Association of patient characteristics and insurance type with anti-obesity medications prescribing and fills

AIM

To characterize factors associated with the receipt of anti-obesity medication (AOM) prescription and fill.

MATERIALS AND METHODS

This retrospective cohort study used electronic health records from 1 January 2015 to 30 June 2023, in a large health system in Ohio and Florida. Adults with a body mass index ≥30 kg/m2 who attended ≥1 weight-management programme or had an initial AOM prescription between 1 July 2015 and 31 December 2022, were included. The main measures were a prescription for an AOM (naltrexone-bupropion, orlistat, phentermine-topiramate, liraglutide 3.0 mg and semaglutide 2.4 mg) and an AOM fill during the study follow-up.

RESULTS

We identified 50 678 adults, with a mean body mass index of 38 ± 8 kg/m2 and follow-up of 4.7 ± 2.4 years. Only 8.0% of the cohort had AOM prescriptions and 4.4% had filled prescriptions. In the multivariable analyses, being a man, Black, Hispanic and other race/ethnicity (vs. White), Medicaid, traditional Medicare, Medicare Advantage, self-pay and other insurance types (vs. private insurance) and fourth quartile of the area deprivation index (vs. first quartile) were associated with lower odds of a new prescription. Hispanic ethnicity, being a man, Medicaid, traditional Medicare and Medicare Advantage insurance types, liraglutide and orlistat (vs. naltrexone-buproprion) were associated with lower odds of AOM fill, while phentermine-topiramate was associated with higher odds. Among privately insured individuals, the insurance carrier was associated with both the odds of AOM prescription and fill.

CONCLUSIONS

Significant disparities exist in access to AOM both at the prescribing stage and getting the prescription filled based on patient characteristics and insurance type.

Predictors of adherence to direct oral anticoagulants after cardiovascular or bleeding events in Medicare Advantage Plan enrollees with atrial fibrillation

BACKGROUND

Direct oral anticoagulants (DOACs) are recommended for patients with atrial fibrillation (AF) given their improved safety profile. Suboptimal adherence to DOACs remains a significant concern among individuals with AF. However, the extent of adherence to DOACs following a cardiovascular or bleeding event has not been fully evaluated.

OBJECTIVE

To evaluate the pattern of adherence trajectories of DOACs after a cardiovascular or bleeding event and to investigate the sociodemographic and clinical predictors associated with each adherence trajectory by using claims-based data.

METHODS

This retrospective study was conducted among patients with AF prescribed with DOACs (dabigatran/apixaban/rivaroxaban) between July 2016 and December 2017 and who were continuously enrolled in the Texas-based Medicare Advantage Plan. Patients who experienced a cardiovascular or bleeding event while using the DOACs were further included in the analysis. The sample was limited to patients who experienced a clinical event such as a cardiovascular or bleeding event while using the DOACs. The clinical events considered in this study were cardiovascular (stroke, congestive heart failure, myocardial infarction, systemic embolism) and bleeding events. To assess adherence patterns, each patient with a DOAC prescription was followed up for a year after experiencing a clinical event. The monthly adherence to DOACs after these events was evaluated using the proportion of days covered (PDC). A group-based trajectory model incorporated the monthly PDC to classify groups of patients based on their distinct patterns of adherence. Predictors associated with each trajectory were assessed using a multinomial logistic regression model, with the adherent trajectory serving as the reference group in the outcome variable.

RESULTS

Among the 694 patients with AF who experienced clinical events after the initiation of DOACs, 3 distinct adherence trajectories were identified: intermediate nonadherent (30.50%), adherent (37.7%), and low adherent (31.8%); the mean PDC was 0.47 for the intermediate nonadherent trajectory, 0.93 for the adherent trajectory, and 0.01 for low adherent trajectory. The low-income subsidy was significantly associated with lower adherence trajectories (odds ratio [OR] = 4.81; 95% CI = 3.07-7.51) and with intermediate nonadherent trajectories (OR = 1.57; 95% CI = 1.06-2.34). Also, nonsteroidal anti-inflammatory drug use was significantly associated with lower adherence trajectories (OR = 5.10; 95% CI = 1.95-13.36) and intermediate nonadherent trajectories (OR = 3.17; 95% CI = 1.26-7.93). Other predictors significantly associated with both nonadherent trajectories are type of DOACs (OR = 0.53; 95% CI = 0.35-0.79), presence of coronary artery disease (OR = 1.89; 95% CI = 1.01-3.55), and having 2 or more clinical events (OR = 1.65; 95% CI = 1.09-2.50).

CONCLUSIONS

Predictors identified provide valuable insights into the suboptimal adherence of DOACs among Medicare Advantage Plan enrollees with AF, which can guide the development of targeted interventions to enhance adherence in this high-risk patient population.

Medicare Advantage and Home Health Care: A Systematic Review

OBJECTIVES

Home health care serves millions of Americans who are "Aging in Place," including the rapidly growing population of Medicare Advantage (MA) enrollees. This study systematically reviewed extant evidence illustrating home health care (HHC) services to MA enrollees.

METHODS

A comprehensive literature search was conducted in 6 electronic databases to identify eligible studies, which resulted in 386 articles. Following 2 rounds of screening, 30 eligible articles were identified. Each study was also assessed independently for study quality using a validated quality assessment checklist.

RESULTS

Of the 30 studies, nearly half (n=13) were recently published between January 1, 2017 - January 6, 2022. Among various issues related to HHC to MA enrollees examined, which were often compared with Traditional Medicare (TM) enrollees, the 2 most studied issues were HHC use rate (including access) and care dosage/intensity. Inconsistencies were common in findings across reviewed studies, with slight variations in the level of inconsistency by studied outcomes. Several critical issues, such as heterogeneity of MA plans, influence of MA-specific features, and program response to policy and quality improvement initiatives, were only examined by 1 or 2 studies. The depth and scope of scientific investigation were also limited by the scale and details available in MA data in addition to other methodological limits.

CONCLUSIONS

Wild variations and conflicting findings on HHC to MA beneficiaries exist across studies. More research with rigorous designs and robust MA encounter data is warranted to determine home health care for MA enrollees and the relevant outcomes.

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

OBJECTIVES

High-need Medicare beneficiaries require elevated levels of care and coordination to manage their conditions. We evaluated the extent to which high-need beneficiaries enrolled in Medicare Advantage (MA) or traditional Medicare (TM) accountable care organizations (ACOs) relative to TM non-ACOs.

STUDY DESIGN

Using Medicare claims and MA encounter data, we identified 3 groups of high-need beneficiaries: (1) individuals younger than 65 years with a disability or end-stage kidney disease, (2) frail individuals, and (3) older individuals with major complex or multiple noncomplex chronic conditions. For comparison, we included non-high-need beneficiaries in the analysis, including those with minor complex chronic conditions.

METHODS

Descriptive analysis of Medicare enrollment patterns and beneficiary characteristics of high-need and other beneficiaries between 2016 and 2019.

RESULTS

In 2019, high-need beneficiaries accounted for 18 million or 32% of enrollees in TM and MA, an increase of approximately 1 million since 2016, driven by growth in MA. A larger share of beneficiaries in TM ACOs was high need (38%) compared with MA (24%). Although the total count of high-need beneficiaries in TM remained stable from 2016 to 2019, ACOs saw an increase of almost 1.5 million high-need beneficiaries (39% increase), and TM non-ACOs saw a decrease of 1.9 million (23% decrease).

CONCLUSIONS

We found that high-need beneficiaries were more likely to be in TM non-ACOs than in MA through 2019. However, an increasing number of these beneficiaries are enrolling in MA or aligned with a TM ACO. A projected increase in the population of older adults will increase the economic burden of caring for high-need individuals.

Trends in low-value cancer care during the COVID-19 pandemic

OBJECTIVE

To assess the association between the onset of the COVID-19 pandemic and change in low-value cancer services.

STUDY DESIGN

In this retrospective cohort study, we used administrative claims from the HealthCore Integrated Research Environment, a repository of medical and pharmacy data from US health plans representing more than 80 million members, between January 1, 2016, and March 31, 2021.

METHODS

We used linear probability models to investigate the relation between the onset of the COVID-19 pandemic and 4 guideline-based metrics of low-value cancer care: (1) conventional fractionation radiotherapy instead of hypofractionated radiotherapy for early-stage breast cancer; (2) non-guideline-based antiemetic use for minimal-, low-, or moderate- to high-risk chemotherapies; (3) off-pathway systemic therapy; and (4) aggressive end-of-life care. We identified patients with new diagnoses of breast, colorectal, and/or lung cancer. We excluded members who did not have at least 6 months of continuous insurance coverage and members with prevalent cancers.

RESULTS

Among 117,116 members (median [IQR] age, 60 [53-69] years; 72.4% women), 59,729 (51.0%) had breast cancer, 25,751 (22.0%) had colorectal cancer, and 31,862 (27.2%) had lung cancer. The payer mix was 18.7% Medicare Advantage or Medicare supplemental and 81.2% commercial non-Medicare. Rates of low-value cancer services exhibited minimal changes during the pandemic, as adjusted percentage-point differences were 3.93 (95% CI, 1.50-6.36) for conventional radiotherapy, 0.82 (95% CI, -0.62 to 2.25) for off-pathway systemic therapy, -3.62 (95% CI, -4.97 to -2.27) for non-guideline-based antiemetics, and 2.71 (95% CI, -0.59 to 6.02) for aggressive end-of-life care.

