White Beneficiaries Research Articles

Food Insecurity Among Medicare Beneficiaries With Type 2 Diabetes: Implications for Diabetes Care and Education Specialists.

The purpose of the study was to examine factors associated with food insecurity among Medicare beneficiaries with type 2 diabetes. The 2019 Medicare Current Beneficiary Survey Public Use File of beneficiaries ≥65 years old with type 2 diabetes (n = 1343) was analyzed. A binary variable was created to represent food insecurity (1 = food insecurity, 0 = without food insecurity) with ≥2 affirmative responses adapting an established algorithm of the United States Department of Agriculture food insecurity questionnaire. A survey-weighted logistic model was performed to examine factors (ie, sociodemographic characteristics, health status, and insurance coverage) associated with food insecurity. Approximately 11.6% of study Medicare beneficiaries with type 2 diabetes reported food insecurity. Non-Hispanic Black beneficiaries were more likely to report food insecurity than non-Hispanic White beneficiaries. Beneficiaries with incomes < $25 000 were more likely to report food insecurity than those with higher incomes. Beneficiaries enrolled in Medicare Advantage programs (vs traditional Medicare), having Medicare-Medicaid dual eligibility (vs nondual), and living with instrumental activities of daily living or activities of daily living limitations (vs without) were also more likely to report food insecurity than their respective counterparts. Sociodemographic disparities in food insecurity were observed among Medicare beneficiaries with type 2 diabetes. Implementation of screening protocols, interventions related to social determinants of health, and the diabetes care continuum may mitigate the prevalence of food insecurity in this demographic.

Demographic and Socioeconomic Disparities in Long-term Outcomes After Endovascular Abdominal Aortic Aneurysm Repair Among Medicare Beneficiaries

Age, sex, and race-related disparities in outcomes following abdominal aortic aneurysm (AAA) repair have been described, but the impact of socioeconomic factors on these outcomes is poorly understood. We examined 5-year outcomes after endovascular abdominal aortic aneurysm repair (EVAR) for intact AAA stratified by demographic and socioeconomic factors and explored potential mechanisms underlying outcome disparities. All Medicare fee-for-service beneficiaries ≥66 years of age who underwent EVAR for intact AAA between January 1, 2011, and December 31, 2019, were identified and stratified by the following disparity measures: age category (66-75 years/76-85 years/>85 years), sex, race (White/Black/other), Medicare/Medicaid dual enrollment, distressed communities index (distressed >80th percentile/nondistressed ≤80th percentile), and residential location (urban/rural). The primary outcome was a composite endpoint of late aneurysm rupture, aortic reintervention (graft relining or endograft extension), conversion to open repair, or all-cause mortality. Kaplan-Meier and Cox regression analyses were used to examine outcomes by each disparity measure. A total of 113,261 beneficiaries were identified. Mean age was 77 years, and most beneficiaries were male (79%), White (93%), enrolled in Medicare only (91%), and resided in urban locations (95%; Table). Median follow-up time was 3.2 years. At 5 years, compared with beneficiaries aged 66 to 75, incidence of the composite endpoint was higher in those aged 76 to 85 years (38% vs 25%, unadjusted hazard ratio [uHR], 1.7l 95% confidence interval [CI], 1.6-1.7) and in those aged >85 years (52% vs 25%; uHR, 2.6; 95% CI, 2.5-2.7) (Table). Higher incidence of the composite endpoint was also observed in female vs male beneficiaries (37% vs 32%; uHR, 1.2, 1.2-1.3), Black vs White beneficiaries (38% vs 33%; uHR; 1.2; 95% CI, 1.2-1.3), dual-enrolled vs Medicare-only beneficiaries (42% vs 32%; uHR, 1.4; 95% CI, 1.4-1.4), and in beneficiaries residing in distressed vs non-distressed communities (35% vs 33%; uHR, 1.1; 95% CI, 1.1-1.1). In adjusted analyses, these outcome disparities were partly explained by a higher burden of comorbid conditions in beneficiaries who were older, female, Black, dual-enrolled, or residing in distressed communities. Among Medicare fee-for-service beneficiaries who underwent EVAR for intact AAA, we observed significant 5-year outcome disparities by demographic and socioeconomic measures. These disparities seem to be driven, in part, by a higher burden of comorbidities in beneficiaries who are older, female, Black, or socioeconomically disadvantaged. These findings highlight the need for early identification and management of comorbid conditions to reduce outcome disparities following EVAR. Further work to examine other potential contributing factors, including healthcare utilization and imaging surveillance after EVAR, is ongoing and may highlight additional actionable targets for improvement.TableBaseline rates of disparity measures and associated cumulative incidence of the composite endpoint of late aneurysm rupture, aortic reintervention (graft relining or endograft extension), conversion to open repair, or all-cause mortality in Medicare beneficiaries who underwent EVAR for intact AAADisparity measureNo. (%)5-Year event rate (%)uHR (95% CI)Age category, years 66-7553,009 (47)25Ref 76-8548,084 (42)381.7 (1.6-1.7) >8512,168 (11)522.6 (2.5-2.7)Sex Male89,219 (79)32Ref Female24,042 (21)371.2 (1.2-1.3)Race White105,158 (93)33Ref Black4289 (3.8)381.2 (1.2-1.3) Other3814 (3.4)280.84 (0.79-0.89)Medicare/Medicaid enrollment Medicare only103,095 (91)32Ref Dual10,166 (9.0)421.4 (1.4-1.4)Distressed communities index Nondistressed90,074 (80)33Ref Distressed23,187 (20)351.1 (1.1-1.1)Residential location Urban107,305 (95)33Ref Rural5956 (5.3)320.97 (0.93-1.0)AAA, Abdominal aortic aneurysm; CI, confidence interval; EVAR, endovascular abdominal aortic aneurysm repair; Ref, reference; uHR, unadjusted hazard ratio.aEvent rates (%) at 5 years were estimated using Kaplan-Meier methods, and Cox regression was used to determine the uHRs at each time point. Open table in a new tab

