Medicare Enrollees Research Articles

The Medicare Care Choices Model was associated with reductions in disparities in the use of hospice care for Medicare beneficiaries with terminal illness.

To assess the effects of the Medicare Care Choices Model (MCCM) on disparities in hospice use and quality of end-of-life care for Medicare beneficiaries from underserved groups-those from racial and ethnic minority groups, dually eligible for Medicare and Medicaid, or living in rural areas. Medicare enrollment and claims data from 2013 to 2021 for terminally ill Medicare fee-for-service beneficiaries nationwide. Through MCCM, terminally ill enrolled Medicare beneficiaries received supportive and palliative care services from hospice providers concurrently with curative treatments. Using a matched comparison group, we estimated subgroup-specific effects on hospice use, days at home, and aggressive treatment and multiple emergency department visits in the last 30 days of life. The sample included decedent Medicare beneficiaries enrolled in MCCM and a matched comparison group from the same geographic areas who met model eligibility criteria at time of enrollment: having a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or HIV/AIDS; living in the community; not enrolled in the Medicare hospice benefit in the previous 30 days; and having at least one hospital stay and three office visits in the previous 12 months. Eligible beneficiaries from underserved groups were underrepresented in MCCM. MCCM increased enrollees' hospice use and the number of days at home and reduced aggressive treatment among all subgroups analyzed. MCCM also reduced disparities in hospice use by race and ethnicity and dual eligibility by 4.1 (90% credible interval [CI]: 1.3-6.1) and 2.4 (90% CI: 0.6-4.4) percentage points, respectively. It also reduced disparities in having multiple emergency department visits for rural enrollees by 1.3 (90% CI: 0.1-2.7) percentage points. MCCM increased hospice use and quality of end-of-life care for model enrollees from underserved groups and reduced disparities in hospice use and having multiple emergency department visits.

Availability and use of telehealth services among patients with ADRD enrolled in traditional Medicare vs. Medicare advantage during the COVID-19 pandemic.

The objective of this study was to examine differences in availability and use of telehealth services among Medicare enrollees according to Alzheimer's disease and related dementias (ADRD) status and enrollment in Medicare Advantage (MA) versus Traditional Medicare (TM) during the period surrounding the COVID-19 pandemic. This was a retrospective cross-sectional analysis of data from community-dwelling MA and TM enrollees with and without ADRD from the Medicare Current Beneficiary Survey (MCBS) Fall 2020 and Winter 2021 COVID-19 Supplement Public Use Files. We examined self-reported availability of telehealth service before and during the COVID-19 pandemic and use of telehealth services during COVID-19. We analyzed marginal effects under multivariable logistic regression. There were 13,700 beneficiaries with full-year enrollment in MA (6,046) or TM (7,724), 518 with ADRD and 13,252 without ADRD. Telehealth availability during COVID-19 was positively associated with having a higher income (2.81 pp. [percentage points]; 95% CI: 0.57, 5.06), having internet access (7.81 pp.; 95% CI: 4.96, 10.66), and owning telehealth-related technology (3.86; 95% CI: 1.36, 6.37); it was negatively associated with being of Black Non-Hispanic ethnicity (-8.51 pp.; 95% CI: -12.31, -4.71) and living in a non-metro area (-8.94 pp.; 95% CI: -13.29, -4.59). Telehealth availability before COVID-19 was positively associated with being of Black Non-Hispanic ethnicity (9.34 pp.; 95% CI: 3.74, 14.94) and with enrollment in MA (4.72 pp.; 95% CI: 1.63, 7.82); it was negatively associated having dual-eligibility (-5.59 pp.; 95% CI: -9.91, -1.26). Telehealth use was positively associated with being of Black Non-Hispanic ethnicity (6.47 pp.; 95% CI: 2.92, 10.01); it was negatively associated with falling into the age group of 75+ years (-4.98 pp.; 95% CI: -7.27, -2.69) and with being female (-4.98 pp.; 95% CI: -7.27, -2.69). Telehealth services were available to and used by Medicare enrollees with ADRD to a similar extent compared to their non-ADRD counterparts. Telehealth services were available to MA enrollees to a greater extent before COVID-19 but not during COVID-19, and this group did not use telehealth services more than TM enrollees during COVID-19.

