New risk-adjustment system was associated with reduced favorable selection in medicare advantage

Do Contemporary Cancer Survivors Experience Better Quality of Life? Evaluating a Decade of SEER Medicare Health Outcomes Survey Data

BACKGROUND

A cancer diagnosis may have deleterious effects on health-related quality of life (HRQOL) as adults age. This study examined differences in HRQOL between cancer and matched noncancer Medicare beneficiaries over 65, within and across two time periods.

METHODS

We used novel matching methods on data from the Surveillance, Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS) data resource. We matched SEER-MHOS respondents with cancer from a recent period (2015-2019) to respondents with cancer from an earlier period (2008-2012). We then matched these two cohorts, without replacement, to contemporary cohorts without cancer diagnoses. We estimated Veteran's RAND 12-Item Short Form Survey Physical Component Summary (PCS) and Mental Component Summary (MCS) scores for all cohorts.

RESULTS

Our analysis found significantly higher mean MCS scores in the recent period for those with cancer relative to the recent noncancer control group. Breast and lung cancer presented positive and statistically significant trends. We found statistically insignificant differences in PCS scores between the two time periods. No cancer sites had different PCS scores over time compared with the comparison group.

CONCLUSIONS

Mental health for those with cancer improved more between 2008 and 2019 than a matched noncancer comparison group. Physical health remained stable across time. These findings highlight the importance of including a matched noncancer group when evaluating HRQOL outcomes.

IMPACT

SEER-MHOS respondents with cancer report stable PCS scores across 15 years of data and higher MCS scores relative to noncancer controls.

Health care utilization before and after a dementia diagnosis in Medicare Advantage versus traditional Medicare

BACKGROUND

Half of all Medicare beneficiaries are enrolled in Medicare Advantage (MA). Many studies document lower care utilization and mortality in MA than traditional Medicare (TM), but evidence for persons with Alzheimer's disease and related dementias (ADRD) is limited.

METHODS

We conducted a retrospective cohort study of 2015-2018 Medicare claims and encounter data for community-dwelling beneficiaries aged 65 and over in TM and MA with an incident ADRD diagnosis in 2017. We compared monthly hospitalization rates and outpatient visits 12 months before and after diagnosis and mortality 1 year from diagnosis. Models adjusted for sociodemographic characteristics and comorbidities. Sensitivity analyses addressed residual confounding using a control group with incident arthritis/glaucoma or excluding MA Special Needs Plans, and potential underreporting by restricting to MA plans with high data completeness.

RESULTS

Among 454,508 beneficiaries diagnosed with ADRD in 2017, 250,837 (55%) were in TM and 203,671 (45%) in MA. Four to 12 months before diagnosis, monthly hospitalizations and outpatient visits were similar in TM and MA. In the diagnosis month, 36.5% of beneficiaries in TM had a hospitalization compared with 25.4% in MA, an adjusted difference of 10.7 percentage points [95% CI: 10.3, 11.1]. Beneficiaries in TM averaged 10.5 outpatient visits in the diagnosis month compared with 8.4 in MA, an adjusted difference of 1.59 visits [95% CI: 1.47-1.70]. Utilization differences narrowed but remained higher in TM for many months. One-year mortality was 27.9% in TM and 22.2% in MA; an adjusted odds ratio of 1.152 [95% CI: 1.135-1.169] for those in TM compared with MA. Controlling for hospitalization in the diagnosis month substantially reduced the mortality difference.

CONCLUSION

Hospitalization rates and outpatient visits increased more after an ADRD diagnosis in TM than MA. One-year post-diagnosis, mortality was not higher in MA than TM but comparisons of quality of life and caregiver burden are needed.

Postacute Care Services Use and Outcomes Among Traditional Medicare and Medicare Advantage Beneficiaries

Importance

Better evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes.

Objective

To compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees.

Design, Setting, and Participants

This cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design.

Exposures

Enrollment in MA and dual eligibility for Medicare and Medicaid.

Main Outcomes and Measures

Postacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services.

Results

Included in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility.

Conclusions and relevance

In this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.

Use of High-Risk Medications Among Older Adults Enrolled in Medicare Advantage Plans vs Traditional Medicare

Importance

Limiting the use of high-risk medications (HRMs) among older adults is a national priority to provide a high quality of care for older beneficiaries of both Medicare Advantage and traditional fee-for-service Medicare Part D plans.

Objective

To evaluate the differences in the rate of HRM prescription fills among beneficiaries of traditional Medicare vs Medicare Advantage Part D plans and to examine the extent to which these differences change over time and the patient-level factors associated with higher rates of HRMs.

Design, Setting, and Participants

This cohort study used a 20% sample of Medicare Part D data on filled drug prescriptions from 2013 to 2017 and a 40% sample from 2018. The sample comprised Medicare beneficiaries aged 66 years or older who were enrolled in Medicare Advantage or traditional Medicare Part D plans. Data were analyzed between April 1, 2022, and April 15, 2023.

Main Outcomes and Measures

The primary outcome was the number of unique HRMs prescribed to older Medicare beneficiaries per 1000 beneficiaries. Linear regression models were used to model the primary outcome, adjusting for patient characteristics and county characteristics and including hospital referral region fixed effects.

Results

The sample included 5 595 361 unique Medicare Advantage beneficiaries who were propensity score-matched on a year-by-year basis to 6 578 126 unique traditional Medicare beneficiaries between 2013 and 2018, resulting in 13 704 348 matched pairs of beneficiary-years. The traditional Medicare vs Medicare Advantage cohorts were similar in age (mean [SD] age, 75.65 [7.53] years vs 75.60 [7.38] years), proportion of males (8 127 261 [59.3%] vs 8 137 834 [59.4%]; standardized mean difference [SMD] = 0.002), and predominant race and ethnicity (77.1% vs 77.4% non-Hispanic White; SMD = 0.05). On average in 2013, Medicare Advantage beneficiaries filled 135.1 (95% CI, 128.4-142.6) unique HRMs per 1000 beneficiaries compared with 165.6 (95% CI, 158.1-172.3) HRMs per 1000 beneficiaries for traditional Medicare. In 2018, the rate of HRMs had decreased to 41.5 (95% CI, 38.2-44.2) HRMs per 1000 beneficiaries in Medicare Advantage and to 56.9 (95% CI, 54.1-60.1) HRMs per 1000 beneficiaries in traditional Medicare. Across the study period, Medicare Advantage beneficiaries received 24.3 (95% CI, 20.2-28.3) fewer HRMs per 1000 beneficiaries per year compared with traditional Medicare beneficiaries. Female, American Indian or Alaska Native, and White populations were more likely to receive HRMs than other groups.

Conclusion and Relevance

Results of this study showed that HRM rates were consistently lower among Medicare Advantage than traditional Medicare beneficiaries. Higher use of HRMs among female, American Indian or Alaska Native, and White populations is a concerning disparity that requires further attention.

Effects of Medicare Advantage on preventive care use and health behavior

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on preventive care use and health behavior.

DATA SOURCES

The Medicare Current Beneficiary Survey, the Area Health Resources File, the Geographic Variation Public Use File, and the Centers for Medicare and Medicaid Services annual risk and ratebook files for 2012-2016.

STUDY DESIGN

Outcomes included 11 measures of preventive care use and six measures of health behavior. My primary independent variable was MA enrollment. For each outcome, I first conducted linear regression analysis while adjusting for individual-level and county-level characteristics. Then, I conducted the following alternative analyses to account for differences in observed and/or unobserved characteristics between MA and traditional Medicare (TM) enrollees: propensity score (PS) matching analysis and instrumental variable (IV) analysis.

DATA COLLECTION/EXTRACTION METHODS

I extracted 9399 MA enrollees and 15,543 TM enrollees.

FINDINGS

Linear regression and PS matching analyses showed that MA enrollment was statistically significantly associated with higher likelihood of having blood pressure measurement, cholesterol measurement, and influenza vaccine, lower likelihood of receiving an HbA1C test, and higher likelihood of currently smoking. However, the magnitude of the associations was small. There were no statistically significant associations in other measures. IV analyses also found no or limited evidence that MA enrollment led to statistically significant changes in preventive care use and health behavior. Specifically, MA enrollment led to statistically significant improvements in the likelihood of doing any physical activities (1.29 [95% CI: 0.51-2.07]) or doing muscle-strengthening activities (0.72 [95% CI: 0.03-1.41]). No statistically significant changes were observed in other measures.

CONCLUSIONS

MA plans may not necessarily increase the use of preventive services and improve health behaviors. As improvements in preventive services and health behavior may have the potential to achieve better outcomes while lowering costs, policy makers should consider developing targeted interventions for MA to achieve those improvements.

Racial and ethnic disparities in access to and enrollment in high-quality Medicare Advantage plans

OBJECTIVE

Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower-quality plans, measured by a 5-star quality rating system. We examine whether differential access to high-rated plans was associated with this differential enrollment in high-rated plans by race and ethnicity among MA enrollees.

DATA SOURCES

The Medicare Master Beneficiary Summary File and MA Landscape File for 2016.

STUDY DESIGN

We first examined county-level MA plan offerings by race and ethnicity. We then examined the association of racial and ethnic differences in enrollment by star rating by controlling for the following different sets of covariates: (1) individual-level characteristics only, and (2) individual-level characteristics and county-level MA plan offerings.

