Urban Medicare Beneficiaries Research Articles

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.

Federal telehealth policy changes during the COVID-19 public health emergency: Associations with telemental health use among rural and urban Medicare beneficiaries.

The COVID-19 public health emergency (PHE) led to increased mental health (MH) concerns among Medicare beneficiaries while inhibiting their access to MH services (MHS). To help address these problems, the federal government introduced temporary flexibilities permitting broader telehealth use in Medicare. This study compared rural versus urban patterns of change in telemental health (TMH) use among adult MHS users in fee-for-service Medicare from 2019 to 2020, when PHE-related telehealth expansions were enacted. In this cross-sectional investigation based on 2019-2020 Medicare claims data, we used chi-square tests, t-tests and adjusted logistic regression to explore how year (pre-PHE vs. PHE), rurality, and beneficiary characteristics were related to TMH use. From 2019 to 2020, the proportion of MHS users who used TMH rose from 4.8% to 51.9% among rural residents (p<0.0001) and from 1.1% to 61.3% (p<0.0001) among urban residents. Across study years, adjusted odds of TMH use grew more than 18-fold for rural MHS users (OR=18.10, p<0.001) and nearly 120-fold for their urban counterparts (OR=119.75, p<0.001). Among rural MHS users in 2020, adjusted odds of TMH use diminished with increasing age. TMH mitigated PHE-related barriers to MHS access for rural and urban beneficiaries, but urban residents benefited disproportionately. Among rural beneficiaries, older age was related to lower TMH use. To avoid reinforcing existing MHS access disparities, policies must address factors limiting TMH use among rural beneficiaries, especially those over 75 and those from historically underserved communities.

Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries

Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs). To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals. This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021. The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization. The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs. The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.

