Factors associated with self-reports of limitations in activities of daily living among Medicare Fee-for-Service recipients.

BACKGROUND: Physical function is an important indicator of physical health and predicts mortality. This study identified characteristics associated with limitations in Medicare recipients' activities of daily living. METHODS: 2019 Consumer Assessment of Healthcare Providers and Systems Fee-for-Service Medicare Survey data: 79,725 respondents (34% response rate) who were 65 and older and 53% female; 7% Black, 5% Hispanic, 4% Asian American, Native Hawaiian, or other Pacific Islander, 2% Multiracial, 1% American Indian/Alaskan Native; 35% with high school education or less. Walking, getting in and out of chairs, bathing, dressing, toileting, and eating (scored as having no difficulty versus being able to do with difficulty or unable to do) and a scale of these items were regressed on patient characteristics. RESULTS: After adjustment for all characteristics, function limitations were found for those who smoked (effect sizes of significant associations range .04-.13), had chronic health conditions (.02-.33), were 85 years or older (.09-.46), needed assistance completing the survey (.32-1.29), were female (.05-.07), and had low income and assets (.15-.47). CONCLUSIONS: These nationally representative U.S. estimates of physical function characteristics are useful for interventions for vulnerable population subgroups.

Patient Experience for Hispanic Older Adults Varies by Language Preference.

BACKGROUND: Hispanic people with Medicare report worse patient experiences than non-Hispanic White counterparts. However, little research examines how these disparities may vary by language preference (English/Spanish). OBJECTIVES: Using Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data, assess whether 2014-2018 disparities in patient experiences for Hispanic people with Medicare vary by language preference. RESEARCH DESIGN: We fit a series of linear, case-mix adjusted models predicting Medicare CAHPS measures by race/ethnicity/language preference (Hispanic Spanish-respondents; Hispanic Spanish-preferring English-respondents; Hispanic English-preferring respondents; and non-Hispanic White English-respondents). SUBJECTS: A total of 1,006,543 Hispanic and non-Hispanic White respondents to the Medicare 2014-2018 CAHPS surveys. RESULTS: There were disparities for all Hispanic groups relative to non-Hispanic White English-respondents. Hispanic Spanish-preferring English-respondents reported worse experience than Hispanic Spanish-respondents for getting care quickly (-8 points), getting needed care (-5 points), doctor communication (-2 points), and customer service (-1 point), but better experiences for flu immunization (+2 points). Similarly, Hispanic Spanish-preferring English-respondents reported worse experience than Hispanic English-preferring respondents for getting care quickly (-4 points) and getting needed care (-2 points). Hispanic English-preferring respondents reported worse experience than Hispanic Spanish-respondents for getting care quickly (-4 points), getting needed care (-3 points), doctor communication and customer service (-2 points each), but better experience for flu immunization (+2 points). CONCLUSIONS: Regardless of language preference, Hispanic people with Medicare experience disparities in patient care relative to non-Hispanic White English-preferring counterparts. Hispanic Spanish-preferring English-respondents report the worse experiences, followed by Hispanic English-preferring respondents. Hispanic Spanish-respondents experienced the least disparities of the three Hispanic language subgroups.

Disparities in Care Experienced by Older Hispanic Medicare Beneficiaries in Urban and Rural Areas.

