Percent Of Beneficiaries Research Articles

Outcomes after ischemic stroke for dual-eligible Medicare-Medicaid beneficiaries in the United States.

Medicaid serves as a safety net for low-income US Medicare beneficiaries with limited assets. Approximately 7.7 million Americans aged ≥65 years rely on a combination of Medicare and Medicaid to obtain critical medical services, yet little is known about whether these patients have worse outcomes after stroke than patients with Medicare alone. We compared geographic patterns in dual Medicare-Medicaid eligibility and ischemic stroke hospitalizations and examined whether these dual-eligible beneficiaries had worse post-stroke outcomes than those with Medicare alone. We identified fee-for-service Medicare beneficiaries aged ≥65 years who were discharged from US acute-care hospitals with a principal diagnosis of ischemic stroke in 2014. Medicare beneficiaries with ≥1 month of Medicaid coverage were considered dual eligible. We mapped risk-standardized stroke hospitalization rates and percentages of beneficiaries with dual eligibility. Mixed models and Cox regression were used to evaluate relationships between dual-eligible status and outcomes up to 1 year after stroke, adjusting for demographic and clinical factors. At the national level, 12.5% of beneficiaries were dual eligible. Dual-eligible rates were highest in Maine, Alaska, and the southern half of the United States, whereas stroke hospitalization rates were highest in the South and parts of the Midwest (Pearson's r = 0.469, p<0.001). Among 254,902 patients hospitalized for stroke, 17.4% were dual eligible. In adjusted analyses, dual-eligible patients had greater risk of all-cause readmission within 30 days (hazard ratio 1.06, 95% confidence interval [CI] 1.03-1.09) and 1 year (hazard ratio 1.03, 95% CI 1.02-1.05) and had greater odds of death within 1 year (odds ratio 1.20, 95% CI 1.17-1.23) when compared with Medicare-only patients; there was no difference in in-hospital or 30-day mortality. Dual-eligible stroke patients had higher readmissions and long-term mortality than other patients, even after comorbidity adjustment. A better understanding of the factors contributing to these poorer outcomes is needed.

Home-Based Medical Care Use In Medicare Advantage And Traditional Medicare In 2018.

The use of home-based medical care differed in Medicare Advantage and traditional Medicare in 2018. Having exactly one such visit was thirty-one times as likely for Medicare Advantage beneficiaries (18.6percent) as for traditional Medicare beneficiaries (0.6percent), likely reflecting incentives in the Medicare Advantage program to code all accurate diagnoses. Multiple home-based medical care visits were less likely in Medicare Advantage than in traditional Medicare (1.6percent versus 2.1percent of beneficiaries, respectively).

1214-P: Trends in the Use of Glycemic Testing for Diabetes among Medicare Fee-for-Service Beneficiaries, 2001–2018

Glycemic tests are an important tool in screening patients for diabetes and prediabetes but there is little literature describing changes in patterns of glycemic testing over time. Using claims data for Medicare Fee-for-Service (FFS) beneficiaries without diabetes, we examined trends and demographic variation in the use of glycemic screening tests. Beneficiaries with diabetes were identified by ICD diagnosis codes while tests were identified with HCPCS/CPT procedure codes. The number of fully enrolled Medicare FFS beneficiaries without diagnosed diabetes ranged from 17.1 million in 2001 to 14.6 million in 2018. The total number of tests ranged from 2.7 million in 2001 to 4.8 million in 2018, and after 2009, the majority administered were HbA1c tests. The rate of glycemic testing was calculated as the percent of beneficiaries without diagnosed diabetes having at least one of any glycemic test per year. Testing rates were calculated by sex, age, race/ethnicity and state. The annual percentage of beneficiaries without diabetes who had any glycemic test increased from 10.6% in 2001 to 22.5% in 2018. Testing rate varied little across sex, age and race/ethnicity groups with 2 exceptions: beneficiaries age 85+ had a much lower testing rate (17.8% in 2018) than other age groups (23.6%); and beneficiaries of Asian or Pacific Islander descent had a much higher testing rate (31.7% in 2018) than other race/ethnicity groups (between 22.0–24.8%). However, testing rates did vary considerably among states: in 2018, ranging from a low of 11.1% in Wyoming to a high of 33.9% in Hawaii. Glycemic testing for diabetes has increased steadily since 2010, largely due to increased use of HbA1c tests. However, fewer than 1 in 4 Medicare FFS beneficiaries were tested in 2018, suggesting that opportunities remain to improve screening and diagnosis of diabetes among older adults. Disclosure L.J.Andes: None. S.R.Benoit: None. D.B.Rolka: None. G.Imperatore: None. C.S.Holliday: None.

