Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model.

Importance: The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model. Objective: To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients' social risk. Design, Setting, and Participants: A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021. Exposure: Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics. Main Outcomes and Measures: Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization. Results: Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001). Conclusions: In the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.

Potentially More Out of Reach: Public Reporting Exacerbates Inequities in Home Health Access.

Policy Points Public reporting is associated with both mitigating and exacerbating inequities in high-quality home health agency use for marginalized groups. Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does. Targeted federal, state, and local interventions should focus on raising awareness about the five-star quality ratings among marginalized populations for whom inequities have been exacerbated. CONTEXT: Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high-quality, long-term care for older adults. The objective of this study is to evaluate the impact of the home health five-star ratings on changes in high-quality home health agency use by race, ethnicity, income status, and place-based factors. METHODS: We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high-quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five-star rating introduction on the use of high-quality home health agencies, we use a longitudinal observational pretest-posttest design. FINDINGS: After the introduction of the home health five-star ratings in 2016, we found that adjusted rates of high-quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high-quality home health agency use between low-income and higher-income home health patients was exacerbated after the introduction of the five-star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high-quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high-quality home health agency use. Other neighborhoods experience a nonsignificant change in high-quality home health agency use. CONCLUSIONS: Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low-income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five-star ratings.

A digital divide in the COVID-19 pandemic: information exchange among older Medicare beneficiaries and stakeholders during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic resulted in unprecedented challenges for older adults. Medicare enrollment was already an overwhelming process for a high fraction of older adults pre-pandemic. Therefore, the purpose of this qualitative study was to gain understanding from community organizations and stakeholders about their pre-pandemic and during-pandemic experiences while adapting to continue offering insurance advice to seniors, what resources are available to seniors, and what needs to be done to help seniors make higher quality insurance choices in the Medicare program. In addition, we wanted to explore how the COVID-19 pandemic may have changed the ways that these stakeholders interacted with Medicare beneficiaries. METHODS: We employed a qualitative strategy to gain a deep understanding of the challenges that these organizations may have faced while offering advice/counseling to older adults. We accomplished this by interviewing a group of 30 stakeholders from different states. RESULTS: Every stakeholder mentioned that some older adults have difficulty making Medicare decisions, and 16 stakeholders mentioned that their system is complex and/or overwhelming for older adults. Twenty-three stakeholders mentioned that Medicare beneficiaries are often confused about Medicare, and this is more noticeable among new enrollees. With the onset of the pandemic, 22 of these organizations mentioned that they had to move to a virtual model in order to assist beneficiaries, especially at the beginning of the pandemic. However, older adults seeking advice/meetings have a strong preference for in-person meetings even during the pandemic. Given that the majority of the beneficiaries that these stakeholders serve may not have access to technology, it was difficult for some of them to smoothly transition to a virtual environment. With Medicare counseling moving to virtual or telephone methods, stakeholders discussed that many beneficiaries had difficulty utilizing these options in a variety of ways. CONCLUSIONS: Findings from our interviews with stakeholders provided information regarding experiences providing Medicare counseling pre- and during-COVID-19 pandemic. Some of the barriers faced by older adults included a complex and overwhelming system, a strong preference for in-person meetings among beneficiaries, challenges with technology, and an increased risk of information overload and misinformation. While bias may exist within the study and sample, given that technology-savvy beneficiaries may not seek help from organizations our study participants work in, they show how the current Medicare system may impact vulnerable older adults who may need support with access to high-speed internet and digital literacy.

Examining the role of race and quality of home health agencies in delayed initiation of home health services for individuals with Alzheimer's disease and related dementias (ADRD).

INTRODUCTION: We examined differences in the timeliness of the initiation of home health care by race and the quality of home health agencies (HHA) among patients with Alzheimer's disease and related dementias (ADRD). METHODS: Medicare claims and home health assessment data were used for the study cohort: individuals aged ≥65 years with ADRD, and discharged from the hospital. Home health latency was defined as patients receiving home health care after 2 days following hospital discharge. RESULTS: Of 251,887 patients with ADRD, 57% received home health within 2 days following hospital discharge. Black patients were significantly more likely to experience home health latency (odds ratio [OR] = 1.15, 95% confidence interval [CI] = 1.11-1.19) compared to White patients. Home health latency was significantly higher for Black patients in low-rating HHA (OR = 1.29, 95% CI = 1.22-1.37) compared to White patients in high-rating HHA. DISCUSSION: Black patients are more likely to experience a delay in home health care initiation than White patients.

