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Journal of the American Geriatrics... Aug 2021More than three million Americans turn 65 each year and newly enroll in Medicare, making this one of the most common insurance transitions. Non-Medicare insurance... (Review)
Review
BACKGROUND
More than three million Americans turn 65 each year and newly enroll in Medicare, making this one of the most common insurance transitions. Non-Medicare insurance transitions are associated with changes in health, healthcare utilization and costs. In addition, older Americans have higher morbidity, mortality, healthcare utilization, and healthcare costs than the general population. However, the effect of new Medicare enrollment on these outcomes is unclear.
DESIGN
We conducted a scoping review to rigorously identify the scope of evidence on the association between new Medicare enrollment and health, healthcare utilization and costs.
SETTING
We included English-language, peer-reviewed, studies cataloged in Medline (PubMed) and EconLit from 1998 to 2018.
PARTICIPANTS
Individuals newly enrolling in Medicare.
MEASUREMENTS
We measured health (e.g., self-reported health), healthcare utilization (e.g., provider visits, preventive care, and hospitalizations) and costs (e.g., patient out-of-pocket and health plan spending).
RESULTS
We screened 5265 articles and included 20 articles. New Medicare enrollment was found to increase self-reported health and healthcare utilization overall, as well as reduce disparities across racial and socioeconomic strata. Provider visits, preventive care and hospitalizations all increased. However, patient out-of-pocket spending decreased, and health plan spending also decreased, when Medicare's lower prices were accounted for. Few studies compared outcomes among new Medicare Advantage enrollees with new Medicare fee-for-service enrollees. None of the studies specifically evaluated the effect of new Medicare enrollment on adults with multiple chronic conditions.
CONCLUSION
New Medicare enrollment improves access overall and reduces access disparities. However, the impact of new Medicare enrollment among subgroups defined by insurance coverage type and number of chronic conditions is less clear. Future work should also evaluate the mechanism for increases in hospitalizations.
Topics: Aged; Ambulatory Care; Health Care Costs; Hospitalization; Humans; Medicare; Patient Acceptance of Health Care; United States
PubMed: 33721340
DOI: 10.1111/jgs.17113 -
The American Journal of Managed Care Sep 2021To evaluate the impact of pharmacist-delivered medication safety reviews (MSRs) on total medical expenditures, hospitalizations, emergency department (ED) visits, and...
OBJECTIVE
To evaluate the impact of pharmacist-delivered medication safety reviews (MSRs) on total medical expenditures, hospitalizations, emergency department (ED) visits, and mortality in Medicare Part D beneficiaries, whose plan was a participant of the Enhanced Medication Therapy Management model.
STUDY DESIGN
Retrospective, pre-post, cohort study.
METHODS
We evaluated the aforementioned outcomes for beneficiaries who were targeted, according to their MedWise Risk Scores (MRS), for MSR services in both 2018 and 2019. The "MSR" cohort included those who received their first-ever MSR in 2018 and received another MSR in 2019. The "failed to engage" (FTE) cohort included beneficiaries who were targeted in both 2018 and 2019 but did not engage in an MSR at any point through the end of 2019. For both cohorts, we calculated the change from 2018 to 2019 for each outcome and then determined whether unadjusted year-over-year changes differed significantly between cohorts. Additionally, these difference-in-differences (DiD) analyses were adjusted for baseline MRS and multimorbidity.
RESULTS
A total of 11,436 beneficiaries were targeted for MSRs in both 2018 and 2019. Beneficiaries were, on average, aged 76.6 ± 10.0 years. The MSR cohort (N = 4384) outperformed the FTE cohort (N = 7052) in total medical costs (DiD = $958/y [7.5% savings]; P = .042), hospitalizations (DiD = 3.9 admissions/100 beneficiaries/y [10% reduction]; P = .032), ED visits (DiD = 6.2 visits/100 beneficiaries/y [10% reduction]; P = .014), and mortality (2.1% fewer died in 2019; P < .001). Each outcome remained significant after adjusting for baseline MRS and multimorbidity.
CONCLUSION
MSRs were effective at improving annual health care costs, hospitalizations, ED visits, and mortality in Medicare beneficiaries targeted according to MRS.