Associations Between Annual Medicare Part D Low-Income Subsidy Loss and Prescription Drug Spending and Use

The Medicare Part D Low Income Subsidy (LIS) program provides millions of beneficiaries with drug plan premium and cost-sharing assistance. The extent to which LIS recipients experience subsidy losses with annual redetermination cycles and the resulting associations with prescription drug affordability and use are unknown. To examine how frequently annual LIS benefits are lost among Medicare Part D beneficiaries and how this is associated with prescription drug use and out-of-pocket costs. In this cohort study of Medicare Part D beneficiaries from 2007 to 2018, annual changes in LIS recipients among those automatically deemed eligible (eg, due to dual eligibility for Medicare and Medicaid) and nondeemed beneficiaries who must apply for LIS benefits were analyzed using Medicare enrollment and Part D event data. Subsidy losses were classified in 4 groups: temporary losses (<1 year); extended losses (≥1 year); subsidy reductions (change to partial LIS); and disenrollment from Medicare Part D after subsidy loss. Temporary losses could more likely represent subsidy losses among eligible beneficiaries. Multinomial logit models were used to examine associations between beneficiary characteristics and subsidy loss; linear regression models were used to compare changes in prescription drug cost and use in the months after subsidy losses vs before. Analyses were conducted between November 2022 and November 2023. Subsidy loss at the beginning of each year among subsidy recipients in December of the prior year. The main outcomes were out-of-pocket costs and prescription drug fills overall and for 4 classes: antidiabetes, antilipid, antidepressant, and antipsychotic drugs. In 2008, 731 070 full LIS beneficiaries (17%) were not deemed automatically eligible (39% were aged <65 years; 59% were female). Nearly all beneficiaries deemed automatically eligible (≥99%) retained the subsidy annually from 2007 to 2018, compared with 78% to 84% of nondeemed beneficiaries. Among nondeemed beneficiaries, disabled individuals younger than 65 years and racial and ethnic minority groups were more likely to have temporary subsidy losses vs none. Temporary losses were associated with an average 700% increase in out-of-pocket drug costs (+$52.72/mo [95% CI, 52.52-52.92]) and 15% reductions in prescription fills (-0.58 fills/mo [95% CI, -0.59 to -0.57]) overall. Similar changes were found for antidiabetes, antilipid, antidepressant, and antipsychotic prescription drug classes. Beneficiaries who retained their subsidy had few changes. The conclusions of this cohort study suggest that efforts to help eligible beneficiaries retain Medicare Part D subsidies could improve drug affordability, treatment adherence, and reduce disparities in medication access.

Access to inflatable penile prosthesis surgery as indicated by distances traveled among US men with Medicare.

The significance of geographic barriers to receiving inflatable penile prosthesis (IPP) treatment is uncertain according to the existing medical literature. To describe the travel patterns of men with erectile dysfunction (ED) in the United States who underwent IPP surgery. This retrospective cohort study utilized data from the 100% Medicare Standard Analytical Files. Men aged ≥65 years with an ED diagnosis who underwent IPP surgery between January 2016 and December 2021 were identified from the database. Federal Information Processing Series codes from the National Bureau of Economic Research's County Distance Database were used to determine geographic distances from patients' homes to the facilities at which surgery was performed. Evaluations included the proportions of men who traveled outside their county of residence or state for IPP treatment and the average distances in miles traveled. Among 15 954 men with ED undergoing IPP treatment, 56.4% received care out of their county for IPP, at a mean distance of 125.6miles (range, 3.8-4935.0). Although patients aged ≥80 years were less likely to travel outside their county as compared with men aged 65 to 69 years (48.1% vs 57.1%, P < .001), if they traveled, they were likely to travel farther (mean, 171.8 vs 117.7miles; P < .001). South Dakota had the highest proportion of men traveling outside their county for IPP treatment (91.3%; mean, 514.2miles), while Vermont had the highest proportion traveling outside their home state (73.7%). By unveiling disparities in access, this study will potentially lead to tailored interventions that enhance patient care and health outcomes. Strengths include the uniqueness in (1) evaluating the proportions of patients who travel out of their county of residence or home state for IPP treatment and (2) quantifying the average distances that patients traveled. An additional strength is the large sample size due to the retrospective design and database used. The analysis did not capture all Medicare enrollees; however, it did encompass all traditional Medicare enrollees, representing approximately half of all men in the US aged ≥65years. Limitations include not being generalizable to entire population of the US, as the study examined only Medicare enrollees. In addition, the study period includes the pandemic, which could have affected travel patterns. Furthermore, the coding and accuracy of the data are limitations of using administrative claims data for research. Study findings showed that many men with Medicare and ED traveled from their home geographic location for IPP treatment.

Abstract WP109: Framework for Evaluating Sequential Patterns in Post-Acute Transitions of Care Among Ischemic and Hemorrhagic Stroke Survivors: Analysis of Medicare Beneficiaries in the State of Texas

