Disparities in Access to Outpatient Surgery Related to Removal of Procedures from Medicare's Inpatient Only List.

OBJECTIVE: We assessed the shift from inpatient to outpatient surgical care related to changes to the Inpatient Only List in 2020 and 2021 compared to 2019. SUMMARY BACKGROUND DATA: The extent to which procedures shift from the inpatient to outpatient setting following removal from Medicare's Inpatient Only List is unknown. Many health systems also encouraged a shift from inpatient to outpatient surgery during the COVID-19 pandemic. Assessing the relative change in outpatient surgical utilization for procedures removed from the Inpatient Only List during COVID-19 would provide empirical data on whether reimbursement policy changes or inpatient capacity needs during the pandemic were more likely to shift care from the inpatient to outpatient setting. METHODS: We used administrative data from the PINC AI Healthcare Database across 723 hospitals to determine the within-facility relative change in outpatient vs inpatient procedural volume in 2020 and 2021 compared to 2019 using a multivariable conditional fixed-effects Poisson regression model. We also assessed whether outpatient surgical utilization varied by race and ethnicity. Using a multivariable linear probability model, we assessed the absolute change in risk-adjusted 30-day complication, readmission, and mortality rates for inpatient and outpatient surgical procedures. RESULTS: In 2020 and 2021 compared to 2019 respectively, there was a 5.3% (95% CI, 1.4% to 9.5%) and 41.3% (95% CI 33.1% to 50.0%) relative increase in outpatient elective procedural volume. Outpatient procedural volume increased most significantly for hip replacement which was removed from the Inpatient Only List in 2020 (increase in outpatient surgical utilization of 589.3% (95% CI, 524.9% to 660.3%)). The shift to outpatient hip replacement procedures was concentrated among White patients; in 2021, hip replacement procedural volume increased by 271.1% (95% CI, 241.2% and 303.7%) for White patients and 29.5% (95% CI, 24.4% and 34.9%) for Black patients compared to 2019 levels. There were no consistent or large changes in 30-day complication, readmission, or mortality risk in 2020 and 2021 compared to 2019. CONCLUSION: There was a modest increase in elective outpatient surgeries and a pronounced increase in outpatient orthopedic surgeries which were removed from the Inpatient Only List during the COVID-19 pandemic. Utilization of outpatient surgical procedures was concentrated among White patients.

Medicaid Eligibility Loss Among Dual-Eligible Beneficiaries Before and During COVID-19 Public Health Emergency.

Importance: Medicaid coverage loss can substantially compromise access to and affordability of health care for dual-eligible beneficiaries. The extent to which this population lost Medicaid coverage before and during the COVID-19 public health emergency (PHE) and the characteristics of beneficiaries more at risk for coverage loss are currently not well known. Objective: To assess the loss of Medicaid coverage among dual-eligible beneficiaries before and during the first year of the PHE, and to examine beneficiary-level and plan-level factors associated with heightened likelihood of losing Medicaid. Design, Setting, and Participants: This repeated cross-sectional study used national Medicare data to estimate annual rates of Medicaid loss among dual-eligible beneficiaries before (2015 to 2019) and during the PHE (2020). Individuals who were dual eligible for Medicare and Medicaid at the beginning of a given year and who continuously received low-income subsidies for Medicare Part D prescription drug coverage were included in the sample. Multivariable regression models were used to examine beneficiary-level and plan-level factors associated with Medicaid loss. Data analyses were conducted between March 2023 and October 2023. Exposure: Onset of PHE. Main Outcomes and Measures: Loss of Medicaid for at least 1 month within a year. Results: Sample included 56 172 736 dual-eligible beneficiary-years between 2015 and 2020. In 2020, most dual-eligible beneficiaries were aged over 65 years (5 984 420 [61.1%]), female (5 868 866 [59.9%]), non-Hispanic White (4 928 035 [50.3%]), full-benefit eligible (6 837 815 [69.8%]), and enrolled in traditional Medicare (5 343 537 [54.6%]). The adjusted proportion of dual-eligible beneficiaries losing Medicaid for at least 1 month increased from 6.6% in 2015 to 7.3% in 2019 and then dropped to 2.3% in 2020. Between 2015 and 2019, dual-eligible beneficiaries who were older (ages 55-64 years: -1.4%; 95% CI, -1.8% to -1.0%; ages 65-74 years: -2.0%; 95% CI, -2.5% to -1.5%; ages 75 and older: -4.5%; 95% CI, -5.0% to -4.0%), disabled (-0.8%; 95% CI, -1.1% to -0.6%), and in integrated care programs were less likely to lose Medicaid. In 2020, the disparities within each of these demographic groups narrowed significantly. Notably, while Black (0.6%; 95% CI, 0.2% to 0.9%) and Hispanic (0.7%; 95% CI, 0.3% to 1.2%) dual-eligible beneficiaries were more likely to lose Medicaid than their non-Hispanic White counterparts between 2015 and 2019, such gap was eliminated for Black beneficiaries and narrowed for Hispanic beneficiaries in 2020. Conclusions and Relevance: During the PHE, Medicaid coverage loss declined significantly among dual-eligible beneficiaries, and disparities were mitigated across subgroups. As the PHE unwinds, it is crucial for policymakers to implement strategies to minimize Medicaid coverage disruptions and racial and ethnic disparities, especially given that loss of Medicaid was slightly increasing over time before the PHE.