BACKGROUND: Hispanic older adults face substantial health disparities compared with non-Hispanic-White (hereafter "White") older adults. To the extent that these disparities stem from cultural and language barriers faced by Hispanic people, they may be compounded by residence in rural areas. OBJECTIVE: The objective of this study was to investigate possible interactions between Hispanic ethnicity and rural residence in predicting the health care experiences of older adults in the United States, and whether disparities in care for rural Hispanic older adults differ in Medicare Advantage versus Medicare Fee-for-Service. SUBJECTS: Medicare beneficiaries age 65 years and older who responded to the 2017-2018 nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. METHODS: We fit a series of linear, case-mix-adjusted models predicting Medicare CAHPS measures of patient experience (rescaled to a 0-100 scale) from ethnicity, place of residence, and Medicare coverage type. RESULTS: In all residential areas, Hispanic beneficiaries reported worse experiences with getting needed care (-3 points), getting care quickly (-4 points), and care coordination (-1 point) than White beneficiaries (all P's<0.001). In rural areas only, Hispanic beneficiaries reported significantly worse experiences than White beneficiaries on doctor communication and customer services (-3 and -9 points, respectively, P<0.05). Tests of a 3-way interaction between ethnicity, rural residence, and coverage type were nonsignificant. CONCLUSIONS: There is a need to improve access to care and care coordination for Hispanic beneficiaries overall and doctor-patient communication and customer service for rural Hispanic beneficiaries. Strategies for addressing deficits faced by rural Hispanics may involve cultural competency training and provision of language-appropriate services for beneficiaries (perhaps as telehealth services).

The Contribution of First-name Information to the Accuracy of Racial-and-Ethnic Imputations Varies by Sex and Race-and-Ethnicity Among Medicare Beneficiaries.

BACKGROUND: Data on race-and-ethnicity that are needed to measure health equity are often limited or missing. The importance of first name and sex in predicting race-and-ethnicity is not well understood. OBJECTIVE: The objective of this study was to compare the contribution of first-name information to the accuracy of basic and more complex racial-and-ethnic imputations that incorporate surname information. RESEARCH DESIGN: We imputed race-and-ethnicity in a sample of Medicare beneficiaries under 2 scenarios: (1) with only sparse predictors (name, address, sex) and (2) with a rich set (adding limited administrative race-and-ethnicity, demographics, and insurance). SUBJECTS: A total of 284,627 Medicare beneficiaries who completed the 2014 Medicare Consumer Assessment of Healthcare Providers and Systems survey and reported race-and-ethnicity were included. RESULTS: Hispanic, non-Hispanic Asian/Pacific Islander, and non-Hispanic White racial-and-ethnic imputations are more accurate for males than females under both sparse-predictor and rich-predictor scenarios; adding first-name information increases accuracy more for females than males. In contrast, imputations of non-Hispanic Black race-and-ethnicity are similarly accurate for females and males, and first names increase accuracy equally for each sex in both sparse-predictor and rich-predictor scenarios. For all 4 racial-and-ethnic groups, incorporating first-name information improves prediction accuracy more under the sparse-predictor scenario than under the rich-predictor scenario. CONCLUSION: First-name information contributes more to the accuracy of racial-and-ethnic imputations in a sparse-predictor scenario than in a rich-predictor scenario and generally narrows sex gaps in accuracy of imputations.

Patient-Reported Care Coordination is Associated with Better Performance on Clinical Care Measures.

BACKGROUND: Prior studies using aggregated data suggest that better care coordination is associated with higher performance on measures of clinical care process; it is unclear whether this relationship reflects care coordination activities of health plans or physician practices. OBJECTIVE: Estimate within-plan relationships between beneficiary-reported care coordination measures and HEDIS measures of clinical process for the same individuals. DESIGN: Mixed-effect regression models in cross-sectional data. PARTICIPANTS: 2013 Medicare Advantage CAHPS respondents (n=152,069) with care coordination items linked to independently collected HEDIS data on clinical processes. MAIN MEASURES: Care coordination measures assessed follow-up, whether doctors had medical records during visits, whether doctors discussed medicines being taken, how informed doctors seemed about specialist care, and help received with managing care among different providers. HEDIS measures included mammography, colorectal cancer screening, cardiovascular LDL-C screening, controlling blood pressure, 5 diabetes care measures (LDL-C screening, retinal eye exam, nephropathy, blood sugar/HbA1c <9%, LCL-C<100 mg/dL), glaucoma screening in older adults, BMI assessment, osteoporosis management for women with a fracture, and rheumatoid arthritis therapy. KEY RESULTS: For 9 of the 13 HEDIS measures, within health plans, beneficiaries who reported better care coordination also received better clinical care (p<0.05) and none of the associations went in the opposite direction; HEDIS differences between those with excellent and poor coordination exceeded 5 percentage points for 7 measures. Nine measures had positive associations (breast cancer screening, colorectal cancer screening, cardiovascular care LDL-C screening, 4 of 5 diabetes care measures, osteoporosis management, and rheumatoid arthritis therapy). CONCLUSIONS: Within health plans, beneficiaries who report better care coordination also received higher-quality clinical care, particularly for care processes that entail organizing patient care activities and sharing information among different healthcare providers. These results extend prior research showing that health plans with better beneficiary-reported care coordination achieved higher HEDIS performance scores.