Vital Directions, Quality, And More

From the Editor-In-Chief Health AffairsVol. 40, No. 2: Vital Directions, Quality & More Vital Directions, Quality, And MoreAlan R. WeilPUBLISHED:February 2021Free Accesshttps://doi.org/10.1377/hlthaff.2021.00033AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSQuality of careHealth equityHealth disparitiesRacismMedicaidMedicare AdvantageMedicaid patientsAccess to carePandemicsOut-of-pocket expensesNonprofit statusMortality ratesMortalityMedicare savings programs PhysiciansEmergency departmentsWomen's healthChildren's healthMental healthSubstance use disorderThis month’s issue leads with articles from the National Academy of Medicine’s Vital Directions for Health and Health Care 2021 project, which sets forth priorities for the new administration of President Joe Biden, who took office January 20, 2021.Vital DirectionsVictor Dzau and coauthors identify the overarching theme of the Vital Directions series as “the clear and urgent obligation for the US to turn its full attention to the growing problem of health inequities and to the structural racism that perpetuates such disparities.” Peter Daszak and coauthors review US pandemic preparedness and outline steps to strengthen our ability to anticipate and respond to future pandemics. Elena Fuentes-Afflick and coauthors draw on a life-course framework to identify promising interventions to improve the health of women and children. Terry Fulmer and coauthors identify six strategies to improve care and quality of life for older adults. Margarita Alegría and coauthors describe new models of care that focus on mental health and addiction. William Shrank and coauthors discuss health cost and financing priorities to advance access, affordability, and equity.QualityDavid Meyers and coauthors use data from a natural experiment to quantify the degree to which Medicare Advantage (MA) plans with higher star ratings provide better care. Enrollees in an MA plan with one more star were 3.4 percent more likely to use a higher-rated hospital and 2.6 percent less likely to be readmitted within ninety days of discharge.Peter Smulowitz and coauthors describe physician-level variation in emergency department admission rates for Medicare fee-for-service patients. Within-hospital admission rates range from 32.2 to 45.6 percent for physicians at the tenth and ninetieth percentiles, leading the authors to conclude that there is “substantial variation in rates of admissions among physicians at the same hospital that is not related to observable patient characteristics.”Fabian Duarte and coauthors show that the reduction in the rate of uninsurance among adults ages 60–64 due to the Affordable Care Act greatly increased rates of cancer detection for this population. Fifty-nine additional incidents of cancer were detected per 100,000 people, and 68 percent of these were early- and middle-stage cancers—and thus more likely treatable.EquityAll-cause mortality rates increased dramatically in 2020 because of coronavirus disease 2019 (COVID-19). Maria Polyakova and coauthors show that excess mortality in April 2020 was much higher for Blacks than for Whites and that racial and ethnic disparities varied significantly by state.Rishi Wadhera and coauthors analyze all-cause mortality rates for rural and urban Medicare beneficiaries dually enrolled in Medicaid from 2004 to 2017. Although all-cause mortality declined for both groups across the study period, rates were higher among rural beneficiaries (92.8 per 1,000) than among their urban counterparts (75.1 per 1,000).Lisa Iezzoni and coauthors surveyed US physicians about their perceptions of care for people with disability. Only 40.7 percent of respondents were “very confident” they could “provide the same quality of care” to patients with disability as to patients without disability.This month, Health Affairs launches our own equity initiative. Please keep an eye out for more information on the Health Affairs Blog.Access To CareIn 2012 the South Carolina Medicaid program began paying for long-acting reversible contraceptive (LARC) separately from the global maternity payment. Maria Steenland and coauthors find that this increased immediate postpartum LARC use among adolescents by 0.19 percentage points per month.Johanna Catherine Maclean and coauthors find that Medicaid acceptance by residential substance use disorder treatment facilities increased in states that received Institutions for Mental Diseases waivers by 19 percent in the first year and 34 percent in the second year.Tamara Beetham and coauthors audited 368 residential addiction treatment programs in the US. They find that 65 percent of for-profit programs use one or more aggressive recruitment techniques compared with only 9 percent of nonprofit programs.Steven Chen and coauthors analyze commercial health insurance claims in 2017 and find that “nearly 40 percent of commercially insured people incurred half of their annual out-of-pocket spending in just one encounter, and 26 percent incurred 90 percent of their annual out-of-pocket spending in only one or two encounters.”AcknowledgmentsHealth Affairs thanks the Gordon and Betty Moore Foundation, The John A. Hartford Foundation, the National Academy of Medicine, and the Robert Wood Johnson Foundation for their financial support of publication of the Vital Directions articles in this issue. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 February 2021 Information© 2021 Project HOPE—The People-to-People Health Foundation, Inc.PDF download

Assessment of Rural-Urban Differences in Health Care Use and Survival Among Medicare Beneficiaries With Alzheimer Disease and Related Dementia

There is poor understanding as to how survival and health care use varies among older adults living with Alzheimer disease and related dementia (ADRD) in rural vs urban areas of the United States. To describe survival and trajectories of hospital, hospice, nursing home, and home health care use among rural and urban Medicare beneficiaries with ADRD in the 6 years after diagnosis. This retrospective cohort study linked Medicare claims data from January 1, 2009, to December 31, 2016, with nursing home and home health assessment data from all US counties. A total of 555 333 Medicare fee-for-service beneficiaries newly diagnosed with ADRD in 2010 were included. A total of 424 561 individuals (76.5%) resided in metropolitan counties, 75 001 (13.5%) in micropolitan counties, and 55 771 (10.0%) in rural counties. Rurality of beneficiary's county of residence. Number of days survived after initial ADRD diagnosis; percent of survived days per month spent in the hospital, hospice nursing home, community with home health care services, and community without home health care services. A total of 555 333 Medicare beneficiaries (mean [SD] age, 82.0 [7.5] years; 345 294 women [62.2%]; 480 286 White [86.5%]) were evaluated. Compared with metropolitan county residents, rural beneficiaries were younger (mean [SD] age, 81.6 [7.6] vs 82.1 [7.5] years), were less likely to be women (34 100 [61.1%] vs 264 688 [62.3%]), were more likely to be White (50 886 [91.2%] vs 361 205 [85.1%]) and Medicaid-eligible (14 264 [25.6%] vs 71 656 [16.9%]), and had fewer preexisting chronic conditions (mean [SD], 6.9 [2.8] vs 7.4 [2.9]). Medicare beneficiaries residing in metropolitan counties survived a mean (SD) of 1183.5 (826.0) days after diagnosis. Adjusting for individual demographic and clinical characteristics, rural and micropolitan county residents survived approximately 1.5 months less than metropolitan residents. The adjusted share of survived days spent in nursing homes was 5.7 (95% CI, 4.0-7.5) percentage points higher for rural vs metropolitan residents. The adjusted share of days in hospitals was 0.7 (95% CI, -0.9 to -0.4) percentage points lower, and the share of days in community without home health care was 4.6 (95% CI, -6.1 to -3.1) percentage points lower for rural vs metropolitan county residents. There were no statistically significant differences in home health or hospice use. Similar patterns were found for micropolitan vs metropolitan residents as for rural vs metropolitan residents, although the magnitude of the differences were smaller. Differences in time spent in community and nursing homes between rural vs metropolitan beneficiaries became more pronounced with further time from diagnosis. Study results suggest that, after diagnosis, rural Medicare beneficiaries with ADRD spend more time in nursing homes and less time in the community, receive less home health care, and have shorter survival than their urban counterparts.