The Costs Of Disparities In Preventable Heart Failure Hospitalizations In The US South, 2015-17.

Black Americans in the US South have high rates of preventable heart failure hospitalizations, which reflects systemic inequities that also produce economic costs. We measured the direct medical costs of disparities in preventable heart failure admissions (that is, excess admissions) among Medicare beneficiaries living in six states in the US South (Kentucky, Arkansas, Florida, Georgia, Mississippi, and North Carolina). We used 2015-17 data from the Healthcare Cost and Utilization Project and constructed negative binomial models with state-level fixed effects to calculate adjusted admission rates with heart failure as the principal diagnosis. We calculated the number of these admissions that would have been avoided if Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native Medicare beneficiaries had the same admission rates as White beneficiaries. We found 28,213 excess admissions (48percent excess) with $60,845,855 annual costs among Black beneficiaries, 3,499 (14percent excess) with $8,179,381 annual costs among Hispanic beneficiaries, and 550 (51percent excess) with $1,093,472 in annual costs among American Indian/Alaska Native beneficiaries. Failure to address heart failure treatment inequities in the community has a high opportunity cost.

Association Between Myopia and Primary Open-Angle Glaucoma by Race and Ethnicity in Older Adults in the California Medicare Population

Racial and ethnic differences in the association between myopia and primary open-angle glaucoma (POAG) are not well understood. To investigate the association between myopia and POAG in the 2019 California Medicare population and to investigate whether there was evidence of effect measure modification of this association by race and ethnicity. This cross-sectional study used administrative claims data from 2019 California Medicare beneficiaries 65 years or older with California residence and active coverage with Medicare parts A and B. Analysis took place between October 2021 and October 2023. The primary exposure was myopia, which was defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes. The outcome of interest was POAG, which was defined by ICD-10-CM code. Of 2 717 346 California Medicare beneficiaries in 2019, 1 440 769 (53.0%) were aged 65 to 74 years, 1 544 479 (56.8%) identified as female, 60 211 (2.2%) had myopia, and 171 988 (6.3%) had POAG. Overall, 346 723 individuals (12.8%) identified as Asian, 117 856 (4.3%) as Black, 430 597 (15.8%) as Hispanic, 1 705 807 (62.8%) as White, and 115 363 (4.2%) as other race and ethnicity. In adjusted logistic regression analyses, beneficiaries with myopia had higher odds of POAG compared with beneficiaries without myopia (odds ratio [OR], 2.41; 95% CI, 2.35-2.47). In multivariable models stratified by race and ethnicity, the association between myopia and POAG was stronger in Asian (OR, 2.74; 95% CI, 2.57-2.92), Black (OR, 2.60; 95% CI, 2.31-2.94), and Hispanic (OR, 3.28; 95% CI, 3.08-3.48) beneficiaries compared with non-Hispanic White beneficiaries (OR, 2.14; 95% CI, 2.08-2.21). In the 2019 California Medicare population, myopia was associated with greater adjusted odds of POAG. This association was stronger among Asian, Black, and Hispanic beneficiaries compared with non-Hispanic White beneficiaries. These findings suggest possible disparities in glaucoma risk by race and ethnicity in individuals with myopia and may indicate greater need for glaucoma screening in individuals with myopia from racial and ethnic minority backgrounds.

Health Care Use among Medicare Beneficiaries with HIV and Depression during the COVID-19 Pandemic-United States, 2020.

Access and use of health care services are essential to health and well-being for people with HIV and HIV-related comorbidities. Health care use during the COVID-19 pandemic among Medicare beneficiaries (MBs) with concurrent HIV and depression has not been investigated. We used 2020 Medicare data to assess the percentage of MBs with claims for HIV and depression who also received hospitalization, outpatient diagnostic services, drug treatment, and outpatient procedures. We assessed person-level association between service receipt and HIV and depression, adjusting for known risk factors. MBs with claims for HIV and depression were more likely than those with neither claim to have claims for short-stay hospitalization, long-stay hospitalization, outpatient diagnostic services, prescription drugs, or outpatient procedures, supplies, and products. Non-White beneficiaries were more likely than White beneficiaries to be hospitalized but were less likely to receive drug treatment, outpatient diagnostic services, or outpatient procedures, supplies, and products during the pandemic. Significant disparities in health care use by race/ethnicity existed among MBs. Policymakers and practitioners can use these findings to implement public health policies and programs that reduce disparities in health care access and optimize use among vulnerable populations during a public health emergency.

