The Longitudinal Impact Of A Multistate Commercial Accountable Care Program On Cost, Use, And Quality.

The prevalence of accountable care organizations (ACOs) has grown significantly across Medicare and commercial payers in the past decade, but there are limited insights regarding the effect of ACOs on costs in the commercial population. We used longitudinal administrative claims data over the course of nineteen calendar quarters from 2016 to 2021 to assess the ongoing incremental impact of Elevance Health's commercial ACO program on cost and use across fifteen US states. We also analyzed the program's impact on spending subcategories (inpatient, outpatient, professional, and pharmacy) and measured differences in quality performance. The program was associated with incremental savings during this period. Incremental savings were greater in the fully insured population relative to the administrative services only population and were due to outpatient and pharmacy savings. ACO providers had superior quality performance measures relative to contracted providers not participating in ACOs. Payers should be aware of the potential for diminishing marginal returns of ACO contracting on containing health care costs.

Encouraging Medicare Advantage Enrollees to Switch to Higher Quality Plans: Assessing the Effectiveness of a "Nudge" Letter.

There are considerable quality differences across private Medicare Advantage insurance plans, so it is important that beneficiaries make informed choices. During open enrollment for the 2013 coverage year, the Centers for Medicare & Medicaid Services sent letters to beneficiaries enrolled in low-quality Medicare Advantage plans (i.e., plans rated less than 3 stars for at least 3 consecutive years by Medicare) explaining the stars and encouraging them to reexamine their choices. To understand the effectiveness of these low-cost, behavioral "nudge" letters, we used a beneficiary-level national retrospective cohort and performed multivariate regression analysis of plan selection during the 2013 open enrollment period among those enrolled in plans rated less than 3 stars. Our analysis controls for beneficiary demographic characteristics, health and health care spending risks, the availability of alternative higher rated plan options in their local market, and historical disenrollment rates from the plans. We compared the behaviors of those beneficiaries who received the nudge letters with those who enrolled in similar poorly rated plans but did not receive such letters. We found that beneficiaries who received the nudge letter were almost twice as likely (28.0% [95% confidence interval = 27.7%, 28.2%] vs. 15.3% [95% confidence interval = 15.1%, 15.5%]) to switch to a higher rated plan compared with those who did not receive the letter. White beneficiaries, healthier beneficiaries, and those residing in areas with more high-performing plan choices were more likely to switch plans in response to the nudge. Our findings highlight both the importance and efficacy of providing timely and actionable information to beneficiaries about quality in the insurance marketplace to facilitate informed and value-based coverage decisions.

One-Year Outcomes of Diabetes Self-Management Training Among Medicare Beneficiaries Newly Diagnosed With Diabetes.

BACKGROUND: Diabetes is highly prevalent among Medicare beneficiaries, resulting in costly health care utilization. Strategies to improve health outcomes, such as disease self-management, could help reduce the increasing burden of diabetes. OBJECTIVES: Short-term benefits of diabetes self-management training (DSMT) are established; however, longer-term impacts among Medicare beneficiaries are unknown. RESEARCH DESIGN: Claims-based observational study with 1-year follow-up beginning 6 months after diabetes diagnosis. SUBJECTS: Twenty percent random sample of Medicare beneficiaries newly diagnosed with diabetes during 2009-2011 who used DSMT (N=14,680), matched to a nonuser comparison group. MEASURES: We compared health service utilization and costs between DSMT users and nonusers. Health service utilization included any utilization of the hospital or emergency department (ED) and any hospitalizations due to diabetes-related ambulatory care sensitive conditions as well as the number of hospitalizations and ED visits within the follow-up year. Costs included all Medicare Parts A and B expenditures. RESULTS: Multivariate regression results found that DSMT users had 14% reduced odds of any hospitalization, lower numbers of hospitalizations and ED visits (approximately 3 fewer per 100 for each), and approximately $830 lower Medicare expenditures (95% CI, -$1198, -$470) compared with nonusers. Odds of any hospitalization due to diabetes-related ambulatory care sensitive conditions and any ED visit were lower for DSMT users compared with nonusers, but the reductions were not statistically significant. CONCLUSIONS: Findings demonstrate benefits from DSMT use, including lower health service utilization and costs. The low cost of DSMT relative to the reduction in Medicare expenditures highlights an opportunity to reduce the burden of diabetes on both individuals and the health care system.

