The Impact of Adherence to Clinical Practice Guidelines on Medical Costs.

OBJECTIVE: To examine the association between non-adherence to clinical practice guidelines (CPGs) and medical and indemnity spending among back and shoulder injury patients. METHODS: Workers compensation claims data was used from a large, US insurer (1999 to 2010). Least square regression models were created to examine the association between spending and guideline-discordant care. RESULTS: Non-adherence to CPGs was associated with higher medical and indemnity spending for 11 of the 28 CPG indicators. Failure to adhere to the other CPGs did not increase medical or total spending. After covariate adjustment, non-adherence to these 11 CPGs was associated with spending increases that ranged from $16,000 for physical therapy (PT) to $114,000 for surgery. CONCLUSIONS: Our results demonstrate that failure to adhere to a subset of CPG indicators significantly predicts increased medical and indemnity spending for two important occupational injuries.

Dental, Vision, And Hearing Services: Access, Spending, And Coverage For Medicare Beneficiaries.

Among Medicare beneficiaries, dental, vision, and hearing services could be characterized as high need, high cost, and low use. While Medicare does not cover most of these services, coverage has increased recently as a result of changes in state Medicaid programs and increased enrollment in Medicare Advantage (MA) plans, many of which offer these services as supplemental benefits. Using data from the 2016 Medicare Current Beneficiary Survey, this analysis shows that MA plans are filling an important gap in dental, vision, and hearing coverage, particularly among low- and middle-income beneficiaries. In 2016 only 21 percent of beneficiaries in traditional Medicare had purchased a stand-alone dental plan, whereas 62 percent of MA enrollees were in plans with a dental benefit. Among Medicare beneficiaries with coverage overall, out-of-pocket expenses still made up 70 percent of dental spending, 62 percent of vision spending, and 79 percent of hearing spending. While Medicare beneficiaries are enrolling in private coverage options, they are not getting adequate financial protection. This article examines these findings in the context of recent proposals in Congress to expand Medicare coverage of dental, vision, and hearing services.

Complex Patients and Quality of Care in Medicare Advantage.

OBJECTIVES: New federal policies aim to focus Medicare Advantage (MA) plans on the needs of individuals with complex health conditions. Our objective was to examine enrollment patterns of MA beneficiaries with complex needs and the association of enrollment patterns with MA plan performance. DESIGN: Cross-sectional study. SETTING: The 2015 Medicare Health Outcome Survey baseline survey. PARTICIPANTS: A total of 273 336 MA beneficiaries enrolled in 467 MA plans who lived in the community. MEASUREMENTS: Complex patients included individuals 65 years and older with multiple self-reported chronic conditions and functional limitations and all patients with disabilities younger than 65 years. Outcomes included 27 performance measures reported under the 5-Star Part C Star Rating. Linear probability regression was used to examine the association of concentration of complex patients and performance measures. RESULTS: Most complex patients were enrolled in general MA plans. Concentration of complex patients ranged from 25.9% in MA contracts in the lowest quintile to 68.9% in the top quintile. MA contract performance scores generally decreased as the concentration of complex patients increased. After adjusting for contract and enrollee characteristics, MA contracts with more complex patients performed less well on half of the Part C performance measures including patient experience, preventive care, and chronic care measures. CONCLUSION: MA contracts with a high concentration of complex patients have lower performance scores on more than half of Part C measures. Further study is needed to understand whether these performance measures are capturing the delivery of poor care, deficiencies in the health plan's care systems, or whether some measures may not be appropriate for complex patients. J Am Geriatr Soc 68:395-402, 2020.

Targeting High-Need Beneficiaries in Medicare Advantage: Opportunities to Address Medical and Social Needs.

