Trends and Disparities in Ambulatory Follow-Up After Cardiovascular Hospitalizations : A Retrospective Cohort Study.

BACKGROUND: Timely follow-up after cardiovascular hospitalization is recommended to monitor recovery, titrate medications, and coordinate care. OBJECTIVE: To describe trends and disparities in follow-up after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations. DESIGN: Retrospective cohort study. SETTING: Medicare. PARTICIPANTS: Medicare fee-for-service beneficiaries hospitalized between 2010 and 2019. MEASUREMENTS: Receipt of a cardiology visit within 30 days of discharge. Multivariable logistic regression models were used to estimate changes over time overall and across 5 sociodemographic characteristics on the basis of known disparities in cardiovascular outcomes. RESULTS: The cohort included 1 678 088 AMI and 4 245 665 HF hospitalizations. Between 2010 and 2019, the rate of cardiology follow-up increased from 48.3% to 61.4% for AMI hospitalizations and from 35.2% to 48.3% for HF hospitalizations. For both conditions, follow-up rates increased for all subgroups, yet disparities worsened for Hispanic patients with AMI and patients with HF who were Asian, Black, Hispanic, Medicaid dual eligible, and residents of counties with higher levels of social deprivation. By 2019, the largest disparities were between Black and White patients (AMI, 51.9% vs. 59.8%, difference, 7.9 percentage points [pp] [95% CI, 6.8 to 9.0 pp]; HF, 39.8% vs. 48.7%, difference, 8.9 pp [CI, 8.2 to 9.7 pp]) and Medicaid dual-eligible and non-dual-eligible patients (AMI, 52.8% vs. 60.4%, difference, 7.6 pp [CI, 6.9 to 8.4 pp]; HF, 39.7% vs. 49.4%, difference, 9.6 pp [CI, 9.2 to 10.1 pp]). Differences between hospitals explained 7.3 pp [CI, 6.7 to 7.9 pp] of the variation in follow-up for AMI and 7.7 pp [CI, 7.2 to 8.1 pp]) for HF. LIMITATION: Generalizability to other payers. CONCLUSION: Equity-informed policy and health system strategies are needed to further reduce gaps in follow-up care for patients with AMI and patients with HF. PRIMARY FUNDING SOURCE: National Institute on Aging.

Medicare Transitional Care Management Program and Changes in Timely Postdischarge Follow-Up.

Importance: In 2013, Medicare implemented payments for transitional care management (TCM) services, which provide increased reimbursement to clinicians providing ambulatory care to patients after discharge from medical facilities to the community. Objective: To determine whether the introduction of TCM payments was associated with an increase in timely postdischarge follow-up. Design, Setting, and Participants: This cross-sectional interrupted time-series study assessed quarterly postdischarge visit rates before (2010-2012) and after (2013-2019) TCM implementation 100% sample of Medicare fee-for-service beneficiaries discharged to the community after a hospital or skilled nursing facility stay. Data analyses were performed February 1 to December 15, 2023. Exposure: Implementation of payments for TCM. Main Outcomes and Measures: Timely postdischarge primary care follow-up, defined as receipt of a primary care ambulatory visit within 14 days of discharge. Secondary outcomes included receipt of a TCM visit and specialty care follow-up. Results: The study sample comprised 79 125 965 eligible discharges. Of these, 55.4% were female; 1.5% were Asian, 12.1% Black, 5.6% Hispanic, and 79.0% were White individuals; and 79.6% were beneficiaries aged 65 years and older. Timely primary care follow-up increased from 31.5% in 2010 to 38.8% in 2019 (absolute increase 7.3%), whereas specialist follow-up increased from 27.6% to 30.8% (absolute increase 3.2%). By 2019, 11.3% of eligible patients received TCM services. Interrupted time-series analyses demonstrated an increased slope of timely primary care follow-up after the introduction of TCM services (pre-TCM slope, 0.12% per quarter vs post-TCM slope, 0.29% per quarter; difference, 0.13%; 95% CI, 0.02% to 0.22%). Receipt of timely follow-up increased for all demographic groups; however, Black, Hispanic, and Medicaid dual-eligible patients and patients residing in urban areas and counties with high-level social deprivation were less likely to receive follow-up during the study period. These disparities widened for Black patients (difference-in-differences in pre-TCM vs post-TCM slope, -0.14%; 95% CI, -0.25% to -0.2%) and patients who were Medicaid dual-eligible (difference-in-differences pre-TCM vs post-TCM slope, -0.21%; 95% CI, -0.35% to -0.07%). Conclusions: These findings indicate that Medicare's introduction of payments for TCM services was associated with a persistent increase in the rate of timely postdischarge primary care but did not narrow demographic or socioeconomic disparities. Most beneficiaries did not receive timely primary care follow-up.

