Traditional Medicare Beneficiaries Research Articles

Evaluation of Low-Value Services Across Major Medicare Advantage Insurers and Traditional Medicare

Compared with traditional Medicare (TM), Medicare Advantage (MA) insurers have greater financial incentives to reduce the delivery of low-value services (LVS); however, there is limited evidence at a national level on the prevalence of LVS utilization among MA vs TM beneficiaries and whether LVS utilization rates vary among the largest MA insurers. To determine whether there are differences in the rates of LVS delivered to Medicare beneficiaries enrolled in MA vs TM, overall and by the 7 largest MA insurers. This cross-sectional study included Medicare beneficiaries aged 65 years and older residing in the US in 2018 with complete demographic information. Eligible TM beneficiaries were enrolled in Parts A, B, and D, and eligible MA beneficiaries were enrolled in Part C with Part D coverage. Data analysis was conducted between February 2022 and August 2024. Medicare plan type. The primary outcome was utlization of 35 LVS defined by the Milliman Health Waste Calculator. An overdispersed Poisson regression model was used to calculate estimated margins comparing risk-adjusted rates of LVS in TM vs MA, overall and across the 7 largest MA insurers. The study sample included 3 671 364 unique TM beneficiaries (mean [SD] age, 75.7 [7.7] years; 1 502 631 female [40.9%]) and 2 299 618 unique MA beneficiaries (mean [SD] age, 75.3 [7.3] years; 983 592 female [42.8%]). LVS utilization was lower among those enrolled in MA compared with TM (50.02 vs 52.48 services per 100 beneficiary-years; adjusted absolute difference, -2.46 services per 100 beneficiary-years; 95% CI, -3.16 to -1.75 services per 100 beneficiary-years; P < .001). Within MA, LVS utilization was lower among beneficiaries enrolled in HMOs vs PPOs (48.03 vs 52.66 services per 100 beneficiary-years; adjusted absolute difference, -4.63 services per 100 beneficiary-years; 95% CI, -5.53 to -3.74 services per 100 beneficiary-years; P < .001). While MA beneficiaries enrolled in UnitedHealth, Humana, Centene, and smaller MA insurers had lower rates of LVS compared with those in TM, beneficiaries enrolled in CVS, Cigna, and Anthem showed no differences. Blue Cross Blue Shield Association plans had higher rates of LVS compared with TM. In this cross-sectional study of nearly 6 million Medicare beneficiaries, utilization of LVS was on average lower among MA beneficiaries compared with TM beneficiaries, possibly owing to stronger financial incentives in MA to reduce LVS; however, meaningful differences existed across some of the largest MA insurers, suggesting that MA insurers may have variable ability to influence LVS reduction.

Impact of skilled nursing facility quality on Medicare beneficiaries with dementia: Evidence from vacancies.

People living with dementia are less likely to be admitted to high-rated nursing homes than people without dementia, despite their increased care needs. We investigated the effect of admission to nursing homes with higher staffing ratings on adverse outcomes for individuals with and without dementia post-hospitalization. Among Traditional Medicare beneficiaries discharged to nursing homes between 2011 and 2017, we examined the relationship between facility staffing star-ratings and short-term readmission and mortality using an instrumental variables approach to account for selection bias. The instrumental variables were the number of nearby vacant beds in high-rated facilities. Admission to a higher-rated nursing home lowered post-discharge mortality risk at 90 days and reduced 30- and 90-day readmission. Point estimates were larger for people with dementia. Findings underscore the need for enhancing direct care staffing in nursing homes and addressing access disparities, particularly for individuals with dementia who benefit significantly from high-quality care. We assessed how admission to nursing homes with higher staffing ratings impacted outcomes for individuals with and without dementia by exploiting variation in local bed vacancies as a source of quasi-random assignment. For both persons with and without dementia, adjusted short-term mortality and readmission rates were lower among those discharged to nursing homes with higher staffing ratings. Effects were larger for persons with dementia, indicating welfare loss from inequitable access to higher-rated nursing homes. Increasing staffing in nursing homes and reducing disparities for persons with dementia is essential for enhancing both equity and value.

Racial/ethnic disparities in cost-related barriers to care among near-poor beneficiaries in Medicare Advantage vs traditional Medicare.

