Closing Gaps in Public Services for US Residents With Intellectual and Developmental Disabilities

This Viewpoint describes existing public health and social service systems for persons with intellectual and developmental disabilities as they transition to adult care, barriers and opportunities faced in service access, and potential actions to narrow these gaps and enhance equity.

Medicaid Eligibility Loss Among Dual-Eligible Beneficiaries Before and During COVID-19 Public Health Emergency

Importance

Medicaid coverage loss can substantially compromise access to and affordability of health care for dual-eligible beneficiaries. The extent to which this population lost Medicaid coverage before and during the COVID-19 public health emergency (PHE) and the characteristics of beneficiaries more at risk for coverage loss are currently not well known.

Objective

To assess the loss of Medicaid coverage among dual-eligible beneficiaries before and during the first year of the PHE, and to examine beneficiary-level and plan-level factors associated with heightened likelihood of losing Medicaid.

Design, Setting, and Participants

This repeated cross-sectional study used national Medicare data to estimate annual rates of Medicaid loss among dual-eligible beneficiaries before (2015 to 2019) and during the PHE (2020). Individuals who were dual eligible for Medicare and Medicaid at the beginning of a given year and who continuously received low-income subsidies for Medicare Part D prescription drug coverage were included in the sample. Multivariable regression models were used to examine beneficiary-level and plan-level factors associated with Medicaid loss. Data analyses were conducted between March 2023 and October 2023.

Exposure

Onset of PHE.

Main Outcomes and Measures

Loss of Medicaid for at least 1 month within a year.

Results

Sample included 56 172 736 dual-eligible beneficiary-years between 2015 and 2020. In 2020, most dual-eligible beneficiaries were aged over 65 years (5 984 420 [61.1%]), female (5 868 866 [59.9%]), non-Hispanic White (4 928 035 [50.3%]), full-benefit eligible (6 837 815 [69.8%]), and enrolled in traditional Medicare (5 343 537 [54.6%]). The adjusted proportion of dual-eligible beneficiaries losing Medicaid for at least 1 month increased from 6.6% in 2015 to 7.3% in 2019 and then dropped to 2.3% in 2020. Between 2015 and 2019, dual-eligible beneficiaries who were older (ages 55-64 years: -1.4%; 95% CI, -1.8% to -1.0%; ages 65-74 years: -2.0%; 95% CI, -2.5% to -1.5%; ages 75 and older: -4.5%; 95% CI, -5.0% to -4.0%), disabled (-0.8%; 95% CI, -1.1% to -0.6%), and in integrated care programs were less likely to lose Medicaid. In 2020, the disparities within each of these demographic groups narrowed significantly. Notably, while Black (0.6%; 95% CI, 0.2% to 0.9%) and Hispanic (0.7%; 95% CI, 0.3% to 1.2%) dual-eligible beneficiaries were more likely to lose Medicaid than their non-Hispanic White counterparts between 2015 and 2019, such gap was eliminated for Black beneficiaries and narrowed for Hispanic beneficiaries in 2020.

Conclusions and Relevance

During the PHE, Medicaid coverage loss declined significantly among dual-eligible beneficiaries, and disparities were mitigated across subgroups. As the PHE unwinds, it is crucial for policymakers to implement strategies to minimize Medicaid coverage disruptions and racial and ethnic disparities, especially given that loss of Medicaid was slightly increasing over time before the PHE.

No Improvement In Mental Health Treatment Or Patient-Reported Outcomes At Medicare ACOs For Depression And Anxiety Disorders

Accountable care organizations (ACOs) have become Medicare's dominant care model because policy makers believe that ACOs will improve the quality and efficiency of care for chronic conditions. Depression and anxiety disorders are the most prevalent and undertreated chronic mental health conditions in Medicare. Yet it is unknown whether ACOs influence treatment and outcomes for these conditions. To explore these questions, this longitudinal study used data from the 2016-19 Medicare Current Beneficiary Survey, linked to validated depression and anxiety symptom instruments, among diagnosed and undiagnosed fee-for-service Medicare patients with these conditions. Among patients not enrolled in ACOs at baseline, those who newly enrolled in ACOs in the following year were 24 percent less likely to have their depression or anxiety treated during the year than patients who remained unenrolled in ACOs, and they saw no relative improvements at twelve months in their depression and anxiety symptoms. Better-designed incentives are needed to motivate Medicare ACOs to improve mental health treatment.

State Public Assistance Spending and Survival Among Adults With Cancer

Importance

Social determinants of health contribute to disparities in cancer outcomes. State public assistance spending, including Medicaid and cash assistance programs for socioeconomically disadvantaged individuals, may improve access to care; address barriers, such as food and housing insecurity; and lead to improved cancer outcomes for marginalized populations.

Objective

To determine whether state-level public assistance spending is associated with overall survival (OS) among individuals with cancer, overall and by race and ethnicity.

Design, Setting, and Participants

This cohort study included US adults aged at least 18 years with a new cancer diagnosis from 2007 to 2013, with follow-up through 2019. Data were obtained from the Surveillance, Epidemiology, and End Results program. Data were analyzed from November 18, 2021, to July 6, 2023.

Exposure

Differential state-level public assistance spending.

Main Outcome and Measure

The main outcome was 6-year OS. Analyses were adjusted for age, race, ethnicity, sex, metropolitan residence, county-level income, state fixed effects, state-level percentages of residents living in poverty and aged 65 years or older, cancer type, and cancer stage.

Results

A total 2 035 977 individuals with cancer were identified and included in analysis, with 1 005 702 individuals (49.4%) aged 65 years or older and 1 026 309 (50.4%) male. By tertile of public assistance spending, 6-year OS was 55.9% for the lowest tertile, 55.9% for the middle tertile, and 56.6% for the highest tertile. In adjusted analyses, public assistance spending at the state-level was significantly associated with higher 6-year OS (0.09% [95% CI, 0.04%-0.13%] per $100 per capita; P < .001), particularly for non-Hispanic Black individuals (0.29% [95% CI, 0.07%-0.52%] per $100 per capita; P = .01) and non-Hispanic White individuals (0.12% [95% CI, 0.08%-0.16%] per $100 per capita; P < .001). In sensitivity analyses examining the roles of Medicaid spending and Medicaid expansion including additional years of data, non-Medicaid spending was associated with higher 3-year OS among non-Hispanic Black individuals (0.49% [95% CI, 0.26%-0.72%] per $100 per capita when accounting for Medicaid spending; 0.17% [95% CI, 0.02%-0.31%] per $100 per capita Medicaid expansion effects).

Conclusions and Relevance

This cohort study found that state public assistance expenditures, including cash assistance programs and Medicaid, were associated with improved survival for individuals with cancer. State investment in public assistance programs may represent an important avenue to improve cancer outcomes through addressing social determinants of health and should be a topic of further investigation.

Risk Selection and Care Fragmentation at Medicare Accountable Care Organizations for Patients With Dementia

BACKGROUND

Patients with dementia are a growing and vulnerable population within Medicare. Accountable care organizations (ACOs) are becoming Medicare's dominant care model, but ACO enrollment and care patterns for patients with dementia are unknown.

OBJECTIVE

The aim of this study was to compare differences in ACO enrollment for patients with versus without dementia, and in risk profiles and ambulatory care among patients with dementia by ACO enrollment status.

RESEARCH DESIGN

Cohort study assessing the relationships between patient dementia, following-year ACO enrollment, and ambulatory care patterns.

SUBJECTS

A total of 13,362 (weighted: 45, 499,049) person-years for patients [2761 (weighted: 6,312,304) for dementia patients] ages 65 years and above in the 2015-2019 Medicare Current Beneficiary Survey.

MEASURES

We assessed differences in ACO enrollment rates for patients with versus without dementia, and in dementia-relevant ambulatory care visit rates and validated care fragmentation indices among patients with dementia by ACO enrollment status.