CONCLUSIONS

Low-value cancer care remained prevalent throughout the pandemic. Policy makers should consider changes to payment and incentive design to turn the tide against low-value cancer care.

Medication persistence and its impact on type 2 diabetes

OBJECTIVES

Medication persistence in type 2 diabetes (T2D) is a critical factor for preventing adverse clinical events. We assessed persistence among newly treated patients with T2D and documented the impact of persistence on clinical outcomes and costs.

STUDY DESIGN

Retrospective study of Optum Clinformatics Data Mart commercial and Medicare Advantage enrollees from 2007 to 2020.

METHODS

We identified adult patients who initiated antidiabetic treatments. Patients were required to have at least 1 treatment-free year prior to their first T2D prescription. Persistence was measured as the duration of continuous therapy until a 60-day gap in drug availability appeared in any antidiabetic therapy. Factors associated with duration were documented, focusing on the initial class(es) of T2D drugs. The impact of treatment duration on the risk of hospitalization and on total health care costs was also examined.

RESULTS

A total of 673,265 patients were included, with a median follow-up of 7 years. Only 22% of patients maintained continuous treatment, of whom 10% added a second medication. A 1-month increase in duration was associated with reduced risk of hospitalization due to stroke by 0.54% (95% CI, 0.46%-0.60%), acute myocardial infarction by 0.51% (95% CI, 0.44%-0.57%), and all-cause hospitalization by 0.36% (95% CI, 0.34%-0.37%). A 1-month increase in duration was associated with a year-to-year decrease in medical costs of $51 (95% CI, -$54 to -$48) and an increase in year-to-year drug costs of $14 (95% CI, $13-$14).

CONCLUSIONS

Our findings show low persistence among patients with T2D and emphasize the importance of medication persistence, which is associated with cost savings and lower risk of hospitalizations.

Comparison of prior authorization across insurers: cross sectional evidence from Medicare Advantage

OBJECTIVE

To measure and compare the scope of US insurers' policies for prior authorization (PA), a process by which insurers assess the necessity of planned medical care, and to quantify differences in PA across insurers, physician specialties, and clinical service categories.

DESIGN

Cross sectional analysis.

SETTING

PA policies for five insurers serving most of the beneficiaries covered by privately administered Medicare Advantage in the US, 2021, as applied to utilization patterns observed in Medicare Part B.

PARTICIPANTS

30 540 086 beneficiaries in traditional Medicare Part B.

MAIN OUTCOME MEASURES

Proportions of government administered traditional Medicare Part B spending and utilization that would have required PA according to Medicare Advantage insurer rules.

RESULTS

The insurers required PA for 944 to 2971 of the 14 130 clinical services (median 1899; weighted mean 1429) constituting 17% to 33% of Part B spending (median 28%; weighted mean 23%) and 9% to 41% of Part B utilization (median 22%; weighted mean 18%). 40% of spending ($57bn; £45bn; €53bn) and 48% of service utilization would have required PA by at least one insurer; 12% of spending and 6% of utilization would have required PA by all insurers. 93% of Part B medication spending, or 74% of medication use, would have required PA by at least one Medicare Advantage insurer. For all Medicare Advantage insurers, hematology and oncology drugs represented the largest proportion of PA spending (range 27-34%; median 33%; weighted mean 30%). PA rates varied widely across specialties.

CONCLUSION

PA policies varied substantially across private insurers in the US. Despite limited consensus, all insurers required PA extensively, particularly for physician administered medications. These findings indicate substantial differences in coverage policies between government administered and privately administered Medicare. The results may inform ongoing efforts to focus PA more effectively on low value services and reduce administrative burdens for clinicians and patients.

Breast cancer screening among Medicare Advantage enrollees with dementia

BACKGROUND

The decision to screen for breast cancer among older adults with dementia is complex and must often be individualized, as these individuals have an elevated risk of harm from over-screening. Medicare beneficiaries with dementia are increasingly enrolling in Medicare Advantage plans, which typically promote receipt of preventive cancer screening among their enrollees. This study examined the utilization of breast cancer screening among Medicare enrollees with dementia, in Medicare Advantage and in fee-for-service Medicare.

METHODS

We conducted a pooled cross-sectional study of women with Alzheimer's disease and related dementias or cognitive impairment who were eligible for mammogram screening. We used Medicare Current Beneficiary Survey data to identify utilization of biennial mammogram screening between 2012 and 2019. Poisson regression models were used to estimate prevalence ratios of mammogram utilization and to calculate adjusted mammogram rates for Medicare Advantage and fee-for-service Medicare enrollees with dementia, and further stratified by rurality and by dual eligibility for Medicare and Medicaid.

RESULTS

Mammogram utilization was 16% higher (Prevalence Ratio [PR] 1.16; 95% CI: 1.05, 1.29) among Medicare Advantage enrollees with dementia, compared to their counterparts in fee-for-service Medicare. Rural enrollees experienced no significant difference (PR 0.99; 95% CI: 0.72, 1.37) in mammogram use between Medicare Advantage and fee-for-service Medicare enrollees. Among urban enrollees, Medicare Advantage enrollment was associated with a 21% higher mammogram rate (PR 1.21; 95% CI: 1.09, 1.35). Dual-eligible Medicare Advantage enrollees had a 34% higher mammogram rate (PR 1.34; 95% CI: 1.10, 1.63) than dual-eligible fee-for-service Medicare enrollees. Among non-dual-eligible enrollees, adjusted mammogram rates were not significantly different (PR 1.11; 95% CI: 0.99, 1.24) between Medicare Advantage and fee-for-service Medicare enrollees.

CONCLUSIONS

Medicare beneficiaries age 65-74 with Alzheimer's disease and related dementias or cognitive impairment had a higher mammogram use rate when they were enrolled in Medicare Advantage plans compared to fee-for-service Medicare, especially when they were dual-eligible or lived in urban areas. However, some Medicare Advantage enrollees with Alzheimer's disease and related dementias or cognitive impairment may have experienced over-screening for breast cancer.

The extent and growth of prior authorization in Medicare Advantage

OBJECTIVES

To assess trends in the use of prior authorization requirements among Medicare Advantage (MA) plans.

STUDY DESIGN

Descriptive quantitative analysis.

METHODS

Data were from the CMS MA benefit and enrollment files for 2009-2019, supplemented with area-level data on demographic and provider market characteristics. For each service category, we calculated the annual share of MA enrollees in plans requiring at least some prior authorization and plotted trends over time. We mapped the county-level share of MA enrollees exposed to prior authorization in 2009 vs 2019. We quantified the association between local share of MA enrollees exposed to prior authorization and characteristics of that county in the same year. Finally, we plotted the share of MA enrollees exposed to prior authorization requirements over time for the 6 largest MA carriers.

RESULTS

From 2009 to 2019, the share of MA enrollees in plans requiring prior authorization for any service remained stable. By service category, the share of MA enrollees exposed to prior authorization ranged from 30.7% (physician specialist services) to 72.2% (durable medical equipment) in 2019, with most service categories requiring prior authorization more often over time. Several area-level demographic and provider market characteristics were associated with prior authorization requirements, but these associations weakened over time. The use of prior authorization varied widely across plans.

CONCLUSIONS

In 2019, roughly 3 in 4 MA enrollees were in a plan requiring prior authorization. Service-level, area-level, and carrier-level patterns suggest a wide range of approaches to prior authorization requirements.

Primary Care Physicians In Medicare Advantage Were Less Costly, Provided Similar Quality Versus Regional Average

The use of many services is lower in Medicare Advantage (MA) compared with traditional Medicare, generating cost savings for insurers, whereas the quality of ambulatory services is higher. This study examined the role of selective contracting with providers in achieving these outcomes, focusing on primary care physicians. Assessing primary care physician costliness based on the gap between observed and predicted costs for their traditional Medicare patients, we found that the average primary care physician in MA networks was $433 less costly per patient (2.9 percent of baseline) compared with the regional mean, with less costly primary care physicians included in more networks than more costly ones. Favorable selection of patients by MA primary care physicians contributed partially to this result. The quality measures of MA primary care physicians were similar to the regional mean. In contrast, primary care physicians excluded from all MA networks were $1,617 (13.8 percent) costlier than the regional mean, with lower quality. Primary care physicians in narrow networks were $212 (1.4 percent) less costly than those in wide networks, but their quality was slightly lower. These findings highlight the potential role of selective contracting in reducing costs in the MA program.

Differences in Home Health Services and Outcomes Between Traditional Medicare and Medicare Advantage

Importance

Private Medicare Advantage (MA) plans recently surpassed traditional Medicare (TM) in enrollment. However, MA plans are facing scrutiny for burdensome prior authorization and potential rationing of care, including home health. MA beneficiaries are less likely to receive home health, but recent evidence on differences in service intensity and outcomes among home health patients is lacking.

Objective

To examine differences in home health service intensity and patient outcomes between MA and TM.

Design, Setting, and Participants

This cross-sectional study was conducted from January 2019 to December 2022 in 102 home health locations in 19 states and included 178 195 TM and 107 102 MA patients 65 years or older with 2 or fewer 60-day home health episodes. It included a secondary analysis of standardized assessment and visit data. Inverse probability of treatment weighting regression compared service intensity and patient outcomes between MA and TM episodes, accounting for differences in demographic characteristics, medical complexity, functional and cognitive impairments, social environment, caregiver support, and local community factors. Models included office location, year, and reimbursement policy fixed effects. Data were analyzed between September 2023 and July 2024.

