospice with a low Consumer Assessment of Healthcare Providers and Systems (CAHPS) global rating, and MA MMP beneficiaries were 6.8 [95% CI, 6.0-7.7] percentage points more likely). When beneficiaries entered hospice from the same hospital or nursing home the results were attenuated: the MA SNP beneficiaries entering from the same hospital were 0.9 (95% CI, 0.5-1.4) percentage points more likely to use a hospice with a low CAHPS global rating, and MA MMP beneficiaries were 3.8 (95% CI, 2.4-5.1) percentage points more likely; MA SNP beneficiaries entering from the same nursing home were 2.8 (95% CI, 2.3-3.3) percentage points more likely to use a hospice with a low CAHPS global rating, and MA MMP beneficiaries were 1.9 (95% CI, 0.9-2.9) percentage points more likely. These results suggest that referral networks were an important mechanism of the hospice quality choice. These findings suggest that policymakers should consider policies for MA programs that incentivize referrals to high-quality hospices and approaches to educating beneficiaries on identifying high-quality hospice care.

Risk of Hospitalization among Assisted Living Residents Dually Enrolled in Medicare and Medicaid

To examine how risk of hospitalization among assisted living (AL) residents differs by dual enrollment in Medicare and Medicaid and by the percent of dually enrolled individuals in an AL community. Retrospective cohort study. We used Medicare data from 2008 to 2018 and a national directory of licensed AL communities to identify Medicare beneficiaries with a change in their ZIP+4 code suggesting a new residence in an AL. We estimated linear regression models of hospitalization onto interactions of residents' dual enrollment status and categories of the AL community's percentage of dually enrolled residents. In the models, we adjusted for person-level clinical and demographic characteristics, year-fixed effects, and fixed effects for the AL residents' prior ZIP code. Among 620,542 Medicare beneficiaries who moved to an AL community, the 1-year risk of hospitalization was higher for dually enrolled residents compared with Medicare-only residents. In adjusted models, dually enrolled residents in high-dual AL communities (>50% dually enrolled) had an 7.4% higher risk of hospital admission compared with dually enrolled residents in low-dual AL communities. Medicare-only beneficiaries in high-dual AL communities had a 9.4% higher risk of hospitalization than Medicare-only beneficiaries in low-dual ALs. The proportion of residents in an AL community who were dually enrolled was associated with residents' risk of hospitalization, regardless of their dual enrollment status. Additional research is needed to understand whether differences observed in residents' risk of hospitalization are due to differences in the types of services provided, unmeasured resident acuity, or the quality of care delivered in these settings.

Medicare Enrollment and Spending Among Patients Initiating Dialysis After the Affordable Care Act

Medicare finances health care for most US patients with end-stage kidney disease (ESKD), regardless of age. Medicare enrollment may have slowed for patients with incident ESKD who gained access to new private insurance options with the 2014 passage of the Affordable Care Act (ACA) and introduction of the ACA Marketplace. To describe trends in public and private insurance coverage and dialysis spending among patients with incident ESKD from 2012 to 2017. This serial cross-sectional study included patients 18 to 64 years old in Colorado who were not enrolled in Medicare at dialysis initiation. Data analysis was conducted from May to August 2023. Introduction of the ACA Marketplace in 2014. Medicare, Medicaid, or private insurance enrollment in the first year after dialysis initiation, and dialysis spending by insurance type. Of 2005 patients included in the sample, 1416 (70.6%) were 45 to 64 years old, and 1259 (62.8%) were male. A lower proportion of patients with incident ESKD starting dialysis were newly enrolled in Medicare in the years following the ACA (361 of 713 [50.6%]) compared to 2 years prior (420 of 595 [70.6%]). Unadjusted rates of switching from Medicaid to Medicare 1 year after dialysis initiation decreased 14.3 percentage points over time (68.9% in 2012-2013 vs 58.3% and 54.6% in 2014-2015 and 2016-2017, respectively). Unadjusted rates of switching from private insurance to Medicare 1 year after dialysis initiation decreased by 22.3 percentage points (68.1% in 2012-2013 vs 52.2% and 45.8% in 2014-2015 and 2016-2017, respectively). Over the entire 2012 to 2017 period, quarterly dialysis spending in the first year of dialysis among patients with private insurance was higher than among those with Medicare coverage ($26 351-$29 781 vs $10 039-$12 741). This cross-sectional study demonstrates that lower Medicare enrollment rates over time among those initiating dialysis may be inducing higher social spending. This finding raises concerns about the effectiveness of Medicare policies and federal leverage to improve access, outcomes, and value of dialysis care.

