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American Journal of Surgery Oct 2023This study highlights the implications of surgical disparities on health care spending. The strengths of this study include pinning down the potential etiologies of how...
This study highlights the implications of surgical disparities on health care spending. The strengths of this study include pinning down the potential etiologies of how surgical disparities contribute to excessive spending. Prior studies have focused primarily on individual social factors, yet this study takes into consideration the financial implications of disparities from multiple levels. Black patients face more challenges in cancer care in part due to late stage presentation and diagnosis, as well as increased exposure to risk factors that place them under a disproportionate burden of disease and risk of post-operative complications. We commend the authors for broaching this rarely discussed and costly combination of minority race and dual eligibility contributing to a "multiple hit" phenomenon that our most vulnerable patients face.
Topics: Aged; Humans; United States; Medicare; Patients; Healthcare Disparities
PubMed: 37500300
DOI: 10.1016/j.amjsurg.2023.07.021 -
The Journal of Cardiovascular NursingCoronary artery disease (CAD) is the leading cause of cardiovascular morbidity, mortality, and healthcare costs in the United States. There are few reports on how public...
BACKGROUND
Coronary artery disease (CAD) is the leading cause of cardiovascular morbidity, mortality, and healthcare costs in the United States. There are few reports on how public health and payment reforms might have influenced inpatient hospital use among patients with CAD.
OBJECTIVE
This study describes trends in hospital discharges, hospital charges, and discharge destinations in a national sample of patients with CAD between 1997 and 2014.
METHODS
This was a longitudinal study with descriptive analysis of the Healthcare Cost and Utilization Project of National Inpatient Sample data.
FINDINGS
During this study period, the total number of discharges was 1 333 996. Patients with CAD between 65 and 84 years old were among the highest users of inpatient hospital services, followed by those in the 45- to 64-year age group. The death rate increased from 5961 to 7217 per 10 000 patients during this time. The mean charge increased more than 5 times, from $9100 to $49 643. There was a large difference in mean hospital charges in urban ($51 666) and rural ($25 548) locations in 2014. Coronary artery disease patients with private insurance paid more than those with Medicaid and Medicare plans. The discharge to home and healthcare costs increased by 4.1% and 4.8%, respectively.
CONCLUSION AND IMPLICATIONS
Future researchers should use data sets, such as Medicare claims/Medical Expenditure Panel Study, that can provide comprehensive insights into patient-level factors influencing the use of inpatient care services among patients with CAD. Healthcare providers in posthospital settings should be well skilled in providing advanced cardiac rehabilitation and education to patients with CAD.
Topics: Humans; Aged; United States; Aged, 80 and over; Medicare; Coronary Artery Disease; Longitudinal Studies; Medicaid; Hospitals
PubMed: 36594990
DOI: 10.1097/JCN.0000000000000965 -
Health Affairs (Project Hope) Oct 2023Safety-net programs do not reach all eligible Americans, partly because of administrative burden, or experiencing bureaucratic obstacles in obtaining and maintaining...
Safety-net programs do not reach all eligible Americans, partly because of administrative burden, or experiencing bureaucratic obstacles in obtaining and maintaining program benefits. This burden often disproportionately affects historically marginalized groups, adding concerns about equity. We used a national survey to examine public thinking about the acceptability of administrative burdens imposed by states when implementing Medicaid and the Supplemental Nutrition Assistance Program and the role of race in these considerations. We found that support for state actions associated with six types of burden was unchanged when respondents were informed about disparate effects by race. Neither racial identity nor prejudice toward other racial groups was associated with support for policies imposing higher burdens. However, non-Hispanic White respondents with higher levels of racial resentment were more supportive of policies that would create burden, whereas respondents who believed that burdens had disparate effects on historically disadvantaged groups favored less burdensome alternatives. Also associated with lower support for more burdensome policies were responses indicative of respondents' empathy, concerns about ability to manage burdens, Democratic party identification, and program experience.
Topics: United States; Humans; Medicaid; Food Assistance; Racial Groups
PubMed: 37782861
DOI: 10.1377/hlthaff.2023.00472 -
Journal of Nutrition Education and... Nov 2023To examine the moderation effect of Supplemental Nutrition Assistance Program (SNAP) participation on the baseline fruit and vegetable (FV) intake of Hispanic/Latino and...
OBJECTIVE
To examine the moderation effect of Supplemental Nutrition Assistance Program (SNAP) participation on the baseline fruit and vegetable (FV) intake of Hispanic/Latino and African American children and parents participating in the Brighter Bites program.
DESIGN
Cross-sectional.
SETTING
Houston, Austin, and Dallas, TX; Washington, DC; and Southwest Florida.
PARTICIPANTS
Self-reported surveys (n = 6,037) of Hispanic/Latino and African American adult-child dyads enrolled in Brighter Bites in Fall 2018.