Distinguishing High-Performing Health Systems Using a Composite of Publicly Reported Measures of Ambulatory Care.

BACKGROUND: Payers and policymakers are rewarding high-performing health care providers on the basis of summaries of overall quality performance, and the methods they use for measuring performance are increasingly important. OBJECTIVE: To develop and evaluate a measure that ranks health care systems by ambulatory care quality. DESIGN: Systems were ranked using a composite model that summarizes individual measures of quality, accounts for their correlation, and does not require health care systems to report every measure. The composite measure's suitability was evaluated by examining whether it captured the quality indicated by component measures (validity), whether differences in rank between health care systems were larger than statistical noise (reliability), and whether year-to-year changes in rank were small (stability). SETTING: California and Minnesota, 2014 to 2016. PARTICIPANTS: 55 health care systems. MEASUREMENTS: Publicly reported measures of ambulatory care quality. RESULTS: The composite measure was valid in that it was broadly representative of the component measures and was not dominated by any single measure. The measure was reliable because the ranks for 93% of California systems and 80% of Minnesota systems were unlikely to be more than 2 places lower or higher. The measure was stable because fewer than half of systems changed ranks by more than 2 ranks from year to year. LIMITATION: The analysis is limited to available measures of ambulatory care quality and includes only 2 states. CONCLUSION: This composite measure uses publicly reported data to produce valid, reliable, and stable ranks of ambulatory care quality for health care systems in Minnesota and California, and this approach could be used in other applications. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Disparities in Care Experienced by American Indian and Alaska Native Medicare Beneficiaries.

BACKGROUND: Little is known about the health care experiences of American Indians and Alaska Natives (AIANs) due to limited data. OBJECTIVE: The objective of this study was to investigate the health care experiences of AIAN Medicare beneficiaries relative to non-Hispanic Whites using national survey data pooled over 5 years. SUBJECTS: A total of 1,193,248 beneficiaries who responded to the nationally representative 2012-2016 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. METHODS: Linear regression models predicted CAHPS measures from race and ethnicity. Scores on the CAHPS measures were linearly transformed to a 0-100 range and case-mix adjusted. Three AIAN groups were compared with non-Hispanic Whites: single-race AIANs (n=2491; 0.4% of the total sample), multiple-race AIANs (n=15,502; 1.3%), and Hispanic AIANs (n=2264; 0.2%). RESULTS: Among AIAN groups, single-race AIANs were most likely to live in rural areas and areas served by the Indian Health Service; Hispanic AIANs were most likely to be Spanish-language-preferring (P's<0.05). Compared with non-Hispanic Whites, single-race AIANs reported worse experiences with getting needed care (adjusted disparity of -5 points; a "large" difference), getting care quickly (-4 points; a "medium" difference), doctor communication (-2 points; a "small" difference), care coordination (-2 points), and customer service (-7 points; P<0.001 for all comparisons). Disparities were similar for Hispanic AIANs but more limited for multiple-race AIANs. CONCLUSIONS: Quality improvement efforts are needed to reduce disparities faced by older AIANs. These findings may assist in developing targeted efforts to address cultural, communication, and health system factors presumed to underlie disparities in health care access and customer service.

Medicare Beneficiaries With a Specialist as Their Personal Doctor Report Better Experiences With Care.

