A Secondary Analysis of the Intensity of Hospice Visits Among Medicare Decedents in the Last Seven Days of Life by Place of Residence.

BACKGROUND: In 2016, Medicare finalized the Service Intensity Add-on (SIA) payment policy to increase the intensity of hospice registered nurse (RN) or social worker (SW) visits in the last 7 days of life. The research objective was to compare the intensity of hospice RN or SW visits in the last 7 days of life among older decedents who received a hospice visit, while residing in a traditional home, an assisted living facility, or long-term nursing home. METHODS: A retrospective analysis using 2016-2018 Medicare data of decedents 65 years or older (n= 2 067 863) related to the Medicare SIA payment policy. Intensity was defined as the number and duration of hospice RN or SW visits in the last 7 days of life using Medicare claims code G0299 and G0155. RESULTS: Regression results suggest that decedents who received a SIA related visit while residing in an assisted living facility, had on average a slightly longer duration of hospice RN visits in the last 7 days of life, compared to decedents residing in a traditional home, after controlling for demographics and other factors (P<.0001). The duration of hospice RN visits remained unchanged among decedents who received a SIA visit in 2017 or 2018, when compared to 2016 (P <.0001). Overall the average number of hospice SW visits did not differ by place of residence among decedents who received a SIA visit. CONCLUSIONS: Among decedents who received a SIA related visit, the duration of hospice RN visits were slightly different by place of residence.

Characteristics of Decedents in Home Settings Using Medicare Place of Hospice Service Codes.

Very little is known about the characteristics of the Medicare beneficiaries receiving hospice at home, defined using the Medicare Healthcare Common Procedure Coding System codes, as a traditional home, an assisted living facility, or a nursing home. A secondary analysis of 2015 Medicare data using regression to describe the characteristics of decedents (n = 675 782) in hospice residing in a traditional home, an assisted living facility, and a nursing home was completed. Results suggest that the proportion of Medicare decedents in hospice with more than 180 lifetime days in hospice was highest among those who resided in an assisted living facility (25.03%) compared with those who resided in a nursing home (18.87%) or in a traditional home (13.04%). Regression findings suggest that, compared with decedents in hospice without dementia who resided in a traditional home, decedents in hospice with a primary diagnosis of dementia were more likely to reside in an assisted living facility (adjusted odds ratio, 2.29; P < .0001) when controlling for other factors. In summary, decedents in hospice who resided in a traditional home have different characteristics than decedents who resided in an assisted living facility or a nursing home. Interdisciplinary providers should consider these differences when managing hospice interventions.

Cancer-Attributable Medical Costs for Colorectal Cancer Patients by Phases of Care: What Is the Effect of a Prior Cancer History?

Medical care costing studies have excluded patients with a prior cancer history. This study aims to update methods for estimating medical care costs attributable to cancer and to evaluate the effect of a prior history of cancer on costs for colorectal cancer (CRC) patients. We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data and matched cancer patients to controls without cancer to estimate cancer-attributable costs by phases of care using Medicare 2007-2013 claims. CRC annualized average cancer-attributable costs were $56.0 K, $5.3 K, $92.5 K, and $24.3 K in the initial, continuing, and end-of-life cancer and noncancer death phases, respectively, in 2014 dollars. Costs were higher for patients diagnosed with more advanced stage, younger ages, and nonwhite races. Costs for patients with prior cancers were consistently higher than patients without prior cancers, especially in the continuing (4.9 K vs 7.2 K) and end-of-life noncancer death (22.7 K vs 30.0 K). Our CRC costs improve previous estimates by using more recent data and updated methods.

Development and Evaluation of a Process to Link Cancer Patients in the SEER Registries to National Medicaid Enrollment Data.

