Medicare Plans Research Articles

The effect of distance to a high-volume center on receipt of treatment for invasive bladder cancer.

461 Background: Regionalization of major surgery such as cystectomy has spurred interest in the association of high-volume centers (HVC) & improved postoperative outcomes. However, concerns have been raised regarding access to care, with increasing travel distance playing a role in treatment selection. Our objective was to evaluate the effect of distance to closest HVC on treatment selection for muscle-invasive bladder cancer (MIBC). Methods: Using a linked data resource combining NC Cancer Registry with administrative claims data from Medicare, Medicaid, and private insurance plans, we included adult patients diagnosed with Stage 2 bladder cancer from 2003-2008. We created 2 mutually exclusive treatment groups (standard: cystectomy or chemo-radiation; non-standard: other or no treatment). HVCs were identified as those performing > 15 cystectomies during the study period. Nearest distance was calculated by using straight-line distance between zip code of the patient and closest HVC. Bivariable analyses and multivariable logistic regression were used to evaluate the effect of nearest distance to a HVC on receipt of non-standard treatment for MIBC. Results: 274 patients with confirmed MIBC were identified, with n = 123 undergoing standard and n = 151 non-standard treatment. Mean age of patients in the standard group was 73.1 vs. 77.7 in the non-standard group (p < 0.001). Groups also differed by race and insurance type (minority patients and those with Medicaid or Medicare were more likely to receive non-standard treatment). However, no significant difference was noted for comorbidity, gender, or education. Patients who underwent non-standard therapy had shorter distances to a HVC (73% have a distance of < 30 miles) vs. those who received standard therapy (56%, < 30 miles) (p < 0.004). On multivariable analysis, distance > 30 miles to a HVC was associated with lower likelihood to undergo non-standard therapy (p = 0.005), even when controlling for age, gender, race, comorbidity, insurance and other factors. Conclusions: Distance to HVC is not associated with increased likelihood of receipt of standard therapy for MIBC. Regionalization of care may not significantly impact access to care as previously hypothesized.

Development of an algorithm to identify fall-related injuries and costs in Medicare data.

BackgroundIdentifying fall-related injuries and costs using healthcare claims data is cost-effective and easier to implement than using medical records or patient self-report to track falls. We developed a comprehensive four-step algorithm for identifying episodes of care for fall-related injuries and associated costs, using fee-for-service Medicare and Medicare Advantage health plan claims data for 2,011 patients from 5 medical groups between 2005 and 2009.MethodsFirst, as a preparatory step, we identified care received in acute inpatient and skilled nursing facility settings, in addition to emergency department visits. Second, based on diagnosis and procedure codes, we identified all fall-related claim records. Third, with these records, we identified six types of encounters for fall-related injuries, with different levels of injury and care. In the final step, we used these encounters to identify episodes of care for fall-related injuries.ResultsTo illustrate the algorithm, we present a representative example of a fall episode and examine descriptive statistics of injuries and costs for such episodes. Altogether, we found that the results support the use of our algorithm for identifying episodes of care for fall-related injuries. When we decomposed an episode, we found that the details present a realistic and coherent story of fall-related injuries and healthcare services. Variation of episode characteristics across medical groups supported the use of a complex algorithm approach, and descriptive statistics on the proportion, duration, and cost of episodes by healthcare services and injuries verified that our results are consistent with other studies.ConclusionsThis algorithm can be used to identify and analyze various types of fall-related outcomes including episodes of care, injuries, and associated costs. Furthermore, the algorithm can be applied and adopted in other fall-related studies with relative ease.Electronic supplementary materialThe online version of this article (doi:10.1186/s40621-015-0066-z) contains supplementary material, which is available to authorized users.

Successful Strategies for Reducing Disparities in Quality of Care: Lessons From Dual-Eligible Special Needs Plans.