Declining Medicare Enrollment Among Patients Initiating Dialysis—Advantage Whom?

Declining Medicare Enrollment Among Patients Initiating Dialysis—Advantage Whom?

Testing the Feasibility of a Cross-Setting Measure to Address the Rising Trend in Hospital Outpatient TJA Procedures.

Elective primary total hip and total knee arthroplasty (collectively, total joint arthroplasties [TJAs]) are commonly performed procedures that can reduce pain and improve function. TJAs are generally safe, but complications can occur. Although historically performed as inpatient procedures, TJAs are increasingly being performed in the outpatient setting. We sought to develop a scientifically acceptable cross-setting measure for evaluating care quality across inpatient and outpatient settings. Using Medicare administrative claims and enrollment data for qualifying TJA patients, we respecified the Centers for Medicare & Medicaid Services (CMS) inpatient-only risk-standardized TJA complications measure to assess complication rates following elective primary TJAs performed in an inpatient or outpatient setting. We aligned inpatient and outpatient coding practices and used hierarchical logistic regression to calculate hospital-specific, risk-standardized complication rates (RSCRs). Lower rates correspond to better quality. Using accepted approaches for CMS measures, we tested measure reliability and vetted key measure decisions with patient and provider input. A single combined model including the procedure setting as a risk variable produced the highest discrimination (C-statistic for a single combined model with a setting indicator: 0.664, C-statistic for the inpatient-only model: 0.651, C-statistic for the outpatient-only model: 0.638). Among the 2,747 hospitals with at least 25 TJAs, the mean RSCR (using the combined model with a setting indicator) was 2.91% (median RSCR: 2.85%; interquartile range: 2.59% to 3.18%). The median odds ratio for complication occurrence at a higher-risk hospital compared with a lower-risk hospital was 1.33. We respecified a measure to assess hospital inpatient or outpatient TJA performance and evaluated the reliability and validity of the measure. The findings showed variation in hospital-level complication rates across settings as indicated by this measure, supporting the feasibility of evaluating hospital performance using a more representative population than inpatient TJAs alone. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Excess Diagnosis Coding In Medicare Advantage: Evidence From Skilled Nursing Facility Clinical Assessments.

Some research suggests that risk adjustment plays a substantial role in explaining the high levels of government spending on Medicare Advantage (MA). We studied whether the reliance on diagnosis codes to risk-adjust payments to MA plans leads to the inflation of submitted diagnoses. Our approach relied on a comparison among diagnoses included in hospital claims, health status measures from similarly timed health assessments completed by skilled nursing facility (SNF) clinicians, and short-term mortality data. SNF assessments are completed for both MA and traditional Medicare enrollees and, in contrast to diagnoses in claims, cannot be directly manipulated by MA plans or inform their payments. We found that among patients with the same assessment-based health status discharged to the same SNF, claims-based disease scores were 4.1percent higher for MA enrollees, on average, relative to traditional Medicare enrollees. However, short-term mortality risk was, on average, 8.8percent lower for MA enrollees. About 60percent of the payer-based difference in disease scores was attributable to MA chart review updates to diagnoses, and additional codes from chart reviews were unrelated to assessment-based health status. Given the growth of MA and current spending on the program, which reached $321billion in 2021, this evidence of potential coding inflation may have large fiscal implications.