VARIABLES MEASURED
Dependent variable, child FV intake; Independent variable, parent FV intake, and FV shopping behavior; Effect Measure Modifier, SNAP participation.
ANALYSIS
Quantitatively used mixed effects linear regression models to test if the effect of parental baseline FV intake and shopping behavior on a child's baseline FV intake differed by SNAP participation. Analyses were performed using STATA with significance set at P < 0.05 and 95% confidence intervals (CIs).
RESULTS
For parents that consumed FV ≥ 2 times/d at baseline, there was a 0.1 times increase in child FV intake at baseline among those who participated in SNAP as compared with those who did not participate in SNAP (ß = 0.1; 95% CI, 0.1-0.2; P = 0.001), and for parents who shopped at convenience stores ≥ 2 times/wk for FV, there was 0.6 times increase in child FV intake at baseline for those who participated in SNAP as compared with those that did not participate in SNAP (ß = 0.6; 95% CI, 0.3-0.9; P < 0.001).
CONCLUSIONS AND IMPLICATIONS
Supplemental Nutrition Assistance Program participation moderated the associations between FV intake among African American and Hispanic/Latino parents and children and FV shopping at convenience stores and child FV intake. Findings indicate a need for future interventions to promote SNAP participation among those eligible and improve access to FV.
Topics: Adult; Humans; Fruit; Vegetables; Feeding Behavior; Food Assistance; Cross-Sectional Studies
PubMed: 37804263
DOI: 10.1016/j.jneb.2023.08.005 -
The New England Journal of Medicine Apr 2024
Topics: Humans; United States; Medicare; Hospitals; Patients; Physicians
PubMed: 38598814
DOI: 10.1056/NEJMc2402132 -
JAMA Health Forum Dec 2023There is growing interest in expanding integrated models, in which 1 insurer manages Medicare and Medicaid spending for dually eligible individuals. Fully integrated...
IMPORTANCE
There is growing interest in expanding integrated models, in which 1 insurer manages Medicare and Medicaid spending for dually eligible individuals. Fully integrated dual-eligible special needs plans (FIDE-SNPs) are one of the largest integrated models, but evidence about their performance is limited.
OBJECTIVE
To evaluate changes in care associated with integrating Medicare and Medicaid coverage in a FIDE-SNP in Pennsylvania.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study using a difference-in-differences analysis compared changes in care between 2 cohorts of dual-eligible individuals: (1) an integration cohort composed of Medicare Dual Eligible Special Needs Plan enrollees who joined a companion Medicaid plan following a 2018 state reform mandating Medicaid managed care (leading to integration), and (2) a comparison cohort with nonintegrated coverage before and after the start of Medicaid managed care. Analyses were conducted between February 2022 and June 2023.
MAIN OUTCOMES AND MEASURES
Analyses examined outcomes in 4 domains: use of home- and community-based services (HCBS), care management and coordination, hospital stays and postacute care, and long-term nursing home stays.
RESULTS
The study included 7967 individuals in the integration cohort and 3832 individuals in the comparison cohort. In the integration cohort, the mean (SD) age at baseline was 63.3 (14.7) years, and 5268 individuals (66.1%) were female and 2699 (33.9%) were male. In the comparison cohort, the mean (SD) age at baseline was 64.8 (18.6) years, and 2341 individuals (61.1%) were female and 1491 (38.9%) were male. At baseline, integration cohort members received a mean (SD) of 2.83 (8.70) days of HCBS per month and 3.34 (3.56) medications for chronic conditions per month, and the proportion with a follow-up outpatient visit after a hospital stay was 0.47. From baseline through 3 years after integration, HCBS use increased differentially in the integration vs comparison cohorts by 0.61 days/person-month (95% CI, 0.28-0.94; P < .001). However, integration was not associated with changes in care management and coordination, including medication use for chronic conditions (-0.02 fills/person-month; 95% CI, -0.10 to 0.06; P = .65) or follow-up outpatient care after a hospital stay (-0.01 visits/hospital stay; 95% CI, -0.04 to 0.03; P = .61). Hospital stays did not change differentially between the cohorts. Unmeasured factors contributing to differential mortality limited the ability to identify changes in long-term nursing home stays associated with integration.
CONCLUSIONS AND RELEVANCE
In this cohort study with a difference-in-differences analysis of 2 cohorts of individuals dually eligible for Medicare and Medicaid, integration was associated with greater HCBS use but not with other changes in care patterns. The findings highlight opportunities to strengthen how integrated programs manage care and a need to further evaluate their performance.
Topics: Aged; Humans; Male; Female; United States; Medicaid; Medicare; Cohort Studies; Length of Stay; Chronic Disease
PubMed: 38127588
DOI: 10.1001/jamahealthforum.2023.4583 -
Child Abuse & Neglect Nov 2023State expansion of Supplemental Nutrition Assistance Program (SNAP) eligibility under broad-based categorical eligibility (BBCE) is associated with decreases in...