To compare racial and ethnic disparities in cost-related medical care and dental care barriers and use of vision care among near-poor Medicare beneficiaries in Medicare Advantage (MA) vs traditional Medicare (TM) overall and stratified by supplemental insurance enrollment. Cross-sectional analysis of 2015-2019 data from the nationally representative Medicare Current Beneficiary Survey. Propensity score-weighted difference-in-disparities analyses comparing Black-White and Hispanic-White disparities in MA vs TM among near-poor Medicare beneficiaries with incomes between 101% and 250% of the federal poverty level. We assessed differences in cost-related medical care barriers and cost-related dental care barriers as well as receipt of annual eye exams in MA vs TM. For cost-related barriers to medical care, Hispanic-White disparities were narrower by 8.8 (95% CI, -14.0 to -3.6) percentage points in MA relative to TM but differences in Black-White disparities were not statistically significant. MA was not associated with narrower differences in Hispanic-White or Black-White disparities in dental care access. Higher proportions of Black and Hispanic beneficiaries in MA received an annual eye exam vs White beneficiaries in both MA and TM. MA was associated with narrower racial disparities primarily compared with TM without supplemental insurance. Among near-poor Black and Hispanic Medicare beneficiaries, MA was associated with greater use of vision care and narrowing of some disparities in cost-related access barriers vs TM. However, MA did not uniformly narrow racial/ethnic disparities in access and use. These findings highlight the importance of maintaining and enhancing features of Medicare coverage that may promote equitable access to care, including additional benefits and lower cost sharing.

Financial burden of care greatest among rural beneficiaries in Medicare advantage.

To examine differences in access to care and financial burden between Traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries in rural and urban areas and then explore whether there were potential differences in MA benefits between urban and rural areas. We conducted a cross-sectional study within the Medicare setting in the United States. Data from three distinct sources for 2017-2021: the Medicare Current Beneficiary Survey, the MA landscape data, and the Plan Benefit Package data. Our sample comprised 43,343 Medicare beneficiary-years, including TM and MA beneficiaries in urban and rural areas. Our adjusted analysis showed that rural MA beneficiaries experienced higher rates of delayed care due to costs (10.0% [95% confidence interval (CI): 8.8-11.1]) compared with rural TM (9.5% [8.8-10.2]), urban MA (7.9% [7.4-8.4]), and urban TM (7.9% [7.5-8.2]) beneficiaries. Similarly, rural MA beneficiaries (11.4% [95% CI: 10.3-12.5]) reported more difficulty paying medical bills compared with rural TM (9.4% [8.7-10.1]), urban MA (8.1% [7.7-8.6]), and urban TM (7.8% [7.5-8.2]) beneficiaries. This disparity was associated with less generous financial structures in rural MA plans. Compared to urban MA plans, rural MA plans offered lower out-of-pocket maximums for in-network care ($5918 vs. $5439), but required higher copayments ($1686 vs. $1724 for a 5-day hospitalization, $37 vs. $41 for a specialist visit, and $35 vs. $38 for a mental health visit). However, differences in quality of care and provision of supplemental benefits were small. Rural Medicare beneficiaries reported a greater financial burden of care than urban Medicare beneficiaries, but the most significant burden was observed among MA beneficiaries in rural areas. One possible mechanism could be the less generous financial structures offered by rural MA plans. These findings suggest the need for policies addressing the affordability of care for rural MA beneficiaries.

Association of Participation in Medicare's Oncology Care Model With Spending, Utilization, and Quality Outcomes Among Commercially Insured and Medicare Advantage Members.