Chronic conditions among transgender Medicare beneficiaries: Variation by race, ethnicity, and Medicaid dual-enrollment.

Transgender and gender diverse (TGD) adults experience disability at twice the rate of cisgender (non-TGD) adults in the US. TGD people of color and low-income TGD people experience intersecting discrimination that may compound chronic conditions and disability. To our knowledge, no research has focused on chronic conditions among TGD Medicare beneficiaries with disabilities. We compared the probability of chronic conditions among TGD adults with disability-based eligibility for Medicare across race, ethnicity, and dual Medicaid-Medicare enrollment. We used cross-sectional Medicare enrollment and claims data between 2008 and 2017 for fee-for-service beneficiaries eligible based on disability. We applied a claims-based algorithm to identify TGD beneficiaries. We assessed differences in beneficiaries' age-adjusted predicted probability of chronic conditions across race, ethnicity, and dual eligibility. Dual-eligible TGD beneficiaries (N=8041) had a higher predicted probability of nine out of ten health condition categories relative to Medicare-only TGD beneficiaries (N=6237). For each race and ethnicity category, the most prevalent condition categories were mental health, cardiovascular conditions, and non-cardiovascular-related physical health conditions. Hispanic and non-Hispanic Black TGD beneficiaries had over two and three times the probability of infectious disease as non-Hispanic White TGD beneficiaries, respectively. TGD adults with disabilities have high rates of chronic conditions with additional disparities by race, ethnicity, and dual eligibility status. Our findings offer potential directions for mixed-methods and intervention research aimed at identifying and ameliorating the drivers of these disparities among TGD Medicare beneficiaries with disabilities.

HSD78 Potentially Inappropriate Medication Use Among Dual-Eligible Beneficiaries With Dementia by Medicare Enrollment Type

HSD78 Potentially Inappropriate Medication Use Among Dual-Eligible Beneficiaries With Dementia by Medicare Enrollment Type

Trends and disparities in antiretroviral therapy prescription rates among US Medicare beneficiaries with HIV.

Our objective was to evaluate antiretroviral therapy (ART) prescription rates over time among US Medicare enrolees with HIV and to describe disparities in ART prescription and associated factors. We constructed successive cross-sectional cohorts including adult enrollees with HIV and fee-for-service coverage and Part D enrolment in US Medicare between 2007 and 2019. We calculated the percentage of receipt of any ART prescription (ART%) in a calendar year by sex, age, and original Medicare entitlement and calculated age-sex standardized ART% over time. We used multivariable logistic regression to assess the association between ART prescription and sociodemographic factors and chronic conditions by age strata (<65, ≥65 years) in 2019. ART% increased over time and was highest among people with HIV aged 50-64 years in 2019: 95% in males and 92% in females. Multivariable analysis showed that female sex was associated with less ART%, with odds ratios (ORs) of 0.65 (95% confidence interval [CI] 0.60-0.70) and 0.34 (95% CI 0.30-0.39), than male sex in those aged <65 and ≥65 years, respectively. The youngest and oldest enrollees had lower ART use (e.g., OR 0.43 [95% CI 0.34-0.54] for 18-29 vs. 50-64 years; OR 0.34 [95% CI 0.30-0.39] for ≥80 vs. 65-69 years). The top conditions associated with less ART included dementia and alcohol use disorder. Other factors included no Part D low-income subsidy, non-Hispanic white race, and Midwest residence. ART use increased over time in US Medicare enrollees. Non-Hispanic white, female, and the youngest and oldest enrollees received less ART. Multimorbidity, substance use, and dementia were associated with less ART use. Research to overcome these disparities is needed.

