Clinical Risk and Outpatient Therapy Utilization for COVID-19 in the Medicare Population.

Importance: Multiple therapies are available for outpatient treatment of COVID-19 that are highly effective at preventing hospitalization and mortality. Although racial and socioeconomic disparities in use of these therapies have been documented, limited evidence exists on what factors explain differences in use and the potential public health relevance of these differences. Objective: To assess COVID-19 outpatient treatment utilization in the Medicare population and simulate the potential outcome of allocating treatment according to patient risk for severe COVID-19. Design, Setting, and Participants: This cross-sectional study included patients enrolled in Medicare in 2022 across the US, identified with 100% Medicare fee-for-service claims. Main Outcomes and Measures: The primary outcome was any COVID-19 outpatient therapy utilization. Secondary outcomes included COVID-19 testing, ambulatory visits, and hospitalization. Differences in outcomes were estimated based on patient demographics, treatment contraindications, and a composite risk score for mortality after COVID-19 based on demographics and comorbidities. A simulation of reallocating COVID-19 treatment, particularly with nirmatrelvir, to those at high risk of severe disease was performed, and the potential COVID-19 hospitalizations and mortality outcomes were assessed. Results: In 2022, 6.0% of 20 026 910 beneficiaries received outpatient COVID-19 treatment, 40.5% of which had no associated COVID-19 diagnosis within 10 days. Patients with higher risk for severe disease received less outpatient treatment, such as 6.4% of those aged 65 to 69 years compared with 4.9% of those 90 years and older (adjusted odds ratio [aOR], 0.64 [95% CI, 0.62-0.65]) and 6.4% of White patients compared with 3.0% of Black patients (aOR, 0.56 [95% CI, 0.54-0.58]). In the highest COVID-19 severity risk quintile, 2.6% were hospitalized for COVID-19 and 4.9% received outpatient treatment, compared with 0.2% and 7.5% in the lowest quintile. These patterns were similar among patients with a documented COVID-19 diagnosis, those with no claims for vaccination, and patients who are insured with Medicare Advantage. Differences were not explained by variable COVID-19 testing, ambulatory visits, or treatment contraindications. Reallocation of 2022 outpatient COVID-19 treatment, particularly with nirmatrelvir, based on risk for severe COVID-19 would have averted 16 503 COVID-19 deaths (16.3%) in the sample. Conclusion: In this cross-sectional study, outpatient COVID-19 treatment was disproportionately accessed by beneficiaries at lower risk for severe infection, undermining its potential public health benefit. Undertreatment was not driven by lack of clinical access or treatment contraindications.

Use of Telemedicine and Quality of Care Among Medicare Enrollees With Serious Mental Illness.

Importance: During the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized. Objective: To compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use. Design, Setting, and Participants: In this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022. Exposure: Practice-level use of telemedicine during the first year of the COVID-19 pandemic. Main Outcomes and Measures: The primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization. Results: The pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were -0.4% (95% CI, -1.3% to 0.5%) and -0.1% (95% CI, -1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, -1.5% to 6.2%) and 2.8% (95% CI, -1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use. Conclusions and Relevance: In this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.

Telemedicine Visits in US Skilled Nursing Facilities.

Importance: Telemedicine in skilled nursing facilities (SNFs) has the potential to improve access and timeliness of care. During the COVID-19 pandemic in 2020 to 2022, telemedicine coverage expanded, but little is known about patterns of use in SNFs. Objective: To describe patterns of telemedicine use in SNFs. Design, Setting, and Participants: This cohort study used 2018 to 2022 Medicare fee-for-service claims and Minimum Data Set 3.0 records to identify short- and long-term care SNF residents. Clinician visits were grouped into routine SNF visits (ie, regular primary care within SNF) and other outpatient visits (ie, with non-SNF affiliated primary and specialty care clinicians). Using a difference-in-differences approach, assessments included whether off-hours visits (measured as weekend visits), new specialist visits, psychiatrist visits, or visits for residents with limited mobility changed differentially between 2018 to 2019 and 2020 to 2021 for SNFs with high compared with low telemedicine use in 2020. Exposure: Telemedicine adoption at SNF after 2020. Main Outcomes and Measures: Number and proportion of telemedicine SNF and outpatient visits. Results: Across 15 434 SNFs and 4 463 591 residents from the period January 2019 through June 2022 (mean [SD] age, 79.7 [11.6] years; 61% female in 2020), telemedicine visits increased from 0.15% in January 2019 to February 2020 to 15% SNF visits and 25% outpatient visits in May 2020. By 2022, telemedicine dropped to 2% of SNF visits and 8% of outpatient visits. The proportion of SNFs with any telemedicine visits annually dropped from 91% in 2020 to 61% in 2022. The facilities with high telemedicine use were more likely to be rural (adjusted odds ratio vs urban, 2.06; 95% CI, 1.77 to 2.40). Psychiatry visits differentially increased in high vs low telemedicine-use SNFs (20.2% relative increase; 95% CI, 1.2% to 39.2%). In contrast, there was little change in outpatient visits for residents with limited mobility (7.2%; 95% CI, -0.1% to 14.6%) or new specialist visits (-0.7%; 95% CI, -2.5% to 1.2%). Conclusions and Relevance: In this cohort study of SNF residents, telemedicine was rapidly adopted in early 2020 but subsequently stabilized at a low use rate that was nonetheless higher than before 2020. Higher telemedicine use in SNFs was associated with improved access to psychiatry visits in SNFs. A policy to encourage continued telemedicine use may facilitate further access to important services as the technology matures.