The Broader Opportunity Costs in the Broader Cost-Effectiveness Analysis Framework.

The traditional cost-effectiveness analysis framework usually takes a healthcare system perspective, where the aim is to maximise population health from a fixed budget allocated to healthcare. Extensions to this framework have been suggested, including: (i) incorporating impacts that fall outside the healthcare sector; (ii) accounting for outcomes beyond health; and (iii) assessing equity considerations. Several alternatives have been proposed that serve these purposes, for example, the extended "impact inventory", the "beyond-the-QALY" approach and the distributional cost-effectiveness analysis. This paper aims to develop a comprehensive framework that incorporates into the cost-effectiveness analysis framework some of its most advocated extensions and provides a means of arriving at a unidimensional cost-effectiveness analysis result measure. Building on previous work, I proposed a framework that explicitly incorporates the full extent of the opportunity costs that arise when new dimensions and distributional concerns are included in cost-effectiveness analyses. A hypothetical example is provided as a way of illustration. Operationalising the proposed framework requires system-wide representative values and/or robust estimates concerning: (i) selecting dimensions; (ii) measuring opportunity costs associated with each dimension; (iii) quantifying equity weights and percentages of beneficiaries and losers meeting equity considerations; and (iv) attaching monetary values to dimensions measured using a non-monetary metric. Extending the cost-effectiveness analysis framework entails extending the measurement of the opportunity costs of funding decisions. This implies populating an ambitious puzzle that in some cases poses fundamental conceptual and empirical questions. Potential routes of further research that might facilitate such undertaking are proposed.

Targeting Co-Stimulatory Receptors of the TNF Superfamily for Cancer Immunotherapy.

The clinical approval of immune checkpoint inhibitors is an important advancement in the field of cancer immunotherapy. However, the percentage of beneficiaries is still limited and it is becoming clear that combination therapies are required to further enhance the treatment efficacy. The potential of strategies targeting the immunoregulatory network by "hitting the gas pedal" as opposed to "blocking the brakes" is being recognized and intensively investigated. Hence, next to immune checkpoint inhibitors, agonists of co-stimulatory receptors of the tumor necrosis factor superfamily (TNF-SF) are emerging as promising options to expand the immunomodulatory toolbox. In this review the development of different categories of recombinant antibody and ligand-based agonists of 4-1BB, OX40, and GITR is summarized and discussed in the context of the challenges presented by the structural and mechanistical features of the TNFR-SF. An overview of current formats, trends, and clinical studies is provided.

Evaluating The Accuracy Of Medicare Risk Adjustment For Alzheimer's Disease And Related Dementias.

In 2020 Medicare reintroduced Alzheimer's disease and related dementias (ADRD) Hierarchical Condition Categories (HCCs) to risk-adjust Medicare Advantage and accountable care organization (ACO) payments. The potential for Medicare spending increases from this policy change are not well understood because the baseline accuracy of ADRD HCCs is uncertain. Using linked 2016-18 claims and electronic health record data from a large ACO, we evaluated the accuracy of claims-based ADRD HCCs against a reference standard of clinician-adjudicated disease. An estimated 7.5percent of beneficiaries had clinician-adjudicated ADRD. Among those with ADRD HCCs, 34percent did not have clinician-adjudicated disease. The false-negative and false-positive rates were 22.7percent and 3.2percent, respectively. Medicare spending for those with false-negative ADRD HCCs exceeded that of true positives by $14,619 per beneficiary. If, after the reintroduction of risk adjustment for ADRD, all false negatives were coded as having ADRD, expenditure benchmarks for beneficiaries with ADRD would increase by 9percent. Monitoring ADRD coding could become challenging in the setting of concurrent incentives to decrease false-negative rates and increase false-positive rates.