Identifying strategies to reduce health care disparities is a national priority. This study examines factors within higher performing Medicare Advantage dual-eligible special needs plans (SNPs) that contribute to improved diabetic control. These structural and process elements include nonprofit status, interdisciplinary care teams, medication management, home visiting clinicians, and motivational interviewing. We suggest further research into the value of requiring all Medicare plans serving duals comply with standards for the SNP Model of Care. Finally, we recommend that all plans with dual and nondual members report scores separately to demonstrate the quality provided to the dual population.

The Economic Burden of Out-of-Pocket Medical Expenditures Before and after Implementation of the Medicare Prescription Drug Program

Older Americans, although covered by Medicare, bear a large economic burden of medical expenses in the form of premiums for Medicare and supplemental plans, as well as the cost of uncovered or under-covered medical services. This study compares the patterns of this economic burden in 2010 with the baseline year of 2005. The period covered was marked by economic shocks, health care technology innovations and major Medicare reforms, including implementation of the prescription drug (Part D) program and changes in premium rules. Consequently, we present a description of the economic burden and do not attempt to make causal inferences. The definition of expenditures is limited to three components of out-of-pocket (OOP) medical spending: premiums, prescription drugs costs, and health services. While this definition is a limitation of the study, it also allows the researchers to focus on the costs most likely to be affected by improved access to prescription drugs and premium reforms.This paper found that:• Overall, the economic burden (expressed as a percent of income spent on OOP expenditures and premiums) averaged 18.5 percent of 2010 income, with top decile spending at 32 percent or more of their income going to health care. • A typical beneficiary spent 1.4 percentage points less of their income in 2010 than in 2005. When this burden is decomposed, we observed that the share of income spent for prescription drugs declined by 1.3 percentage points. This was the major component of the decline in this burden. The burden of premiums increased over the period, offsetting some of the gains from declining expenses for prescription drugs.• These gains were mostly observed at the high end of the burden distribution, i.e., those who were spending more than 20 percent of their income on health care. This group had lower incomes, on average, and were much less likely to possess employer-sponsored supplemental (or self-purchased) coverage. • Dual eligibles experienced a lower economic burden in 2010, even though their incomes were also significantly lower compared to the rest of the Medicare beneficiaries. Compared to other Medicare beneficiaries, they experienced relatively larger reductions in economic burden between 2005 and 2010.The policy implications of this paper are:• We observed some relief in the economic burden of prescription drug expenditures and overall health care, particularly for those who were most vulnerable to financial strains.• Our observations were consistent with the intended direction of policies implemented during the period. However, one can argue that the size of the gains was unremarkable when compared to the scope of the Part D reform. • Medicaid continued to fulfill its role as a safety net for those who are most vulnerable to financial strains. The relatively higher rate of decline for duals or low-income beneficiaries suggests that key components of the reform (premium- and cost-sharing assistance) are reaching the intended targets.• Affordability of high-cost drugs for the management of chronic conditions continues to be a major national health policy challenge. Medicare policy changes are likely to continue affecting out-of-pocket cost exposure to medications, particularly with the introduction and expansion in use of very high-priced specialty medications. Given the size and the unequal distribution of the economic burden of health care, we conclude that the economic burden needs to be a continuous concern when policy alternatives are discussed.

PDB26 - Costs for Diabetic Patients Receiving Dipeptidyl Peptidase-4 (DPP-4) Inhibitors in US Medicare and Commercial Insurance Plans

PDB26 - Costs for Diabetic Patients Receiving Dipeptidyl Peptidase-4 (DPP-4) Inhibitors in US Medicare and Commercial Insurance Plans

Listening to Women: Expectations and Experiences in Breast Imaging.