BACKGROUND: Health plans often require that patients have a personal doctor. Older adults rely on specialists for much of their care and may use a specialist in this role, but little is known about how many or which Medicare beneficiaries use specialists as their personal doctor and how their care experiences differ from others'. OBJECTIVE: To examine the prevalence and characteristics of Medicare beneficiaries with a specialist as a personal doctor and compare their patient experiences and immunization to other beneficiaries'. RESEARCH DESIGN: Logistic regression predicted having a specialist as a personal doctor from beneficiary characteristics. Doubly-robust models compared 7 patient experience and 2 immunization measures for beneficiaries with and without a specialist as their personal doctor. Interactions of a specialist indicator and beneficiary characteristics tested for moderators. STUDY POPULATION: A total of 227,642 Medicare beneficiaries aged 65+ who reported having a personal doctor on the 2014 Medicare CAHPS survey. RESULTS: In total, 20% of beneficiaries reported that their personal doctor was a specialist, fewer than previously reported for the most frequently visited physician (43%); beneficiaries who were older, less healthy, less educated, racial/ethnic minorities, had fee-for-service coverage, or had lower income were more likely to do so. They also reported better patient experiences than those with nonspecialist personal physicians on 6 of 7 measures and more immunizations; the largest difference was for care coordination. Having a specialist personal doctor was associated with particularly positive patient experience for low income, Black, Hispanic, and less healthy beneficiaries. CONCLUSION: Future research should investigate whether specialists as personal doctors may reduce patient-experience disparities for vulnerable patients.

Differences in Hospitalizations Between Fee-for-Service and Medicare Advantage Beneficiaries.

BACKGROUND: Previous studies found lower hospitalization rates for enrollees in Medicare Advantage (MA) plans than for beneficiaries with fee-for-service (FFS) coverage. MA enrollment is increasing, especially for those newly eligible for Medicare, but little is known about how service use in FFS or MA differs for new beneficiaries. OBJECTIVE: To compare differences in rates of hospitalization between MA and FFS. RESEARCH DESIGN: A retrospective study of hospitalization among FFS and MA respondents to the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey. Differences in hospitalization rates were assessed using multivariable logistic regression models that controlled for patient sociodemographic and health characteristics. Models included an interaction between age and coverage type to determine whether patterns of care were distinct for enrollees recently eligible for Medicare. STUDY POPULATION: In total, 259,335 respondents to the 2013 MCAHPS survey. RESULTS: In total, 14% of FFS and 12% of MA enrollees had ≥1 hospitalization in the 6 months before survey administration. Models adjusted for enrollee demographics found that MA enrollees had 0.81 the odds of being hospitalized relative to those with FFS coverage (95% confidence interval, 0.78-0.84). Differences between groups were substantially reduced and no longer statistically significant when they were fully adjusted (adjusted odds ratio 1.01, 95% confidence interval, 0.97-1.08). Models with interactions indicated no significant age differences in the MA/FFS hospitalization gap. CONCLUSION: Differences in hospital admissions between those with MA and FFS coverage appear to be primarily related to differences in health status.

A Comparison of Methods for Classifying and Modeling Respondents Who Endorse Multiple Racial/Ethnic Categories: A Health Care Experience Application.