Leveraging Administrative Data for Program Evaluations: A Method for Linking Data Sets Without Unique Identifiers.

In community-based wellness programs, Social Security Numbers (SSNs) are rarely collected to encourage participation and protect participant privacy. One measure of program effectiveness includes changes in health care utilization. For the 65 and over population, health care utilization is captured in Medicare administrative claims data. Therefore, methods as described in this article for linking participant information to administrative data are useful for program evaluations where unique identifiers such as SSN are not available. Following fuzzy matching methodologies, participant information from the National Study of the Chronic Disease Self-Management Program was linked to Medicare administrative data. Linking variables included participant name, date of birth, gender, address, and ZIP code. Seventy-eight percent of participants were linked to their Medicare claims data. Linking program participant information to Medicare administrative data where unique identifiers are not available provides researchers with the ability to leverage claims data to better understand program effects.

The Roles of Cost and Quality Information in Medicare Advantage Plan Enrollment Decisions: an Observational Study.

BACKGROUND: To facilitate informed decision-making in the Medicare Advantage marketplace, the Centers for Medicare & Medicaid Services publishes plan information on the Medicare Plan Finder website, including costs, benefits, and star ratings reflecting quality. Little is known about how beneficiaries weigh costs versus quality in enrollment decisions. OBJECTIVE: We aimed to assess associations between publicly reported Medicare Advantage plan attributes (i.e., costs, quality, and benefits) and brand market share and beneficiaries' enrollment decisions. DESIGN, SETTING, PARTICIPANTS: We performed a nationwide, beneficiary-level cross-sectional analysis of 847,069 beneficiaries enrolling in Medicare Advantage for the first time in 2011. MAIN MEASURES: Matching beneficiaries with their plan choice sets, we used conditional logistic regression to estimate associations between plan attributes and enrollment to assess the proportion of enrollment variation explained by plan attributes and willingness to pay for quality. KEY RESULTS: Relative to the total variation explained by the model, the variation in plan choice explained by premiums (25.7 %) and out-of-pocket costs (11.6 %) together explained nearly three times as much as quality ratings (13.6 %), but brand market share explained the most variation (35.3 %). Further, while beneficiaries were willing to pay more in total annual combined premiums and out-of-pocket costs for higher-rated plans (from $4,154.93 for 2.5-star plans to $5,698.66 for 5-star plans), increases in willingness to pay diminished at higher ratings, from $549.27 (95 %CI: $541.10, $557.44) for a rating increase from 2.5 to 3 stars to $68.22 (95 %CI: $61.44, $75.01) for an increase from 4.5 to 5 stars. Willingness to pay varied among subgroups: beneficiaries aged 64-65 years were more willing to pay for higher-rated plans, while black and rural beneficiaries were less willing to pay for higher-rated plans. CONCLUSIONS: While beneficiaries prefer higher-quality and lower-cost Medicare Advantage plans, marginal utility for quality diminishes at higher star ratings, and their decisions are strongly associated with plans' brand market share.

Concordance between Self-Reports and Medicare Claims among Participants in a National Study of Chronic Disease Self-Management Program.

OBJECTIVES: To evaluate the concordance between self-reported data and variables obtained from Medicare administrative data in terms of chronic conditions and health care utilization. DESIGN: Retrospective observational study. PARTICIPANTS: We analyzed data from a sample of Medicare beneficiaries who were part of the National Study of Chronic Disease Self-Management Program (CDSMP) and were eligible for the Centers for Medicare and Medicaid Services (CMS) pilot evaluation of CDSMP (n = 119). METHODS: Self-reported and Medicare claims-based chronic conditions and health care utilization were examined. Percent of consistent numbers, kappa statistic (κ), and Pearson's correlation coefficient were used to evaluate concordance. RESULTS: The two data sources had substantial agreement for diabetes and chronic obstructive pulmonary disease (COPD) (κ = 0.75 and κ = 0.60, respectively), moderate agreement for cancer and heart disease (κ = 0.50 and κ = 0.47, respectively), and fair agreement for depression (κ = 0.26). With respect to health care utilization, the two data sources had almost perfect or substantial concordance for number of hospitalizations (κ = 0.69-0.79), moderate concordance for ED care utilization (κ = 0.45-0.61), and generally low agreement for number of physician visits (κ ≤ 0.31). CONCLUSION: Either self-reports or claim-based administrative data for diabetes, COPD, and hospitalizations can be used to analyze Medicare beneficiaries in the US. Yet, caution must be taken when only one data source is available for other types of chronic conditions and health care utilization.