Those who discuss breast cancer detection and diagnosis with women know that many patients have misconceptions and anxieties about mammography. Some patients may misunderstand screening recommendations of their primary care provider or receive misinformation from friends, family, or other sources. Other women might be confused by changes or updates in official recommendations about the frequency for screening mammography or the age to begin obtaining mammograms. Still others might not be aware of breast cancer mammography screening coverage by the Patient Protection and Affordable Care Act (ACA), requiring that all new private insurance and Medicare plans eliminate cost-sharing by patients. Furthermore, healthcare providers can add to the confusion if they are not informed about the latest guidance. Anxiety about breast cancer screening can occur especially in women who have been called back for additional tests based on an inconclusive mammogram. In a recent database review of 1,723,139 women who received a screening mammogram between January 2011 and June 2013, Alcusky and colleagues found that 15% were recalled,1 while other studies reported recall rates between 10–14%.2,3 Most recalls result in “false positives,” meaning that additional testing ultimately yielded a benign outcome. Additional tests can include diagnostic mammography, breast ultrasound, breast biopsy, or magnetic resonance imaging. The majority of recalls reveal normal tissue, cysts, or other benign processes.4 The denser the breast tissue5–8 and the more annual mammograms a woman has had, the greater the probability of a callback and a false positive finding. False positives have been shown to increase patient anxiety in the short term,9 temporarily reduce quality of life,10 and lead to worries about breast cancer that can last for several years beyond the resolution of a false positive diagnosis.11 Anxiety and fear have been reported to have a major impact on breast cancer screening behaviors.12 As Harvey and colleagues note in a recent report, behaviors and responses to healthcare screenings can vary based on race/ethnicity and socioeconomic factors,13 perhaps helping to explain the greater fear of the healthcare system among African-American women.14 This undoubtedly plays a role in why African-American women present for diagnosis at later stages of breast cancer.15 We do know that almost all women experience increased anxiety when faced with finding a possible breast screening abnormality.16 Breast cancer is the most common cancer in U.S. women.17 The National Cancer Institute (NCI) of the National Institutes of Health projects 231,840 new cases of breast cancer in U.S. women and 40,290 deaths from the disease in 2015.18 NCI further estimates that 12.3% (1 in 8) of U.S. women with average risk will be diagnosed with breast cancer during their lifetime. Mortality from breast cancer has decreased significantly since 1990, probably related to improved mammography technology and detection, increased public awareness of the value of screening, and more effective treatments. Despite these improvements, breast cancer remains a serious health concern and is the second leading cause of cancer death among all women. There is one notable exception, which is for Hispanic women, in whom breast cancer is the number one cause of cancer death.17 Mammography screening is highly effective at detecting existing disease and reducing mortality. It has been associated with a 19% reduction in breast cancer deaths.19 The likelihood that mammography will detect existing breast cancer is 70% to 90% in most women; the exception is women with dense breast tissue where the sensitivity falls to 30 to 48%.20 Newer screening technologies including digital breast tomosynthesis (DBT) may yield even better results. This technology has the ability to both increase invasive cancer detection and decrease false positive results.4,21–24 In 2014, The Society for Women's Health Research conducted a national survey to assess women's knowledge and attitudes regarding mammography. We sought to identify misunderstandings about mammography among women of different racial/ethnic and age groups. We further sought to identify barriers that keep women from seeking screening mammography and motivators that would propel women toward screening. We queried participants about their emotional responses to being recalled for follow-up diagnostic testing and about what might lead them to use one mammography center over another for their breast cancer screening. Our results clearly showed areas where there are successes and areas where there are challenges. Our results demonstrate opportunities and potential ways forward to improve access and utilization of screening mammography. The authors believe that with improved access and utilization paired with new technologies, there may be potential for improved outcomes.

MANAGED COMPETITION IN HEALTH INSURANCE

Rising healthcare costs have sparked debate about the best way to provide high-quality affordable health insurance. We discuss the potential for regulated insurance markets to outperform single-payer public insurance. We use as an example the private Medicare plans that now provide insurance to almost a third of seniors in the United States. The evidence suggests that private plans can limit costs and potentially appeal to enrollees, and that well-designed risk adjustment can mitigate market failures due to adverse selection. However, fostering competition between insurers, especially in smaller markets, is difficult. We discuss how future research might illuminate the relative advantages of public and private health insurance.