Quality at nursing homes with high proportion of residents with cognitive impairment.

INTRODUCTION: There is limited data on staffing ratings at nursing homes (NHs) serving residents with dementia, despite staffing impacting quality of care. METHODS: Residents' cognitive impairment status, staffing rating, and facility characteristics were obtained for 11,469 NHs, using data from the Centers for Medicare & Medicaid Services and Long-term Care: Facts on Care in the U.S. The association between the proportion of residents with cognitive impairment and nurse staffing rating was analyzed using multiple logistic regression in a cross-sectional study design. RESULTS: NHs with a high proportion of residents with cognitive impairment were 41% less likely to have a high staffing rating or high RN staffing rating (95% CI: 0.52-0.67) compared to NHs with a low proportion. DISCUSSION: NHs that serve a higher proportion of residents with cognitive impairment have lower staffing ratings, and this disparity is more pronounced in NHs with more minority residents. Increasing staffing levels is a necessary policy measure to improve care in these facilities.

Medicaid Expansion and Incidence of Kidney Failure among Nonelderly Adults.

BACKGROUND: Low-income individuals without health insurance have limited access to health care. Medicaid expansions may reduce kidney failure incidence by improving access to chronic disease care. METHODS: Using a difference-in-differences analysis, we examined the association between Medicaid expansion status under the Affordable Care Act (ACA) and the kidney failure incidence rate among all nonelderly adults, aged 19-64 years, in the United States, from 2012 through 2018. We compared changes in kidney failure incidence in states that implemented Medicaid expansions with concurrent changes in nonexpansion states during pre-expansion, early postexpansion (years 2 and 3 postexpansion), and later postexpansion (years 4 and 5 postexpansion). RESULTS: The unadjusted kidney failure incidence rate increased in the early years of the study period in both expansion and nonexpansion states before stabilizing. After adjustment for population sociodemographic characteristics, Medicaid expansion status was associated with 2.20 fewer incident cases of kidney failure per million adults per quarter in the early postexpansion period (95% CI, -3.89 to -0.51) compared with nonexpansion status, a 3.07% relative reduction (95% CI, -5.43% to -0.72%). In the later postexpansion period, Medicaid expansion status was not associated with a statistically significant change in kidney failure incidence (-0.56 cases per million per quarter; 95% CI, -2.71 to 1.58) compared with nonexpansion status and the pre-expansion time period. CONCLUSIONS: The ACA Medicaid expansion was associated with an initial reduction in kidney failure incidence among the entire, nonelderly, adult population in the United States; but the changes did not persist in the later postexpansion period. Further study is needed to determine the long-term association between Medicaid expansion and changes in kidney failure incidence.

Seniors don't use Medicare.Gov: how do eligible beneficiaries obtain information about Medicare Advantage Plans in the United States?

BACKGROUND: Managed care programs in the US are becoming a preferred alternative among low-income individuals in the US. Every year during open enrollment, seniors can enroll in Medicare Advantage (MA) or switch MA plans. However, there is very limited information about how seniors obtain information to help them make their choices. While the Centers for Medicaid and Medicare offer online resources that are designed to enable potential beneficiaries to make informed coverage decisions, there is no information as to whether seniors use these resources, and therefore whether these resources are effective compared to other information retrieval methods. METHODS: The purpose of the present study was to qualitatively explore how seniors obtain information about insurance plans in MA. We conducted semi-structured interviews with 26 MA beneficiaries from Rhode Island. RESULTS: We found that most seniors have strong preferences for obtaining information in-person regarding benefits, cost and other plan information. Some seniors relied heavily on insurance brokers or representatives, and considered the information provided to them without questioning the potential for bias. Others consulted with family and/or friends for guidance, or to compare costs and benefits. Only a few of these seniors used the available internet resources, and in fact most of them mentioned that they did not have a computer/smart device with internet capabilities. However, among those who used and appeared to be comfortable with navigating the internet, www.medicare.gov was not discussed as a useful resource for making decisions regarding health insurance. CONCLUSIONS: This study suggests that existing online medical resource usage and effects among senior citizens in the United States may need supplementing with in-person communication among influential agents.

Hospital Readmission Rates in Medicare Advantage and Traditional Medicare: A Retrospective Population-Based Analysis.