The Oncology Care Model (OCM), a value-based payment model for traditional Medicare beneficiaries with cancer, yielded total spending reductions that were outweighed by incentive payments, resulting in net losses to the Centers for Medicare & Medicaid Services. We studied whether the OCM yielded spillover effects in total episode spending, utilization, and quality among commercially insured and Medicare Advantage (MA) members, who were not targeted by the program. This observational study used administrative claims from a large national payer, yielding 157,189 total patients with commercial insurance or MA with solid malignancies who initiated 229,376 systemic anticancer therapy episodes before (2012-2015) and during (2016-2021) the OCM at 125 OCM-participating practices (a subset of total OCM practices) and a 1:10 propensity-matched set of 860 non-OCM practices. We used difference-in-differences analyses to assess the association between the OCM and total episode spending, defined as medical spending during a 6-month episode. Secondary outcomes included hospitalization and emergency department (ED) utilization and quality measures. From the pre-OCM to the OCM period, mean total episode payments increased from $45,504 in US dollars (USD) to $46,239 USD for OCM-participating practices, and increased from $50,519 USD to $58,591 USD for non-OCM practices (adjusted difference-in-differences -$6,287 USD [95% CI, -$10,076 USD to -$2,498 USD], P = .001). The OCM was associated with adjusted spending decreases for both high-risk (-$6,756 USD [95% CI, -$10,731 USD to -$2,781 USD], P = .001) and low-risk (-$4,171 USD [95% CI, -$7,799 USD to -$543 USD], P = .025) episodes. OCM-associated spending reductions were strongest for outpatient (-$5,243 USD [95% CI, -$8,589 USD to -$1,897 USD], P = .002) and infused/injected anticancer drug (-$3,031 USD [95% CI, -$5,193 USD to -$869 USD], P = .006) spending. There were no associations between OCM participation and changes in hospital or ED utilization nor quality of care. The OCM was associated with reductions in spending for nontargeted members, a spillover effect.

Skilled home healthcare utilization and outcomes for older adults with dementia: A scoping review.

This study aims to summarize the existing research literature examining Medicare-skilled home health (HH) utilization and clinical outcomes for persons with dementia (PwD). We sought to answer the following questions: (1) How is dementia defined and classified in the HH literature? (2) What associations have been observed between dementia status and patterns of HH utilization? (3) What associations have been observed between dementia status and HH outcomes? Using Arksey and O'Malley's framework for scoping reviews, we searched PubMed, Google Scholar, and select relevant journals for quantitative studies conducted in the United States between 2000 and 2023 examining Medicare HH use and outcomes for PwD. We describe and compare approaches to classify dementia, identify findings related to HH utilization and outcomes supported by the preponderance of evidence, and comment on existing gaps and areas of ambiguity in the literature. Thirty-two articles met the inclusion criteria. Most used claims-based data to classify dementia, leveraged national data, and were limited to traditional Medicare beneficiaries. Studies found meaningful differences in HH utilization by dementia status; most notably, PwD were more likely to access HH without a preceding hospitalization, had longer lengths of stay, and incurred higher HH costs. Literature relating to clinical outcomes was more difficult to interpret, due to significant variation in study objectives, samples, and outcome measures which prompted more nuanced and even contradictory conclusions. There is a dearth of research identifying how specific HH care pathways (e.g., service types, visit frequency) impact outcomes for this patient population. This review supports the understanding that PwD are a unique subpopulation of HH patients who require special attention in policy development and evaluation. Critical research is needed to examine clinical outcomes in PwD further to inform practice and improve care quality.

Trends in Post-Acute Care use in Medicare Advantage Versus Traditional Medicare: A Retrospective Cohort Analysis

ObjectivesWe sought to describe national trends in hospitalization and post-acute care utilization rates in skilled nursing facilities (SNFs) and home health (HH) for both Medicare Advantage (MA) and Traditional Medicare (TM) beneficiaries, reaching up to the COVID-19 pandemic (2015–2019). DesignRetrospective, observational using 100% sample of Medicare Provider Analysis and Review file (MedPAR), the Medicare Beneficiary Summary File, the Minimum Data Set (MDS), and the Outcome and Assessment Information Set (OASIS). Setting and ParticipantsMedicare beneficiaries aged 66 and older enrolled in MA or TM who were hospitalized and discharged alive. MethodsWe first calculated the proportions of MA and TM beneficiaries who were hospitalized and who used any post-acute care, as well as the total number of days of post-acute care used. We also calculated the size of the post-acute care network used by TM and MA beneficiaries within each hospital in our sample and the measured quality (star ratings) of the post-acute care providers used. ResultsWe found hospitalizations, SNF stays, and HH stays were all decreasing over time in both populations. Although similar proportions of MA and TM beneficiaries received SNF or HH care, MA beneficiaries received fewer days. The largest difference we found was in the number of post-acute care providers used in TM and MA, with MA using far fewer; however, quality ratings were similar among post-acute care providers used in each program. Conclusions and ImplicationsTogether, these results suggest MA beneficiaries have fewer days in post-acute care, receive care from fewer providers of similar measured quality to TM, but have a similar number of days outside the hospital or SNF in the first 100 days after hospital discharge.