Topics: Aged; Cohort Studies; Humans; Medicare Part D; Medication Therapy Management; Outcome Assessment, Health Care; Retrospective Studies; United States
PubMed: 34529369
DOI: 10.37765/ajmc.2021.88755 -
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 -
JAMA Health Forum Jun 2021Spending in Medicare Part D continues to increase. Yet, studies of Medicare Part D are plagued by a common limitation: none can fully account for confidential rebates...
IMPORTANCE
Spending in Medicare Part D continues to increase. Yet, studies of Medicare Part D are plagued by a common limitation: none can fully account for confidential rebates and other discounts that drug manufacturers and pharmacies pay to Medicare Part D plans.
OBJECTIVES
To review existing methods and to propose an approach for estimating rebates and other discounts received by Medicare Part D.
EVIDENCE REVIEW
Publicly available data from the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds, the Centers for Medicare & Medicaid Services, the Medicare Payment Advisory Commission, the Congressional Budget Office, the Government Accountability Office, and the Office of Inspector General.
FINDINGS
Existing methods for estimating rebates and other discounts in Medicare Part D have several limitations. This analysis used an approach that aims to improve on those methods. Based on this approach, estimated discounts on brand-name drugs increased in Medicare Part D from 25.4% of gross brand-name spending in 2014 to 37.3% in 2018. There was substantial variation between classes, with estimated 2016 discounts surpassing 50% for some drugs (eg, ophthalmologic and gastrointestinal tract agents) while remaining below 10% for others (eg, antineoplastic and immunologic agents). Between 2014 and 2018, estimated net Medicare Part D spending on prescription drugs increased by 21% from $99 billion to $119 billion. With increasing enrollment, estimated annual net spending per beneficiary remained stable, increasing by just 3% from $2622 to $2694, which was below the 6% rate of inflation during the same period.
CONCLUSIONS AND RELEVANCE
Models that fail to properly account for increasing rebates and other discounts will overestimate Medicare Part D expenditures. Rigorous and transparent methods for estimating discounts are critical for understanding patterns in spending and developing new cost-containment strategies.
Topics: Health Expenditures; Medicare Part D; Prescription Drugs; United States
PubMed: 36218748
DOI: 10.1001/jamahealthforum.2021.0626 -
Annals of Internal Medicine Apr 2023Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including...
BACKGROUND
Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown.
OBJECTIVE
To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures.
DESIGN
Cross-sectional.
SETTING
Population-based.
PARTICIPANTS
Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program.
MEASUREMENTS
Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated.
RESULTS
Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings.
LIMITATION
Hospital performance measurement and risk adjustment differed slightly from those used by Medicare.
CONCLUSION
Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance.
PRIMARY FUNDING SOURCE
Laura and John Arnold Foundation.
Topics: Aged; Humans; United States; Medicare Part C; Patient Readmission; Cross-Sectional Studies; Hospitals; Myocardial Infarction; Fee-for-Service Plans
PubMed: 36972544
DOI: 10.7326/M22-3165 -
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 -
JCO Oncology Practice Nov 2021In 2018, Medicare issued a national coverage determination (NCD) providing reimbursement for next-generation sequencing (NGS) tests for beneficiaries with advanced or...
PURPOSE
In 2018, Medicare issued a national coverage determination (NCD) providing reimbursement for next-generation sequencing (NGS) tests for beneficiaries with advanced or metastatic cancer and no previous NGS testing. We examined the association between NCD implementation and NGS utilization trends in Medicare beneficiaries versus commercially insured patients.
METHODS
This was a retrospective study of patients with advanced non-small-cell lung cancer (aNSCLC), metastatic colorectal cancer (mCRC), metastatic breast cancer (mBC), or advanced melanoma with a de novo or recurrent advanced diagnosis from January 1, 2011, through December 30, 2019, using a nationwide US electronic health record-derived deidentified database. Patients were classified by insurance and by advanced diagnosis date. NGS testing was assessed by receipt of first NGS test result ≤ 60 days of advanced diagnosis. Interrupted time series analysis assessed NGS utilization pre- and post-NCD effective date by insurance type.
RESULTS
The utilization and repeat NGS testing analysis included 70,290 and 4,295 patients, respectively. Use of NGS rose from < 1% in 2011 to > 45% in Q4 2019 in aNSCLC while remaining < 20% in mBC and advanced melanoma. Among patients with aNSCLC, mCRC, or mBC, NGS testing increased post-NCD versus pre-NCD ( < .05). There was no significant difference in trends pre- and post-NCD between Medicare beneficiaries and commercially insured patients in any tumor. Repeat NGS testing was similar before the NCD (Medicare commercial: 24.8% 28.5%). Post-NCD, fewer Medicare beneficiaries had repeat NGS testing (27.7% 36.0%; < .01).