BACKGROUND: Race/ethnicity information is vital for measuring disparities across groups, and self-report is the gold standard. Many surveys assign simplified race/ethnicity based on responses to separate questions about Hispanic ethnicity and race and instruct respondents to "check all that apply." When multiple races are endorsed, standard classification methods either create a single heterogenous multiracial group, or attempt to impute the single choice that would have been selected had only one choice been allowed. OBJECTIVES: To compare 3 options for classifying race/ethnicity: (a) hierarchical, classifying Hispanics as such regardless of racial identification, and grouping together all non-Hispanic multiracial individuals; (b) a newly proposed additive model, retaining all original endorsements plus a multiracial indicator; (c) an all-combinations approach, separately categorizing every observed combination of endorsements. RESEARCH DESIGN: Cross-sectional comparison of racial/ethnic distributions of patient experience scores; using weighted linear regression, we model patient experience by race/ethnicity using 3 classification systems. SUBJECTS: In total, 259,763 Medicare beneficiaries age 65+ who responded to the 2017 Medicare Consumer Assessments of Healthcare Providers and Systems Survey and reported race/ethnicity. MEASURES: Self-reported race/ethnicity, 4 patient experience measures. RESULTS: Additive and hierarchical models produce similar classifications for non-Hispanic single-race respondents, but differ for Hispanic and multiracial respondents. Relative to the gold standard of the all-combinations model, the additive model better captures ratings of health care experiences and response tendencies that differ by race/ethnicity than does the hierarchical model. Differences between models are smaller with more specific measures. CONCLUSIONS: Additive models of race/ethnicity may afford more useful measures of disparities in health care and other domains. Our results have particular relevance for populations with a higher prevalence of multiracial identification.

Indirect Estimation of Race/Ethnicity for Survey Respondents Who Do Not Report Race/Ethnicity.

BACKGROUND: Researchers are increasingly interested in measuring race/ethnicity, but some survey respondents skip race/ethnicity items. OBJECTIVES: The main objectives of this study were to investigate the extent to which racial/ethnic groups differ in skipping race/ethnicity survey items, the degree to which this reflects reluctance to disclose race/ethnicity, and the utility of imputing missing race/ethnicity. RESEARCH DESIGN: We applied a previously developed method for imputing race/ethnicity from administrative data (Medicare Bayesian Improved Surname and Geocoding 2.0) to data from a national survey where race/ethnicity was usually self-reported, but was sometimes missing. A linear mixed-effects regression model predicted the probability of self-reporting race/ethnicity from imputed racial/ethnic probabilities. SUBJECTS: In total, 508,497 Medicare beneficiaries responding to the 2013-2014 Medicare Consumer Assessment of Healthcare Providers and Systems surveys were included in this study. MEASURES: Self-reported race/ethnicity and estimated racial/ethnic probabilities. RESULTS: Black beneficiaries were most likely to not self-report their race/ethnicity (6.6%), followed by Hispanic (4.7%) and Asian/Pacific Islander (4.7%) beneficiaries. Non-Hispanic whites were the least likely to skip these items (3.2%). The 3.7% overall rate of missingness is similar to adjacent demographic items. General patterns of item missingness rather than a specific reluctance to disclose race/ethnicity appears to explain the elevated rate of missing race/ethnicity among Asian/Pacific Islander and Hispanic beneficiaries and most but not all among Black beneficiaries. Adding imputed cases to the data set did not substantially alter the estimated overall racial/ethnic distribution, but it did modestly increase sample size and statistical power. CONCLUSIONS: It may be worthwhile to impute race/ethnicity when this information is unavailable in survey data sets due to item nonresponse, especially when missingness is high.

Speaking Up and Walking Out: Are Vulnerable Patients Less Likely to Disagree With or Change Doctors?

BACKGROUND: Disparities in clinical process-of-care and patient experiences are well documented for Medicare beneficiaries with ≥1 social risk factors. If such patients are less willing to express disagreement with their doctors or change doctors when dissatisfied, these behaviors may play a role in observed disparities. OBJECTIVE: To investigate the association between social risk factors and self-reported likelihood of disagreeing with or changing doctors if dissatisfied among the Medicare fee-for-service population. SUBJECTS: Fee-for-service beneficiaries (N=96,317) who responded to the 2014 Medicare Consumer Assessment of Healthcare Providers and Systems survey. Subgroups were defined based on age, education, income, and race/ethnicity. METHODS: Respondents reported how likely they would be to express disagreement with their doctors and change doctors if dissatisfied (1=very unlikely to 4=very likely; rescaled to 0-100 points). We fit mixed-effect linear regression models predicting these outcomes from social risk factors, controlling for health status and geographic location. RESULTS: Beneficiaries who were older, less educated, and had lower incomes were least inclined to express disagreement or change doctors (P<0.001). Compared with non-Hispanic whites, Asian/Pacific Islander (-9.5) and Hispanic (-3.6) beneficiaries said they would be less likely, and black (+2.8) beneficiaries more likely, to express disagreement. Asian/Pacific Islander (-8.7), Hispanic (-5.9), and American Indian/Alaska Native (-3.8) beneficiaries were less inclined than non-Hispanic whites to change doctors (P<0.01). DISCUSSION: Reduction in health care disparities may be achieved if doctors and advocates encourage vulnerable patients to express their concerns and perspectives and if communities and caregivers provide support for changing providers when care is poor.