Cancer patients receiving Medicaid have worse prognosis. Patients in 14 Surveillance, Epidemiology, and End Results (SEER) cancer registries were linked to national Medicaid enrollment files, 2006-2013, to determine enrollment status during the year before and after diagnosis. A deterministic algorithm based on Social Security number, Medicare Health Insurance Claim number, sex, and date of birth was utilized. Results were compared with an independent linkage of Kentucky-based SEER and Medicaid data. A total 559 484 cancer cases were linked to national Medicaid enrollment files, representing 15-17% of persons with cancer yearly. About 60% of these cases were a complete match on all variables. There was 99% agreement on enrollment status compared with the Kentucky linked data. SEER data were successfully linked to national Medicaid enrollment data. NCI will make the linked data available to researchers, allowing for more detailed assessments of the impact Medicaid enrollment has on cancer diagnosis and outcomes.

Updated Overview of the SEER-Medicare Data: Enhanced Content and Applications.

BACKGROUND: The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database was first created almost 30 years ago. Over time, additional data have been added to the SEER-Medicare database, allowing for expanded insights into the delivery of health care across the cancer continuum from screening to end of life. METHODS: This article includes an overview of the current SEER-Medicare database, presenting potential users with an introduction to how the data can facilitate innovative epidemiologic and health services research studies. With a focus on the population 65 years and older, this article presents descriptive data on beneficiary demographics, cancer characteristics, service settings, Medicare coverage (eg, Parts A, B, C, and D), and use (number of services or bills) from 2011 to 2015. RESULTS: From 2011 to 2015, 857 056 cancer patients and 601 470 population-based noncancer controls were added to the database. The database includes detailed tumor characteristics and clinical assessments for cancer cases, and demographics and health-care use (eg, hospitals, outpatient facilities, individual providers, hospice, home health-care providers, and pharmacies) for both cases and controls. Although characteristics varied overall between cases and controls, sufficient cancer-specific matched controls are available. Roughly 60% of cases were enrolled in fee for service at cancer diagnosis. The annual average number of claims per case was 60.7 and 92.3 during the year before and after cancer diagnosis, respectively, and 127.5 during the year before death. CONCLUSIONS: The large sample size and diverse array of data on cancer patients and noncancer controls in the SEER-Medicare database make it a unique resource for conducting cancer health services research.

Prescription Drug Use and Cost Trends Among Medicaid-Enrolled Children with Disruptive Behavioral Disorders.

Disruptive behavior disorders (DBDs) are the most common mental health conditions in children. These conditions profoundly affect healthcare utilization and costs. Service use, costs, and diagnostic trends among pediatric Medicaid beneficiaries provide information regarding healthcare quality and potential for smarter spending. Using nationwide Medicaid administrative data, this study investigates diagnoses, prescription drug fills, and payments in 49 states and D.C. from 2006 to 2009 in Medicaid beneficiaries age 20 and under. Psychotherapeutic drug prescriptions and payments were calculated as a proportion of prescription totals. Results were considered by age, gender, race, and state. The results show a trend of increasing DBD diagnosis. Among prescription claims for children with diagnosed DBD, psychotherapeutic drug claims represented 30-40% of prescription claims but over half of prescription costs. This study indicates increasing clinical and financial needs for Medicaid-enrolled children with DBDs. Medicaid could potentially foster reforms in pediatric DBD treatments, particularly regarding medication use.

Understanding factors associated with loss of medicaid coverage among dual eligibles can help identify vulnerable enrollees.

For people who receive both Medicare and Medicaid benefits (dual-eligible beneficiaries), the loss of Medicaid coverage may lead to problems with care coordination, higher out-of-pocket expenses, or reduced access to services. Using administrative data, we followed 292,242 full-benefit and 91,020 partial-benefit dual eligibles from January 2009 through December 2011. Among those with full Medicaid benefits, 15.6 percent lost Medicaid coverage at least once, with more frequent losses among younger beneficiaries. Many of these losses lasted only one to three months and were followed by reinstatement. Loss of Medicaid coverage was more common (23.2 percent) among enrollees with partial Medicaid benefits. Medicare Current Beneficiary Survey data indicate that most dual eligibles who lost Medicaid coverage had no other source of supplemental insurance. Medicaid coverage is relatively stable among dual eligibles. However, some lose Medicaid for several months or more, putting them at risk for poor outcomes and potentially complicating their care, especially when it needs to be integrated under the two programs.