Exposure

TM vs MA plan.

Main Outcomes and Measures

Home health length of stay and number of visits from nursing, physical, occupational, and speech therapy, social work, and home health aides. Patient outcomes included improvement in self-care and mobility function, discharge to the community, and transfer to an inpatient facility during home health.

Results

Of 285 297 total patients, 180 283 (63.2%) were female; 586 (0.2%) were American Indian/Alaska Native, 8957 (3.1%) Asian, 28 694 (10.1%) Black, 7406 (2.6%) Hispanic, 1959 (0.7%) Native Hawaiian/Pacific Islander, 237 017 (83.1%) non-Hispanic White, and 678 (0.2%) multiracial individuals. MA patients had shorter home health length of stay by 1.62 days (95% CI, -1.82 to 1.42) and received fewer visits from all disciplines except social work. There were no differences in inpatient transfers. MA patients had 3% and 4% lower adjusted odds of improving in mobility and self-care, respectively (mobility odds ratio [OR], 0.97; 95% CI, 0.94-0.99; self-care OR, 0.96; 95% CI, 0.92-0.99). MA patients were 5% more likely to discharge to the community compared with TM (OR, 1.05; 95% CI, 1.01-1.08).

Conclusions and Relevance

The results of this cross-sectional study suggest that MA patients receive shorter and less intensive home health care vs TM patients with similar needs. Differences may be due to the administrative burden and cost-limiting incentives of MA plans. MA patients experienced slightly worse functional outcomes but were more likely to discharge to the community, which may have negative implications for MA patients, including reduced functional independence or increased caregiver burden.

Gaps In Quality Of Care Not Consistent Between Traditional Medicare, Medicare Advantage For Racial And Ethnic Groups

The quality of care experienced by members of racial and ethnic minority groups in Medicare Advantage, which is an increasingly important source of Medicare coverage for these groups, has critical implications for health equity. Comparing gaps in Medicare Advantage and traditional Medicare for three quality-of-care outcomes, measured by adverse health events, between minority and non-Hispanic White populations, we found that the relative magnitude of the gaps varied both by racial and ethnic minority group and by quality measure. Hispanic versus non-Hispanic White gaps were smaller in Medicare Advantage than in traditional Medicare for all outcomes: avoidable emergency department use, preventable hospitalizations, and thirty-day hospital readmissions. The gap between non-Hispanic Black and non-Hispanic White populations was larger in Medicare Advantage than in traditional Medicare for avoidable emergency department use but was no different for hospital readmissions and was smaller for preventable hospitalizations. The Asian versus non-Hispanic White gap was similar in Medicare Advantage and traditional Medicare for avoidable emergency department use and preventable hospitalizations but was larger in Medicare Advantage for hospital readmissions. As Medicare Advantage enrollment expands, monitoring the quality of care for enrollees who are members of racial and ethnic minority groups will remain important.

Medicare Part D Plans Greatly Increased Utilization Restrictions On Prescription Drugs, 2011-20

Drug utilization management tools can be employed to ensure that medicines are prescribed cost-effectively, but they can also be implemented in ways that reduce adherence and harm patient health. We examined trends in the prevalence of utilization restrictions on non-protected-class compounds in Medicare Part D plans during the period 2011-20, including prior authorization and step therapy requirements as well as formulary exclusions. Part D plans became significantly more restrictive over time, rising from an average of 31.9 percent of compounds restricted in 2011 to 44.4 percent restricted in 2020. The prevalence of formulary exclusions grew particularly fast: By 2020, plan formularies excluded an average of 44.7 percent of brand-name-only compounds. Formulary restrictions were more common among brand-name-only compared with generic-available compounds, among more expensive compounds, and in stand-alone compared with Medicare Advantage prescription drug plans.

Coverage Denials in Medicare Advantage-Balancing Access and Efficiency

This essay compares Medicare Advantage’s claim denials and reversals with traditional Medicare and questions whether coverage obligations are being met.

Mental Health Referrals Among Medicare Advantage Enrollees Receiving Home-Based Annual Wellness Visits in Puerto Rico During the COVID-19 Pandemic

Annual Wellness Visits (AWV) promote preventive care for older adults, yet uptake remains low. To increase AWVs, a Medicare Advantage (MA) plan in Puerto Rico contracted a medical group to provide home-based AWVs during the last quarter of 2020. Using data from 464 visits, we conducted descriptive and multivariable analysis to profile patient characteristics and identify predictors of mental health referrals. We found that 87% of patients had multiple chronic conditions, 75% were taking more than 5 medications, and the odds of a mental health referral were higher for those who also had a nutrition-related condition (AOR = 5.05, CI95: 1.76-11.88), diabetes (AOR = 3.34, CI95: 1.18-7.58), or an additional reported uncontrolled health issue (AOR = 28.18, CI95: 8.96-70.59). This strategy helped one MA plan reach high-need patients, but coordination of follow-up care is needed to ensure patients receive recommended services.

Increasing prevalence of cirrhosis among insured adults in the United States, 2012-2018

BACKGROUND

Liver cirrhosis is a chronic disease that is known as a "silent killer" and its true prevalence is difficult to describe. It is imperative to accurately characterize the prevalence of cirrhosis because of its increasing healthcare burden.

METHODS

In this retrospective cohort study, trends in cirrhosis prevalence were evaluated using administrative data from one of the largest national health insurance providers in the US. (2011-2018). Enrolled adult (≥18-years-old) patients with cirrhosis defined by ICD-9 and ICD-10 were included in the study. The primary outcome measured in the study was the prevalence of cirrhosis 2011-2018.

RESULTS

Among the 371,482 patients with cirrhosis, the mean age was 62.2 (±13.7) years; 53.3% had commercial insurance and 46.4% had Medicare Advantage. The most frequent cirrhosis etiologies were alcohol-related (26.0%), NASH (20.9%) and HCV (20.0%). Mean time of follow-up was 725 (±732.3) days. The observed cirrhosis prevalence was 0.71% in 2018, a 2-fold increase from 2012 (0.34%). The highest prevalence observed was among patients with Medicare Advantage insurance (1.67%) in 2018. Prevalence increased in each US. state, with Southern states having the most rapid rise (2.3-fold). The most significant increases were observed in patients with NASH (3.9-fold) and alcohol-related (2-fold) cirrhosis.

CONCLUSION

Between 2012-2018, the prevalence of liver cirrhosis doubled among insured patients. Alcohol-related and NASH cirrhosis were the most significant contributors to this increase. Patients living in the South, and those insured by Medicare Advantage also have disproportionately higher prevalence of cirrhosis. Public health interventions are important to mitigate this concerning trajectory of strain to the health system.

Short term exposure to low level ambient fine particulate matter and natural cause, cardiovascular, and respiratory morbidity among US adults with health insurance: case time series study

OBJECTIVE

To estimate the excess relative and absolute risks of hospital admissions and emergency department visits for natural causes, cardiovascular disease, and respiratory disease associated with daily exposure to fine particulate matter (PM2.5) at concentrations below the new World Health Organization air quality guideline limit among adults with health insurance in the contiguous US.

DESIGN

Case time series study.

SETTING

US national administrative healthcare claims database.

PARTICIPANTS

50.1 million commercial and Medicare Advantage beneficiaries aged ≥18 years between 1 January 2010 and 31 December 2016.

MAIN OUTCOME MEASURES

Daily counts of hospital admissions and emergency department visits for natural causes, cardiovascular disease, and respiratory disease based on the primary diagnosis code.

RESULTS

During the study period, 10.3 million hospital admissions and 24.1 million emergency department visits occurred for natural causes among 50.1 million adult enrollees across 2939 US counties. The daily PM2.5 levels were below the new WHO guideline limit of 15 μg/m3 for 92.6% of county days (7 360 725 out of 7 949 713). On days when daily PM2.5 levels were below the new WHO air quality guideline limit of 15 μg/m3, an increase of 10 μg/m3 in PM2.5 during the current and previous day was associated with higher risk of hospital admissions for natural causes, with an excess relative risk of 0.91% (95% confidence interval 0.55% to 1.26%), or 1.87 (95% confidence interval 1.14 to 2.59) excess hospital admissions per million enrollees per day. The increased risk of hospital admissions for natural causes was observed exclusively among adults aged ≥65 years and was not evident in younger adults. PM2.5 levels were also statistically significantly associated with relative risk of hospital admissions for cardiovascular and respiratory diseases. For emergency department visits, a 10 μg/m3 increase in PM2.5 during the current and previous day was associated with respiratory disease, with an excess relative risk of 1.34% (0.73% to 1.94%), or 0.93 (0.52 to 1.35) excess emergency department visits per million enrollees per day. This association was not found for natural causes or cardiovascular disease. The higher risk of emergency department visits for respiratory disease was strongest among middle aged and young adults.

CONCLUSIONS

Among US adults with health insurance, exposure to ambient PM2.5 at concentrations below the new WHO air quality guideline limit is statistically significantly associated with higher rates of hospital admissions for natural causes, cardiovascular disease, and respiratory disease, and with emergency department visits for respiratory diseases. These findings constitute an important contribution to the debate about the revision of air quality limits, guidelines, and standards.

Medicare Advantage Is Associated with Lower Utilization of Total Joint Arthroplasty

BACKGROUND

Medicare Advantage (MA) insurers use managed care techniques to review the utilization of medical services and control costs. It is unclear if MA enrollees have a lower utilization of elective surgical procedures such as inpatient hip and knee total joint arthroplasty (TJA), which have traditionally been covered by traditional Medicare (TM) without restrictions.