DATA COLLECTION/EXTRACTION METHODS

Not applicable PRINCIPAL FINDINGS: Racial and ethnic minority enrollees had, on average, more MA plans available in their counties of residence compared to White enrollees (16.1, 20.8, 20.2, vs. 15.1 for Black, Asian/Pacific Islander, Hispanic, and White enrollees), but had fewer number of high-rated plans (4-star plans or higher) and/or more number of low-rated plans (3.5-star plans or lower). While racial and ethnic minority enrollees had lower enrollment in 4-4.5 star plans than White enrollees, this difference substantially decreased after accounting for county-level MA plan offerings (-9.1 to -0.5 percentage points for Black enrollees, -15.9 to -5.0 percentage points for Asian/Pacific Islander enrollees, and -12.7 to 0.6 percentage points for Hispanic enrollees). Results for Black enrollees were notable as the racial difference reversed when we limited the analysis to those who live in counties that offer a 5-star plan. After accounting for county-level MA plan offerings, Black enrollees had 3.2 percentage points higher enrollment in 5-star plans than White enrollees.

CONCLUSIONS

Differences in enrollment in high-rated MA plans by race and ethnicity may be explained by limited access and not by individual characteristics or enrollment decisions.

Increased Medicare Advantage Penetration Is Associated With Lower Postacute Care Use For Traditional Medicare Patients

Medicare Advantage (MA) plans, which accounted for 45 percent of total Medicare enrollment in 2022, are incentivized to minimize spending on low-value services. Prior research indicates that MA plan enrollment is associated with reduced postacute care use without adverse impacts on patient outcomes. However, it is unclear whether a rising MA enrollment level is associated with a change in postacute care use in traditional Medicare, especially given growing participation in traditional Medicare Alternative Payment Models that have been found to be associated with lower postacute care spending. We hypothesize that market-level MA expansion is associated with reduced postacute care use among traditional Medicare beneficiaries-a "spillover" effect of providers modifying their practice patterns in response to MA plans' incentives. We found increased MA market penetration associated with reduced postacute care use among traditional Medicare beneficiaries, without a corresponding increase in hospital readmissions. This association was generally stronger in markets with a greater share of traditional Medicare beneficiaries attributed to accountable care organizations, suggesting that policy makers should account for MA penetration when evaluating potential savings in Alternative Payment Models within traditional Medicare.

Variations in Medicare Advantage Switching Rates Among African American and Hispanic Medicare Beneficiaries With Alzheimer's Disease and Related Dementias, by Sex and Dual Eligibility

OBJECTIVES

The objective of this study was to identify rates of switching to Medicare Advantage (MA) among fee-for-service (FFS) Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD) by race/ethnicity and whether these rates vary by sex and dual-eligibility status for Medicare and Medicaid.

METHODS

Data came from the Medicare Master Beneficiary Summary File from 2017 to 2018. The outcome of interest for this study was switching from FFS to MA during any month in 2018. The primary independent variable was race/ethnicity including non-Hispanic White, non-Hispanic African American, and Hispanic beneficiaries. Two interaction terms among race/ethnicity and dual eligibility, and race/ethnicity and sex were included. The model adjusted for age, year of ADRD diagnosis, the number of chronic/disabling conditions, total health care costs, and ZIP code fixed effects.

RESULTS

The study included 2,284,175 FFS Medicare beneficiaries with an ADRD diagnosis in 2017. Among dual-eligible beneficiaries, adjusted rates of switching were higher among African American (1.91 percentage points [p.p.], 95% confidence interval [CI]: 1.68-2.15) and Hispanic beneficiaries (1.36 p.p., 95% CI: 1.07-1.64) compared to non-Hispanic White beneficiaries. Among males, adjusted rates were higher among African American (3.28 p.p., 95% CI: 2.97-3.59) and Hispanic beneficiaries (2.14 p.p., 95% CI: 1.86-2.41) compared to non-Hispanic White beneficiaries.

DISCUSSION

Among persons with ADRD, African American and Hispanic beneficiaries are more likely than White beneficiaries to switch from FFS to MA. This finding underscores the need to monitor the quality and equity of access and care for these populations.

Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions

BACKGROUND

Enrollment in high-quality Medicare Advantage (MA) plans, measured by a 5-star quality rating system, was lower among racial and ethnic minority enrollees than White enrollees partly due to fewer high-quality plans available in their counties of residence. This may contribute to racial and ethnic disparities in ambulatory care sensitive condition (ACSC) hospitalizations.

OBJECTIVE

We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating.

METHODS

Using the Medicare enrollment and claims data for 2016, we identified White, Black, Hispanic, and Asian/Pacific Islander enrollees in MA plans. We estimated racial and ethnic disparities in ACSC hospitalizations (per 10,000 enrollees) overall and by star rating.

RESULTS

We found that the adjusted rates of ACSC hospitalizations were significantly higher among Black enrollees than White enrollees overall [39.4 (95% confidence interval: 36.3-42.5)]. However, no significant disparities were found among Hispanic and Asian/Pacific Islander enrollees. The adjusted rates of ACSC hospitalizations were higher in lower-rated plans than higher-rated plans in all racial and ethnic groups. The significant disparities in ACSC hospitalizations by star rating were the most pronounced between White and Black enrollees. We found suggestive evidence that enrollment in lower-rated plans was associated with higher disparities in ACSC hospitalizations between White and Black enrollees.

CONCLUSIONS

Substantial disparities in ACSC hospitalizations exist between White and Black enrollees in MA plans, especially for lower-rated plans. Policies aimed at reducing racial disparities in ACSC hospitalizations could include improving access to high-rated plans.

Impact of higher payments for rural home health episodes on rehospitalizations

PURPOSE

Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on patient outcomes.

METHODS

Using 100% Medicare data on postacute HH episodes from 2007 to 2014, we estimated the impact of higher payments on beneficiaries outcomes using difference-in-differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010.

FINDINGS

Our sample included 5.6 million postacute HH episodes (18% rural). In the preperiod, the 30- and 60-day rehospitalization rates for urban HH episodes were 11.30% and 18.23% compared to 11.38% and 18.39% for rural HH episodes. After 2010, 30- and 60-day rehospitalization rates declined, 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference-in-difference estimate was 0.29 percentage points (P = .005) and 0.57 percentage points (P < .001) for 30- and 60-day rehospitalization, respectively.

CONCLUSIONS

Increasing payments resulted in a statistically significant reduction in rehospitalizations for rural postacute HH episodes. The add-on payment is set to sunset in 2022 and its impact on access and quality to HH for rural older adults should be reconsidered.

Effect of Medicare Advantage on health care use and care dissatisfaction in mental illness

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on health care use and dissatisfaction with care received among Medicare beneficiaries with mental illness.

DATA SOURCES

I identified traditional Medicare (TM) and MA beneficiaries with mental illness using the Medicare Current Beneficiary Survey for 2012-2016.

STUDY DESIGN

I included two types of outcomes: four measures of health care use and 10 measures of care dissatisfaction. My primary independent variable was enrollment in TM versus MA. To address selective enrollment into MA, I used an instrumental variable (IV) approach. Following prior research, I decomposed the MA benchmark into exogenous and endogenous components and then used the exogenous component as my instrument.

DATA COLLECTION/EXTRACTION METHODS

Not Applicable.

PRINCIPAL FINDINGS

IV analyses showed that compared with TM enrollment, MA enrollment significantly decreased outpatient hospital visits and medical provider visits by 6.73 (95% CI: -12.10 to -1.36) and 36.48 (95% CI: -52.67 to -20.28). However, there were no significant changes in inpatient hospital admissions and prescription drug purchases. Compared with TM enrollment, MA enrollment significantly increased dissatisfaction with out-of-pocket expenses by 25.51 percentage points (95% CI: 0.43 to 50.60). However, there were no significant changes in other measures of care dissatisfaction in terms of access to care, quality of care, and prescription medication.

CONCLUSIONS

These findings suggest that MA enrollment may lead to low health care use among those with mental illness, indicating efficient care delivery. Also, MA enrollment may not preclude those with mental illness from accessing needed care. However, high dissatisfaction with out-of-pocket expenses among MA beneficiaries may imply the use of out-of-network providers. Further research is warranted to investigate whether high dissatisfaction with out-of-pocket expenses may be attributable to MA's narrow networks for mental services.

Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program

IMPORTANCE

The 2 primary efforts of Medicare to advance value-based care are Medicare Advantage (MA) and the fee-for-service-based Medicare Shared Savings Program (MSSP). It is unknown how spending differs between the 2 programs after accounting for differences in patient clinical risk.

OBJECTIVE

To examine how spending and utilization differ between MA and MSSP beneficiaries after accounting for differences in clinical risk using data from administrative claims and electronic health records.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective economic evaluation used data from 15 763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022.

EXPOSURES

Enrollment in MA or attribution to an accountable care organization in the MSSP program.

MAIN OUTCOMES AND MEASURES

Per-beneficiary annual total spending and subcomponents, including inpatient hospital, outpatient hospital, skilled nursing facility, emergency department, primary care, and specialist spending.