Care Experiences Among Medicare Beneficiaries With and Without a Personal Physician.

BACKGROUND: Having a "personal" physician is a critical element to care continuity. Little is known about which older adults are more likely to lack personal physicians and if their care experiences differ from those with a personal physician. OBJECTIVE: The objective of this study was to describe care experiences and characteristics associated with not having a personal physician. RESEARCH DESIGN: We compare rates of lacking a personal physician across subgroups. Using doubly robust propensity-score-weighted regression, we compare patient experience among beneficiaries with and without a personal physician. SUBJECTS: A total of 272,463 nationally representative beneficiaries age 65+ responding to the 2012 Medicare CAHPS survey. MEASURES: Beneficiary characteristics, having a personal physician, 4 patient experience measures. RESULTS: Five percent of respondents reported no personal physician. Lacking a personal physician was more common for men, racial/ethnic minorities (eg, 16% of American Indian/Alaska Natives), and the younger and less educated. Those without a personal physician reported substantially poorer experiences on 4 measures (P<0.001); these differences are larger than those observed by key demographic characteristics. Beneficiaries without a personal physician were more than 3 times as likely to have not seen any health care provider in the last 6 months. CONCLUSIONS: Even with the access provided by Medicare, a small but nontrivial proportion of seniors report having no personal physician. Those without a personal physician report substantially worse patient experiences and lacking a personal physician is more common for some vulnerable groups. This may underlie some previously observed disparities. Efforts should be made to encourage and help seniors without personal physicians to select one.

How Do Gender Differences in Quality of Care Vary Across Medicare Advantage Plans?

BACKGROUND: Healthcare Effectiveness Data and Information Set (HEDIS) quality measures have long been used to compare care across health plans and to study racial/ethnic and socioeconomic disparities among Medicare Advantage (MA) beneficiaries. However, possible gender differences in seniors' quality of care have received less attention. OBJECTIVE: To test for the presence and nature of any gender differences in quality of care across MA Plans, overall and by domain; to identify those most at risk of poor care. DESIGN: Cross-sectional analysis of individual-level HEDIS measure scores from 23.8 million records using binomial mixed-effect models to estimate the effect of gender on performance. For each measure, we assess variation in gender gaps and their correlation with plan performance. PARTICIPANTS: Beneficiaries from 456 MA plans in 2011-2012 HEDIS data. MAIN MEASURES: Performance on 32 of 34 HEDIS measures which were available in both measurement years. The two excluded measures had mean performance scores below 10%. KEY RESULTS: Women experienced better quality of care than men for 22/32 measures, with most pertaining to screening or treatment. Men experienced better quality on nine measures, including four related to cardiovascular disease and three to potentially harmful drug-disease interactions. Plans varied substantially in the magnitude of gender gaps for 21/32 measures; in general, the gender gap in quality of care was least favorable to men in low-performing plans. CONCLUSIONS: Women generally experienced better quality of care than men. However, women experienced poorer care for cardiovascular disease-related intermediate outcomes and potentially harmful drug-disease interactions. Quality improvement may be especially important for men in low-performing plans and for cardiovascular-related care and drug-disease interactions for women. Gender-stratified reporting could reveal gender gaps, identify plans for which care varies by gender, and motivate efforts to address faults and close the gaps in the delivery system.