METHODS

We conducted a cross-sectional study using a 20% sample of 2018 TM claims and MA encounter records for 5,300,188 TM enrollees and 1,970,032 MA enrollees who were 65 to 85 years of age. We calculated unadjusted and adjusted differences (controlling for beneficiary and market characteristics) in the incidence of TJA for MA compared with TM, and by MA plan type. Finally, we calculated differences in the time to contact with an orthopaedic surgeon and time to the surgical procedure among enrollees with an osteoarthritis diagnosis.

RESULTS

After controlling for observable characteristics, there was a 15.6% lower incidence of TJA in MA enrollees compared with TM enrollees (p < 0.001). Compared with TM enrollees, health maintenance organization (HMO) enrollees were 28.1% less likely to undergo TJA, controlling for observable characteristics (p < 0.001). From the initial diagnosis, the time to contact with an orthopaedic surgeon and the time to the surgical procedure were also lower among TM enrollees compared with MA enrollees. At 2 years after an osteoarthritis diagnosis, 10.4% of TM enrollees, 7.9% of preferred provider organization (PPO) enrollees, and 5.7% of HMO enrollees had undergone inpatient TJA.

CONCLUSIONS

MA coverage was associated with a lower utilization of elective, inpatient hip and knee TJA. MA was also associated with a longer time to orthopaedic surgeon evaluation and surgical procedure.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Dental Use and Spending in Medicare Advantage and Traditional Medicare, 2010-2021

This cross-sectional study examines Medicare Advantage and traditional Medicare beneficiaries’ use of and spending for dental services.

National Estimates of Short- and Longer-Term Hospital Readmissions After Major Surgery Among Community-Living Older Adults

Importance

Nationally representative estimates of hospital readmissions within 30 and 180 days after major surgery, including both fee-for-service and Medicare Advantage beneficiaries, are lacking.

Objectives

To provide population-based estimates of hospital readmission within 30 and 180 days after major surgery in community-living older US residents and examine whether these estimates differ according to key demographic, surgical, and geriatric characteristics.

Design, Setting, and Participants

A prospective longitudinal cohort study of National Health and Aging Trends Study data (calendar years 2011-2018), linked to records from the Centers for Medicare & Medicaid Services (CMS). Data analysis was conducted from April to August 2023. Participants included community-living US residents of the contiguous US aged 65 years or older who had at least 1 major surgery from 2011 to 2018. Data analysis was conducted from April 10 to August 28, 2023.

Main Outcomes and Measures

Major operations and hospital readmissions within 30 and 180 days were identified through data linkages with CMS files that included both fee-for-service and Medicare Advantage beneficiaries. Data on frailty and dementia were obtained from the annual National Health and Aging Trends Study assessments.

Results

A total of 1780 major operations (representing 9 556 171 survey-weighted operations nationally) were identified from 1477 community-living participants; mean (SD) age was 79.5 (7.0) years, with 56% being female. The weighted rates of hospital readmission were 11.6% (95% CI, 9.8%-13.6%) for 30 days and 27.6% (95% CI, 24.7%-30.7%) for 180 days. The highest readmission rates within 180 days were observed among participants aged 90 years or older (36.8%; 95% CI, 28.3%-46.3%), those undergoing vascular surgery (45.8%; 95% CI, 37.7%-54.1%), and persons with frailty (36.9%; 95% CI, 30.8%-43.5%) or probable dementia (39.0%; 95% CI, 30.7%-48.1%). In age- and sex-adjusted models with death as a competing risk, the hazard ratios for hospital readmission within 180 days were 2.29 (95% CI, 1.70-3.09) for frailty and 1.58 (95% CI, 1.15-2.18) for probable dementia.

Conclusions and Relevance

In this nationally representative cohort study of community-living older US residents, the likelihood of hospital readmissions within 180 days after major surgery was increased among older persons who were frail or had probable dementia, highlighting the potential value of these geriatric conditions in identifying those at increased risk.

Disparities in Enrollment in Medicare Advantage Plans With Dental Benefits

This cross-sectional study evaluates the association of Medicare beneficiaries’ sociodemographic characteristics with having Medicare Advantage plans that cover oral health services.

Postacute Care for Medicare Advantage Enrollees Who Switched to Traditional Medicare Compared With Those Who Remained in Medicare Advantage

Importance

Medicare Advantage (MA) plans receive capitated per enrollee payments that create financial incentives to provide care more efficiently than traditional Medicare (TM); however, incentives could be associated with MA plans reducing use of beneficial services. Postacute care can improve functional status, but it is costly, and thus may be provided differently to Medicare beneficiaries by MA plans compared with TM.

Objective

To estimate the association of MA compared with TM enrollment with postacute care use and postdischarge outcomes.

Design, Setting, and Participants

This was a cohort study using Medicare data on 4613 hospitalizations among retired Ohio state employees and 2 comparison groups in 2015 and 2016. The study investigated the association of a policy change with use of postacute care and outcomes. The policy changed state retiree health benefits in Ohio from a mandatory MA plan to subsidies for either supplemental TM coverage or an MA plan. After policy implementation, approximately 75% of retired Ohio state employees switched to TM. Hospitalizations for 3 high-volume conditions that usually require postacute rehabilitation were assessed. Data from the Medicare Provider Analysis and Review files were used to identify all hospitalizations in short-term acute care hospitals. Difference-in-difference regressions were used to estimate changes for retired Ohio state employees compared with other 2015 MA enrollees in Ohio and with Kentucky public retirees who were continuously offered a mandatory MA plan. Data analyses were performed from September 1, 2019, to November 30, 2023.

Exposures

Enrollment in Ohio state retiree health benefits in 2015, after which most members shifted to TM.

Main Outcomes and Measures

Received care in an inpatient rehabilitation facility, skilled nursing facility, or home health, or any postacute care; the occurrence of any hospital readmission; the number of days in the community during the 30 days after hospital discharge; and mortality.

Results

The study sample included 2373 hospitalizations for Ohio public retirees, 1651 hospitalizations for other Humana MA enrollees in Ohio, and 589 hospitalizations for public retirees in Kentucky. After the 2016 policy implementation, the percentage of hospitalizations covered by MA decreased by 70.1 (95% CI, -74.2 to -65.9) percentage points (pp), inpatient rehabilitation facility admissions increased by 9.7 (95% CI, 4.7 to 14.7) pp, use of only home health or skilled nursing facility care fell by 8.6 (95% CI, -14.6 to -2.6) pp, and days in the community fell by 1.6 (95% CI, -2.9 to -0.3) days for Ohio public retirees compared with other Humana MA enrollees in Ohio. There was no change in 30-day mortality or hospital readmissions; similar results were found by comparisons using Kentucky public retirees as a control group.

Conclusions and Relevance

The findings of this cohort study indicate that after a change in retiree health benefits, most Ohio public retirees shifted from MA to TM and received more intensive postacute care with no significant change in measured short-term postdischarge outcomes. Future work should consider additional measures of postacute functional status over a longer follow-up period.

The effects of patient out-of-pocket costs on insulin use among people with type 1 and type 2 diabetes with Medicare Advantage insurance-2014-2018

OBJECTIVE

To identify the association between insulin out-of-pocket costs (OOPC) and adherence to insulin in Medicare Advantage (MA) patients.

DATA SOURCES AND STUDY SETTING

The study is based on Optum Labs Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data.

STUDY DESIGN

Using descriptive and multivariable logistic regression analyses, we identified the likelihood of patients with diabetes having ≥60 consecutive days between an expected insulin fill date and the actual fill date (refill lapse) by OOPC, categorized by $0, >$0-$20 (reference), >$20-$35, >$35-$50, and > $50 per 30-day supply.

DATA COLLECTION/EXTRACTION METHODS

The study included MA enrollees with type 1 or type 2 diabetes and prescription claims for insulin between 2014 and 2018.

PRINCIPAL FINDINGS

Those with average insulin OOPC per 30-day supply >$35 or $0 were more likely to have an insulin refill lapse versus OOPC of >$0 to $20, with odds ratios ranging 1.18 (95% CI 1.13-1.22) to 1.74 (95% CI 1.66-1.83) depending on OOPC group and diabetes type.

CONCLUSIONS

Capping average insulin OOPC at $35 per 30-day supply may help avoid cost-related insulin non-adherence in MA patients; efforts to address non-cost barriers to medication adherence remain important.

Measuring restrictiveness of Medicare Advantage networks: A claims-based approach

OBJECTIVE

To develop and validate a measure of provider network restrictiveness in the Medicare Advantage (MA) population.

DATA SOURCES

Prescription drug event data and beneficiary information for Part D enrollees from the Center for Medicare and Medicaid Services, along with prescriber identifiers; geographic variables from the Area Health Resources Files.

STUDY DESIGN

A prediction model was used to predict the unique number of primary care providers that would have been seen by MA beneficiaries absent network restrictions. The model was trained and validated on Traditional Medicare (TM) beneficiaries. A pseudo-Poisson and a random forest model were evaluated. An observed-to-expected (O/E) ratio was calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based the TM prediction model. Multivariable linear models were used to assess the relationship between network restrictiveness and plan and market factors.

DATA COLLECTION/EXTRACTION METHODS

Prescription drug event data were obtained for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017.