RESULTS

The sample of 15 763 participants included 12 720 (81%) MA and 3043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). The mean unadjusted per-member per-year spending difference between MSSP and MA disease-specific subcohorts was $2159 in diabetes, $4074 in CHF, $2560 in CKD, and $2330 in hypertension. After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2454; 95% CI, $1431-$3574), CHF ($3699; 95% CI, $1235-$6523), CKD ($2478; 95% CI, $1172-$3920), and hypertension ($2258; 95% CI, $1616-2,939). Higher MSSP spending among matched beneficiaries was consistent over time. In the matched cohort in 2018, MSSP total spending ranged from 23% (CHF) to 30% (CKD) higher than MA. Adjusting for differential trends in coding intensity did not affect these results. Higher outpatient hospital spending among MSSP beneficiaries contributed most to spending differences between MSSP and MA, representing 49% to 62% of spending differences across disease cohorts.

CONCLUSIONS AND RELEVANCE

In this study, utilization and spending were consistently higher for MSSP than MA beneficiaries within the same health system even after adjusting for granular metrics of clinical risk. Nonclinical factors likely contribute to the large differences in MA vs MSSP spending, which may create challenges for health systems participating in MSSP relative to their participation in MA.

Effects of Medicare Advantage on patterns of end‐of‐life care among Medicare decedents

OBJECTIVE

To examine the effects of Medicare Advantage (MA) enrollment on patterns of end-of-life care.

DATA SOURCES

We used data from the Master Beneficiary Summary File, the Medicare Provider Analysis and Review, hospice claims, the Minimum Data Set, the Outcome and Assessment Information Set, the Area Health Resources File, and Geographic Variation Public Use File for 2012-2014.

STUDY DESIGN

To address selective enrollment into MA, we exploited a discontinuity in payment rates by county population (urban floor payments) as an instrument.

DATA COLLECTION/EXTRACTION METHODS

We identified Medicare beneficiaries continuously enrolled in MA or TM during their last year of life between 2012 and 2014 using Medicare administrative data.

PRINCIPAL FINDINGS

We did not find evidence that MA enrollment led to a change in hospital admissions in the last 30 days of life, but MA enrollment decreased hospital as the site of death by 11.0 (95% CI: -13.9 to -8.1) percentage points. Once hospitalized, however, MA enrollment increased use of intensive care by 6.7 (95% CI: 0.3 to 13.1) percentage points and non-invasive mechanical ventilation by 9.2 (95% CI: 5.5 to 12.9) percentage points. MA enrollment increased hospice use by 6.2 (95% CI: 2.3 to 10.1) percentage points at time of death and 7.7 (95% CI: 3.8 to 11.6) percentage points in the last 30 days of life. Particularly, MA enrollment increased hospice admissions among those who were admitted to the hospital within 30 days prior to hospice admission by 18.8 (95% CI: 13.8 to 23.8) percentage points. However, MA enrollment decreased hospice admissions among those who were admitted to home health within 30 days prior to hospice admission by 18.6 (95% CI: -21.9 to -15.2) percentage points.

CONCLUSIONS

MA plans may improve end-of-life care by reducing hospital death while also improving access to hospice, especially among recently hospitalized persons.

Coding-Driven Changes In Measured Risk In Accountable Care Organizations

Claims data, which form the foundation of risk adjustment in payment for health care services, may reflect efforts to capture more-or more severe-clinical conditions rather than true changes in health status. This can distort payments. We quantify this in the context of Medicare's accountable care organization (ACO) program by comparing risk scores derived from two different measurement approaches. One approach uses diagnoses coded on claims based on Centers for Medicare and Medicaid Services Hierarchical Condition Categories (HCC), and the other uses self-reported, survey-based health data from the Consumer Assessment of Healthcare Providers and Systems (CAHPS). During 2013-16 HCC-based risk scores grew faster than CAHPS-based risk scores (2.1 percent versus 0.3 percent annually), and the gap in HCC- and CAHPS-based risk score growth varied widely across ACOs. The average gap in risk score growth appears to be the result primarily of HCC coding practices rather than poor performance of the CAHPS model, suggesting that coding practices (not necessarily driven by ACO contracts) may account for most of the observed risk score growth for ACO beneficiaries.

Patterns of incident dementia codes during the COVID-19 pandemic at an integrated healthcare system

BACKGROUND

The COVID-19 pandemic delayed diagnosis and care for some acute conditions and reduced monitoring for some chronic conditions. It is unclear whether new diagnoses of chronic conditions such as dementia were also affected. We compared the pattern of incident Alzheimer's disease and related dementia (ADRD) diagnosis codes from 2017 to 2019 through 2020, the first pandemic year.

METHODS

Retrospective cohort design, leveraging 2015-2020 data on all members 65 years and older with no prior ADRD diagnosis, enrolled in a large integrated healthcare system for at least 2 years. Incident ADRD was defined as the first ICD-10 code at any encounter, including outpatient (face-to-face, video, or phone), hospital (emergency department, observation, or inpatient), or continuing care (home, skilled nursing facility, and long-term care). We also examined incident ADRD codes and use of telehealth by age, sex, race/ethnicity, and spoken language.

RESULTS

Compared to overall annual incidence rates for ADRD codes in 2017-2019, 2020 incidence was slightly lower (1.30% vs. 1.40%), partially compensating later in the year for reduced rates during the early months of the pandemic. No racial or ethnic group differences were identified. Telehealth ADRD codes increased fourfold, making up for a 39% drop from face-to-face outpatient encounters. Older age (85+) was associated with higher odds of receiving telecare versus face-to-face care in 2020 (OR:1.50, 95%CI: 1.25-1.80) and a slightly lower incidence of new codes; no racial/ethnic, sex, or language differences were identified in the mode of care.

CONCLUSIONS

Rates of incident ADRD codes dropped early in the first pandemic year but rose again to near pre-pandemic rates for the year as a whole, as clinicians rapidly pivoted to telehealth. With refinement of protocols for remote dementia detection and diagnosis, health systems could improve access to equitable detection and diagnosis of ADRD going forward.

Mitigating Risk Selection in Healthcare Entitlement Programs: A Beneficiary-Level Competitive Bidding Approach

Many developed countries rely, to varying degrees, on competition among private health plans to obtain affordable and high-quality health insurance for their residents. Incorporating beneficiary-level competitive bidding into these healthcare systems can better align the incentives of these health plans, increase their willingness to enroll, and serve the sickest and most vulnerable patients while keeping costs manageable. We identify two digitally enabled program designs that allow private insurance plans to competitively bid to enroll individual beneficiaries. Compared with those used in existing entitlement programs, these designs always make a larger share of the beneficiary population profitable to enroll, thereby increasing willingness of the plans to enroll the most costly beneficiaries and improving access to care. On simulating the conditions of existing real-word healthcare entitlement programs, we found that these new designs actually tend to lower the tax burden in up to 83% of simulations. The research findings suggest that these new designs hold great promise in achieving the dual aim of improved access and lower costs. We believe that findings from this research can guide policymakers implement policies that will enroll more beneficiaries and cost the taxpayers less.

Comprehensive Analysis of Trends in Medicare Utilization and Reimbursement in Physical Medicine & Rehabilitation: 2012 to 2017

INTRODUCTION

There is an absence of literature describing Medicare utilization by physiatrists, despite their key role in treating Medicare enrollees with qualifying disabilities and common neuromusculoskeletal conditions.

OBJECTIVE

Analyze Medicare data regarding physiatrists and their beneficiaries, services, and reimbursement, as well as trends in utilization and geographic distribution.

DESIGN AND SETTING

Retrospective analysis of publicly available Center for Medicare & Medicaid Services data for Medicare beneficiaries receiving physiatric services from 2012-2017.

MAIN OUTCOME MEASURES

After adjustment for inflation, variables assessed for changes over time included provider and beneficiary demographics, total Medicare reimbursement, and number of services provided, subsequently separated by drug and medical service metrics. Lorenz curves and Gini coefficients were computed to study reimbursement inequality. Choropleth maps were generated to assess geographic differences in physician density and reimbursement, both by state and ZIP code.

RESULTS

The number of physiatrists utilizing Medicare increased from 7230 to 7895 from 2012-2017, while the average number of unique beneficiaries per clinician remained constant (307 vs 310; P = 0.51). Beneficiaries' mean hierarchical conditions category (HCC) health risk score, normalized to 1.0 for the average beneficiary, increased significantly from 2012-2017 (1.72 vs 1.80; P < 0.01). Mean Medicare reimbursement per physiatrist decreased significantly from 2012-2017 ($131 960 vs $117 623; P < 0.001), while mean number of services remained constant (3243 vs 3077; P = 0.132). Botulinum toxin and baclofen injections were the two most reimbursed drug-related services. Gini coefficients ranged from 0.52-0.53 for 2012-2017, suggesting moderate reimbursement inequality, with the 75th percentile receiving on average 2 times the median. Both physician density and top earners were concentrated in urban and metropolitan areas.

CONCLUSIONS

Despite rising healthcare costs and increasing medical complexity of physiatrists' beneficiaries, Medicare payments have decreased over time. These trends are relevant to both providers and policy makers, particularly in light of unequal geographic distribution of physiatrists across the country. This article is protected by copyright. All rights reserved.

