Postacute Care Services Use and Outcomes Among Traditional Medicare and Medicare Advantage Beneficiaries.

Importance: Better evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes. Objective: To compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees. Design, Setting, and Participants: This cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design. Exposures: Enrollment in MA and dual eligibility for Medicare and Medicaid. Main Outcomes and Measures: Postacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services. Results: Included in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility. Conclusions and relevance: In this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.

Publicly Reported Quality Performance for Dual-eligible Special Needs Plans, 2010-2019.

As enrollment increases in Dual-eligible Special Needs Plans (D-SNPs) that exclusively enroll low-income Medicare beneficiaries with Medicaid coverage, better evidence is needed about quality of care in these managed care plans. Using 2010-2019 publicly reported Healthcare Effectiveness Data and Information Set (HEDIS) measures, we found that median HEDIS performance scores were usually slightly worse for D-SNPs than the overall MA program with some reductions in quality performance gaps between 2010 and 2019. D-SNPs had more incomplete performance reporting than MA contracts, especially for measures focused on clinical conditions. Medicare Advantage reporting requirements should require greater transparency about performance in D-SNPs.

Traditional Medicare Episode-Related Spending on Postacute Care for Dual-Eligible and Medicare-Only Beneficiaries, 2009-2017.

Dual-eligible beneficiaries with Medicare and Medicaid coverage generally have greater utilization and spending levels than Medicare-only beneficiaries on postacute services, raising questions about how strategies to curb postacute spending will affect dual-eligible beneficiaries. We compared trends in postacute spending and use related to inpatient episodes at a population and episode level for dual-eligible and Medicare-only beneficiaries over the years 2009-2017. Although dual-eligible beneficiaries had consistently higher inpatient and postacute service use and spending than Medicare-only populations, both populations experienced similar declines in inpatient and postacute measures over time. Conditional on having an inpatient stay, most types of postacute service use increased regardless of dual-eligible status. These consistent patterns in episode-related postacute spending for Medicare-only and dual-eligible beneficiaries-decreased episode-related spending and use on a per beneficiary basis and increased use and spending on a per episode basis-suggest that changing patterns of care affect both populations.

Association of Race and Income with Incident Diagnosis of Alzheimer's Disease and Related Dementias among Black and White Older Adults.

To investigate how differences in income and education levels may contribute to disparities in incidence of Alzheimer's disease and related dementia (ADRD), we compared ADRD incidence in traditional Medicare claims for 11,132 Black and 7703 White participants aged 65 and over from a predominantly low-income cohort. We examined whether the relationship between ADRD incidence and race varied by income or education. Based on 2015 incident ADRD diagnoses, Black and White participants had unadjusted incidence rates of 26.5 and 23.2 cases per 1000 person-years, respectively (rate ratio 1.14, 95% CI 1.05-1.25). In multivariable Cox proportional hazard models, the relationship between race and incident ADRD diagnosis did not vary by education level (p-interaction = 0.748) but was modified by income level (p-interaction = 0.007), with higher ADRD incidence among Black participants observed only among higher income groups. These results highlight the importance of understanding how race and economic factors influence ADRD incidence and diagnosis rates.

Trends in and Factors Contributing to the Slowdown in Medicare Spending Growth, 2007-2018.