Racial and Ethnic Disparities in Health Care Use and Access Associated With Loss of Medicaid Supplemental Insurance Eligibility Above the Federal Poverty Level

Medicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program's income eligibility threshold (100% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries' ability to afford care. To examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care. This cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0% to 200% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022. Patient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data. This cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1% of beneficiaries were women, 14.8% were non-Hispanic Black, 13.6% were Hispanic, and 71.6% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95% CI, 2.0-9.4), lower outpatient use (-6.3 services per person-year; 95% CI, -10.4 to -2.2), and fewer medication fills (-6.9 fills per person-year; 95% CI, -11.4 to -2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: -6.2 services per person-year; 95% CI, -11.7 to -0.6; P = .03) and medication fills (disparity: -7.2 fills per person-year; 95% CI, -13.4 to -1.0; P = .02) among Black and Hispanic vs White beneficiaries. This cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.

Disparities in 30-day readmission rates among Medicare enrollees with dementia.

Readmissions contribute to excessive care costs and burden for people living with dementia. Assessments of racial disparities in readmissions among dementia populations are lacking, and the role of social and geographic risk factors such as individual-level exposure to greater neighborhood disadvantage is poorly understood. We examined the association between race and 30-day readmissions in a nationally representative sample of Black and non-Hispanic White individuals with dementia diagnoses. This retrospective cohort study used 100% Medicare fee-for-service claims from all 2014 hospitalizations nationwide among Medicare enrollees with dementia diagnosis linked to patient, stay, and hospital factors. The sample consisted of 1,523,142 hospital stays among 945,481 beneficiaries. The relationship between all cause 30-day readmissions and the explanatory variable of self-reported race (Black, non-Hispanic White) was examined via generalized estimating equations approach adjusting for patient, stay, and hospital-level characteristics to model 30-day readmission odds. Black Medicare beneficiaries had 37% higher readmission odds compared to White beneficiaries (unadjusted OR 1.37, CI 1.35-1.39). This heightened readmission risk persisted after adjusting for geographic factors (OR 1.33, CI 1.31-1.34), social factors (OR 1.25, CI 1.23-1.27), hospital characteristics (OR 1.24, CI 1.23-1.26), stay-level factors (OR 1.22, CI 1.21-1.24), demographics (OR 1.21, CI 1.19-1.23), and comorbidities (OR 1.16, CI 1.14-1.17), suggesting racially-patterned disparities in care account for a portion of observed differences. Associations varied by individual-level exposure to neighborhood disadvantage such that the protective effect of living in a less disadvantaged neighborhood was associated with reduced readmissions for White but not Black beneficiaries. Conversely, among White beneficiaries, exposure to the most disadvantaged neighborhoods associated with greater readmission rates compared to White beneficiaries residing in less disadvantaged contexts. There are significant racial and geographic disparities in 30-day readmission rates among Medicare beneficiaries with dementia diagnoses. Findings suggest distinct mechanisms underlying observed disparities differentially influence various subpopulations.

Disparities in Telemedicine Use Among Louisiana Medicaid Beneficiaries During the COVID-19 Pandemic.

The COVID-19 pandemic led to an increased reliance on telemedicine. Whether this exacerbated existing disparities within vulnerable populations is not yet known. Characterize changes in outpatient telemedicine evaluation and management (E&M) services for Louisiana Medicaid beneficiaries by race, ethnicity, and rurality during the COVID-19 pandemic. Interrupted time series regression models estimated pre-COVID-19 trends and changes in E&M service use at the April and July 2020 peaks in COVID-19 infections in Louisiana and in December 2020 after those peaks had subsided. Louisiana Medicaid beneficiaries continuously enrolled between January 2018 and December 2020 who were not also enrolled in Medicare. Monthly outpatient E&M claims per 1000 beneficiaries. Prepandemic differences in service use between non-Hispanic White and non-Hispanic Black beneficiaries narrowed by 34% through December 2020 (95% CI: 17.6%-50.6%), while differences between non-Hispanic White and Hispanic beneficiaries increased by 10.5% (95% CI: 0.1%-20.7%). Non-Hispanic White beneficiaries used telemedicine at higher rates than non-Hispanic Black (difference=24.9 claims per 1000 beneficiaries, 95% CI: 22.3-27.4) and Hispanic beneficiaries (difference=42.3 claims per 1000 beneficiaries, 95% CI: 39.1-45.5) during the first wave of COVID-19 infections in Louisiana. Telemedicine use increased slightly for rural beneficiaries compared with urban beneficiaries (difference=5.3 claims per 1000 beneficiaries, 95% CI: 4.0-6.6). The COVID-19 pandemic narrowed gaps in outpatient E&M service use between non-Hispanic White and non-Hispanic Black Louisiana Medicaid beneficiaries, though gaps in telemedicine use emerged. Hispanic beneficiaries experienced large reductions in service use and relatively small increases in telemedicine use.