Factors related to initial treatment for adhesive capsulitis in the medicare population

BackgroundPrimary adhesive capsulitis (AC) is not well understood, and controversy remains about the most effective treatment approaches. Even less is known about the treatment of AC in the Medicare population. We aimed to fully characterize initial treatment for AC in terms of initial treatment utilization, timing of initial treatments and treatment combinations.MethodsUsing United States Medicare claims from 2010–2012, we explored treatment utilization and patient characteristics associated with initial treatment for primary AC among 7,181 Medicare beneficiaries. Patients with primary AC were identified as patients seeking care for a new shoulder complaint in 2011, with the first visit related to shoulder referred to as the index date, an x-ray or MRI of the shoulder region, and two separate diagnoses of AC (ICD-9-CM codes: 726.00). The treatment period was defined as the 90 days immediately following the index shoulder visit. A multivariable logistic model was used to assess baseline patient factors associated with receiving surgery within the treatment period.ResultsNinety percent of beneficiaries with primary AC received treatment within 90 days of their index shoulder visit. Physical therapy (PT) alone (41%) and injection combined with PT (34%) were the most common treatment approaches. Similar patient profiles emerged across treatment groups, with higher proportions of racial minorities, socioeconomically disadvantaged and more frail patients favoring injections or watchful waiting. Black beneficiaries (OR = 0.37, [0.16, 0.86]) and those residing in the northeast (OR = 0.36, [0.18, 0.69]) had significantly lower odds of receiving surgery in the treatment period. Conversely, younger beneficiaries aged 66–69 years (OR = 6.75, [2.12, 21.52]) and 70–75 years (OR = 5.37, [1.67, 17.17]) and beneficiaries with type 2 diabetes had significantly higher odds of receiving surgery (OR = 1.41, [1.03, 1.92]).ConclusionsFactors such as patient baseline health and socioeconomic characteristics appear to be important for physicians and Medicare beneficiaries making treatment decisions for primary AC.

MP26-02 PREVALENCE OF 24-HOUR URINE ABNORMALITIES AMONG OLDER ADULTS WITH URINARY STONE DISEASE

You have accessJournal of UrologyCME1 May 2022MP26-02 PREVALENCE OF 24-HOUR URINE ABNORMALITIES AMONG OLDER ADULTS WITH URINARY STONE DISEASE Ryan Hsi, Mary Oerline, Joseph Crivelli, Vahakn Shahinian, and John Hollingsworth Ryan HsiRyan Hsi More articles by this author , Mary OerlineMary Oerline More articles by this author , Joseph CrivelliJoseph Crivelli More articles by this author , Vahakn ShahinianVahakn Shahinian More articles by this author , and John HollingsworthJohn Hollingsworth More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002569.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While urinary stone disease (USD) is traditionally considered a condition affecting working age adults, its prevalence among the older population is increasing. Given physiologic and lifestyle differences between these two populations, there is reason to believe that the frequency of urine chemistry abnormalities may also differ in older adults. In this context, we characterized 24-hour urine findings in a large convenience sample of Medicare beneficiaries. METHODS: For our study, we analyzed urine chemistry data from Medicare beneficiaries 65 years of age and older with a diagnosis of USD, who had a 24-hour urine specimen processed by a large central laboratory in the U.S. between 2010 to 2019. For beneficiaries with multiple submitted specimens, we extracted analyte values from their first collection. Using laboratory reference ranges, we then determined whether a given beneficiary had evidence of hypercalciuria, hyperoxaluria, hypocitraturia, hyperuricosuria, or abnormal urine pH. Finally, we examined the frequency of multiple abnormalities (2, 3, and 4 or more) on a single collection. RESULTS: A total of 196,297 beneficiaries underwent 24-hour urine testing for USD. The tests increased from 24,744 in 2010 to 50,936 in 2019 (Figure 1). The sample adequacy, as determined by urine creatinine per body weight, was normally distributed (mean ± SD, 15.0 ± 4.5 mg/kg). Low urine volume was the most common abnormality (urine output less than 2 L/day in 61.9%), followed by hypocitraturia (43.8%), hyperoxaluria (34.2%), hypercalciuria (25%), and hyperuricosuria (17.3%). Twenty-five percent and 31.4% of beneficiaries had high and low urine pH, respectively. High urine sodium was observed in 17.3%. The percentages of beneficiaries with 2, 3, and 4 or more concurrent abnormalities were 33.9%, 35.2%, and 15.8%, respectively. CONCLUSIONS: Older adults with USD frequently have urine chemistry abnormalities, and often more than one abnormality is present. These data suggest that 24-hour urine testing in this population can help providers select interventions to help reduce future stone risk. Source of Funding: NIDDK R01DK121709 © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e438 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ryan Hsi More articles by this author Mary Oerline More articles by this author Joseph Crivelli More articles by this author Vahakn Shahinian More articles by this author John Hollingsworth More articles by this author Expand All Advertisement PDF DownloadLoading ...

