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The American Journal of Managed Care May 2024Most Medicare beneficiaries obtain supplemental insurance or enroll in Medicare Advantage (MA) to protect against potentially high cost sharing in traditional Medicare...
OBJECTIVES
Most Medicare beneficiaries obtain supplemental insurance or enroll in Medicare Advantage (MA) to protect against potentially high cost sharing in traditional Medicare (TM). We examined changes in Medicare supplemental insurance coverage in the context of MA growth.
STUDY DESIGN
Repeated cross-sectional analysis of the Medicare Current Beneficiary Survey from 2005 to 2019.
METHODS
We determined whether Medicare beneficiaries 65 years and older were enrolled in MA (without Medicaid), TM without supplemental coverage, TM with employer-sponsored supplemental coverage, TM with Medigap, or Medicaid (in TM or MA).
RESULTS
From 2005 to 2019, beneficiaries with TM and supplemental insurance provided by their former (or current) employer declined by approximately half (31.8% to 15.5%) while the share in MA (without Medicaid) more than doubled (13.4% to 35.1%). The decline in supplemental employer-sponsored insurance use was greater for White and for higher-income beneficiaries. Over the same period, beneficiaries in TM without supplemental coverage declined by more than a quarter (13.9% to 10.1%). This decline was largest for Black, Hispanic, and lower-income beneficiaries.
CONCLUSIONS
The rapid rise in MA enrollment from 2005 to 2019 was accompanied by substantial changes in supplemental insurance with TM. Our results emphasize the interconnectedness of different insurance choices made by Medicare beneficiaries.
Topics: Humans; United States; Medicare Part C; Aged; Cross-Sectional Studies; Male; Female; Medicare; Insurance Coverage; Aged, 80 and over; Cost Sharing; Insurance, Medigap
PubMed: 38748929
DOI: 10.37765/ajmc.2024.89539 -
JAMA Health Forum Dec 2022
Topics: United States; Medicare Part C
PubMed: 36580327
DOI: 10.1001/jamahealthforum.2022.4896 -
Journal of the American Geriatrics... Dec 2021Model 3 of Medicare's Bundled Payments for Care Improvement (BPCI) was a voluntary alternative payment model that held participating skilled nursing facilities (SNFs)...
BACKGROUND
Model 3 of Medicare's Bundled Payments for Care Improvement (BPCI) was a voluntary alternative payment model that held participating skilled nursing facilities (SNFs) accountable for 90-day costs of care. Its overall impact on Medicare spending and clinical outcomes is unknown.
METHODS
Retrospective cohort study using Medicare claims from 2012 to 2017. We used an interrupted time-series design to compare participating vs matched control SNFs on total 90-day Medicare payments and payment components (initial SNF stay, readmissions, and outpatient/clinician), case mix (volume, proportion Medicaid, proportion black, number of comorbidities), and clinical outcomes (90-day readmission, mortality and healthy days at home, and length of initial SNF stay), overall and among key subgroups with frailty or dementia, for 47 of the 48 conditions in the program (excluding major lower extremity joint replacement).
RESULTS
Our sample included 1001 participating and 3873 matched control SNFs. At baseline, total Medicare institutional payments were increasing at BPCI SNFs at a rate of $121 per episode per quarter; during the intervention period, payments decreased at a rate of -$398/episode/quarter. Among controls, payments were stable in the baseline period (+$17/episode/quarter) but decreased at -$424/episode/quarter during the intervention period, yielding a nonsignificant difference in slope changes of -$79/episode/quarter (95% confidence interval [CI] -$188, $31, p = 0.16). However, among patients with frailty, spending declined by $620/episode/quarter in the BPCI group, compared with $330/episode/quarter in the non-BPCI group, for a difference in slope changes of -$289 (95% CI -$482, -$96, p = 0.003). There were no differences in the change in slopes in case selection or clinical outcomes overall or in any clinical subgroup.
CONCLUSIONS
SNF participation in BPCI was associated with no overall differential change in total Medicare payments per episode, case selection, or clinical outcomes. Exploratory analyses revealed a decrease in Medicare payments in patients with frailty that may warrant further study.
Topics: Aged; Aged, 80 and over; Case-Control Studies; Diagnosis-Related Groups; Episode of Care; Female; Health Expenditures; Humans; Interrupted Time Series Analysis; Male; Medicare; Outcome Assessment, Health Care; Patient Care Bundles; Reimbursement Mechanisms; Retrospective Studies; Skilled Nursing Facilities; United States
PubMed: 34379323
DOI: 10.1111/jgs.17409 -
JAMA Network Open Aug 2023Reducing Medicare expenditures is a key objective of Medicare's transition to value-based reimbursement models. Improving access to primary care is an important way to...