Comparing the Health Workforce Provider Mix and the Distance Travelled for Mental Health Services by Rural and Urban Medicare Beneficiaries.

To describe the mix of health professionals who care for rural and urban seniors suffering from mood and/or anxiety disorders, the quantity of services they receive, and to understand where beneficiaries receive care for mood and/or anxiety disorders and the distance and time they travel for care. We used 2014 Medicare administrative claims data to examine access to health care for fee-for-service Medicare beneficiaries aged ≥ 65 years who received outpatient services for mood and anxiety disorders. We classified providers into 9 categories: (1) family physicians/general practice, (2) internists, (3) nurse practitioners (NPs) and physician assistants (PAs), (4) psychiatrists, (5) psychologists, (6) clinical social workers, (7) emergency medicine physicians, (8) other physicians, and (9) other providers. We calculated the 1-way driving distance and travel time between the beneficiary residence and provider location. We classified beneficiaries into 1 of 4 geographic categories based on their residence ZIP Code. Urban beneficiaries had an average of 2.7 visits for mood and anxiety disorders, while rural beneficiaries had 2.4. Generalist physicians and NPs/PAs provided 50.8% of all visits. Urban beneficiaries saw more behavioral health specialists (34.3%) than rural beneficiaries (16.1%). NPs and PAs provided more than twice as much of the care for rural beneficiaries (14.8%) as for urban beneficiaries (6.4%). Rural beneficiaries travelled about twice as far as urban beneficiaries. Rural and urban Medicare beneficiaries received care for mood/anxiety disorders from different mixes of health care providers, and ensuring access for rural populations will require innovative solutions.

Rural‐Urban Differences in Survival and Health care Utilization Among Medicare Beneficiaries Diagnosed with Alzheimer’s Disease and Related Dementias

