RESUMO
OBJECTIVES: Health inequities are frequently driven by social determinants of health (SDOH) and structural determinants of health. Our pilot sought to test the feasibility of screening for health literacy (HL) and perceived health care discrimination (PHD) through a live telephonic-facilitated survey experience with managed care patients. STUDY DESIGN: Cross-sectional study. METHODS: Newly enrolled Medicare Advantage patients were screened for self-reported PHD, HL, and multiple SDOH using validated screening tools. Response rates for both HL and PHD screens were analyzed. A χ2 test for association between response to PHD screen and patient race was conducted. A weighted logistic regression model was used to understand how HL is associated with SDOH and demographic factors (age, gender, race/ethnicity, and income). RESULTS: HL and PHD screening questions have different levels of feasibility. Administering the HL screen did not present a challenge, and patients felt comfortable responding to it. On the other hand, the PHD question had a lower response rate among patients, and some concierge advocates felt uncomfortable asking patients the question. Based on the self-reported HL data collected, low/limited HL is associated with patients who were Black, were low income, reported loneliness or isolation, or reported food insecurity. It is important to note that the study's findings are limited by the small sample size and that study results do not imply causality. CONCLUSIONS: It is feasible to collect self-reported HL data through a live telephonic format at the time of patient enrollment into a health plan. Health plans can leverage such screenings to better understand patient barriers for health equity-oriented interventions.
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Letramento em Saúde , Determinantes Sociais da Saúde , Estados Unidos , Humanos , Idoso , Estudos Transversais , Medicare , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The problem of loneliness has garnered increased attention from policymakers, payors, and providers due to higher rates during the pandemic, particularly among seniors. Prior systematic reviews have in general not been able to reach conclusions about effectiveness of interventions. METHODS: Computerized databases were searched using broad terms such as "loneliness" or "lonely" or "social isolation" or "social support" from Jan 1, 2011 to June 23, 2021. We reference mined existing systematic reviews for additional and older studies. The Social Interventions Research & Evaluation Network database and Google were searched for gray literature on Feb 4, 2022. Eligible studies were RCTs and observational studies of interventions to reduce loneliness in community-living adults that used a validated loneliness scale; studies from low- or middle-income countries were excluded, and studies were excluded if restricted to populations where all persons had the same disease (such as loneliness in persons with dementia). RESULTS: A total of 5971 titles were reviewed and 60 studies were included in the analysis, 36 RCTs and 24 observational studies. Eleven RCTs and 5 observational studies provided moderate certainty evidence that group-based treatment was associated with reduced loneliness (standardized mean difference for RCTs = - 0.27, 95% CI - 0.48, - 0.08). Five RCTs and 5 observational studies provided moderate certainty evidence that internet training was associated with reduced loneliness (standardized mean difference for RCTs = - 0.22, 95% CI - 0.30, - 0.14). Low certainty evidence suggested that group exercises may be associated with very small reductions in loneliness. Evidence was insufficient to reach conclusions about group-based activities, individual in-person interactions, internet-delivered interventions, and telephone-delivered interventions. DISCUSSION: Low-to-moderate certainty evidence exists that group-based treatments, internet training, and possibly group exercises are associated with modest reductions in loneliness in community-living older adults. These findings can inform the design of supplemental benefits and the implementation of evidence-based interventions to address loneliness. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO ( CRD42021272305 ).
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Vida Independente , Solidão , Humanos , Solidão/psicologia , Idoso , Vida Independente/psicologia , Apoio Social , Isolamento Social/psicologiaRESUMO
When the Medicare Part D benefit was constructed, drugs for weight loss were explicitly excluded from coverage, as the limited effectiveness and unfavorable safety profile of medications available at the time failed to justify coverage of drugs perceived to be used for cosmetic purposes. In recent years, drugs activating the glucagon-like peptide-1 receptor (GLP-1R) pathway have proved to achieve significant reductions in body weight with a favorable safety profile. The effectiveness of GLP-1R agonists in reducing weight and improving the metabolic profile warrants the reconsideration of the historical exclusion of weight loss drugs from Part D coverage. In this perspective, we outline policy options to enable Part D coverage of GLP-1R agonists. These include legislative change through the passage of the Treat and Reduce Obesity Act and evaluation of coverage policies under the waiver authority of the Center for Medicare and Medicaid Innovation.
