Epidemiology of Homebound Population Among Beneficiaries of a Large National Medicare Advantage Plan.

BACKGROUND: Interest in home-based care is increasing among Medicare Advantage (MA) plans. The epidemiology of homebound MA beneficiaries is unknown. OBJECTIVE: To determine the prevalence, characteristics, predictors, health service use, and mortality outcomes of homebound beneficiaries of a large national MA plan. DESIGN: Cross-sectional. SETTING: National MA plan. PARTICIPANTS: Humana MA beneficiaries in 2022 (n = 2 435 519). MEASUREMENTS: Homebound status was assessed via in-home assessment using previously defined categories: homebound (never or rarely left home in the past month), semihomebound (left home with assistance, had difficulty, or needed help leaving home), and not homebound. Demographic, clinical, health service use, and mortality outcomes were compared by homebound status. RESULTS: In 2022, the overall prevalence of homebound beneficiaries was 22.0% (8.4% of beneficiaries were homebound, and 13.6% were semihomebound). In adjusted models, female sex (odds ratio [OR], 1.36 [95% CI, 1.35 to 1.37), low-income status or dual eligibility for Medicare and Medicaid (OR, 1.56 [CI, 1.55 to 1.57]), dementia (OR, 2.36 [CI, 2.33 to 2.39]), and moderate to severe frailty (OR, 4.32 [CI, 4.19 to 4.45]) were predictive of homebound status. In multivariable logistic regression, homebound status was associated with increased odds of any emergency department visit (OR, 1.14 [ CI, 1.14 to 1.15]), any inpatient hospital admission (OR, 1.44 [CI, 1.42 to 1.46]), any skilled-nursing facility admission (OR, 2.18 [CI, 2.13 to 2.23]), and death (OR, 2.55 [CI, 2.52 to 2.58]). LIMITATION: The study period overlapped the tail end of the COVID-19 pandemic, and data were derived from a single national MA plan, which limits generalizability. CONCLUSION: Overall homebound prevalence in a national MA plan was 22.0% and was independently associated with increased health service use and mortality. Study findings can inform strategic initiatives to identify and manage care for homebound beneficiaries. PRIMARY FUNDING SOURCE: Humana, under a collaborative research agreement with Johns Hopkins University.

Recruitment and enrollment of African Americans and Caucasians in a health promotion trial for persons with serious mental illness.

African Americans with serious mental illness (SMI) continue to experience inadequate representation in clinical trials. Persons with SMI, regardless of race, have an increased burden of all cardiovascular disease (CVD) risk factors including obesity, hypertension, diabetes mellitus, dyslipidemia, metabolic syndrome and tobacco smoking. Having SMI and being African American, however, is each associated with an increased risk of CVD mortality compared to the general population. There is a critical need, therefore, to adapt health promotion interventions for African Americans with SMI. We sought to examine overall recruitment into a randomized clinical trial of CVD prevention among persons with SMI, and to examine racial differences in interest, enrollment, and potential barriers to participation. Although similar levels of interest in participation were seen between African Americans and Caucasians in signing screening consent, 9.6% fewer African Americans enrolled due to inability to complete initial data collection. Further work is needed to better understand the nature of the barriers encountered by African Americans with SMI who otherwise may be interested in participating within clinical trials.

The effect of emergency department copayments for Medicaid beneficiaries following the Deficit Reduction Act of 2005.

IMPORTANCE: High unemployment during the 2007-2009 Great Recession and eligibility expansions have increased the size and cost of Medicaid. To provide states with flexibility in administering the program while containing costs, the Deficit Reduction Act of 2005 (DRA) gave states the authority to impose cost-sharing strategies, including emergency department (ED) copayments for nonurgent visits. To our knowledge, there has been no previous longitudinal analysis of the effect of the DRA on health care utilization outcomes for Medicaid beneficiaries. OBJECTIVES: To evaluate the effect of the DRA, which allowed states to enforce ED copayments for nonurgent visits, on ED utilization among Medicaid beneficiaries and to compare the effect among beneficiaries living in states that did and did not adopt ED copayments. DESIGN, SETTING, AND PARTICIPANTS: A difference-in-difference quasi-experimental approach was used to compare trends in ED use among Medicaid beneficiaries from January 2001 to December 2010. Eight states with ED copayments for nonurgent ED visits (copayment states) were compared with 10 states with zero ED copayments (control states). The study cohort was the population of individuals 19 to 64 years old enrolled in Medicaid for a full calendar year as collected by the Medical Expenditure Panel Survey, a nationally representative survey of noninstitutionalized US civilians. The cohort consisted of 3122 adult Medicaid recipients in copayment states and 7433 adult Medicaid recipients in control states. EXPOSURES: The main exposure was the copayment enforcement authority of the DRA. The study controlled for sex, age, race, marital status, income relative to the federal poverty level, educational level, and self-reported health status. MAIN OUTCOMES AND MEASURES: The primary outcome of this study was the change in the rate of ED utilization following the DRA. Additional outcomes included changes in the rate of outpatient medical provider visits and inpatient length of stay. Visits were not coded according to urgency, which prevented us from examining only nonurgent ED use. RESULTS: Estimates from a zero-inflated Poisson regression model detected no statistically significant change in annual ED admissions per Medicaid enrollee (change, 0.05; 95% CI, -0.05 to 0.16) in copayment states compared with control states following the DRA. There was also no change in the rate of outpatient medical provider visits (change, 0.02; 95% CI, -0.31 to 0.35) or in annual inpatient days (change, 0.13; 95% CI, -0.31 to 0.57) per Medicaid enrollee. CONCLUSIONS AND RELEVANCE: Granting states permission to collect copayments for nonurgent visits under the DRA did not significantly change ED or outpatient medical provider use among Medicaid beneficiaries.