Practice Billing for Medicare Advance Care Planning Across the USA.

Medicare introduced billing codes in 2016 to encourage clinicians to engage in advance care planning (ACP) and promote goal-concordantend-of-life care, but uptake has been modest. While prior research examined individual-level factors in ACP billing, organization-level factors associated with physician practices billing for ACP remain unknown. Examine the role of practices in ACP billing. Retrospective cohort study analyzing 2016-2018 national Medicare data. A total of 53,926 practices with at least 10 attributed Medicare beneficiaries. Outcomes were practice-level ACP billing (any use by the practice) and ACP use rate by practice-attributed beneficiaries. Practice characteristics were number of beneficiaries attributed to the practice; percentage of beneficiaries by race, Medicare-Medicaid dual enrollment, sex, and age; practice size; and specialty mix. Fifteen percent of practices billed for ACP. In adjusted models, we found higher odds of ACP billing and higher ACP use rates among practices with more primary care physicians (billing AOR: 10.01, 95%CI: 8.81-11.38 for practices with 75-100% (vs 0) primary care physicians), and those serving more Medicare beneficiaries (billing AOR: 4.55, 95%CI 4.08-5.08 for practices with highest (vs lowest) quintile of beneficiaries), and larger shares of female beneficiaries (billing AOR: 3.06, 95% CI 2.01-4.67 for 75-100% (vs <25%) female ). Several years after Medicare introduced ACP reimbursements for physicians, relatively few practices bill for ACP. ACP billing was more likely in large practices with a greater percentage of primary care physicians. To increase ACP billing uptake, policymakers and health system leaders might target interventions to larger practices where a small number of physicians already bill for ACP and to specialty practices that serve as the primary source of care for seriously ill patients.

Making Medicare Complicated: The Consequences of Privatization

Starting with policy changes in the 1980s, Medicare has largely become privatized, with nearly 40 percent of beneficiaries enrolled in private Medicare Advantage plans and another 30 percent with private supplemental coverage, including for prescription drug coverage. As a result, Medicare has become laden with administrative burdens and barriers. Beneficiaries are faced with a confusing array of plans and coverage options when they enroll, and are expected to choose a new plan every year. The choice they make has large implications for their health care costs, as well as their actual access to health care. While we typically think that targeted policies are burdensome and social insurance programs are accessible, Medicare contradicts this easy categorization. Instead, it demonstrates how private sector involvement in public programs can increase complexity and increase burdens for beneficiaries.

Evaluation of a pharmacist-driven medication adherence enhancement service

BACKGROUND: There are limited data that evaluate how pharmacists who are integrated within primary care clinics influence proportion of days covered (PDC) and Part D star ratings for the 3 adherence measures: diabetes, hypertension (renin-angiotensin-system antagonists), and cholesterol (statin) medications. OBJECTIVE: To assess the difference in percentage of beneficiaries with a prescription with a PDC of 80% or higher in the adherence prioritization group versus control group. METHODS: A retrospective cohort study was conducted that collected data from 2019 monthly and end-of-year files provided by Humana Medicare Advantage (MA) Part D for patients attributed to a Banner Medical Group (BMG) primary care provider who filled at least 1 prescription for a medication included in any of the medication adherence classes. The Banner Pharmacy Services population health team prioritized beneficiaries and provided worklists to pharmacists embedded in the BMG primary care clinics in Colorado. The pharmacists performed telephonic outreach, which included patient education, along with leveraging of pharmacist-provider collaborative practice agreements to address barriers, facilitate refills, and convert prescriptions to 90-day supply and mail order. Outreach status was tracked. Colorado patients reached at least once during the study time frame served as the adherence prioritization group, while Arizona patients were propensity score matched and served as the control group. We evaluated the effects of contact with the pharmacist on adherence between the adherence prioritization and control groups with PDC as a binary variable (≥ 80% vs. not) and a continuous variable (0%-100%). Analysis with PDC as a binary variable was also completed for the entire Humana MA Part D cohort. RESULTS: A total of 881 unique patients with prescriptions that fell into one of the medication adherence classes were included in the analysis-294 in the adherence prioritization group and 587 in the control group. Baseline demographics were well balanced between groups. Across the 3 medication classes, the adherence prioritization group had a higher percentage of patients with PDC of 80% or higher (71.0%) versus the matched control group (62.3%), a difference of 8.6% (95% CI = 3.47-13.82, P < 0.001). End-of-year data for the adherence prioritization population shows the percentage of patients who passed the medication adherence measure for diabetes, hypertension, and cholesterol was 88%, 89%, and 89%, respectively, while in the control population passing rates were 85%, 88%, and 87%, respectively. CONCLUSIONS: Pharmacist-driven interventions can have a meaningful effect on PDC for medication adherence and can ultimately affect star rating measures. Since 2019 data are used for 2021 star rating measures, even small numerical differences as seen in this study may account for the difference between a 4- or 5-star rating. Moving the needle in the right direction can be significant, since the cut point is yet to be determined. DISCLOSURES: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Rinehart, Rice, and Collins are employed by Banner Health but received no specific financial incentives or otherwise related to this research and manuscript. Glover is employed by Pfizer, which had no role in this study. The authors have no other relevant declarations of interest to disclose. This study was presented as a platform presentation at the Southwestern States Residency Conference, June 2020, Phoenix, AZ.