Background: Utilizing medical claims derived information, we evaluated temporal trends in post-acute care utilization pathways among patients with acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH). Methods: Data were retrieved from a CMS Qualified Entity housing healthcare utilization data for ≥80% of the Texas state population (100% of Medicare Fee-for-Service). Analytical sample included all Medicare enrollees with a primary discharge diagnosis (AIS or ICH) from 2016 to 2020. Episodes of care within 1 year of discharge were collated and categorized “Discharged”, “Inpatient Rehab”, “Skilled Nursing”, “Hospice”, “Readmission”, or “Death”. Sequential pattern mining was used to calculate conditional probabilities (likelihoods) of post-discharge transitions of care. Prediction rules were generated by converting care sequences into antecedent-consequent pairs. Rule based performance was evaluated by extracting 90 day sequences (antecedent) and assigning predictions of 1 year settings (consequent) based on highest likelihoods (Panel A). Results: A total of 82,829 AIS and 12,761 ICH hospitalizations were analyzed (described in Panel B). An example rulebook of care sequences and associated likelihoods of subsequent transitions for ICH is depicted in Panel C. Whereas ICH survivors entering inpatient rehab had respective likelihoods of 11.2% and 16.2% for subsequently being admitted to hospice care or death, those entering skilled nursing facilities had respective likelihoods of 21.9% and 30.5%. Using 90 day transition of care sequences, predictive accuracy of exact 1 year setting for AIS was 65.3% (1 attempt) and 84.0% (2 attempts); for ICH, the respective accuracy was 50.9% and 82.3% (Panel D). Conclusion: Post stroke transitions of care patterns may yield insights as to the long-term trajectory of outcomes. Predictive capability is expected to strengthen with planned multi-modal integration of EMR-derived clinical and imaging features.

Medicare, Medicaid, and dual enrollment for adults with intellectual and developmental disabilities.

Given high rates of un- and underemployment among disabled people, adults with intellectual and developmental disabilities rely on Medicaid, Medicare, or both to pay for healthcare. Many disabled adults are Medicare eligible before the age of 65 but little is known as to why some receive Medicare services while others do not. We described the duration of Medicare enrollment for adults with intellectual and developmental disabilities in 2019 and then compared demographics by enrollment type (Medicare-only, Medicaid-only, dual-enrolled). Additionally, we examined the percent in each enrollment type by state, and differences in enrollment type for those with Down syndrome. 2019 Medicare and Medicaid claims data for all adults (≥18 years) in the US with claim codes for intellectual disability, Down syndrome, or autism at any time between 2011 and 2019. Administrative claims cohort. Data were from the Transformed Medicaid Statistical Information System Analytic Files and Medicare Beneficiary Summary files. In 2019, Medicare insured 582,868 adults with identified intellectual disability, autism, or Down syndrome. Of 582,868 Medicare beneficiaries, 149,172 were Medicare only and 433,396 were dual-enrolled. Most Medicare enrollees were enrolled as child dependents (61.5%) Medicaid-only enrollees (N = 819,256) were less likely to be white non-Hispanic (58.5% white non-Hispanic vs. 72.9% white non-Hispanic in dual-enrolled), more likely to be Hispanic (19.6% Hispanic vs. 9.2% Hispanic in dual-enrolled) and were younger (mean 34.2 years vs. 50.5 years dual-enrolled). There is heterogeneity in public insurance enrollment which is associated with state and disability type. Action is needed to ensure all are insured in the program that works for their healthcare needs.

Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020.

With greater acceptance of postmastectomy breast reconstruction (PMBR) as a safe and reliable treatment option, the role of plastic surgeons in breast cancer management continues to rise. As Medicare reimbursements for surgical procedures decline, hospitals may increase charges. Excessive markups can negatively affect uninsured and underinsured patients. We aimed to analyze mastectomy and breast reconstruction procedures to gain insights into recent trends in utilization and billing. We queried the 2013 to 2020 Medicare Provider Utilization and Payment Data with 14 Current Procedural Terminology (CPT) codes to collect service count numbers, hospital charges, and reimbursements. We calculated utilization (service counts per million female Medicare enrollees), weighted mean charges and reimbursements, and charge-to-reimbursement ratios (CRRs). We calculated total and annual percentage changes for the included CPT codes. Among the 14 CPT codes, 12 CPT codes (85.7%) with nonzero service counts were included. Utilization of mastectomy and breast reconstruction procedures decreased from 1,889 to 1,288 (-31.8%) procedures per million female Medicare beneficiaries from 2013 to 2020. While the utilization of immediate implant placements (CPT 19340) increased by 36.2%, the utilization of delayed implant placements (CPT 19342) decreased by 15.1%. Reimbursements for the included CPT codes changed minimally over time (-2.9%) but charges increased by 28.9%. These changes resulted in CRRs increasing from 3.3 to 4.4 (+33.3%) from 2013 to 2020. Free flap reconstructions (CPT 19364) had the highest CRRs throughout the study period, increasing from 7.0 in 2013 to 10.3 in 2020 (+47.1%). Our analysis of mastectomy and breast reconstruction procedures billed to Medicare Part B from 2013 to 2020 showed increasingly excessive procedural charges. Rises in hospital charges and CRRs may limit uninsured and underinsured patients from accessing necessary care for breast cancer management. Legislations that monitor hospital markups for PMBR procedures may be considered by policymakers.