Medicare Plans to Reimburse Physicians for Advance Care Counseling Neurologists Weigh in on Next Steps

Medicare Plans to Reimburse Physicians for Advance Care Counseling Neurologists Weigh in on Next Steps

The Roles of Cost and Quality Information in Medicare Advantage Plan Enrollment Decisions: an Observational Study.

To facilitate informed decision-making in the Medicare Advantage marketplace, the Centers for Medicare & Medicaid Services publishes plan information on the Medicare Plan Finder website, including costs, benefits, and star ratings reflecting quality. Little is known about how beneficiaries weigh costs versus quality in enrollment decisions. We aimed to assess associations between publicly reported Medicare Advantage plan attributes (i.e., costs, quality, and benefits) and brand market share and beneficiaries' enrollment decisions. We performed a nationwide, beneficiary-level cross-sectional analysis of 847,069 beneficiaries enrolling in Medicare Advantage for the first time in 2011. Matching beneficiaries with their plan choice sets, we used conditional logistic regression to estimate associations between plan attributes and enrollment to assess the proportion of enrollment variation explained by plan attributes and willingness to pay for quality. Relative to the total variation explained by the model, the variation in plan choice explained by premiums (25.7%) and out-of-pocket costs (11.6%) together explained nearly three times as much as quality ratings (13.6%), but brand market share explained the most variation (35.3%). Further, while beneficiaries were willing to pay more in total annual combined premiums and out-of-pocket costs for higher-rated plans (from$4,154.93 for 2.5-star plans to $5,698.66 for 5-star plans), increases in willingness to pay diminished at higher ratings, from $549.27 (95%CI: $541.10, $557.44) for a rating increase from 2.5 to 3 stars to $68.22 (95%CI: $61.44, $75.01) for an increase from 4.5 to 5 stars. Willingness to pay varied among subgroups: beneficiaries aged 64-65years were more willing to pay for higher-rated plans, while black and rural beneficiaries were less willing to pay for higher-rated plans. While beneficiaries prefer higher-quality and lower-cost Medicare Advantage plans, marginal utility for quality diminishes at higher star ratings, and their decisions are strongly associated with plans' brand market share.

Why Medicare Advantage Plans Pay hospitals traditional Medicare prices.

The policy community generally has assumed Medicare Advantage (MA) plans negotiate hospital payment rates similar to those for commercial insurance products and well above those in traditional Medicare. After surveying senior hospital and health plan executives, we found, however, that MA plans nominally pay only 100-105percent of traditional Medicare rates and, in real economic terms, possibly less. Respondents broadly identified three primary reasons for near-payment equivalence: statutory and regulatory provisions that limit out-of-network payments to traditional Medicare rates, de facto budget constraints that MA plans face because of the need to compete with traditional Medicare and other MA plans, and a market equilibrium that permits relatively lower MA rates as long as commercial rates remain well above the traditional Medicare rates. We explored a number of policy implications not only for the MA program but also for the problem of high and variable hospital prices in commercial insurance markets.

Private payers disagree with Medicare over medical device coverage about half the time.

There are multiple payers in the US health care system, each making its own coverage determinations for medical technologies. For each of the forty-seven medical devices considered in national coverage determinations (NCDs) of the Centers for Medicare and Medicaid Services (CMS) issued between February1999 and August2013, we compared CMS's coverage policy with the policies issued by the largest sixteen private payers that made their decisions publicly available. Overall, we found that NCDs were equivalent to the corresponding private payer policies roughly half of the time, more restrictive approximately a quarter of the time, and less restrictive about a quarter of the time. Our findings indicate that patients may have variable access to medical technology across Medicare and private plans. They also suggest that private plans do not necessarily follow CMS's lead in making coverage decisions.

Waiving the three-day rule: admissions and length-of-stay at hospitals and skilled nursing facilities did not increase.

