Facilitators and barriers to optimal preventive service use among providers and older patients.

Preventive service use remains low among Medicare beneficiaries despite the Affordable Care Act's waiver of coinsurance. This study sought to understand barriers and facilitators to preventive service provision, access, and uptake. We used a mixed methods approach synthesizing quantitative survey and qualitative focus group data. Self-reported utilization of and factors related to preventive services were explored using quantitative data from the 2012 Medicare Current Beneficiary Survey. Qualitative data from 16 focus groups conducted in 2016 with a range of providers, health advocates, and Medicare beneficiaries explored perspectives on preventive service use. Providers indicated time and competing priorities as factors for not offering patients a full range of preventive services, while beneficiaries reported barriers related to knowledge, perception, and trust. Current healthcare reform efforts incorporating team-based care, nurses and other non-physician providers, and coordinated electronic health records could support enhanced use of preventive services if fully implemented and utilized.

Use of Welcome to Medicare Visits Among Older Adults Following the Affordable Care Act.

INTRODUCTION: To encourage greater utilization of preventive services among Medicare beneficiaries, the 2010 Affordable Care Act waived coinsurance for the Welcome to Medicare visit, making this benefit free starting in 2011. The objective of this study was to determine the impact of the Affordable Care Act on Welcome to Medicare visit utilization. METHODS: A 5% sample of newly enrolled fee-for-service Medicare beneficiaries for 2005-2016 was used to estimate changes in Welcome to Medicare visit use over time. An interrupted time series model examined whether Welcome to Medicare visits increased significantly after 2011, controlling for pre-intervention trends and other autocorrelation. RESULTS: Annual Welcome to Medicare visit rates began at 1.4% in 2005 and increased to 12.3% by 2016. The quarterly Welcome to Medicare visit rate, which was almost 1% at baseline, was increasing by 0.06% before the 2011 Affordable Care Act provision (p<0.001). Immediately following the 2011 Affordable Care Act provision, the rate increased by about 1% in the first quarter of 2011 (intercept, p<0.001), followed by an increase of 0.13% every subsequent quarter (slope, p<0.001). This general trend was observed in subgroup analyses, although this trend varied by subgroups where the pre-Affordable Care Act trends of lower utilization persisted over time for non-whites and improved less quickly for men, regions other than Northeast, and beneficiaries without any supplemental insurance. CONCLUSIONS: The Affordable Care Act, and perhaps the removal of cost sharing, was associated with increased use of the Welcome to Medicare visit; however, even with the increased use, there is room for improvement.

Design Challenges of an Episode-Based Payment Model in Oncology: The Centers for Medicare & Medicaid Services Oncology Care Model.

The Centers for Medicare & Medicaid Services developed the Oncology Care Model as an episode-based payment model to encourage participating practitioners to provide higher-quality, better-coordinated care at a lower cost to the nearly three-quarter million fee-for-service Medicare beneficiaries with cancer who receive chemotherapy each year. Episode payment models can be complex. They combine into a single benchmark price all payments for services during an episode of illness, many of which may be delivered at different times by different providers in different locations. Policy and technical decisions include the definition of the episode, including its initiation, duration, and included services; the identification of beneficiaries included in the model; and beneficiary attribution to practitioners with overall responsibility for managing their care. In addition, the calculation and risk adjustment of benchmark episode prices for the bundle of services must reflect geographic cost variations and diverse patient populations, including varying disease subtypes, medical comorbidities, changes in standards of care over time, the adoption of expensive new drugs (especially in oncology), as well as diverse practice patterns. Other steps include timely monitoring and intervention as needed to avoid shifting the attribution of beneficiaries on the basis of their expected episode expenditures as well as to ensure the provision of necessary medical services and the development of a meaningful link to quality measurement and improvement through the episode-based payment methodology. The complex and diverse nature of oncology business relationships and the specific rules and requirements of Medicare payment systems for different types of providers intensify these issues. The Centers for Medicare & Medicaid Services believes that by sharing its approach to addressing these decisions and challenges, it may facilitate greater understanding of the model within the oncology community and provide insight to others considering the development of episode-based payment models in the commercial or government sectors.

One-Year Outcomes of Diabetes Self-Management Training Among Medicare Beneficiaries Newly Diagnosed With Diabetes.

BACKGROUND: Diabetes is highly prevalent among Medicare beneficiaries, resulting in costly health care utilization. Strategies to improve health outcomes, such as disease self-management, could help reduce the increasing burden of diabetes. OBJECTIVES: Short-term benefits of diabetes self-management training (DSMT) are established; however, longer-term impacts among Medicare beneficiaries are unknown. RESEARCH DESIGN: Claims-based observational study with 1-year follow-up beginning 6 months after diabetes diagnosis. SUBJECTS: Twenty percent random sample of Medicare beneficiaries newly diagnosed with diabetes during 2009-2011 who used DSMT (N=14,680), matched to a nonuser comparison group. MEASURES: We compared health service utilization and costs between DSMT users and nonusers. Health service utilization included any utilization of the hospital or emergency department (ED) and any hospitalizations due to diabetes-related ambulatory care sensitive conditions as well as the number of hospitalizations and ED visits within the follow-up year. Costs included all Medicare Parts A and B expenditures. RESULTS: Multivariate regression results found that DSMT users had 14% reduced odds of any hospitalization, lower numbers of hospitalizations and ED visits (approximately 3 fewer per 100 for each), and approximately $830 lower Medicare expenditures (95% CI, -$1198, -$470) compared with nonusers. Odds of any hospitalization due to diabetes-related ambulatory care sensitive conditions and any ED visit were lower for DSMT users compared with nonusers, but the reductions were not statistically significant. CONCLUSIONS: Findings demonstrate benefits from DSMT use, including lower health service utilization and costs. The low cost of DSMT relative to the reduction in Medicare expenditures highlights an opportunity to reduce the burden of diabetes on both individuals and the health care system.