Housing Affordability In Nigeria: A Comparative Analysis Of Beneficiaries And Non-Beneficiaries Of Organized Private Sector Housing

Housing delivery in Nigeria has been dominated by the On-Site-Builders, each building incrementally as private individual for his household. The need to take advantage of economy of scale in housing delivery to enhance affordability led to the emergence of Organized Private Sector Housing Delivery in Nigeria. Despite this initiative, the majority of the people are not accessing housing from the Organized Private Sector Housing Developers, still employing their incremental housing approach. This study is therefore a comparative analysis of housing affordability of beneficiaries and non-beneficiaries of Organized Private Sector Housing Delivery in Nigeria. A cross-sectional survey design was adopted. The respondents, beneficiaries and non-beneficiaries, were selected by systematic random sampling technique. Ten percent of beneficiaries’ household heads were selected from the occupied houses (19500) in the estates. The respondents among the non-beneficiaries were selected among the occupied housing units within 1km radius of the houses around each of the sampled estates until equal numbers of respondents from beneficiaries was selected, where possible. Thus, there were 1,950 and 1,332 number of respondents among beneficiaries and no-beneficiaries respectively. The structured questionnaire administered on the heads of households’ elicited information on demographic characteristics (age, sex, household size, etc) and housing affordability variables such as (household income, housing expenditure, access to mortgage, other non-housing expenditure, etc). The questionnaire administered on Organized Private Sector Housing Developers (OPSHDs) seeks information on types of houses produced, selling prices, sales terms, among others. We rely on affordability rating scale of: normal ≤30%; tolerable 30.1-50% and stressed ≥50% to measure and compare housing affordability of beneficiaries and non-beneficiaries. They study revealed that while about 42% of beneficiaries fall within normal housing affordability, about 76% of non-beneficiaries are in that category. About 37% of beneficiaries are in tolerable housing affordability category while only about 16% of non-beneficiaries are there. Those under varying degrees of housing affordability stress are about 21% and 8% among beneficiaries and non-beneficiaries respectively. The major policy implication of the findings is that direct support to non-beneficiaries – the On-Site-Builders by government, through serviced plots and mortgage facility may be a more veritable approach for resolving the current housing crisis in the country.

The association between the supply of select nonpharmacologic providers for pain and use of nonpharmacologic pain management services and initial opioid prescribing patterns for Medicare beneficiaries with persistent musculoskeletal pain.