PRINCIPAL FINDINGS

Health Maintenance Organization plans were more restrictive (O/E = 55.5%; 95% CI 55.3%-55.7%) than Health Maintenance Organization-Point of Service plans (67.2%; 95% CI 66.7%-67.8%) or Preferred Provider Organization plans (74.7%; 95% CI 74.3%-75.1%), and rural areas had more restrictive networks (31.6%; 95% CI 29.0%-34.2%) than metropolitan areas (61.5%; 95% CI 61.3%-61.7%). Multivariable results confirmed these findings, and also indicated that increased provider supply was associated with less restrictive networks.

CONCLUSIONS

We developed a means of estimating provider network restrictiveness in MA from claims data. Our results validate the approach, providing confidence for wider application (e.g., for other markets and specialties) and use for regulation.

Is there an advantage? Considerations for researchers studying the effects of the type of Medicare coverage

OBJECTIVE

To describe common methodological problems that arise in comparisons of Medicare Advantage (MA) and Traditional Medicare (TM) and within-MA studies and provide suggestions of how researchers can address these issues.

STUDY SETTING

Published research evaluating Medicare coverage options in the United States.

STUDY DESIGN

We considered key conceptual challenges and promising solutions that have been used thus far and suggest additional directions.

DATA COLLECTION

Not available.

PRINCIPAL FINDINGS

Many existing studies of MA versus TM include significant limitations, such as failing to account for unobserved confounders driving both beneficiary coverage choice and health outcomes once enrolled, not accounting for variation in benefit generosity, provider networks, or plan design across MA plans, and/or having been conducted at a time when MA enrollment was less than a third of all Medicare beneficiaries. We provide a review of methods that can help researchers to overcome these weaknesses and suggest additional methods and data sources that may aid future research.

CONCLUSIONS

The MA program is becoming an essential part of the US healthcare system. By accounting for non-random movement into and out of MA and studying the heterogeneity of beneficiary experience across plan and market characteristics, researchers can provide the high-quality evidence necessary for policymakers to design the program and reform TM in ways that maximize beneficiary outcomes.

Trajectories of adherence to ACEI/ARB medications following a motivational interviewing intervention among Medicare Advantage beneficiaries in Texas

OBJECTIVES

To assess the impact of student telephone motivational interviewing intervention on angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACEI/ARBs) adherence trajectories and identify predictors of each trajectory.

METHODS

The intervention group included continuously enrolled Medicare Advantage Plan patients non-adherent to ACEI/ARBs vs the control group (1:2 ratio). The intervention was tailored by pre-intervention trajectories and included an initial and five follow-up calls. Adherence was measured 6 months after initial calls using the proportion of days covered (PDC). Monthly PDCs were integrated into a group-based trajectory model and categorized patients into 4-groups. A multinomial logistic regression model was used to evaluate trajectory predictors.

RESULTS

The study comprised 240 intervention patients and 480 controls with four trajectories: adherent trajectory 44.2%, gradual improvement in adherence 13.4%, slow decline in adherence 24.1%, and discontinuation 18.3%. Patients with the intervention were less likely to experience a slow decline in adherence than controls (OR: 0.627 [0.401-0.981]). Patients with specialty prescribers' visits, ≥ 1 previous hospitalization, rapid decline in adherence as pre-intervention trajectory, and higher CMS risk score were associated with discontinuation trajectory.

CONCLUSION

Intervention patients vs controls had a lower likelihood of following a slow decline in adherence pattern.

PRACTICE IMPLICATIONS

This study underscores the importance of individualized interventions and the association between past adherence patterns and post-intervention trajectories.

Outcomes Following Initiation of Triple Therapy with Fluticasone Furoate/Umeclidinium/Vilanterol versus Multiple-Inhaler Triple Therapy Among Medicare Advantage with Part D Beneficiaries and Those Commercially Enrolled for Health Care Insurance in the United States

Purpose

Patients with chronic obstructive pulmonary disease (COPD) have been shown to benefit from triple therapy commonly delivered by multiple-inhaler triple therapy (MITT); however, the complexity of MITT regimens may decrease patient adherence. Fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI), a once-daily single-inhaler triple therapy (SITT), became available in the United States (US) in 2017, but real-world data comparing outcomes for SITT versus MITT are currently limited. This study compared outcomes among patients with COPD initiating MITT versus SITT with FF/UMEC/VI who were either Medicare Advantage with Part D (MAPD) beneficiaries or commercial enrollees in the US.

Methods

Retrospective study using administrative claims data from the Optum Research Database for patients with COPD who initiated FF/UMEC/VI or MITT between September 1, 2017, and March 31, 2019 (index date: first pharmacy claim for FF/UMEC/VI cohort; earliest day of ≥30 consecutive days-long period of overlap in the day's supply of all triple therapy components for MITT cohort). COPD exacerbations, adherence to triple therapy, and all-cause and COPD-related health care resource utilization (HCRU) and costs were compared between FF/UMEC/VI and MITT initiators.

Results

In total, 4659 FF/UMEC/VI initiators and 9845 MITT initiators for the MAPD population, and 821 FF/UMEC/VI initiators and 1893 MITT initiators for the commercial population were included in the study. MAPD beneficiaries initiating FF/UMEC/VI had a significantly lower annual rate of severe exacerbations compared to MITT initiators (0.26 vs 0.29; p=0.014). They also had a significantly higher mean adherence (proportion of days covered) (0.51 vs 0.37; p<0.001) and significantly lower all-cause and COPD-related inpatient stays compared to MITT initiators ([32.02% vs 34.27%; p=0.017], [16.09% vs 17.72%; p=0.037]). Trends were similar among the commercial population, but the results were not statistically significant.

Conclusion

FF/UMEC/VI initiators had significantly fewer severe exacerbations, higher triple therapy adherence, and lower HCRU costs compared to MITT initiators for MAPD beneficiaries.

Enrollment Patterns of Medicare Advantage Beneficiaries by Dental, Vision, and Hearing Benefits

Importance

Most Medicare beneficiaries now choose to enroll in Medicare Advantage (MA) plans. Racial and ethnic minority group and low-income beneficiaries are increasingly enrolling in MA plans.

Objective

To examine whether dental, vision, and hearing supplemental benefits offered in MA plans are associated with the plan choices of traditionally underserved Medicare beneficiaries.

Design, Setting, and Participants

This exploratory observational cross-sectional study used data from the 2018 to 2020 Medicare Current Beneficiary Survey linked to MA plan benefits. The nationally representative sample comprised primarily community-dwelling MA beneficiaries enrolled in general enrollment MA plans. Data analysis was performed between April and October 2023.

Exposures

Beneficiary self-identified race and ethnicity and combined individual and spouse income and educational attainment.

Main Outcomes and Measures

Binary indicators were developed to determine whether beneficiaries were enrolled in a plan offering any dental, comprehensive dental, any vision, eyewear, any hearing, or hearing aid benefit. Mixed-effects logistic regression models were estimated to report average marginal effects adjusted for beneficiary-level demographic and health characteristics, plan attributes, and plan availability.

Results

This study included 8139 (weighted N = 31 million) eligible MA beneficiaries, with a mean (SD) age of 77.7 (7.5) years. More than half of beneficiaries (54.9%) were women; 9.8% self-identified as Black, 2.0% as Hispanic, 83.9% as White, and 4.2% as other or multiple races or ethnicities. Plan choices by dental benefits were examined among 7516 beneficiaries who were not enrolled in any dental standalone plan, by vision benefits for 8026 beneficiaries not enrolled in any vision standalone plan, and by hearing benefits for 8131 beneficiaries not enrolled in any hearing standalone plan. Black beneficiaries were more likely to enroll in plans with any dental benefit (9.0 percentage points [95% CI, 3.4-14.4]; P < .001), any comprehensive dental benefit (11.2 percentage points [95% CI, 5.7-16.7]; P < .001), any eye benefit (3.0 percentage points [95% CI, 1.0 to 5.0]; P = .004), or any eyewear benefit (6.0 percentage points [95% CI, 0.6-11.5]; P = .03) compared with White beneficiaries. Lower-income individuals (earning ≤200% of the federal poverty level) were more likely to enroll in a plan with a comprehensive dental benefit (4.4 percentage-point difference [95% CI, 0.1-7.9]; P = .01) compared with higher-income beneficiaries. Beneficiaries without a college degree were more likely to enroll in a plan with a comprehensive dental benefit (4.7 percentage-point difference [95% CI, 1.4-8.0]; P = .005) compared with those with higher educational attainment.

Conclusions and Relevance

The results of this study suggest that racial and ethnic minority individuals and those with lower income or educational attainment are more likely to choose MA plans with dental or vision benefits. As the federal government prepares to adjust MA plan star ratings for health equity, implements MA payment cuts, and allows increasing flexibility in supplemental benefit offerings, these findings may inform benefit monitoring for MA.

Clinical Risk and Outpatient Therapy Utilization for COVID-19 in the Medicare Population

Importance

Multiple therapies are available for outpatient treatment of COVID-19 that are highly effective at preventing hospitalization and mortality. Although racial and socioeconomic disparities in use of these therapies have been documented, limited evidence exists on what factors explain differences in use and the potential public health relevance of these differences.

Objective

To assess COVID-19 outpatient treatment utilization in the Medicare population and simulate the potential outcome of allocating treatment according to patient risk for severe COVID-19.

Design, Setting, and Participants

This cross-sectional study included patients enrolled in Medicare in 2022 across the US, identified with 100% Medicare fee-for-service claims.