RESULTS

Patients with versus without dementia were less likely to be enrolled in (38.3% vs. 44.6%, P<0.001), and more likely to exit (21.1% vs. 13.7%, P<0.01) ACOs. Among patients with dementia, those enrolled versus not enrolled in ACOs had a more favorable social and health risk profile on 6 of 16 measures (P<0.05). There were no differences in rates of dementia-relevant, primary, or specialty care visits. ACO enrollment was associated with 45.7% higher wellness visit rates (P<0.001), and 13.4% more fragmented primary care (P<0.01) spread across 8.7% more distinct physicians (P<0.05).

CONCLUSION

Medicare ACOs are less likely to enroll and retain patients with dementia than other patients and provide more fragmented primary care without providing additional dementia-relevant ambulatory care visits.

Proportion of Physicians Who Treat Patients With Greater Social and Clinical Risk and Physician Inclusion in Medicare Advantage Networks

Importance

Medicare Advantage (MA) plans are expanding rapidly, now serving 50% of all Medicare enrollees. Little is known about how inclusion rates of physicians in MA plan networks vary by the social and clinical risks of their patients.

Objective

To examine the association of physicians caring for patients with higher levels of social and clinical risk in traditional Medicare (TM) with the likelihood of inclusion in MA plan networks.

Design, Setting, and Participants

This cross-sectional study evaluated the number of patients of physicians participating in TM Part B in 2019. The data analysis was conducted between June 2022 and March 2023.

Exposures

Quintiles of the proportion of patients who were dually eligible for Medicare and Medicaid and average beneficiary hierarchical condition category (HCC) score (a measure of a patient's chronic disease burden that is used in risk adjustment and MA plan payment, where higher scores indicate higher risk) in the Part B TM program.

Main Outcomes and Measures

The main outcomes were the proportion of MA plans and enrollees for which physicians were in network.

Results

The analysis sample included 259 932 physicians billing Medicare Part B in 2019. After adjusting for physician, patient, and county characteristics, physicians with the highest quintile of patients with dual eligibility were associated with a lower likelihood of being included in MA plans and being in network with MA enrollees than the lowest quintile physicians (MA inclusion rate, -3.0% [95% CI, -3.2% to -2.8%]; P < .001; in-network enrollee proportion, -6.5% [95% CI, -7.0% to -6.0%]; P < .001). Similarly, physicians with the highest quintile HCC score were associated with a lower likelihood of being included in MA plans and being in network with MA enrollees than the lowest quintile physicians (MA inclusion rate, -7.5% [95% CI, -7.9% to -7.2%]; P < .001; in-network enrollee proportion, -18.7% [95% CI, -19.5% to -18.1%]; P < .001). Physicians in medical specialties in the highest clinical risk group (highest quintile HCC score) were associated with a significantly lower likelihood of being in network with MA enrollees than those in the lowest clinical risk group (in-network enrollee proportion, -20.4% [95% CI, -21.1% to -19.8%]; P < .001).

Conclusions and Relevance

This cross-sectional study of physicians participating in TM Part B in 2019 found that physicians with higher numbers of patients with social and medical risks in TM were significantly less likely to be associated with MA plans.

Rapid Enrollment Growth In 'Look-Alike' Dual-Eligible Special Needs Plans: A Threat To Integrated Care

Policy makers are increasingly investing in efforts to better integrate Medicare and Medicaid services for people who are eligible for both programs, including expanding Dual-Eligible Special Needs Plans (D-SNPs). In recent years, however, a potential threat to integration has emerged in the form of D-SNP "look-alike" plans, which are conventional Medicare Advantage plans that are marketed toward and primarily enroll dual eligibles but are not subject to federal regulations requiring integrated Medicaid services. To date, limited evidence exists documenting national enrollment trends in look-alike plans or the characteristics of dual eligibles in these plans. We found that look-alike plans experienced rapid enrollment growth among dual eligibles during the period 2013-20, increasing from 20,900 dual eligibles across four states to 220,860 dual eligibles across seventeen states, for an elevenfold increase. Nearly one-third of dual eligibles in look-alike plans were previously in integrated care programs. Compared with D-SNPs, look-alike plans were more likely to enroll dual eligibles who were older, Hispanic, and from disadvantaged communities. Our findings suggest that look-alike plans have the potential to compromise national efforts to integrate care delivery for dual eligibles, including vulnerable subgroups who may benefit the most from integrated coverage.

Health Equity for Individuals With Intellectual and Developmental Disabilities

This Viewpoint discusses 3 types of systemic health inequity experienced by individuals with intellectual and developmental disabilities—stigma, exclusion, and devaluation of worth; underrepresentation in population epidemiology and research; and inadequate access to care and social services—and suggests potential approaches to ameliorating inequities in each of these areas.

State Mandatory Paid Sick Leave Associated With A Decline In Emergency Department Use In The US, 2011-19

Paid sick leave provides workers with job-protected paid time off to address short-term illnesses or seek preventive care for themselves and their family members. We studied the impact of mandatory paid sick leave at the state level on emergency department (ED) visit rates, using all-payer, longitudinal ED data from the Healthcare Cost and Utilization Project for the period 2011-19. We found that state implementation of paid sick leave mandates was associated with a 5.6 percent reduction in the total ED visit rate relative to the baseline, equivalent to 23 fewer visits per 1,000 population per year. The reduction was concentrated in Medicaid patients. Some of the largest reductions were ED visits related to adult dental conditions, adult mental health or substance use disorders, and pediatric asthma. Mandatory paid sick leave may be an effective policy lever to reduce excess ED use and costs.

State public welfare spending and racial/ethnic disparities in overall survival among adults with cancer

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Background: State public welfare spending may partially address social determinants of health and mitigate structural racism. However, its association with racial and ethnic disparities and overall survival for newly diagnosed patients with cancer is unknown. Methods: Adults ages 18 and older with a new cancer diagnosis from 2007-2016 were queried from the Surveillance, Epidemiology, and End Results program. Annual state spending data were obtained from the US Census Bureau. We evaluated the association of 5-year overall survival (OS) and public welfare spending using cluster-robust regression. Analyses were conducted overall, by race and ethnicity, and by cancer site. To determine whether public welfare spending was associated with changes in racial and ethnic disparities in survival, we additionally assessed for interaction effects between public welfare spending and race and ethnicity. Analyses were adjusted for covariates including age, sex, metropolitan residence, state, county-level income and education, insurance status, cancer site, stage at diagnosis, and year of diagnosis. Sensitivity analyses were conducted also accounting for state Medicaid expansion effects and state spending on health care and hospitals. Results: A total of 2,925,550 individuals were identified in our cohort. 5-year OS was 10.6% lower in non-Hispanic Black vs. White patients. Public welfare spending was not associated with 5-year OS overall (0.25 % per 10% increase in spending, -1.47 to 1.96, p =.78) or for non-Hispanic White patients (0.52% per 10% increase in spending, 95% CI -1.30 to 2.33, p =.58). However, increased public welfare spending was associated with increased 5-year OS among non-Hispanic Black patients (2.02% per 10% increase in spending, 95% CI = 0.01 to 4.03, p =.049). There was a 4.46% (95% CI = 2.63 to 6.30, pinteraction<.001) narrowing of the 5-year OS disparity in non-Hispanic Black relative to White patients per 10% increase in spending, or a 42% closure of the 10.6% OS disparity. Specifically, increased public welfare spending was associated with a narrowed Black vs. White 5-year OS disparity for patients with breast (7.50% increase in 5-yr OS for non-Hispanic Black relative to White per 10% increasing in spending, corresponding to closing 42.1% of the disparity), cervical (12.2%, 45.9%), colorectal (3.37%, 44.9%), head and neck (8.23%, 35.7%), liver (4.54%, 44.8%), lung (1.76%, 63.3%), ovarian (6.43%, 35.9%), prostate (2.89%, 41.9%), bladder (7.62%, 42.9%), and uterine cancers (14.9%, 40.9%). Results were similar after accounting for state health care and hospital spending and state Medicaid expansion effects. Conclusions: State investment in public welfare was associated with improved 5-year OS for non-Hispanic Black individuals with cancer, decreasing racial disparities in cancer outcomes overall and for many cancer sites.