Associations between greenness and kidney disease in Massachusetts: The US Medicare longitudinal cohort study

BackgroundRecent studies have identified the association of environmental stressors with reduced kidney function and the development of kidney disease. While residential greenness has been linked to many health benefits, the association between residential greenness and the development of kidney disease is not clear. We aimed to investigate the association between residential greenness and the development of kidney disease. MethodsWe performed a longitudinal population-based cohort study including all fee-for-service Medicare Part A beneficiaries (aged 65 years or older) in Massachusetts (2000–2016). We assessed greenness with the annual average Enhanced Vegetation Index (EVI) based on residential ZIP codes of beneficiaries. We applied Cox-equivalent Poisson models to estimate the association between EVI and first hospital admission for total kidney disease, chronic kidney disease (CKD), and acute kidney injury (AKI), separately. ResultsData for 1,462,949 beneficiaries who resided in a total of 644 ZIP codes were analyzed. The total person-years of follow-up for total kidney disease, CKD, and AKI were 9.8, 10.9, and 10.8 million person-years, respectively. For a 0.1 increase in annual EVI, the hazard ratios (HRs) were 0.95 (95% CI: 0.93 to 0.97) for the first hospital admission for total kidney disease, and the association was more prominent for AKI (HR: 0.94 with 95% CI: 0.92 to 0.97) than CKD (HR: 0.98 with 95% CI: 0.95–1.01]). The estimated effects of EVI on kidney disease were generally more evident in White beneficiaries and those residing in metropolitan areas compared to the overall population. ConclusionsThis study found that higher levels of annual residential greenness were associated with a lower risk of the first hospital admission for kidney diseases. Results are consistent with the hypothesis that higher residential greenness benefits kidney patients.

Race, neighborhood disadvantage, and survival of Medicare beneficiaries after aortic valve replacement and concomitant coronary artery bypass grafting

BackgroundRace, neighborhood disadvantage, and the interaction between these 2 social determinants of health remain poorly understood with regards to survival after aortic valve replacement with concomitant coronary artery bypass grafting (AVR+CABG). MethodsWeighted Kaplan–Meier survival analyses and Cox proportional hazards modeling were used to evaluate the association between race, neighborhood disadvantage, and long-term survival in 205,408 Medicare beneficiaries undergoing AVR+CABG from 1999 to 2015. Neighborhood disadvantage was measured using the Area Deprivation Index, a broadly validated ranking of socioeconomic contextual disadvantage. ResultsSelf-identified race was 93.9% White and 3.2% Black. Residents of the most disadvantaged quintile of neighborhoods included 12.6% of all White beneficiaries and 40.0% of all Black beneficiaries. Black beneficiaries and residents of the most disadvantaged quintile of neighborhoods had more comorbidities compared with White beneficiaries and residents of the least disadvantaged quintile of neighborhoods, respectively. Increasing neighborhood disadvantage linearly increased the hazard for mortality for Medicare beneficiaries of White but not Black race. Residents of the most and least disadvantaged neighborhood quintiles had weighted median overall survival of 93.0 and 82.1 months, respectively, a significant difference (P < .001 by Cox test for equality of survival curves). Black and White beneficiaries had weighted median overall survival of 93.4 and 90.6 months, respectively, a nonsignificant difference (P = .29 by Cox test for equality of survival curves). A statistically significant interaction between race and neighborhood disadvantage was noted (likelihood ratio test P = .0215) and had implications on whether Black race was associated with survival. ConclusionsIncreasing neighborhood disadvantage was linearly associated with worse survival after combined AVR+CABG in White but not Black Medicare beneficiaries; race, however, was not independently associated with postoperative survival.

