Role of Telehealth Use in Chronic Care Management and Disparity Reduction Among the Aging Population.

Introduction: To examine telehealth use in chronic care management and disparity reduction among the aging population. Methods: This longitudinal cohort study compared the changes in chronic care quality measures among patients with and without telehealth visits during the COVID-19 pandemic relative to patients in the previous years and by patient sociodemographic subgroup. Participants were Medicare fee-for-service beneficiaries 65 years or older from an Accountable Care Organization in the Midwest United States. Three utilization-based measures included having 2+ A1C tests, breast cancer screening, and depression screening. Three outcome-based measures included A1C control, blood pressure control, and depression diagnosis. Results: During the study period, the pandemic cohort experienced 5-17 percentage points' decrease in utilization-based measures (e.g., 2+ A1C tests 63.9% vs. 51.1%; OR [95% confidence intervals] = 0.35 [0.34-0.36]) from baseline relative to the control cohort. The outcome-based measures also significantly decreased but at smaller magnitudes (3-5 percentage points). About 51.5% patients had at least one telehealth visit. The utilization-based measures for these patients were significantly higher than those without any telehealth visit (e.g., 2+ A1C 57.1% vs. 51.1%, p < 0.01). However, the outcome-based measures were comparable. Patients from historically underserved groups had a larger decline in health care outcomes than their counterparts. Among patient with at least one telehealth visit, these disparities were no longer significant. Discussions: Telehealth was associated with less negative impact of the pandemic and better performance in chronic care management, but more for utilization-based measures and less for outcome-based measures. Telehealth was also associated with less disparities in care outcomes.

Use telehealth as needed: telehealth substitutes in-person primary care and associates with the changes in unplanned events and follow-up visits.

BACKGROUND: Telehealth rapidly expanded since the outbreak of the COVID-19 pandemic. This study aims to understand how telehealth can substitute in-person services by 1) estimating the changes in non-COVID emergency department (ED) visits, hospitalizations, and care costs among US Medicare beneficiaries by visit modality (telehealth vs. in-person) during the COVID-19 pandemic relative to the previous year; 2) comparing the follow-up time and patterns between telehealth and in-person care. METHODS: A retrospective and longitudinal study design using US Medicare patients 65 years or older from an Accountable Care Organization (ACO). The study period was April-December 2020, and the baseline period was March 2019 - February 2020. The sample included 16,222 patients, 338,872 patient-month records and 134,375 outpatient encounters. Patients were categorized as non-users, telehealth only, in-person care only and users of both types. Outcomes included the number of unplanned events and costs per month at the patient level; number of days until the next visit and whether the next visit happened within 3-, 7-, 14- and 30-days at the encounter level. All analyses were adjusted for patient characteristics and seasonal trends. RESULTS: Beneficiaries who used only telehealth or in-person care had comparable baseline health conditions but were healthier than those who used both types of services. During the study period, the telehealth only group had significantly fewer ED visits/hospitalizations and lower Medicare payments than the baseline (ED 13.2, 95% CI [11.6, 14.7] vs. 24.6 per 1,000 patients per month and hospitalization 8.1 [6.7, 9.4] vs. 12.7); the in-person only group had significantly fewer ED visits (21.9 [20.3, 23.5] vs. 26.1) and lower Medicare payments, but not hospitalizations; the both-types group had significantly more hospitalizations (23.0 [21.4, 24.6] vs. 17.8). Telehealth was not significantly different from in-person encounters in number of days until the next visit (33.4 vs. 31.2 days) or the probabilities of 3- and 7-day follow-up visits (9.2 vs. 9.3% and 21.8 vs.23.5%). CONCLUSIONS: Patients and providers treated telehealth and in-person visits as substitutes and used either depending on medical needs and availability. Telehealth did not lead to sooner or more follow-up visits than in-person services.

Post-Acute Care in Inpatient Rehabilitation Facilities Between Traditional Medicare and Medicare Advantage Plans Before and During the COVID-19 Pandemic.