Trends in observation stays for Medicare beneficiaries with and without Alzheimer's disease and related dementias.

BACKGROUND: There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown. METHODS: Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-). RESULTS: Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7). CONCLUSIONS: Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation.

The Rise and Risks of Medicare Advantage "Affinity Plans".

This Viewpoint discusses the proliferation of Medicare Advantage plans targeting specific groups of individuals and whether these plans will improve quality of care for beneficiaries.

Institutional Efforts to Address Legacies of Slavery-Implications for the Health Care System.

This JAMA Forum discusses the legacies of slavery, efforts underway at colleges and universities to explore and address the legacies of slavery, and health care system actions to address structural racism.

Improving health equity through health care systems research.

OBJECTIVE: To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence-based solutions to persistent racial and ethnic inequities in health outcomes. DATA SOURCES AND STUDY SETTING: This project was conducted as a component of the Agency for Healthcare Research and Quality's (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government. STUDY DESIGN: Expert group consensus, informed by stakeholder engagement and targeted evidence review. DATA COLLECTION/EXTRACTION METHODS: Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQ's 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors' consensus. PRINCIPAL FINDINGS: Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data-driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity-informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross-cutting themes regarding research workforce and research timelines. CONCLUSIONS: As the nation's primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care.

Comparison of Claims-Based Frailty Indices in U.S. Veterans 65 and Older for Prediction of Long-Term Institutionalization and Mortality.

BACKGROUND: Frailty is increasingly recognized as a useful measure of vulnerability in older adults. Multiple claims-based frailty indices (CFIs) can readily identify individuals with frailty, but whether 1 CFI improves prediction over another is unknown. We sought to assess the ability of 5 distinct CFIs to predict long-term institutionalization (LTI) and mortality in older Veterans. METHODS: Retrospective study conducted in U.S. Veterans ≥65 years without prior LTI or hospice use in 2014. Five CFIs were compared: Kim, Orkaby (Veteran Affairs Frailty Index [VAFI]), Segal, Figueroa, and the JEN-FI, grounded in different theories of frailty: Rockwood cumulative deficit (Kim and VAFI), Fried physical phenotype (Segal), or expert opinion (Figueroa and JFI). The prevalence of frailty according to each CFI was compared. CFI performance for the coprimary outcomes of any LTI or mortality from 2015 to 2017 was examined. Because Segal and Kim include age, sex, or prior utilization, these variables were added to regression models to compare all 5 CFIs. Logistic regression was used to calculate model discrimination and calibration for both outcomes. RESULTS: A total of 3 million Veterans were included (mean age 75, 98% male participants, 80% White, and 9% Black). Frailty was identified for between 6.8% and 25.7% of the cohort with 2.6% identified as frail by all 5 CFIs. There was no meaningful difference between CFIs in the area under the receiver operating characteristic curve for LTI (0.78-0.80) or mortality (0.77-0.79). CONCLUSIONS: Based on different frailty constructs, and identifying different subsets of the population, all 5 CFIs similarly predicted LTI or death, suggesting each could be used for prediction or analytics.