Importance: After decades of rapid increase, Medicare per-beneficiary spending growth was historically low in the period leading up to the passage of the Affordable Care Act. In the years immediately following the legislation, Medicare expenditure growth slowed even further. Objective: To evaluate factors contributing to the slowdown in Medicare per-beneficiary spending growth. Design, Setting, and Participants: In this cross-sectional study, expected spending growth for 2012 to 2015 and 2016 to 2018 was predicted holding payment rates and population characteristics constant. By contrasting predicted and actual spending growth during these periods, the contribution of population vs payment factors to the Medicare spending slowdown was determined. Analyses included all Medicare fee-for-service beneficiaries aged 65 years and older, ranging from 30 to 35 million beneficiaries annually between 2007 and 2018. Data analyses were conducted from January 2018 to August 2018 and updated with new data in June 2021. Main Outcomes and Measures: The main outcome included annual growth in total per-beneficiary spending. The roles of payment rate changes and differences in the Medicare population over time were considered, including demographic characteristics and numbers of chronic conditions. Results: Between 2008 to 2011 and 2012 to 2015, the adjusted annual Medicare Parts A and B per-beneficiary spending growth rate declined from 3.3% to -0.1%. From 2016 to 2018, the mean annual Medicare spending growth rate rose relative to the previous period but remained lower than in the baseline period at 1.7% per year. This slowdown extended across all sectors within Parts A and B, except for physician-administered drugs offered under Part B. Changes in payment rates (including sequestration measures) and beneficiary characteristics explained 44% of the difference in overall per-beneficiary spending growth between 2007 to 2011 and 2012 to 2015, and 63% between 2007 to 2011 and 2016 to 2018. Conclusions and Relevance: In this cross-sectional study of trends in spending growth per Medicare beneficiary aged 65 years or older, results suggested that Medicare payment policy, including sector-specific payment rate changes and sequestration, will be a critical determinant of whether the Medicare spending growth slowdown persists.

Association of Healthy Lifestyles With Risk of Alzheimer Disease and Related Dementias in Low-Income Black and White Americans.

BACKGROUND AND OBJECTIVES: Although the importance of healthy lifestyles for preventing Alzheimer disease and related dementias (ADRD) has been recognized, epidemiologic evidence remains limited for non-White or low-income individuals who bear disproportionate burdens of ADRD. This population-based cohort study aims to investigate associations of lifestyle factors, individually and together, with the risk of ADRD among socioeconomically disadvantaged Americans. METHODS: In the Southern Community Cohort Study, comprising two-thirds self-reported Black and primarily low-income Americans, we identified incident ADRD using claims data among participants enrolled in Medicare for at least 12 consecutive months after age 65 years. Five lifestyle factors-tobacco smoking, alcohol consumption, leisure-time physical activity (LTPA), sleep hours, and diet quality-were each scored 0 (unhealthy), 1 (intermediate), or 2 (healthy) based on the health guidelines. A composite lifestyle score was created by summing all scores. Cox regression was used to estimate hazard ratios (HRs, 95% CIs) for incident ADRD, treating death as a competing risk. RESULTS: We identified 1,694 patients with newly diagnosed ADRD among 17,209 participants during a median follow-up of 4.0 years in claims data; the mean age at ADRD diagnosis was 74.0 years. Healthy lifestyles were individually associated with an 11%-25% reduced risk of ADRD: multivariable-adjusted HR (95% CI) was 0.87 (0.76-0.99) for never vs current smoking, 0.81 (0.72-0.92) for low-to-moderate vs no alcohol consumption, 0.89 (0.77-1.03) for ≥150 minutes of moderate or ≥75 minutes of vigorous LTPA each week vs none, 0.75 (0.64-0.87) for 7-9 hours vs >9 hours of sleep, and 0.85 (0.75-0.96) for the highest vs lowest tertiles of the Healthy Eating Index. The composite lifestyle score showed a dose-response association with up to 36% reduced risk of ADRD: multivariable-adjusted HRs (95% CIs) across quartiles were 1 (ref), 0.88 (0.77-0.99), 0.79 (0.70-0.90), and 0.64 (0.55-0.74); p trend <0.001. The beneficial associations were observed regardless of participants' sociodemographics (e.g., race, education, and income) and health conditions (e.g., history of cardiometabolic diseases and depression). DISCUSSION: Our findings support significant benefits of healthy lifestyles for ADRD prevention among socioeconomically disadvantaged Americans, suggesting that promoting healthy lifestyles and reducing barriers to lifestyle changes are crucial to tackling the growing burden and disparities posed by ADRD.

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.

Establishing Medicaid incentives for liberating nursing home patients from ventilators.