OBJECTIVES: Compare post-acute care (PAC) utilization and outcomes in inpatient rehabilitation facilities (IRF) between beneficiaries covered by Traditional Medicare (TM) and Medicare Advantage (MA) plans during the COVID-19 pandemic relative to the previous year. DESIGN: This multiyear cross-sectional study used Inpatient Rehabilitation Facility-Patient Assessment Instrument (IRF-PAI) data to assess PAC delivery from January 2019 to December 2020. SETTING AND PARTICIPANTS: Inpatient rehabilitation for stroke, hip fracture, joint replacement, and cardiac and pulmonary conditions among Medicare beneficiaries 65 years or older. METHODS: Patient-level multivariate regression models with difference-in-differences approach were used to compare TM and MA plans in length of stay (LOS), payment per episode, functional improvements, and discharge locations. RESULTS: A total of 271,188 patients were analyzed [women (57.1%), mean (SD) age 77.8 (0.06) years], among whom 138,277 were admitted for stroke, 68,488 hip fracture, 19,020 joint replacement, and 35,334 cardiac and 10,069 pulmonary conditions. Before the pandemic, MA beneficiaries had longer LOS (+0.22 days; 95% CI: 0.15-0.29), lower payment per episode (-$361.05; 95% CI: -573.38 to -148.72), more discharges to home with a home health agency (HHA) (48.9% vs 46.6%), and less to a skilled nursing facility (SNF) (15.7% vs 20.2%) than TM beneficiaries. During the pandemic, both plan types had shorter LOS (-0.68 day; 95% CI: 0.54-0.84), higher payment (+$798; 95% CI: 558-1036), increased discharges to home with an HHA (52.8% vs 46.6%), and decreased discharges to an SNF (14.5% vs 20.2%) than before. Differences between TM and MA beneficiaries in these outcomes became smaller and less significant. All results were adjusted for beneficiary and facility characteristics. CONCLUSIONS AND IMPLICATIONS: Although the COVID-19 pandemic affected PAC delivery in IRF in the same directions for both TM and MA plans, the timing, time duration, and magnitude of the impacts were different across measures and admission conditions. Differences between the 2 plan types shrank and performance across all dimensions became more comparable over time.

The Relative Importance of Hospital Discharge and Patient Composition in Changing Post-Acute Care Utilization and Outcomes Among Medicare Beneficiaries.

Background: The COVID-19 pandemic changed care delivery. But the mechanisms of changes were less understood. Objectives: Examine the extent to which the volume and pattern of hospital discharge and patient composition contributed to the changes in post-acute care (PAC) utilization and outcomes during the pandemic. Research design: Retrospective cohort study. Medicare claims data on hospital discharges in a large healthcare system from March 2018 to December 2020. Subjects: Medicare fee-for-service beneficiaries, 65 years or older, hospitalized for non-COVID diagnoses. Measures: Hospital discharges to Home Health Agencies (HHA), Skilled Nursing Facilities (SNF), and Inpatient Rehabilitation Facilities (IRF) versus home. Thirty- and ninety-day mortality and readmission rates. Outcomes were compared before and during the pandemic with and without adjustment for patient characteristics and/or interactions with the pandemic onset. Results: During the pandemic, hospital discharges declined by 27%. Patients were more likely to be discharged to HHA (+4.6%, 95% CI [3.2%, 6.0%]) and less likely to be discharged to either SNF (-3.9%, CI [-5.2%, -2.7%]) or to home (-2.8% CI [-4.4%, -1.3%]). Thirty- and ninety-day mortality rates were significantly higher by 2% to 3% points post-pandemic. Readmission were not significantly different. Up to 15% of the changes in discharge patterns and 5% in mortality rates were attributable to patient characteristics. Conclusions: Shift in discharge locations were the main driver of changes in PAC utilization during the pandemic. Changes in patient characteristics explained only a small portion of changes in discharge patterns and were mainly channeled through general impacts rather than differentiated responses to the pandemic.

Disparities in the Use of In-Person and Telehealth Primary Care Among High- and Low-Risk Medicare Beneficiaries During COVID-19.

We conducted a retrospective cohort study using a difference-in-differences design to estimate differences in primary care outpatient clinic visit utilization among high- and low-risk Medicare aging beneficiaries from an Accountable Care Organization during the COVID-19 pandemic compared to a control cohort from the previous year. High-risk was defined as having a Hierarchical Condition Category score of 2 or higher. A total of 582 101 patient-month records were analyzed. After adjusting for patient characteristics, those in the high-risk group had 339 (95% CI [333, 345]) monthly outpatient encounters (in-person and telehealth) per 1000 patients compared to 186 (95% CI [182, 190]) in the low-risk group. This represented a 22.8% and 26.5% decline from the previous year in each group, respectively. Within each group, there was lower utilization among those who were older, male, or dually eligible for Medicaid in the high-risk group and among those who were younger, male, or non-white in the low-risk group. Telehealth use was less common among patients who were older, dually eligible for Medicaid or living in rural/suburban areas compared to urban areas. All results were significant at the 95% level. We found significant disparities based on age, gender, insurance status, and non-white race in primary care utilization during the pandemic among Medicare beneficiaries. With the exception of gender, these disparities differed between high- and low-risk groups. Interventions targeting these vulnerable groups may improve health equity in the setting of public health emergencies.

AcademyHealth Annual Research Meeting (ARM): A Selection of Abstracts Accepted for Oral Presentation, 2021.