Association of Practice-Level Hospital Use With End-of-Life Outcomes, Readmission, and Weekend Hospitalization Among Medicare Beneficiaries With Cancer.

PURPOSE: To determine the relationships between hospital use of treating oncology practices and patient outcomes. PATIENTS AND METHODS: Retrospective analysis of 397,646 Medicare beneficiaries who received anticancer therapy in 2012. Each beneficiary was associated with a practice; practices were ranked on the basis of risk-adjusted hospital use, that is, inpatient intensity. Outcomes included 30-day readmission, weekend admissions, intensive care unit stays in the last month of life, and hospice stay of ≥ 7 days. Outcomes were measured for each quartile of practice-level inpatient intensity. We fit multivariable logistic regression models to calculate adjusted odds ratios (ORs) for each outcome for each quartile of inpatient intensity. RESULTS: Total 30-day readmissions were 22.8% and 31.9% (OR, 1.45; 95% CI, 1.39 to 1.50) for patients in practices with the lowest versus highest quartiles of inpatient intensity, respectively; unplanned readmissions were 19.8% and 27.1% (OR, 1.36; 95% CI, 1.31 to 1.41), respectively. The proportion of admissions that occurred on weekends was similar across quartiles. Patients of practices in the highest quartiles of inpatient intensity had higher rates of death in an ICU stay in the last month of life (25.5% versus 18.0%; OR, 1.33; 95% CI, 1.19 to 1.49) and a lower rate of hospice stay of at least 7 days (50.9% to 42.5%; OR, 0.79; 95% CI, 0.74 to 0.86). CONCLUSION: Medical oncology practices that seek to reduce hospitalizations should consider focusing initially on processes related to end-of-life care and care transitions.

Use of Medicare's Diabetes Self-Management Training Benefit.

Medicare began reimbursing for outpatient diabetes self-management training (DSMT) in 2000; however, little is known about program utilization. Individuals diagnosed with diabetes in 2010 were identified from a 20% random selection of the Medicare fee-for-service population (N = 110,064). Medicare administrative and claims files were used to determine DSMT utilization. Multivariate logistic regression analyses evaluated the association of demographic, health status, and provider availability factors with DSMT utilization. Approximately 5% of Medicare beneficiaries with newly diagnosed diabetes used DSMT services. The adjusted odds of any utilization were lower among men compared with women, older individuals compared with younger, non-Whites compared with Whites, people dually eligible for Medicare and Medicaid compared with nondual eligibles, and patients with comorbidities compared with individuals without those conditions. Additionally, the adjusted odds of utilizing DSMT increased as the availability of providers who offered DSMT services increased and varied by Census region. Utilization of DSMT among Medicare beneficiaries with newly diagnosed diabetes is low. There appear to be marked disparities in access to DSMT by demographic and health status factors and availability of DSMT providers. In light of the increasing prevalence of diabetes, future research should identify barriers to DSMT access, describe DSMT providers, and explore the impact of DSMT services. With preventive services being increasingly covered by insurers, the low utilization of DSMT, a preventive service benefit that has existed for almost 15 years, highlights the challenges that may be encountered to achieve widespread dissemination and uptake of the new services.

Epilepsy across the spectrum: promoting health and understanding. A summary of the Institute of Medicine report.

Approximately 1 in 26 people will develop epilepsy at some point in their lives. Although epilepsy is one of the nation's most common neurological disorders, public understanding is limited. A complex spectrum of disorders, epilepsy affects an estimated 2.2 million people in the United States. Living with epilepsy is about more than just seizures; it is often defined in practical terms, such as challenges, uncertainties, and limitations in school, social situations, employment, driving, and independent living. People with epilepsy are also faced with health and community services that are fragmented, uncoordinated, and difficult to obtain. The Institute of Medicine's report (2012) [1], Epilepsy across the spectrum: promoting health and understanding, examines the public health dimensions of epilepsy with a focus on (a) public health surveillance and data collection and integration; (b) population and public health research; (c) health policy, health care, and human services; and (d) education for providers, people with epilepsy and their families, and the public. The report's recommendations range from the expansion of collaborative epilepsy surveillance efforts to the independent accreditation of epilepsy centers, to the coordination of public awareness efforts, and to the engagement of people with epilepsy and their families in education, dissemination, and advocacy activities. Given the current gaps in epilepsy knowledge, care, and education, there is an urgent need to take action-across multiple dimensions-to improve the lives of people with epilepsy and their families. The realistic, feasible, and action-oriented recommendations in this report can help enable short- and long-term improvements for people with epilepsy.