Burden of chronic obstructive pulmonary disease in Medicare beneficiaries residing in long-term care facilities.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD increases health care resource utilization and spending and adversely affects quality of life. Data from the clinical and economic outcomes in Medicare beneficiaries with COPD who reside in long-term care (LTC) facilities are limited. OBJECTIVE: The purpose of this study was to investigate the clinical and economic outcomes associated with COPD in Medicare beneficiaries residing in LTC facilities. METHODS: This retrospective cohort study analyzed data from MarketScan Medicaid, a large US administrative claims database containing data on Medicaid programs in 8 states. The study cohort comprised LTC facility residents aged > or =60 years who had a diagnosis of COPD. Eligible patients also had a prescription filled between January 1, 2003, and June 30, 2005, for one of the following COPD treatments: fluticasone propionate + salmeterol xinafoate, tiotropium bromide, ipratropium bromide, or ipratropium bromide + albuterol sulfate. The date of the first prescription fill was considered the index date. Measures of health care resource utilization included COPD-related and all-cause hospitalizations and emergency department (ED) visits. Cost analysis outcomes included COPD-related and all-cause inpatient, outpatient, pharmacy, LTC, and total costs during the 12-month postindex period. RESULTS: Data from 3037 patients were included (63.0% women; 82.2% white; mean [SD] age, 78.1 [10.0] years). A total of 43.3% of patients had > or =1 hospitalization; 90.0%, > or =1 ED visit. With the exception of age <70 years, age was associated with all-cause hospitalization (age 70-<75 years, hazard ratio [HR] = 1.31 [95% CI, 1.03-1.68]; age 75-<80 years, HR = 1.40 [95% CI, 1.11-1.78]; age > or =80 years, HR = 1.48 [95% CI, 1.19-1.85]). Age was not associated with COPD-related hospitalization, all-cause ED visits, or COPD-related ED visits. The risk for all-cause hospitalization in white patients was significantly lower compared with that in nonwhite patients (HR = 0.79 [95% CI, 0.69-0.91]). Patients with comorbid asthma had a higher risk for a COPD-related ED visit (HR = 1.34 [95% CI, 1.08-1.66]) than did patients without asthma. Preindex all-cause hospitalization was associated with COPD-related hospitalization (HR = 1.78 [95% CI, 1.49-2.14]) and all-cause hospitalization (HR = 2.05 [95% CI, 1.932.19]). Twelve-month COPD-related and all-cause direct expenditures per beneficiary were US $7391 and $48,183. In COPD-related and all-cause estimates, mean (SD) LTC costs were the largest cost components ($5629 [$12,562] and $32,966 [$14,871], respectively), followed by pharmacy costs ($956 [$957] and $5565 [$3873]), inpatient costs ($466 [$3393] and $6436 [$22,603]), and outpatient costs ($341 [$1793] and $3216 [$6458]). CONCLUSION: This study found that the utilization of health care resources and economic burden of LTC residents with COPD were primarily due to LTC, pharmacy, and inpatient costs.