The traditional Medicare program requires an enrollee to have a hospital stay of at least three consecutive calendar days to qualify for coverage of subsequent postacute care in a skilled nursing facility. This long-standing policy, implemented to discourage premature discharges from hospitals, might now be inappropriately lengthening hospital stays for patients who could be transferred sooner. To assess the implications of eliminating the three-day qualifying stay requirement, we compared hospital and postacute skilled nursing facility utilization among Medicare Advantage enrollees in matched plans that did or did not eliminate that requirement in 2006-10. Among hospitalized enrollees with a skilled nursing facility admission, the mean hospital length-of-stay declined from 6.9 days to 6.7 days for those no longer subject to the qualifying stay but increased from 6.1 to 6.6 days among those still subject to it, for a net decline of 0.7 day when the three-day stay requirement was eliminated. The elimination was not associated with more hospital or skilled nursing facility admissions or with longer lengths-of-stay in a skilled nursing facility. These findings suggest that eliminating the three-day stay requirement conferred savings on Medicare Advantage plans and that study of the requirement in traditional Medicare plans is warranted.

Upcoding: Evidence from Medicare on Squishy Risk Adjustment.

In most US health insurance markets, plans face strong incentives to "upcode" the patient diagnoses they report to the regulator, as these affect the risk-adjusted payments plans receive. We show that enrollees in private Medicare plans generate 6% to 16% higher diagnosis-based risk scores than they would under fee-for-service Medicare, where diagnoses do not affect most provider payments. Our estimates imply that upcoding generates billions in excess public spending and significant distortions to firm and consumer behavior. We show that coding intensity increases with vertical integration, suggesting a principal-agent problem faced by insurers, who desire more intense coding from the providers with whom they contract.

Coverage for high-cost specialty drugs for rheumatoid arthritis in Medicare Part D.

More than 1 in 4 Medicare beneficiaries with rheumatoid arthritis use high-cost biologic disease-modifying antirheumatic drugs (DMARDs), and spending for these drugs has risen sharply for Medicare Part D. Our aim was to conduct the first systematic, national investigation of how Part D plans cover biologic DMARDs and to determine patients' financial burden under current cost-sharing structures. We performed a cross-sectional analysis of Part D plan formularies (n = 2,737) in 50 states and Washington, DC using the January 2013 Centers for Medicare and Medicaid Services Prescription Drug Plan Formulary and Pharmacy Network Files. We calculated the percentage of plans covering each DMARD as well as the percentage requiring prior authorization and/or coinsurance. We also compared biologic drug coverage in Medicare Advantage prescription drug plans to that in Medicare Part D stand-alone plans. All plans covered at least 1 biologic DMARD, but the vast majority required prior authorizations (95%). Nearly all plans (81-100%) required patients to pay a coinsurance percentage (averaging 29.6% of drug costs) rather than a fixed dollar copayment. This translated into mean out-of-pocket costs of $2,712-$2,774 before reaching the catastrophic phase of coverage, during which beneficiaries pay 5% of drug costs. Medicare Advantage prescription drug plans covered more individual biologic DMARDs (55-100%) than did Medicare Part D stand-alone plans (22-100%), but Medicare Advantage prescription drug plans required higher average coinsurance (31.1% versus 29.0%). In contrast, 6 of 9 nonbiologic DMARDs were covered by nearly all plans without prior authorizations at fixed copayments averaging $5-$10/month. Nationally, nearly all Part D plans cover at least 1 biologic DMARD, but the vast majority require cost sharing sufficiently high to risk significant financial burden to patients.

For uninsured cancer patients, outpatient charges can be costly, putting treatments out of reach.

Reimbursement information for public and private payers has long been available. However, information about charges—the amounts that providers request before payments are negotiated—has been scarce, particularly for outpatient care. Using the new Medicare Provider Utilization and Payment Data Public Use File and other sources, we evaluated physician charges, reimbursements by Medicare and large private health plans, and expected patient cost sharing for outpatient oncology care. In 2012 the average Medicare reimbursement for chemotherapy was 39.6 percent of charges; for private insurance, the share was 55.7 percent. Uninsured patients faced potential prices for chemotherapy that were 2-43 times as much as the total Medicare-allowed amount and 2-5 times as much as the private insurance-allowed amount. Charges for outpatient chemotherapy and office visits were substantially higher than insurer-reimbursed amounts, which is consistent with previous evidence about hospital charges. The charges for outpatient services underscore the pressure that the current system places on the people who are least able to pay. Encouraging rational pricing for health care services will be an important step toward ensuring access to care for everyone.