Comparing Medicare Advantage And Traditional Medicare: A Systematic Review

Medicare Advantage enrollment has almost doubled since 2010 and now accounts for more than a third of all Medicare beneficiaries. We performed a systematic review to compare Medicare Advantage and traditional Medicare on key metrics. Evidence from forty-eight studies showed that in most or all comparisons, Medicare Advantage was associated with more preventive care visits, fewer hospital admissions and emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending. Medicare Advantage outperformed traditional Medicare in most studies comparing quality-of-care metrics. However, the evidence on patient experience, readmission rates, mortality, and racial/ethnic disparities did not show a trend of better performance in Medicare Advantage. Evidence to date might not fully account for selection bias, unobserved differences in social determinants of health, or risk adjustment challenges, in part because of differences in data quality that limit the comparability of outcomes between Medicare Advantage and traditional Medicare. With Medicare Advantage plans expected to grow in popularity, policy makers should support policies to improve data completeness and comparability, and health plans should focus on improving patient experience.

Mandated Copayment Reductions in Medicare Advantage: Effects on Skilled Nursing Care, Hospitalizations, and Plan Exit

OBJECTIVES

To address concerns that postacute cost-sharing may deter high-need beneficiaries from participating in Medicare Advantage (MA) plans, the Centers for Medicare and Medicaid Services have capped cost-sharing for skilled nursing facility (SNF) services in MA plans since 2011. This study examines whether SNF use, inpatient use, and plan disenrollment changed following stricter regulations in 2015 that required most MA plans to eliminate or substantially reduce cost-sharing for SNF care.

DESIGN

Difference-in-differences retrospective analysis from 2013 to 2016.

SETTING

MA plans.

PARTICIPANTS

Thirty-one million MA members in 320 plans with mandatory cost-sharing reductions and 261 plans without such reductions.

MEASUREMENTS

Mean monthly number of SNF admissions, SNF days, hospitalizations, and plan disenrollees per 1000 members.

RESULTS

Mean total cost-sharing for the first 20 days of SNF services decreased from $911 to $104 in affected plans. Relative to concurrent changes in plans without mandated cost-sharing reductions, plans with mandatory cost-sharing reductions experienced no significant differences in the number of SNF days per 1000 members (adjusted between-group difference: 0.4 days per 1000 members [95% confidence interval (95% CI), -5.2 to 6.0, P=0.89], small decreases in the number of hospitalizations per 1000 members [adjusted between-group difference: 0.6 admissions per 1000 members (95% CI, -1.0 to -0.1; P=0.03)], and small decreases in the number of SNF users who disenrolled at year-end [adjusted between-group difference: -16.8 disenrollees per 1000 members (95% CI, -31.9 to -1.8; P=0.03)].

CONCLUSIONS

Mandated reductions in SNF cost-sharing may have curbed selective disenrollment from MA plans without significantly increasing use of SNF services.

Trends in Use of Low-Value Care in Traditional Fee-for-Service Medicare and Medicare Advantage

IMPORTANCE

Decreasing use of low-value care is a major goal for Medicare given the potential to decrease costs and harms. Compared with traditional fee-for-service Medicare (TM), Medicare Advantage (MA) is more strongly financially incentivized to decrease use of low-value care.

OBJECTIVES

To compare use of low-value care among individuals enrolled in TM and those enrolled in MA overall and to examine trends in use of low-value care in both programs from 2006 to 2015.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed individuals enrolled in TM and MA using data from the 2006 to 2015 Medical Expenditure Panel Survey. To account for differences in characteristics between individuals enrolled in TM and those enrolled in MA, a propensity score-based approach was used. Data were analyzed from August 2020 through January 2021.

EXPOSURES

Being enrolled in MA or TM.

MAIN OUTCOMES AND MEASURES

Binary measures of use were collected for 13 low-value services in 4 categories (ie, [1] cancer screening: cervical, colorectal, and prostate cancer screening in older adults; [2] antibiotic use: antibiotic for acute upper respiratory infection and antibiotic for influenza; [3] medication: anxiolytic, sedative, or hypnotic in an adult older than 65 years; benzodiazepine for depression; opioid for headache; opioid for back pain; and nonsteroidal anti-inflammatory drug [NSAID] for hypertension, heart failure, or chronic kidney disease; and [4] imaging: magnetic resonance imaging [MRI] or computed tomography [CT] for back pain, radiograph for back pain, and MRI or CT for headache) and 4 low-value composites corresponding to the categories (ie, cancer screening composite, antibiotic use composite, medication composite, and imaging composite).

RESULTS

Among 11 677 individuals enrolled in TM and 5164 individuals enrolled in MA, 9429 (56.0%) were women and the mean (SD) age was 74.5 (6.3) years. Of 13 low-value services and 4 low-value composites, statistically significant differences were found in 2 measures. For the low-value medication composite, 2054 of 11 636 eligible individuals enrolled in TM (adjusted mean, 17.6%; 95% CI, 16.8%-18.3%) received the care, and 981 of 5141 eligible individuals enrolled in MA (adjusted mean, 19.7%; 95% CI, 18.3%-21.2%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.2 percentage points (95% CI, 0.5-3.8 percentage points; P = .02). For the NSAID use for hypertension, heart failure, or kidney disease metric, 807 of 7832 individuals enrolled in TM (adjusted mean, 10.0%; 95% CI, 9.2%-10.8%) received the care, and 447 of 3566 individuals enrolled in MA (adjusted mean, 12.9%; 95% CI, 19.7%-27.1%) received the care, for a rate of use that was significantly higher among individuals enrolled in MA, by 2.9 percentage points (95% CI, 1.3-4.6 percentage points; P = .001). Overall, there were no decreases in use of low-value care in TM or MA over time.

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that use of low-value care was similarly prevalent in MA and TM, suggesting that MA enrollment was not associated with decreased provision of low-value care compared with TM.

Assessment of Trends in Statin Therapy for Secondary Prevention of Atherosclerotic Cardiovascular Disease in US Adults From 2007 to 2016

IMPORTANCE

Atherosclerotic cardiovascular disease (ASCVD) is highly prevalent in the US, with studies indicating substantial rates of nonadherence to and undertreatment with statin therapy. The 2013 American College of Cardiology/American Heart Association guideline recommended high-intensity statins for all patients age 75 years and younger with documented ASCVD in whom such therapy is tolerated, but there is limited evidence documenting population trends of statin use, adherence, and outcomes in the periods before and after the update to the guideline.

OBJECTIVE

To assess trends in the use, adherence, cost, and outcomes of statin therapy for secondary prevention in patients with different types of ASCVD between 2007 and 2016.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used data from the OptumLab Data Warehouse database containing privately insured and Medicare Advantage enrollees with demographic characteristics similar to the national US population. Participants were adult patients (age ≥21 years) who had their first ASCVD event between January 1, 2007, and December 31, 2016. Data were characterized as belonging to 3 groups: (1) cardiovascular heart disease (CHD); (2) ischemic stroke or transient ischemic attack (TIA); and (3) peripheral artery disease (PAD). Data were analyzed from July 1 to August 1, 2018.

EXPOSURES

Calendar year of the initial ASCVD event.

MAIN OUTCOMES AND MEASURES

Trends in the statin use (within 30 days of discharge from hospitalization), adherence (proportion of days covered ≥80% within the first year), cost, major adverse cardiac events (1-year cumulative risk), and statin intolerance (within the first year).

RESULTS

Of the 284 954 patients with a new ASCVD event, 128 422 (45.1%) were women; the median age was 63 years (interquartile range [IQR], 54-72 years); 207 781 (72.9%) were White. The use of statins increased from 50.3% in 2007 to 59.9% in 2016, the use of high-intensity statins increased from 25.0% to 49.2%, and the adherence increased from 58.7% to 70.5% (P < .001 for all trends). Patients with CHD were more likely to receive statins and high-intensity statins and adhere to medications than patients with ischemic stroke, TIA, or PAD despite similar observed treatment benefit. In 2016, 80.9% of patients with CHD used a statin vs 65.8% of patients with ischemic stroke or TIA and 37.5% of patients with PAD. Out-of-pocket cost per 30-day decreased from a median of $20 (interquartile range, $7.6-$31.9) in 2007 to $2 (interquartile range, $1.6-$10.0) in 2016 (P < .001) with the increasing use of generic statins (42.0% in 2007 vs 94.9% in 2016; P < .001). Major adverse cardiac events decreased from 8.9% in 2007 to 6.5% in 2016 (P < .001) whereas statin intolerance increased from 4.0% to 5.1% (P < .001).

CONCLUSIONS AND RELEVANCE

There have been modest improvements in the use, adherence, and cardiovascular outcomes over the past decade for statin therapy in patients with ASCVD, but a substantial and persistent treatment gap exists between patients with and without CHD, between men and women.

Variation in dental services by rurality among privately insured adults in the United States

OBJECTIVES

Rurality is associated with reduced dental access and worse oral health outcomes. It is unknown whether there is variation in dental services received by rural adults who visit a dentist.

METHODS

This was a retrospective analysis of claims data from a large private insurer. All individuals who had at least one dental visit in 2018 were included. Patient demographics, whether or not a patient's ZIP code was rural as defined by the Federal Office of Rural Health Policy, as well as ZIP code demographics were collected. Differences in the frequency of dental services received were evaluated using χ² tests. Multilevel logistic regressions were used to evaluate the individual and ZIP code-level correlates of receiving a preventive dental procedure, a tooth extraction, or a denture-related dental procedure.