Comparison of Performance of Psychiatrists vs Other Outpatient Physicians in the 2020 US Medicare Merit-Based Incentive Payment System

Question

How did psychiatrists perform in the 2020 Medicare Merit-Based Incentive Payment System (MIPS) compared with other outpatient physicians?

Findings

In this cross-sectional study of 9356 psychiatrists and 196 306 other outpatient physicians participating in the 2020 MIPS, psychiatrists had significantly lower performance scores, were significantly more likely to be assessed a performance penalty, and were less likely to be assessed a bonus than other physicians.

Meaning

Psychiatrists performed worse than other physicians in Medicare’s new mandatory outpatient value-based payment system; therefore, more research is needed to evaluate the appropriateness of MIPS measures for psychiatrists.

Importance

Medicare’s Merit-Based Incentive Payment System (MIPS) is a new, mandatory, outpatient value-based payment program that ties reimbursement to performance on cost and quality measures for many US clinicians. However, it is currently unknown how the program measures the performance of psychiatrists, who often treat a different patient case mix with different clinical considerations than do other outpatient clinicians.

Objective

To compare performance scores and value-based reimbursement for psychiatrists vs other outpatient physicians in the 2020 MIPS.

Design, Setting, and Participants

In this cross-sectional study, the Centers for Medicare & Medicaid Services Provider Data Catalog was used to identify outpatient Medicare physicians listed in the National Downloadable File between January 1, 2018, and December 31, 2020, who participated in the 2020 MIPS and received a publicly reported final performance score. Data from the 593 863 clinicians participating in the 2020 MIPS were used to compare differences in the 2020 MIPS performance scores and value-based reimbursement (based on performance in 2018) for psychiatrists vs other physicians, adjusting for physician, patient, and practice area characteristics.

Exposures

Participation in MIPS.

Main Outcomes and Measures

Primary outcomes were final MIPS performance score and negative (penalty), positive, and exceptional performance bonus payment adjustments. Secondary outcomes were scores in the MIPS performance domains: quality, promoting interoperability, improvement activities, and cost.

Results

This study included 9356 psychiatrists (3407 [36.4%] female and 5 949 [63.6%] male) and 196 306 other outpatient physicians (69 221 [35.3%] female and 127 085 [64.7%] male) (data on age and race are not available). Compared with other physicians, psychiatrists were less likely to be affiliated with a safety-net hospital (2119 [22.6%] vs 64 997 [33.1%]) or a major teaching hospital (2148 [23.0%] vs 53 321 [27.2%]) and had lower annual Medicare patient volume (181 vs 437 patients) and mean patient risk scores (1.65 vs 1.78) (P < .001 for all). The mean final MIPS performance score for psychiatrists was 84.0 vs 89.7 for other physicians (absolute difference, −5.7; 95% CI, −6.2 to −5.2). A total of 573 psychiatrists (6.1%) received a penalty vs 5739 (2.9%) of other physicians (absolute difference, 3.2%; 95% CI, 2.8%-3.6%); 8664 psychiatrists (92.6%) vs 189 037 other physicians (96.3%) received a positive payment adjustment (absolute difference, −3.7%; 95% CI, −3.3% to −4.1%), and 7672 psychiatrists (82.0%) vs 174 040 other physicians (88.7%) received a bonus payment adjustment (absolute difference, −6.7%; 95% CI, −6.0% to −7.3%). These differences remained significant after adjustment.

Conclusions and Relevance

In this cross-sectional study that compared US psychiatrists with other outpatient physicians, psychiatrists had significantly lower 2020 MIPS performance scores, were penalized more frequently, and received fewer bonuses. Policy makers should evaluate whether current MIPS performance measures appropriately assess the performance of psychiatrists.

Comparison of Ambulatory Care Access and Quality for Beneficiaries With Disabilities Covered by Medicare Advantage vs Traditional Medicare Insurance

Question

Do Medicare beneficiaries aged 18 to 64 years with disability entitlement have different rates of enrollment in Medicare Advantage (MA) vs traditional Medicare (TM) compared with other beneficiaries, and how do the 2 programs compare on rates of ambulatory care access and quality for beneficiaries with disabilities?

Findings

In this cohort study of a nationally representative sample of 7201 person-years for Medicare beneficiaries in 2015 through 2018, beneficiaries with disability entitlement were significantly less likely to enroll in MA compared with those without disability entitlement. However, enrollment in MA vs TM was associated with better outcomes on 2 of 3 access measures and 3 of 3 quality measures for beneficiaries with disabilities.

Meaning

Although Medicare beneficiaries with disabilities enrolled in MA at lower rates than other beneficiaries in this study, MA appeared to compare favorably with TM in meeting key ambulatory care access and quality measures for beneficiaries with disabilities.

Importance

Medicare beneficiaries with disabilities aged 18 to 64 years face barriers accessing ambulatory care. Past studies comparing Medicare Advantage (MA) with traditional Medicare (TM) have not assessed how well these programs meet the needs of beneficiaries with disabilities.

Objective

To compare differences in enrollment rates, ambulatory care access, and ambulatory care quality for beneficiaries with disabilities in MA vs TM.

Design, Setting, and Participants

This cohort study included a nationally representative, weighted sample of 7201 person-years for beneficiaries aged 18 to 64 years with disability entitlement in the Medicare Current Beneficiary Survey from 2015 through 2018. Differences in program enrollment and in measures of access and quality by program enrollment were compared after adjusting for demographic, insurance, social, health, and area characteristics and after reweighting the sample by propensity to enroll in MA as estimated by observed confounders. Data analyses were conducted between November 1, 2020, and November 11, 2021.

Exposures

Medicare Advantage vs TM program enrollment.

Main Outcomes and Measures

Six patient-reported measures of ambulatory care access (usual source of care, primary care usual source of care, specialist visit) and quality (cholesterol screening, influenza vaccination, colon cancer screening).

Results

The mean (SD) age of the overall study population was 52.1 (11.0) years; 49.5% were female and 50.5% were male; 1.6% were Asian/Pacific Islander; 17.4%, Black; 10.2% Hispanic; 1.4%, Native American; 65.1%, White, and 4.2%, multiracial. Among all beneficiaries living in the community, individuals with disability entitlement were less likely to enroll in MA than other beneficiaries (34.8% vs 41.2%). The final sample of beneficiaries with disabilities included 2444 person-years in MA and 4757 person-years in TM. Beneficiaries with disabilities in MA vs TM were more likely to be of a minority race or ethnicity (35.7% vs 27.6%) and less likely to be enrolled in private insurance (11.9% vs 25.0%). Comparing MA with TM among beneficiaries with disabilities, those in MA had significantly better rates of access to a usual source of care (90.2% vs 84.9%; adjusted propensity-weighted marginal difference [APWMD], 2.9%; 95% CI, 0.2%-5.7%), access to specialist visits (53.2% vs 44.8%; APWMD, 5.5%; 95% CI, 0.6%-10.5%), cholesterol screenings (91.1% vs 86.4%; APWMD, 3.8%; 95% CI, 0.9%-6.7%), influenza vaccinations (61.4% vs 51.5%; APWMD, 10.4%; 95% CI, 5.3%-15.5%), and colon cancer screenings (68.4% vs 54.6%; APWMD, 10.3%; 95% CI, 4.8%-15.8%).

Conclusions and Relevance

In this cohort study, Medicare beneficiaries with disabilities were enrolled in MA at significantly lower rates than those without disabilities. However, MA was associated with significantly better ambulatory care access and quality for these beneficiaries on 5 of 6 measures compared with TM.