Background: Medicare's Hospital Readmissions Reduction Program reports risk-standardized readmission rates for traditional Medicare but not Medicare Advantage beneficiaries. Objective: To compare readmission rates between Medicare Advantage and traditional Medicare. Design: Retrospective cohort study linking the Medicare Provider Analysis and Review (MedPAR) file with the Healthcare Effectiveness Data and Information Set (HEDIS). Setting: 4748 U.S. acute care hospitals. Patients: Patients aged 65 years or older hospitalized for acute myocardial infarction (AMI) (n = 841 613), congestive heart failure (CHF) (n = 1 458 652), or pneumonia (n = 2 020 365) between 2011 and 2014. Measurements: 30-day readmissions. Results: Among admissions for AMI, CHF, and pneumonia identified in MedPAR, 29.2%, 38.0%, and 37.2%, respectively, did not have a corresponding record in HEDIS. Of these, 18.9% for AMI, 23.7% for CHF, and 18.3% for pneumonia resulted in a readmission that was identified in MedPAR. However, among index admissions appearing in HEDIS, 14.4% for AMI, 18.4% for CHF, and 13.9% for pneumonia resulted in a readmission. Patients in Medicare Advantage had lower unadjusted readmission rates than those in traditional Medicare for all 3 conditions (16.6% vs. 17.1% for AMI, 21.4% vs. 21.7% for CHF, and 16.3% vs. 16.4% for pneumonia). However, after standardization, patients in Medicare Advantage had higher readmission rates than patients in traditional Medicare for AMI (17.2% vs. 16.9%; difference, 0.3 percentage point [95% CI, 0.1 to 0.5 percentage point]), CHF (21.7% vs. 21.4%; difference, 0.3 percentage point [CI, 0.2 to 0.5 percentage point]), and pneumonia (16.5% vs. 16.0%; difference, 0.5 percentage point [95% CI, 0.4 to 0.6 percentage point]). Rate differences increased between 2011 and 2014. Limitation: Potential unobserved differences between populations. Conclusion: The HEDIS data underreported hospital admissions for 3 common medical conditions, and readmission rates were higher among patients with underreported admissions. Medicare Advantage beneficiaries had higher risk-adjusted 30-day readmission rates than traditional Medicare beneficiaries. Primary Funding Source: National Institute on Aging.

Preventive healthcare-seeking behavior among poor older adults in Mexico: the impact of Seguro Popular, 2000-2012.

OBJECTIVE: Determine the effect of Seguro Popular (SP) on preventive care utilization among low-income SP beneficiaries and uninsured elders in Mexico. MATERIALS AND METHODS: Fixed-effects instrumental-variable (FE-IV) pseudo-panel estimation from three rounds of the Mexican National Health and Nutrition Survey (2000, 2006 and 2012). RESULTS: Our findings suggest that SP has no significant effect on the use of preventive services, including screening for diabetes, hypertension, breast cancer and cervical cancer, by adults aged 50 to 75 years. CONCLUSIONS: Despite the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in healthcare access and utilization still exist in Mexico. The Mexican government must keep working on extending health insurance coverage to vulnerable adults. Additional efforts to increase health care coverage and to support preventive care are needed to reduce persistent disparities in healthcare utilization.

OBJETIVO: Determinar el efecto del Seguro Popular (SP) en la utilización de la atención preventiva entre beneficiarios de SP de bajos ingresos y ancianos sin seguro en México. MATERIAL Y MÉTODOS: Estimación de pseudopanel de variables instrumentales de efectos fijos (FE-IV) en tres rondas de la Encuesta Nacional de Salud y Nutrición de México (2000, 2006 y 2012). RESULTADOS: El SP no tiene un efecto significativo en el uso de los servicios preventivos, incluida la detección de diabetes, hipertensión, cáncer de mama y cáncer de cuello uterino en adultos de 50 años o más. CONCLUSIONES: Aún existen desigualdades en el acceso a la asistencia médica en México. El gobierno mexicano debe seguir trabajando para extender la cobertura del seguro de salud a la población más vulnerable. Se necesitan esfuerzos adicionales para aumentar la cobertura de atención médica y apoyar la atención preventiva para reducir las disparidades persistentes.

The growth of gerontology and geriatrics in Mexico: Past, present, and future.

