Clinical and Economic Assessment in Early-Stage Dementia by Severity and Amyloid-ß Status: A 5-Year Retrospective Claims Study of GERAS-US Patients.

BACKGROUND: The high burden of dementia and Alzheimer's disease (AD) increases substantially as disease progresses. Characterizing early patterns of health care utilization among patients who develop cognitive impairment may deepen our understanding of early disease trajectory and potentially facilitate timely diagnosis and management. OBJECTIVE: Describe clinical characteristics, healthcare utilization, and costs in early-stage dementia by disease severity and amyloid-ß status before enrollment in an observational study (GERAS-US). METHODS: Consented patients' GERAS-US data were linked to available five-years of Medicare claims history before GERAS-US enrollment. Clinical characteristics, comorbidity, and pre-/post-diagnosis healthcare use and costs were assessed. Continuous and categorical variables were compared between severity and amyloid-status cohorts using t-test and Chi-square statistics; linear regression models were used to compare cost and utilization measures after adjusting for differences in patients' observation time. Relative likelihood of observed diagnoses, comorbidity, and prescription drug use among cohorts were presented as OR and 90% confidence interval (CI). RESULTS: Of 174 patients clinically diagnosed with early dementia (mild cognitive impairment (MCI): 101; mild dementia (MILD): 73), 55% were amyloid-positive. Memory loss was more likely in MILD versus MCI (OR:1.85, 90% CI 1.10-3.09) and in amyloid-positive versus amyloid-negative cohorts (OR:1.98, 90% CI 1.19-3.29). Mean annual healthcare costs after cognitive impairment/dementia diagnosis were significantly higher for MILD versus MCI ($1191 versus $712, p = 0.067) and amyloid-negative versus amyloid-positive ($1281 versus $701, p = 0.034). Diabetes was more prevalent in MILD and amyloid-negative cohorts. CONCLUSION: Comorbidity and economic burden increased in earliest stages of MCI and MILD and were higher in patients who were amyloid-negative.

Integrated Home- and Community-Based Services Improve Community Survival Among Independence at Home Medicare Beneficiaries Without Increasing Medicaid Costs.

OBJECTIVES: To determine the effect of home-based primary care (HBPC) for frail older adults, operating under Independence at Home (IAH) incentive alignment on long-term institutionalization (LTI). DESIGN: Case-cohort study using HBPC site, Medicare administrative data, and National Health and Aging Trends Study (NHATS) benchmarks. SETTING: Three IAH-participating HBPC sites in Philadelphia, PA, Richmond, VA, and Washington, DC. PARTICIPANTS: HBPC integrated with long-term services and supports (LTSS) cases (n = 721) and concurrent comparison groups (HBPC not integrated with LTSS: n = 82; no HBPC: n = 573). Cases were eligible if enrolled at one of the three HBPC sites from 2012 to 2015. Independence at Home-qualified (IAH-Q) concurrent comparison groups were selected from Philadelphia, PA; Richmond, VA; and Washington, DC. INTERVENTION: HBPC integrated with LTSS under IAH demonstration incentives. MEASUREMENTS: Measurements include LTI rate and mortality rates, community survival, and LTSS costs. RESULTS: The LTI rate in the three HBPC programs (8%) was less than that of both concurrent comparison groups (IAH-Q beneficiaries not receiving HBPC, 16%; patients receiving HBPC but not in the IAH demonstration practices, 18%). LTI for patients at each HBPC site declined over the three study years (9.9%, 9.4%, and 4.9%, respectively). Costs of home- and community-based services (HCBS) were nonsignificantly lower among integrated care patients ($2151/mo; observed-to-expected ratio = .88 [.68-1.09]). LTI-free survival in the IAH HBPC group was 85% at 36 months, extending average community residence by 12.8 months compared with IAH-q participants in NHATS. CONCLUSION: HBPC integrated with long-term support services delays LTI in frail, medically complex Medicare beneficiaries without increasing HCBS costs.

A Claims-Based Examination of Health Care Costs Among Spouses of Patients With Alzheimer's Disease.