Behavioral Health, Nursing Home Workforce, And More

From the Editor-In-Chief Health AffairsVol. 42, No. 2: Behavioral Health, Nursing Home Workforce & More Behavioral Health, Nursing Home Workforce, And MoreAlan R. WeilPUBLISHED:February 2023Free Accesshttps://doi.org/10.1377/hlthaff.2023.00023AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSBehavioral health careNursing homesWorkforce issuesEmergency departmentsTelehealthHealth equityThe February issue of Health Affairs covers behavioral health, including mental health and substance use; the nursing home workforce; and health equity issues such as racial and ethnic disparities in ambulance transportation destinations and adverse birth outcomes.Behavioral HealthIn the midst of a mental health provider shortage, Lisa Rotenstein and coauthors find an almost 50 percent increase in the share of primary care physician visits that address a mental health concern, with growth from 10.7 percent of visits in 2006–07 to 15.9 percent in 2016 and 2018. Black patients and Hispanic patients are 40 percent less likely than White patients and non-Hispanic patients, respectively, to have a mental health concern addressed during a primary care visit.K. John McConnell and colleagues use newly available national Medicaid claims data from 2018 to examine emergency department (ED) visits for mental health conditions among Medicaid beneficiaries. They report substantial state-to-state variation “both in ED visits for mental health conditions and in outpatient mental health visits, with these measures positively correlated.”Lori Uscher-Pines and coauthors explore recent trends in the use of telemedicine to address opioid use disorder (OUD). More than three-quarters of clinicians treating OUD report the use of one or more digital equity strategies designed to address barriers patients may have to using telemedicine, with about one-third offering real-time technical assistance and more than 15 percent supplying patients with electronic devices if they do not have them.Brendan Saloner and coauthors investigate smoking rates among people involved in the criminal legal system—a group of people with relatively high rates of smoking and substance use disorder (SUD). Using data from the period 2010–19, the authors find that “overall smoking rates among people with SUD decreased by 9.4 percentage points…during the study period, but they remained effectively unchanged in the subgroup of people with SUD who had criminal legal involvement.”Nursing Home WorkforceUsing a novel database of real estate investment trust (REIT) investments in US nursing homes and Medicare cost data from the period 2013–19, Robert Tyler Braun and coauthors determine that REIT investment in a nursing home increased licensed practical nurse and certified nursing assistant staffing hours per resident day by 2.15 percent and 1.55 percent, respectively, while decreasing registered nurse staffing in years 2 and 3 after investment.Elizabeth White and coauthors explore the relationship between nursing home staff shift times and COVID-19 testing and vaccination status. They find that day-shift staff had the highest testing rates and odds of vaccination, whereas night-shift staff had the lowest.Adequate staffing is central to ensuring high nursing home quality. To help illuminate the implications of various policy recommendations, John Bowblis and coauthors analyze nursing home staff expenditures and determine that “any specific threshold for nursing staff expenditures…would have a varying degree of effectiveness in ensuring that any given nursing home was adequately staffed.” Ultimately, the authors argue, increased expenditures on staff do not necessarily translate to an increase in staffing levels.EquityChristine Pack and coauthors investigate ambulance destinations for patients transported in 2020 from the same ZIP code and find meaningful differences by race and ethnicity. “In half of the studied ZIP codes, at least 8 percent of White patients would have had to be transported to different hospitals to achieve evenness in the transport destinations of White and non-White patients,” the authors report.Clare Brown and coauthors examine disparities in rates of preterm birth and low birthweight across racial and ethnic subcategories. They find sizable variation in adverse birth outcomes within racial and ethnic groups, demonstrating that broad racial and ethnic categorizations can conceal important intragroup differences.Eunhae Grace Oh and coauthors analyze dialysis facility networks for Medicare Advantage (MA) plans in 2020, one year before changes that significantly increased MA enrollment among patients with end-stage renal disease (ESRD). Nearly one-quarter of dialysis networks were narrow, which the authors define as including 25 percent or less of the dialysis facilities within the plan’s service area. Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native beneficiaries with ESRD were more likely than White beneficiaries to be enrolled in narrow-network MA plans.Examining COVID-19 booster rates at the end of the first Omicron wave in 462 Massachusetts communities, Adam Gaffney and coauthors find lower rates in communities with higher uninsurance rates and lower prevalence of medical checkups, after controlling for demographic factors. They call for “innovative vaccination outreach efforts to communities with a high prevalence of chronic illness…to mitigate the inequitable burden of COVID-19.” Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 6 February 2023 Information© 2023 Project HOPE—The People-to-People Health Foundation, Inc.PDF download

Association of Hospital Quality and Neighborhood Deprivation With Mortality After Inpatient Surgery Among Medicare Beneficiaries

Although the hospital at which a patient is treated is a known source of variation in mortality after inpatient surgery, far less is known about how the neighborhoods from which patients come may also contribute. To compare postoperative mortality among Medicare beneficiaries based on the level of neighborhood deprivation where they live and hospital quality where they received care. This cross-sectional study examined outcomes among Medicare beneficiaries undergoing 1 of 5 common surgical procedures (colon resection, coronary artery bypass, cholecystectomy, appendectomy, or incisional hernia repair) between 2014 and 2018. Hospital quality was assigned using the Centers for Medicare & Medicaid Services Star Rating. Each beneficiary's neighborhood was identified at the census tract level and sorted in quintiles based on its Area Deprivation Index score, a composite measure of neighborhood quality, including education, employment, and housing quality. A risk matrix across hospital quality and neighborhood deprivation was created to determine the relative contribution of each to mortality after surgery. Data were analyzed from June 1 to December 31, 2021. Hospital quality and neighborhood deprivation. The main outcome was risk-adjusted 30-day mortality after surgery using a multivariable logistic regression model taking into account patient factors and procedure type. A total of 1 898 829 Medicare beneficiaries (mean [SD] age, 74.8 [7.0] years; 961 216 [50.6%] male beneficiaries; 28 432 [1.5%] Asian, 145 160 [77%] Black, and 1 622 304 [86.5%] White beneficiaries) were included in analyses. Patients from all neighborhood deprivation group quintiles sought care at hospitals across hospital quality levels. For example, 9.1% of patients from the highest deprivation neighborhoods went to a hospital in the highest star rating of quality and 4.2% of patients from the lowest deprivation neighborhoods went to a hospital in the lowest star rating of quality. Thirty-day risk-adjusted mortality varied across high- and low-quality hospitals (4.3% vs 7.2%; adjusted odds ratio [aOR], 1.78; 95% CI, 1.66-1.92) and across the least and most deprived neighborhoods (4.5% vs 6.8%; aOR, 1.58; 95% CI, 1.53-1.64). When combined, comparing patients from the least deprived neighborhoods going to high-quality hospitals vs patients from the most deprived neighborhoods going to low-quality hospitals, the variation increased further (3.8% vs 8.1%; aOR, 2.20; 95% CI, 1.96-2.46). These findings suggest that characteristics of a patient's neighborhood and the hospital where they received treatment were both associated with risk of death after commonly performed inpatient surgical procedures. The associations of these factors on mortality may be additive. Efforts and investments to address variation in postoperative mortality should include both hospital quality improvement as well as addressing drivers of neighborhood deprivation.