IMPORTANCE
Reducing Medicare expenditures is a key objective of Medicare's transition to value-based reimbursement models. Improving access to primary care is an important way to reduce expenditures, yet less is known about how visits should be organized to maximize savings.
OBJECTIVE
To examine the association between Medicare savings and primary care visit patterns.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective cohort study used data from a 5% sample of traditional Medicare claims from 2016 to 2019. Participants had at least 3 primary care visits with at least 180 days between the first and the last visit, were not enrolled in Medicare Advantage, did not have end-stage kidney disease, and were not institutionalized. Data were analyzed from June 2022 to April 2023.
EXPOSURES
Primary care visit patterns: visit frequency, regularity, continuity of care.
MAIN OUTCOMES AND MEASURES
Savings in Medicare expenditures; risk-adjusted Medicare expenditures, number of emergency department (ED) visits, and hospitalizations.
RESULTS
Among 504 471 beneficiaries (298 422 [59.16%] women; mean [SD] age, 74.26 [10.41] years), temporally regular visits with higher continuity were associated with the highest savings. For these patients, the savings increased with increasing visit frequencies, with peak savings observed at higher visit frequencies as clinical complexity increased. As regularity and continuity decreased, the association between savings and visit frequencies progressively inverted. The group with a regular and highly continuous pattern was associated with greater savings (175.87%; 95% CI, 167.40% to 184.33%; P < .001), lower risk-adjusted expenditures (-16.61%; 95% CI, -16.73% to -16.48%; P < .001), fewer risk-adjusted ED visits (-40.49%; 95% CI, -40.55% to -40.43%; P < .001), and fewer risk-adjusted hospitalizations (-53.32%; 95% CI, -53.49% to -53.14%; P < .001) compared with the irregular noncontinuous group.
CONCLUSIONS AND RELEVANCE
In this cohort study, savings in Medicare expenditures and improvements in acute care utilization were associated with visit frequency, regularity, and continuity in primary care in an interrelated fashion such that optimization of primary care visit patterns along each axis were associated with the largest improvement in outcomes. Demonstrating the magnitude and interdependence of these associations is useful for health care professionals and policymakers as Medicare continues its transition to value-based reimbursement models.
Topics: United States; Humans; Aged; Female; Male; Medicare; Cohort Studies; Retrospective Studies; Continuity of Patient Care; Critical Care
PubMed: 37603335
DOI: 10.1001/jamanetworkopen.2023.29991 -
The American Journal of Hospice &... Aug 2019As the Medicare program struggles to control expenditures, there is increased focus on opportunities to manage patient populations more efficiently and at a lower cost....
As the Medicare program struggles to control expenditures, there is increased focus on opportunities to manage patient populations more efficiently and at a lower cost. A major source of expense for the Medicare program is beneficiaries at end of life. Estimates of the percentage of Medicare costs that arise from patients in the last year of life differ, ranging from 13% to 25%, depending on methods and assumptions. We analyze the most recently available Medicare Limited Data Set to update prior studies of end-of-life costs and examine different methods of performing this calculation. Based upon these findings, we conclude that higher estimates that take into account the spending over the 12 months leading up to death more accurately reflect the full cost of a patient's last year of life. Comparing current year costs of decedents with Medicare's current year costs understates the full budgetary impact of end-of-life patients. Because risk-taking entities such as Medicare Advantage plans and Accountable Care Organizations (ACOs) need to reduce costs while improving the quality of care, they should initiate programs to better manage the care of patients with serious or advanced illness. We also calculate costs for beneficiaries dying in different settings and conclude that more effective use of palliative care and hospice benefits offers a lower cost, higher quality alternative for patients at end of life.
Topics: Accountable Care Organizations; Centers for Medicare and Medicaid Services, U.S.; Female; Health Expenditures; Hospice Care; Humans; Male; Medicare; Medicare Part C; Models, Economic; Terminal Care; United States
PubMed: 30884954
DOI: 10.1177/1049909119836204 -
Annals of Internal Medicine Jul 2019Medicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries.
BACKGROUND
Medicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries.
OBJECTIVE
To compare readmission rates between Medicare Advantage and traditional Medicare.
DESIGN
Retrospective cohort study linking the Medicare Provider Analysis and Review (MedPAR) file with the Healthcare Effectiveness Data and Information Set (HEDIS).
SETTING
4748 U.S. acute care hospitals.
PATIENTS
Patients aged 65 years or older hospitalized for acute myocardial infarction (AMI) (n = 841 613), congestive heart failure (CHF) (n = 1 458 652), or pneumonia (n = 2 020 365) between 2011 and 2014.