RESULTS

Rates of preventive, oral and maxillofacial surgery, and denture-related procedures were higher among rural adults. Accounting for individual age and gender, and ZIP code average income and dentist density, rural dwellers were more likely to receive a preventive procedure [odds ratio (OR) 1.15, P < 0.0001] or tooth extraction (OR 1.08, P < 0.0001), and less likely to have a denture-related procedure (OR 0.94, P = 0.015) compared to nonrural dwellers. Female gender was the strongest predictor of receiving a preventive procedure (OR 1.30, P < 0.0001).

CONCLUSIONS

Even among privately insured individuals with known access to dental care, rurality was associated with significant differences in the frequency of various dental procedures. Rural dental patients may have higher needs for oral surgical procedures, even when they have access to preventive care.

Open enrollment periods and plan choices

Open enrollment periods are pervasively used in insurance markets to limit adverse selection risks resulting when enrollees can switch plans at will. We exploit a change in the open enrollment rules of Medicare Advantage to analyze how beneficiaries responded to the option of switching to a 5-star-rated plan at anytime, in a setting where insurers adjusted premiums and benefit design to counterbalance the increased selection risk. We present three findings: Within-year switches to 5-star plans increase by 7-16%; demand for 5-star plans across the years does not decline; and the enrollees who switch to a 5-star plan during the year are in better health status than those who do not switch.

Home Health Use Following a Cancer Diagnosis Among Patients Enrolled in Medicare Advantage and Traditional Medicare: Findings From the Newly Linked SEER-Medicare and Home Health OASIS Data

BACKGROUND

This article describes characteristics of patients receiving home health following an initial cancer diagnosis, comparing those enrolled in Medicare Advantage (MA) and Traditional Medicare (TM), using the newly linked 2010-2014 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare and home health Outcome and Assessment Information Set (OASIS) data.

METHODS

We identified SEER-Medicare beneficiaries with at least one OASIS assessment within 3 months of cancer diagnosis in 2010-2014, and summarized their demographic and clinical characteristics. Demographic and diagnostic data were obtained from the SEER-Medicare data, while further details about cognitive status, mood, function, and medical history were obtained from OASIS. We assessed differences between MA and TM beneficiaries using chi-square tests for independence, t-tests, and Kruskal-Wallis tests.

RESUTLS

We identified 104 023 patients who received home health within 3 months of cancer diagnosis: 81 587 enrolled in TM and 22 436 enrolled in MA. TM cancer patients had higher unadjusted rates of home health use than MA patients (16.3% vs 10.3%, P < .001). TM cancer patients receiving home health had more limitations in their cognitive function than their MA counterparts and longer lengths of service (mean = 42.2 days vs 39.4 days, P < .001; median = 27 vs 26 days, interquartile range = 42).

CONCLUSION

This study demonstrates the large number of cancer patients in the SEER-Medicare-OASIS data and describes characteristics for TM and MA patients. These newly linked data can be used to assess home health care among older patients with cancer.

Association of Medicare Part D Benzodiazepine Coverage Expansion With Changes in Fall-Related Injuries and Overdoses Among Medicare Advantage Beneficiaries

IMPORTANCE

Benzodiazepines, which are associated with safety-related harms for older adults, were not covered when the US Medicare Part D prescription drug benefit began. Coverage was extended to benzodiazepines in 2013.

OBJECTIVE

To examine whether the expansion of benzodiazepine coverage among Medicare Advantage (MA) beneficiaries was associated with increases in fall-related injuries or overdoses among older adults.

DESIGN, SETTING, AND PARTICIPANTS

This ecological study used interrupted time-series with comparison-series analyses of MA claims data from 4 635 312 age-eligible MA beneficiaries and 940 629 commercially insured individuals (comparison group) stratified by age (65-69, 70-74, 75-79, and ≥80 years) to separately compare trends in fall-related injury and overdose before (January 1, 2010, to December 31, 2012) and after (January 1, 2013, to December 31, 2015) coverage expansion for benzodiazepines. Data analysis was performed from September 1, 2018, to August 31, 2019.

EXPOSURES

Expansion of benzodiazepine coverage in Medicare Part D in 2013.

MAIN OUTCOMES AND MEASURES

Monthly rate of fall-related injury and overdose.

RESULTS

In 2012 (the year before the policy change), women constituted 57.5% of the MA group and 47.4% of the comparison group. A total of 25.8% of individuals in the MA group were aged 65 to 69 years, and 29.3% were 80 years or older (mean [SD], 75.1 [6.4] years); 56.7% of individuals in the comparison group were aged 65 to 69 years, and 15.1% were 80 years or older (mean [SD] age, 70.9 [6.5] years). In the MA group, 4 635 312 individuals contributed 156 754 749 person-months from 2010 through 2015; in the comparison group, 940 629 individuals contributed 25 104 534 person-months. After coverage of benzodiazepines began, the rate (ie, slope) of fall-related injury among MA beneficiaries increased from before to after coverage among all age groups. Compared with the comparison group, the increase in rate was statistically significant for those 80 years or older (rate changes for the MA vs comparison groups: 0.12 [95% CI, 0.07 to 0.17] vs -0.01 [95% CI, -0.11 to 0.10]; P = .04 for interaction). The overdose trend changed from decreasing to increasing among MA beneficiaries after coverage for all age groups, with a statistically significant increase compared with the comparison group among those aged 65 to 69 years (rate changes for the MA vs comparison groups: 0.23 [95% CI, 0.17 to 0.30] vs 0.02 [95% CI, -0.06 to 0.11]; P < .001 for interaction) and among those 80 years or older (rate changes for the MA vs comparison groups: 0.07 [95% CI, 0.00 to 0.14] vs -0.20 [95% CI, -0.35 to -0.05]; P = .002 for interaction). Results among MA beneficiaries were consistent when stratified by sex and when limited to those prescribed opioids.

CONCLUSIONS AND RELEVANCE

Medicare's expansion of benzodiazepine coverage may have been associated with increases in the rates of overdose among adults ages 65 to 69 years and in the rates of overdose and fall-related injury among those 80 years or older.

Continuation of Annual Screening Mammography and Breast Cancer Mortality in Women Older Than 70 Years

BACKGROUND

Randomized trials have shown that initiating breast cancer screening between ages 50 and 69 years and continuing it for 10 years decreases breast cancer mortality. However, no trials have studied whether or when women can safely stop screening mammography. An estimated 52% of women aged 75 years or older undergo screening mammography in the United States.

OBJECTIVE

To estimate the effect of breast cancer screening on breast cancer mortality in Medicare beneficiaries aged 70 to 84 years.

DESIGN

Large-scale, population-based, observational study of 2 screening strategies: continuing annual mammography, and stopping screening.

SETTING

U.S. Medicare program, 2000 to 2008.

PARTICIPANTS

1 058 013 beneficiaries aged 70 to 84 years who had a life expectancy of at least 10 years, had no previous breast cancer diagnosis, and underwent screening mammography.

MEASUREMENTS

Eight-year breast cancer mortality, incidence, and treatments, plus the positive predictive value of screening mammography by age group.

RESULTS

In women aged 70 to 74 years, the estimated difference in 8-year risk for breast cancer death between continuing and stopping screening was -1.0 (95% CI, -2.3 to 0.1) death per 1000 women (hazard ratio, 0.78 [CI, 0.63 to 0.95]) (a negative risk difference favors continuing). In those aged 75 to 84 years, the corresponding risk difference was 0.07 (CI, -0.93 to 1.3) death per 1000 women (hazard ratio, 1.00 [CI, 0.83 to 1.19]).

LIMITATIONS

The available Medicare data permit only 8 years of follow-up after screening. As with any study using observational data, the estimates could be affected by residual confounding.

CONCLUSION

Continuing annual breast cancer screening past age 75 years did not result in substantial reductions in 8-year breast cancer mortality compared with stopping screening.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Health Care Utilization, Care Satisfaction, and Health Status for Medicare Advantage and Traditional Medicare Beneficiaries With and Without Alzheimer Disease and Related Dementias

Importance

Compared with traditional Medicare (TM) fee-for-service plans, Medicare Advantage (MA) plans may provide more-efficient care for beneficiaries with Alzheimer disease and related dementias (ADRD) without compromising care quality.

Objective

To determine differences in health care utilization, care satisfaction, and health status for MA and TM beneficiaries with and without ADRD.

Design, Setting, and Participants

A cohort study was conducted of MA and TM beneficiaries with and without ADRD from all publicly available years of the Medicare Current Beneficiary Survey between 2010 and 2016. To address advantageous selection into MA plans, county-level MA enrollment rate was used as an instrument. Data were analyzed between July 2019 and December 2019.

Exposures

Enrollment in MA.

Main Outcomes and Measures

Self-reported health care utilization, care satisfaction, and health status.

