Variation of hospital-based adoption of care coordination services by community-level social determinants of health.

BACKGROUND: Hospital investments in care coordination services and innovative delivery models represent an important source for improving care efficiency and population health. OBJECTIVE: The aim of this study was to explore variation of hospital-initiated care coordination services and participation in Accountable Care Organizations (ACOs) by community characteristics within an organizational theory framework. METHODS: Our main data sets included the 2015 American Hospital Association Annual Survey, Survey of Care Systems and Payment, American Community Survey, and Area Health Resource File. Two main outcomes were (a) hospital-reported initiation of care coordination practices (such as chronic disease management, post-hospital discharge continuity of care, and predictive analytics) and (b) participation in ACO models. State fixed-effects models were used to test the association between the adoption of care coordination practices and hospital characteristics, community-level sociodemographic characteristics, and health policies. RESULTS: Hospitals with large bed size, located in urban areas, and/or with high volume of operations were more likely to adopt care coordination practices and participate in the ACO models. Hospitals serving communities with high uninsurance rates and/or poverty rates were significantly less likely to provide care coordination practices. More stringent Community Benefit Laws (CBLs) were positively associated with the implementation of care coordination practices suggesting strong normative impacts of CBLs. CONCLUSION: Greater hospital-initiated care coordination practices and innovative ACO models were available in well-resourced areas. Policymakers may consider increasing resources for care coordination practices in rural, underserved, and high-poverty-high-uninsured areas to ensure that vulnerable populations can benefit from these services.

Familiarity and Communication in the Operating Room.

BACKGROUND: Poor communication is implicated in many adverse events in the operating room (OR); however, many hospitals' scheduling practices permit unfamiliar operative teams. The relationship between unfamiliarity, team communication and effectiveness of communication is poorly understood. We sought to evaluate the relationship between familiarity, communication rates, and communication ineffectiveness of health care providers in the OR. MATERIALS AND METHODS: We performed purposive sampling of 10 open operations. For each case, six providers (anesthesiology attending, in-room anesthetist, circulator, scrub, surgery attending, and surgery resident) were queried about the number of mutually shared cases. We identified communication events and created dyad-specific communication rates. RESULTS: Analysis of 48 h of audio-video content identified 2570 communication events. Operations averaged 58.0 communication events per hour (range, 29.4-76.1). Familiarity was not associated with communication rate (P = 0.69) or communication ineffectiveness (P = 0.21). Cross-disciplinary dyads had lower communication rates than intradisciplinary dyads (P < 0.001). Anesthesiology-nursing, anesthesiology-surgery, and nursing-surgery dyad communication rates were 20.1%, 42.7%, and 57.3% the rate predicted from intradisciplinary dyads, respectively. In addition, cross-disciplinary dyad status was a significant predictor of having at least one ineffective communication event (P = 0.02). CONCLUSIONS: Team members do not compensate for unfamiliarity by increasing their verbal communication, and dyad familiarity is not protective against ineffective communication. Cross-disciplinary communication remains vulnerable in the OR suggesting poor crosstalk across disciplines in the operative setting. Further investigation is needed to explore these relationships and identify effective interventions, ensuring that all team members have the necessary information to optimize their performance.

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.

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.

Qualitative Evaluation of the Coach Training within a Community Paramedicine Care Transitions Intervention.