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Fármacos Antiobesidade , Medicare Part D , Idoso , Humanos , Estados Unidos , Fármacos Antiobesidade/uso terapêutico , Obesidade/tratamento farmacológico , Redução de Peso , PolíticasRESUMO
Importance: Much of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality. Objective: To evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery. Design, Setting, and Participants: Cross-sectional study of 23â¯034 LEJR surgical episodes that emulated a stepped-wedge design by using the time-varying, geographically staggered rollout of the bundled payment program from January 1, 2012, to September 30, 2019. Episode-level multivariable regression models were estimated within practice to compare changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. Data analyses were performed from July 1, 2021, to June 30, 2022. Exposures: Physician practice participation in the bundled payment program. Main Outcomes and Measures: The primary outcome was episode spending (plan and beneficiary). Secondary outcomes included postacute care use (skilled nursing facility and home health care), surgical setting (inpatient vs outpatient), and quality (90-day complications [including deep vein thrombosis, wound infection, fracture, or dislocation] and readmissions). Results: The final analytic sample included 23â¯034 LEJR episodes (6355 bundled episodes and 16â¯679 control episodes) from 109 physician practices participating in the program. Of the beneficiaries, 7730 were male and 15â¯304 were female, 3057 were Black, 19â¯351 were White, 447 were of other race or ethnicity (assessed according to the Centers for Medicare & Medicaid Services beneficiary race and ethnicity code, which reflects data reported to the Social Security Administration), and 179 were of unknown race and ethnicity. The mean (SD) age was 70.9 (7.2) years. Participation in the bundled payment program was associated with a 2.7% (95% CI, 1.3%-4.1%) decrease in spending per episode (mean episodic spending, $21â¯964 [95% CI, $21â¯636-$22â¯296] vs $22â¯562 [95% CI, $22â¯346-$22â¯779]), as well as reductions in skilled nursing facility use after discharge (21.3% for bundled episodes vs 25.0% for control episodes; odds ratio [OR], 0.81 [95% CI, 0.67-0.98]) and increased use of the outpatient surgical setting (14.1% for bundled episodes vs 8.4% for control episodes; OR, 1.79 [95% CI, 1.53-2.09]). The program was not associated with changes in quality outcomes, including 90-day complications (8.8% for bundled episodes vs 8.6% for control episodes; OR, 1.02 [95% CI, 0.86-1.20]) and readmissions (4.3% for bundled episodes vs 4.6% for control episodes; OR, 0.92 [95% CI, 0.75-1.13]). Conclusions and Relevance: In this study of an LEJR bundled payment program offered by a national Medicare Advantage insurer, findings suggest that physician practice participation in the program was associated with a decrease in episode spending without changes in quality. Bundled payments offered by private insurers, including Medicare Advantage plans, are an alternate payment option to fee for service that may reduce spending for LEJR episodes while maintaining quality of care.