Issue: Serving Medicare beneficiaries with complex health care needs requires understanding both the medical and social factors that may affect their health. Goal: Describe the prevalence and characteristics of high-need individuals enrolled in the Medicare Advantage program. Methods: Analysis of the 2015 Medicare Health Outcomes Survey. Key Findings: Thirty-seven percent of enrollees in large Medicare Advantage plans have high needs, requiring both medical and social services. Individuals with high needs are more likely to report having limited financial resources, low levels of education, social isolation, and poor health. Conclusion: Federal policymakers should consider allowing Medicare Advantage plans to identify high-need beneficiaries based on their medical and social risk factors, rather than just medical diagnoses. Doing so would enable plans to deliver better-targeted services that meet their members' needs and facilitate implementation of the CHRONIC Care Act provision that allows plans to offer nonhealth supplemental benefits.

Neighborhood disadvantage and chronic disease management.

OBJECTIVE: To assess the relationship between a composite measure of neighborhood disadvantage, the Area Deprivation Index (ADI), and control of blood pressure, diabetes, and cholesterol in the Medicare Advantage (MA) population. DATA SOURCES: Secondary analysis of 2013 Medicare Healthcare Effectiveness Data and Information Set, Medicare enrollment data, and a neighborhood disadvantage indicator. STUDY DESIGN: We tested the association of neighborhood disadvantage with intermediate health outcomes. Generalized estimating equations were used to adjust for geographic and individual factors including region, sex, race/ethnicity, dual eligibility, disability, and rurality. DATA COLLECTION: Data were linked by ZIP+4, representing compact geographic areas that can be linked to Census block groups. PRINCIPAL FINDINGS: Compared with enrollees residing in the least disadvantaged neighborhoods, enrollees in the most disadvantaged neighborhoods were 5 percentage points (P < 0.05) less likely to have controlled blood pressure, 6.9 percentage points (P < 0.05) less likely to have controlled diabetes, and 9.9 percentage points (P < 0.05) less likely to have controlled cholesterol. Adjustment attenuated this relationship, but the association remained. CONCLUSIONS: The ADI is a strong, independent predictor of diabetes and cholesterol control, a moderate predictor of blood pressure control, and could be used to track neighborhood-level disparities and to target disparities-focused interventions in the MA population.

Impact Of Risk Adjustment For Socioeconomic Status On Medicare Advantage Plan Quality Rankings.

Sociodemographically disadvantaged patients have worse outcomes on some quality measures that inform Medicare Advantage plan ratings. Performance measurement that does not adjust for sociodemographic factors may penalize plans that disproportionately serve disadvantaged populations. We assessed the impact of adjusting for socioeconomic and demographic factors (sex, race/ethnicity, dual eligibility, disability, rurality, and neighborhood disadvantage) on Medicare Advantage plan rankings for blood pressure, diabetes, and cholesterol control. After adjustment, 20.3 percent, 19.5 percent, and 11.4 percent of Medicare Advantage plans improved by one or more quintiles in rank on the diabetes, cholesterol, and blood pressure measures, respectively. Plans that improved in ranking after adjustment enrolled higher proportions of disadvantaged enrollees. Adjusting quality measures for socioeconomic factors is important for equitable payment and quality reporting. Our study suggests that plans serving disadvantaged populations would have improved relative rankings for three important outcome measures if socioeconomic factors were included in risk-adjustment models.

Geographic Variations in Physician Relationships Over Time: Implications for Care Coordination.

Care coordination may be more challenging when the specific physicians with whom primary care physicians (PCPs) are expected to coordinate care change over time. Using Medicare data on physician patient-sharing relationships and the Dartmouth Atlas, we explored the extent to which PCPs tend to share patients with other physicians over time. We found that 70.7% of ties between PCPs and other physicians that were present in 2012 persisted in 2013, and additional shared patients in 2012 increased the odds of being connected in 2013. Regions with higher persistent ties tended to have lower rates of emergency room visits, and regions where PCPs had more physician connections were more likely to have higher emergency room visits. The results point to potential opportunities and challenges faced by health care reforms that seek to improve coordination.

Can Claims Data Algorithms Identify the Physician of Record?