BACKGROUND: Chronic ventilator use in Tennessee nursing homes surged following 2010 increases in respiratory care payment rates. Tennessee's Medicaid program implemented multiple policies between 2014 and 2017 to promote ventilator liberation in 11 nursing homes, including quality reporting, on-site monitoring, and pay-for-performance incentives. METHODS: Using repeated cross-sectional analysis of Medicare and Medicaid nursing home claims (2011-2017), hospital discharge records (2010-2017), and nursing home quality reports (2015-2017), we examined how service use changed as Tennessee implemented policies designed to promote ventilator liberation in nursing homes. We measured the annual number of nursing home patients with ventilator-related service use; discharge destination of ventilated inpatients and percent of nursing home patients liberated from ventilators. RESULTS: Between 2011 and 2014, the number of Medicare SNF and Medicaid nursing home patients with ventilator use increased more than sixfold. Among inpatients with prolonged mechanical ventilation, discharges to home decreased as discharges to nursing homes increased. As Tennessee implemented policy changes, ventilator-related service use moderately declined in nursing homes from a peak of 198 ventilated Medicare SNF patients in 2014 to 125 in 2017 and from 182 Medicaid patients with chronic ventilator use in 2014 to 145 patients in 2017. Nursing home weaning rates peaked at 49%-52% in 2015 and 2016, but declined to 26% by late 2017. Median number of days from admission to wean declined from 81 to 37 days. CONCLUSIONS: This value-based approach demonstrates the importance of designing payment models that target key patient outcomes like ventilator liberation.

Aligning Medicaid and Medicare Advantage Managed Care Plans for Dual-Eligible Beneficiaries.

To coordinate Medicare and Medicaid benefits, multiple states are creating opportunities for dual-eligible beneficiaries to join Medicare Advantage Dual-Eligible Special Needs Plans (D-SNPs) and Medicaid plans operated by the same insurer. Tennessee implemented this approach by requiring insurers who offered Medicaid plans to also offer a D-SNP by 2015. Tennessee's aligned D-SNP participation increased from 7% to 24% of dual-eligible beneficiaries aged 65 years and above between 2011 and 2017. Within a county, a 10-percentage-point increase in aligned D-SNP participation was associated with 0.3 fewer inpatient admissions (p = .048), 13.9 fewer prescription drugs per month (p = .048), and 0.3 fewer nursing home users (p = .06) per 100 dual-eligible beneficiaries aged 65 years and older. Increased aligned plan participation was associated with 0.2 more inpatient admissions (p = .004) per 100 dual-eligible beneficiaries younger than 65 years. For some dual-eligible beneficiaries, increasing Medicare and Medicaid managed plan alignment has the potential to promote more efficient service use.

Traditional Medicare Spending on Inpatient Episodes as Hospitalizations Decline.

OBJECTIVE: To describe Medicare inpatient episode spending trends between 2009 and 2017 as inpatient use declined among traditional Medicare beneficiaries. METHODS: Inpatient episodes included claims for all traditional Medicare inpatient, outpatient, and Part D services provided during the 30 days prehospitalization, the inpatient stay, and the 90 subsequent days. We describe the mean number of episodes per 1000 beneficiaries, mean episode-related spending per beneficiary, and mean spending per episode for all beneficiaries and for specific populations and types of episodes. Spending measures are reported with and without adjustment for payment rate increases over the study period. RESULTS: The number of inpatient-initiated episodes per 1000 beneficiaries declined by 18.2% between 2009 and 2017 from 326 to 267. After adjusting for payment rate increases, Medicare spending per beneficiary on episode- related care declined by 8.9%, although spending per episode increased by 11.4% over this period. Between 2009 and 2017, all subgroups defined by age, sex, race, or Medicaid status experienced declines in inpatient use accompanied by decreased overall episode-related spending per beneficiary and increased spending per episode. Larger declines in the number of episodes per 1000 beneficiaries were seen among episodes that began with a planned admission (28.8%) or involved no use of post-acute care services (23.9%). When comparing admissions according to medical diagnosis, the largest decline occurred for episodes initiated by a hospitalization for a cardiac or circulatory condition (31.8%). CONCLUSION: Medicare inpatient episodes per beneficiary decreased, but spending decreases due to declining volume were offset by increased spending per episode.

Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare.

BACKGROUND/OBJECTIVE: Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM). DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment. MEASUREMENTS: Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing. RESULTS: Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM. CONCLUSIONS: Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.

Mandated Copayment Reductions in Medicare Advantage: Effects on Skilled Nursing Care, Hospitalizations, and Plan Exit.

OBJECTIVES: To address concerns that postacute cost-sharing may deter high-need beneficiaries from participating in Medicare Advantage (MA) plans, the Centers for Medicare and Medicaid Services have capped cost-sharing for skilled nursing facility (SNF) services in MA plans since 2011. This study examines whether SNF use, inpatient use, and plan disenrollment changed following stricter regulations in 2015 that required most MA plans to eliminate or substantially reduce cost-sharing for SNF care. DESIGN: Difference-in-differences retrospective analysis from 2013 to 2016. SETTING: MA plans. PARTICIPANTS: Thirty-one million MA members in 320 plans with mandatory cost-sharing reductions and 261 plans without such reductions. MEASUREMENTS: Mean monthly number of SNF admissions, SNF days, hospitalizations, and plan disenrollees per 1000 members. RESULTS: Mean total cost-sharing for the first 20 days of SNF services decreased from $911 to $104 in affected plans. Relative to concurrent changes in plans without mandated cost-sharing reductions, plans with mandatory cost-sharing reductions experienced no significant differences in the number of SNF days per 1000 members (adjusted between-group difference: 0.4 days per 1000 members [95% confidence interval (95% CI), -5.2 to 6.0, P=0.89], small decreases in the number of hospitalizations per 1000 members [adjusted between-group difference: 0.6 admissions per 1000 members (95% CI, -1.0 to -0.1; P=0.03)], and small decreases in the number of SNF users who disenrolled at year-end [adjusted between-group difference: -16.8 disenrollees per 1000 members (95% CI, -31.9 to -1.8; P=0.03)]. CONCLUSIONS: Mandated reductions in SNF cost-sharing may have curbed selective disenrollment from MA plans without significantly increasing use of SNF services.

Association of Inclusion of Medicare Advantage Patients in Hospitals' Risk-Standardized Readmission Rates, Performance, and Penalty Status.

Importance: The Hospital Readmissions Reduction Program publicly reports and financially penalizes hospitals according to 30-day risk-standardized readmission rates (RSRRs) exclusively among traditional Medicare (TM) beneficiaries but not persons with Medicare Advantage (MA) coverage. Exclusively reporting readmission rates for the TM population may not accurately reflect hospitals' readmission rates for older adults. Objective: To examine how inclusion of MA patients in hospitals' performance is associated with readmission measures and eligibility for financial penalties. Design, Setting, and Participants: This is a retrospective cohort study linking the Medicare Provider Analysis and Review file with the Healthcare Effectiveness Data and Information Set at 4070 US acute care hospitals admitting both TM and MA patients. Participants included patients admitted and discharged alive with a diagnosis of acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia between 2011 and 2015. Data analyses were conducted between April 1, 2018, and November 20, 2020. Exposures: Admission to an acute care hospital. Main Outcomes and Measures: The outcome was readmission for any reason occurring within 30 days after discharge. Each hospital's 30-day RSRR was computed on the basis of TM, MA, and all patients and estimated changes in hospitals' performance and eligibility for financial penalties after including MA beneficiaries for calculating 30-day RSRRs. Results: There were 748 033 TM patients (mean [SD] age, 76.8 [83] years; 360 692 [48.2%] women) and 295 928 MA patients (mean [SD] age, 77.5 [7.9] years; 137 422 [46.4%] women) hospitalized and discharged alive for AMI; 1 327 551 TM patients (mean [SD] age, 81 [8.3] years; 735 855 [55.4%] women) and 457 341 MA patients (mean [SD] age, 79.8 [8.1] years; 243 503 [53.2%] women) for CHF; and 2 017 020 TM patients (mean [SD] age, 80.7 [8.5] years; 1 097 151 [54.4%] women) and 610 790 MA patients (mean [SD] age, 79.6 [8.2] years; 321 350 [52.6%] women) for pneumonia. The 30-day RSRRs for TM and MA patients were correlated (correlation coefficients, 0.31 for AMI, 0.40 for CHF, and 0.41 for pneumonia) and the TM-based RSRR systematically underestimated the RSRR for all Medicare patients for each condition. Of the 2820 hospitals with 25 or more admissions for at least 1 of the outcomes of AMI, CHF, and pneumonia, 635 (23%) had a change in their penalty status for at least 1 of these conditions after including MA data. Changes in hospital performance and penalty status with the inclusion of MA patients were greater for hospitals in the highest quartile of MA admissions. Conclusions and Relevance: In this cohort study, the inclusion of data from MA patients changed the penalty status of a substantial fraction of US hospitals for at least 1 of 3 reported conditions. This suggests that policy makers should consider including all hospital patients, regardless of insurance status, when assessing hospital quality measures.