Assuntos
Artroplastia de Substituição , Medicare Part C , Humanos , Masculino , Feminino , Idoso , Estados Unidos , Estudos Transversais , Planos de Pagamento por Serviço Prestado , Extremidade InferiorRESUMO
Importance: Payers are increasingly using approaches to risk adjustment that incorporate community-level measures of social risk with the goal of better aligning value-based payment models with improvements in health equity. Objective: To examine the association between community-level social risk and health care spending and explore how incorporating community-level social risk influences risk adjustment for Medicare beneficiaries. Design, Setting, and Participants: Using data from a Medicare Advantage plan linked with survey data on self-reported social needs, this cross-sectional study estimated health care spending health care spending was estimated as a function of demographics and clinical characteristics, with and without the inclusion of Area Deprivation Index (ADI), a measure of community-level social risk. The study period was January to December 2019. All analyses were conducted from December 2021 to August 2022. Exposures: Census block group-level ADI. Main Outcomes and Measures: Regression models estimated total health care spending in 2019 and approximated different approaches to social risk adjustment. Model performance was assessed with overall model calibration (adjusted R2) and predictive accuracy (ratio of predicted to actual spending) for subgroups of potentially vulnerable beneficiaries. Results: Among a final study population of 61â¯469 beneficiaries (mean [SD] age, 70.7 [8.9] years; 35â¯801 [58.2%] female; 48â¯514 [78.9%] White; 6680 [10.9%] with Medicare-Medicaid dual eligibility; median [IQR] ADI, 61 [42-79]), ADI was weakly correlated with self-reported social needs (r = 0.16) and explained only 0.02% of the observed variation in spending. Conditional on demographic and clinical characteristics, every percentile increase in the ADI (ie, more disadvantage) was associated with a $11.08 decrease in annual spending. Directly incorporating ADI into a risk-adjustment model that used demographics and clinical characteristics did not meaningfully improve model calibration (adjusted R2 = 7.90% vs 7.93%) and did not significantly reduce payment inequities for rural beneficiaries and those with a high burden of self-reported social needs. A postestimation adjustment of predicted spending for dual-eligible beneficiaries residing in high ADI areas also did not significantly reduce payment inequities for rural beneficiaries or beneficiaries with self-reported social needs. Conclusions and Relevance: In this cross-sectional study of Medicare beneficiaries, the ADI explained little variation in health care spending, was negatively correlated with spending conditional on demographic and clinical characteristics, and was poorly correlated with self-reported social risk factors. This prompts caution and nuance when using community-level measures of social risk such as the ADI for social risk adjustment within Medicare value-based payment programs.
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Equidade em Saúde , Medicare , Idoso , Humanos , Feminino , Estados Unidos , Masculino , Risco Ajustado , Estudos Transversais , Gastos em SaúdeRESUMO
Importance: Medicare beneficiaries with co-occurring chronic conditions and complex care needs experience high rates of acute care utilization and poor outcomes. These patterns are well described among traditional Medicare (TM) beneficiaries, but less is known about outcomes among Medicare Advantage (MA) beneficiaries. Compared with TM, MA plans have additional levers to potentially address beneficiary needs, such as network design, care management, supplemental benefits, and value-based contracting. Objective: To compare health care utilization for MA and TM beneficiaries with complex care needs. Design, Setting, and Participants: This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. Beneficiaries were segmented into the following cohorts: frail elderly, major complex chronic, and minor complex chronic. Regression models estimated the association between MA enrollment and health care utilization in 2018, using inverse probability of treatment weighting to balance the MA and TM cohorts on observable characteristics. The study period was January 1, 2017, through December 31, 2018. All analyses were conducted from December 2020 to August 2022. Exposures: Enrollment in MA vs TM. Main Outcomes and Measures: Hospital stays (inpatient admissions and observation stays), emergency department (ED) visits, and 30-day readmissions. Results: Among a study population of 1â¯844â¯326 Medicare beneficiaries (mean [SD] age, 75.6 [7.1] years; 1â¯021â¯479 [55.4%] women; 1â¯524â¯458 [82.7%] White; 223â¯377 [12.1%] with Medicare-Medicaid dual eligibility), 1â¯177â¯896 (63.9%) were enrolled in MA and 666â¯430 (36.1%) in TM. Beneficiary distribution across cohorts was as follows: frail elderly, 116â¯047 with MA (10.0% of the MA sample) and 104â¯036 with TM (15.6% of the TM sample); major complex chronic, 320â¯954 (27.2%) and 158â¯811 (23.8%), respectively; and minor complex chronic, 740â¯895 (62.9%) and 403â¯583 (60.6%), respectively. Beneficiaries enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions. The largest relative differences were observed for hospital stays, which ranged from -9.3% (95% CI, -10.9% to -7.7%) for the frail elderly cohort to -11.9% (95% CI, -13.2% to -10.7%) for the major complex chronic cohort. Conclusions and Relevance: In this cross-sectional study of Medicare beneficiaries with complex care needs, those enrolled in MA had lower rates of hospital stays, ED visits, and 30-day readmissions than similar beneficiaries enrolled in TM, suggesting that managed care activities in MA may influence the nature and quality of care provided to these beneficiaries.