Life expectancy is increasing in Mexico, creating new opportunities and challenges in different areas, including gerontology and geriatric education and research. Although in the European Union there are more than 3,000 institutions that focus on aging research, in Latin America there are only 250 programs where theoretical and practical knowledge is taught. In Mexico, the number of institutions that offer gerontology and geriatric education is relatively small. One of the major concerns is that Mexico is not adequately prepared to optimally deal with the aging of its population. Thus, the main challenge that Mexico faces is to train practitioners, researchers, and policy makers to be able to respond to the aging priorities of this country. The goal of this review is to investigate the literature regarding 60 years in the fields of gerontology and geriatrics in Mexico. Even when programs have evolved within the past decades, there are some challenges to gerontological and geriatric education and aging research in Mexico. The implications for Mexico are discussed, as well as opportunities for moving these fields forward.

Religiosity, Social Support and Care Associated with Health in Older Mexicans with Diabetes.

The main purpose of this study was to examine the relationships between religiosity, social support, diabetes care and control and self-rated health of people living in Mexico who have been diagnosed with diabetes. Structural equation modeling was used to examine these associations using the Mexican Health and Aging Study, a national representative survey of older Mexicans. Findings indicate that emotional support from one's spouse/partner directly affects diabetes care and control and health. Although there is no direct relationship between religiosity and health, religiosity was positively associated with diabetes care and control, but not significantly related to health.

The role of religious leaders in health promotion for older Mexicans with diabetes.

Clergy in the Mexico play a major role in addressing the health care needs of their congregants. With qualitative semi-structured key-informant interviews, this study explored the views of ten male Mexican religious leaders (mostly Catholic) about their understanding of their role in diabetes health promotion. The major themes from the qualitative interviews emphasized the importance of open communication between church leaders and their parishioners, the role of the church in diabetes programs, and the unique position of religious institutions as a link between physical and spiritual aspects of health. Implications for diabetes interventions are discussed.

Pay-for-Performance Incentives for Home Dialysis Use and Kidney Transplant.

Importance: The Centers for Medicare & Medicaid Services' mandatory End-Stage Renal Disease Treatment Choices (ETC) model, launched on January 1, 2021, randomly assigned approximately 30% of US dialysis facilities and managing clinicians to financial incentives to increase the use of home dialysis and kidney transplant. Objective: To assess the ETC's association with use of home dialysis and kidney transplant during the model's first 2 years and examine changes in these outcomes by race, ethnicity, and socioeconomic status. Design, Setting, and Participants: This retrospective cross-sectional study used claims and enrollment data for traditional Medicare beneficiaries with kidney failure from 2017 to 2022 linked to same-period transplant data from the United Network for Organ Sharing. The study data span 4 years (2017-2020) before the implementation of the ETC model on January 1, 2021, and 2 years (2021-2022) following the model's implementation. Exposure: Receiving dialysis treatment in a region randomly assigned to the ETC model. Main Outcomes and Measures: Primary outcomes were use of home dialysis and kidney transplant. A difference-in-differences (DiD) approach was used to estimate changes in outcomes among patients treated in regions randomly selected for ETC participation compared with concurrent changes among patients treated in control regions. Results: The study population included 724 406 persons with kidney failure (mean [IQR] age, 62.2 [53-72] years; 42.5% female). The proportion of patients receiving home dialysis increased from 12.1% to 14.3% in ETC regions and from 12.9% to 15.1% in control regions, yielding an adjusted DiD estimate of -0.2 percentage points (pp; 95% CI, -0.7 to 0.3 pp). Similar analysis for transplant yielded an adjusted DiD estimate of 0.02 pp (95% CI, -0.01 to 0.04 pp). When further stratified by sociodemographic measures, including age, sex, race and ethnicity, dual Medicare and Medicaid enrollment, and poverty quartile, there was not a statistically significant difference in home dialysis use across joint strata of characteristics and ETC participation. Conclusions and Relevance: In this cross-sectional study, the first 2 years of the ETC model were not associated with increased use of home dialysis or kidney transplant, nor changes in racial, ethnic, and socioeconomic disparities in these outcomes.

Medicare Advantage enrollment by immigration and English proficiency status.