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.

Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis.

Importance: Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management. Objective: To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults. Design, Setting, and Participants: In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023. Exposure: Incident dementia diagnosis. Main Outcomes and Measures: The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date. Results: The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase). Conclusions and Relevance: In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.

Differences In Use Of Services And Quality Of Care In Medicare Advantage And Traditional Medicare, 2010 And 2017.

Medicare Advantage (MA) enrollment growth could make it difficult for MA plans to maintain their track record of limiting discretionary utilization while delivering higher-quality care than traditional Medicare. We compared quality and utilization measures in Medicare Advantage and traditional Medicare in 2010 and 2017. Clinical quality performance was higher in MA health maintenance organizations (HMOs) and preferred provider organizations (PPOs) than in traditional Medicare for almost all measures in both years. MA HMOs outperformed traditional Medicare on all measures in 2017. MA HMOs' performance on nearly all seven patient-reported quality measures improved, and MA HMOs outperformed traditional Medicare on five of those measures in 2017. MA PPOs performed the same as or better than traditional Medicare on all but one patient-reported quality measure in 2010 and 2017. The number of emergency department visits was 30 percent lower, the number of elective hip and knee replacements was approximately 10 percent lower, and the number of back surgeries was almost 30 percent lower in MA HMOs than in traditional Medicare in 2017. Utilization trends were similar in MA PPOs, but differences from traditional Medicare were narrower. Despite increased enrollment, overall utilization remains lower in Medicare Advantage than in traditional Medicare, whereas quality performance is the same or higher.

National Trends in Antihypertensive Treatment Among Older Adults by Race and Presence of Comorbidity, 2008 to 2017.

BACKGROUND: In 2014, hypertension guidelines for older adults endorsed increased use of fixed-dose combinations, prioritized thiazide diuretics and calcium channel blockers (CCBs) for Black patients, and no longer recommend beta-blockers as first-line therapy. OBJECTIVE: To evaluate older adults' antihypertensive use following guideline changes. DESIGN: Time series analysis. PATIENTS: Twenty percent national sample of Medicare Part D beneficiaries aged 66 years and older with hypertension. INTERVENTION: Eighth Joint National Committee (JNC8) guidelines MAIN MEASURES: Quarterly trends in prevalent and initial antihypertensive use were examined before (2008 to 2013) and after (2014 to 2017) JNC8. Analyses were conducted among all beneficiaries with hypertension, beneficiaries without chronic conditions that might influence antihypertensive selection (hypertension-only cohort), and among Black patients, given race-based guideline recommendations. KEY RESULTS: The number of beneficiaries with hypertension increased from 1,978,494 in 2008 to 2,809,680 in 2017, the proportions using antihypertensives increased from 80.3 to 81.2%, and the proportion using multiple classes and fixed-dose combinations declined (60.8 to 58.1% and 20.7 to 15.1%, respectively, all P<.01). Prior to JNC8, the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and CCBs was increasing. Use of CCBs as initial therapy increased more rapidly following JNC8 (relative change in quarterly trend 0.15% [95% CI, 0.13-0.18%), especially among Black beneficiaries (relative change 0.44% [95% CI, 0.21-0.68%]). Contrary to guidelines, the use of thiazides and combinations as initial therapy consistently decreased in the hypertension-only cohort (13.8 to 8.3% and 25.1 to 15.7% respectively). By 2017, 65.9% of Black patients in the hypertension-only cohort were initiated on recommended first-line or combination therapy compared to 80.3% of non-Black patients. CONCLUSIONS: Many older adults, particularly Black patients, continue to be initiated on antihypertensive classes not recommended as first-line, indicating opportunities to improve the effectiveness and equity of hypertension care and potentially reduce antihypertensive regimen complexity.

Use of diabetes medications in traditional Medicare and Medicare Advantage.