Risk adjusting for Medicaid participation in Medicare Advantage.

OBJECTIVES: Determining appropriate capitated payments has important access implications for dual-eligible Medicare Advantage (MA) members. In 2017, MA plans began receiving higher capitated payments for beneficiaries with full vs partial Medicaid when payments started being risk adjusted for level of Medicaid benefits instead of any Medicaid participation. This approach could favor MA plans in states with more generous Medicaid programs where more beneficiaries qualify for full Medicaid and thus a higher capitated payment. To understand this issue, we examined adjusted Medicare spending for dual-eligible beneficiaries across states with differing Medicaid eligibility criteria. STUDY DESIGN: Retrospective analysis of 2007-2015 traditional Medicare data for dual-eligible beneficiaries 65 years and older. METHODS: We compared predicted per-beneficiary spending levels after adjusting for any Medicaid participation and for level of Medicaid benefits across states with varying Medicaid eligibility requirements. RESULTS: States with the most generous Medicaid requirements had more dual-eligible beneficiaries with full Medicaid compared with the most restrictive states (median, 82% vs 55%). Nationally, Medicare spending levels were 1.3 times greater for full vs partial Medicaid participants (range across states, 0.8-1.7). When per-beneficiary spending was adjusted for level of Medicaid benefits, rather than any Medicaid participation, states with more generous Medicaid eligibility had larger gains in predicted spending per dual-eligible beneficiary than states with less generous Medicaid coverage (1.7% vs 1.3% increase). CONCLUSIONS: Distinguishing between partial and full Medicaid in MA payments may disproportionately increase MA payments in states that have more full Medicaid beneficiaries due to more generous Medicaid eligibility.

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.

States With Medically Needy Pathways: Differences in Long-Term and Temporary Medicaid Entry for Low-Income Medicare Beneficiaries.

Medically needy pathways may provide temporary catastrophic coverage for low-income Medicare beneficiaries who do not otherwise qualify for full Medicaid benefits. Between January 2009 and June 2010, states with medically needy pathways had a higher percentage of low-income beneficiaries join Medicaid than states without such programs (7.5% vs. 4.1%, p < .01). However, among new full Medicaid participants, living in a state with a medically needy pathway was associated with a 3.8 percentage point (adjusted 95% confidence interval [1.8, 5.8]) increase in the probability of switching to partial Medicaid and a 4.5 percentage point (adjusted 95% confidence interval [2.9, 6.2]) increase in the probability of exiting Medicaid within 12 months. The predicted risk of leaving Medicaid was greatest when new Medicaid participants used only hospital services, rather than nursing home services, in their first month of Medicaid benefits. Alternative strategies for protecting low-income Medicare beneficiaries' access to care could provide more stable coverage.