Association Between Race and Receipt of Home- and Community-Based Rehabilitation After Traumatic Brain Injury Among Older Medicare Beneficiaries

Non-Hispanic Black (hereafter Black) patients with traumatic brain injury (TBI) experience worse long-term outcomes and residual disability compared with non-Hispanic White (hereafter White) patients. Receipt of appropriate rehabilitation can improve function among older adults after TBI. To assess the association between race and receipt of home- and community-based rehabilitation among a nationally representative sample of older Medicare beneficiaries with TBI. This cohort study analyzed a random sample of Medicare administrative claims data for community-dwelling Medicare beneficiaries aged 65 years or older who were hospitalized with a primary diagnosis of TBI and discharged alive to a nonhospice setting from 2010 through 2018. Claims data for Medicare beneficiaries of other races and ethnicities were excluded due to the small sample sizes within each category. Data were analyzed January 21 to August 30, 2022. Black or White race. Monthly use rates of home-based or outpatient rehabilitation were calculated over the 6 months after discharge from the hospital. The denominator for rate calculations accounted for variation in length of hospital and rehabilitation facility stays and loss to follow-up due to death. Rates over time were modeled using generalized estimating equations, controlling for TBI acuity, demographic characteristics, comorbidities, and socioeconomic factors. Among 19 026 Medicare beneficiaries (mean [SD] age, 81.6 [8.1] years; 10 781 women [56.7%]; and 994 Black beneficiaries [5.2%] and 18 032 White beneficiaries [94.8%]), receipt of 1 or more home health rehabilitation visits did not differ by race (Black vs White, 47.4% vs 46.2%; P = .46), but Black beneficiaries were less likely to receive 1 or more outpatient rehabilitation visits compared with White beneficiaries (3.4% vs 7.1%; P < .001). In fully adjusted regression models, Black beneficiaries received less outpatient therapy over the 6 months after TBI (rate ratio, 0.60; 95% CI, 0.38-0.93). However, Black beneficiaries received more home health rehabilitation therapy over the 6 months after TBI than White beneficiaries (rate ratio, 1.15; 95% CI, 1.00-1.32). This cohort study found relative shifts in rehabilitation use, with markedly lower outpatient therapy use and modestly higher home health care use among Black patients compared with White patients with TBI. These disparities may contribute to reduced functional recovery and residual disability among racial and ethnic minority groups. Additional studies are needed to assess the association between the amount of outpatient rehabilitation care and functional recovery after TBI in socioeconomically disadvantaged populations.

State Cannabis Legalization and Psychosis-Related Health Care Utilization

Psychosis is a hypothesized consequence of cannabis use. Legalization of cannabis could therefore be associated with an increase in rates of health care utilization for psychosis. To evaluate the association of state medical and recreational cannabis laws and commercialization with rates of psychosis-related health care utilization. Retrospective cohort design using state-level panel fixed effects to model within-state changes in monthly rates of psychosis-related health care claims as a function of state cannabis policy level, adjusting for time-varying state-level characteristics and state, year, and month fixed effects. Commercial and Medicare Advantage claims data for beneficiaries aged 16 years and older in all 50 US states and the District of Columbia, 2003 to 2017 were used. Data were analyzed from April 2021 to October 2022. State cannabis legalization policies were measured for each state and month based on law type (medical or recreational) and degree of commercialization (presence or absence of retail outlets). Outcomes were rates of psychosis-related diagnoses and prescribed antipsychotics. This study included 63 680 589 beneficiaries followed for 2 015 189 706 person-months. Women accounted for 51.8% of follow-up time with the majority of person-months recorded for those aged 65 years and older (77.3%) and among White beneficiaries (64.6%). Results from fully-adjusted models showed that, compared with no legalization policy, states with legalization policies experienced no statistically significant increase in rates of psychosis-related diagnoses (medical, no retail outlets: rate ratio [RR], 1.13; 95% CI, 0.97-1.36; medical, retail outlets: RR, 1.24; 95% CI, 0.96-1.61; recreational, no retail outlets: RR, 1.38; 95% CI, 0.93-2.04; recreational, retail outlets: RR, 1.39; 95% CI, 0.98-1.97) or prescribed antipsychotics (medical, no retail outlets RR, 1.00; 95% CI, 0.88-1.13; medical, retail outlets: RR, 1.01; 95% CI, 0.87-1.19; recreational, no retail outlets: RR, 1.13; 95% CI, 0.84-1.51; recreational, retail outlets: RR, 1.14; 95% CI, 0.89-1.45). In exploratory secondary analyses, rates of psychosis-related diagnoses increased significantly among men, people aged 55 to 64 years, and Asian beneficiaries in states with recreational policies compared with no policy. In this retrospective cohort study of commercial and Medicare Advantage claims data, state medical and recreational cannabis policies were not associated with a statistically significant increase in rates of psychosis-related health outcomes. As states continue to introduce new cannabis policies, continued evaluation of psychosis as a potential consequence of state cannabis legalization may be informative.