Health Care Spending, Use, and Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With Mental Health Symptoms

ObjectiveWe examined the differences in health care spending and utilization, and financial hardship between Traditional Medicare (TM) and Medicare Advantage (MA) enrollees with mental health symptoms. DesignCross-sectional study. ParticipantsWe identified Medicare beneficiaries with mental health symptoms using the Patient Health Questionnaire-2 and the Kessler-6 Psychological Distress Scale in the 2015–2021 Medical Expenditure Panel Survey. MeasurementsOutcomes included health care spending and utilization (both general and mental health services), and financial hardship. The primary independent variable was MA enrollment. ResultsMA enrollees with mental health symptoms were 2.3 percentage points (95% CI: -3.4, -1.2; relative difference: 16.1%) less likely to have specialty mental health visits than TM enrollees with mental health symptoms. There were no significant differences in total health care spending, but annual out-of-pocket spending was $292 (95% CI: 152–432; 18.2%) higher among MA enrollees with mental health symptoms than TM enrollees with mental health symptoms. Additionally, MA enrollees with mental health symptoms were 5.0 (95% CI: 2.9–7.2; 22.3%) and 2.5 percentage points (95% CI: 0.8–4.2; 20.9%) more likely to have difficulty paying medical bills over time and to experience high financial burden than TM enrollees with mental health symptoms. ConclusionOur findings suggest that MA enrollees with mental health symptoms were more likely to experience limited access to mental health services and high financial hardship compared to TM enrollees with mental health symptoms. There is a need to develop policies aimed at improving access to mental health services while reducing financial burden for MA enrollees.

Effectiveness of Bivalent mRNA COVID-19 Vaccines in Preventing COVID-19-Related Thromboembolic Events Among Medicare Enrollees Aged ≥65 Years and Those with End Stage Renal Disease - United States, September 2022-March 2023.

COVID-19 has been associated with an increased risk for thromboembolic events, including ischemic stroke, venous thromboembolism, and myocardial infarction. Studies have reported lower rates of COVID-19-related thromboembolic events among persons who received the COVID-19 vaccine compared with persons who did not, but rigorous estimates of vaccine effectiveness (VE) in preventing COVID-19-related thromboembolic events are lacking. This analysis estimated the incremental benefit of receipt of a bivalent mRNA COVID-19 vaccine after receiving an original monovalent COVID-19 vaccine. To estimate VE of a bivalent mRNA COVID-19 dose in preventing thromboembolic events compared with original monovalent COVID-19 vaccine doses only, two retrospective cohort studies were conducted among Medicare fee-for-service enrollees during September 4, 2022-March 4, 2023. Effectiveness of a bivalent COVID-19 vaccine dose against COVID-19-related thromboembolic events compared with that of original vaccine alone was 47% (95% CI=45%-49%) among Medicare enrollees aged ≥65 years and 51% (95% CI=39%-60%) among adults aged ≥18 years with end stage renal disease receiving dialysis. VE was similar among Medicare beneficiaries with immunocompromise: 46% (95% CI=42%-49%) among adults aged ≥65 years and 45% (95% CI=24%-60%) among those aged ≥18 years with end stage renal disease. To help prevent complications of COVID-19, including thromboembolic events, adults should stay up to date with COVID-19 vaccination.

Accuracy of Cancer Registry Primary Payer Information and Implications for Policy Research.

Cancer registry-based "primary payer at diagnosis" (PPDx) data are commonly used to evaluate the effect of insurance on cancer care outcomes, yet little is known about how well they capture Medicaid or Medicare enrollment. We linked the National Cancer Institute's Surveillance, Epidemiology, and End Results registry data to monthly Centers for Medicare and Medicaid Services (CMS) Medicaid and Medicare enrollment records, state-year Medicaid policy, and managed care enrollment. We selected adults aged 19-64 years diagnosed between 2007 and 2011. We used bivariate analyses to compare PPDx to CMS enrollment at diagnosis month and assessed underreporting rates by patient characteristics and state-year policy. PPDx reported 7.8% Medicare and 10.1% Medicaid, whereas CMS enrollment indicated 5.5% Medicare, 10.4% Medicaid, and 3.4% dual Medicare-Medicaid (N = 896,031). Positive predictive values for PPDx assignment to Medicaid and Medicare were 65.3% and 75.4%, with false negative rates of 52.0% and 33.8%, respectively. Medicaid underreporting was higher in low (56.5%) versus high (50.8%) poverty areas, for males (56.1%) versus females (48.9%), for Medicaid poverty expansion or waiver enrolled (63.8%) versus cash assistance-related eligibility (47.3%), and in states with large managed care enrollment (all P < 0.001). If Medicaid and Medicare enrollment data were used to edit PPDx, 12.0% of persons would switch primary payer assignment. Registry-reported PPDx fails to fully capture Medicaid and Medicare enrollment, which may result in biased estimates of insurance-related policy impacts. Enhancement with objective enrollment data could reduce measurement error and bias in estimates necessary to support policy assessment.

Tamsulosin use in benign prostatic hyperplasia and risks of Parkinson's disease, Alzheimer's disease and mortality: An observational cohort study of elderly Medicare enrollees.