BACKGROUND
State expansion of Supplemental Nutrition Assistance Program (SNAP) eligibility under broad-based categorical eligibility (BBCE) is associated with decreases in household poverty and food insecurity, child protective services investigations, and mental health and substance use disorders among adults, key contributors to foster care entry.
OBJECTIVE
To examine the association of state expansion of SNAP eligibility under BBCE with rates of foster care entries.
PARTICIPANTS
Foster care entries among children ages <18 years.
METHODS
We used 2005-2019 data from the SNAP Policy Database and the Adoption and Foster Care Analysis and Reporting System (AFCARS). We conducted difference-in-differences analyses and generated event study plots adjusting for state economic conditions (percent population unemployed, median household income) and policies (minimum wage, refundable Earned Income Tax Credits, maximum Temporary Assistance for Needy Families benefit for a family of 3).
RESULTS
On average, there were 1.8 fewer foster care entries (95 % confidence interval (CI) -2.8, -0.8) per 1000 children per year in states that expanded SNAP eligibility than there would have been if they had not expanded eligibility. Average decreases in foster care entries were similar among young (-1.7 per 1000 children per year, 95 % -3.1, -0.3) and school-age (-1.8 per 1000 children per year, 95 % CI -2.7, -0.8) children and larger among Black non-Hispanic (-5.6 per 1000 children per year, 95 % CI -9.1, -2.0) than among White non-Hispanic (-1.4 per 1000 children per year, 95 % CI -2.2, -0.6) children. The magnitude of these decreases increased with greater time since policy adoption.
CONCLUSIONS
Results add to growing evidence that programs and policies that support and stabilize household economic and material conditions may contribute to reductions in foster care entries at the population-level.
Topics: Child; Humans; Ethnicity; Food Assistance; Income; Poverty; United States; Black or African American; White; Foster Home Care
PubMed: 37591049
DOI: 10.1016/j.chiabu.2023.106399 -
PloS One 2023Medicaid serves as a safety net for low-income US Medicare beneficiaries with limited assets. Approximately 7.7 million Americans aged ≥65 years rely on a combination...
BACKGROUND
Medicaid serves as a safety net for low-income US Medicare beneficiaries with limited assets. Approximately 7.7 million Americans aged ≥65 years rely on a combination of Medicare and Medicaid to obtain critical medical services, yet little is known about whether these patients have worse outcomes after stroke than patients with Medicare alone. We compared geographic patterns in dual Medicare-Medicaid eligibility and ischemic stroke hospitalizations and examined whether these dual-eligible beneficiaries had worse post-stroke outcomes than those with Medicare alone.
METHODS
We identified fee-for-service Medicare beneficiaries aged ≥65 years who were discharged from US acute-care hospitals with a principal diagnosis of ischemic stroke in 2014. Medicare beneficiaries with ≥1 month of Medicaid coverage were considered dual eligible. We mapped risk-standardized stroke hospitalization rates and percentages of beneficiaries with dual eligibility. Mixed models and Cox regression were used to evaluate relationships between dual-eligible status and outcomes up to 1 year after stroke, adjusting for demographic and clinical factors.
RESULTS
At the national level, 12.5% of beneficiaries were dual eligible. Dual-eligible rates were highest in Maine, Alaska, and the southern half of the United States, whereas stroke hospitalization rates were highest in the South and parts of the Midwest (Pearson's r = 0.469, p<0.001). Among 254,902 patients hospitalized for stroke, 17.4% were dual eligible. In adjusted analyses, dual-eligible patients had greater risk of all-cause readmission within 30 days (hazard ratio 1.06, 95% confidence interval [CI] 1.03-1.09) and 1 year (hazard ratio 1.03, 95% CI 1.02-1.05) and had greater odds of death within 1 year (odds ratio 1.20, 95% CI 1.17-1.23) when compared with Medicare-only patients; there was no difference in in-hospital or 30-day mortality.
CONCLUSION
Dual-eligible stroke patients had higher readmissions and long-term mortality than other patients, even after comorbidity adjustment. A better understanding of the factors contributing to these poorer outcomes is needed.
Topics: Humans; Aged; United States; Medicare; Medicaid; Ischemic Stroke; Hospitalization; Alaska
PubMed: 37797070
DOI: 10.1371/journal.pone.0292546 -
The American Journal of Bioethics : AJOB Nov 2023
Topics: Humans; Canada; Suicide, Assisted; Medical Assistance
PubMed: 37930942
DOI: 10.1080/15265161.2023.2264096 -
Health Services Research Feb 2024To describe common methodological problems that arise in comparisons of Medicare Advantage (MA) and Traditional Medicare (TM) and within-MA studies and provide... (Review)
Review
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.
Topics: Aged; Humans; Medicare Part C; United States; Research Design
PubMed: 38043544
DOI: 10.1111/1475-6773.14264