RESEARCH OBJECTIVE: To investigate the extent to which telehealth visits mitigated COVID-19 pandemic-related impacts on in-person outpatient visits among Medicare beneficiaries, including those who are high-cost high-need. High-cost high-need patients were defined as those 65 years or older and with 2 or higher Hierarchical Condition Categories (HCC) scores. STUDY DESIGN: A difference-in-difference design was used to estimate the change in outpatient in-person and telehealth utilization for the COVID-19 pandemic cohort compared to the control cohort in the prior year. POPULATION STUDIED: Medicare patients from an Accountable Care Organization (ACO) were used as the study sample. The pandemic cohort was defined as those enrolled in the ACO in 2019-2020 (N = 21,361). The control cohort was defined as those enrolled in the ACO in 2018-2019 (N = 20,028). The study period was defined as April-September 2020 for the pandemic cohort and the same months in 2019 for the control cohort, with the preceding 12 months used as the baseline periods, respectively. Over 740,000 patient-month records were analyzed using logistic and negative binomial regressions. The models were adjusted for patient-level characteristics, including HCC scores, which reflect the complexity of patient health conditions and risk for future healthcare costs. PRINCIPAL FINDINGS: The total number of outpatient encounters (in-person and telehealth) in both primary and specialty care decreased by 41.5% in April 2020 compared to the pre-pandemic period. Telehealth comprised 78% of all outpatient encounters in April 2020 but declined to 22% by the end of September 2020. Only about 40% of all patients had at least one telehealth encounter between April-September 2020. Compared to the control cohort, the pandemic cohort experienced a monthly average of 113 fewer primary care encounters per 1000 patients (OR: 0.75, 95% CI: [0.73, 0.77]) and 49 fewer specialty care encounters (OR: 0.82, 95% CI: [0.80, 0.85]) over the six-month study period. This represented a decline of 25.6% and 17.3% in primary care and specialty encounters, respectively, among high-cost high-need patients. High-cost high-need patients or those with disabilities were more likely to use telehealth and experienced a lesser reduction in outpatient care utilization than other Medicare beneficiaries (OR: 1.20 and 1.06). Medicare beneficiaries with dual Medicaid coverage, those of non-white race/ethnic groups, and those living in rural/suburban areas were less likely to use telehealth and experienced a greater reduction in total outpatient care (OR: 0.86, 0.96 and 0.90). CONCLUSIONS: While there was a substantial significant increase in telehealth use in April 2020, utilization declined significantly during the six-month study period, and did not fully mitigate the decline in in-person outpatient visits resulting from the COVID-19 pandemic. While high-cost high-need Medicare patients and those with disabilities were more likely to use telehealth, disparities in telehealth usage and reductions in outpatient care remain among low-income, non-white, and rural Medicare beneficiaries. IMPLICATIONS FOR POLICY OR PRACTICE: Older patients insured by Medicare, including those with high-cost high-need or disabilities were able to make use of telehealth services for outpatient visits during the COVID-19 pandemic. Health policies and interventions should target improving telehealth access and delivery for advancing sustainability and equity among Medicare beneficiaries. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Inpatient rehabilitation service utilization and outcomes under US ACA Medicaid expansion.

BACKGROUND: To investigate the impact of the US Medicaid expansion on care utilization and health outcomes of patients treated in the inpatient rehabilitation facilities (IRF). METHODS: A retrospective observational study with a difference-in-difference design. The data was obtained from Inpatient Rehabilitation Facility - Patient Assessment Instrument (IRF-PAI). Sample included all Medicaid beneficiaries (aged 18-64 years) who received initial inpatient rehabilitation for stroke, hip fracture (acute conditions), or joint replacement (elective condition) (N = 14,917) before (2013) and after (2016) the expansion. The study estimated the differences in length of stay, functional improvement, and possibility of returning to community before and after ACA Medicaid expansion in the expansion regions relative to the non-expansion regions. The analysis was fully adjusted for patient demographics, health conditions, facility characteristics and time trends. RESULTS: Compared with non-expansion states, service volume in the expansion regions increased more for the two acute conditions (49 and 27% vs. 1% and - 4%) and decreased less for the selective condition (- 12% vs. -34%) after ACA Medicaid expansion. Medicaid expansion was associated with significant decreases in patient functional improvements (- 1.63 points for stroke, - 3.61 points for fracture and - 2.73 points for joint; P < 0.05). Length of stay and the possibility of returning to community after discharge were not significantly different. CONCLUSIONS: Medicaid expansion was associated with increases in the utilization of inpatient rehabilitation services and decreases in the patient functional improvements. Cautions should be taken with the decreases in functional improvements among some subpopulation in the short-term; longer follow up periods are needed to account for gradual changes in patient needs.

Life Partner Influence on Uptake of Preventive Services: Evidence From Flu Vaccine Adoption Among the Aging Population.

Objectives: This study examines how the patterns of life partner concordance on preventive health service uptake vary by a partner's previous behavioral history and between genders. Method: This study uses 2008 and 2012 waves of Health and Retirement Study (HRS), a nationally representative sample of U.S. aging population, to examine one's decision to receive a preventive service as a function of the partner's decision changes over time (N = 2,680). Results: Life partner concordance on preventive service use is different by the partner's previous use history and gender. Positive partner preventive engagement showed greater association than negative ones. Women are more responsive to the positive health behaviors (of their partners), and men are more sensitive to the negative partner health behaviors. Conclusion: The asymmetric partner concordance by gender and the partner's previous usage experience provide implications to develop efficient and culturally acceptable interventions to increase the uptake of preventive health services.