To study the effects of benign prostatic hyperplasia treatments, namely: alpha-adrenergic receptor blockers, 5-alpha-reductase inhibitors and phosphodiesterase-5 inhibitors on the risk of Parkinson's disease, Alzheimer's disease and mortality. All male Medicare enrollees aged 65 or above who were diagnosed with benign prostatic hyperplasia and received one of the study drugs between 2007-2020 were followed-up for the three outcomes. We used Cox regression analysis to assess the relative risk of each of the outcomes for each study drug compared to the most prescribed drug, tamsulosin, while controlling for demographic, socioeconomic and comorbidity factors. The study analyzed 1.1 million patients for a mean follow-up period of 3.1 years from being prescribed one of the study drugs. For all outcomes, patients on tamsulosin were used as the reference for comparison. For mortality, alfuzosin was associated with 27% risk reduction (HR 0.73, 95%CI 0.68-0.78), and doxazosin with 6% risk reduction (HR 0.94, 95%CI 0.91-0.97). For Parkinson's disease, terazosin was associated with 26% risk reduction (HR 0.74, 95%CI 0.66-0.83), and doxazosin with 21% risk reduction (HR 0.79, 95%CI 0.72-0.88). For Alzheimer's disease, terazosin was associated with 27% risk reduction (HR 0.73, 95%CI 0.65-0.82), and doxazosin with 16% risk reduction (HR 0.84, 95%CI 0.76-0.92). Tadalafil was associated with risk reduction (27-40%) in all 3 outcomes. More research is needed to elucidate the underlying mechanisms of these observations. Given the availability of safer alternatives for treating benign prostatic hyperplasia, caution should be exercised when using tamsulosin in elderly patients, especially those with an increased risk of developing neurodegenerative diseases.

Contraceptive Use Among Traditional Medicare And Medicare Advantage Enrollees.

Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.

Outcomes of cardiac arrest hospitalizations in patients with obesity with versus without prior bariatric surgery status:A nationwide propensity-matched analysis

IntroductionPrior bariatric surgery (PBS) status in obese patients is thought to curtail the risk of cardiovascular events, but its role in change of outcomes of patients with obesity developing new acute cardiac events such as cardiac arrests (CA) remains largely unknown. MethodsHospitalizations among adult patients with obesity and CA were identified retrospectively using the National Inpatient Sample (2015 October-2017 December). Propensity-matched analysis (1:1) was performed for sociodemographic/hospital characteristics to identify two cohorts, with (PBS+) or without (PBS-) status. The primary endpoint was in-hospital mortality, and the secondary endpoint was healthcare resource utilization. ResultsBoth cohorts (n = 1275 each), had patients with comparable age (mean 58 years), with a higher frequency of white (>70 %), females (>60 %), and Medicare enrollees (>40 %). PBS + cohort had lower rates of diabetes (27.8 % vs 36.1 %), hyperlipidemia (33.7 % vs 48.6 %), renal failure (17.3 % vs 22.0 %), chronic pulmonary disease (11.8 % vs 21.2 %) and higher rates of anemias (18.4 % vs 12.2 %), liver disease (5.1 % vs 2.4 %) and alcohol abuse (6.7 % vs 2.4 %) than PBS- cohort (p < 0.05). All-cause mortality (46.3 % vs 45.1 %, p = 0.551) was comparable between the two cohorts. The PBS + cohort was less often transferred routinely (p<0.001) but had a shorter hospital stay (p<0.001) with equivalent hospital charges compared to the PBS- cohort. ConclusionsThe PBS status (regardless of chronology) did not increase survival in CA admissions among patients with obesity. Preventive measures are necessary to manage enduring cardiovascular disease risk factors that may limit the advantages of surgery for patients with obesity and aggravate the worse outcomes of future cardiac events.

DIFFERENCES IN FRAILTY BETWEEN TRADITIONAL MEDICARE AND MEDICARE ADVANTAGE BENEFICIARIES

Abstract Medicare Advantage (MA) plans cover at a minimum the same services as fee-for-service Medicare (FFS), but may target patient populations that differ in health and frailty. Leveraging 2011 and 2015 National Health and Aging Trends Study (NHATS) linked to Medicare claims, we classified participants as FFS or MA beneficiaries based on 12 months of Medicare enrollment. We calculated a deficit accumulation-based frailty index (FI) and phenotypic frailty from the survey assessment. All analyses accounted for the complex sampling design and weighted to reflect national estimates. In 2011, MA beneficiaries were more likely to be female (MA vs FFS: 59.1% vs 55.6%), Black (9.6% vs 7.4%) or other race (9.8% vs 5.2%), and to have an estimated income &amp;lt;$25,000 (44.5% vs 39.4%). Although the mean FI was similar between MA and FFS (MA vs FFS: 0.25 vs 0.25), MA beneficiaries were more likely to have mild frailty by FI (20.1% vs 18.6%) but less likely to have severe frailty by FI (10.0% vs 11.7%) or phenotypic frailty (13.5% vs 14.0%). MA beneficiaries had a higher prevalence of some comorbidities, such as hypertension (MA vs FFS: 64.9% vs 63.3%) and diabetes (24.4% vs 23.3%), but a lower mean number of ADL disability (0.32 vs 0.39). In 2015 the results were similar, although MA beneficiaries had a higher prevalence of pre-frailty (MA 46.0% vs 43.3%). In conclusion, MA beneficiaries seem to have a lower level of deficit-accumulation frailty and phenotypic frailty. This difference is driven by comorbidities, but not functional disability.