Variation in patterns of telestroke usage during the COVID-19 pandemic.

OBJECTIVES: Early in the pandemic, there was a substantial increase in telestroke uptake among hospitals. The motivations for using telestroke during the pandemic might have been different than for hospitals that adopted telestroke previously. We compared stroke care at hospitals that adopted telestroke prior to the pandemic to care at hospitals that adopted telestroke during the pandemic. MATERIALS AND METHODS: Stroke episodes and telestroke use were identified in Medicare Fee-for-Service Data. Hospital and episode characteristics were compared between pre-pandemic (Jan. 2019-Mar. 2020) and pandemic (Apr. 2020-Dec. 2020) adopters. RESULTS: Hospital bed counts, critical access statuses, stroke volumes, clinical operating margins, shares of stroke care via telestroke, and vascular neurology consult rates did not differ significantly between pre-pandemic and pandemic-adopting hospitals. Hospitals that never adopted telestroke during the study period were more likely to be small critical access hospitals with low clinical operating margins. CONCLUSIONS: Compared to hospitals that adopted telestroke before the pandemic, hospitals that adopted telestroke during the pandemic were similar in characteristics and how they used telestroke.

Trends in characteristics of neurologists who provide stroke consultations in the USA, 2008-2021.

INTRODUCTION: Patients with acute ischaemic strokes (AIS), on average, fare better with timely neurologist consultation, and a growing proportion of them receive one. However, little is known about trends in the characteristics of neurologists who treat AIS. METHODS: We identified AIS and transient ischaemic attack (TIA) episodes with neurologist consults in fee-for-service Medicare from January 2008 to September 2021. For each episode, we determined whether the neurologist was a vascular neurologist, was a high-volume provider, whether the patient was transferred between hospitals and the distance between the patient's home and physician's practice. RESULTS: From 2008 to 2021, the share of AIS/TIA episodes (n=5 073 294) with neurologist consults increased (52.9% to 61.7%). Among episodes with consults, the fraction conducted by a vascular neurologist (5.2% to 13.7%) or by a high-volume neurologist (13.2% to 14.9%) also increased. The fraction with the patient's home and neurologist greater than 100 miles apart (4.8% to 9.6%) or in different states (5.1% to 8.1%) increased, as did the fraction with transfers (4.2% to 8.5%). DISCUSSION: Over the study period, the proportion of AIS/TIA episodes with consultations from neurologists with either vascular neurology certifications or high volumes increased substantially.

Legislation Increased Medicare Telestroke Billing, But Underbilling And Erroneous Billing Remain Common.

In the Furthering Access to Stroke Telemedicine (FAST) Act, passed as part of a budget omnibus in 2018, Congress permanently expanded Medicare payment for telemedicine consultations for acute stroke ("telestroke") from delivery only in rural areas to delivery in both urban and rural areas, effective January 1, 2019. Using a controlled time-series analysis, we found that one year after FAST Act implementation, billing for Medicare telestroke increased substantially in emergency departments at both directly affected urban hospitals and indirectly affected rural hospitals. However, at that time only a minority of hospitals with known telestroke capacity had ever billed Medicare for that service, and there was substantial billing inconsistent with Medicare requirements. As Congress considers options for Medicare telemedicine payment after the COVID-19 pandemic, our findings, which are consistent with confusion among providers regarding telemedicine billing requirements, suggest that simplified payment rules would help ensure that expanded reimbursement achieves its intended impact.

Association Between Telepsychiatry Capability and Treatment of Patients With Mental Illness in the Emergency Department.