Comparing Preventable Acute Care Use of Rural Versus Urban Americans: an Observational Study of National Rates During 2008-2017

BACKGROUND

Rural Americans have less access to care than urban Americans. Preventable acute care use is a marker of unmet ambulatory healthcare needs, but little is known about how such utilization has differed between rural and urban areas over time.

OBJECTIVE

Compare preventable emergency department (ED) visit and hospitalization rates among rural versus urban residents over the past decade.

DESIGN

Observational study using a validated algorithm to compute age-sex-adjusted rates per 100,000 individuals of preventable ED visits and hospitalizations. Differences in overall, annual, and condition-specific rates for rural versus urban residents were assessed and linear regression was used to assess 10-year trends.

SETTING

Nationwide Emergency Department Sample, National Inpatient Sample, and US Census, 2008-2017.

PARTICIPANTS

US adults, an annual average of 241.3 million individuals.

MEASUREMENTS

Preventable ED visits and hospitalizations.

RESULTS

Compared to urban residents, rural residents had 45% higher rates of preventable ED visits in 2008 (3003 vs. 2070 per 100,000, adjusted difference [AD]: 933; 95% CI: 928-938) and 44% higher rates of preventable ED visits in 2017 (3911 vs. 2708 per 100,000, AD: 1202; 95% CI: 1196-1208). Rural residents had 26% higher rates of preventable hospitalizations in 2008 (2104 vs. 1666 per 100,000, AD: 439; 95% CI: 434-443) and 13% higher rates in 2017 (1634 vs. 1440 per 100,000, AD: 194; 95% CI: 190-199). Preventable ED visits increased more in absolute terms in rural versus urban residents, but the percentage increase was similar (30% vs. 31%) because rural residents started at a higher baseline. Preventable hospitalizations decreased at a faster rate (22% vs. 14%) among rural versus urban residents.

LIMITATIONS

Observational study; unable to infer causality.

CONCLUSIONS

Rural disparities in acute care use are narrowing for preventable hospitalizations but have persisted for all preventable acute care use, suggesting unmet demand for high-quality ambulatory care in rural areas.

Association of Race and Ethnicity and Medicare Program Type With Ambulatory Care Access and Quality Measures

IMPORTANCE

There are racial inequities in health care access and quality in the United States. It is unknown whether such differences for racial and ethnic minority beneficiaries differ between Medicare Advantage and traditional Medicare or whether access and quality are better for minority beneficiaries in 1 of the 2 programs.

OBJECTIVE

To compare differences in rates of enrollment, ambulatory care access, and ambulatory care quality by race and ethnicity in Medicare Advantage vs traditional Medicare.

DESIGN, SETTING, AND PARTICIPANTS

Exploratory observational cohort study of a nationally representative sample of 45 833 person-years (26 887 persons) in the Medicare Current Beneficiary Survey from 2015 to 2018, comparing differences in program enrollment and measures of access and quality by race and ethnicity.

EXPOSURES

Minority race and ethnicity (Black, Hispanic, Native American, or Asian/Pacific Islander) vs White or multiracial; Medicare Advantage vs traditional Medicare enrollment.

MAIN OUTCOMES AND MEASURES

Six patient-reported measures of ambulatory care access (whether a beneficiary had a usual source of care in the past year, had a primary care clinician usual source of care, or had a specialist visit) and quality (influenza vaccination, pneumonia vaccination, and colon cancer screening).

RESULTS

The final sample included 6023 persons (mean age, 68.9 [SD, 12.6] years; 57.3% women) from minority groups and 20 864 persons (mean age, 71.9 [SD, 10.8] years; 54.9% women) from White or multiracial groups, who accounted for 9816 and 36 017 person-years, respectively. Comparing Medicare Advantage vs traditional Medicare among minority beneficiaries, those in Medicare Advantage had significantly better rates of access to a primary care clinician usual source of care (79.1% vs 72.5%; adjusted marginal difference, 4.0%; 95% CI, 1.0%-6.9%), influenza vaccinations (67.3% vs 63.0%; adjusted marginal difference, 5.2%; 95% CI, 1.9%-8.5%), pneumonia vaccinations (70.7% vs 64.6%; adjusted marginal difference, 6.1%; 95% CI, 2.7%-9.4%), and colon cancer screenings (69.4% vs 61.1%; adjusted marginal difference, 7.1%; 95% CI, 3.8%-10.3%). Comparing minority vs White or multiracial beneficiaries across both programs, minority beneficiaries had significantly lower rates of access to a primary care clinician usual source of care (adjusted marginal difference, 4.7%; 95% CI, 2.5%-6.8%), specialist visits (adjusted marginal difference, 10.8%; 95% CI, 8.3%-13.3%), influenza vaccinations (adjusted marginal difference, 4.3%; 95% CI, 1.2%-7.4%), and pneumonia vaccinations (adjusted marginal difference, 6.4%; 95% CI, 3.9%-9.0%). The interaction of race and ethnicity with insurance type was not statistically significant for any of the 6 outcome measures.

CONCLUSIONS AND RELEVANCE

In this exploratory study of Medicare beneficiaries in 2015-2018, enrollment in Medicare Advantage vs traditional Medicare was significantly associated with better outcomes for access and quality among minority beneficiaries; however, minority beneficiaries were significantly more likely to experience worse outcomes for most access and quality measures than White or multiracial beneficiaries in both programs.

Ambulatory Care Access And Emergency Department Use For Medicare Beneficiaries With And Without Disabilities

Establishing care with primary care and specialist clinicians is critical for Medicare beneficiaries with complex care needs. However, beneficiaries with disabilities may struggle to access ambulatory care. This study uses the 2015-17 national Medicare Current Beneficiary Survey linked to claims and administrative data to explore these questions. Medicare beneficiaries (ages 21-64) with disabilities were 119 percent more likely to report difficulty accessing care and were 33 percent and 49 percent more likely to lack annual clinician evaluation and management visits for primary and specialty care, respectively, than those without disabilities. Beneficiaries (ages 21-64) with disabilities also had 42 percent, 67 percent, and 77 percent higher likelihood of having all-cause, nonemergent, and preventable emergency department (ED) visits. Furthermore, people with both a disability and a lack of specialist evaluation and management visits also had 21 percent, 48 percent, and 64 percent increased likelihood of all-cause, nonemergent, and preventable ED visits. Barriers to accessing ambulatory care may be a key contributor to the reliance of Americans with disabilities on ED services.

Clinicians With High Socially At-Risk Caseloads Received Reduced Merit-Based Incentive Payment System Scores

To understand how clinicians with high caseloads of socially at-risk patients fare under Medicare's new outpatient Merit-based Incentive Payment System (MIPS), we examined the first (2019) round of MIPS performance data for 510,020 clinicians. Compared with clinicians with the lowest socially at-risk caseloads, those with the highest had 13.4 points lower MIPS performance scores, were 99 percent more likely to receive a negative payment adjustment, and were 52 percent less likely to receive an exceptional performance bonus payment. The lower performance scores were partly explained by lower clinician reporting of and performance on technology-dependent measures, which may reflect a lack of practice-level technological capability. If the Complex Patient Bonus were in effect, the performance scores and likelihood of receiving an exceptional performance bonus (payment of clinicians with the highest socially at-risk caseloads) would have increased by 4.7 percent and 2.8 percent, respectively; however, the proportion receiving negative payment adjustments would have remained unchanged. The Complex Patient Bonus appears unlikely to mitigate the most regressive effects of MIPS.

Association of Clinician Minority Patient Caseload With Performance in the 2019 Medicare Merit-based Incentive Payment System

This study assesses the association between US clinicians’ caseload of minority patients and their 2019 Medicare Merit-based Incentive Payment System performance score.