Finding social need-les in a haystack: ascertaining social needs of Medicare patients recorded in the notes of care managers

BackgroundUnmet social needs may impair health and access to health care, and intervening on these holds particular promise in high-risk patient populations, such as those with multiple chronic conditions. Our objective was to identify social needs in a patient population at significant risk—Medicare enrollees with multiple chronic illnesses enrolled in care management services—and measure their prevalence prior to any systematic screening.MethodsWe partnered with Renova Health, an independent Medicare Chronic Care Management (CCM) provider with patients in 10 states during our study period (January 2017 through August 2020). Our data included over 3,000 Medicare CCM patients, representing nearly 20,000 encounters. We used a dictionary-based natural language processing approach to ascertain the prevalence of six domains of barriers to care (food insecurity, housing instability, utility hardship) and unmet social needs (health care affordability, need for supportive services, transportation) in notes taken during telephonic Medicare CCM patient encounters.ResultsBarriers to care, specifically need for supportive services (2.4%) and health care affordability (0.8%), were the most prevalent domains identified. Transportation as a barrier to care came up relatively less frequently in CCM encounters (0.1%). Unmet social needs were identified at a comparatively lower rate, with potential housing instability (0.3%) flagged most followed by potential utility hardship (0.2%) and food insecurity (0.1%).ConclusionsThere is substantial untapped opportunity to systematically screen for social determinants of health and unmet social needs in care management.

Racial and Ethnic Differences in Hospice Use Among Medicaid-Only and Dual-Eligible Decedents

Hospice care enhances quality of life for people with terminal illness and is most beneficial with longer length of stay (LOS). Most hospice research focuses on the Medicare-insured population. Little is known about hospice use for the racially and ethnically diverse, low-income Medicaid population. To compare hospice use and hospice LOS by race and ethnicity among Medicaid-only individuals and those with dual eligibility for Medicare and Medicaid (duals) in the Connecticut Medicaid program who died over a 4-year period. This retrospective population-based cohort study used Medicaid and traditional Medicare enrollment and claims data for 2015 to 2020. The study included Connecticut Medicaid recipients with at least 1 of 5 most common hospice diagnoses who died from 2017 to 2020. Race and ethnicity. Hospice use (yes/no) and hospice LOS (1-7 days vs ≥8 days.) Covariates included sex, age, and nursing facility stay within 60 days of death. Overall, 2407 and 23 857 duals were included. Medicaid-only decedents were younger (13.8% ≥85 vs 52.5%), more likely to be male (50.6% vs 36.4%), more racially and ethnically diverse (48.7% non-Hispanic White vs 79.9%), and less likely to have a nursing facility stay (34.9% vs 56.1%). Race and ethnicity were significantly associated with hospice use and LOS in both populations: non-Hispanic Black and Hispanic decedents had lower odds of using hospice than non-Hispanic White decedents, and Hispanic decedents had higher odds of a short LOS. In both populations, older age and female sex were also associated with more hospice use. For duals only, higher age was associated with lower odds of short LOS. For decedents with nursing facility stays, compared with those without, Medicaid-only decedents had higher odds of using hospice (odds ratio [OR], 1.49; 95% CI, 1.24-1.78); duals had lower odds (OR, 0.60; 95% CI, 0.57-0.63). Compared with decedents without nursing facility stays, duals with a nursing facility stay had higher odds of short LOS (OR, 2.63; 95% CI, 2.43-2.85). Findings raise concerns about equity and timing of access to hospice for Hispanic and non-Hispanic Black individuals in these understudied Medicaid populations. Knowledge about, access to, and acceptance of hospice may be lacking for these low-income individuals. Further research is needed to understand barriers to and facilitators of hospice use for people with nursing facility stays.

Trends in Hospital Billing for Mastectomy and Breast Reconstruction Procedures from 2013 to 2020.