OBJECTIVE: The Care Transitions Intervention (CTI) has potential to improve the emergency department (ED)-to-home transition for older adults. Community paramedics may function as the CTI coaches; however, this requires the appropriate knowledge, skills, and attitudes, which they do not receive in traditional emergency medical services (EMS) education. This study aimed to define community paramedics' perceptions regarding their training needs to serve as CTI coaches supporting the ED-to-home transition. METHODS: This study forms part of an ongoing randomized controlled trial evaluating a community paramedic-implemented CTI to enhance the ED-to-home transition. The community paramedics' training covered the following domains: the CTI program, geriatrics, effective coaching, ED discharge processes, and community paramedicine. Sixteen months after starting the study, we conducted audio-recorded semi-structured interviews with community paramedics at both study sites. After transcribing the interviews, team members independently coded the transcripts. Ensuing group analysis sessions led to the development of final codes and identifying common themes. Finally, we conducted member checking to confirm our interpretations of the interview data. RESULTS: We interviewed all 8 participating community paramedics. Participants consisted solely of non-Hispanic whites, included 5 women, and had a mean age of 43. Participants had extensive backgrounds in healthcare, primarily as EMS providers, but minimal experience with community paramedicine. All reported some prior geriatrics training. Four themes emerged from the interviews: (1) paramedics with positive attitudes and willingness to acquire the needed knowledge and skills will succeed as CTI coaches; (2) active rather than passive learning is preferred by paramedics; (3) the existing training could benefit from adjustments such as added content on mental health, dementia, and substance abuse issues, as well as content on coaching subjects with a range of illness severity; and (4) continuing education should address the paramedic coaches' evolving needs as they develop proficiency with the CTI. CONCLUSIONS: Paramedics as CTI coaches represent an untapped resource for supporting ED-to-home care transitions. Our results provide the necessary first step to make the community paramedic CTI coach more successful. These findings may apply to training for similar community paramedicine roles, but additional research must investigate this possibility.

A randomized controlled trial testing the effectiveness of a paramedic-delivered care transitions intervention to reduce emergency department revisits.

BACKGROUND: Approximately 20% of community-dwelling older adults discharged from the emergency department (ED) return to an ED within 30 days, an occurrence partially resulting from poor care transitions. Prior published interventions to improve the ED-to-home transition have either lacked feasibility or effectiveness. The Care Transitions Intervention (CTI) has been validated to decrease rehospitalization among patients transitioning from the hospital to the home but has never been tested for patients transitioning from the ED to the home. Paramedics, traditionally involved only in emergency care, are well-positioned to deliver the CTI, but have never been previously evaluated in this role. METHODS: This single-blinded randomized controlled trial tests whether the paramedic-delivered ED-to-home CTI reduces community-dwelling older adults' ED revisits in the 30 days after an index visit. We are prospectively recruiting patients aged≥ 60 years at 3 EDs in Rochester, NY and Madison, WI to enroll 2400 patient subjects. Subjects are randomized into control and treatment groups, with the latter receiving the adapted CTI. The intervention consists of the paramedic performing one home visit and up to three follow-up phone calls. During these interactions, the paramedic follows the CTI approach by coaching patients toward their goals, with a focus on their personal health record, medication management, red flags, and primary care follow-up. We follow patient participants for 30 days. All receive a survey during the index ED visit to capture baseline demographic and health information and two telephone-based surveys to assess process objectives and outcomes. We also perform a medical record review. The primary outcome is the odds of ED revisit within 30 days after discharge from the index ED visit. DISCUSSION: This is the first study to test whether the CTI, applied to the ED-to-home transition and delivered by community paramedics, can decrease the rate at which older adults revisit an ED. Outcomes from this research will help address a major emergency care challenge by supporting older adults in the transition from the ED to home, thereby improving health outcomes for this population and reducing potentially avoidable ED visits. TRIAL REGISTRATION: ClinicalTrials.gov Registration: NCT02520661 . Trial registration date: August 13, 2015.

Hospital discharge documentation of a designated clinician for follow-up care and 30-day outcomes in hip fracture and stroke patients discharged to sub-acute care.

BACKGROUND: Transitions to sub-acute care are regularly complicated by inadequate discharge communication, which is exacerbated by a lack of clarity regarding accountability for important follow-up care. Patients discharged to sub-acute care often have complex medical conditions and are at heightened risk for poor post-hospital outcomes, yet many do not see a provider until 30 days post discharge due to current standards in Medicare regulations. Lack of designation of a responsible clinician or clinic for follow-up care may adversely impact patient outcomes, but the magnitude of this potential impact has not been previously studied. METHODS: We examined the association of designating a responsible clinician/clinic for post-hospital follow-up care within the hospital discharge summary on risk for 30-day rehospitalization and/or death in stroke and hip fracture patients discharged to sub-acute care. This retrospective cohort study used Medicare Claims and Electronic Health Record data to identify non-hospice Medicare beneficiaries with primary discharge diagnoses of stroke/ or hip fracture discharged from one of two urban hospitals to sub-acute care facilities during 2003-2008 (N = 1130). We evaluated the association of omission of the designation of a responsible clinician/clinic for follow-up care in the hospital discharge summary on the composite outcome of 30-day rehospitalization and/or death after adjusting for patient characteristics and utilization. We used multivariate logistic regression robust estimates clustered by discharging hospital. RESULTS: Patients whose discharge summaries omitted designation of a responsible clinician/clinic for follow-up care were significantly more likely to experience 30-day rehospitalization and/or death (OR: 1.51, 95% CI 1.07-2.12, P = 0.014). CONCLUSIONS: The current study found a strong relationship between the omission of a responsible clinician/clinic for follow-up care from the hospital discharge summary and the poor outcomes for patients transferred to sub-acute care. More research is needed to understand the role and impact of designating accountability for follow-up care needs on patient outcomes.