OBJECTIVES: Complex Medicare Advantage (MA) health plan choices may overwhelm immigrants, especially for those facing decision-making constraints due to limited English proficiency (LEP). We examined the trends and patterns of MA enrollment by immigration and English proficiency status. STUDY DESIGN: We employed a cross-sectional design using data from the 2008-2019 Medical Expenditure Panel Survey. METHODS: Our outcome was enrollment in an MA plan. Our primary independent variables were immigration and English proficiency status. We categorized the sample into 3 groups: LEP immigrants, non-LEP immigrants, and US-born residents. After adjusting for individual-level characteristics, we estimated the adjusted rates of MA enrollment for each group. RESULTS: Our adjusted analysis showed that MA enrollment was higher among immigrants than US-born residents, but the highest enrollment was found among LEP immigrants (LEP immigrants: 45.5%; 95% CI, 42.7%-48.2%; non-LEP immigrants: 42.1%; 95% CI, 39.4%-44.8%; US-born residents: 35.1%; 95% CI, 34.5%-35.6%). MA enrollment was higher among LEP immigrants with better health status (good self-reported health: 45.4%; 95% CI, 41.9%-48.8%; poor self-reported health: 41.4%; 95% CI, 37.7%-45.1%). However, we found small to no differences in the adjusted rates of MA enrollment between those with good vs poor self-reported health in both the non-LEP immigrants and US-born residents groups. We found no consistent enrollment patterns by socioeconomic status such as race/ethnicity, education, and income. CONCLUSIONS: Our findings suggest higher MA enrollment among immigrants, especially for LEP immigrants. Future research should study the care experience of immigrants in MA.

Effect of Variation in Early Rehabilitation on Hospital Readmission After Hip Fracture.

OBJECTIVE: Provision of early rehabilitation services during acute hospitalization after a hip fracture is vital for improving patient outcomes. The purpose of this study was to examine the association between the amount of rehabilitation services received during the acute care stay and hospital readmission in older patients after a hip fracture. METHODS: Medicare claims data (2016-2017) for older adults admitted to acute hospitals for a hip fracture (n = 131,127) were used. Hospital-based rehabilitation (physical therapy, occupational therapy, or both) was categorized into tertiles by minutes per day as low (median = 17.5), middle (median = 30.0), and high (median = 48.8). The study outcome was risk-adjusted 7-day and 30-day all-cause hospital readmission. RESULTS: The median hospital stay was 5 days (interquartile range [IQR] = 4-6 days). The median rehabilitation minutes per day was 30 (IQR = 21-42.5 minutes), with 17 (IQR = 12.6-20.6 minutes) in the low tertile, 30 (IQR = 12.6-20.6 minutes) in the middle tertile, and 48.8 (IQR = 42.8-60.0 minutes) in the high tertile. Compared with high therapy minutes groups, those in the low and middle tertiles had higher odds of a 30-day readmission (low tertile: odds ratio [OR] = 1.11, 95% CI = 1.06-1.17; middle tertile: OR = 1.07, 95% CI = 1.02-1.12). In addition, patients who received low rehabilitation volume had higher odds of a 7-day readmission (OR = 1.20; 95% CI = 1.10-1.30) compared with high volume. CONCLUSION: Elderly patients with hip fractures who received less rehabilitation were at higher risk of readmission within 7 and 30 days. IMPACT: These findings confirm the need to update clinical guidelines in the provision of early rehabilitation services to improve patient outcomes during acute hospital stays for individuals with hip fracture. LAY SUMMARY: There is significant individual- and hospital-level variation in the amount of hospital-based rehabilitation delivered to older adults during hip fracture hospitalization. Higher intensity of hospital-based rehabilitation care was associated with a lower risk of hospital readmission within 7 and 30 days.

Resident Factors Associated With Breakthrough SARS-CoV-2 Infections.

OBJECTIVE: To examine incidence of and resident characteristics associated with breakthrough infections (BTIs) and severe illness among residents with 2 messenger RNA (mRNA) vaccinations. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Nursing home (NH) residents who completed their primary series of mRNA COVID-19 vaccination by March 31, 2021. METHODS: Electronic health records and Minimum Data Set assessments from a multistate NH data consortium were used to identify BTI and severe illness (a composite measure of hospitalization and/or death within 30 days of BTI) occurring prior to November 24, 2021. A t test for differences in means was used to compare covariates for residents with and without BTI. Finally, we estimated incidence rate ratios (IRRs) for BTI with 95% CIs using a modified Poisson regression approach, comparing residents with BTI vs residents without. We adjusted for facility fixed effects in our model. RESULTS: Our sample included 23,172 residents from 984 NHs who were at least 14 days past their second mRNA vaccine dose. Of those, 1173 (5%) developed an incident COVID-19 BTI (mean follow-up time: 250 days). Among residents with BTI, 8.6% were hospitalized or died within 30 days of BTI diagnosis. Factors associated with severe illness included age ≥85 years (IRR 2.08, 95% CI 1.08-4.02, reference age <65 years), bowel incontinence (IRR 1.73, 95% CI 1.01-2.99), coronary artery disease (IRR 1.96, 95% CI 1.31-2.94), chronic kidney disease (IRR 1.65, 95% CI 1.07-2.54), and schizophrenia (IRR 2.38, 95% CI 1.19-4.75). CONCLUSIONS AND IMPLICATIONS: Among vaccinated NH residents, BTIs and associated severe illness are rare. Residents aged ≥85 years and with certain comorbidities appear to be the most vulnerable. Given that the pandemic continues and testing policies have relaxed, these data provide prognostic information for NH facilities faced with continued outbreaks.