Employer-Sponsored Medicare Advantage Plans and the 2018 Therapy Cap Repeal: Reduced Overall Spending Does Not Constrain Out-of-Pocket Costs.

Policy impacting traditional Medicare beneficiaries may have unintended effects for privately insured patients. After the repeal of a longstanding $1500 outpatient therapy cap in 2018, we aimed to evaluate if this policy change was associated with differences in use of cost of postoperative therapy after common hand surgeries, including carpal tunnel release, trigger finger release, ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, and distal radius fracture open reduction/internal fixation or percutaneous pinning. The Medicare Supplement and Coordination of Benefits files from Marketscan were used. Frequency of therapy appointments, overall costs, and out-of-pocket costs were obtained. A segmented interrupted time series with Poisson and log-transformed linear regression was performed. No significant monthly change in odds of therapy use was found in the postpolicy period for patients who underwent trigger finger release, carpal tunnel release, Ganglion cyst excision, De Quervain tenosynovitis release, carpometacarpal arthroplasty, or distal radius fracture, pinning, or open reduction/internal fixation. Overall cost decreased in the postpolicy period by 2% for comprehensive plans (95% confidence interval [CI]: -0.03 to -0.01, P < 0.001), by 7% for those with exclusive provider organizations (95% CI: -0.10 to -0.04, P < 0.001), by 1% for HMOs (95% CI: -0.01 to 0.002, P = 0.01), and by 3% for preferred provider organizations (95% CI: -0.03 to -0.02, P < 0.001). In the postpolicy period, no monthly change in out-of-pocket cost was observed for patients with comprehensive, exclusive provider organization, health maintenance organization, preferred provider organization, or point of service with capitation insurance plans. Patients with employer-sponsored Medicare Advantage plans experienced increased out-of-pocket costs for therapy despite lower net costs. These data highlight an urgent need for policy ensuring that patients benefit when overall costs of care decrease.

Frailty in Medicare Advantage Beneficiaries and Traditional Medicare Beneficiaries

A growing proportion of the population is enrolling in Medicare Advantage (MA), which typically offers additional benefits compared with traditional Medicare (TM). To determine whether frailty and frailty trajectories differ between MA enrollees and TM enrollees. This retrospective cohort study used data from the National Health and Aging Trends Study (2015-2016). Analyses were conducted from August 2023 to March 2024. Participants were community-dwelling Medicare beneficiaries aged 65 years and older. Enrollment in MA vs TM. Frailty was calculated by a frailty index (FI) (range, 0-1, with higher values indicating greater frailty) and the Fried Frailty Phenotype (FFP) score (range, 0-5, with higher values indicating greater frailty). Physical performance, including Short Physical Performance Battery (SPPB) score (range, 0-12, with higher values indicating better performance), and gait speed (meters per second) were measured. The primary outcome was the difference in FI and FFP scores from the 2015 baseline assessment to the 2016 follow-up assessment. Secondary outcomes include the 1-year changes in SPPB and gait speed. The final cohort consisted of 7063 participants (2775 [23.1%] aged >80 years; 4040 [54.7%] female), representing a sample of the 38.8 million beneficiaries. There were 2583 (35.0%) MA enrollees (13.6 million) and 4480 (65.0%) TM enrollees (25.2 million). At baseline, the FI score was similar between MA and TM enrollees (mean [SD], 0.22 [0.15] vs 0.21 [0.14]), although MA enrollees had worse phenotypic frailty (496 participants [15.2%] vs 811 participants [13.7%] considered frail by FFP score), SPPB scores (mean [SD], 6.91 [3.34] vs 7.21 [3.27]), and gait speed (0.79 [0.24] m/s vs 0.82 [0.23] m/s) than TM enrollees. One year later, there were no differences between MA and TM enrollees in the 1-year change in FI score (mean [SD], 0.016 [0.071] vs 0.014 [0.066]; adjusted mean difference, 0.001 [95% CI, -0.004 to 0.005]), FFP score (mean [SD], 0.017 [1.004] vs 0.007 [0.958]; adjusted mean difference, -0.009 [95% CI, -0.067 to 0.049]), SPPB score (mean [SD], -0.144 [2.064] vs -0.211 [1.968]; adjusted mean difference, 0.068 [95% CI, -0.076 to 0.212]), and gait speed (mean [SD], -0.0160 [0.148] m/s vs -0.007 [0.148] m/s; adjusted mean difference, -0.010 m/s [95% CI, -0.067 to 0.049 m/s]). In this cohort study of Medicare beneficiaries from 2015, MA enrollees experienced similar declines in frailty over 1 year compared with TM enrollees. Future work should examine whether the specific types of services covered by health insurance can impact frailty and health trajectories for older adults.