BACKGROUND: Claims-based algorithms based on administrative claims data are frequently used to identify an individual's primary care physician (PCP). The validity of these algorithms in the US Medicare population has not been assessed. OBJECTIVE: To determine the agreement of the PCP identified by claims algorithms with the PCP of record in electronic health record data. DATA: Electronic health record and Medicare claims data from older adults with diabetes. SUBJECTS: Medicare fee-for-service beneficiaries with diabetes (N=3658) ages 65 years and older as of January 1, 2008, and medically housed at a large academic health system. MEASURES: Assignment algorithms based on the plurality and majority of visits and tie breakers determined by either last visit, cost, or time from first to last visit. RESULTS: The study sample included 15,624 patient-years from 3658 older adults with diabetes. Agreement was higher for algorithms based on primary care visits (range, 78.0% for majority match without a tie breaker to 85.9% for majority match with the longest time from first to last visit) than for claims to all visits (range, 25.4% for majority match without a tie breaker to 63.3% for majority match with the amount billed tie breaker). Percent agreement was lower for nonwhite individuals, those enrolled in Medicaid, individuals experiencing a PCP change, and those with >10 physician visits. CONCLUSIONS: Researchers may be more likely to identify a patient's PCP when focusing on primary care visits only; however, these algorithms perform less well among vulnerable populations and those experiencing fragmented care.

Continuity of Care in Older Adults With Multiple Chronic Conditions: How Well Do Administrative Measures Correspond With Patient Experiences?

Continuity of care (COC) is a fundamental component of primary care and particularly important to older adults who are managing multiple chronic conditions. Administrative measures of continuity are often used to evaluate care coordination interventions, but it is not known whether administrative continuity are correlated with patient reports of continuity among older adults with multiple chronic conditions (MCCs). The objective of this study is to assess the concordance of administrative continuity indices and patient reports of continuity among older adults with MCCs. We use patient survey data collected from July to October 2011 linked to administrative claims data collected from July 2010 to December 2011 for 710 Medicare Advantage Chronic Care Special Needs Plan beneficiaries living in the US South. Among older adults with two or more conditions, the Usual Provider of Care Index was not associated with any patient experience measure; COC Index was associated with informational and management continuity items. These findings suggest that among older adults with MCCs, the administrative continuity measures have limited concordance with patient reported continuity measures.

Differences in Receipt of Three Preventive Health Care Services by Race/Ethnicity in Medicare Advantage Plans: Tracking the Impact of Pay for Performance, 2010 and 2013.

INTRODUCTION: In 2012, the Centers for Medicare and Medicaid Services (CMS) introduced the Quality Bonus Payment Demonstration, a pay-for-performance (P4P) program, into Medicare Advantage plans. Previous studies documented racial/ethnic disparities in receipt of care among participants in these plans. The objective of this study was to determine whether P4P incentives have affected these disparities in Medicare Advantage plans. METHODS: We studied 411 Medicare Advantage health plans that participated in the Medicare Health Outcome Survey in 2010 and 2013. Preventive health care was defined as self-reported receipt of health care provider communication or treatment to reduce risk of falling, improve bladder control, and monitor physical activity among individuals reporting these problems. Logistic regression stratified by health care plan was used to examine racial/ethnic disparities in receipt of preventive health care before and after the introduction of the P4P program in 2012. RESULTS: We found similar racial/ethnic differences in receipt of preventive health care before and after the introduction of P4P. Blacks and Asians were less likely than whites to receive advice to improve bladder control and more likely to receive advice to reduce risk of falling and improve physical activity. Hispanics were more likely to report receiving advice about all 3 health issues than whites. After the introduction of P4P, the gap decreased between Hispanics and whites for improving bladder control and monitoring physical activity and increased between blacks and whites for monitoring physical activity. CONCLUSION: Racial/ethnic differences in receipt of preventive health care are not always in the expected direction. CMS should consider developing a separate measure of equity in preventive health care services to encourage health plans to reduce gaps among racial/ethnic groups in receiving preventive care services.

Comparing Prognostic Tools for Cancer Screening: Considerations for Clinical Practice and Performance Assessment.