MEASUREMENTS
30-day readmissions.
RESULTS
Among admissions for AMI, CHF, and pneumonia identified in MedPAR, 29.2%, 38.0%, and 37.2%, respectively, did not have a corresponding record in HEDIS. Of these, 18.9% for AMI, 23.7% for CHF, and 18.3% for pneumonia resulted in a readmission that was identified in MedPAR. However, among index admissions appearing in HEDIS, 14.4% for AMI, 18.4% for CHF, and 13.9% for pneumonia resulted in a readmission. Patients in Medicare Advantage had lower unadjusted readmission rates than those in traditional Medicare for all 3 conditions (16.6% vs. 17.1% for AMI, 21.4% vs. 21.7% for CHF, and 16.3% vs. 16.4% for pneumonia). However, after standardization, patients in Medicare Advantage had higher readmission rates than patients in traditional Medicare for AMI (17.2% vs. 16.9%; difference, 0.3 percentage point [95% CI, 0.1 to 0.5 percentage point]), CHF (21.7% vs. 21.4%; difference, 0.3 percentage point [CI, 0.2 to 0.5 percentage point]), and pneumonia (16.5% vs. 16.0%; difference, 0.5 percentage point [95% CI, 0.4 to 0.6 percentage point]). Rate differences increased between 2011 and 2014.
LIMITATION
Potential unobserved differences between populations.
CONCLUSION
The HEDIS data underreported hospital admissions for 3 common medical conditions, and readmission rates were higher among patients with underreported admissions. Medicare Advantage beneficiaries had higher risk-adjusted 30-day readmission rates than traditional Medicare beneficiaries.
PRIMARY FUNDING SOURCE
National Institute on Aging.
Topics: Aged; Female; Heart Failure; Humans; Male; Medicare; Medicare Part C; Myocardial Infarction; Patient Readmission; Pneumonia; Retrospective Studies; United States
PubMed: 31234205
DOI: 10.7326/M18-1795 -
Journal of General Internal Medicine Nov 2017Increasing emphasis on value in health care has spurred the development of value-based and alternative payment models. Inherent in these models are choices around... (Review)
Review
Increasing emphasis on value in health care has spurred the development of value-based and alternative payment models. Inherent in these models are choices around program scope (broad vs. narrow); selecting absolute or relative performance targets; rewarding improvement, achievement, or both; and offering penalties, rewards, or both. We examined and classified current Medicare payment models-the Hospital Readmissions Reduction Program (HRRP), Hospital Value-Based Purchasing Program (HVBP), Hospital-Acquired Conditions Reduction Program (HACRP), Medicare Advantage Quality Star Rating program, Physician Value-Based Payment Modifier (VM) and its successor, the Merit-Based Incentive Payment System (MIPS), and the Medicare Shared Savings Program (MSSP) on these elements of program design and reviewed the literature to place findings in context. We found that current Medicare payment models vary significantly across each parameter of program design examined. For example, in terms of scope, the HRRP focuses exclusively on risk-standardized excess readmissions and the HACRP on patient safety. In contrast, HVBP includes 21 measures in five domains, including both quality and cost measures. Choices regarding penalties versus bonuses are similarly variable: HRRP and HACRP are penalty-only; HVBP, VM, and MIPS are penalty-or-bonus; and the MSSP and MA quality star rating programs are largely bonus-only. Each choice has distinct pros and cons that impact program efficacy. Unfortunately, there are scant data to inform which program design choice is best. While no one approach is clearly superior to another, the variability contained within these programs provides an important opportunity for Medicare and others to learn from these undertakings and to use that knowledge to inform future policymaking.
Topics: Humans; Medicare; Patient Readmission; Program Evaluation; Reimbursement, Incentive; United States; Value-Based Purchasing
PubMed: 28717900
DOI: 10.1007/s11606-017-4125-8 -
Nursing ResearchSelf-care is a multicomponent set of capacities that influence beliefs about health and well-being.
BACKGROUND
Self-care is a multicomponent set of capacities that influence beliefs about health and well-being.
OBJECTIVES
We examined the relationship between self-care capacity, age, and disability status with two perceptions of well-being in a cohort of Medicare beneficiaries.
METHODS
The current study is part of a multisite research project to determine factors associated with cross-sectional and longitudinal morbidity and mortality trajectories observed in Medicare beneficiaries. Variable selection was informed by the health disparities and outcomes model. Using data from the 2013 Medicare Current Beneficiary Survey and logistic regression models, we determined associations between self-care capacity, including indicators of self-care ability and self-care agency and two perceptions of well-being. Participants were divided into four groups based on how they qualified for Medicare: (a) over 65 years of age, and below 65 years of age and disabled because of (b) physical or (c) mental disorder, or (d) disabled and could not be classified as physically or mentally disabled as the primary cause of eligibility.