Abstract 4124875: Association between Elevated Lipoprotein(a) and Cardiovascular Events and Mortality in a Nationally Representative Sample of US Medicare, Medicaid, and Commercial Enrollees with ASCVD

Background: Elevated lipoprotein(a) [Lp(a)] is an independent and causal risk driver for atherosclerotic cardiovascular disease (ASCVD). Few patients with ASCVD receive Lp(a) screening and real-world data assessing the association between elevated Lp(a) and risk of cardiovascular (CV) events and mortality is limited. Objectives: To examine the association of elevated Lp(a) and risk of CV events and death in an ASCVD population using large US health claims databases. Methods: Patients with ASCVD were pooled from US Medicare, commercial, and Medicaid health plans from 2017 to 2022. Lp(a) levels were linked at the patient level from HealthVerity Lab Data and categorized as: &lt;30 mg/dL (&lt;75 nmol/L), ≥30-&lt;50 mg/dL ( &gt; 75-&lt;125 nmol/L), ≥50-&lt;70 mg/dL ( &gt; 125-&lt;175 nmol/L), ≥70-&lt;90 mg/dL (≥175-&lt;225 nmol/L) and ≥90 mg/dL (≥225 nmol/L). Patients were followed from the 1 st ASCVD diagnosis (index) to insurance plan disenrollment, death, or end of study. Cox regression, adjusted for age, sex, race, insurance, comorbidities, LDL-C, and other risk factors, measured the association between Lp(a) levels and risk of CV events and death. Results: Of 28.8 million ASCVD patients, 180,240 (0.6%) had Lp(a) levels: mean(±SD) age 68.6±1 years, 50.1% male, 5.9% Black, 2.8% Hispanic, 2.1% Asian, 72.8% Medicare, 21.8% commercial, and 5.4% Medicaid. Mean follow-up was 3.7 years; 23.3% and 15.7% had Lp(a) ≥50mg/dL [≥125 nmol/L] and ≥70 mg/dL (≥175 nmol/L), respectively. Black patients had highest median Lp(a) (50 mg/dL/111 nmol/L), followed by Asian (13.5 mg/dL/35.5 nmol/L), White (13 mg/dL/32 nmol/L), and Hispanic (11.5 mg/dL/29 nmol/L) patients. Lp(a) levels of ≥30-&lt;50 mg/dL, ≥50-&lt;70 mg/dL, ≥70-&lt;90 mg/dL, and ≥90 mg/dL were associated with 7%, 10%, 16%, and 26% greater risks of CV events vs. &lt;30 mg/dL (p-values &lt;0.0001; cumulative incidence reported in Figure 1). All-cause mortality risk was also greater for those with Lp(a) ≥90 mg/dL vs. &lt;30 mg/dL: hazard ratio (HR)=1.11, p=0.003. Similar trends persisted for patients with LDL-C ≤70 mg/dL. Conclusion: In this national-scale real-world cohort of patients with ASCVD, Lp(a) testing is infrequent and elevated Lp(a) levels were significantly associated with a greater risk of CV events and mortality.

Abstract 4137461: Elevated Lipoprotein(a) Increases Cardiovascular-Related Healthcare Resources Utilization and Costs among US Medicare, Medicaid, and Commercial Enrollees with ASCVD