Main Outcomes and Measures

The primary outcome was any COVID-19 outpatient therapy utilization. Secondary outcomes included COVID-19 testing, ambulatory visits, and hospitalization. Differences in outcomes were estimated based on patient demographics, treatment contraindications, and a composite risk score for mortality after COVID-19 based on demographics and comorbidities. A simulation of reallocating COVID-19 treatment, particularly with nirmatrelvir, to those at high risk of severe disease was performed, and the potential COVID-19 hospitalizations and mortality outcomes were assessed.

Results

In 2022, 6.0% of 20 026 910 beneficiaries received outpatient COVID-19 treatment, 40.5% of which had no associated COVID-19 diagnosis within 10 days. Patients with higher risk for severe disease received less outpatient treatment, such as 6.4% of those aged 65 to 69 years compared with 4.9% of those 90 years and older (adjusted odds ratio [aOR], 0.64 [95% CI, 0.62-0.65]) and 6.4% of White patients compared with 3.0% of Black patients (aOR, 0.56 [95% CI, 0.54-0.58]). In the highest COVID-19 severity risk quintile, 2.6% were hospitalized for COVID-19 and 4.9% received outpatient treatment, compared with 0.2% and 7.5% in the lowest quintile. These patterns were similar among patients with a documented COVID-19 diagnosis, those with no claims for vaccination, and patients who are insured with Medicare Advantage. Differences were not explained by variable COVID-19 testing, ambulatory visits, or treatment contraindications. Reallocation of 2022 outpatient COVID-19 treatment, particularly with nirmatrelvir, based on risk for severe COVID-19 would have averted 16 503 COVID-19 deaths (16.3%) in the sample.

Conclusion

In this cross-sectional study, outpatient COVID-19 treatment was disproportionately accessed by beneficiaries at lower risk for severe infection, undermining its potential public health benefit. Undertreatment was not driven by lack of clinical access or treatment contraindications.

Medicare Advantage: Growth Amidst Mounting Scrutiny

The Medicare Advantage Program, home to nearly half of the eligible Medicare population, has recently come under increased scrutiny. The Government Accountability Office called on the Centers for Medicare & Medicaid Services to monitor "disenrollment of MA beneficiaries in the last year of life, validate MA-provided encounter data, and strengthen audits used to identify and recover improper payments to MA plans." The House Subcommittee on Oversight and Investigations of the Committee on Energy & Commerce, dedicated a hearing to "Protecting America's Seniors: Oversight of Private Sector Medicare Advantage Plans." In addition, a recently conducted audit of the Office of the Inspector General of the Department of Health and Human Services raised concerns over "denials of prior authorization requests" and "beneficiary access to medically necessary care." In this article we consider the backdrop for the growing scrutiny of the MA program and the implications thereof to its future trajectory.

Lingering Impact of COVID-19, Preventive Care Considerations, and US Health System Challenges

This issue includes articles on the lingering impact of COVID-19, often negative but occasionally positive, on patients, treatment, practices, and health care personnel. Other articles inform on prevention, such as awareness of lung cancer screening among women undergoing screening mammography; failures on sports preparticipation physicals; advance care planning as prevention; and screening for social risk factors. Another article reports on patient experiences of legal recreational cannabis in Washington State. There is a review of perinatal depression recognition and treatment. Two articles separately identify the difficulties of the congressionally created Medicare Advantage & Pharmaceutical Benefit Managers.

Association Between the Medicare Advantage Quartile Adjustment System and Plan Behavior and Enrollment

Importance

Medicare Advantage (MA) has grown in popularity, but critics believe that insurers are overpaid, partially due to the quartile adjustment system that determines plan benchmarks. However, elimination of the quartile adjustments may be associated with less generous benefits and fewer plan offerings, which could slow MA enrollment growth.

Objective

To examine whether the quartile adjustment system is associated with differences in county-level benefits, insurer offerings, and MA enrollment.

Design, Setting, and Participants

The quartile adjustments create discontinuous jumps in county-level base payments based on historical traditional Medicare spending. Data from January 2017 to December 2021 and a regression discontinuity design were used to examine changes in insurer behavior and MA enrollment between quartiles. The analytic sample included 1557 county observations.

Main Outcomes and Measures

Study outcomes included monthly premiums, the share of plans charging premiums, primary care copayments, the share of plans using rebates to reduce Part B premiums, supplemental benefits, plan and contract availability, and MA enrollment.

Results

Discontinuities were found in the quartile adjustments and benchmarks. A 1-percentage point (pp) increase in the quartile adjustment was associated with a $6.36 increase in monthly benchmarks (95% CI, 5.10-7.62), a $0.51 decrease in monthly premiums (95% CI, -0.96 to -0.07), and a 0.68 pp decrease in the share of plans charging premiums (95% CI, -1.25 to -0.10). Significant changes were not found in primary care copayments (-$0.04; 95% CI, -0.17 to 0.09), the share of plans using rebates to reduce Part B premiums (-0.17 pp; 95% CI, -0.34 to 0.01), supplemental benefits (eg, preventive dental coverage; 0.17 pp; 95% CI, -0.25 to 0.0), the number of plans (1.06; 95% CI, -3.44 to 5.57) or contracts (0.31; 95% CI, -0.18 to 0.81), or the MA enrollment rate (0.16 pp; 95% CI, -0.61 to 0.94).

Conclusions and Relevance

The study results suggest that MA plans are not very sensitive to modest changes in payment rates. Modifications to the quartile adjustment system may generate savings without substantially affecting MA beneficiaries.

Traditional Medicare or Medicare Advantage? The Leukemia and Cancer Perspective

Today, approximately 50% of patients eligible for Medicare have opted for Medicare Advantage as their primary coverage. Whereas Medicare Advantage is a reasonable option for healthy senior Americans, issues arise once they have serious or chronic medical problems, which are prevalent among older Americans. This review details the pros and cons of standard Medicare vs Medicare Advantage. The authors recommend considering standard Medicare as a better form of insurance coverage. In addition, patients should also enroll in Medicare Part D to get prescription drug coverage; buy a supplemental MediGap policy; and buy additional coverage for hearing, vision, and dental care. Although this is a more complicated process, it is also a better one until Medicare Advantage revises its plans to address the current issues facing Americans on such plans who have serious illnesses.

Fostering Flexibility: How Medicare Advantage Potentially Accelerated Telehealth Benefits

In 2018, the US Congress enacted a policy permitting Medicare Advantage (MA) plans to cover telehealth services in a beneficiary's home and through audio-only means as part of the basic benefit package of services, where prior to the policy change such benefits were only allowed to be covered as a supplemental benefit. MA plans were afforded 2 years of lead time for strategizing, negotiating, and capital investment prior to the start date (January 1, 2020) of the new coverage option. Our data analysis found basic benefit telehealth was offered by plans comprising 71% of enrollment in 2020 and increased to 95% in 2021. At the same time, remote access telehealth was offered as a supplemental benefit for 69% of enrollees in 2020, a decrease of 23% compared to 2019. These efforts by MA plans may have enabled traditional Medicare (TM) to leverage an existing telehealth infrastructure as a solution to the access issues created by public health policies requiring sheltering in place and social distancing during the COVID-19 pandemic. The success of this MA policy prompts consideration of additional flexibility beyond the standard basic benefit package, and whether such benefits reduce costs while improving access and/or outcomes in the context of a managed care environment like MA. Subject to oversight, such flexibility could potentially improve value in MA, and facilitate future changes in TM, as appropriate.

Trends in Opioid Use Disorder Outpatient Treatment and Telehealth Utilization Before and During the COVID-19 Pandemic

OBJECTIVE

The authors examined trends in opioid use disorder treatment and in-person and telehealth modalities before and after COVID-19 pandemic onset among patients who had received treatment prepandemic.

METHODS

The sample included 13,113 adults with commercial insurance or Medicare Advantage and receiving opioid use disorder treatment between March 2018 and February 2019. Trends in opioid use disorder outpatient treatment, treatment with medications for opioid use disorder (MOUD), and in-person and telehealth modalities were examined 1 year before pandemic onset and 2 years after (March 2019-February 2022).

RESULTS

From March 2019 to February 2022, the proportion of patients with opioid use disorder outpatient and MOUD visits declined by 2.8 and 0.3 percentage points, respectively. Prepandemic, 98.6% of outpatient visits were in person; after pandemic onset, at least 34.9% of patients received outpatient care via telehealth.

CONCLUSIONS

Disruptions in opioid use disorder outpatient and MOUD treatments were marginal during the pandemic, possibly because of increased telehealth utilization.

Filgrastim and infliximab biosimilar uptake in Medicare Advantage compared with Traditional Medicare, 2016-2019

BACKGROUND

Medicare Advantage (MA) and Traditional Medicare face different financing structures and incentives and may implement different strategies to encourage biosimilar uptake. Strategies used by health insurers can influence biosimilar uptake, which can in turn promote savings to insurers and patients.

OBJECTIVE

To compare filgrastim and infliximab biosimilar uptake between MA and Traditional Medicare from 2016 to 2019 and examine biosimilar uptake by different MA carriers and plan types (Health Maintenance Organization [HMO] or Preferred Provider Organization).