Use of Medicare's Diabetes Self-Management Training Benefit.

Medicare began reimbursing for outpatient diabetes self-management training (DSMT) in 2000; however, little is known about program utilization. Individuals diagnosed with diabetes in 2010 were identified from a 20% random selection of the Medicare fee-for-service population (N = 110,064). Medicare administrative and claims files were used to determine DSMT utilization. Multivariate logistic regression analyses evaluated the association of demographic, health status, and provider availability factors with DSMT utilization. Approximately 5% of Medicare beneficiaries with newly diagnosed diabetes used DSMT services. The adjusted odds of any utilization were lower among men compared with women, older individuals compared with younger, non-Whites compared with Whites, people dually eligible for Medicare and Medicaid compared with nondual eligibles, and patients with comorbidities compared with individuals without those conditions. Additionally, the adjusted odds of utilizing DSMT increased as the availability of providers who offered DSMT services increased and varied by Census region. Utilization of DSMT among Medicare beneficiaries with newly diagnosed diabetes is low. There appear to be marked disparities in access to DSMT by demographic and health status factors and availability of DSMT providers. In light of the increasing prevalence of diabetes, future research should identify barriers to DSMT access, describe DSMT providers, and explore the impact of DSMT services. With preventive services being increasingly covered by insurers, the low utilization of DSMT, a preventive service benefit that has existed for almost 15 years, highlights the challenges that may be encountered to achieve widespread dissemination and uptake of the new services.

Validity of a Claims-Based Diagnosis of Obesity Among Medicare Beneficiaries.

Population-level data on obesity are difficult to obtain. Claims-based data sets are useful for studying public health at a population level but lack physical measurements. The objective of this study was to determine the validity of a claims-based measure of obesity compared to obesity diagnosed with clinical data as well as the validity among older adults who suffer from chronic disease. This study used data from the National Health and Nutrition Examination Survey 1999-2004 for adults aged ≥ 65 successfully linked to 1999-2007 Medicare claims (N = 3,554). Sensitivity, specificity, positive and negative predictive values, κ statistics as well as logistic regression analyses were computed for the claims-based diagnosis of obesity versus obesity diagnosed with body mass index. The claims-based diagnosis of obesity underestimates the true prevalence in the older Medicare population with a low sensitivity (18.4%). However, this method has a high specificity (97.3%) and is accurate when it is present. Sensitivity was improved when comparing the claim-based diagnosis to Class II obesity (34.2%) and when used in combination with chronic conditions such as diabetes, congestive heart failure, chronic obstructive pulmonary disease, or depression. Understanding the validity of a claims-based obesity diagnosis could aid researchers in understanding the feasibility of conducting research on obesity using claims data.

Utilization and costs of medications associated with CKD mineral and bone disorder in dialysis patients enrolled in Medicare Part D.

BACKGROUND: Information is limited regarding utilization patterns and costs for chronic kidney disease-mineral and bone disorder (CKD-MBD) medications in Medicare Part D-enrolled dialysis patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Annual cohorts of dialysis patients, 2007-2010. PREDICTORS: Cohort year, low-income subsidy status, and dialysis provider. OUTCOMES: Utilization and costs of prescription phosphate binders, oral and intravenous vitamin D analogues, and cinacalcet. MEASUREMENTS: Using logistic regression, we calculated adjusted odds of medication use for low-income subsidy versus non-low-income subsidy patients and for patients from various dialysis organizations, and we report per-member-per-month and average out-of-pocket costs. RESULTS: Phosphate binders (∼83%) and intravenous vitamin D (77.5%-79.3%) were the most commonly used CKD-MBD medications in 2007 through 2010. The adjusted odds of prescription phosphate-binder, intravenous vitamin D, and cinacalcet use were significantly higher for low-income subsidy than for non-low-income subsidy patients. Total Part D versus CKD-MBD Part D medication costs increased 22% versus 36% from 2007 to 2010. For Part D-enrolled dialysis patients, CKD-MBD medications represented ∼50% of overall net Part D costs in 2010. LIMITATIONS: Inability to describe utilization and costs of calcium carbonate, an over-the-counter agent not covered under Medicare Part D; inability to reliably identify prescriptions filled through a non-Part D reimbursement or payment mechanism; findings may not apply to dialysis patients without Medicare Part D benefits or with Medicare Advantage plans, or to pediatric dialysis patients; could identify only prescription drugs dispensed in the outpatient setting; inability to adjust for MBD laboratory values. CONCLUSIONS: Part D net costs for CKD-MBD medications increased at a faster rate than costs for all Part D medications in dialysis patients despite relatively stable use within medication classes. In a bundled environment, there may be incentives to shift to generic phosphate binders and reduce cinacalcet use.