To test the relationship between the supply of select nonpharmacologic providers (physical therapy (PT) and mental health (MH)) and use of nonpharmacologic services among older adults with a persistent musculoskeletal pain (MSP) episode. Claims data from a 5 percent random sample of Medicare beneficiaries enrolled fee-for-service (2007-2014) and the Area Health Resource File (AHRF). This retrospective study used generalized estimating equations to estimate the association between the county nonpharmacologic provider supply and individual service use with opioid prescriptions filled during Phase 1 (first three months of an episode) and Phase 2 (three months following Phase 1). We identified beneficiaries (>65years) with ≥2 MSP diagnoses ≥90days apart and no opioid prescription six months before the first pain diagnosis (N=69456). Beneficiaries' county characteristics were assigned using the AHRF. About 13.9 percent of beneficiaries used PT, 1.8 percent used MH services, and 10.7 percent had an opioid prescription during the first three months of a persistent MSP episode. An additional MH provider/10000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT/10000 people/county [aOR: 0.98, 95% CI: 0.97-1.00] was associated with lower odds of filling an opioid prescription in Phase 1. An additional MH provider/10000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT use in Phase 1 [aOR: 0.62, 95% CI: 0.58-0.67] were associated with lower odds of filling an opioid prescription in Phase 2. The associations between the supply of providers and nonpharmacologic service use in Phase 1 and Phase 1 opioid prescriptions significantly differed by metropolitan and rural counties (P-value: .019). Limited access to nonpharmacologic services is associated with opioid prescriptions at the onset of a persistent MSP episode. Initiating PT at the onset of an episode may reduce future opioid use. Strategies for engaging beneficiaries in nonpharmacologic services should be tailored for metropolitan and rural counties.

A Qualitative Comparative Analysis of the Drivers of HIV Status Knowledge in Orphans and Vulnerable Children in Mozambique.

In Mozambique, more than a million children are living with HIV or are otherwise vulnerable due to HIV. In response to this crisis, the US President's Emergency Plan for AIDS Relief funds programs that serve orphans and vulnerable children affected by HIV and their families. These programs retain case workers, known as activistas, who provide and refer beneficiaries to services to increase beneficiaries' knowledge of their HIV status and to improve retention in care among those living with HIV. To improve program effectiveness, implementing organizations need to understand how different case management attributes affect beneficiary outcomes. We applied fuzzy-set qualitative comparative analysis (QCA), based on 119 interviews, to identify the combinations of case management attributes that led to (1) increased knowledge of HIV status, and (2) high percentages of beneficiaries with known HIV status. We identified 6 pathways for the first outcome and 5 pathways for the second outcome. Each pathway demonstrates an alternative combination of conditions that positively influences the outcome and is equally sufficient in achieving the outcome. To improve knowledge of HIV status, programs in a similar context as this study may select any of the identified pathways based on their existing resources and work on ensuring the presence of each of the conditions in the pathway. Overall, based on the presence of some of the factors in multiple pathways, we conclude that to improve knowledge of HIV status it is important that programs implement a formal process to assign cases considering case complexity and existing caseload to reduce overwork; provide activistas with external support such as weekly care team meetings, weekly supervisor meetings, and/or low supervision ratios; hire experienced activistas; provide all activistas with follow-up trainings so they have the tools to address challenging cases; expand the financial resources offered to activistas; and reimburse activistas for work-related expenses.

Regional Variation in Billed Advance Care Planning Visits.

Advance care planning (ACP) is associated with improved patient and caregiver outcomes, but is underutilized. To encourage ACP, the Centers for Medicare & Medicaid Services implemented specific ACP visit reimbursement codes in 2016. To better understand the utilization of these ACP reimbursement codes, we explored regional variation in billed ACP visits. We performed a retrospective cross-sectional analysis using a randomly sampled 5% cohort of Medicare fee-for-service (FFS) beneficiaries' claims files from 2017. Region was defined by hospital referral region. National Medicare FFS. A total of 1.3 million Medicare beneficiaries aged 65 years and older. Receipt of billed ACP service, identified through Current Procedural Terminology code 99497 or 99498. Proportion of beneficiaries who received billed ACP service(s) by region was calculated. We fit a multilevel logistic regression model with a random regional intercept to determine the variation in billed ACP visits attributable to the region after accounting for patient (demographics, comorbidities, and medical care utilization) and regional factors (hospital size, emergency department visits, hospice utilization, and costs). The study population included about 1.3 million beneficiaries, of which 32,137 (2.4%) had at least one billed ACP visit in 2017. There was substantial regional variation in the percentage of beneficiaries with billed ACP visits: lowest quintile region, less than 0.83%; subsequent regions, less than 1.6%, less than 2.4%, less than 3.3% to less than 8.4% in the highest quintile regions. A total of 15.4% of the variance in whether an older adult had a billed ACP visit was explained by the region. Although numerous regional factors were associated with billed ACP visits, none were strong predictors. In 2017, we found wide regional variation in the use of billed ACP visits, although use overall was low in all regions. Increasing the understanding of the drivers and the effects of billed ACP visits could inform strategies for increasing ACP.