OBJECTIVE: Because of limited access to psychiatrists, patients with acute mental illness in some emergency departments (EDs) may wait days for a consultation in the ED or as a medical-surgical admission. The study assessed whether telepsychiatry improves access to care and decreases ED wait times and hospital admissions. METHODS: ED visits with a primary diagnosis of mental illness were identified from 2010-2018 Medicare claims. A total of 134 EDs across 22 states that implemented telepsychiatry between 2013 and 2016 were matched 1:1 with control EDs without telepsychiatry on several characteristics, including availability of in-person psychiatrist consultations. Outcomes included patients' likelihood of admission to a medical-surgical or psychiatric bed, mental illness spending, prolonged ED length of stay (LOS) (two or more midnights in the ED), 90-day mortality, and outpatient follow-up care. Using a difference-in-difference design, changes in outcomes between the 3 years before telepsychiatry adoption and the 2 years after were examined. RESULTS: There were 172,708 ED mental illness visits across the 134 matched ED pairs in the study period. Telepsychiatry adoption was associated with increased admissions to a psychiatric bed (differential increase, 4.3 percentage points; p<0.001), decreased admissions to a medical-surgical bed (differential decrease, 2.0 percentage points; p<0.001), increased likelihood of a prolonged ED LOS (differential increase, 3.0 percentage points; p<0.001), and increased mental illness spending (differential increase, $292; p<0.01). CONCLUSIONS: Telepsychiatry adoption was associated with a lower likelihood of admission to a medical-surgical bed but an increased likelihood of admission to a psychiatric bed and a prolonged ED LOS.

Luck of the draw: Role of chance in the assignment of medicare readmissions penalties.

Pay-for-performance programs are one strategy used by health plans to improve the efficiency and quality of care delivered to beneficiaries. Under such programs, providers are often compared against their peers in order to win bonuses or face penalties in payment. Yet luck has the potential to affect performance assessment through randomness in the sorting of patients among providers or through random events during the evaluation period. To investigate the impact luck can have on the assessment of performance, we investigated its role in assigning penalties under Medicare's Hospital Readmissions Reduction Policy (HRRP), a program that penalizes hospitals with excess readmissions. We performed simulations that estimated program hospitals' 2015 readmission penalties in 1,000 different hypothetical fiscal years. These hypothetical fiscal years were created by: (a) randomly varying which patients were admitted to each hospital and (b) randomly varying the readmission status of discharged patients. We found significant differences in penalty sizes and probability of penalty across hypothetical fiscal years, signifying the importance of luck in readmission performance under the HRRP. Nearly all of the impact from luck arose from events occurring after hospital discharge. Luck played a smaller role in determining penalties for hospitals with more beds, teaching hospitals, and safety-net hospitals.

Hospital Responses to Incentives in Episode-Based Payment for Joint Surgery: A Controlled Population-Based Study.

Importance: Medicare's Comprehensive Care for Joint Replacement (CJR) model, initiated in 2016, is a national episode-based payment model for lower-extremity joint replacement (LEJR). Metropolitan statistical areas (MSAs) were randomly assigned to participation. In the third year of the program, Medicare made hospital participation voluntary in half of the MSAs and enabled LEJRs for knees to be performed in the outpatient setting without being subject to episode-based payment. How these changes affected program savings is unclear. Objective: To estimate savings from the CJR program over time and assess how responses by hospitals to changing incentives were associated with those savings. Design, Participants, and Setting: This controlled population-based study used Medicare claims data from January 1, 2014, to December 31, 2019, to analyze the spending for beneficiaries who received LEJR in 171 MSAs randomized to CJR vs typical payment. One-quarter of beneficiaries before and after the April 1, 2016, start date were excluded as a 6-month washout period (January 1 to June 30, 2016) to allow time in the evaluation period for hospitals to respond to the program rules. Main Outcomes and Measures: The main outcomes were episode spending and, starting in year 3 of the program, the hospitals' decision to no longer participate in CJR and perform LEJRs in the outpatient setting. Results: Data from 1 087 177 patients (mean [SD] age, 74.4 [8.4] years; 692 604 women [63.7%]; 980 635 non-Hispanic White patients [90.2%]) were analyzed. Over the first 4 years of CJR, 321 038 LEJR episodes were performed at 702 CJR hospitals, and 456 792 episodes were performed at 826 control hospitals. From the second to the fourth year of the program, savings in CJR vs control MSAs diminished from -$976 per LEJR episode (95% CI, -$1340 to -$612) to -$331 (95% CI, -$792 to $130). In MSAs where hospital participation was made voluntary in the third year, more hospitals in the highest quartile of baseline spending dropped out compared with the lowest quartile (56 of 60 [93.3%] vs 29 of 56 [51.8%]). In MSAs where participation remained mandatory, CJR hospitals shifted fewer knee replacements to the outpatient setting in years 3 to 4 than controls (12 571 of 59 182 [21.2%] vs 21 650 of 68 722 [31.5%] of knee LEJRs). In these mandatory MSAs, 75% of the reduction in savings per episode from years 1 to 2 to years 3 to 4 of the program ($455; 95% CI, $137-$722) was attributable to CJR hospitals' decision on which patients would undergo surgery or whether the surgical procedure would occur in the outpatient setting. Conclusions and Relevance: This controlled population-based study found that savings observed in the second year of CJR largely dissipated by the fourth year owing to a combination of responses among hospitals to changes in the program. These results suggest a need for caution regarding the design of new alternative payment models.