Hospital and emergency department utilization associated with treatment for chronic obstructive pulmonary disease in a managed-care Medicare population.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a highly prevalent condition with high morbidity and mortality among older and disabled adults. Few studies have examined the comparative effectiveness of maintenance therapies for chronic obstructive pulmonary disease (COPD) in this vulnerable population. OBJECTIVES: The study aims to compare healthcare resource utilization associated with hospitalization or emergency department (ED) visits between FDA-approved inhaled corticosteroid/long-acting beta-agonist combinations [fluticasone propionate 250 microg/salmeterol 50 microg combination (FSC)] and anticholinergic treatments (ATC) in managed-care Medicare beneficiaries with COPD. RESEARCH DESIGN AND METHODS: Data from the Integrated Health Care Information Systems (IHCIS) National Managed Care Benchmark Database was used in this retrospective, observational cohort study. The cohort consisted of managed-care Medicare beneficiaries with a diagnosis of COPD [International Classification of Disease, 9th revision, Clinical Modification (ICD-9-CM) codes 491.xx, 492.xx, or 496.xx] without evidence of comorbid asthma (ICD-9-CM 493.xx) who received treatment with FSC or ATC between 2003 and 2005. Cox proportional hazards regression models were conducted to examine the risk of all-cause and COPD-related hospitalizations and emergency department (ED) visits. RESULTS: COPD patients treated with FSC had a 18% lower risk of a COPD-related hospitalization (HR = 0.82; 95% CI = 0.75, 0.89) and an ED visit (HR = 0.82; 95% CI = 0.76, 0.89) compared to patients treated with ATC. Findings were similar for all-cause utilization (hospitalization HR = 0.83; 95% CI = 0.78, 0.88; ED visit HR = 0.84; 95% CI = 0.80, 0.88). CONCLUSIONS: FSC is associated with a lower risk of COPD-related exacerbation events relative to ATC in managed-care Medicare beneficiaries with COPD. Findings from this study are only generalizable to managed-care Medicare beneficiaries residing in the community.

Association of antipsychotic use with hospital events and mortality among medicare beneficiaries residing in long-term care facilities.

OBJECTIVE: Antipsychotic (AP) utilization has grown significantly in long-term care (LTC) settings. Although a growing literature associates AP use with higher mortality in elderly with dementia, the association of APs with hospital events is unclear. The authors examine prevalence and trends in AP use by Medicare beneficiaries residing in LTC and the association of APs and other drug use variables with hospital events and mortality. DESIGN: Retrospective analysis using sequential multivariate Cox proportional hazards models. SETTING: Medicare Current Beneficiary Survey linked to Institutional Drug Administration and Minimum Data Set files. PARTICIPANTS: A total of 2,363 LTC Medicare beneficiaries, 1999-2002. MEASUREMENTS: Trends in LTC AP use overall and by type and duplicative use; association of AP utilization and two outcomes: hospital events and all-cause mortality. RESULTS: AP use rose markedly from 1999 to 2002 (26.4%-35.9%), predominantly due to increased use of atypical agents. After controlling for sociodemographic and clinical factors, AP use is not related to hospital events (hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.82-1.63 p = 0.7951). AP use is associated with reduced mortality in unadjusted and intermediate models, but loss of significance in the final model (HR = 0.83, 95% CI = 0.69-1.00, p = 0.0537) suggests that disease and drug burden factors may confound the AP-mortality relationship. CONCLUSION: This study provides no evidence of increased hospital events or mortality in LTC residents who use AP medications. Findings contribute to a growing body of evidence that APs, particularly atypical agents, may be associated with reduced mortality in LTC residents.

Increased persistency in medication use by U.S. Medicare beneficiaries with diabetes is associated with lower hospitalization rates and cost savings.

OBJECTIVE: To assess the relationship between annual fills for antidiabetes medications, ACE inhibitors, angiotensin II receptor blockers (ARBs), and lipid-lowering agents on hospitalization and Medicare spending for beneficiaries with diabetes. RESEARCH DESIGN AND METHODS: Using Medicare Current Beneficiary Survey data from 1997 to 2004, we identified 7,441 community-dwelling beneficiaries with diabetes, who contributed 14,317 person-years of data for the analysis. We used multivariate regression analysis to estimate the effect of persistency in medication fills on hospitalization risk, hospital days, and Medicare spending. RESULTS: For users of older oral antidiabetes agents, ACE inhibitors, ARBs, and statins, each additional prescription fill was associated with significantly lower risk of hospitalization, fewer hospital days, and lower Medicare spending. CONCLUSIONS: These results suggest an economic case for promoting greater persistency in use of drugs with approved indications by Medicare beneficiaries with diabetes; however, additional research is needed to corroborate the study's cross-sectional findings.