Post-Acute Transitions for Traditional Medicare Beneficiaries with Serious Mental Illness

Post-Acute Transitions for Traditional Medicare Beneficiaries with Serious Mental Illness

Prevalence of Independence at Home–Qualifying Beneficiaries in Traditional Medicare, 2014-2021

The Centers for Medicare & Medicaid Services Innovation Center Independence at Home (IAH) demonstration, a test of home-based primary care operating in a value-based shared-savings payment model, ended December 2023 after a decade of consistently showing savings to Medicare. It is important to assess whether high-need, IAH-qualified beneficiaries continue to pose a growing challenge to traditional Medicare (TM) or if Medicare Advantage (MA), with programmatic features favorable to caring for this subset of the general Medicare population, can disproportionately provide such care. To examine the size and share of IAH-qualified beneficiaries in TM and MA. This cohort study used all Medicare claims data and MA encounter data for 2014 and 2021. IAH qualifying criteria were applied to the TM populations enrolled in Parts A and B in 2014 and 2021, and to MA enrollees in 2021. Growth in the number of IAH-qualified TM beneficiaries from 2014 to 2021 was calculated, and the proportions and numbers of IAH-qualified enrollees in the total 2021 TM and MA populations were compared. Data were analyzed between April and June 2023. The number and share of beneficiaries meeting IAH criteria in TM and MA; the share of TM spending among IAH-qualified beneficiaries. Among 64 million Medicare beneficiaries in 2021, there were 30.55 million beneficiaries in TM with Parts A and B coverage, down from 33.82 million in 2014. The number of IAH-qualified beneficiaries in TM grew 51%, from 2.16 million to 3.27 million, while their proportionate share in TM grew 67% from 6.4% to 10.7% of TM between 2014 and 2021. IAH-qualified beneficiaries represented $155 billion in 2021 Medicare Parts A and B spending, 44% of all TM spending, up from 29% of total spending in 2014. In 2021, 2.15 million IAH-qualified beneficiaries represented 8.0% of Medicare Advantage enrollees. Combining TM and MA, 5.42 million IAH-qualified beneficiaries represented 9.3% of all Medicare beneficiaries, with 3.27 million (60.3%) being insured by TM. In this cohort study of IAH-qualified Medicare beneficiaries, the share of IAH-qualified beneficiaries in TM grew between 2014 and 2021, with 60% of Medicare high-need beneficiaries accounting for 44% of TM spending. The Centers for Medicare & Medicaid Services should continue to operate value-based programs like IAH that are specifically designed for these high-needs individuals.

In-Home Health Risk Assessments And Chart Reviews Contribute To Coding Intensity In Medicare Advantage.

There is widespread agreement that taxpayers pay more when Medicare beneficiaries are enrolled in Medicare Advantage (MA) plans than if those beneficiaries were enrolled in traditional Medicare. MA plans are paid on the basis of submitted diagnoses and thus have a clear incentive to encourage providers to find and report as many diagnoses for their enrollees as possible. Two mechanisms that MA plans use to identify diagnoses that are not available for beneficiaries in traditional Medicare are in-home health risk assessments and chart reviews. Using MA encounter data for 2015-20, I isolated the impact of these two types of encounters on the risk scores used for payments to MA plans during 2016-21. I found that encounter-based risk scores for MA enrollees were higher by 0.091 points, or 7.4percent, in 2021 when in-home health risk assessments and chart reviews were included than they would have been without the use of these tools.