Association between Medicare Advantage plan star ratings and enrollment.

IMPORTANCE: The US Centers for Medicare & Medicaid Services publishes star ratings reflecting Medicare Advantage plan quality to inform enrollment decisions. OBJECTIVE: To assess the association between publicly reported Medicare Advantage plan quality ratings and enrollment. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 2011 Medicare Advantage enrollments among 952,352 first-time enrollees and 322,699 enrollees switching plans. MAIN OUTCOME MEASURE: Association between star ratings and enrollment was modeled using conditional logit regression, controlling for beneficiary and plan characteristics. RESULTS: Among the 952,352 included first-time enrollees, a 1-star higher rating was associated with a 9.5 (95% CI, 9.3-9.6) percentage-point increase in likelihood to enroll. The highest rating available to a beneficiary was associated with a 1.9 (95% CI, 1.8-2.1) percentage-point increase in likelihood to enroll. Among the 322,699 enrollees switching plans, a 1-star higher rating was associated with a 4.4 (95% CI, 4.2-4.7) percentage-point increase in likelihood to enroll. A rating at least as high as a beneficiary's prior plan was associated with a 6.3 (95% CI, 6.0-6.6) percentage-point increase in likelihood to enroll. Star ratings were less strongly associated with enrollment for black, rural, low-income, and the youngest beneficiaries. CONCLUSION AND RELEVANCE: Medicare's 5-star rating program for Medicare Advantage is associated with beneficiaries' enrollment decisions.

Sources of drug coverage among Medicare beneficiaries with ESRD.

Despite extensive use of prescription medications in ESRD, relatively little is known about the participation of Medicare ESRD beneficiaries in the Part D program. Here, we quantitated the sources of drug coverage among ESRD beneficiaries and explored the Part D plan preferences of ESRD beneficiaries with regard to deductibles, coverage gaps, and monthly premiums. We obtained data on beneficiary sources of creditable coverage, characteristics of Part D plans, demographics, and residence from the Centers for Medicare and Medicaid Chronic Condition Data Warehouse and identified beneficiaries with ESRD from the US Renal Data System. We found that a substantial proportion (17.0%) of ESRD beneficiaries lacked a known source of creditable drug coverage in 2007 and 64.3% were enrolled in Part D. Of those enrolled, 72% received the Medicare Part D low-income subsidy. ESRD beneficiaries who enrolled in standalone Part D plans without the assistance of the low-income subsidy tended to prefer more comprehensive coverage options. In conclusion, more outreach is needed to ensure that beneficiaries who lack coverage obtain the coverage they need and that ESRD beneficiaries join the best plans for managing their disease and accompanying comorbid conditions.

Utilization and costs of cardiovascular disease medications in dialysis patients in Medicare Part D.

BACKGROUND: Cardiovascular disease (CVD) is a major source of mortality and morbidity in dialysis patients. Population-level descriptions of CVD medication use are lacking in this population. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adult dialysis patients in the United States, alive on December 31, 2006, with Medicare Parts A and B and enrollment in Medicare Part D continuously in 2007. PREDICTOR: CVDs and demographic characteristics. OUTCOME: ≥1 prescription fill during follow-up (2007). MEASUREMENTS: Average out-of-pocket costs per user per month and average total drug costs per member per month were calculated. RESULTS: Of 225,635 dialysis patients who met inclusion criteria during the entry period, 70% (n = 158,702) had continuous Part D coverage during follow-up. Of these, 76% received the low-income subsidy. ß-Blockers were the most commonly used CVD medication (64%), followed by renin-angiotensin system inhibitors (52%), calcium channel blockers (51%), lipid-lowering agents (44%), and α-agonists (23%). Use varied by demographics, geographic region, and low-income subsidy status. For CVD medications, mean out-of-pocket costs per user per month were $3.44 and $49.59 and mean total costs per member per month were $124.02 and $110.32 for patients with and without the low-income subsidy, respectively. LIMITATIONS: Information was available for only filled prescriptions under the Part D benefit; information for clinical contraindications was lacking, information for over-the-counter medications was unavailable, and medication adherence and persistence were not examined. CONCLUSIONS: Most Medicare dialysis patients in 2007 were enrolled in Part D, and most enrollees received the low-income subsidy. ß-Blockers were the most used CVD medication. Total costs of CVD medications were modestly higher for low-income subsidy patients, but out-of-pocket costs were much higher for patients not receiving the subsidy. Further study is warranted to delineate sources of variation in the use and costs of CVD medications across subgroups.