Results

The sample included 47 100 Medicare beneficiaries (25 900 women [54.9%]; mean [SD] age, 72.2 [11.4] years). Compared with TM beneficiaries with ADRD, MA beneficiaries with ADRD had lower utilization across the board, including a mean of -22.3 medical practitioner visits (95% CI, -24.9 to -19.8 medical practitioner visits), -2.3 outpatient hospital visits (95% CI, -3.6 to -1.1 outpatient hospital visits), -0.2 inpatient hospital admissions (95% CI, -0.3 to -0.1 inpatient hospital admissions), and -0.1 long-term care facility stays (95% CI, -0.2 to -0.1 long-term care facility stays). A similar trend was observed among beneficiaries without ADRD, but the difference was greater between MA and TM beneficiaries with ADRD than between MA and TM beneficiaries without ADRD (mean, -15.0 medical practitioner visits [95% CI, -18.7 to -11.3 medical practitioner visits], -1.7 outpatient hospital visits [95% CI, -3.0 to -0.3 outpatient hospital visits], and -0.1 inpatient hospital admissions [95% CI, -1.0 to 0.0 inpatient hospital admissions]). Overall, no or negligible differences were detected in care satisfaction and health status between MA and TM beneficiaries with and without ADRD.

Conclusions and Relevance

Compared with TM beneficiaries, MA beneficiaries had lower health care utilization without compromising care satisfaction and health status. This difference was more pronounced among beneficiaries with ADRD. These findings suggest that MA plans may be delivering health care more efficiently than TM, especially for beneficiaries with ADRD.

Social and Health-Related Factors Associated with Enrollment in Medicare Advantage Plans in Older Adults

OBJECTIVES

We assessed the characteristics of older Mexican American enrollees in traditional fee-for-service (FFS) and Medicare Advantage (MA) plans and the factors associated with disenrollment from FFS and enrollment in MA plans.

DESIGN

Longitudinal study linked with Medicare claims data.

SETTING

The Hispanic Established Populations for the Epidemiologic Study of the Elderly.

PARTICIPANTS

Community-dwelling Mexican American older adults (N = 1455).

MEASUREMENTS

We examined insurance status using the Medicare Beneficiary Summary File and estimated the association of sociodemographic and clinical factors with insurance plan switching.

RESULTS

Among Mexican American older adults, FFS enrollees were more likely to be born in Mexico, speak Spanish, have lower levels of education, and have more disability than MA enrollees. Older adults with a larger number of limitations of instrumental activities of daily living (odds ratio [OR] = .50; 95% confidence interval [CI] = .26-.98) and more social support (OR = .70; 95% CI = .45-.98) were less likely to switch from FFS to MA compared with older adults with no limitations and less social support. Additionally, older adults living in counties with a greater number of MA plans were more likely to switch from FFS to MA (OR = 2.1; 95% CI = 1.45-3.16), compared with counties with a lower number of MA plans. In counties with a higher number of MA plans, older adults with more social support had lower odds of switching from FFS to MA (OR = .48; 95% CI = .28-.82) compared with older adults with less social support.

CONCLUSION

Compared with those enrolled in MA, older Mexican American adults enrolled in Medicare FFS are more socioeconomically disadvantaged and more likely to demonstrate poor health status. Stronger social support and increased physical limitations were strongly associated with less frequent switching from FFS to MA plans. Additionally, increased availability of MA plans at the county level is a significant driver of enrollment in MA plans. J Am Geriatr Soc 68:313-320, 2020.

What's Driving High Disenrollment in Medicare Advantage?

Disenrollment rates are one way that policy makers assess the performance of Medicare Advantage (MA) health plans. We use 3 years of data published by the Centers for Medicare & Medicaid Services (CMS) to examine the characteristics of MA contracts with high disenrollment rates from 2015 to 2017 and the relationship between disenrollment rates in MA contracts and 6 patient experiences of care performance measures. We find that MA contracts with high disenrollment rates were significantly more likely to be for-profit, small, and enroll a greater proportion of low-income and disabled individuals. After adjusting for plan characteristics, contracts with the highest levels of disenrollment were statistically significantly more likely to perform poorly on all 6 patient experience measures. CMS should consider additional oversight of MA contracts with high levels of disenrollment and consider publishing disenrollment rates at the plan level instead of at the contract level.

Disease-Specific Plan Switching Between Traditional Medicare and Medicare Advantage

INTRODUCTION

Previous research has reported switching from traditional Medicare (TM) to Medicare Advantage (MA) plans increased from 2006 to 2011 at the aggregate level, and switching from MA plans to TM also increased. However, little is known about switching behavior among individuals with specific chronic diseases.

OBJECTIVE

To examine disease-specific switching patterns between TM and MA to understand the impact on MA plans.

METHODS

Using the 2006 to 2012 Medicare Current Beneficiary Survey, we examined disease-specific switching rates between TM and MA and disease-specific ratios of mean baseline total Medicare expenditures of beneficiaries remaining in the same plan (stayers) vs those switching to another plan (switchers), respectively. We focused on beneficiaries with 1 or more of 10 incident diagnoses.

RESULTS

Beneficiaries with a new diagnosis of Alzheimer disease and related dementias, hypertension, and psychiatric disorders had relatively high rates of switching into MA plans and low rates of switching out of MA plans. Among those with new diagnoses of psychiatric disorders and diabetes, more costly beneficiaries (those with higher costs) switched into MA plans. For cancer, more costly beneficiaries remained in MA plans.

CONCLUSION

Together, these results suggest that MA plans may have not only higher caseloads but also a more costly case mix of beneficiaries with certain diseases than historically was the case. Our findings can help inform MA plans to understand their beneficiaries' disease burden and prepare for provision of relevant services.

Complex Patients and Quality of Care in Medicare Advantage

OBJECTIVES

New federal policies aim to focus Medicare Advantage (MA) plans on the needs of individuals with complex health conditions. Our objective was to examine enrollment patterns of MA beneficiaries with complex needs and the association of enrollment patterns with MA plan performance.

DESIGN

Cross-sectional study.

SETTING

The 2015 Medicare Health Outcome Survey baseline survey.

PARTICIPANTS

A total of 273 336 MA beneficiaries enrolled in 467 MA plans who lived in the community.

MEASUREMENTS

Complex patients included individuals 65 years and older with multiple self-reported chronic conditions and functional limitations and all patients with disabilities younger than 65 years. Outcomes included 27 performance measures reported under the 5-Star Part C Star Rating. Linear probability regression was used to examine the association of concentration of complex patients and performance measures.

RESULTS

Most complex patients were enrolled in general MA plans. Concentration of complex patients ranged from 25.9% in MA contracts in the lowest quintile to 68.9% in the top quintile. MA contract performance scores generally decreased as the concentration of complex patients increased. After adjusting for contract and enrollee characteristics, MA contracts with more complex patients performed less well on half of the Part C performance measures including patient experience, preventive care, and chronic care measures.

CONCLUSION

MA contracts with a high concentration of complex patients have lower performance scores on more than half of Part C measures. Further study is needed to understand whether these performance measures are capturing the delivery of poor care, deficiencies in the health plan's care systems, or whether some measures may not be appropriate for complex patients. J Am Geriatr Soc 68:395-402, 2020.

State variation in the characteristics of Medicare-Medicaid dual enrollees: Implications for risk adjustment

OBJECTIVE

To examine between-state differences in the socioeconomic and health characteristics of Medicare beneficiaries dually enrolled in Medicaid, focusing on characteristics not observable to or used by policy makers for risk adjustment.

DATA SOURCE

2010-2013 Medicare Current Beneficiary Survey.

STUDY DESIGN

Retrospective analyses of survey-reported health and socioeconomic status (SES) measures among low-income Medicare beneficiaries and low-income dual enrollees. We used hierarchical linear regression models with state random effects to estimate the between-state variation in respondent characteristics and linear models to compare the characteristics of dual enrollees by state Medicaid policies.

PRINCIPAL FINDINGS

Between-state differences in health and socioeconomic risk among low-income Medicare beneficiaries, as measured by the coefficient of variation, ranged from 17.5 percent for an index of socioeconomic risk to 20.3 percent for an index of health risk. Between-state differences were comparable among the subset of low-income beneficiaries dually enrolled in Medicare and Medicaid. Dual enrollees with incomes below the Federal Poverty Level were in better health and had higher SES in states that offered Medicaid to individuals with relatively higher incomes. Duals' average incomes were higher in states with Medically Needy programs.

CONCLUSIONS

Characteristics of dual enrollees differ substantially across states, reflecting differences in states' low-income Medicare populations and Medicaid policies. Risk-adjustment methods using dual enrollment to proxy for poor health and low SES should account for this state-level heterogeneity.

Trends In Medicare Fee-For-Service Spending Growth For Dual-Eligible Beneficiaries, 2007-15

Cost containment for dual-eligible beneficiaries (those enrolled in Medicare and Medicaid) is a key policy goal, but few studies have examined spending trends for this population. We contrasted growth in Medicare fee-for-service per beneficiary spending for those with and without Medicaid in the period 2007-15. Relative to Medicare-only enrollees, dual-eligible beneficiaries consistently had higher overall Medicare spending levels; however, they experienced steeper declines in spending growth over the study period. These trends varied across populations of interest. For instance, dual-eligible beneficiaries ages sixty-five and older went from having annual spending growth rates that were 1.8 percentage points higher than Medicare-only beneficiaries in 2008 to rates that were 1.1 percentage points lower in 2015. Across population groups, long-term users of nursing home care had some of the highest spending growth rates, averaging 1.7-4.1 percent annually depending on age group and Medicaid participation. These findings have implications for value-based payment and other Medicare policies aimed at controlling spending for dual-eligible beneficiaries.