Association of hospital-area deprivation with hospital performance on health care associated infection rates in 2018

BACKGROUND AND OBJECTIVE

Healthcare-associated infections (HAIs) are common and often preventable complications of care, with reduction emphasized in national policy. The Centers for Medicare and Medicaid Services introduced an HAI-focused Hospital Acquired Condition Reduction Program in 2015 to penalize poor-performing hospitals. Standardized infection ratios (SIRs) are used for comparisons between healthcare organizations, though they are not adjusted for socioeconomic risks known to impact infection. The objectives of this study were to assess the relationship between hospital-area deprivation with reported SIRs and reimbursement penalties.

METHODS

This was a cohort study using 2018 Hospital Compare, as well as area deprivation data and other hospital characteristics. Multivariable regression models were used to evaluate associations between hospital-area deprivation and SIR reporting as well as payment reduction, adjusting for case mix index and hospital ownership.

RESULTS

Of the 2102 unique hospitals in our study, 12.8% reported at least one worse than national benchmark SIR and 23.7% had a payment reduction. After adjustment, there was a 17% increased risk of reporting worse than benchmarked SIRs with quartile increases in deprivation (95% confidence interval: 5%-30%, P = .004). Despite this, there were no significant relationships between reimbursement penalties and ADI (risk ratio: 1.00, 95% confidence interval: 0.997-1.005, P = .567).

CONCLUSIONS

This study documented a significant relationship between hospital-area deprivation and the risk of reporting worse than national benchmark SIRs. Though this did not appear to translate to Hospital Acquired Condition Reduction Program penalties in this dataset, it reinforces problems with the current use of SIRs for interhospital comparisons.

Medicaid Expansion Associated With Reductions In Preventable Hospitalizations

Hospitalizations for ambulatory care-sensitive conditions indicate barriers to care outside of inpatient settings. We found that Medicaid expansions under the Affordable Care Act were associated with meaningful reductions in these hospitalizations, which suggests the potential of Medicaid expansions to reduce the need for preventable hospitalizations in vulnerable populations and produce cost savings for the US health care system.

The Role Of Social, Cognitive, And Functional Risk Factors In Medicare Spending For Dual And Nondual Enrollees

The Centers for Medicare and Medicaid Services is increasingly focused on value-based payment programs, which tie payment to performance on quality and cost measures. In this context, there is rising concern that such programs systematically disadvantage providers that care for vulnerable populations, such as the poor, by holding the providers accountable for factors beyond their control that influence patient outcomes and utilization. In this nationally representative study of Medicare beneficiaries, we found that dually enrolled Medicare beneficiaries (those also enrolled in Medicaid) had strikingly higher levels of medical, functional, and cognitive comorbidities, as well as social needs, compared to their non-dually enrolled counterparts. Dual enrollees also had significantly higher annual costs of care. Including functional, cognitive, and social factors in cost prediction, in addition to risk factors derived from medical claims, improved risk prediction and decreased differences between dual and nondual enrollees. Medicare could consider such adjustment to improve accuracy and fairness in value-based payment programs.

Association of Clinician Health System Affiliation With Outpatient Performance Ratings in the Medicare Merit-based Incentive Payment System

IMPORTANCE

Integration of physician practices into health systems composed of hospitals and multispecialty practices is increasing in the era of value-based payment. It is unknown how clinicians who affiliate with such health systems perform under the new mandatory Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS) relative to their peers.

OBJECTIVE

To assess the relationship between the health system affiliations of clinicians and their performance scores and value-based reimbursement under the 2019 MIPS.

DESIGN, SETTING, AND PARTICIPANTS

Publicly reported data on 636 552 clinicians working at outpatient clinics across the US were used to assess the association of the affiliation status of clinicians within the 609 health systems with their 2019 final MIPS performance score and value-based reimbursement (both based on clinician performance in 2017), adjusting for clinician, patient, and practice area characteristics.

EXPOSURES

Health system affiliation vs no affiliation.

MAIN OUTCOMES AND MEASURES

The primary outcome was final MIPS performance score (range, 0-100; higher scores intended to represent better performance). The secondary outcome was MIPS payment adjustment, including negative (penalty) payment adjustment, positive payment adjustment, and bonus payment adjustment.

RESULTS

The final sample included 636 552 clinicians (41% female, 83% physicians, 50% in primary care, 17% in rural areas), including 48.6% who were affiliated with a health system. Compared with unaffiliated clinicians, system-affiliated clinicians were significantly more likely to be female (46% vs 37%), primary care physicians (36% vs 30%), and classified as safety net clinicians (12% vs 10%) and significantly less likely to be specialists (44% vs 55%) (P < .001 for each). The mean final MIPS performance score for system-affiliated clinicians was 79.0 vs 60.3 for unaffiliated clinicians (absolute mean difference, 18.7 [95% CI, 18.5 to 18.8]). The percentage receiving a negative (penalty) payment adjustment was 2.8% for system-affiliated clinicians vs 13.7% for unaffiliated clinicians (absolute difference, -10.9% [95% CI, -11.0% to -10.7%]), 97.1% vs 82.6%, respectively, for those receiving a positive payment adjustment (absolute difference, 14.5% [95% CI, 14.3% to 14.6%]), and 73.9% vs 55.1% for those receiving a bonus payment adjustment (absolute difference, 18.9% [95% CI, 18.6% to 19.1%]).

CONCLUSIONS AND RELEVANCE

Clinician affiliation with a health system was associated with significantly better 2019 MIPS performance scores. Whether this represents differences in quality of care or other factors requires additional research.

State Medicaid expansion status, insurance coverage and stage at diagnosis in head and neck cancer patients

OBJECTIVES

Only one in three head and neck cancer (HNC) patients present with early-stage disease. We aimed to quantify associations between state Medicaid expansions and changes in insurance coverage rates and stage at diagnosis of HNC.

METHODS

Using a quasi-experimental difference-in-differences (DID) approach and data from 26,330 cases included in the Surveillance, Epidemiology, and End Results program (2011-2015), we retrospectively examined changes in insurance coverage and stage at diagnosis of adult HNC in states that expanded Medicaid (EXP) versus those that did not (NEXP).

RESULTS

There was a significant increase in Medicaid coverage in EXP (+1.6 percentage point (PP) versus) vs. NEXP (-1.8 PP) states (3.36 PP, 95% CI = 1.32, 5.41; p = 0.001), and this increase was mostly among residents of low income and education counties. We also observed a reduction in uninsured rates among HNC patients in low income counties (-4.17 PP, 95% CI = -6.84, -1.51; p = 0.002). Overall, early stage diagnosis rates were 28.3% (EXP) vs. 26.7% (NEXP), with significant increases in early stage diagnosis post-Medicaid expansion among young adults, 18-34 years (17.2 PP, 95% CI - 1.34 to 33.1, p = 0.034), females (7.54 PP, 95% CI = 2.00 to 13.10, p = 0.008), unmarried patients (3.83 PP, 95% CI = 0.30-7.35, p = 0.033), and patients with lip cancer (13.5 PP, 95% CI = 2.67-24.3, p = 0.015).

CONCLUSIONS

Medicaid expansion is associated with improved insurance coverage rates for HNC patients, particularly those with low income, and increases in early stage diagnoses for young adults and women.