1131 Obstructive Sleep Apnea Treatment and Dementia Risk in Older Adults

Abstract Introduction Obstructive Sleep Apnea (OSA) has been linked to dementia and Alzheimer’s Disease (AD), as well as pre-dementia. The potential benefits of OSA treatment on cognitive performance are inconclusive. Further, the impact of OSA treatment on the development of neurodegenerative disorders has not been sufficiently studied. This study examined associations between Positive Airway Pressure (PAP) therapy and incident diagnosis of pre-dementia (MCI), dementia (DNOS), or AD in a population-level sample of older adults. Methods Using a random 5% sample from Medicare claims data (persons age 65 and older), individuals with an ICD-9 diagnosis code for OSA prior to 2011 (n=53,321) were selected for analyses. Over the survey period (2011-2013), we further identified persons newly diagnosed with MCI (n=443), DNOS (n=378), or AD (n=1,057). We also identified individual HCPCS claims for PAP equipment as evidence of prescription, and repeated HCPCS claims for supplies as evidence of adherence to PAP treatment. Logistic regression models were used to adjust for potential confounders including age, gender, hypertension, and Parkinson’s Disease that might increase risk for dementia. Results Seventy-eight percent of beneficiaries with OSA were prescribed PAP, and 74% showed evidence of adherent use. After adjustment for potential confounders, prescription of PAP was associated with significantly lower odds of incident AD and DNOS (OR=0.78, 95% CI: 0.69, 0.89; and OR=0.69, 95% CI: 0.55, 0.85). Lower odds of MCI, approaching statistical significance, were also observed among beneficiaries who were prescribed PAP (OR=0.82, (95% CI: 0.66, 1.02). Evidence of adherence to PAP was significantly associated with lower odds of incident AD (OR=0.65, 95% CI: 0.56, 0.76). Conclusion Among older individuals with OSA, PAP prescription and adherence are each associated with a significantly lower risk of incident AD or DNOS, though not MCI. Although a prospective cohort design cannot prove causality, results suggest that treatment of OSA could reduce risk of subsequent dementia. Support This study was supported by The American Academy of Sleep Medicine Foundation Strategic Research Award 115-SR-15 (PI Braley).

Did the Medicaid Expansion Harm the Medicare Population?

While a large and growing literature has examined the effects of the Affordable Care Act (ACA) Medicaid expansion on newly eligible Medicaid recipients, relatively few studies have explored the impact of the expansion on the Medicare population. This study uses data on Medicare fee-for-service utilization and quality from 2007-2017 in conjunction with difference-in-difference models with a variety of inter-temporal controls and county fixed effects. It finds strong evidence of negative spillovers on the Medicare population. Beneficiaries in expansion states experienced reductions in their utilization of physician services (Evaluation and Management (E & M), procedures, and testing), increases in their use of hospital services (emergency room visits, outpatient visits, and inpatient care). Further, the quality of their care declined with reductions in the percentage of beneficiaries who had at least one primary care visit during the year, as well as reductions in the percentage of diabetic Medicare beneficiaries who had a recommended eye exam or LDL-C cholesterol screening.

Resistance to change. The problem of high non-take up in implementing policy innovations in the Italian long-term care system

ABSTRACTThis article illustrates how the implementation of ‘interstitial’ innovation in welfare policy can be hampered by resistance to change on the part of its intended beneficiaries by means of a case study of a policy innovation in long-term care in Italy: the Home Care Premium (HCP) programme. In a policy area characterised by long-standing institutional inertia, HCP represents an innovative programme which provides a generous, conditional cash-for-care benefit to encourage the regular employment of in-house care assistants. However, the implementation of the scheme was hampered by high non-take up (NTU) rates, i.e. the percentage of beneficiaries who did not claim the cash-for-care benefit for which they were eligible.The article uses a ‘mixed method’ approach to show how high NTU rates can be explained by individually ‘situated’ decisions taken by the intended beneficiaries based on cost-benefit evaluations that are deeply rooted in social attitudes and adaptive practices shaped by the existing institutional context. The study also shows how the policy design of the programme partially failed to manage the institutional complementarity of different welfare programs effectively, thus weakening the capacity of this ‘interstitial’ policy to bring about policy innovation. The results of the case study may therefore be of interest to scholars interested in policy change and the role played by beneficiaries in policy implementation.Abbreviations: non-take up (NTU); long-term care (LTC)