Coverage Parity And Racial And Ethnic Disparities In Mental Health And Substance Use Care Among Medicare Beneficiaries.

Many older Americans do not receive needed care for mental health and substance use disorders (MHSUD), and there are substantial racial and ethnic disparities in receipt of this care across the lifespan. Medicare introduced cost-sharing parity for outpatient MHSUD care during the period 2010-14, reducing beneficiaries' out-of-pocket share of MHSUD spending from 50percent to 20percent. Among traditional Medicare beneficiaries ages sixty-five and older, we examined changes in MHSUD use and spending during the period 2008-18 for low-income beneficiaries with the cost-sharing reduction versus a control group of beneficiaries with free care throughout the study period among Black, Hispanic, Asian, and American Indian/Alaska Native versus White beneficiaries. Among older Medicare beneficiaries, overall use of MHSUD services increased during this period. For White beneficiaries, MHSUD cost-sharing parity was associated with an increased likelihood of having specialty MHSUD visits and medication use and a reduced likelihood of having unmonitored MHSUD medication use and MHSUD emergency department visits and hospitalizations. However, cost-sharing parity was associated with smaller or no gains in MHSUD services use for racial and ethnic minority beneficiaries compared with White beneficiaries, thus widening racial and ethnic disparities in MHSUD care.

No Study Without Struggle by Leigh Patel

Reviewed by: No Study Without Struggle by Leigh Patel Charles H. F. Davis III No Study Without Struggle Leigh Patel Boston, MA: Beacon Press, 2021, 192 pages, $24.95 (cloth) Broadly speaking, No Study Without Struggle rigorously engages the systemic and structural entanglements of oppression and organized resistance within education and its social contexts. Bringing together historical records, oral histories, and contemporary case examples, Patel beautifully illustrates relationships of power through the analytical lens of settler colonialism. Moreover, the expressed intention of the text is to provide a sense of grounding for the reader about the longstanding symbiosis of study and struggle. As such, Patel provides compelling evidence to demonstrate the connections between higher education as a settler colonial project and the always already confrontations with settler colonial violence. This is noteworthy in that, until recently, the higher education literature has been largely deficient in its engagement with (de)colonization and (de)colonial studies. Yet, as Patel notes, many of the endemic and intractable problems confronting contemporary higher education find their roots in the stolen land and stolen labor and the exploitative and extractive nature of colleges and universities, which continue with their modern function as neoliberal enterprises. The book includes six chapters, each with a conceptual focus that altogether renders a comprehensive yet succinct analysis of higher and postsecondary education as a settler colonial project. Building from the offering of historian Robin D. G. Kelley's seminal essay "Black Study, Black Struggle," Chapter 1 provides Patel's argumentative basis for focusing specifically on settler colonialism as a framework. Whereas "naming the problem of racism in higher education is necessary but insufficient," Patel argues settler colonialism offers a more complete framework for understanding the relationships and distinctions between how marginalized and minoritized people experience various forms of what Mustaffa (2017) has described as educational violence. As a faculty member whose research and teaching broadly focus on systemic oppression in higher education and its social context, I find this particular critique to be as accurate as it is timely. Although the rhetorics of antiracism and decolonization have permeated postsecondary and institutional discourse in recent years, they have not necessarily been understood as complementary endeavors. Patel, however, reconciles these otherwise discrete categories of analysis in education research and practice by putting racism and settler colonialism in conversation as co-determinants that continue to shape endemic inequities in higher education and society. For contemporary students and emerging professionals in the field of higher education, this book provides an important primer for understanding postsecondary institutions as contested terrains in the advancement and retrenchment of social and political inequity. In Chapter 2, Patel describes settler colonialism as an ongoing process of three mutually dependent practices: (a) the theft of land/ resources, (b) Indigenous erasure, and (c) the theft of labor. In the context of postsecondary education, this is established by stating the accomplished fact that all US colleges and universities occupy stolen land, many of which were also built through stolen labor and [End Page 117] the profits therein. Further, Patel recasts the racialized experiences of minoritized students as concurrent transactions of cultural taxation and indebtedness. These transactions are presented as evidence of gift economies, a colonial structure in which the worthiness of the oppressed is determined by the benevolence of "gifting" opportunity or reprieve from their oppressors. Such framing is deeply instructive given how often postsecondary institutions and their agents purport to be solutions to otherwise inescapable problems, a point that has been widely challenged by critical scholars for decades (la paperson, 2017; Mustaffa, 2017). Chapter 3 interrogates the symbiosis of profit and debt, broadly conceived, in which the accumulation-dispossession paradox of resources (i.e., environmental, financial, and social) has shaped higher education since its inception. Noting sharp increases in tuition and the rising cost-share of attending college for students and families, Patel enumerates the consequences of steep declines in federal subsidies following the 2008 recession. Examples such as the racialized student debt crisis and the re-opening of campuses just months after the COVID-19 pandemic are used to thoroughly illustrate a "racial trade-off" between white beneficiaries (i.e., property, institutions, and people) and the proximal Black (and brown) communities...