Volatility and Persistence of Value-Based Purchasing Adjustments: A Challenge to Integrating Population Health and Community Benefit Into Business Operations

With the passage of the Deficit Reduction Act of 2005 and the Patient Protection and Affordable Care Act in 2010, Medicare's Inpatient Prospective Payment System (IPPS) began a transition to value-based purchasing (VBP) that rewards or penalizes hospitals based on patient satisfaction, clinical processes of care, outcomes, and efficiency metrics. However, hospital-level volatility vs. persistence in value-based payments year-over-year could result in unpredictable cash flows that negatively influence investment behavior, drive underinvestment in community benefit/population health management initiatives, and make management of the factors that drive the VBP adjustment more challenging. To evaluate the volatility and persistence of hospital VBP adjustments, the sample includes VBP adjustments and the associated domain scores for the 2,547 hospitals that participated in the program from 2013 to 2016. The sample includes urban (74%), teaching (29.1%), system affiliated (46.5%), and not-for-profit (63.6%) facilities. Volatility was measured using basic descriptive statistics, relative risk ratios, and a fixed effect, autoregressive, dynamic panel model that robust-clustered the standard errors. There is substantial change in a given facility's total VBP score with an average standard deviation of 10.74 (on a 100-point scale) that is driven by significant volatility in all metrics but particularly by efficiency and outcomes metrics. Relative risk ratios have dropped substantially over the life of the program, and there is low persistence of VBP scores from one period to the next. Findings indicate that if hospitals receive a positive adjustment in 1 year, they are almost as likely to receive a negative adjustment as a positive adjustment the following year. Furthermore, using a fixed-effect dynamic panel model that controls for autocorrelation, we find that only 13.5% of a facility's prior year IPPS adjustment (positive or negative) carries forward to the next year. The low persistence makes investment in population health management and community benefit more challenging.

Abstract A121: Effect of state Medicaid expansion status on insurance coverage and stage at diagnosis in head and neck cancer patients

Objective: Access to care is an important issue for head and neck cancer (HNC) patients as HNC is one of the most expensive cancers, particularly for late stage disease. While some data show increased insurance coverage with Medicaid expansion, evidence is limited for impacts on socioeconomic disparities in insurance or on stage at diagnoses. This study aimed to quantify the impact of state Medicaid expansion status on insurance status and stage at diagnosis in HNC patients. Methods: Using a quasi-experimental design, the 2011-2015 Surveillance, Epidemiology, and End Results database was queried for adults with HNC in the United States. Changes in insurance coverage and stage at diagnosis after 2014 in states that expanded Medicaid (EXP) were compared to changes in states that did not expand Medicaid (NEXP). Difference-in-differences analyses were used to assess changes in the percentage of Medicaid coverage, uninsured, and early stage diagnoses in EXP relative to NEXP states. Results: A total of 26,330 HNC cases were identified. In difference-in-difference analyses, we observed an increase in Medicaid insurance in expansion relative to non-expansion states (3.36 percentage points (PP), 95% CI = 1.32, 5.41, p=.001), especially for residents of low income and education counties. We also observed a reduction in uninsured status among HNC patients in low income counties (-4.17 PP, 95% CI = -6.84, -1.51; p=.002). Additionally, we found significant increases among young adults age 18-34 years (17.2 PP, 95% CI – 1.34, 33.10, p=0.034), females (7.54 PP, 95% CI = 2.00, 13.10, p=0.008), unmarried patients (3.83 PP, 95% CI = 0.30, 7.35, p=0.033), and patients with cancer of the lip (13.5 PP, 95% CI = 2.67, 24.30, p=0.015). There was some evidence for greater expansion-associated increases in early stage diagnoses for non-Hispanic blacks (8.53 PP) and other races (20.4 PP) relative to white HNC patients (p=.025). Conclusions: Medicaid expansion is associated with improved insurance coverage for HNC patients, particularly those with low income, and increased early stage diagnoses for young adults and for racial/ethnic minorities. Thus, Medicaid expansion may improve access to care for patients with HNC. Our findings are particularly relevant at a time when there is debate in the United States about healthcare financing, Medicaid, and the Affordable Care Act.

Citation Format: Nosayaba Osazuwa-Peters, Justin M Barnes, Eric Adjei Boakye, Matthew E Gaubatz, Kenton J Johnston, Neelima Panth, Rosh KV Sethi, Uchechukwu Megwalu, Mark A Varvares. Effect of state Medicaid expansion status on insurance coverage and stage at diagnosis in head and neck cancer patients [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A121.

Assessment of HF Outcomes Using a Claims-Based Frailty Index

OBJECTIVES

This study used a claims-based frailty index to investigate outcomes of frail patients with heart failure (HF).

BACKGROUND

Medicare value-based payment programs financially reward and penalize hospitals based on HF patients' outcomes. Although programs adjust risks for comorbidities, they do not adjust for frailty. Hospitals caring for high proportions of frail patients may be unfairly penalized. Understanding frail HF patients' outcomes may allow improved risk adjustment and more equitable assessment of health care systems.

METHODS

Adapting a claims-based frailty index, the study assigned a frailty score to each adult in the National in-patient Sample (NIS) from 2012 through September 2015 with a primary diagnosis of HF and dichotomized frailty by using a cutoff value established in the general NIS population. Multivariate regression models were estimated, controlling for comorbidities and hospital characteristics, to investigate relationships between frailty and outcomes.

RESULTS

Of 732,932 patients, 369,298 were frail. Frail patients were more likely than nonfrail patients to die during hospital stay (3.57% vs. 2.37%, respectively; adjusted odds ratio [aOR]: 1.67; 95% confidence interval [CI]: 1.61 to 1.72; p < 0.001); were less likely to be discharged to home (66.5% vs. 79.3%, respectively; aOR: 0.58; 95% CI: 0.57 to 0.58; p < 0.001); were hospitalized for more days (5.89 vs. 4.63 days, respectively; adjusted coefficient: 0.21 days; 95% CI: 0.21 to 0.22; p < 0.001); and incurred higher charges ($47,651 vs. $40,173, respectively; adjusted difference = $9,006; 95% CI: $8,596 to $9,416; p < 0.001).

CONCLUSIONS

Frail patients with HF had significantly poorer outcomes than nonfrail patients after accounting for comorbidities. Clinicians should screen for frailty to identify high-risk patients who could benefit from targeted intervention. Policymakers should perform risk adjustments for frailty for more equitable quality measurement and financial incentive allocation.

Relationship of a Claims-Based Frailty Index to Annualized Medicare Costs: A Cohort Study

BACKGROUND

Medicare uses the Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) model to predict patients' annualized Medicare costs in value-based payment programs. The CMS-HCC model does not include measures of frailty, and prior research shows that it systematically underpredicts costs for frail Medicare beneficiaries.

OBJECTIVE

To determine whether a claims-based frailty index can improve Medicare cost prediction.

DESIGN

Retrospective cohort study.

SETTING

Medicare Current Beneficiary Survey linked to Medicare claims, 2006 to 2013.

PARTICIPANTS

16 535 community-dwelling, fee-for-service beneficiaries representing 26 705 patient-years.

MEASUREMENTS

Patient frailty status was classified using a validated claims-based frailty index. The association between the frailty index and annualized Medicare costs was examined, and regression methods were used to compare observed Medicare costs versus predictions based on the standard CMS-HCC model with and without the frailty index.

RESULTS

Mean costs were $5724 for the 8910 patients classified as robust (46.4% of patient-years), $12 462 for the 8405 prefrail patients (41.6%), $26 239 for the 2215 mildly frail patients (9.6%), and $44 586 for the 593 patients classified as moderately to severely frail (2.5%). The frailty index addition to the CMS-HCC model predicted on average an additional $2712, $7915, and $16 449 in costs for prefrail, mildly frail, and moderately to severely frail patients, respectively, beyond the CMS-HCC model alone. On average, the model with the frailty index addition resulted in more accurate predictions of costs for patients at all 4 levels of frailty. However, observed costs remained more widely distributed than predictions from the enhanced model at all levels of frailty.

LIMITATION

The claims-based index is a proxy for frailty and is likely less accurate than an in-person examination.

CONCLUSION

The CMS-HCC model with the frailty index addition is an improvement over current Medicare cost prediction.

PRIMARY FUNDING SOURCE

None.

Patient social risk factors and continuity of care for Medicare beneficiaries

OBJECTIVE

To identify patient social risk factors associated with Continuity of Care (COC) index.