Research ObjectiveThere is poor understanding as to how survival and health care utilization vary among older adults living with Alzheimer’s disease and related dementias (ADRD) in rural versus urban areas of the United States. The objective of this study was to describe survival and trajectories of hospital, nursing home, and home health care use in the six years following a new diagnosis of ADRD among rural and urban Medicare beneficiaries.Study DesignProspective cohort study using 2008‐2015 Medicare claims linked with nursing home and home health assessment data.Population Studied1 203 897 Medicare fee‐for‐service beneficiaries who were newly diagnosed with ADRD in 2008 or 2009. 77% (n = 921 853) resided in metropolitan counties, 14% (n = 162 857) in micropolitan counties, and 10% (n = 119 187) in rural counties.Principal FindingsThe average age at ADRD diagnosis was about six months younger for beneficiaries residing in rural counties compared to metropolitan counties. Beneficiaries residing in metropolitan counties survived a mean of 1211 days (median 1188 days) after diagnosis. Adjusting for individual demographic and clinical characteristics, beneficiaries in rural and micropolitan counties survived 29.2 fewer days (95% CI −34.0, −24.4) and 31.9 fewer days (95% CI −36.1, −27.7) than metropolitan residents, respectively. Compared with metropolitan residents, rural residents spent an adjusted 82.9 fewer days (95% CI −87.6, −78.2) in the community without home health care services, received 3.0 fewer days of home health care services (95% CI −3.5, −2.5), and spent 59.8 more days (95% CI 56.7, 63.0) in nursing homes. We found similar patterns in health care utilization for micropolitan vs. metropolitan residents, though the magnitude of the differences was smaller. Differences between groups became more pronounced the greater the time from diagnosis.ConclusionsUrban‐dwelling older adults with ADRD are significantly more likely to remain in the community and less likely to use nursing homes than individuals in rural and micropolitan counties, particularly in later disease stages.Implications for Policy or PracticeDifferences in health care utilization and survival between rural and urban Medicare beneficiaries with ADRD likely reflect geographic differences in health care access for timely diagnosis, proximity to informal caregivers, and availability of formal support services offered by home health agencies and other community‐based long‐term care providers.Primary Funding SourceNational Institutes of Health.

Trends Among Rural and Urban Medicare Beneficiaries in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks, 2008-2017

Over the last decade or so, there have been substantial investments in the development of stroke systems of care to improve access and quality of care in rural communities. Whether these have narrowed rural-urban disparities in care is unclear. To describe trends among rural and urban patients with acute ischemic stroke or transient ischemic attack in the type of health care centers to which patients were admitted, what care was provided, and the outcomes patients experienced. This descriptive observational study included 100% claims for beneficiaries of traditional fee-for-service Medicare from 2008 through 2017. All rural and urban areas in the US were included, defined by whether a beneficiary's residential zip code was in a metropolitan or nonmetropolitan area. All admissions in the US among patients with traditional Medicare who had a transient ischemic attack or acute stroke (N = 4.01 million) were eligible to be included in this study. Admissions for beneficiaries with end-stage kidney disease (n = 85 927 [2.14%]), beneficiaries with unidentified Rural-Urban Commuting Area codes (n = 12 797 [0.32%]), and beneficiaries not continuously enrolled in traditional Medicare in the 12 months before and 3 months after their admission (n = 442 963 [11.0%]) were excluded. Residence in an urban or rural area; admission to a hospital with a transient ischemic attack or acute stroke. Discharge from a certified stroke center, receiving a neurology consultation during admission, treatment with alteplase, days institutionalized, and 90-day mortality. The final sample included 3.47 million admissions from 2008 through 2017. In this sample, 2.01 million patients (58.0%) were female, and the mean (SD) age was 78.6 (10.5) years. In 2008, 24 681 patients (25.2%) and 161 217 patients (60.6%) in rural and urban areas, respectively, were cared for at a certified stroke center (disparity, -35.4%). By 2017, this disparity was -26.6%, having narrowed by 8.7 percentage points (95% CI, 6.6-10.8 percentage points). There was also narrowing in the rural-urban disparity in neurologist evaluation during admission (6.3% [95% CI, 4.2%-8.4%]). However, the rural-urban disparity widened or was similar with regard to receiving alteplase (0.5% [95% CI, 0.1%-0.8%]), mean days in an institution from admission (0.5 [95% CI, 0.2-0.8] days), and mortality at 90 days (0.3% [95% CI, -0.02% to 0.6%]), respectively. In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack has shifted to certified stroke centers and now more likely includes neurologist input. However, disparities in access to treatments, such as alteplase, and outcomes persist, highlighting that work still is needed to extend improvements in stroke care to all US residents.