OBJECTIVES: To compare use of diabetes medications between beneficiaries enrolled in Medicare Advantage (MA) and traditional Medicare (TM). STUDY DESIGN: Retrospective cohort analysis of Medicare enrollment and Part D event claims during 2015-2016. METHODS: Data came from 1,027,884 TM and 838,420 MA beneficiaries who received at least 1 prescription for an oral or injectable diabetes medication. After matching MA and TM enrollees by demographic characteristics and geography, we analyzed use of medication overall, choices of first diabetes medication for those new to medication, and patterns of adding medications. RESULTS: Overall and for patients on 1, 2, or 3 diabetes medications, use of metformin was higher in MA by about 3 percentage points, but use of newer medication classes was 5.1 percentage points higher in TM overall (21.3% vs 16.2%). Use of guideline-recommended first-line agents was higher in MA. For those who started metformin first, use of a sulfonylurea as a second medication was 7.8 percentage points higher in MA than TM (61.5% vs 53.7%), whereas use of medications from newer classes was 7.7 percentage points lower (22.0% vs 29.7%). Mean total spending was $149 higher in TM for those taking 1 medication and $298 higher for those taking 2 medications. Differences in spending among MA plans were of similar magnitude to the MA-TM differences. CONCLUSIONS: MA enrollees are more likely to be treated with metformin and sulfonylureas and less likely to receive costly newer medications than those in TM, but there also is substantial variation within MA. A limitation of the study is that we could not assess glucose control using glycated hemoglobin levels.

Medicare's Care Management Codes Might Not Support Primary Care As Expected.

To enhance compensation for primary care activities that occur outside of face-to-face visits, the Centers for Medicare and Medicaid Services recently introduced new billing codes for transitional care management (TCM) and chronic care management (CCM) services. Overall, rates of adoption of these codes have been low. To understand the patterns of adoption, we compared characteristics of the practices that billed for these services to those of the practices that did not and determined the extent to which a practice other than the beneficiary's usual primary care practice billed for the services. Larger practices and those using other novel billing codes were more likely to adopt TCM or CCM. Over a fifth of all TCM claims and nearly a quarter of all CCM claims were billed by a practice that was not the beneficiary's assigned primary care practice. Our results raise concerns about whether these codes are supporting primary care as originally expected.

Association Of Medicare's Annual Wellness Visit With Cancer Screening, Referrals, Utilization, And Spending.

Medicare's annual wellness visit was introduced in 2011 to promote evidence-based preventive care and identify risk factors and undiagnosed conditions in aging adults. Use of the visit has risen steadily since then, yet its benefits remain unclear. Using national Medicare data for 2008-15, we examined claims from fee-for-service Medicare beneficiaries attributed to practices that did or did not adopt the visit. We performed difference-in-differences analysis to compare differential changes in appropriate and low-value cancer screening, functional and neuropsychiatric care, emergency department visits, hospitalizations, and total spending. Examining 17.8 million beneficiary-years, we found modest differential improvements in rates of evidence-based screening and declines in emergency department visits. However, when we accounted for trends that predated the introduction of the visit, none of these benefits persisted. In sum, we found no substantive association between annual wellness visits and improvements in care.

Adjusted Mortality Rates Are Lower For Medicare Advantage Than Traditional Medicare, But The Rates Converge Over Time.

Overall mortality rates, adjusted for age, sex, and Medicaid status, in Medicare Advantage have been below those in traditional Medicare for many years. Much attention has been paid to the resulting issue of favorable selection in Medicare Advantage. The common study design used to estimate causal effects of Medicare Advantage on utilization and outcomes compares new Medicare Advantage beneficiaries immediately before and after enrollment in Medicare Advantage with beneficiaries who choose to remain in traditional Medicare. What has not been studied is the mortality experience of a cohort that initially chooses enrollment in Medicare Advantage versus one that chooses traditional Medicare. In this study we found that the adjusted mortality rate of a cohort newly enrolled in Medicare Advantage was initially well below that of a cohort newly enrolled in traditional Medicare, but the difference markedly decreased after five years. As a result, the common study design is flawed because it assumes that any initial difference in mortality risk remains constant after enrollment in Medicare Advantage. In other words, those initially choosing Medicare Advantage become sicker relative to traditional Medicare beneficiaries over five years. Whether the mortality rates would fully converge if a period longer than five years were observed is a topic for further research.

Trends in Diabetes Treatment and Monitoring among Medicare Beneficiaries.