RESULTS
Self-care ability limitations in activities of daily living (ADL), instrumental activities of living (IADL), and social activity participation were associated with both health perceptions. Those with physical disabilities reported more ADL and IADL limitations when compared with the other eligibility groups and were significantly more likely to have negative health perceptions. Those with serious mental illness were most likely to report the most severe IADL limitations. The over 65 years of age group reported less self-care incapacity than the other three eligibility types. Other components of self-care, including health literacy, agency, and health behaviors, significantly influenced perceptions of health. Women and people identifying as non-Whites were more likely to have negative health perceptions.
DISCUSSION
Self-care capacity is a complex construct, and its varied elements have differential relationships with perceptions of well-being. Those with physical disabilities reported more self-care limitations, poorer perceived health, and more health worries than the other groups. Still, there were different patterns of self-care capacities in the serious mental illness type-especially in IADL limitations. The study adds empirical evidence to previous research documenting inequities in health outcomes for women and non-Whites. Findings provide empirical support for the health disparities and outcomes model.
Topics: Activities of Daily Living; Age Factors; Aged; Aged, 80 and over; Cross-Sectional Studies; Disabled Persons; Female; Humans; Male; Medicare; Perception; Self Care; Surveys and Questionnaires; United States
PubMed: 34534184
DOI: 10.1097/NNR.0000000000000551 -
Health Affairs (Project Hope) Jan 2022Little is publicly known about coverage denials for medical services that do not meet medical necessity criteria. We characterized the extent of these denials and their...
Little is publicly known about coverage denials for medical services that do not meet medical necessity criteria. We characterized the extent of these denials and their key features, using Medicare Advantage claims for a large insurer from the period 2014-19. In this setting, claims could be denied because of traditional Medicare's coverage rules or additional Medicare Advantage private insurer rules. We observed $416 million in denied spending, with 0.81 denials and $60 of denied spending per beneficiary annually. We found that 1.40 percent of services were denied and 0.68 percent of total spending was denied, with rates rising over time. Traditional Medicare's coverage rules accounted for 85 percent of denied services and 64 percent of denied spending; the remaining denials were due to additional Medicare Advantage insurer rules. Denial rates varied greatly across service type and provider type, with the most denials being for laboratory services and hospital outpatient providers. Traditional Medicare and Medicare Advantage insurer coverage policies each addressed different sources of medical spending; together they contributed to the denial of a modest but nontrivial portion of payments.
Topics: Aged; Government; Humans; Insurance Carriers; Medicare; Policy; United States
PubMed: 34982629
DOI: 10.1377/hlthaff.2021.01054 -
The American Journal of Managed Care Mar 2022To study the association between Medicare's wage index adjustment and the differential use of labor-intensive surgical procedures and medical device-intensive minimally...
OBJECTIVES
To study the association between Medicare's wage index adjustment and the differential use of labor-intensive surgical procedures and medical device-intensive minimally invasive clinical procedures across the United States.
STUDY DESIGN
We combine a conceptual model and an empirical investigation of its predictions, applied to aortic valve replacement, to study the relationship between variation in Medicare wage index payment adjustment across hospital referral regions (HRRs) and the utilization of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in these areas.
METHODS
Using detailed individual Medicare claims data for 2013-2018 and a novel geographical crosswalk to nest information on Medicare's wage index and utilization of TAVR and SAVR, we estimate a mixed effects Poisson regression model across HRRs to test our hypotheses.
RESULTS
We find regional variation in Medicare wage index adjustment levels to be correlated with differential TAVR and SAVR utilization and growth over time. In particular, in HRRs where the wage index is half the national mean there is a 35% decline in the rate of TAVR use and in HRRs where the wage index is 50% higher than the national mean there is a 52% increase in the rate of TAVR use.
CONCLUSIONS
Consistent with our framework and hypothesis, our results highlight the importance of adjusting Medicare hospital inpatient payments for device-intensive procedures. Absent such adjustment, access to appropriate interventions may be reduced in areas with low wage index, and lower reimbursement, when driven by wage index adjustment, may influence the treatment approach selected.
Topics: Aged; Aortic Valve Stenosis; Hospitals; Humans; Medicare; Risk Factors; Transcatheter Aortic Valve Replacement; Treatment Outcome; United States
PubMed: 35404553
DOI: 10.37765/ajmc.2022.88842