Abstract 339: Urban and Rural Patients Receive Different Care for Atrial Fibrillation

Background: Atrial fibrillation (AF) accounts for substantial resource utilization that is expected to increase as the US population ages. Management strategies for AF vary widely based on patient preference, physician specialty training, available resources, and other factors, but the impact that geography has on treatment variations for AF is unknown. Objective: We seek to evaluate differences in AF patient characteristics and management between urban and non-urban Medicare beneficiaries. Methods: Our cohort included all Medicare fee-for-service beneficiaries meeting the CMS chronic conditions warehouse definition of AF from 2013-2017. Beneficiaries were designated as urban and non-urban by rural-urban commuting area codes. AF procedures were tabulated based on CPT codes. The use of AF related medications was tabulated based on prescriptions for drugs of interest in Medicare Part D. Results: During our period of interest, Medicare AF patients were average age 79 yrs, and 52% were female. Urban patients were more likely to be black and have chronic kidney disease, diabetes, and ischemic heart disease. The average CHADS2VA2SC score was high (4.90 SD 1.71) and not meaningfully different between urban and non-urban groups. Most advanced interventions for AF increased over time driven mostly by increases in AF ablation (Figure). However, compared with non-urban patients, urban patients were more likely to undergo AF ablation (1.81 vs 1.42%, p&lt;0.001), Watchman implantation (0.15 vs 0.11%, p&lt;0.001), and cardioversion (0.06 vs 0.05%, p=0.015). Non-urban patients were more likely to be prescribed amiodarone (7.08 vs 6.09%, p=0.002) and warfarin (8.84 vs 7.40%, p&lt;0.001) compared with urban patients and were less likely to be prescribed a direct oral anticoagulant. Conclusions: Despite urban and non-urban Medicare patients with AF being similar with regard to demographic and clinical characteristics, treatment of AF varied in important ways between these groups. In general, urban patients were more likely to receive interventional care for AF which, in some cases, has known associated benefits with regard to quality of life, morbidity, and mortality. Further work is needed to understand differences in outcomes between these two groups and to develop policy solutions to reduce treatment disparities.

Abstract 185: Trends in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks Among Rural and Urban Medicare Beneficiaries, 2008-2017

Introduction: Over the last decade substantial investments have been made in implementing stroke systems of care to improve access and quality of care. We sought to determine if these interventions have narrowed the rural-urban disparities in care over time for patients with acute stroke or transient ischemic attack (TIA). Methods: Descriptive observational study using data from all traditional Medicare beneficiaries in the United States from 2008-17 who presented to a hospital emergency department and were admitted either under observation stay or inpatient admission. Patients were classified as rural or urban based on home zip code. The main outcomes were rates of presentation to a certified stroke center, neurology consultation during admission, IV altepase, 90-day mortality, days living independently in the first 90 days post stroke, and 90-day spending. Results: We identified 3.31 million hospital stays for TIA and stroke in the study period. Rural and urban patients had similar age, race, gender, Medicaid status and presence of chronic conditions. In 2008, 24.4% and 60.4% of rural and urban patients respectively were cared for at a certified stroke center (disparity -36.1%). By 2017 this disparity had narrowed by 8.6% points (95% CI 6.6%,10.7%) (Fig). Between 2008 and 2017, the disparity in neurologist evaluation during admission narrowed by 7.4% (5.2%, 9.6%). However, there was no substantive change in disparity in alteplase use -0.1% (95% CI -0.5%,0.3%), mortality at 90 days 0.4% (95% CI 0.1%, 0.7%), or days living independently within 90 days -0.7 days (95% CI -1.1, 0.2). Spending in the first 90 days differentially increased among rural patients by $867 (95% CI 85, 1649). Conclusions: In the last decade, rural residents are more likely to receive care at a certified stroke center and receive neurologist consultation. However, disparities in outcomes are persistent, highlighting more work is needed to equitably extend stroke expertise to all Americans.