Background: Elevated lipoprotein(a) [Lp(a)] is a recognized genetic, independent, and causal risk driver for atherosclerotic cardiovascular disease (ASCVD). Less is known about how elevated Lp(a) affects downstream cardiovascular (CV)-related healthcare resource utilization (HCRU) and costs in patients with ASCVD. Objective: To assess the association of Lp(a) levels with CV-related HCRU (hospitalizations, outpatient and emergency department [ED) visits), and CV-related costs for patients with ASCVD in a national-scale multi-insurance cohort. Methods: Patients with ASCVD were pooled from US Medicare, commercial, and Medicaid health plans from 2017 to 2022. Lp(a) levels (mg/dL and nmol/L) were linked at the patient level with HealthVerity Lab Data. Elevated Lp(a) was defined as Lp(a)≥70mg/dL (≥ 175 nmol/L) and normal Lp(a) was defined as Lp(a)&lt;30mg/dL (&lt;75 nmol/L). Generalized linear models with log link negative binomial distribution (HCRU) and log link gamma distribution (costs) adjusted for age, sex, race, insurance type, comorbidities, statin use, and prior hospitalizations, measured the association of Lp(a) levels with the annualized rate of CV-related hospitalizations, ED visits, and outpatient visits (incidence rate ratio [IRR]) and CV-related costs (annualized cost ratio). Results: A total of 180,240 ASCVD patients were identified with Lp(a) values. Median (IQR) Lp(a) was 14 mg/dL (4 mg/dL – 48 mg/dL) or 35 nmol/L (12 nmol/L – 114 nmol/L). Mean (SD) age was 68.6 (12.0) years with 49.9% being female; 72.8% of patients were from Medicare, followed by commercial (21.8%) and Medicaid (5.4%). Fully adjusted CV-related HCRU was significantly higher in those with elevated Lp(a) compared to normal Lp(a): inpatient hospitalizations (IRR=1.11), outpatient visits (IRR=1.11) and ED visits (IRR=1.06), all p &lt;0.001 (IRR and 95% CI reported in Table 1). Patients with elevated Lp(a) had 14% higher CV-related annualized healthcare costs than patients with normal Lp(a) (p &lt;0.001) with significantly higher CV-related HCRU beginning with Lp(a) levels &gt;30 mg/dL (&gt;75 nmol/L). Conclusion: Elevated Lp(a) was significantly associated with greater CV-related HCRU and costs in patients with ASCVD.

Abstract 4123370: Distance to a Cardiac Imaging Center and Likelihood of Imaging Receipt: Defining Imaging Deserts

Background: Cardiovascular imaging is critical for the diagnosis and management of cardiovascular disease. Whether geographic distance to a cardiovascular imaging center (CVIC) impacts access to care is unknown. Methods: We evaluated all Medicare beneficiaries (Fee-for-service and Medicare Advantage) from 2018-2022, excluding those &lt; 65, without continuous Medicare enrollment in the previous year, individuals missing zip code of residence, or CVICs missing zip codes. We estimated distance from the centroid of an individual’s zip code of residence to the centroid of the zip code with the nearest CVIC (defined as &gt; 10 imaging procedures/year). Multivariable regression models were used to estimate likelihood of imaging receipt by distance. Results/Data: A total of 64,260,530 individuals (age 73.0 ± 8 years, 54.6% female, 80.1% White) received care at 3,886 CVICS. The vast majority (95%) lived within 16 miles of a CVIC, but varied considerably by modality with substantially greater distances for cardiac CT, cardiac MRI, and PET (Median [IQR] distance in miles to CVIC, Echo: 3.4 [0.4-7.0]; SPECT: 3.8 [1.3-7.9]; cardiac CT: 8.1 [3.7-21.3]; cardiac MRI: 17.4 [7.3-43.3]; PET: 88.9 [26.2-194.6]). CVICs performing cardiac CT, cardiac MRI, or PET were nearly all in metropolitan locations. Likelihood of imaging receipt was triphasic: lowest within 0-10 miles of a CVIC (mainly metropolitan locations), greater within 10-15 miles, and then increasingly lower beyond 15 miles ( Figure 1 ). Sites beyond the 16-mile threshold were predominantly in the Midwest and West ( Figure 2 ). Conclusions: In this study of 64 million Medicare beneficiaries, 2018-2022, 95% of the US population was found to live within 16 miles of a CVIC, though varied by modality. While those living &gt; 16 miles from a CVIC received less imaging, the lowest use was identified among individuals living in the same zip code as a CVIC, suggesting a possible disconnect between access to imaging care and proximity.

Incentivizing Network Adequacy in Medicare Advantage

This Viewpoint discusses enrollment in Medicare Advantage vs traditional Medicare among older adults and common reasons for plan disenrollment, including the lack of in-network physicians and hospitals.