BACKGROUND: Diabetes is a costly and common condition, but little is known about recent trends in diabetes management among Medicare beneficiaries. OBJECTIVE: To evaluate the use of diabetes medications and testing supplies among Medicare beneficiaries. DESIGN/SETTING: Retrospective cohort analysis of Medicare claims from 2007 to 2014. PARTICIPANTS: Traditional Medicare beneficiaries with a diagnosis of diabetes in the current or any prior year. MAIN MEASURES: We analyzed choices of first diabetes medication for those new to medication and patterns of adding medications. We also examined the use of testing supplies, use of statins and ACE inhibitors/angiotensin receptor blockers, and spending. KEY RESULTS: Diagnosed diabetes increased from 28.7% to 30.2% of beneficiaries from 2007 to 2014. The use of metformin as the most commonly prescribed first medication increased from 50.2% in 2007 to 70.2% in 2014, whereas long-acting sulfonylureas decreased from 16.6% to 8.2%. The use of thiazolidinediones fell considerably, while the use of new diabetes medication classes increased. Among patients prescribed insulin, long-acting insulin as the first choice increased substantially, from 38.9% to 56.8%, but short-acting or combination regimens remained common, particularly among older or sicker beneficiaries. Prescriptions of testing supplies for more than once-daily testing were also common. The mean total cost of diabetes medications per patient increased over the period due to the increasing use of high-cost drugs, particularly by those patients with costs above the 90th percentile of spending, although the median costs decreased for both medications and testing supplies. CONCLUSIONS: The use of metformin and long-acting insulin have increased substantially among elderly Medicare patients with diabetes, but a substantial subgroup continues to receive costly and complex treatment regimens.

Practices Caring For The Underserved Are Less Likely To Adopt Medicare's Annual Wellness Visit.

In 2011 Medicare introduced the annual wellness visit to help address the health risks of aging adults. The visit also offers primary care practices an opportunity to generate revenue, and may allow practices in accountable care organizations to attract healthier patients while stabilizing patient-practitioner assignments. However, uptake of the visit has been uneven. Using national Medicare data for the period 2008-15, we assessed practices' ability and motivation to adopt the visit. In 2015, 51.2 percent of practices provided no annual wellness visits (nonadopters), while 23.1 percent provided visits to at least a quarter of their eligible beneficiaries (adopters). Adopters replaced problem-based visits with annual wellness visits and saw increases in primary care revenue. Compared to nonadopters, adopters had more stable patient assignment and a slightly healthier patient mix. At the same time, visit rates were lower among practices caring for underserved populations (for example, racial minorities and those dually enrolled in Medicaid), potentially worsening disparities. Policy makers should consider ways to encourage uptake of the visit or other mechanisms to promote preventive care in underserved populations and the practices that serve them.

How Is Telemedicine Being Used In Opioid And Other Substance Use Disorder Treatment?

Only a small proportion of people with a substance use disorder (SUD) receive treatment. The shortage of SUD treatment providers, particularly in rural areas, is an important driver of this treatment gap. Telemedicine could be a means of expanding access to treatment. However, several key regulatory and reimbursement barriers to greater use of telemedicine for SUD (tele-SUD) exist, and both Congress and the states are considering or have recently passed legislation to address them. To inform these efforts, we describe how tele-SUD is being used. Using claims data for 2010-17 from a large commercial insurer, we identified characteristics of tele-SUD users and examined how tele-SUD is being used in conjunction with in-person SUD care. Despite a rapid increase in tele-SUD over the study period, we found low use rates overall, particularly relative to the growth in telemental health. Tele-SUD is primarily used to complement in-person care and is disproportionately used by those with relatively severe SUD. Given the severity of the opioid epidemic, low rates of tele-SUD use represent a missed opportunity. As tele-SUD becomes more available, it will be important to monitor closely which tele-SUD delivery models are being used and their impact on access and outcomes.

Rapid Growth In Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States.

Congress and many state legislatures are considering expanding access to telemedicine. To inform this debate, we analyzed Medicare fee-for-service claims for the period 2004-14 to understand trends in and recent use of telemedicine for mental health care, also known as telemental health. The study population consisted of rural beneficiaries with a diagnosis of any mental illness or serious mental illness. The number of telemental health visits grew on average 45.1 percent annually, and by 2014 there were 5.3 and 11.8 telemental health visits per 100 rural beneficiaries with any mental illness or serious mental illness, respectively. There was notable variation across states: In 2014 nine had more than twenty-five visits per 100 beneficiaries with serious mental illness, while four states and the District of Columbia had none. Compared to other beneficiaries with mental illness, beneficiaries who received a telemental health visit were more likely to be younger than sixty-five, be eligible for Medicare because of disability, and live in a relatively poor community. States with a telemedicine parity law and a pro-telemental health regulatory environment had significantly higher rates of telemental health use than those that did not.

Aggressiveness of cancer care near the end of life: is it a quality-of-care issue?

The purpose of this article is to review the literature and update analyses pertaining to the aggressiveness of cancer care near the end of life. Specifically, we will discuss trends and factors responsible for chemotherapy overuse very near death and underutilization of hospice services. Whether the concept of overly aggressive treatment represents a quality-of-care issue that is acceptable to all involved stakeholders is an open question.