Differences in hospitalizations, emergency room admissions, and outpatient visits among Mexican-American Medicare beneficiaries

BackgroundFew studies have investigated the healthcare utilization of Mexican-American Medicare beneficiaries. We used survey data that has been linked with Medicare claims records to describe the healthcare utilization of Mexican-American Medicare beneficiaries, determine common reasons for hospitalizations, and identify characteristics associated with healthcare utilization.MethodsData came from wave five (2004/05) of the Hispanic Established Populations for the Epidemiological Study of the Elderly. The final sample included 1187 participants aged ≥75 who were followed for two-years (eight-quarters). Generalized estimating equations were used to estimate the probability of ≥1 hospitalization, emergency room (ER) admissions, and outpatient visits.ResultsThe percentage of beneficiaries who had ≥1 hospitalizations, ER admissions, and outpatient visits for each quarter ranged from 10.12–12.59%, 14.15–19.03%, and 76.61–80.68%, respectively. Twenty-three percent of hospital discharges were for circulatory conditions and 17% were for respiratory conditions. Hospitalizations for heart failure and simple pneumonia were most common. Older age was associated with significantly higher odds for ER admissions (OR = 1.49, 95% CI = 1.21–1.84) but lower odds for outpatient visits (OR = 0.74, 95% CI = 0.57–0.96). Spanish language and female gender were associated with significantly higher odds for hospitalizations (OR = 1.53, 95% CI = 1.14–2.06) and outpatient visits (OR = 1.82, 95% CI = 1.43–2.33), respectively. Having a middle-school or higher level of education was associated with significantly lower odds for ER admissions (OR = 0.71, 95% CI = 0.56–0.91). Participants who were deceased within two-years had significantly higher odds for hospitalizations (OR = 6.15, 95% CI = 4.79–7.89) and ER admissions (OR = 3.63, 95% CI = 2.88–4.57) than participants who survived at least three-years.ConclusionWe observed high healthcare utilization among Mexican-American Medicare beneficiaries. Forty percent of all hospitalizations were for circulatory and respiratory conditions with hospitalizations for heart failure and pneumonia being the most common. Older age, gender, education, language, and mortality were all associated with healthcare utilization. Continued research is needed to identify patterns and clusters of social determinants and health characteristics associated with healthcare utilization and outcomes in older Mexican-Americans.

Abstract WMP91: Worse Outcomes After Ischemic Stroke for Dual-Eligible Medicare-Medicaid Beneficiaries

Background: Medicaid serves as a safety net for low-income Medicare beneficiaries with limited assets. Over 6.7 million Americans aged ≥65y rely on a combination of Medicare and Medicaid to obtain critical medical services, yet little is known about geographic patterns of dual-eligible status and whether dual eligibles have worse post-ischemic stroke outcomes than those with Medicare alone. Methods: We identified fee-for-service Medicare beneficiaries aged ≥65y with a primary discharge diagnosis of ischemic stroke in 2014. Those with ≥1m of Medicaid coverage were considered dual eligible. We fit spatial mixed models with county-specific random intercepts and adjustment for demographics to calculate and map the risk-standardized percentage of beneficiaries with dual eligibility and stroke hospitalization rates. Mixed models and Cox regression were used to evaluate the relationship between dual-eligible status and outcomes up to 1y, adjusting for demographic and clinical factors. Results: At the national level, 12.5% of beneficiaries were dual eligible. The highest rates of dual eligibility were in Maine, Alaska, and the southern half of the US (Figure), whereas the highest rates of stroke hospitalization were concentrated in the central divisions of the South and parts of the Midwest (Pearson’s r=0.469, p&lt;0.001). Among those hospitalized for stroke, 17.5% were dual eligible (n=44,476 dual eligible: mean age 78.3y, 64% female, 36% nonwhite; n=219,426 Medicare only: mean age 78.9y, 51% female, 12% nonwhite). Dual eligibles had greater risk of readmission within 30d and were more likely to die within 6m and 1y when compared with Medicare-only beneficiaries; there was no difference for in-hospital or 30d mortality. Conclusions: Dual-eligible stroke patients had higher short-term readmissions and long-term mortality than other patients, even after comorbidity adjustment. A better understanding of the factors contributing to these poorer outcomes is needed.