Rapid Enrollment Growth In 'Look-Alike' Dual-Eligible Special Needs Plans: A Threat To Integrated Care.

Policy makers are increasingly investing in efforts to better integrate Medicare and Medicaid services for people who are eligible for both programs, including expanding Dual-Eligible Special Needs Plans (D-SNPs). In recent years, however, a potential threat to integration has emerged in the form of D-SNP "look-alike" plans, which are conventional Medicare Advantage plans that are marketed toward and primarily enroll dual eligibles but are not subject to federal regulations requiring integrated Medicaid services. To date, limited evidence exists documenting national enrollment trends in look-alike plans or the characteristics of dual eligibles in these plans. We found that look-alike plans experienced rapid enrollment growth among dual eligibles during the period 2013-20, increasing from 20,900 dual eligibles across four states to 220,860 dual eligibles across seventeen states, for an elevenfold increase. Nearly one-third of dual eligibles in look-alike plans were previously in integrated care programs. Compared with D-SNPs, look-alike plans were more likely to enroll dual eligibles who were older, Hispanic, and from disadvantaged communities. Our findings suggest that look-alike plans have the potential to compromise national efforts to integrate care delivery for dual eligibles, including vulnerable subgroups who may benefit the most from integrated coverage.

Integrating Medicare and Medicaid Coverage for Dual Eligibles-Recommendations for Reform.

This Viewpoint highlights costly inefficiencies in delivery of care to patients who qualify to receive both Medicare and Medicaid and proposes more effective care models.

High-performing primary care clinics across high-need, high-cost Medicare populations.

BACKGROUND: To reduce spending and improve quality, some primary care clinics in the USA have focused on high-need, high-cost (HNHC) Medicare beneficiaries, which include clinically distinct subpopulations: older adults with frailty, adults under 65 years with disability and beneficiaries with major complex chronic conditions. Nationally, the extent to which primary care clinics are high-performing 'Bright Spots'-clinics that achieve favourable outcomes at lower costs across HNHC beneficiary subpopulations-is not known. OBJECTIVE: To determine the prevalence of primary care clinics that perform highly on commonly used cost or quality measures for HNHC subpopulations. DESIGN AND PARTICIPANTS: Cross-sectional study using Medicare claims data from 2014 to 2015. MAIN MEASURES: Annual spending, avoidable hospitalisations for ambulatory care-sensitive conditions, treat-and-release emergency department visits, all-cause 30-day unplanned hospital readmission rates and healthy days at home. Clinics were high performing when they ranked in the top quartile of performance for ≥4 measures for an HNHC subpopulation. 'Bright Spot' clinics were in the top quartile of performance for ≥4 measures across all the HNHC subpopulations. KEY RESULTS: A total of 2770 primary care clinics cared for at least 10 beneficiaries from each of the three HNHC subpopulations (adults under 65 with disability, older adults with frailty and beneficiaries with major complex chronic conditions). Less than 4% of clinics were high performing for each HNHC subpopulation; <0.5% of clinics were in the top quartile for all five measures for a given subpopulation. No clinics met the definition of a primary care 'Bright Spot'. CONCLUSIONS: High-performing primary care clinics that achieved favourable health outcomes or lower costs across subpopulations of HNHC beneficiaries in the Medicare programme in 2015 were rare. Efforts are needed to support primary care clinics in providing optimal care to HNHC subpopulations.

Trends in healthy days at home for Medicare beneficiaries using the emergency department.

BACKGROUND: Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status. METHODS: We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status. RESULTS: We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD. CONCLUSIONS: Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.

Use of High-Risk Medications Among Older Adults Enrolled in Medicare Advantage Plans vs Traditional Medicare.