Mean Streets and Mental Health: Depression and Post-Traumatic Stress Disorder at Crime Hot Spots.

This study explores the relationship between mental health and place at microgeographic units of analysis. We examine self-reported symptomology for depression and PTSD for 2,724 survey respondents interviewed in three types of randomly selected street segments: violent crime hot spots, cool spots, and cold spots. We find that the mean symptomology score is 61% higher for depression in violent crime hot spots than cold spots, and 85% higher for PTSD. Overall, we estimate that 14.8% of residents of violent crime hot spots meet thresholds for moderate depression or a diagnosis of PTSD. This can be compared to only 6.5% of residents at the cold spots. Using PSM and weighted negative binomial regression approaches we show that observable selection factors are not responsible for the relationships identified. Examining geographic influences, we find an important area effect of violent crime for both mental health measures, and an additional impact of the specific street of residence for PTSD.

What Matters Most to Whom: Racial, Ethnic, and Language Differences in the Health Care Experiences Most Important to Patients.

BACKGROUND: Some aspects of patient experience are more strongly related to overall ratings of care than others, reflecting their importance to patients. However, little is known about whether the importance of different aspects of this experience differs across subgroups. OBJECTIVES: To determine whether the aspects of health care most important to patients differ according to patient race, ethnicity, and language preference. RESEARCH DESIGN: In response to the 2013 Medicare Consumer Assessment of Health Plans Study (CAHPS) survey, patients rated their overall health care and completed items measuring five patient experience domains. We estimated a linear regression model to assess associations between overall rating of care and the 5 domains, testing for differences in these relationships for race/ethnicity/language groups, controlling for covariates. SUBJECTS: In total 242,782 Medicare beneficiaries, age 65 years or older. MEASURES: Overall rating of health care, composite patient experience scores for: doctor communication, getting needed care, getting care quickly, customer service, and care coordination. RESULTS: A joint test of the interactions between the composite scores and the 5 largest racial/ethnic/language subgroups was statistically significant (P <0.0001), suggesting the importance of domains varied across subgroups. Doctor communication had the strongest relationship with care ratings for non-Hispanic whites and English-preferring Hispanics. Getting needed care had the strongest relationship for Spanish-preferring Hispanics and Asian/Pacific Islanders. Doctor communication and getting care quickly were strongest for African Americans. CONCLUSIONS: Tailoring quality improvement programs to the factors most important to the racial, ethnic, and language mix of the patient population of the practice, hospital, or plan may more efficiently reduce disparities and improve quality.

Clinician advice to quit smoking among seniors.

OBJECTIVE: Little smoking research in the past 20years includes persons 50 and older; herein we describe patterns of clinician cessation advice to US seniors, including variation by Medicare beneficiary characteristics. METHOD: In 2012-4, we analyzed 2010 Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data from Medicare beneficiaries over age 64 (n=346,674). We estimated smoking rates and the proportion of smokers whose clinicians encouraged cessation. RESULTS: 12% of male and 8% of female respondents aged 65 and older smoke. The rate decreases with age (14% of 65-69, 3% of 85+) and education (12-15% with no high school degree, 5-6% with BA+). Rates are highest among American Indian/Alaskan Native (16%), multiracial (14%), and African-American (13%) seniors, and in the Southeast (14%). Only 51% of smokers say they receive cessation advice "always" or "usually" at doctor visits, with advice more often given to the young, those in low-smoking regions, Asians, and women. For all results cited p<0.05. CONCLUSIONS: Smoking cessation advice to seniors is variable. Providers may focus on groups or areas in which smoking is less common or when they are most comfortable giving advice. More consistent interventions are needed, including cessation advice from clinicians.

Which medicare advantage enrollees are at highest one-year mortality risk?