Pay-for-Performance Incentives for Home Dialysis Use and Kidney Transplant

The Centers for Medicare & Medicaid Services' mandatory End-Stage Renal Disease Treatment Choices (ETC) model, launched on January 1, 2021, randomly assigned approximately 30% of US dialysis facilities and managing clinicians to financial incentives to increase the use of home dialysis and kidney transplant. To assess the ETC's association with use of home dialysis and kidney transplant during the model's first 2 years and examine changes in these outcomes by race, ethnicity, and socioeconomic status. This retrospective cross-sectional study used claims and enrollment data for traditional Medicare beneficiaries with kidney failure from 2017 to 2022 linked to same-period transplant data from the United Network for Organ Sharing. The study data span 4 years (2017-2020) before the implementation of the ETC model on January 1, 2021, and 2 years (2021-2022) following the model's implementation. Receiving dialysis treatment in a region randomly assigned to the ETC model. Primary outcomes were use of home dialysis and kidney transplant. A difference-in-differences (DiD) approach was used to estimate changes in outcomes among patients treated in regions randomly selected for ETC participation compared with concurrent changes among patients treated in control regions. The study population included 724 406 persons with kidney failure (mean [IQR] age, 62.2 [53-72] years; 42.5% female). The proportion of patients receiving home dialysis increased from 12.1% to 14.3% in ETC regions and from 12.9% to 15.1% in control regions, yielding an adjusted DiD estimate of -0.2 percentage points (pp; 95% CI, -0.7 to 0.3 pp). Similar analysis for transplant yielded an adjusted DiD estimate of 0.02 pp (95% CI, -0.01 to 0.04 pp). When further stratified by sociodemographic measures, including age, sex, race and ethnicity, dual Medicare and Medicaid enrollment, and poverty quartile, there was not a statistically significant difference in home dialysis use across joint strata of characteristics and ETC participation. In this cross-sectional study, the first 2 years of the ETC model were not associated with increased use of home dialysis or kidney transplant, nor changes in racial, ethnic, and socioeconomic disparities in these outcomes.

Antiretroviral Therapy Use and Disparities Among Medicare Beneficiaries with HIV.

Antiretroviral therapy (ART) is recommended for all people with HIV. Understanding ART use among Medicare beneficiaries with HIV is therefore critically important for improving quality and equity of care among the growing population of older adults with HIV. However, a comprehensive national evaluation of filled ART prescriptions among Medicare beneficiaries is lacking. To examine trends in ART use among Medicare beneficiaries with HIV from 2013 to 2019 and to evaluate whether racial and ethnic disparities in ART use are narrowing over time. Retrospective observational study. Traditional Medicare beneficiaries with Part D living with HIV in 2013-2019. Months of filled ART prescriptions each year. Compared with beneficiaries not on ART, beneficiaries on ART were younger, less likely to be Black (41.6% vs. 47.0%), and more likely to be Hispanic (13.1% vs. 9.7%). While the share of beneficiaries who filled ART prescriptions for 10 + months/year improved (+ 0.48 percentage points/year [p.p.y.], 95% CI 0.34-0.63, p < 0.001), 25.8% of beneficiaries did not fill ART for 10 + months in 2019. Between 2013 and 2019, the proportion of beneficiaries who filled ART for 10 + months improved for Black beneficiaries (65.8 to 70.3%, + 0.66 p.p.y., 95% CI 0.43-0.89, p < 0.001) and White beneficiaries (74.8 to 77.4%, + 0.38 p.p.y.; 95% CI 0.19-0.58, p < 0.001), while remaining stable for Hispanic beneficiaries (74.5 to 75.0%, + 0.12 p.p.y., 95% CI - 0.24-0.49, p = 0.51). Although Black-White disparities in ART use narrowed over time, the share of beneficiaries who filled ART prescriptions for 10 + months/year was significantly lower among Black beneficiaries relative to White beneficiaries each year. ART use improved from 2013 to 2019 among Medicare beneficiaries with HIV. However, about 25% of beneficiaries did not consistently fill ART prescriptions within a given year. Despite declining differences between Black and White beneficiaries, concerning disparities in ART use persist.

Cancer care service use intensity in Medicare Advantage versus traditional Medicare.