Trends Among Rural and Urban Medicare Beneficiaries in Care Delivery and Outcomes for Acute Stroke and Transient Ischemic Attacks, 2008-2017.

Importance: Over the last decade or so, there have been substantial investments in the development of stroke systems of care to improve access and quality of care in rural communities. Whether these have narrowed rural-urban disparities in care is unclear. Objective: To describe trends among rural and urban patients with acute ischemic stroke or transient ischemic attack in the type of health care centers to which patients were admitted, what care was provided, and the outcomes patients experienced. Design, Setting, and Participants: This descriptive observational study included 100% claims for beneficiaries of traditional fee-for-service Medicare from 2008 through 2017. All rural and urban areas in the US were included, defined by whether a beneficiary's residential zip code was in a metropolitan or nonmetropolitan area. All admissions in the US among patients with traditional Medicare who had a transient ischemic attack or acute stroke (N = 4.01 million) were eligible to be included in this study. Admissions for beneficiaries with end-stage kidney disease (n = 85 927 [2.14%]), beneficiaries with unidentified Rural-Urban Commuting Area codes (n = 12 797 [0.32%]), and beneficiaries not continuously enrolled in traditional Medicare in the 12 months before and 3 months after their admission (n = 442 963 [11.0%]) were excluded. Exposures: Residence in an urban or rural area; admission to a hospital with a transient ischemic attack or acute stroke. Main Outcomes and Measures: Discharge from a certified stroke center, receiving a neurology consultation during admission, treatment with alteplase, days institutionalized, and 90-day mortality. Results: The final sample included 3.47 million admissions from 2008 through 2017. In this sample, 2.01 million patients (58.0%) were female, and the mean (SD) age was 78.6 (10.5) years. In 2008, 24 681 patients (25.2%) and 161 217 patients (60.6%) in rural and urban areas, respectively, were cared for at a certified stroke center (disparity, -35.4%). By 2017, this disparity was -26.6%, having narrowed by 8.7 percentage points (95% CI, 6.6-10.8 percentage points). There was also narrowing in the rural-urban disparity in neurologist evaluation during admission (6.3% [95% CI, 4.2%-8.4%]). However, the rural-urban disparity widened or was similar with regard to receiving alteplase (0.5% [95% CI, 0.1%-0.8%]), mean days in an institution from admission (0.5 [95% CI, 0.2-0.8] days), and mortality at 90 days (0.3% [95% CI, -0.02% to 0.6%]), respectively. Conclusions and Relevance: In the last decade, care for rural residents with acute ischemic stroke and transient ischemic attack has shifted to certified stroke centers and now more likely includes neurologist input. However, disparities in access to treatments, such as alteplase, and outcomes persist, highlighting that work still is needed to extend improvements in stroke care to all US residents.

Search and You Shall Find: Geographic Characteristics Associated With Google Searches During the Affordable Care Act's First Enrollment Period.

Previous studies indicate that Internet searching was a major source of information for the public during the launch of the Affordable Care Act, but little is known about geographic variation in searching. Our objective was to examine factors associated with health insurance-related Google searches in 199 U.S. metro areas during the first open enrollment period (October 2013 through March 2014), by merging data from Google Trends with metro-area-level and state-level characteristics. Our results indicate substantial geographic variation in the volumes of searching across the United States, and these patterns were related to local uninsurance rates. Specifically, areas with higher uninsurance rates were more likely to search in higher volumes for "Obamacare" and "health insurance," after adjusting for sociodemographic, political, and insurance market characteristics. The enormous political, advocacy, and media attention to the Affordable Care Act's launch may have contributed to heightened Internet search activity, particularly in areas characterized by higher uninsurance.