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Medicare Part C , Idoso , Estudos de Coortes , Estudos Transversais , Definição da Elegibilidade , Feminino , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde , Estados UnidosRESUMO
Importance: Low-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care. Objectives: To compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care. Design, Setting, and Participants: This cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022. Exposures: Enrollment in MA vs TM. Main Outcomes and Measures: Low-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries. Results: Among a study population of 2â¯470â¯199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1â¯346â¯777 [54.5%] female; 229â¯107 [9.3%] Black and 2â¯126â¯353 [86.1%] White individuals), 1â¯527â¯763 (61.8%) were enrolled in MA and 942â¯436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements. Conclusions and Relevance: In this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.
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Medicare Part C , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Estados UnidosRESUMO
Value-based payment programs adjust payments to providers based on spending, quality, or health outcomes. Concern that these programs penalize providers disproportionately serving vulnerable patients prompted calls to adjust performance measures for social risk factors. We reviewed fourteen studies of social risk adjustment in Medicare's Hospital Readmissions Reduction Program (HRRP), a value-based payment model that initially did not adjust for social risk factors but subsequently began to do so. Seven studies found that adding social risk factors to the program's base risk-adjustment model (which adjusts only for age, sex, and comorbidities) reduced differences in risk-adjusted readmissions and penalties between safety-net hospitals and other hospitals. Three studies found that peer grouping, the HRRP's current approach to social risk adjustment, reduced penalties among safety-net hospitals. Two studies found that differences in risk-adjusted readmissions and penalties were further narrowed when augmentation of the base model was combined with peer grouping. Two studies showed that it is possible to adjust for social risk factors without obscuring quality differences between hospitals. These findings support the use of social risk adjustment to improve provider payment equity and highlight opportunities to enhance social risk adjustment in value-based payment programs.
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Readmissão do Paciente , Risco Ajustado , Idoso , Humanos , Medicare , Políticas , Provedores de Redes de Segurança , Estados UnidosRESUMO
Importance: There is increased focus on identifying and addressing health-related social needs (HRSNs). Understanding how different HRSNs relate to different health outcomes can inform targeted, evidence-based policies, investments, and innovations to address HRSNs. Objective: To examine the association between self-reported HRSNs and acute care utilization among older adults enrolled in Medicare Advantage. Design Setting and Participants: This cross-sectional study used data from a large, national survey of Medicare Advantage beneficiaries to identify the presence of HRSNs. Survey data were linked to medical claims, and regression models were used to estimate the association between HRSNs and rates of acute care utilization from January 1, 2019, through December 31, 2019. Exposures: Self-reported HRSNs, including food insecurity, financial strain, loneliness, unreliable transportation, utility insecurity, housing insecurity, and poor housing quality. Main Outcomes and Measures: All-cause hospital stays (inpatient admissions and observation stays), avoidable hospital stays, all-cause emergency department (ED) visits, avoidable ED visits, and 30-day readmissions. Results: Among a final study population of 56 155 Medicare Advantage beneficiaries (mean [SD] age, 74.0 [5.8] years; 32 779 [58.4%] women; 44 278 [78.8%] White; and 7634 [13.6%] dual eligible for Medicaid), 27 676 (49.3%) reported 1 or more HRSNs. Health-related social needs were associated with statistically significantly higher rates of all utilization measures, with the largest association observed for avoidable hospital stays (incident rate ratio for any HRSN, 1.53; 95% CI, 1.35-1.74; P < .001). Compared with beneficiaries without HRSNs, beneficiaries with an HRSN had a 53.3% higher rate of avoidable hospitalization (incident rate ratio, 1.53; 95% CI, 1.35-1.74; P < .001). Financial strain and unreliable transportation were each independently associated with increased rates of hospital stays (marginal effects of 26.5 [95% CI, 14.2-38.9] and 51.2 [95% CI, 30.7-71.8] hospital stays per 1000 beneficiaries, respectively). All HRSNs, except for utility insecurity, were independently associated with increased rates of ED visits. Unreliable transportation had the largest association with increased hospital stays and ED visits, with marginal effects of 51.2 (95% CI, 30.7-71.8) and 95.5 (95% CI, 65.3-125.8) ED visits per 1000 beneficiaries, respectively. Only unreliable transportation and financial strain were associated with increased rates of 30-day readmissions, with marginal effects of 3.3% (95% CI, 2.0%-4.0%) and 0.4% (95% CI, 0.2%-0.6%), respectively. Conclusions and Relevance: In this cross-sectional study of older adults enrolled in Medicare Advantage, self-reported HRSNs were common and associated with statistically significantly increased rates of acute care utilization, with variation in which HRSNs were associated with different utilization measures. These findings provide evidence of the unique association between certain HRSNs and different types of acute care utilization, which could help refine the development and targeting of efforts to address HRSNs.