DATA SOURCES/STUDY SETTING

Medicare Current Beneficiary Survey (MCBS), the Dartmouth Institute, and Area Resource File for 2006-2013.

STUDY DESIGN

We use regression methods to assess the effect of patient social risk factors on COC after adjusting for medical complexity. In secondary analyses, we assess the effect of social risk factors on annual utilization of physicians and specialists for evaluation and management (E&M).

DATA COLLECTION/EXTRACTION METHODS

We retrospectively identified 59 499 patient years for Medicare beneficiaries with one year of enrollment and three or more E&M visits.

PRINCIPAL FINDINGS

After adjustment for medical complexity, individual-level social risk factors such as lack of education, low income, and living alone are all associated with better patient COC (P < .05). Similarly, area-level social risk factors such as living in areas that are nonurban or high poverty, as well as in areas with low specialist or high primary care physician supply, are all associated with better patient COC (P < .05). We found the opposite pattern of associations between these same risk factors and annual patient utilization of physicians and specialists (P < .05).

CONCLUSIONS

Medicare patients with multiple social risk factors have consistently better COC; these same social risk factors are associated with reduced patient-realized access to specialist physician care.

Inadequate Risk Adjustment Impacts Geriatricians' Performance on Medicare Cost and Quality Measures

OBJECTIVES

Medicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures.

DESIGN

A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors.

SETTING

Eight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey.

PARTICIPANTS

Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data.

MEASUREMENTS

Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression.

RESULTS

Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P < .001 for each). Under standard Medicare risk adjustment, geriatricians performed more poorly on costs compared to other PCPs (observed-expected [O-E] ratio = 1.24 vs 0.99) and preventable hospitalizations (O-E ratio = 1.16 vs 0.98). Adding frailty, institutionalization, dementia, and depression to risk adjustment improved geriatricians' performance on costs by 25% and on preventable hospitalization rates by 35%, relative to other PCPs. Concurrent-year risk prediction that removed the influence of unpredictable acute events further improved geriatricians' performance vs other PCPs (O-E ratio = 0.99 vs 1.00).

CONCLUSION

Medicare should consider risk adjusting for frailty, long-term institutionalization, dementia, and depression to avoid inappropriately penalizing geriatricians who care for vulnerable older adults. J Am Geriatr Soc 68:297-304, 2020.

Association of Patient Social, Cognitive, and Functional Risk Factors with Preventable Hospitalizations: Implications for Physician Value-Based Payment

BACKGROUND

Ambulatory care-sensitive condition (ACSC) hospitalizations are used to evaluate physicians' performance in Medicare value-based payment programs. However, these measures may disadvantage physicians caring for vulnerable populations because they omit social, cognitive, and functional factors that may be important determinants of hospitalization.

OBJECTIVE

To determine whether social, cognitive, and functional risk factors are associated with ACSC hospitalization rates and whether adjusting for them changes outpatient safety-net providers' performance.

DESIGN

Using data from the Medicare Current Beneficiary Survey, we conducted patient-level multivariable regression to estimate the association (as incidence rate ratios (IRRs)) between patient-reported social, cognitive, and functional risk factors and ACSC hospitalizations. We compared outpatient safety-net and non-safety-net providers' performance after adjusting for clinical comorbidities alone and after additional adjustment for social, cognitive, and functional factors captured in survey data.

SETTING

Safety-net and non-safety-net clinics.

PARTICIPANTS

Community-dwelling Medicare beneficiaries contributing 38,616 person-years from 2006 to 2013.

MEASUREMENTS

Acute and chronic ACSC hospitalizations.

RESULTS

After adjusting for clinical comorbidities, Alzheimer's/dementia (IRR 1.30, 95% CI 1.02-1.65), difficulty with 3-6 activities of daily living (ADLs) (IRR 1.43, 95% CI 1.05-1.94), difficulty with 1-2 instrumental ADLs (IADLs, IRR 1.54, 95% CI 1.26-1.90), and 3-6 IADLs (IRR 1.90, 95% CI 1.49-2.43) were associated with acute ACSC hospitalization. Low income (IRR 1.28, 95% CI 1.03-1.58), lack of educational attainment (IRR 1.33, 95% CI 1.04-1.69), being unmarried (IRR 1.18, 95% CI 1.01-1.36), difficulty with 1-2 IADLs (IRR 1.30, 95% CI 1.05-1.60), and 3-6 IADLs (IRR 1.44, 95% CI 1.16-1.80) were associated with chronic ACSC hospitalization. Adding these factors to standard Medicare risk adjustment eliminated outpatient safety-net providers' performance gap (p < .05) on ACSC hospitalization rates relative to non-safety-net providers.

CONCLUSIONS

Social, cognitive, and functional risk factors are independently associated with ACSC hospitalizations. Failure to account for them may penalize outpatient safety-net providers for factors that are beyond their control.

The incremental cost of infections associated with multidrug-resistant organisms in the inpatient hospital setting-A national estimate

OBJECTIVE

To estimate the cost of infections associated with multidrug-resistant organisms (MDROs) during inpatient hospitalization in the United States.

DATA SOURCES/STUDY SETTING

2014 National Inpatient Sample.

STUDY DESIGN

Multivariable regression models assessed the incremental effect of MDROs on the cost of hospitalization and hospital length of stay among patients with bacterial infections.

DATA COLLECTION/EXTRACTION METHODS

We retrospectively identified 6 385 258 inpatient stays for patients with bacterial infection.

PRINCIPAL FINDINGS

The national incidence rate of inpatient stays with bacterial infection is 20.1 percent. At least 10.8 percent of such stays-and as many as 16.9 percent if we account for undercoded infections-show evidence of one or more MDROs. MRSA, C. difficile, infection with another MDRO, and the presence of more than one MDRO are associated with $1718 (95% CI, $1609-$1826), $4617 (95% CI, $4407-$4827), $2302 (95% CI, $2044-$2560), and $3570 (95% CI, $3019-$4122) in additional costs per stay, respectively. The national cost of infections associated with MDROs is at least $2.39 billion (95% CI, $2.25-$2.52 billion) and as high as $3.38 billion (95% CI, $3.13-$3.62 billion) if we account for undercoded infections.

CONCLUSIONS

Infections associated with MDROs result in a substantial cost burden to the US health care system.

Association Between Patient Cognitive and Functional Status and Medicare Total Annual Cost of Care: Implications for Value-Based Payment

IMPORTANCE

Medicare is moving toward value-based payment. The Merit-Based Incentive Payment System (MIPS) program judges outpatient clinicians' performance on a measure of annual Medicare spending. However, this measure may disadvantage outpatient clinicians who care for vulnerable populations because the algorithm omits meaningful determinants of cost.

OBJECTIVES

To determine whether factors not included in Medicare risk adjustment, including patient neuropsychological and functional status, as well as local area health resources and economic conditions, are associated with Medicare total annual cost of care (TACC), and evaluate whether accounting for these factors is associated with improved TACC performance by outpatient safety-net clinicians.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective observational study, we used the Medicare Current Beneficiary Survey (MCBS) to examine patient-reported neuropsychological and functional status and the Area Health Resources File to obtain information on local area characteristics. Included were Medicare beneficiaries with annual physician or clinic visits to outpatient safety-net (federally qualified health centers and rural health clinics) and non-safety-net clinics, contributing 76 927 person-years of data to the MCBS from 2006 through 2013. We used patient-level multivariable regression models to estimate the association between each factor and annual Medicare spending, and compared outpatient safety-net performance under current risk adjustment and after adding additional adjustment for these factors.

MAIN OUTCOMES AND MEASURES

Medicare TACC, measured as the total annual reimbursed amount per patient for Medicare Part A and Part B services, in all categories.