Cost-related nonadherence to prescribed medication therapy among Medicare Part D beneficiaries with end-stage renal disease.

PURPOSE: Medication nonadherence due to cost issues among community-dwelling patients with end-stage renal disease (ESRD) enrolled in Medicare prescription drug plans was evaluated. METHODS: Demographic and health status data were collected on 1329 patients with ESRD enrolled in Medicare Part D prescription drug plans who responded to a Centers for Medicare and Medicaid Services consumer survey in early 2007. The survey data were assessed for self-reported cost-related nonadherence (CRN), defined as delaying or not filling a prescription due to cost concerns. Multivariate logistic regression analysis was performed to evaluate CRN risk relative to patient demographic characteristics, socioeconomic status, other chronic conditions, health behaviors, and access to health care services. RESULTS: Overall, survey respondents with ESRD were significantly more likely than those without ESRD to report CRN in the prior six months (unadjusted odds ratio [OR], 2.34; 95% confidence interval [CI], 2.00-2.75). After controlling for potential confounding factors such as other chronic conditions, the data analysis continued to show a significant association between ESRD and an increased risk of CRN (adjusted OR, 1.23; 95% CI, 1.07-1.41). Black race and receipt of Medicare Part D Low-Income Subsidy assistance were significant independent predictors of CRN for respondents with ESRD. CONCLUSION: In early 2007, 31% of survey respondents with ESRD enrolled in Medicare Part D drug plans reported CRN in the preceding six months. After adjusting for potential confounders, respondents with ESRD remained 23% more likely than respondents without ESRD to report CRN in the preceding six months.

Prescription medication cost-related non-adherence among Medicare CAHPS respondents: disparity by Hispanic ethnicity.

PURPOSE: We examined whether there was disparity in prescription medication cost-related non-adherence (CRN) by Hispanic ethnicity among Medicare enrollees. METHODS: Multivariate logistic regression, adjusting for race, other socio-demographic variables, health status, health care utilization, and patient rating of their personal physician, was used to examine association of Hispanic ethnicity with CRN using cross-sectional data from Medicare's Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey (data collected in Spring 2007). RESULTS: Hispanic respondents constituted 6.9% (unweighted n=22,304) of the analytic sample (unweighted n=272,701; response rate 5 48%). Overall, 13.4% of respondents reported CRN; among Hispanics and non-Hispanics, 20.3% and 12.9% reported CRN, respectively, p<.0001. Adjusted odds ratio (95% CI) of reporting CRN in the past six months was 1.18 (1.08, 1.29) for Hispanic compared with non-Hispanic respondents. CONCLUSIONS: Hispanic ethnicity was significantly associated with CRN. More research is needed to understand interventions to eliminate the disparity for this minority group.

Do panel surveys make people sick? US arthritis trends in the Health and Retirement Study.

Researchers have long viewed large, longitudinal studies as essential for understanding chronic illness and generally superior to cross-sectional studies. In this study, we show that (1) age-specific arthritis prevalence in the longitudinal Health and Retirement Study (HRS) from the United States has risen sharply since its inception in 1992, and (2) this rise is almost surely spurious. In periods for which the data sets are comparable, we find no such increase in the cross-sectional National Health Interview Survey (NHIS), the primary source for prevalence data of chronic conditions in the US. More important, the upward trend in the HRS is not internally consistent: even though prevalence in the HRS rises sharply between 1992 and 1996 for 55-56 year-olds, the prevalence for that age group plummets to its 1992 level among the new cohort added in 1998 and then rises rapidly again between 1998 and 2002. We discuss possible reasons for these discrepancies and demonstrate that they are not due to sample attrition in the HRS.