Assuntos
Medicare Part C , Idoso , Estudos Transversais , Feminino , Hospitalização , Humanos , Masculino , Medicaid , Autorrelato , Estados Unidos/epidemiologiaRESUMO
Among older adults enrolled in Medicare Advantage, health-related social needs are highly prevalent, with financial strain, food insecurity, and poor housing quality the most commonly reported. The distribution of health-related social needs is uneven, with significant disparities according to race, socioeconomic status, and sex.
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Medicare Part C , Idoso , Humanos , Estados UnidosRESUMO
Medication nonadherence in the United States contributes to 125,000 deaths and 10% of hospitalizations annually. The pain of preventable deaths and the personal costs of nonadherence are borne disproportionately by Black, Latino, and other minority groups because nonadherence is higher in these groups due to a variety of factors. These factors include socioeconomic challenges, issues with prescription affordability and convenience of filling and refilling them, lack of access to pharmacies and primary care services, difficulty taking advantage of patient engagement opportunities, health literacy limitations, and lack of trust due to historical and structural discrimination outside of and within the medical system. Solutions to address the drivers of lower medication adherence, specifically in minority populations, are needed to improve population outcomes and reduce inequities. While various solutions have shown some traction, these solutions have tended to be challenging to scale for wider impact. We propose that integrated medical and pharmacy plans are well positioned to address racial and ethnic health disparities related to medication adherence. DISCLOSURES: This study was not supported by any funding sources other than employment of all authors by Humana Inc. Humana products and programs are referred to in this article.
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Disparidades nos Níveis de Saúde , Adesão à Medicação , Medicamentos sob Prescrição , Etnicidade , Hispânico ou Latino , Humanos , Adesão à Medicação/etnologia , Grupos Raciais , Estados UnidosRESUMO
BACKGROUND: Health plans and risk-bearing provider organizations seek information sources to inform proactive interventions for patients at risk of adverse health events. Interventions should take into account the strong relationship between social context and health. This retrospective cohort study of a Medicare Advantage population examined whether a change in self-reported health-related quality of life (HRQOL) signals a subsequent change in healthcare needs. METHODS: A retrospective longitudinal analysis of administrative claims data was conducted for participants in a Medicare Advantage plan with prescription drug coverage (MAPD) who responded to 2 administrations of the Centers for Disease Control and Prevention 4-item Healthy Days survey within 6-18 months during 2015-2018. Changes in HRQOL, as measured by the Healthy Days instrument, were compared with changes in utilization and costs, which were considered to be a reflection of change in healthcare needs. RESULTS: A total of 48,841 individuals met inclusion criteria. Declining HRQOL was followed by increases in utilization and costs. An adjusted analysis showed that every additional unhealthy day reported one year after baseline was accompanied by an $8 increase in monthly healthcare costs in the subsequent six months for the average patient. CONCLUSIONS: Declining HRQOL signaled subsequent increases in healthcare needs and utilization. IMPLICATIONS: Findings suggest that HRQOL assessments in general, and the Healthy Days instrument in particular, could serve as a leading indicator of the need for interventions designed to mitigate poor health outcomes and rising healthcare costs. LEVEL OF EVIDENCE: III.