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.

Systematic Review of Programs Treating High-Need and High-Cost People With Multiple Chronic Diseases or Disabilities in the United States, 2008-2014.

INTRODUCTION: Finding ways to provide better and less expensive health care for people with multiple chronic conditions or disability is a pressing concern. The purpose of this systematic review was to evaluate different approaches for caring for this high-need and high-cost population. METHODS: We searched Medline for articles published from May 31, 2008, through June 10, 2014, for relevant studies. Articles were considered eligible for this review if they met the following criteria: included people with multiple chronic conditions (behavioral or mental health) or disabilities (2 or more); addressed 1 or more of clinical outcomes, health care use and spending, or patient satisfaction; and compared results from an intervention group with a comparison group or baseline measurements. We extracted information on program characteristics, participant characteristics, and significant (positive and negative) clinical findings, patient satisfaction, and health care use outcomes. For each outcome, the number of significant and positive results was tabulated. RESULTS: Twenty-seven studies were included across 5 models of care. Of the 3 studies reporting patient satisfaction outcomes, 2 reported significant improvements; both were randomized controlled trials (RCTs). Of the 14 studies reporting clinical outcomes, 12 reported improvements (8 were RCTs). Of the 13 studies reporting health care use and spending outcomes, 12 reported significant improvements (2 were RCTs). Two models of care - care and case management and disease management - reported improvements in all 3 outcomes. For care and case management models, most improvements were related to health care use. For the disease management models, most improvements were related to clinical outcomes. CONCLUSIONS: Care and case management as well as disease management may be promising models of care for people with multiple chronic conditions or disabilities. More research and consistent methods are needed to understand the most appropriate care for these high-need and high-cost patients.

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.

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.

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.

Racial/Ethnic Variations in Social Determinants of Mental Health Among Medicare Advantage Beneficiaries.

OBJECTIVES: We examine associations between social determinants and mental health and assess how the associations vary by race/ethnicity using a large, diverse sample of older adults. METHOD: A retrospective study of 444,057 older adults responding to the Medicare Health Outcomes Survey in 2015-2017 was conducted. Using a multilevel linear regression, we examined the associations between the self-reported number of unhealthy days due to mental health and social determinants, stratified by race/ethnicity. RESULTS: Health factors were most strongly associated with unhealthy days across all racial/ethnic groups. Strength of other factors varied by race/ethnicity. Social/economic factors had stronger associations among Whites, Asians, and multiracial individuals, while such factors were not significant for American Indians/Alaska Natives and Native Hawaiians/Other Pacific Islanders. DISCUSSION: We found varying degrees of associations between social determinants and poor mental health by racial/ethnic groups. These results suggest that homogeneous interventions may not meet the mental health needs of all.

Quality, health, and spending in Medicare Advantage and traditional Medicare.