BACKGROUND: While a number of tools exist to predict mortality among older adults, less research has described the characteristics of Medicare Advantage (MA) enrollees at higher risk for 1 year mortality. OBJECTIVES: To describe the characteristics of MA enrollees at higher mortality risk using patient survey data. RESEARCH DESIGN: Retrospective cohort. SUBJECTS: MA enrollees completing the 2019 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. MEASURES: Linked demographic, health, and mortality data from a sample of MA enrollees were used to predict 1-year mortality risk and describe enrollee characteristics across levels of predicted mortality risk. RESULTS: The mortality model had a 0.80 c-statistic. Mortality risks were skewed: 6 % of enrollees had a ≥ 10 % 1-year mortality risk, while 45 % of enrollees had 1 % to < 5 % 1-year mortality risk. Among the high-risk (≥10 %) group, 47 % were age 85+ versus 12 % among those with mortality risk <5 %. 79 % were in fair or poor self-rated health versus 29 % among those with mortality risk of <5 %. 71 % reported needing urgent care in the prior 6 months versus 40 % among those with a mortality risk of 1 to<5 %. CONCLUSIONS: Relatively few older adults enrolled in MA are at high 1-year mortality risk. Nonetheless, MA enrollees over age 85, in fair or poor health, or with recent urgent care needs are far more likely to be in a high mortality risk group.

Comparing HEDIS performance of Dual Eligible Special Needs Plans with other coverage types for dually eligible people.

People eligible for both Medicare and Medicaid coverage ("dually eligible individuals") have lower levels of income and assets and often higher health care needs and costs than those eligible for Medicare but not Medicaid coverage. Their 3 most common Medicare coverage options are Medicare Advantage (MA) Dual Eligible Special Needs Plans (D-SNPs), non-D-SNP MA plans, and fee-for-service (FFS) Medicare with a stand-alone prescription drug plan. No prior study has examined clinical quality of care for dually eligible individuals across these 3 coverage types. To fill that void, we used logistic regression to compare these coverage types on 6 HEDIS measures of clinical quality of care that were available for both MA and FFS (constructed from claims files). D-SNPs and non-D-SNP MA plans significantly outperformed FFS for all 6 measures for dually eligible individuals, by approximately 5 percentage points for 2 measures and by 18-34 percentage points for the other 4 measures. For the 4 measures with the greatest advantage over FFS, performance was 3-8 percentage points higher in D-SNPs than in non-D-SNP MA plans.

Experiences of care among Medicare beneficiaries with ESRD: Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results.

BACKGROUND: Patients with end-stage renal disease (ESRD) have special health needs; little is known about their care experiences. STUDY DESIGN: Secondary analysis of 2009-2010 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) data, using representative random samples of Medicare beneficiaries. Description of Medicare beneficiaries with ESRD and investigation of differences in patient experiences by sociodemographic characteristics and coverage type. SETTING & PARTICIPANTS: Data were collected from 823,564 Medicare beneficiaries (3,794 with ESRD) as part of the Medicare CAHPS survey, administered by mail with telephone follow-up of nonrespondents. PREDICTOR: ESRD status, age, education, self-reported general and mental health status, race/ethnicity, sex, Medicare coverage type, state of residence, and other demographic measures. OUTCOMES: 6 composite measures of patient experience in 4 care domains (access to care, physician communication, customer service, and access to prescription drugs and drug information) and 4 ratings (overall care, personal physician, specialist physician, and prescription drug plan). RESULTS: Patients with ESRD reported better care experiences than non-ESRD beneficiaries for 7 of 10 measures (P < 0.05) after adjustment for patient characteristics, geography, and coverage type, although to only a small extent (adjusted mean difference, <3 points [scale, 0-100]). Black patients with ESRD and less educated patients were more likely than other patients with ESRD to report poor experiences. LIMITATIONS: Inability to distinguish patient experiences of care for different treatment modalities. CONCLUSIONS: On average, beneficiaries with ESRD report patient experiences that are at least as positive as non-ESRD beneficiaries. However, black and less educated patients with ESRD reported worse experiences than other ESRD patients. Stratified reporting of patient experience by race/ethnicity or education in patients with ESRD can be used to monitor this disparity. Physician choice and confidence and trust in physicians may be particularly important for patients with ESRD.