OBJECTIVES: To compare the agreement and rates of cancer screening using four prognostic tools that require different types of clinical information. DESIGN: Observational retrospective cohort study. SETTING: 2009 and 2010 waves of the Medicare Current Beneficiary Survey. PARTICIPANTS: Adults aged 66-90 with survey and claims data (N = 9,469). MEASUREMENTS: Agreement between four indices predicting short-term (4-5 years) and long-term (9-10 years) survival; self-reported breast and prostate cancer screening. RESULTS: Agreement between the four prognostic tools was high. Pearson correlation coefficients ranged from 0.63 to 0.90 for short-term survival and 0.68 to 0.94 for long-term survival. When defining limited short-term life expectancy as less than 25% chance of surviving 4 or 5 years, all four tools agreed in 96.4% of the sample. All four tools agreed in their placement of participants into limited or not-limited long-term life expectancy in 77.1% of participants (<25% chance of surviving 9 or 10 years). Rates of cancer screening were similarly high in individuals with limited long-term life expectancy regardless of the tool used: greater than 31% for mammographic screening in women and greater than 69% for prostate cancer screening. CONCLUSION: There is substantial agreement among different prognostic tools for short- and long-term survival in Medicare beneficiaries. The high rates of cancer screening of individuals with limited life expectancy suggest the importance of incorporating tools into clinical decision-making.

Evaluating Clinical Practice Guidelines Based on Their Association with Return to Work in Administrative Claims Data.

OBJECTIVE: To examine the association between non-adherence to clinical practice guidelines (CPGs) and time to return to work (RTW) for patients with workplace injuries. DATA SOURCES/STUDY SETTING: Secondary analysis of medical billing and disability data for 148,199 for shoulder and back injuries from a workers' compensation insurer. STUDY DESIGN: Cox proportional hazard regression is used to estimate the association between time to RTW and receipt of guideline-discordant care. We test the robustness of our findings to an omitted confounding variable. DATA COLLECTION: Collected by the insurer from the time an injury was reported, through recovery or last follow-up. PRINCIPAL FINDINGS: Receiving guideline-discordant care was associated with slower RTW for only some guidelines. Early receipt of care, and getting less than the recommended amount of care, were correlated with faster RTW. Excessive physical therapy, bracing, and injections were associated with slower RTW. CONCLUSIONS: There is not a consistent relationship between performance on CPGs and RTW. The association between performance on CPG and RTW is difficult to measure in observational data, because analysts cannot control for omitted variables that affect a patient's treatment and outcomes. CPGs supported by observational studies or randomized trials may have a more certain relationship to health outcomes.

Physician social networks and variation in rates of complications after radical prostatectomy.

OBJECTIVES: Variation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks-as defined by shared patients-are associated with rates of complications after radical prostatectomy. METHODS: In five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure-along with specific characteristics of the network subgroups-was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume. RESULTS: Networks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics-average urologist centrality and patient racial composition-were significantly associated with rates of surgical complications. CONCLUSIONS: Analysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.

Multiple chronic conditions and life expectancy: a life table analysis.

BACKGROUND: The number of people living with multiple chronic conditions is increasing, but we know little about the impact of multimorbidity on life expectancy. OBJECTIVE: We analyze life expectancy in Medicare beneficiaries by number of chronic conditions. RESEARCH DESIGN: A retrospective cohort study using single-decrement period life tables. SUBJECTS: Medicare fee-for-service beneficiaries (N=1,372,272) aged 67 and older as of January 1, 2008. MEASURES: Our primary outcome measure is life expectancy. We categorize study subjects by sex, race, selected chronic conditions (heart disease, cancer, chronic obstructive pulmonary disease, stroke, and Alzheimer disease), and number of comorbid conditions. Comorbidity was measured as a count of conditions collected by Chronic Conditions Warehouse and the Charlson Comorbidity Index. RESULTS: Life expectancy decreases with each additional chronic condition. A 67-year-old individual with no chronic conditions will live on average 22.6 additional years. A 67-year-old individual with 5 chronic conditions and ≥10 chronic conditions will live 7.7 fewer years and 17.6 fewer years, respectively. The average marginal decline in life expectancy is 1.8 years with each additional chronic condition-ranging from 0.4 fewer years with the first condition to 2.6 fewer years with the sixth condition. These results are consistent by sex and race. We observe differences in life expectancy by selected conditions at 67, but these differences diminish with age and increasing numbers of comorbid conditions. CONCLUSIONS: Social Security and Medicare actuaries should account for the growing number of beneficiaries with multiple chronic conditions when determining population projections and trust fund solvency.