Importance: Limiting the use of high-risk medications (HRMs) among older adults is a national priority to provide a high quality of care for older beneficiaries of both Medicare Advantage and traditional fee-for-service Medicare Part D plans. Objective: To evaluate the differences in the rate of HRM prescription fills among beneficiaries of traditional Medicare vs Medicare Advantage Part D plans and to examine the extent to which these differences change over time and the patient-level factors associated with higher rates of HRMs. Design, Setting, and Participants: This cohort study used a 20% sample of Medicare Part D data on filled drug prescriptions from 2013 to 2017 and a 40% sample from 2018. The sample comprised Medicare beneficiaries aged 66 years or older who were enrolled in Medicare Advantage or traditional Medicare Part D plans. Data were analyzed between April 1, 2022, and April 15, 2023. Main Outcomes and Measures: The primary outcome was the number of unique HRMs prescribed to older Medicare beneficiaries per 1000 beneficiaries. Linear regression models were used to model the primary outcome, adjusting for patient characteristics and county characteristics and including hospital referral region fixed effects. Results: The sample included 5 595 361 unique Medicare Advantage beneficiaries who were propensity score-matched on a year-by-year basis to 6 578 126 unique traditional Medicare beneficiaries between 2013 and 2018, resulting in 13 704 348 matched pairs of beneficiary-years. The traditional Medicare vs Medicare Advantage cohorts were similar in age (mean [SD] age, 75.65 [7.53] years vs 75.60 [7.38] years), proportion of males (8 127 261 [59.3%] vs 8 137 834 [59.4%]; standardized mean difference [SMD] = 0.002), and predominant race and ethnicity (77.1% vs 77.4% non-Hispanic White; SMD = 0.05). On average in 2013, Medicare Advantage beneficiaries filled 135.1 (95% CI, 128.4-142.6) unique HRMs per 1000 beneficiaries compared with 165.6 (95% CI, 158.1-172.3) HRMs per 1000 beneficiaries for traditional Medicare. In 2018, the rate of HRMs had decreased to 41.5 (95% CI, 38.2-44.2) HRMs per 1000 beneficiaries in Medicare Advantage and to 56.9 (95% CI, 54.1-60.1) HRMs per 1000 beneficiaries in traditional Medicare. Across the study period, Medicare Advantage beneficiaries received 24.3 (95% CI, 20.2-28.3) fewer HRMs per 1000 beneficiaries per year compared with traditional Medicare beneficiaries. Female, American Indian or Alaska Native, and White populations were more likely to receive HRMs than other groups. Conclusion and Relevance: Results of this study showed that HRM rates were consistently lower among Medicare Advantage than traditional Medicare beneficiaries. Higher use of HRMs among female, American Indian or Alaska Native, and White populations is a concerning disparity that requires further attention.

Enrollment And Characteristics Of Dual-Eligible Medicare And Medicaid Beneficiaries In Integrated Care Programs.

Integrated care programs (ICPs) are meant to make Medicare and Medicaid coverage for dual-eligible beneficiaries work more seamlessly. Evidence is limited on ICP enrollment trends and the characteristics of dual-eligible beneficiaries who enroll in these programs-specifically, the Program of All-Inclusive Care for the Elderly, Medicare Advantage (MA) Fully Integrated Dual-Eligible Special Needs Plans, and state demonstration Medicare-Medicaid plans. Using national data, we evaluated changes in ICP enrollment between 2013 and 2020 and compared the demographic characteristics of beneficiaries in these programs relative to the characteristics of beneficiaries not in them. The proportion of dual-eligible beneficiaries in ICPs increased from 2.0 percent in 2013 to 9.4 percent in 2020. However, nonintegrated or partially integrated coordination-only MA plans experienced the plurality of growth in enrollment of dual-eligible beneficiaries. Relative to non-ICP fee-for-service Medicare, beneficiaries in ICPs were more likely to be Black and Hispanic versus White and were less likely to be rural, younger, or disabled. Policy makers should diligently monitor growth in ICPs and less integrated dual-eligible plans in MA while also evaluating their impact on equity, spending, and quality of care.

Changes in Medicare Accountable Care Organization Spending, Utilization, and Quality Performance 2 Years Into the COVID-19 Pandemic.

This cohort study uses data from the Medicare Shared Savings Program to assess changes in spending, utilization, and quality performance from before the COVID-19 pandemic (2019) to year 2 of the pandemic (2021).

Association Between Emergency Physician's Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit.