Enrollment in Supplemental Insurance Coverage Among Medicare Beneficiaries by Race/Ethnicity.

OBJECTIVES: The objective of this study was to examine racial/ethnic differences in enrollment trends for supplemental insurance coverage among traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries. STUDY DESIGN: We employed a retrospective cohort study design using the 2010-2016 Medicare Current Beneficiary Survey. METHODS: We included two types of outcomes: 1) seven exclusive types of insurance coverage in a given year and 2) changes in insurance coverage in the next year for those with each of the seven exclusive types of insurance coverage. Our primary independent variable was race/ethnicity. We conducted regression while controlling for demographic, socioeconomic, and health characteristics. We calculated the adjusted value of the outcome by race/ethnicity after adjusting for demographic, socioeconomic, and health status characteristics. RESULTS: We found substantial racial/ethnic differences in supplemental insurance coverage among TM and MA beneficiaries. Compared to White beneficiaries, racial/ethnic minority beneficiaries had lower adjusted rates of enrollment in Medigap among TM beneficiaries and higher enrollment in Medicaid among both TM and MA beneficiaries. Trends in enrollment differed by supplemental insurance coverage, but an increasing trend in enrollment among MA beneficiaries without supplemental insurance coverage and MA beneficiaries with Medicaid was notable. Overall trends were consistent across all racial/ethnic groups. Finally, most beneficiaries were less likely to change insurance coverage in the next year, but a distinct phenomenon was observed among Black beneficiaries with the lowest rates of remaining in Medigap or MA only. CONCLUSIONS: Our findings indicate the minority Medicare beneficiaries may not have equitable access to supplemental insurance coverage.

Comparing the care experiences of Medicare Advantage beneficiaries with and without Alzheimer's disease and related dementias.

BACKGROUND: The Medicare Advantage (MA) program is rapidly growing. Limited evidence exists about the care experiences of MA beneficiaries with Alzheimer's Disease and Related Dementia (ADRD). Our objective was to compare care experiences for MA beneficiaries with and without ADRD. METHODS: We examined MA beneficiaries who completed the Medicare Advantage Consumer Assessment of Healthcare Providers and Systems (CAHPS) and used inpatient, nursing home, or home health services in the past 3 years. We classified beneficiaries with ADRD using the presence of diagnosis codes in hospitals, nursing homes, and home health records. Our key measures included overall ratings of care and health plan, and indices of receiving timely care, care coordination, receiving needed care, and customer service. We compared differences between beneficiaries with and without ADRD using regression analysis adjusting for demographic, health, and plan characteristics, and stratifying by proxy response status. RESULTS: Among beneficiaries sampled by CAHPS, 22.2% with ADRD completed the survey compared to 38.5% without ADRD. Among proxy responses, beneficiaries with ADRD were 4.2 (95% CI: 0.1-8.4) percentage points less likely to report a high score for receiving needed care, and 3.5 percentage points (95% CI: 0.2-6.9) less likely to report a high score for customer service. Among non-proxy responses, those with ADRD were 9.0 (95% CI: 5.5-12.5) percentage points less likely to report a high score for needed care, and 8.5 (95% CI: 5.4-11.5) percentage points less likely to report a high score for customer service. CONCLUSIONS: ADRD respondents to the CAHPS were more likely to be excluded from CAHPS performance measures because they did not meet eligibility requirements and rates of non-response were higher. Among responders with or without a proxy, MA enrollees with an ADRD diagnosis reported worse care experiences in receiving needed care and in customer service than those without an ADRD diagnosis.