Building blocks for measuring care coordination with claims data.

Tools to measure care coordination are needed to evaluate federal, state, and private sector efforts encouraging coordination to improve health outcomes and contain costs. Administrative data are a rich source of data for studying the use of medical services, thus allowing for measurement of patient level, provider level, and system measures of care coordination. Based on a review the literature and input from an expert panel, this article describes 4 key components-building blocks-of care coordination and corresponding measures. These building blocks should have utility across clinical conditions. They may be used to test hypotheses about the impact of coordinated care on medication utilization, adherence to medications, and clinical outcomes.

Generalizing observational study results: applying propensity score methods to complex surveys.

OBJECTIVE: To provide a tutorial for using propensity score methods with complex survey data. DATA SOURCES: Simulated data and the 2008 Medical Expenditure Panel Survey. STUDY DESIGN: Using simulation, we compared the following methods for estimating the treatment effect: a naïve estimate (ignoring both survey weights and propensity scores), survey weighting, propensity score methods (nearest neighbor matching, weighting, and subclassification), and propensity score methods in combination with survey weighting. Methods are compared in terms of bias and 95 percent confidence interval coverage. In Example 2, we used these methods to estimate the effect on health care spending of having a generalist versus a specialist as a usual source of care. PRINCIPAL FINDINGS: In general, combining a propensity score method and survey weighting is necessary to achieve unbiased treatment effect estimates that are generalizable to the original survey target population. CONCLUSIONS: Propensity score methods are an essential tool for addressing confounding in observational studies. Ignoring survey weights may lead to results that are not generalizable to the survey target population. This paper clarifies the appropriate inferences for different propensity score methods and suggests guidelines for selecting an appropriate propensity score method based on a researcher's goal.

Setting standards at the forefront of delivery system reform: aligning care coordination quality measures for multiple chronic conditions.

The primary study objective is to assess how three major health reform care coordination initiatives (Accountable Care Organizations, Independence at Home, and Community-Based Care Transitions) measure concepts critical to care coordination for people with multiple chronic conditions. We find that there are major differences in quality measurement across these three large and politically important programs. Quality measures currently used or proposed for these new health reform-related programs addressing care coordination primarily capture continuity of care. Other key areas of care coordination, such as care transitions, patient-centeredness, and cross-cutting care across multiple conditions are infrequently addressed. The lack of a comprehensive and consistent measure set for care coordination will pose challenges for healthcare providers and policy makers who seek, respectively, to provide and reward well-coordinated care. In addition, this heterogeneity in measuring care coordination quality will generate new information, but will inhibit comparisons between these care coordination programs.

A decomposition analysis of medical expenditure growth among injured workers.

The factors driving the rapid increase in US medical spending are a concern for both policymakers and payers. This article analyzes variation in spending growth rates for a large sample of persons with workplace injuries. We analyze trends by type and age of injury, and by type of provider. Medical spending growth ranged from 2 percent to 12 percent for different injuries, and 3 percent to 16 percent across different types of providers. We decomposed spending growth into price, volume, and service intensity growth rates. Service intensity accounts for 20 percent of overall expenditure growth, but is a particularly large and variable contributor to spending growth in inpatient services, ranging from 35 percent to 73 percent of total spending growth among the four most prevalent injuries we studied. Efforts to forecast spending, and to design policies that manage spending growth, should account for heterogeneous trends across patients and providers.