Long-Term Services and Supports Use Among Older Medicare Beneficiaries in Rural and Urban Areas

State and federal policies have shifted long-term services and support (LTSS) priorities from nursing home care to home and community-based services (HCBS). It is not clear whether the rural LTSS system reflects this system transformation. Using the Medicare Current Beneficiary Survey, we examined nursing home use among rural and urban Medicare beneficiaries aged 65 and older. Study findings indicate that even after controlling for known predictors of nursing home use, rural Medicare beneficiaries exhibited greater odds of nursing home residence and that the higher odds of rural nursing home residence are, in part, associated with higher rural nursing home bed supplies. A complex interplay of policy, LTSS infrastructure, and social, cultural, and other factors may be influencing the observed differences. Federal and state efforts to build rural HCBS capacity may be necessary to mitigate stubbornly persistent rural-urban differences in the patterns of institutional and community-based LTSS use.

Neighborhood Environment and Disparities in Health Care Access Among Urban Medicare Beneficiaries With Diabetes: A Retrospective Cohort Study.

Older adults’ health is sensitive to variations in neighborhood environment, yet few studies have examined how neighborhood factors influence their health care access. This study examined whether neighborhood environmental factors help to explain racial and socioeconomic disparities in health care access and outcomes among urban older adults with diabetes. Data from 123 233 diabetic Medicare beneficiaries aged 65 years and older in New York City were geocoded to measures of neighborhood walkability, public transit access, and primary care supply. In 2008, 6.4% had no office-based “evaluation and management” (E&M) visits. Multilevel logistic regression indicated that this group had greater odds of preventable hospitalization in 2009 (odds ratio = 1.31; 95% confidence interval: 1.22-1.40). Nonwhites and low-income individuals had greater odds of a lapse in E&M visits and of preventable hospitalization. Neighborhood factors did not help to explain these disparities. Further research is needed on the mechanisms underlying these disparities and older adults’ ability to navigate health care. Even in an insured population living in a provider-dense city, targeted interventions may be needed to overcome barriers to chronic illness care for older adults in the community.

Capsule Commentary for Tsilimingras et al., Post-Discharge Adverse Events Among Urban and Rural Patients of an Urban Community Hospital: A Prospective Cohort Study.

Tsilimingras et al. 1 investigate whether patients from urban and rural areas have similar rates of adverse events. They carefully consider a sample in one urban community hospital and track rates of adverse events using a rigorous, independently adjudicated method of detecting and classifying adverse events. There was little difference between the two patient groups; both had high rates of adverse events, with the majority being either preventable or ameliorable. The focus on patients discharged from one hospital is important to consider and is a study strength, as it holds constant the quality and practices of the specific facility. But it raises an additional element to consider: if rural patients “bypassing” their local hospital have better insurance (e.g., commercial), and are more likely to be admitted for complex conditions,2 the patients may differ in their baseline risk of adverse events. Curiously, the patient populations appear to exhibit some of these differences (e.g., slightly more secondary discharge diagnoses in rural) but not others (rural have lower income and are more likely to be on public insurance). Naturally, this reflects the difference in the underlying prevalence of conditions within the two patient groups. In this case, the urban patients of the hospital tend to live much closer to the study hospital: 90 % of the urban Medicare beneficiaries admitted to the hospital lived within 20 miles of Tallahassee Memorial Hospital (TMH), compared to 10 % of the rural Medicare beneficiaries.3 Although this suggests potential barriers to timely post-acute care—combined with more complex conditions and poorer socioeconomic status among the rural group—there seemed to be little difference in risk. Understanding the pathway to these similar rates of adverse events in the face of multiple risk factors would help improve transitions to post-acute care, something from which all acute patients would benefit.

Rural And Urban Medicare Beneficiaries Use Remarkably Similar Amounts Of Health Care Services

Medicare payment policies for rural health care providers are influenced by the assumption that the limited supply of physicians in rural areas causes rural Medicare beneficiaries to receive fewer health care services than their urban counterparts do. This assumption has contributed to the growth in special payments to rural providers. As a result, Medicare pays rural providers $3billion more each year in special payments than they would receive under traditional payment rates. To test the validity of the assumption that rural beneficiaries systematically receive less care, we analyzed claims data for all Medicare fee-for-service beneficiaries in 2008, stratified by rural/urban status and region. After adjusting for health status, we found no significant differences between rural and urban beneficiaries in either the amount of health care received or satisfaction with access to care. Although there were systematic differences in the amount of care used across regions of the country, there was very little difference within a region between rural and urban areas. To the extent that Medicare payment policies are designed to ensure access, they should be assessed on the basis of achieving similar service use rather than similar local physician supply. They should also be targeted to isolated rural providers needed to preserve access to care.