MP5-05 UNDERSTANDING THE RELATIONSHIP BETWEEN 30— AND 90—DAY EMERGENCY ROOM VISITS AND READMISSIONS FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes I1 Apr 2015MP5-05 UNDERSTANDING THE RELATIONSHIP BETWEEN 30— AND 90—DAY EMERGENCY ROOM VISITS AND READMISSIONS FOLLOWING RADICAL CYSTECTOMY E. Sophie Spencer, Peter Greene, Matthew Lyons, Anne Marie Meyer, Ke Meng, Raj Pruthi, Eric Wallen, Michael Woods, Matthew Nielsen, and Angela Smith E. Sophie SpencerE. Sophie Spencer More articles by this author , Peter GreenePeter Greene More articles by this author , Matthew LyonsMatthew Lyons More articles by this author , Anne Marie MeyerAnne Marie Meyer More articles by this author , Ke MengKe Meng More articles by this author , Raj PruthiRaj Pruthi More articles by this author , Eric WallenEric Wallen More articles by this author , Michael WoodsMichael Woods More articles by this author , Matthew NielsenMatthew Nielsen More articles by this author , and Angela SmithAngela Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.232AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Readmissions are particularly common following radical cystectomy (RC) for bladder cancer, with several institutional case series demonstrating rates approximating 24%. Our objective was to determine the frequency of ER visits and readmissions within 30 and 90 days following RC for bladder cancer and establish the relationship between emergency room (ER) visits and readmissions at both time points using a state-wide multipayer database. METHODS Using a linked data resource combining NC Central Cancer Registry with administrative claims data from Medicare, Medicaid, and private insurance plans, we included adult patients diagnosed with bladder cancer from 2003–2010 who received RC within 1 year after diagnosis. We identified readmissions and ER visits 30 and 31–90 days after discharge. Comparisons between 30 and 90-day readmissions and ER visits were performed using the chi-squared test. RESULTS 842 patients were identified as receiving RC within 1 year of diagnosis. Mean age was 69 years, with 72% male. Approximately 19% (n=161) presented to the ER within 30 days, and 18% (n=152) presented to the ER within 31–90 days (total n=313). Of those who presented to the ER within 30 and 31–90 days, 63% and 74% were subsequently readmitted, respectively. Only 26% of the patients presenting to the ER were observed at both time points (see table). 30- and 90-day overall readmissions were also evaluated with 22% (n=189) readmitted within 30 days, and 21% (n=178) within 31–90 days. Approximately 30% of those readmitted within 30 days were also readmitted at 31–90 days. Finally, we evaluated those readmitted through the ER, with 12% (n=103) and 14% (n=115) readmitted within 30 days and 31–90 days after discharge, respectively. One quarter of patients readmitted through the ER within 30 days were also readmitted through the ER between 31–90 days. CONCLUSIONS To our knowledge, these results represent the first evaluation of both 30- and 90-day readmissions following RC for BC in a population-based sample. An equal proportion of readmissions occur within 30 and 31–90 days following RC for bladder cancer with anywhere from one quarter to one third being readmitted at both time points. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e46-e47 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information E. Sophie Spencer More articles by this author Peter Greene More articles by this author Matthew Lyons More articles by this author Anne Marie Meyer More articles by this author Ke Meng More articles by this author Raj Pruthi More articles by this author Eric Wallen More articles by this author Michael Woods More articles by this author Matthew Nielsen More articles by this author Angela Smith More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Do Racial/Ethnic Disparities in Quality and Patient Experience within Medicare Plans Generalize across Measures and Racial/Ethnic Groups?