RESULTS

Our study included 111 414 unique identifiable physicians, and the final weighted sample included 213 904 324 patient-years (unweighted, 76 927 patient-years) from 30 058 unique patients, of whom 17 478 (58.1%) were women. The mean (SD) patient age was 71.84 (12.48) years. The mean TACC was $9117. Those with higher than mean TACC included beneficiaries with depression ($14 436), dementia ($18 311), and difficulty with 3 or more activities of daily living (ADLs, $19 113) or instrumental ADLs ($17 443). After adjusting for comorbidities, depression and dementia were still associated with $2740 (95% CI, $2200-$2739) and $2922 (95% CI, $2399-$3445) higher TACC, respectively. Difficulty with 3 or more ADLs ($3121 higher; 95% CI, $2633-$3609) or instrumental ADLs ($895 higher; 95% CI, $452-$1337) was also associated with higher TACC. Adding these neuropsychological and functional factors, as well as local residence area factors, to risk adjustment calculations reduced outpatient safety-net clinicians' underperformance on Medicare TACC relative to non-safety-net clinicians by 52% (from 0.098 to 0.047 difference in the observed to expected ratio).

CONCLUSIONS AND RELEVANCE

Neuropsychological and functional impairment are common in Medicare beneficiaries and are associated with increased annual Medicare spending. Failure to account for these factors may inappropriately penalize outpatient clinicians who care for these vulnerable groups, such as safety-net clinicians, for factors that are arguably beyond their control.

Antibiotic-Resistant Infection Treatment Costs Have Doubled Since 2002, Now Exceeding $2 Billion Annually

Antibiotic-resistant infections are a global health care concern. The Centers for Disease Control and Prevention estimates that 23,000 Americans with these infections die each year. Rising infection rates add to the costs of health care and compromise the quality of medical and surgical procedures provided. Little is known about the national health care costs attributable to treating the infections. Using data from the Medical Expenditure Panel Survey, we estimated the incremental health care costs of treating a resistant infection as well as the total national costs of treating such infections. To our knowledge, this is the first national estimate of the costs for treating the infections. We found that antibiotic resistance added $1,383 to the cost of treating a patient with a bacterial infection. Using our estimate of the number of such infections in 2014, this amounts to a national cost of $2.2 billion annually. The need for innovative new infection prevention programs, antibiotics, and vaccines to prevent and treat antibiotic-resistant infections is an international priority.

A "Patch" to the NYU Emergency Department Visit Algorithm

OBJECTIVE

To document erosion in the New York University Emergency Department (ED) visit algorithm's capability to classify ED visits and to provide a "patch" to the algorithm.

DATA SOURCES

The Nationwide Emergency Department Sample.

STUDY DESIGN

We used bivariate models to assess whether the percentage of visits unclassifiable by the algorithm increased due to annual changes to ICD-9 diagnosis codes. We updated the algorithm with ICD-9 and ICD-10 codes added since 2001.

PRINCIPAL FINDINGS

The percentage of unclassifiable visits increased from 11.2 percent in 2006 to 15.5 percent in 2012 (p < .01), because of new diagnosis codes. Our update improves the classification rate by 43 percent in 2012 (p < .01).

CONCLUSIONS

Our patch significantly improves the precision and usefulness of the most commonly used ED visit classification system in health services research.

Are Two Heads Better Than One or Do Too Many Cooks Spoil the Broth? The Trade-Off between Physician Division of Labor and Patient Continuity of Care for Older Adults with Complex Chronic Conditions

OBJECTIVE

To examine the effects of physician division of labor and patient continuity of care (COC) on the care quality and outcomes of older adults with complex chronic conditions.

DATA SOURCES/STUDY SETTING

Seven years (2006-2012) of panel data from the Medicare Current Beneficiary Survey (MCBS).

STUDY DESIGN

Regression models were used to estimate the effect of the specialty-type of physicians involved in annual patient evaluation and management, as well as patient COC, on simultaneous care processes and following year outcomes.

DATA COLLECTION/EXTRACTION METHODS

Multiyear cohorts of Medicare beneficiaries with diabetes and/or heart failure were retrospectively identified to create a panel of 15,389 person-year observations.

PRINCIPAL FINDINGS

Involvement of both primary care physicians and disease-relevant specialists is associated with better compliance with process-of-care guidelines, but patients seeing disease-relevant specialists also receive more repeat cardiac imaging (p < .05). Patient COC is associated with less repeat cardiac imaging and compliance with some recommended care processes (p < .05), but the effects are small. Receiving care from a disease-relevant specialist is associated with lower rates of following year functional impairment, institutionalization in long-term care, and ambulatory care sensitive hospitalization (p < .05).

CONCLUSIONS

Annual involvement of disease-relevant specialists in the care of beneficiaries with complex chronic conditions leads to more resource use but has a beneficial effect on outcomes.

Darwin--a mission to detect and search for life on extrasolar planets

The discovery of extrasolar planets is one of the greatest achievements of modern astronomy. The detection of planets that vary widely in mass demonstrates that extrasolar planets of low mass exist. In this paper, we describe a mission, called Darwin, whose primary goal is the search for, and characterization of, terrestrial extrasolar planets and the search for life. Accomplishing the mission objectives will require collaborative science across disciplines, including astrophysics, planetary sciences, chemistry, and microbiology. Darwin is designed to detect rocky planets similar to Earth and perform spectroscopic analysis at mid-infrared wavelengths (6-20 mum), where an advantageous contrast ratio between star and planet occurs. The baseline mission is projected to last 5 years and consists of approximately 200 individual target stars. Among these, 25-50 planetary systems can be studied spectroscopically, which will include the search for gases such as CO(2), H(2)O, CH(4), and O(3). Many of the key technologies required for the construction of Darwin have already been demonstrated, and the remainder are estimated to be mature in the near future. Darwin is a mission that will ignite intense interest in both the research community and the wider public.

Vega is a rapidly rotating star

Vega, the second brightest star in the northern hemisphere, serves as a primary spectral type standard. Although its spectrum is dominated by broad hydrogen lines, the narrower lines of the heavy elements suggested slow to moderate rotation, giving confidence that the ground-based calibration of its visible spectrum could be safely extrapolated into the ultraviolet and near-infrared (through atmosphere models), where it also serves as the primary photometric calibrator. But there have been problems: the star is too bright compared to its peers and it has unusually shaped absorption line profiles, leading some to suggest that it is a distorted, rapidly rotating star seen pole-on. Here we report optical interferometric observations that show that Vega has the asymmetric brightness distribution of the bright, slightly offset polar axis of a star rotating at 93 per cent of its breakup speed. In addition to explaining the unusual brightness and line shape peculiarities, this result leads to the prediction of an excess of near-infrared emission compared to the visible, in agreement with observations. The large temperature differences predicted across its surface call into question composition determinations, adding uncertainty to Vega's age and opening the possibility that its debris disk could be substantially older than previously thought.

Objective measures of dysphagia complexity in children related to suckle feeding histories, gestational ages, and classification of their cerebral palsy

Data collected during the routine assessment of 117 dysphagic children with cerebral palsy have been related to both suckle feeding histories and gestational ages and to the classification of cerebral palsy. In addition, a concurrent survey involving 281 children with cerebral palsy in special schools was undertaken which revealed that the sample of referred children appeared to be a true representation of a wider population of dysphagic children with cerebral palsy. A Feeding Difficulty Symptom Score (FDSS) describes the severity of swallowing symptoms reported. A numerical Dysphagia Complexity Index (DCI) quantifies numerically the neurological complexity of the swallowing difficulty. The FDSS correlates closely with the DCI. Twenty-seven percent of mothers of the children who were referred for advice on their present swallowing difficulties stated that they recalled no suckle feeding problems. However, there was no difference in the severity of present swallowing difficulties between those infants who suckle fed well and those who experienced severe difficulties. Those referred children with cerebral palsy born at term exhibited more complex later swallowing problems and were more likely to be classified as athetoid than those born preterm.