METHODS

We use a 2016-2019 nationally representative random 20% sample of the carrier (physician) and outpatient paid claims for Traditional Medicare data and final-action carrier and outpatient records for MA data. We compare quarterly biosimilar uptake from 2016 to 2019 for the first 2 drugs with biosimilar competition: (1) filgrastim, (Neupogen, originator), and biosimilars tbo-filgrastim (GRANIX) and filgrastim-sndz (ZARXIO), and (2) infliximab (Remicade, originator), and biosimilars infliximab-dyyb (Inflectra) and infliximab-abda (Renflexis).

RESULTS

From their introduction, there was consistently greater uptake of filgrastim and infliximab biosimilars in MA compared with Traditional Medicare. By Q4 2019, filgrastim biosimilar uptake was 7.6 percentage points higher in MA (80.3%) than Traditional Medicare (72.7%). By Q4 2019, infliximab biosimilar uptake was 28.7% and 15.4% in MA and Traditional Medicare, respectively. Kaiser HMO plans were primarily responsible for the higher uptake of biosimilars in MA; in Q4 2019, filgrastim and infliximab biosimilar uptake was 98.8% and 78.8%, respectively.

CONCLUSIONS

Our findings suggest that filgrastim and infliximab biosimilar uptake is greater in MA compared with Traditional Medicare, which is driven in part by particularly high uptake of biosimilars in MA Kaiser HMO plans. This highlights the need for future work to examine specific strategies and levers employed by MA Kaiser HMO plans and other insurers to increase biosimilar uptake, which can lead to cost savings for physician-administered drugs.

Lower Revenue Surplus in Medicare Advantage Versus Private Commercial Insurance for Total Joint Arthroplasty: An Analysis of a Single Payor Source at One Institution

BACKGROUND

Since the Affordable Care Act was passed in 2010, reductions in Medicare reimbursement have led to larger discrepancies between the relative cost of Medicare patients and privately insured patients. The purpose of this study was to compare reimbursement between Medicare Advantage and other insurance plans in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

Patients of a single commercial payor source who underwent primary unilateral TKA or THA at 1 institution between the dates of January 4 and June 30, 2021, were included (n = 833). Variables included insurance type, medical comorbidities, total costs, and surplus amounts. The primary outcome measure was revenue surplus between Medicare Advantage and Private Commercial plans. t-tests, Analyses of Variance, and Chi-Squared tests were used for analysis. A THA represented 47% of cases and a TKA 53%. Of these patients, 31.5% had Medicare Advantage and 68.5% had Private Commercial insurance. Medicare Advantage patients were older and had higher medical comorbidity risk for both TKA and THA.

RESULTS

Significant differences were observed in medical costs between Medicare Advantage and Private Commercial insurance for THA ($17,148 versus $31,260, P < .001) and TKA ($16,723 versus $33,593, P < .001). Additionally, differences were seen in surplus amounts between Medicare Advantage and Private Commercial insurance for THA ($3,504 versus $7,128, P < .001) and TKA ($5,581 versus $10,477, P < .001). Deficits were higher in Private Commercial patients undergoing TKA (15.2 versus 6%, P = .001).

CONCLUSION

The lower average surplus associated with Medicare Advantage plans may lead to financial strain on provider groups who care for these patients and face additional overhead costs.

Contraceptive Use Among Traditional Medicare And Medicare Advantage Enrollees

Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.

Biosimilar Uptake in Medicare Advantage vs Traditional Medicare

This cross-sectional study uses Traditional Medicare and Medicare Advantage claims data to evaluate uptake of biosimilars relative to their reference products.

Estimated Savings From the Medicare Shared Savings Program

Importance

The Medicare Shared Savings Program (MSSP) is the largest and most important alternative payment model that has been implemented by the Centers for Medicare & Medicaid Services (CMS). Its budgetary impact to CMS is not well understood.

Objective

To evaluate the association between the MSSP and net savings to CMS for performance years 2013 to 2021.

Design, Setting, and Participants

The economic evaluation used publicly reported data on the MSSP from April 1, 2012, to December 31, 2021, and estimates extracted from 2 prior studies.

Main Outcomes and Measures

Net savings to CMS, calculated as the difference between incentive payments to MSSP accountable care organizations and gross spending reductions. Incentive payments were calculated using the publicly reported data. The association of the MSSP with gross medical spending in traditional Medicare was extracted from 2 prior studies. Spillovers of the MSSP to Medicare Advantage (MA) were estimated by evaluating how gross spending reductions from the MSSP impacted benchmark payments to MA plans. Savings from traditional Medicare and MA were then combined.

Results

The MSSP was associated with net losses to traditional Medicare of between $584 million and $1.423 billion over the study period. Savings from MSSP-related reductions to MA benchmarks totaled between $4.480 billion and $4.923 billion. Across traditional Medicare and MA, the MSSP was associated with savings of between $3.057 billion and $4.339 billion. This represents approximately 0.075% of combined spending for traditional Medicare and MA over the study period.

Conclusions and Relevance

This economic evaluation found that the MSSP was associated with net losses to traditional Medicare, net savings to MA, and overall net savings to CMS. The total budget impact of the MSSP to CMS was small and continues to be uncertain due to challenges in estimating the effects of the MSSP on gross spending, particularly in recent years.

Coding Intensity Through Health Risk Assessments and Chart Reviews in Medicare Advantage: Does It Explain Resource Use?

Medicare Advantage (MA) plans increase their risk-adjusted payments through intensive coding in health risk assessments (HRAs) and chart reviews. Whether the additional diagnoses from HRAs and chart reviews are associated with increased resource use is not known. Using national MA encounter data (2016-2019), we examine the relative contributions of three health risk scores to MA resource use: the base risk score that excludes diagnoses from HRAs and chart reviews; the incremental score added to the base score from diagnoses in HRAs; and the incremental score added from diagnoses in chart reviews. We find that the incremental risk scores explain 53.5% to 64.5% of resource use relative to the base risk score effect-that is, 35.5% to 46.5% of the incremental risk scores are not accompanied by increased resource use. While HRAs and chart reviews contribute to more complete coding of diagnoses, they are sources of intensive coding not accompanied by resource use.

Legislative and Regulatory Options for Improving Medicare Advantage

The Medicare Advantage program was created to expand beneficiary choice and to reduce spending through capitated payment to private insurers. However, many stakeholders now argue that Medicare Advantage is failing to deliver on its promise to reduce spending. Three problematic design features in Medicare Advantage payment policy have received particular scrutiny: (1) how baseline payments to insurers are determined, (2) how variation in patient risk affects insurer payment, and (3) how payments to insurers are adjusted for quality performance. The authors analyze the statute underlying these three design features and explore legislative and regulatory strategies for improving Medicare Advantage. They conclude that regulatory approaches for improving risk adjustment and for recouping overpayments from risk-score gaming have the highest potential impact and are the most feasible improvement measures to implement.

An assessment of completeness and medical coding of Medicare Advantage hospitalizations in two national data sets

OBJECTIVE

To compare the Encounter Data System (EDS) and Medicare Provider Analysis and Review (MedPAR) completeness and medical coding of Medicare Advantage hospitalizations.

DATA SOURCES

FY 2016-FY 2019 data limited to hospitals paid under Medicare's Inpatient Prospective Payment System.

STUDY DESIGN

Secondary data analysis.

DATA COLLECTION/EXTRACTION METHODS

Completeness of EDS and MedPAR data was estimated using the total number of unique hospitalizations in both data sources as denominator. Deriving this denominator involved matching cases in the EDS and MedPAR by MA enrollee, discharge date, and hospital. The higher the match rate, the more informative the comparison of EDS and MedPAR medical coding of the same hospitalization. EDS and MedPAR codes were assessed for similarity on six measures of Medicare Severity Diagnosis-Related Group (MS-DRG) assignment and identical diagnosis and procedure codes.

PRINCIPAL FINDINGS

EDS hospitalizations' completeness increased steadily each year from 90% to 93%, driven by the 23 largest Medicare Advantage Organizations, which account for 83% of total cases. MedPAR completeness was relatively stable (89%) and benefited from 91% completeness among the largest hospitals, which are often teaching hospitals and account for 63% of MedPAR cases. By 2019, 97% of medical cases were assigned the same MS-DRG, indicating the high consistency of the severity level coding, since 98% were assigned the same base MS-DRGs, which include all severity levels for the same condition. Without chart reviews, medical cases with identical diagnosis codes increased from 87% to 92%.

CONCLUSIONS

The EDS has a completeness advantage over MedPAR for studies of non-teaching disproportionate share (DSH) hospitals and individual hospitals generally. MedPAR is only slightly less complete for hospitalizations of teaching DSH hospitals and large hospitals in general. A highly consistent EDS and MedPAR medical coding of matched cases is an important finding since the matched cases are 88% of EDS and 90% of MedPAR cases.

Understanding the social risk factor adjustment's effect on Star Ratings

OBJECTIVES

CMS implemented the Categorical Adjustment Index (CAI) to address measurement bias in the Medicare Advantage (MA) Star Ratings, as unadjusted scores may disadvantage MA contracts serving more enrollees at greater social risk. CAI values are added to a contract's Star Ratings to adjust for the mean within-contract performance disparity associated with its percentage of enrollees with low socioeconomic status (ie, receipt of a Part D low-income subsidy or dual eligibility for Medicare and Medicaid [LIS/DE]) and who are disabled. We examined the CAI's effect on Star Ratings and the type of contracts affected.

STUDY DESIGN

Observational study of MA contracts with health and prescription drug coverage.