Adjusted Mortality Rates Are Lower For Medicare Advantage Than Traditional Medicare, But The Rates Converge Over Time

Overall mortality rates, adjusted for age, sex, and Medicaid status, in Medicare Advantage have been below those in traditional Medicare for many years. Much attention has been paid to the resulting issue of favorable selection in Medicare Advantage. The common study design used to estimate causal effects of Medicare Advantage on utilization and outcomes compares new Medicare Advantage beneficiaries immediately before and after enrollment in Medicare Advantage with beneficiaries who choose to remain in traditional Medicare. What has not been studied is the mortality experience of a cohort that initially chooses enrollment in Medicare Advantage versus one that chooses traditional Medicare. In this study we found that the adjusted mortality rate of a cohort newly enrolled in Medicare Advantage was initially well below that of a cohort newly enrolled in traditional Medicare, but the difference markedly decreased after five years. As a result, the common study design is flawed because it assumes that any initial difference in mortality risk remains constant after enrollment in Medicare Advantage. In other words, those initially choosing Medicare Advantage become sicker relative to traditional Medicare beneficiaries over five years. Whether the mortality rates would fully converge if a period longer than five years were observed is a topic for further research.

Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries

IMPORTANCE

How often enrollees with complex care needs leave the Medicare Advantage (MA) program and what might drive their decisions remain unknown.

OBJECTIVE

To characterize trends in switching to and from MA among high-need beneficiaries and to evaluate the drivers of disenrollment decisions.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of MA and traditional Medicare (TM) enrollees from January 1, 2014, through December 31, 2015, used a multinomial logit regression stratified by Medicare-Medicaid eligibility status. All 14 589 645 non-high-need MA enrollees and 1 302 470 high-need enrollees in the United States who survived until the end of 2014 were eligible for the analysis. Data were analyzed from November 1, 2017, through August 1, 2018.

EXPOSURES

Enrollee dual eligibility and high-need status (based on complex chronic conditions, multiple morbidities, use of health care services, functional impairment, and frailty indicators), MA plan star rating, and cost sharing.

MAIN OUTCOMES AND MEASURES

The proportion of enrollees who disenrolled into TM, remained in the same MA plan, or who switched plans within the MA program.

RESULTS

A total of 13 901 816 enrollees were included in the analysis (56.2% women; mean [SD] age, 70.9 [9.9] years). Among the 1 302 470 high-need enrollees, an adjusted 4.6% (95% CI, 4.5%-4.6%) of Medicare-only and 14.8% (95% CI, 14.5%-15.0%) of Medicare-Medicaid members switched from MA to TM compared with 3.3% (95% CI, 3.3%-3.3%) and 4.6% (95% CI, 4.5%-4.7%), respectively, among non-high-need enrollees. Among enrollees in low-quality plans, 23.0% (95% CI, 22.3%-23.9%) of Medicare and 42.8% (95% CI, 40.5%-45.1%) of dual-eligible high-need enrollees left MA. Even in high-quality plans, high-need members disenrolled at higher rates than non-high-need members (4.9% [95% CI, 4.6%-5.2%] vs 1.8% [95% CI, 1.8%-1.9%] for Medicare-only enrollees and 11.3% vs 2.4% dual eligible enrollees). Enrollment in a 5.0-star rated plan was associated with a 30.1-percentage point reduction (95% CI, -31.7 to -28.4 percentage points) in the probability of disenrollment among high-need individuals. A $100 increase in monthly premiums was associated with a 33.9-percentage point increase (95% CI, -34.9 to -33.0 percentage points) in the likelihood of switching plans, and a small reduction in the likelihood of disenrolling (-2.7 percentage points; 95% CI, -3.2 to -2.2 percentage points). Among Medicare-Medicaid eligible participants, 14.1% (95% CI, 14.0%-14.2%) of high-need and 16.7% (95% CI, 16.6%-16.7%) of non-high-need enrollees switched from TM to MA.

CONCLUSIONS AND RELEVANCE

Results of this study suggest that substantially higher disenrollment from MA plans occurs among high-need and Medicare-Medicaid eligible enrollees. This study's findings suggest that star ratings have the strongest association with disenrollment trends, whereas increases in monthly premiums are associated with greater likelihood of switching plans.

Risk Adjustment In Medicare ACO Program Deters Coding Increases But May Lead ACOs To Drop High-Risk Beneficiaries

The Medicare Shared Savings Program (MSSP) adjusts savings benchmarks by beneficiaries' baseline risk scores. To discourage increased coding intensity, the benchmark is not adjusted upward if beneficiaries' risk scores rise while in the MSSP. As a result, accountable care organizations (ACOs) have an incentive to avoid increasingly sick or expensive beneficiaries. We examined whether beneficiaries' exposure to the MSSP was associated with within-beneficiary changes in risk scores and whether risk scores were associated with entry to or exit from the MSSP. We found that the MSSP was not associated with consistent changes in within-beneficiary risk scores. Conversely, beneficiaries at the ninety-fifth percentile of risk score had a 21.6 percent chance of exiting the MSSP, compared to a 16.0 percent chance among beneficiaries at the fiftieth percentile. The decision not to upwardly adjust risk scores in the MSSP has successfully deterred coding increases but might discourage ACOs to care for high-risk beneficiaries in the MSSP .

Sample Selection for Medicare Risk Adjustment Due to Systematically Missing Data

OBJECTIVE

To assess the issue of nonrepresentative sampling in Medicare Advantage (MA) risk adjustment.

DATA SOURCES

Medicare enrollment and claims data from 2008 to 2011.

DATA EXTRACTION

Risk adjustment predictor variables were created from 2008 to 2010 Part A and B claims and the Medicare Beneficiary Summary File. Spending is based on 2009-2011 Part A and B, Durable Medical Equipment, and Home Health Agency claims files.

STUDY DESIGN

A propensity-score matched sample of Traditional Medicare (TM) beneficiaries who resembled MA enrollees was created. Risk adjustment formulas were estimated using multiple techniques, and performance was evaluated based on R2 , predictive ratios, and formula coefficients in the matched sample and a random sample of TM beneficiaries.

PRINCIPAL FINDINGS

Matching improved balance on observables, but performance metrics were similar when comparing risk adjustment formula results fit on and evaluated in the matched sample versus fit on the random sample and evaluated in the matched sample.

CONCLUSIONS

Fitting MA risk adjustment formulas on a random sample versus a matched sample yields little difference in MA plan payments. This does not rule out potential improvements via the matching method should reliable MA encounter data and additional variables become available for risk adjustment.

Examining unpriced risk heterogeneity in the Dutch health insurance market

A major challenge in regulated health insurance markets is to mitigate risk selection potential. Risk selection can occur in the presence of unpriced risk heterogeneity, which refers to predictable variation in health care spending not reflected in either premiums by insurers or risk equalization payments. This paper examines unpriced risk heterogeneity within risk groups distinguished by the sophisticated Dutch risk equalization model of 2016. Our strategy is to combine the administrative dataset used for estimation of the risk equalization model (n = 16.9 million) with information derived from a large health survey (n = 387k). The survey information allows for explaining and predicting residual spending of the risk equalization model. Based on the predicted residual spending, two metrics are used to indicate unpriced risk heterogeneity at the individual level and at the level of certain (risk) groups: the correlation coefficient between residual spending and predicted residual spending, and the mean absolute value of predicted residual spending. The analyses yield three main findings: (1) the health survey information is able to explain some residual spending of the risk equalization model, (2) unpriced risk heterogeneity exists both in morbidity and in non-morbidity groups, and (3) unpriced risk heterogeneity increases with predicted spending by the risk equalization model. These findings imply that the sophisticated Dutch risk equalization model does not completely remove unpriced risk heterogeneity. Further improvement of the model should focus on broadening and refining the current set of morbidity-based risk adjusters.

Getting What We Pay For: How Do Risk-Based Payments to Medicare Advantage Plans Compare with Alternative Measures of Beneficiary Health Risk?

OBJECTIVE

To estimate the relative health risk of Medicare Advantage (MA) beneficiaries compared to those in Traditional Medicare (TM).

DATA SOURCES/STUDY SETTING

Medicare claims and enrollment records for the sample of beneficiaries enrolled in Part D between 2008 and 2015.

STUDY DESIGN

We assigned therapeutic classes to Medicare beneficiaries based on their prescription drug utilization. We then regressed nondrug health spending for TM beneficiaries in 2015 on demographic and therapeutic class identifiers for 2014 and used coefficients from this regression to predict relative risk of both MA and TM beneficiaries.

PRINCIPAL FINDINGS

Based on prescription drug utilization data, beneficiaries enrolled in MA in 2015 had 6.9 percent lower health risk than beneficiaries in TM, but differences based on coded diagnoses suggested MA beneficiaries were 6.2 percent higher risk. The relative health risk based on drug usage of MA beneficiaries compared to those in TM increased by 3.4 p.p. from 2008 to 2015, while the relative risk using diagnoses increased 9.8 p.p.

CONCLUSIONS

Our results add to a growing body of evidence suggesting MA receives favorable, or, at worst, neutral selection. If MA beneficiaries are no healthier and no sicker than similar beneficiaries in TM, then payments to MA plans exceed what is warranted based on their health status.