STUDY OBJECTIVE: To determine the association between emergency physicians' ages and patient mortality after emergency department visits. METHODS: This observational study used a 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 89 years treated by emergency physicians at EDs from 2016 to 2017. We investigated whether 7-day mortality after ED visits differed by the age of the emergency physician, adjusting for patient and physician characteristics and hospital fixed effects. RESULTS: We observed 2,629,464 ED visits treated by 32,570 emergency physicians (mean age 43.5). We found that patients treated by younger emergency physicians had lower mortality rates compared with those treated by older physicians. Adjusted 7-day mortality was 1.33% for patients treated by emergency physicians aged less than 40 years, 1.36% (adjusted difference, 0.03%; 95% confidence interval [CI], -0.001% to 0.06%) for physicians ages 40 to 49, 1.40% (0.08%; 95% CI 0.04% to 0.12%) for physicians ages 50 to 59, and 1.43% (0.11%; 95% CI 0.06% to 0.16%) for those with a physician age of 60 years and more. Similar patterns were observed when stratified by the patient's disposition (discharged vs admitted), and the association was more pronounced for patients with higher severity of illness. CONCLUSIONS: Medicare patients aged 65 to 89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians aged 50 to 59 years and 60 years or older within the same hospital. Potential mechanisms explaining the association between emergency physician age and patient mortality (eg, differences in training received and other unobservable patient/physician characteristics) are uncertain and require further study.

Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings.

BACKGROUND: Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown. OBJECTIVE: To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures. DESIGN: Cross-sectional. SETTING: Population-based. PARTICIPANTS: Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. MEASUREMENTS: Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated. RESULTS: Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings. LIMITATION: Hospital performance measurement and risk adjustment differed slightly from those used by Medicare. CONCLUSION: Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. PRIMARY FUNDING SOURCE: Laura and John Arnold Foundation.

Association Between Community-Level Social Risk and Spending Among Medicare Beneficiaries: Implications for Social Risk Adjustment and Health Equity.

Importance: Payers are increasingly using approaches to risk adjustment that incorporate community-level measures of social risk with the goal of better aligning value-based payment models with improvements in health equity. Objective: To examine the association between community-level social risk and health care spending and explore how incorporating community-level social risk influences risk adjustment for Medicare beneficiaries. Design, Setting, and Participants: Using data from a Medicare Advantage plan linked with survey data on self-reported social needs, this cross-sectional study estimated health care spending health care spending was estimated as a function of demographics and clinical characteristics, with and without the inclusion of Area Deprivation Index (ADI), a measure of community-level social risk. The study period was January to December 2019. All analyses were conducted from December 2021 to August 2022. Exposures: Census block group-level ADI. Main Outcomes and Measures: Regression models estimated total health care spending in 2019 and approximated different approaches to social risk adjustment. Model performance was assessed with overall model calibration (adjusted R2) and predictive accuracy (ratio of predicted to actual spending) for subgroups of potentially vulnerable beneficiaries. Results: Among a final study population of 61 469 beneficiaries (mean [SD] age, 70.7 [8.9] years; 35 801 [58.2%] female; 48 514 [78.9%] White; 6680 [10.9%] with Medicare-Medicaid dual eligibility; median [IQR] ADI, 61 [42-79]), ADI was weakly correlated with self-reported social needs (r = 0.16) and explained only 0.02% of the observed variation in spending. Conditional on demographic and clinical characteristics, every percentile increase in the ADI (ie, more disadvantage) was associated with a $11.08 decrease in annual spending. Directly incorporating ADI into a risk-adjustment model that used demographics and clinical characteristics did not meaningfully improve model calibration (adjusted R2 = 7.90% vs 7.93%) and did not significantly reduce payment inequities for rural beneficiaries and those with a high burden of self-reported social needs. A postestimation adjustment of predicted spending for dual-eligible beneficiaries residing in high ADI areas also did not significantly reduce payment inequities for rural beneficiaries or beneficiaries with self-reported social needs. Conclusions and Relevance: In this cross-sectional study of Medicare beneficiaries, the ADI explained little variation in health care spending, was negatively correlated with spending conditional on demographic and clinical characteristics, and was poorly correlated with self-reported social risk factors. This prompts caution and nuance when using community-level measures of social risk such as the ADI for social risk adjustment within Medicare value-based payment programs.