Risk Adjustment And Promoting Health Equity In Population-Based Payment: Concepts And Evidence.

The objective of risk adjustment is not to predict spending accurately but to support the social goals of a payment system, which include equity. Setting population-based payments at accurate predictions risks entrenching spending levels that are insufficient to mitigate the impact of social determinants on health care use and effectiveness. Instead, to advance equity, payments must be set above current levels of spending for historically disadvantaged groups. In analyses intended to guide such reallocations, we found that current risk adjustment for the community-dwelling Medicare population overpredicts annual spending for Black and Hispanic beneficiaries by $376-$1,264. The risk-adjusted spending for these populations is lower than spending for White beneficiaries despite the former populations' worse risk-adjusted health and functional status. Thus, continued movement from fee-for-service to population-based payment models that omit race and ethnicity from risk adjustment (as current models do) should result in sizable resource reallocations and incentives that support efforts to address racial and ethnic disparities in care. We found smaller overpredictions for less-educated beneficiaries and communities with higher proportions of residents who are Black, Hispanic, or less educated, suggesting that additional payment adjustments that depart from predictive accuracy are needed to support health equity. These findings also suggest that adding social risk factors as predictors to spending models used for risk adjustment may be counterproductive or accomplish little.

PLACE OF DEATH AMONG MEDICARE BENEFICIARIES: VARIATIONS BY DEMENTIA DIAGNOSIS AND RACE/ETHNICITY

Abstract Death at home is preferred by most people and has become a key indicator of the end-of-life care quality; however cultural attitudes about death and dying may vary by race and ethnicity. This study describes racial and ethnic variation in place of death among Medicare beneficiaries aged 50 years and older who died in 2018 with a dementia diagnosis (n=902,208) and without a dementia diagnosis (n=1,096,074). Among those with dementia, 60% died at home, with the highest percentage for non-Hispanic white (62%) beneficiaries, followed by Black/African American (55%), Hispanic (61%), Asian American/Pacific Islander (58%), and American Indian/Alaska Native (58%) beneficiaries. Among those without dementia 61% died at home, with the highest percentage for non-Hispanic white (60%) beneficiaries, followed by Black (57%), Hispanic (65%), Asian American (65%), and American Indian (60%) beneficiaries. Among those who died at home, about half without dementia received hospice care compared to the majority with dementia.

SURVIVAL AFTER DEMENTIA DIAGNOSIS: VARIATION BY RACE/ETHNICITY AND GEOGRAPHIC FACTORS

Abstract This study describes racial and ethnic variation in dementia diagnosis and survival time between diagnosis and death for Medicare beneficiaries aged 50 years and older who died in 2018 (n=1,998,282). The prevalence of diagnosed dementia was higher among non-Hispanic white (45.7%), Black (45.5%), and American Indian/Alaska Native (44.1%) decedents compared to Asian American/Pacific Islander (42.7%), and Hispanic (38.5%) decedents. Median survival time in years was shorter for American Indian/Alaska Native (2.51, IQR 0.7-6.0) and white (2.85, IQR 0.8-6.3) beneficiaries, and longer for Asian American/Pacific Islander (3.36, IQR 1.0-7.3), Black (3.38, IQR 0.9-7.4), and Hispanic (3.83, IQR 1-8.2) beneficiaries. Median survival time also varied by geography and was shortest for Hispanic decedents in Arizona (2.37, IQR 0.6-6.0) and New Mexico (2.92, IQR 0.8-7.0) compared to New Jersey (4.85, IQR 1.5-8.9) and Puerto Rico (5.45, IQR 1.1-12.8). Among Black decedents, survival was longest in New Jersey (3.80, 1.1-7.9) and Arkansas (4.22, 1.0-8.5).

HOSPICE UTILIZATION AND PLACE OF DEATH BY DEMENTIA DIAGNOSIS AND RACE/ETHNICITY

Abstract Timing of hospice referral is critical to patient’s and family’s quality of life and satisfaction with hospice care. This study examined racial/ethnic variation in hospice use and factors associated with death at home among Medicare beneficiaries aged 50 years and older who died in 2018 (n=1,998,282). Hospice use was most frequent among non-Hispanic white beneficiaries (55.8%) followed by Hispanic (46.2%), Asian American (44.5%), Black (42.7%), and American Indian (42.1%) beneficiaries. Among decedents diagnosed with dementia, initiation of hospice prior to the last day of life was significantly associated with death at home among all racial/ethnic groups: non-Hispanic white (OR=2.62), Black (OR=2.04), Hispanic (OR=2.17), Asian American (OR=2.54), and American Indian (OR=2.76). Among decedents not diagnosed with dementia, initiation of hospice prior to the last day of life was less strongly associated with death at home: white (OR=1.33), Black (OR=0.83), Hispanic (OR=1.32), Asian American (OR=1.69), and American Indian (OR=1.56).