Abstract B23: Socioeconomic factors and correlates of prostatespecific antigen testing in urban African-American Medicare beneficiaries

Abstract Background: Prostate specific antigen (PSA) testing is frequently used for early detection of prostate cancer, including among older adults. Since both race and socioeconomic status are associated with prostate cancer incidence and outcomes, it is often difficult to separate race from socioeconomic status as a determinant of prostate cancer screening. We sought to describe the relationship between socioeconomic status and PSA testing in a sample of urban, African American Medicare beneficiaries, and to examine factors that may contribute to this relationship. Methods: We examined baseline questionnaire data collected from the Cancer Prevention and Treatment Demonstration, a community-based randomized, controlled trial in Baltimore, MD. The study population consisted of 511 community-dwelling African-American men, age 65–75, without a history of prostate cancer. Our main outcome was PSA testing within the past year. Sequential multivariate logistic regression models were performed to study factors that may mediate the relationship between socioeconomic status and PSA screening. Results: Eighty percent of participants reported having had at least one PSA test in their lifetime, and approximately 50% reported having one within the past year. About half of the sample population reported a household income of less than $30,000 a year and one-third reported education past high school, but only 14% reported a bachelor's degree or higher. In bivariate analyses both higher income ($30,000 vs. &amp;lt; $10,000) (Odds Ratio [OR] 3.14, 95% Confidence Interval [CI] 1.79, 5.52) and higher levels of education (Bachelor's degree vs. less than high school) (OR 3.19, CI 1.72, 5.71) were associated with screening in the past year. In a multivariable regression model, which controlled for marital status, family history, and self-reported health status, income was no longer a significantly associated with PSA testing while the association between educational attainment and PSA testing was reduced (OR 2.13, 95% CI 1.07–4.22). The addition of increased healthcare access and patient-provider relationship measures in sequential models did not alter the relationship between educational attainment and screening. However, upon inclusion of cancer knowledge and belief measures the association between education and PSA testing was no longer significant (OR 1.84, 95% CI 0.90–3.75). Conclusions: In this urban, African American Medicare population, socioeconomic status was associated with PSA testing. This relationship may be explained, in part, by demographic factors and cancer knowledge and beliefs. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B23.

Choice of Personal Assistance Services Providers by Medicare Beneficiaries Using a Consumer-Directed Benefit: Rural-Urban Differences

To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19 counties in New York State, West Virginia, and Ohio. A total of 839 participants were randomly assigned to receive a voucher benefit (up to $250 per month with a 20% copayment) that could be used toward PAS provided by either independent or agency workers. A bivariate probit model was used to estimate the probabilities of choosing either type of PAS provider while controlling for potential confounders. The voucher was associated with a 32.4% (P < .01) increase in the probability of choosing agency providers and a 12.5% (P= .03) increase in the likelihood of choosing independent workers. When the analysis was stratified by rural/urban status, rural voucher recipients had 36.8% higher probability of using independent workers compared to rural controls. Urban voucher recipients had 37.1% higher probability of using agency providers compared to urban controls. This study provided evidence that rural and urban Medicare beneficiaries with disabilities may have very different responses to a consumer-choice PAS voucher program. Offering a consumer-choice voucher option to rural populations holds the potential to significantly improve their access to PAS.

Is access to home health care a problem in rural areas?

In 1987, urban Medicare beneficiaries were 13.7% more likely than their rural counterparts to use Medicare home health care services. Regression analysis shows that rural use rates, particularly those in sparsely populated areas, fall short of those in urban areas, other things being equal. Rural areas have lower Medicare ceilings, proportionately fewer visiting nurse associations, and lower availability of auxiliary services. These factors combined account for 82% of the difference between rural and urban use rates.