With greater acceptance of post-mastectomy breast reconstruction (PMBR) as a safe and reliable treatment option, the role of plastic surgeons in breast cancer management continues to rise. As Medicare reimbursements for surgical procedures decline, hospitals may increase charges. Excessive markups can negatively affect uninsured and underinsured patients. We aimed to analyze mastectomy and breast reconstruction procedures to gain insights into recent trends in utilization and billing. We queried the 2013-2020 Medicare Provider Utilization and Payment Data with 14 Current Procedural Terminology (CPT) codes to collect service counts, hospital charges, and reimbursements. We calculated utilization (service counts per million female Medicare enrollees), weighted mean charges and reimbursements, and charge-to-reimbursement ratios (CRRs). We calculated total and annual % changes for the included CPT codes. Among the 14 CPT codes, 12 CPT codes (85.7%) with non-zero service counts were included. Utilization of mastectomy and breast reconstruction procedures decreased from 1,889 to 1,288 (-31.8%) procedures per million female Medicare beneficiaries from 2013 to 2020. While the utilization of immediate implant placements (CPT 19340) increased by 36.2%, the utilization of delayed implant placements (CPT 19342) decreased by 15.1%. Reimbursements for the included CPT codes changed minimally over time (-2.9%), but charges increased by 28.9%. These changes resulted in CRRs increasing from 3.3 to 4.4 (+33.3%) from 2013 to 2020. Free flap reconstructions (CPT 19364) had the highest CRRs throughout the study period, increasing from 7.0 in 2013 to 10.3 in 2020 (+47.1%). Our analysis of mastectomy and breast reconstruction procedures billed to Medicare Part B from 2013 to 2020 showed increasingly excessive procedural charges. Rises in hospital charges and CRRs may limit uninsured and underinsured patients from accessing necessary care for breast cancer management. Legislations that monitor hospital markups for post-mastectomy breast reconstruction procedures may be considered by policymakers.

Sex/Gender Differences in the Diagnosis of Pain by Cognitive Status

AbstractBackgroundUnderdiagnosis of pain is common in women and in those with Alzheimer’s disease and related dementias (ADRD). However, sex/gender differences in pain interference, defined as pain that interferes with daily activities, have not been examined along the cognitive spectrum. We assess sex/gender differences in odds of physician‐diagnosed and self‐reported pain, by cognitive status: normal, cognitively impaired but not dementia (CIND), and dementia.MethodsWe will use data from the 2006 to 2018 waves of the Health and Retirement Study (HRS) linked to Medicare Claims. We will include participants aged 66 and older with at least one year of continued enrollment in Medicare. Our pain diagnosis measure will incorporate self‐reported pain interference, herein referred to as pain, with pain diagnosis in a three‐level variable: no pain, undiagnosed pain (self‐reported only), and diagnosed pain. Cognitive status (normal cognition, CIND, dementia) was measured using the Telephone Interview for Cognitive Status. We will use generalized estimating equation models to calculate gender disparities in the odds of pain diagnosis, by cognitive status. Here we present preliminary results, using cross‐sectional data from the 2018 HRS (n = 7,588) to examine self‐reported pain by cognitive status. We include descriptive statistics and logistic regression models, adjusted for age, race/ethnicity, years of education, marital status, depression, diabetes, arthritis, and obesity.ResultsWomen more often reported pain compared to men for those with normal cognition (women: 27.7%, men: 18.7%; p&lt;0.001) and CIND (women: 32.6%, men: 18.9%; p&lt;0.001). Among those with dementia, 29.9% of women and 22.7% of men reported pain (p = 0.108). For those with normal cognition and CIND, women had higher odds of reporting pain compared to men [normal cognition odds ratio (OR): 1.34, 95% confidence interval (CI): 1.16, 1.55); CIND OR: 1.84 95% CI: 1.38. 2.47]. However, no sex/gender disparity is observed among those with dementia (95% CI: 1.13, 95% CI: 0.66, 1.94).ConclusionsIn our preliminary analysis we found that the sex/gender disparity in self‐reported pain interference is not present among those with dementia. The final version of this work will incorporate the Medicare data from 2006 to 2018 so that we can assess sex/gender differences in clinician‐documented pain diagnosis.

Abstract A126: Differential survival among Medicare beneficiaries diagnosed with breast cancer in California