To examine how similar racial/ethnic disparities in clinical quality (Healthcare Effectiveness Data and Information Set [HEDIS]) and patient experience (Consumer Assessment of Healthcare Providers and Systems [CAHPS]) measures are for different measures within Medicare Advantage (MA) plans. 5.7 million/492,495 MA beneficiaries with 2008-2009 HEDIS/CAHPS data. Binomial (HEDIS) and linear (CAHPS) hierarchical mixed models generated contract estimates for HEDIS/CAHPS measures for Hispanics, blacks, Asian-Pacific Islanders, and whites. We examine the correlation of within-plan disparities for HEDIS and CAHPS measures across measures. Plans with disparities for a given minority group (vs. whites) for a particular measure have a moderate tendency for similar disparities for other measures of the same type (mean r = 0.51/.21 and 53/34 percent positive and statistically significant for CAHPS/HEDIS). This pattern holds to a lesser extent for correlations of CAHPS disparities and HEDIS disparities (mean r = 0.05/0.14/0.23 and 4.4/5.6/4.4 percent) positive and statistically significant for blacks/Hispanics/API. Similarities in CAHPS and HEDIS disparities across measures might reflect common structural factors, such as language services or provider incentives, affecting several measures simultaneously. Health plan structural changes might reduce disparities across multiple measures.

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

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

Cardiology and accountable care.

Cardiovascular disease is the leading cause of death in the United States and accounts for ≈17% of national health expenditures and 30% of Medicare spending.1 Among physician groups and professional societies, cardiologists have been among those leading efforts to create evidence-based guidelines and to measure quality of care. In the post-health reform era, national efforts have expanded beyond quality to include innovative delivery models, such as the patient-centered medical home (PCMH), the medical neighborhood, and accountable care organizations (ACOs). This next generation of care models and the payment strategies that support them incentivize efficiency, patient-centeredness, and care coordination with an emphasis on primary care. We propose strategies for cardiologists to create collaborative opportunities within these new models drawing from examples from around the country within the context of a framework developed by the American College of Physicians.2 Pursuing these approaches or others along similar lines will enable cardiologists to lead and to be active participants in shaping delivery system transformation. These innovative delivery models share similar features. The PCMH is a model of care that emphasizes additional support for primary care providers within a patient-centered team, whereas a medical neighborhood represents a broader collection of primary care doctors, specialists such as cardiologists, hospitals, and other stakeholders within a region that seek to reduce fragmented care by sharing accountability.2,3 The ACO, too, is a broader care delivery arrangement, but in this case, groups of providers are accountable for the quality, cost, and overall care of a particular population, typically defined by the payer. In the Medicare Shared Savings Program (MSSP), an ACO model for Medicare beneficiaries, the ACO can capture shared savings if it reduces its healthcare expenditures and meets certain quality performance standards, nearly half of which are related to cardiovascular disease.4 Within the …

Adverse and Advantageous Selection in the Medicare Supplemental Market: A Bayesian Analysis of Prescription drug Expenditure

This paper develops an extended specification of the two-part model, which controls for unobservable self-selection and heterogeneity of health insurance, and analyzes the impact of Medicare supplemental plans on the prescription drug expenditure of the elderly, using a linked data set based on the Medicare Current Beneficiary Survey data for 2003-2004. The econometric analysis is conducted using a Bayesian econometric framework. We estimate the treatment effects for different counterfactuals and find significant evidence of endogeneity in plan choice and the presence of both adverse and advantageous selections in the supplemental insurance market. The average incentive effect is estimated to be $757 (2004 value) or 41% increase per person per year for the elderly enrolled in supplemental plans with drug coverage against the Medicare fee-for-service counterfactual and is $350 or 21% against the supplemental plans without drug coverage counterfactual. The incentive effect varies by different sources of drug coverage: highest for employer-sponsored insurance plans, followed by Medigap and managed medicare plans.