Assuntos
Medicare Part C , Qualidade de Vida , Idoso , Custos de Cuidados de Saúde , Humanos , Estudos Retrospectivos , Autorrelato , Estados UnidosRESUMO
BACKGROUND: Home health use is rising rapidly in the United States as the population ages, the prevalence of chronic disease increases, and older Americans express their desire to age at home. Enrollment in Medicare Advantage (MA) plans rather than Traditional Medicare (TM) has grown as well, from 13% of total Medicare enrollment in 2004 to 39% in 2020. Despite these shifts, little is known about outcomes and costs following home health in MA as compared with TM. OBJECTIVE: The objective of this study was to measure the association of MA enrollment with outcomes and costs for patients using home health. DESIGN: This was a retrospective cohort study. PARTICIPANTS: Patients enrolled in plans offered by 1 large, national MA organization and patients enrolled in TM, with at least 1 home health visit between January 1, 2017, and June 30, 2018. EXPOSURE: MA enrollment. MAIN MEASURES: We compared the intensity of home health services and types of care delivered. The main outcome measures were hospitalization, the proportion of days in the home, and total allowed costs during the 180-day period following the first qualifying home health visit during the study period. KEY RESULTS: Among patients who used home health, our models demonstrated enrollment in MA was associated with 14%, and 6% decreased odds of 60- and 180-day hospitalization, respectively, a 12.8% and 14.7% decrease in medical costs exclusive and inclusive of home health costs, respectively, and a 0.27% increase in the proportion of days at home during the 180-day follow-up, equivalent to an additional half-day at home. There were few differences in home health care delivered for MA and TM [mean number of visits in the first episode of care (17.1 vs. 17.3) and mean visits per week (3.2 vs. 3.3)]. The mean number of visits by visit type and percent of patients with each type was similar between MA and TM as well. CONCLUSIONS: Compared with enrollment in TM, enrollment in MA was associated with improved patient-centered outcomes and lower cost and utilization, despite few differences in the way home health was delivered. These findings might be explained by structural components of MA that encourage better care management, but further investigation is needed to clarify the mechanisms by which MA enrollment may lead to higher value home health care.
Assuntos
Serviços de Assistência Domiciliar/normas , Medicare Part C/normas , Medicare/normas , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos de Coortes , Serviços de Assistência Domiciliar/estatística & dados numéricos , Humanos , Medicare/estatística & dados numéricos , Medicare Part C/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados UnidosRESUMO
OBJECTIVES: To compare outcomes and costs following skilled nursing facility (SNF) discharge for patients within a Medicare Advantage (MA) organization vs traditional Medicare (TM). STUDY DESIGN: Retrospective analysis of adults with a postacute SNF admission identified from MA claims (MA cohort: n = 56,228) and the Medicare 5% Limited Data Sets (TM cohort: n = 67,859). METHODS: Outcomes included hospitalization, proportion of days at home, and total medical costs during the 180 days post SNF discharge, and successful community discharge. Regression models accounted for patient characteristics and health care utilization in the 180 days prior to the proximal hospitalization and characteristics of the proximal hospitalization using backward variable selection and fixed effects for MA enrollment. To control for observable differences between individuals who selected MA vs TM, inverse probability of treatment weighting (IPTW) was conducted. RESULTS: The MA cohort was younger than the TM cohort (median age, 77 vs 81 years), more likely to have qualified for Medicare based on disability (29% vs 20%), and less likely to have dual Medicare/Medicaid eligibility (16% vs 23%). After adjustment, MA was associated with 22% decreased odds of hospitalization during the 180 days post SNF discharge, 19% increased odds of successful community discharge, a 4% increase in the proportion of days at home (equating to 6.7 additional days), and a 24% decrease in medical costs post SNF discharge. Results using IPTW were similar. CONCLUSIONS: MA was associated with better outcomes and lower costs post SNF discharge, suggesting efficiencies in care for SNF patients with MA. Further research is needed to evaluate specific MA features that may lead to better value.