11054 Background: Prior studies have found evidence of lower cost of care and preserved care quality among Medicare Advantage (MA) plans vs. traditional Medicare (TM). However, MA performance for patients with serious conditions such as cancer is yet to be explored. MA plans are incentivized to reduce expenditures, and the high financial cost (often with marginal clinical benefit) of chemotherapy might be an opportunity for savings. We compared service use intensity and quality between MA and TM cancer patients receiving systemic therapy. Methods: Medicare claims data and MA encounter records (including only MA contracts that had highly complete data), 2015-2019. We included patients with select major cancer types, and measured outcomes during a 6-month chemotherapy episode, defined by the date of systemic therapy initiation after a 1-year washout period. Service use intensity was measured in dollar terms using standardized Medicare prices. Quality measures included treatment-related emergency department (ED) visits and hospitalizations, avoidable ED visits, preventable hospitalizations, and overall survival. To estimate the association between MA enrollment and these outcomes, we used regression models with county-level fixed effects and inverse probability of treatment weighting to balance the MA and TM samples on patient demographics, cancer type, health-risk score, metastatic status, frailty, and area characteristics. We performed separate analyses by cancer type. Results: The study sample comprised 96,501 MA and 206,274 TM beneficiaries who had one of seven cancer types: breast cancer, chronic leukemia, colon cancer, lung cancer, lymphoma, multiple myeloma, and prostate cancer, and who initiated systemic therapy between 2016 and 2019. Estimated mean overall service use among MA enrollees was $62,599, compared to $71,317 for TM beneficiaries (-$8,718, p&lt;0.01). A majority of the overall difference was accounted for by Part B-covered systemic therapy drugs ($20,691 in MA versus $25,723 in TM, difference -$5,032, p&lt;0.01). Although MA enrollees received slightly cheaper drugs (-$277 per treatment day, p&lt;0.01), the lower cost of systemic therapy was driven largely by a lower number of treatment days occurring per 6-month episode for MA enrollees (-1.06 days, p&lt;0.01). MA enrollees had fewer treatment-related ED visits and hospitalizations (-2.5%, p&lt;0.01 and -0.7%, p&lt;0.01 respectively) but had more avoidable ED visits (+0.5%, p&lt;0.01). There was no difference in survival or preventable hospitalizations. Results were similar within individual cancer types. Conclusions: MA enrollment is associated with reduced service utilization but not shorter survival among cancer patients receiving systemic therapy. Further research is needed into the mechanisms of these savings to identify areas where care may be delivered more cost-effectively without negatively impacting outcomes.

Utilization and Outcomes in U.S. ICU Hospitalizations.

Despite its importance, detailed national estimates of ICU utilization and outcomes remain lacking. We aimed to characterize trends in ICU utilization and outcomes over a recent 12-year period in the United States. In this longitudinal study, we examined hospitalizations involving ICU care ("ICU hospitalizations") alongside hospitalizations not involving ICU care ("non-ICU hospitalizations") among traditional Medicare beneficiaries using 100% Medicare part A claims data and commercial claims data for the under 65 adult population from 2008 to 2019. There were 18,313,637 ICU hospitalizations and 78,501,532 non-ICU hospitalizations in Medicare, and 1,989,222 ICU hospitalizations and 16,732,960 non-ICU hospitalizations in the commercially insured population. From 2008 to 2019, about 20% of Medicare hospitalizations and 10% of commercial hospitalizations involved ICU care. Among these ICU hospitalizations, length of stay and ICU length of stay decreased on average. Mortality and hospital readmissions on average also decreased, and they decreased more among ICU hospitalizations than among non-ICU hospitalizations, for both Medicare and commercially insured patients. Both Medicare and commercial populations experienced a growth in shorter ICU hospitalizations (between 2 and 7 d in length), which were characterized by shorter ICU stays and lower mortality. Among these short hospitalizations in the Medicare population, for common clinical diagnoses cared for in both ICU and non-ICU settings, patients were increasingly triaged into an ICU during the study period, despite being younger and having shorter hospital stays. ICUs are used in a sizeable share of hospitalizations. From 2008 to 2019, ICU length of stay and mortality have declined, while short ICU hospitalizations have increased. In particular, for clinical conditions often managed both within and outside of an ICU, shorter ICU hospitalizations involving younger patients have increased. Our findings motivate opportunities to better understand ICU utilization and to improve the value of ICU care for patients and payers.

Audio-Only Telehealth Use Among Traditional Medicare Beneficiaries

This cross-sectional study analyzes how use of audio-only telehealth services by Medicare beneficiaries changed from 2020 to 2022 and assesses which patients would be most affected by policy reforms.