Abstract This study examines the differences in breast cancer survival among Medicare beneficiaries enrolled in either Traditional Medicare (TM) or Medicare Advantage (MA) plans during 1999-2017 in California. Medicare is federal health insurance for people of age 65 or older. Beneficiaries can choose between TM (directly administered by the Federal government) or MA (offered by private companies) plans. California (CA) has the largest number of Medicare beneficiaries of any state (6.6 million), nearly half (49%) of them enrolled in MA plans. Due to different management mechanisms, detailed claims data are not routinely submitted and available for MA enrollees as for TM, making objective assessment for the claimed MA advantages and effectiveness hard to find. Medicare beneficiaries often find it challenging to choose between TM and MA during the Medicare open enrollment period or make changes between these two types of plans. The National Cancer Institute’s (NCI) Surveillance, Epidemiology, and End Results (SEER) Program, routinely link its cancer registry data with Medicare to provide detailed information about Medicare beneficiaries aged 65 and older diagnosed with cancer. Using the SEER-Medicare linked data for the state of California (CA), we were able to compare the survival differences among Medicare beneficiaries with female breast cancer (BC) stratified by TM or MA enrollment in CA during 1999-2017. We identified a total of 189,517 women Medicare beneficiaries who had BC, of which 83,223 (43.9%) enrolled in TM and never had MA, while 106,294 (56.1%) ever enrolled in MA regardless of the length of MA coverage. Because Medicare enrollment is on monthly basis and enrollees may change plans during the annual open enrollment period each year. Therefore, among the MA enrollees, we found 61,006 (57.4%) who switched between MA and TM from time to time (MA switch), in contrast to 45,288 (42.6%) who were in MA for the entire study period (MA only). We calculated 5-year observed survival rates from all causes of death among these Medicare beneficiaries with BC, using Kaplan-Meier method. We found that MA switch group had the highest 5-year survival of 81.5% (95% CI: 81.2%-81.8%), followed by MA only (72.6%, 95% CI: 72.1%-73.0%) and TM (72.5%, 95% CI: 72.2%-72.8%) groups. The survival advantage of the MA switch group is evident across race/ethnicity. Asian MA switchers had the highest 5-year survival rate (87.3%) followed by Hispanic (83.3%), Non-Hispanic White (80.5%), and Non-Hispanic Black (75.9%). In a multivariate Cox proportional hazards regression analysis, controlling for sociodemographic and clinical characteristics (i.e., age at diagnosis, race and ethnicity, poverty indicator, summary stage of tumor, marital status, urbanization, and number of cancers), MA switch group displayed a statistically significant (α&amp;lt;0.05) mortality reduction of 25% as compared to the TM group. No significant differences between TM and MA only group was found. More informed and proactive Medicare beneficiaries are associated with the best health outcomes. Citation Format: Lihua Liu Liu, Ying Yan, Sue E. Kim. Differential survival among Medicare beneficiaries diagnosed with breast cancer in California [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A126.

Abstract A127: Comparing outcomes in breast cancer treatment between fee-for-service and Medicare Advantage patients

Abstract Introduction: Relative to Medicare beneficiaries receiving care through the traditional fee-for-service system (FFS), the percentage of Americans covered by Medicare Advantage (MA) plans has increased over the last decade. As more patients enroll in MA plans, the comparison of outcomes between FFS and MA groups has gained renewed importance. Ohio has a high penetration of MA plans, but differences in outcomes between FFS and MA plans in Ohio is under-studied. Breast cancer is the second most common type of cancer among women, therefore understanding nuances in breast cancer treatment outcomes has broad applicability. In this study, we compare receipt of standard care, time to treatment initiation (TTI), and overall survival (OS) between FFS and MA women diagnosed with incident breast cancer. Methods: We used the Ohio Cancer Incidence Surveillance System (OCISS) cancer registry data linked with Medicare enrollment files and identified patients diagnosed with local and regionally staged breast cancer between 2011-2016. All variables except for FFS and MA enrollment were derived from the OCISS. We developed logistic regression (for analysis of receipt of standard treatment) and Cox regression models (for analysis of TTI and OS) to evaluate the independent association between FFS/MA status and our outcomes of interest, adjusting for age, race, marital status, type of county of residence, neighborhood poverty level, stage at diagnosis, hormone receptor status, and Medicaid dual enrollment. Standard care was defined as receipt of breast-conserving surgery (BCS) or mastectomy, radiotherapy if BCS was received; chemotherapy if regionally staged; and hormone therapy if hormone receptor positive. Results: 12,349 patients were identified that met our inclusion criteria, with 6,801 and 5,548 patients in the FFS and MA groups at the time of diagnosis, respectively. A slightly higher percentage of MA patients were identified as Black (10.3 vs 8.0% on FFS plans). FFS Medicare patients were found to have similar odds of receiving standard care as patients on MA plans (adjusted odds ratio 0.95 [95% CI: 0.88, 1.03]). We detected no difference in TTI between FFS and MA patients, (adjusted hazard ratio (aHR) 0.98 [95% confidence interval (CI): 0.94, 1.01]), or in OS (aHR 1.06 [95% CI: 0.95, 1.18]). No difference was found in receipt of standard care between Black and White patients (aOR 0.88 [95% CI: 0.76, 1.03]). An interaction term with race found that FFS Black patients had significantly lower odds of receiving standard care than their MA counterparts (aOR 0.70 [95% CI: 0.54, 0.92]). We did not find any significant interaction between MA status and race for OS or TTI. Conclusions: MA plans were not associated with any difference in TTI, OS, nor odds of receiving standard treatment for breast cancer compared to FFS Medicare plans. These findings are reassuring given the growing market share of privately administered MA plans, but raise questions with the notable disparity in receipt of standard care between Black FFS enrollees versus Black MA enrollees. Citation Format: Galen Shearn-Nance, Rishi Sachdev, Long Vu, Weichuan Dong, Johnie Rose, Siran Koroukian. Comparing outcomes in breast cancer treatment between fee-for-service and Medicare Advantage patients [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr A127.