METHODS

We compared adjusted and unadjusted 2017-2020 Star Ratings overall and by contracts' proportion of LIS/DE and disabled enrollees. We assessed the CAI's effect on qualifying for quality bonus payments (QBPs), eligibility for rebate payments, and high-performing and low-performing designations.

RESULTS

The CAI's impact was modest overall (3.2%-14.9% of contracts experienced one-half Star Rating changes). Upward changes were concentrated among contracts with high percentages of LIS/DE or disabled enrollees (7.7%-32.3% of these contracts saw increased Star Ratings). In 2020, 26.0% of contracts with a high proportion of LIS/DE or disabled enrollees that qualified for a QBP did so because of the CAI.

CONCLUSIONS

The CAI primarily affected contracts with high LIS/DE or disabled enrollment, which received higher Star Ratings because of the CAI. The adjustment helps ensure that such contracts' performance is not understated and reduces incentives for MA contracts to avoid patients at greater social risk.

Essential not Supplemental: Medicare Advantage Members' Use of Non-Emergency Medical Transportation (NEMT)

BACKGROUND

Over five million people in the USA miss or delay medical care because of a lack of transportation. Transportation barriers are especially relevant to Medicare Advantage (MA) health plan enrollees, who are more likely to live with multiple chronic conditions and experience mobility challenges. Non-Emergency Medical Transportation (NEMT) helps to address transportation gaps by providing rides to and from routine medical care (for example, medical appointments, laboratory tests, and pharmacy visits) and has been added as a supplemental benefit to some MA health plans.

OBJECTIVE

We aimed to characterize MA enrollees' experiences with supplemental NEMT benefits.

DESIGN

Qualitative interviews focused on participants' experiences with existing NEMT benefits, transportation, and mobility.

PARTICIPANTS

Twenty-one MA enrollees who used their MA NEMT benefit in 2019 and who remained eligible for ongoing transportation benefits through 2021.

APPROACH

Using purposive sampling from a list of eligible participants, we recruited individuals who used their MA NEMT benefit in 2019 and who remained eligible for benefit-covered transportation services through 2021.

KEY RESULTS

Participants considered NEMT an essential service, particularly because these services helped them decrease social isolation, reduce financial insecurity, and manage their own medical needs. Navigating logistical challenges associated with arranging NEMT services required participants to commit considerable time and energy and limited the effectiveness and reliability of NEMT.

CONCLUSION

Participants described NEMT as a valued service essential to their ability to access health care. They suggested ways to increase service flexibility and reliability that could inform future NEMT policy and practice. As health systems and payers learn how to best address social risks, particularly as the US population ages, our findings underscore the importance of NEMT services and highlight opportunities to advance comprehensive transportation solutions for MA participants.

Role of Patient Sorting in Avoidable Hospital Stays in Medicare Advantage vs Traditional Medicare

Importance

Unlike traditional Medicare (TM), Medicare Advantage (MA) plans limit in-network care to a specific network of Medicare clinicians. MA plans thus play a role in sorting patients to a subset of clinicians. It is unknown whether the performance of physicians who treat MA and TM beneficiaries is different.

Objective

To examine whether avoidable hospital stay differences between MA and TM can be explained by the primary care clinicians who treat MA and TM beneficiaries.

Design, Setting, and Participants

This was a cross-sectional study of a nationally representative sample of MA and TM beneficiaries in 2019 with any of 5 chronic ambulatory care-sensitive conditions (ACSCs). The relative risk (RR) of avoidable hospital stays in MA compared with TM was estimated with inverse probability of treatment-weighted Poisson regression, both without and with clinician fixed effects. The degree to which the estimated MA vs TM difference could be explained by patient sorting was calculated by comparing the 2 RR estimates. Data were analyzed between February 2022 and April 2023.

Exposure

Enrollment in MA.

Main Outcome and Measures

Whether a beneficiary had avoidable hospital stays in 2019 due to any of the ACSCs. Avoidable hospital stays included both hospitalizations and observation stays.

Results

The study sample comprised 1 323 481 MA beneficiaries (mean [SD] age, 75.4 [7.0] years; 56.9% women; 69.3% White) and 1 965 863 TM beneficiaries (mean [SD] age, 75.9 [7.4] years; 57.1% women; 82.5% White). When controlling for the primary care clinician, the RR of avoidable hospital stays in MA vs TM changed by 2.6 percentage points (95% CI, 1.72-3.50; P < .001), suggesting that compared with TM beneficiaries, MA beneficiaries saw clinicians with lower rates of avoidable hospital stays. This effect size was statistically significant to explain the 2% lower rate of avoidable hospital stays in MA than in TM.

Conclusions and Relevance

In this cross-sectional study of MA and TM beneficiaries, the lower rate of avoidable hospital stays among MA beneficiaries than TM beneficiaries was attributable to MA beneficiaries visiting clinicians with lower rates of avoidable hospital stays. The patient sorting that occurs in MA plays a critical role in the lower rates of avoidable hospital stays compared with TM.

Disparity in initiation of checkpoint inhibitors among commercially insured and Medicare Advantage patients with metastatic melanoma

BACKGROUND: Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of advanced melanoma, but racial disparities in melanoma outcomes continue. These inequities are not fully explained by individual factors. OBJECTIVE: To investigate the associations of neighborhood factors with the use of ICIs in metastatic melanoma. METHODS: We conducted a retrospective cohort study of commercially insured US adults with metastatic melanoma diagnosed between January 2011 and December 2020. We examined the associations between the county-level percentage of population from racial and ethnic minority groups and the time from metastatic melanoma diagnosis to initiating ICIs using Cox proportional hazards models adjusting for patient characteristics. RESULTS: We identified 4,052 patients with metastatic melanoma, of which 49% used ICIs. We found that the adoption of ICIs in a county declined with increasing minority quintile (quintile 1: 52.4%, quintile 2: 50.4%, quintile 3: 50.1%, quintile 4: 45.8%, and quintile 5: 44.7%). The delay in ICI initiation also went up as the percentage of minorities in a county increased (log-rank test P = 0.03). Compared with the lowest quintile, the adjusted hazard ratio of ICI initiation of the second, third, fourth, and highest minority quintile was 0.94 (95% CI = 0.81-1.08), 0.88 (95% CI = 0.76-1.02), 0.81 (95% CI = 0.68-0.97), and 0.77 (95% CI = 0.66-0.91), respectively. Secondary analysis revealed that the slower initiation was driven by the counties with the highest percentage of Hispanic population (hazard ratio = 0.74; 95% CI = 0.61-0.89) in both Cox models and sensitivity analyses. High-minority counties correlated with metro areas, higher poverty levels, and a greater number of medical oncologists. CONCLUSIONS: We found that patients with metastatic melanoma living in counties with higher proportion of minorities, particularly of Hispanic origin, are more likely to experience delays in ICI treatment. This study provides important population-level data on neighborhood-level disparity in medication use. More research is needed on the underlying provider- and system-level factors that directly contributed to the lower use of cancer medicines in high-minority areas, which can help inform the development of evidence-based medication use strategies that can improve health outcomes and equity.

Medicare Care Choices Model Improved End-Of-Life Care, Lowered Medicare Expenditures, And Increased Hospice Use

The Medicare Care Choices Model (MCCM) tested a new option for eligible Medicare beneficiaries to receive conventional treatment for terminal conditions along with supportive and palliative care from participating hospice providers. Using claims data, we estimated differences in average outcomes from enrollment to death between deceased MCCM enrollees and matched comparison beneficiaries who received usual services covered by original Medicare. Enrollees were 15 percentage points less likely to receive an aggressive life-prolonging treatment at the end of life and spent more than five more days at home. MCCM also reduced net Medicare expenditures by 13 percent, decreased inpatient admissions by 26 percent, reduced outpatient emergency department visits by 12 percent, and increased hospice use by 18 percentage points. Although the Centers for Medicare and Medicaid Services did not expand the model, given concerns about generalizability, these results provide evidence that MCCM is a promising approach to transforming care delivery at the end of life.

Medicare Advantage in rural areas: implications for hospital sustainability

OBJECTIVES

A growing number of Medicare beneficiaries in rural areas are enrolled in Medicare Advantage plans, which negotiate hospital reimbursement. This study examined the association between Medicare Advantage penetration levels in rural areas and hospital financial distress and closure.

STUDY DESIGN

This retrospective cohort study followed rural general acute care hospitals open in 2008 through 2019 or until closure using Healthcare Cost and Utilization Project State Inpatient Databases for 14 states.

METHODS

The primary independent variables were the percentage of Medicare Advantage stays out of total Medicare stays at the hospital and the percentage of Medicare Advantage beneficiaries out of total beneficiaries in the hospital's county. Financial distress was defined using the Altman Z score, where values less than or equal to 1.1 indicate financial distress and values greater than 2.8 indicate stability. The Z score was examined as a continuous outcome in hospital and county fixed-effects models. Risk of closure was examined using Cox proportional hazard models adjusted for hospital and market factors.

RESULTS

Rural hospital Medicare Advantage penetration grew from 6.5% in 2008 to 20.6% in 2019. A 1-percentage point increase in hospital penetration was associated with an increase in financial stability of 0.04 units on the Altman Z score (95% CI, 0.00-0.08; P = .03) and a 4% reduction in risk of closure (HR, 0.96; 95% CI, 0.92-1.00; P = .04). Results were consistent when measuring Medicare Advantage penetration at the county level.

CONCLUSIONS

Our findings counter the notion that Medicare Advantage plans financially hurt rural hospitals because they pay less generously than traditional Medicare.