OBJECTIVES: To compare Medicare Advantage (MA) and traditional Medicare (TM) performance on quality, health, and cost outcomes in peer-reviewed literature published since 2010. STUDY DESIGN: Systematic review of peer-reviewed papers published between January 1, 2010, and May 1, 2020. METHODS: To identify relevant research papers, we searched MEDLINE, EBSCO, and ProQuest. We excluded any studies that did not meet several inclusion criteria. Titles, abstracts, and full-text articles were independently reviewed by 1 author and several trained research assistants. Disagreements were resolved through discussion. We also reviewed the bibliographies of included studies and consulted subject matter experts to identify additional papers.For each eligible study, we extracted the first author, year published, study design, data sources, study years, sample sizes, relevant measures, and study quality. To ensure consistent and complete data extraction, each article was reviewed by 2 reviewers. Study quality was assessed using a modified Newcastle-Ottawa Scale. RESULTS: Thirty-five studies including 208 analyses were included. All included studies were observational. Two-thirds of studies were of high methodological quality for observational studies, and 49% addressed selection bias. Analyses compared quality of care (41%), health outcomes (44%), and spending (15%). Overall, 65% of analyses found a statistically significant relationship: 52% favored MA and 13% favored TM. CONCLUSIONS: More than half of recent analyses comparing MA and TM find that MA delivers significantly better quality of care, better health outcomes, and lower costs compared with TM.

Predictors of Older Adult Adherence With Emergency Department Discharge Instructions.

OBJECTIVE: Older adults discharged from the emergency department (ED) are at high risk for adverse outcomes. Adherence to ED discharge instructions is necessary to reduce those risks. The objective of this study is to determine the individual-level factors associated with adherence with ED discharge instructions among older adult ED outpatients. METHODS: We performed a secondary analysis of data from the control group of a randomized controlled trial testing a care transitions intervention among older adults (age ≥ 60 years) discharged home from the ED in two states. Taking data from patient surveys and chart reviews, we used multivariable logistic regression to identify patient characteristics associated with adherence to printed discharge instructions. Outcomes were patient-reported medication adherence, provider follow-up visit adherence, and knowledge of "red flags" (signs of worsening health requiring further medical attention). RESULTS: A total 824 patients were potentially eligible, and 699 had data in at least one pillar. A total of 35% adhered to medication instructions, 76% adhered to follow-up instructions, and 35% recalled at least one red flag. In the multivariate analysis, no factors were significantly associated with failure to adhere to medications. Participants with poor health status (adjusted odds ratio [AOR] = 0.55, 95% confidence interval [CI] = 0.31 to 0.98) were less likely to adhere to follow-up instructions. Participants who were older (AORs trended downward as age category increased) or depressed (AOR = 0.39, 95% CI = 0.17 to 0.85) or had one or more functional limitations (AOR = 0.62, 95% CI = 0.41 to 0.94) were less likely to recall red flags. CONCLUSION: Older adults discharged home from the ED have mixed rates of adherence to discharge instructions. Although it is thought that some subgroups may be higher risk than others, given the opportunity to improve ED-to-home transitions, EDs and health systems should consider providing additional care transition support to all older adults discharged home from the ED.

Association between social isolation and outpatient follow-up in older adults following emergency department discharge.

OBJECTIVES: Follow-up with outpatient clinicians after discharge from the emergency department (ED) reduces adverse outcomes among older adults, but rates are suboptimal. Social isolation, a common factor associated with poor health outcomes, may help explain these low rates. This study evaluates social isolation as a predictor of outpatient follow-up after discharge from the ED. MATERIALS AND METHODS: This cohort study uses the control group from a randomized-controlled trial investigating a community paramedic-delivered Care Transitions Intervention with older patients (age≥60 years) at three EDs in mid-sized cities. Social Isolation scores were measured at baseline using the PROMIS 4-item social isolation questionnaire, grouped into tertiles for analysis. Chart abstraction was conducted to identify follow-up with outpatient primary or specialty healthcare providers and method of contact within 7 and 30 days of discharge. RESULTS: Of 642 patients, highly socially-isolated adults reported significantly worse overall health, as well as increased anxiety, depressive symptoms, functional limitations, and co-morbid conditions compared to those less socially-isolated (p<0.01). We found no effect of social isolation on 30-day follow-up. Patients with high social isolation, however, were 37% less likely to follow-up with a provider in-person within 7 days of ED discharge compared to low social isolation (OR:0.63, 95% CI:0.42-0.96). CONCLUSION: This study adds to our understanding of how and when socially-isolated older adults seek outpatient care following ED discharge. Increased social isolation was not significantly associated with all-contact follow-up rates after ED discharge. However, patients reporting higher social isolation had lower rates of in-person follow-up in the week following ED discharge.

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.

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.