High-need beneficiary enrollment patterns in Medicare Advantage and traditional Medicare.

High-need Medicare beneficiaries require elevated levels of care and coordination to manage their conditions. We evaluated the extent to which high-need beneficiaries enrolled in Medicare Advantage (MA) or traditional Medicare (TM) accountable care organizations (ACOs) relative to TM non-ACOs. Using Medicare claims and MA encounter data, we identified 3 groups of high-need beneficiaries: (1) individuals younger than 65 years with a disability or end-stage kidney disease, (2) frail individuals, and (3) older individuals with major complex or multiple noncomplex chronic conditions. For comparison, we included non-high-need beneficiaries in the analysis, including those with minor complex chronic conditions. Descriptive analysis of Medicare enrollment patterns and beneficiary characteristics of high-need and other beneficiaries between 2016 and 2019. In 2019, high-need beneficiaries accounted for 18 million or 32% of enrollees in TM and MA, an increase of approximately 1 million since 2016, driven by growth in MA. A larger share of beneficiaries in TM ACOs was high need (38%) compared with MA (24%). Although the totalcount of high-need beneficiaries in TM remained stable from 2016 to 2019, ACOs saw an increase of almost 1.5 million high-need beneficiaries (39% increase), and TM non-ACOs saw a decrease of 1.9 million (23% decrease). We found that high-need beneficiaries were more likely to be in TM non-ACOs than in MA through 2019. However, an increasing number of these beneficiaries are enrolling in MA or aligned with a TM ACO. A projected increase in the population of older adults will increase the economic burden of caring for high-need individuals.

Where Are All the Specialists? Current Challenges of Integrating Specialty Care Into Population-Based Total Cost of Care Payment Models.

The Centers for Medicare & Medicaid Services Innovation Center (CMMI) has set the goal for 100% of traditional Medicare beneficiaries to be part of an accountable care relationship by 2030. Lack of meaningful financial incentives, intolerable or unpredictable risk, infrastructure costs, patient engagement, voluntary participation, and operational complexity have been noted by the provider and health care delivery community as barriers to participation or reasons for exiting programs. In addition, most piloted and implemented population-based total cost of care (PB-TCOC) payment models have focused on the role of the primary care physician being the accountability (that is, attributable) leader of a patient's multifaceted care team as well as acting as the mayor of the "medical neighborhood," leaving the role of specialty care physicians undefined. Successful provider specialist integration into PB-TCOC models includes meaningful participation of specialists in achieving whole-person, high-value care where all providers are financially motivated to participate; there is unambiguous prospective attribution and clearly defined accountability for each participating party throughout the care journey or episode; there is a known care attribution transition accountability plan; there is actionable, transparent, and timely data available with appropriate data development and basic analytic costs covered; and there is advanced payment to the accountable person or entity for management of the care episode that is part of a longitudinal care plan. Payment models should be created to address the 7 challenges raised here if specialists are to be incented to join TCOC models that achieve CMMI's goal.

Primary care visit cadence and hospital admissions in high-risk patients.

Most Medicare beneficiaries obtain supplemental insurance or enroll in Medicare Advantage (MA) to protect against potentially high cost sharing in traditional Medicare (TM). We examined changes in Medicare supplemental insurance coverage in the context of MA growth. Repeated cross-sectional analysis of the Medicare Current Beneficiary Survey from 2005 to 2019. We determined whether Medicare beneficiaries 65 years and older were enrolled in MA (without Medicaid), TM without supplemental coverage, TM with employer-sponsored supplemental coverage, TM with Medigap, orMedicaid (in TM or MA). From 2005 to 2019, beneficiaries with TM and supplemental insurance provided by their former (or current) employer declined by approximately half (31.8% to 15.5%) while the share in MA (without Medicaid) more than doubled (13.4% to 35.1%). The decline in supplemental employer-sponsored insurance use was greater for White and for higher-income beneficiaries. Over the same period, beneficiaries in TM without supplemental coverage declined by more than a quarter (13.9% to 10.1%). This decline was largest for Black, Hispanic, and lower-income beneficiaries. The rapid rise in MA enrollment from 2005 to 2019 was accompanied by substantial changes in supplemental insurance with TM. Our results emphasize the interconnectedness of different insurance choices made by Medicare beneficiaries.