Risk equalization in competitive health insurance markets: Identifying healthy individuals on the basis of multiple-year low spending

Objective

To study the extent to which risk equalization (RE) in competitive health insurance markets can be improved by including an indicator for being healthy.

Study Setting/Data Sources

This study is conducted in the context of the Dutch individual health insurance market. Administrative data on spending and risk characteristics (2011‐2014) for the entire population (N = 16.6 m) as well as health survey data from a large sample (N = 387 k) are used.

Study Design

The indicator for being healthy is low spending in three consecutive prior years. “Low spending” is defined in three ways: belonging to the bottom 60%, 70%, or 80% of the annual spending distribution. Versions of the Dutch RE model 2017 with and without the indicator are compared on individual‐level payment fit and, using the survey data, group‐level payment fit.

Principal Findings

All three alternative models outperform the Dutch RE model 2017. However, significant unpriced risk heterogeneity remains. Compared with the 60% threshold, the 80% threshold comes with a larger improvement in fit but identifies a less selective group.

Conclusions

The performance of the RE model can be improved by adding an indicator for being healthy based on multiple‐year low spending. However, risk‐selection potential remains, warranting high priority to further improvement of RE.

Understanding Trends in Medicare Spending, 2007-2014

OBJECTIVES

To analyze the sources of per-beneficiary Medicare spending growth between 2007 and 2014, including the role of demographic characteristics, attributes of Medicare coverage, and chronic conditions.

DATA SOURCES

Individual-level Medicare spending and enrollment data.

STUDY DESIGN

Using an Oaxaca-Blinder decomposition model, we analyzed whether changes in price-standardized, per-beneficiary Medicare Part A and B spending reflected changes in the composition of the Medicare population or changes in relative spending levels per person.

DATA EXTRACTION METHODS

We identified a 5 percent sample of fee-for-service Medicare beneficiaries age 65 and above from years 2007 to 2014.

RESULTS

Mean payment-adjusted Medicare per-beneficiary spending decreased by $180 between the 2007-2010 and 2011-2014 time periods. This decline was almost entirely attributable to lower spending levels for beneficiaries. Notably, declines in marginal spending levels for beneficiaries with chronic conditions were associated with a $175 reduction in per-beneficiary spending. The decline was partially offset by the increasing prevalence of certain chronic diseases. Still, we are unable to attribute a large share of the decline in spending levels to observable beneficiary characteristics or chronic conditions.

CONCLUSIONS

Declines in spending levels for Medicare beneficiaries with chronic conditions suggest that changing patterns of care use may be moderating spending growth.

Do Larger Health Insurance Subsidies Benefit Patients or Producers? Evidence from Medicare Advantage

A central question in the debate over privatized Medicare is whether increased government payments to private Medicare Advantage (MA) plans generate lower premiums for consumers or higher profits for producers. Using difference‑in‑differences variation brought about by a sharp legislative change, we find that MA insurers pass through 45 percent of increased payments in lower premiums and an additional 9 percent in more generous benefits. We show that advantageous selection into MA cannot explain this incomplete pass‑through. Instead, our evidence suggests that market power is important, with premium pass‑through rates of 13 percent in the least competitive markets and 74 percent in the most competitive.

Medicare Advantage Enrollment and Beneficiary Risk Scores: Difference-in-Differences Analyses Show Increases for All Enrollees On Account of Market-Wide Changes

Medicare adjusts payments to Medicare Advantage (MA) insurers using risk scores that summarize the relationship between fee-for-service (FFS) Medicare spending and beneficiaries’ demographic characteristics and documented health conditions. Research shows that MA insurers have increasingly documented conditions more thoroughly than traditional Medicare—resulting in higher payments to insurers—but little is known about what factors contribute to diverging risk scores. We apportion that divergence between market-wide increases and increases that vary with length of MA enrollment. We also examine whether effects vary across plan types and whether the enrollment duration effect is contingent upon remaining with the same insurer. Using Medicare administrative data from 2008 to 2013, we employ a difference-in-differences model to compare the growth in risk scores of Medicare beneficiaries who switch from FFS to MA to that of beneficiaries who remain in FFS. We find that the effect of MA enrollment on risk scores increased from 5% in 2009 to 8% in 2012 and that continuous enrollment in MA was associated with an additional 1.2% increase per year, regardless of continuous enrollment with an insurer. Thus, even among those who switched to MA in 2009, enrollment duration comprised less than one-third of the coding intensity difference in 2012. We also find that risk scores grew faster in areas with greater MA penetration and among Health Maintenance Organization enrollees. Overall, our findings suggest that market-wide factors contributed most to the increasing divergence between FFS and MA risk scores.

Alternative evaluation metrics for risk adjustment methods

Risk adjustment is instituted to counter risk selection by accurately equating payments with expected expenditures. Traditional risk-adjustment methods are designed to estimate accurate payments at the group level. However, this generates residual risks at the individual level, especially for high-expenditure individuals, thereby inducing health plans to avoid those with high residual risks. To identify an optimal risk-adjustment method, we perform a comprehensive comparison of prediction accuracies at the group level, at the tail distributions, and at the individual level across 19 estimators: 9 parametric regression, 7 machine learning, and 3 distributional estimators. Using the 2013-2014 MarketScan database, we find that no one estimator performs best in all prediction accuracies. Generally, machine learning and distribution-based estimators achieve higher group-level prediction accuracy than parametric regression estimators. However, parametric regression estimators show higher tail distribution prediction accuracy and individual-level prediction accuracy, especially at the tails of the distribution. This suggests that there is a trade-off in selecting an appropriate risk-adjustment method between estimating accurate payments at the group level and lower residual risks at the individual level. Our results indicate that an optimal method cannot be determined solely on the basis of statistical metrics but rather needs to account for simulating plans' risk selective behaviors.

Risk of cardiovascular events and incident atrial fibrillation in patients without prior atrial fibrillation: Implications for expanding the indications for anticoagulation

BACKGROUND

There is growing interest in the role for non-vitamin K antagonist oral anticoagulants (NOACs) in patients without atrial fibrillation (AF). We aimed to provide a comprehensive assessment of the risks of ischemic stroke, myocardial infarction (MI), AF, and major bleeding in patients without previously diagnosed AF.

METHODS

Using a large US administrative database, we identified 6,495,875 patients ≥50 years between January 1, 2011, and September 30, 2016, who were not diagnosed with AF and were not treated with oral anticoagulants or nonaspirin antiplatelet agents. We assessed the risks by age, sex, the number of risk factors, and the combination of risk factors. We also calculated the number needed to treat or harm based on the untreated risks in our data set and relative risks of NOAC treatment derived from a recent clinical trial.

RESULTS

The event rates were 0.67%/y for ischemic stroke or MI, 0.96%/y for AF, and 0.52%/y for major bleeding. Among patients who had a stroke during follow-up, 84% were not diagnosed with AF at any time, and only 5% were diagnosed with AF before the stroke. Patients who had low number needed to treat for cardiovascular risk reduction (ie, potentially benefiting the most from the addition of NOACs) also had low number needed to harm for major bleeding (ie, facing serious harm).

CONCLUSIONS

Patients without diagnosed AF but with certain risk factors were at a particularly high cardiovascular risk and may require new prevention approaches. In addition to the ongoing trials, future trials in other high-risk populations, for example, diabetes and chronic kidney disease, may be warranted.

Preferred Provider Relationships Between Medicare Advantage Plans and Skilled Nursing Facilities Reduce Switching Out of Plans: An Observational Analysis

Unlike traditional Medicare, Medicare Advantage (MA) plans contract with specific skilled nursing facilities (SNFs). Patients treated in an MA plan's preferred SNF may benefit from enhanced coordination and have a lower likelihood of switching out of their plan. Using 2011-2014 Medicare enrollment data, the Medicare Healthcare Effectiveness Data and Information Set, and the Minimum Data Set, we examined Medicare enrollees who were newly admitted to SNFs in 2012-2013. We used the Centers for Medicare & Medicaid Services star rating to distinguish between MA plans and show how SNF concentration experienced by patients varies between patients in plans with different star ratings. We found that highly rated MA plans steer their patients to a smaller number of SNFs, and these patients are less likely to switch out of their plans. Strengthening the MA plan-SNF relationship may lower disenrollment rates for SNF beneficiaries, imparting benefits to both patients and payers.

Medicare Advantage Ratings And Voluntary Disenrollment Among Patients With End-Stage Renal Disease

Populations with intensive health care needs and high care costs may be attracted to insurance plans that have high quality ratings, but patients may be likely to disenroll from a plan if their care needs are not met. We assessed the association between publicly reported Medicare Advantage plan star ratings and voluntary disenrollment of incident dialysis patients in the following year over the period 2007-13. We found that Medicare Advantage (MA) plans with lower star ratings had significantly higher rates of disenrollment by incident dialysis patients in the following year. Compared to MA plans with 4.0 or more stars, adjusted disenrollment rates were 3.9 percentage points higher for plans with 3.5 stars, 5.0 percentage points higher for those with 3.0 stars, and 12.1 percentage points higher for those with 2.5 or fewer stars. These findings suggest that low plan quality may lead to increased expenditures, as this high-cost population generally must shift from Medicare Advantage to traditional Medicare upon disenrollment.