Racial and ethnic disparities in the treatment of dementia among Medicare beneficiaries.

OBJECTIVES: Numerous studies have documented disparities in health care utilization between non-Hispanic White and minority elders. We investigated differences in anti-dementia medication use between non-Hispanic White and minority community-dwelling Medicare beneficiaries with dementia. METHODS: Using multivariate analysis with generalized estimating equations, we estimated prevalence ratios (PRs) for anti-dementia medication use by race/ethnicity for 1,120 beneficiaries with dementia from years 2001 through 2003 of the Medicare Current Beneficiary Survey. RESULTS: After adjusting for demographics, socioeconomics, health care access and utilization, comorbidities, and service year, we found that anti-dementia medication use was approximately 30% higher among non-Hispanic Whites compared to other racial/ethnic groups (PR=0.73, 95% confidence interval [CI]=0.59, 0.91). As for individual racial/ethnic groups, prevalence disparities remained significant for non-Hispanic Blacks (PR=0.75, 95% CI=0.57, 0.99) and non-Hispanic others (PR=0.50, 95% CI=0.26, 0.96) but were attenuated for Hispanics (PR=0.84, 95% CI=0.59, 1.20). DISCUSSION: Results provide evidence that racial/ethnic disparities in utilization of drugs used to treat dementia exist and are not accounted for by differences in demographic, economic, health status, or health utilization factors. Findings provide a foundation for further research that should use larger numbers of minority patients and consider dementia type and severity, access to specialty dementia care, and cultural factors.

Obesity, disease burden, and prescription spending by community-dwelling Medicare beneficiaries.

OBJECTIVES: To assess drug utilization and cost patterns by body mass index (BMI) for Medicare beneficiaries including cohorts diagnosed with diseases resulting from, or aggravated by, obesity. RESEARCH DESIGN: We used data from the 2003 Medicare Current Beneficiary Survey to characterize the community-dwelling Medicare population by BMI class and to assess the following outcomes: (1) prevalence of drugs recommended in treating obesity-related chronic diseases, (2) annual spending on these medications by disease cohort, and (3) spending for all medications for the full study sample. Linear regression techniques were used to assess the conditional association of BMI class with drug spending controlling for sociodemographic characteristics, prescription drug coverage, health status, and comorbidities. RESULTS: Annual drug spending in 2003 was significantly higher (p < 0.05) for obese class I ($2374) and class III ($2976) compared to normal-weight beneficiaries ($1764). Obese individuals also had higher utilization rates for selected medications used to treat diabetes, hypertension, ischemic heart disease, heart failure, hyperlipidemia, and osteoarthritis. Regression results indicate that chronic disease is the main reason why drug spending is higher among the obese, but prescription drug coverage is also a significant factor. CONCLUSIONS: Obesity is associated with significantly higher drug spending among Medicare beneficiaries. The combination of growing numbers of obese beneficiaries, high rates of chronic disease, and greater than average prescription spending per condition will all contribute to higher future Part D and overall Medicare program costs. Limitations of the study include: self-reported data on height, weight, and drug use/spending; small sample size; and pre-Part D data.

Does Medicare coverage of colonoscopy reduce racial/ethnic disparities in cancer screening among the elderly?

Racial and ethnic disparities in colorectal cancer screening have been documented extensively in the literature. In July 2001 Medicare began covering colonoscopy for average-risk beneficiaries. We examined the effect of Medicare reimbursement on the rate and disparity of colorectal cancer screening among the elderly in the United States. This policy alleviated the screening disparity between non-Hispanic whites and blacks, but the gap between Hispanics and non-Hispanic whites has widened. Overall, fewer than half of the elderly are screened, even though Medicare now covers colonoscopy.