CONCLUSION
Trends in NGS utilization significantly changed post-NCD, although the magnitude of change was not significantly different by insurance type, indicating private insurers may also be incorporating NCD guidance. Implementation of the NCD may have limited use of repeat NGS testing in Medicare beneficiaries.
Topics: Aged; Carcinoma, Non-Small-Cell Lung; High-Throughput Nucleotide Sequencing; Humans; Insurance Coverage; Lung Neoplasms; Medicare; Retrospective Studies; United States
PubMed: 34043456
DOI: 10.1200/OP.20.01023 -
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 -
Current Psychiatry Reports May 2020I review ethical and legal challenges for end of life (EOL) care in dementia. Is access to hospice care for dementia patients impacted by Medicare's terminal prognosis... (Review)
Review
PURPOSE OF REVIEW
I review ethical and legal challenges for end of life (EOL) care in dementia. Is access to hospice care for dementia patients impacted by Medicare's terminal prognosis requirement? Are dementia-specific advance directives warranted? How does state legislation affect dementia patients' EOL options? Should dementia patients' be able to refuse orally ingested food and fluids by advance directive?
RECENT FINDINGS
The difficulty of predicting time to death in dementia inhibits access to Medicare hospice benefits. Efforts have been made to create dementia-specific advance directives. Advance refusal of artificial nutrition and hydration are common, but the issue of oral ingestion of food and fluids by dementia patients remains controversial. Medicare's hospice benefit should be made more accessible to dementia patients. State advance directive threshold definitions should be broadened to include dementia, and capacitated persons who refuse in advance orally ingested food and fluids should have their choices honored.
Topics: Advance Directives; Aged; Dementia; Ethics, Medical; Humans; Medicare; Terminal Care; United States
PubMed: 32388736
DOI: 10.1007/s11920-020-01150-7 -
Research in Social & Administrative... Jan 2023The rising cost of medications has a disproportionate effect on community-dwelling older adults despite policy changes designed to improve medication access. Medicare... (Review)
Review
BACKGROUND
The rising cost of medications has a disproportionate effect on community-dwelling older adults despite policy changes designed to improve medication access. Medicare insurance counseling provided by pharmacists, including individualized plan comparison and enrollment assistance, improves medication adherence and health care utilization, yet only 15% of community dwelling older adults report using a pharmacy or pharmacist for Medicare information. To determine what information is available to inform expanding implementation of pharmacy as a resource for Medicare insurance counseling, a systematic review of published studies using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was conducted.
METHODS
Articles meeting inclusion criteria were identified through a literature search using PubMed and GoogleScholar; 27 pharmacy Medicare insurance counseling studies were identified representing 13 unique programs in clinical, community outreach, and community pharmacy settings. Each article was coded by two researchers using the RE-AIM Coding Sheet for Publications and the extent of RE-AIM dimension reporting was determined using descriptive statistics at the program level. Discussions were used to arrive at coding consensus and concordance was measured with Krippendorff's alpha.
RESULTS
Across all studies (15 quasi experimental, 10 analytical case reports, and 2 case reports) more than half of the programs reported framework component dimensions for Reach (69%), Adoption (58%), Implementation (54%), and Maintenance (54%), and fewer than half reported comprehensively on Effectiveness (44%). Ten studies in 7 of 13 programs reported estimated out-of-pocket cost savings. Two studies measured patient-centered outcomes: medication adherence by proportion of days covered (PDC) and health care utilization by hospital admissions and emergency department visits. Gaps in the external validity of pharmacy Medicare education programs were identified including staff participation rates, methods to identify participating settings and program costs.
CONCLUSIONS
Based on this review, current research on pharmacy Medicare education is insufficient to guide broad implementation. Additional studies are needed to determine how Medicare education integrating pharmacists and pharmacies can be implemented to address cost-related non-adherence for community dwelling older adults.
Topics: Aged; United States; Humans; Medication Therapy Management; Medicare; Pharmacists; Medication Adherence; Health Services Accessibility
PubMed: 36085121
DOI: 10.1016/j.sapharm.2022.08.013