BACKGROUND: Spouses of Alzheimer's disease patients (AD spouses) may experience substantial health effects associated with their partner's chronic cognitive and behavioral dysfunction. Studies examining associations between the medical experiences of AD spouses in the period before and after their partner's AD diagnosis are limited, particularly those which measure health care resource use and cost. METHODS: AD patients were identified through multiple Medicare claims containing an AD diagnostic code. Their spouses were identified through special coding in the Medicare eligibility records. The AD spouses were matched demographically to the spouses of Medicare beneficiaries without a history of AD. Longitudinal and annual cross-sectional Medicare cost comparisons utilized log-transformed linear regression. The longitudinal period of observation began 12 months before the AD patient's initial claim listing AD and continued for up to 38 months afterwards. RESULTS: The study identified 16,322 AD spouses. Total per person costs were 24% higher in AD spouses than in the controls ($694/month vs $561/month). AD spouses' excess costs began 3 months before their partners' AD diagnoses and continued for ≥30 months. Being an AD spouse predicted 29% higher Medicare costs after adjustment for chronic health status (P < .001). Increasing AD patient care complexity had a substantial impact on AD spouse Medicare costs (P < .001). CONCLUSIONS: This study documents a link between the health status of AD spouses and AD patients. Additional research is required to elicit the mechanism behind the association between AD spouse and AD patient diagnosis.

Treatment patterns and cost-effectiveness of first line treatment of advanced non-squamous non-small cell lung cancer in Medicare patients.

AIM: To assess the cost-effectiveness of first-line pemetrexed/platinum and other commonly administered regimens in a representative US elderly population with advanced non-squamous non-small cell lung cancer (NSCLC). MATERIALS AND METHODS: This study utilized the Surveillance Epidemiology and End Results (SEER) cancer registry linked to Medicare claims records. The study population included all SEER-Medicare patients diagnosed in 2008-2009 with advanced non-squamous NSCLC (stages IIIB-IV) as their only primary cancer and who started chemotherapy within 90 days of diagnosis. The study evaluated the four most commonly observed first-line regimens: paclitaxel/carboplatin, platinum monotherapy, pemetrexed/platinum, and paclitaxel/carboplatin/bevacizumab. Overall survival and total healthcare cost comparisons as well as incremental cost-effectiveness ratios (ICERs) were calculated for pemetrexed/platinum vs each of the other three. Unstratified analyses and analyses stratified by initial disease stage were conducted. RESULTS: The final study population consisted of 2,461 patients. Greater administrative censorship of pemetrexed recipients at the end of the study period disproportionately reduced the observed mean survival for pemetrexed/platinum recipients. The disease stage-stratified ICER analysis found that the pemetrexed/platinum incurred total Medicare costs of $536,424 and $283,560 per observed additional year of life relative to platinum monotherapy and paclitaxel/carboplatin, respectively. The pemetrexed/platinum vs triplet comparator analysis indicated that pemetrexed/platinum was associated with considerably lower total Medicare costs, with no appreciable survival difference. LIMITATIONS: Limitations included differential censorship of the study regimen recipients and differential administration of radiotherapy. CONCLUSIONS: Pemetrexed/platinum yielded either improved survival at increased cost or similar survival at reduced cost relative to comparator regimens in the treatment of advanced non-squamous NSCLC. Limitations in the study methodology suggest that the observed pemetrexed survival benefit was likely conservative.

Diagnostic Pathways to Alzheimer Disease: Costs Incurred in a Medicare Population.

Despite its implications on the personal and policy level, little is currently known about the specific diagnostic pathways that patients with cognitive impairment (CI) pass through before being diagnosed with Alzheimer disease (AD). Four major diagnostic pathways were identified in the Medicare claims records for 2001 to 2006: AD as initial diagnosis, cognitive disturbance followed by AD; dementia with suspected etiologies followed by AD; dementia without known cause followed by AD; and 1 triple pathway, cognitive disturbance followed by dementia without known cause followed by AD. For all of these pathways, previously low medical costs peaked during patients' month of initial diagnosis and then declined to a level substantially higher than before. The 3 CI pathways that transition to AD included another peak in costs when a secondary AD diagnosis occurred. Each time, inpatient and skilled nursing facility services were major cost contributors. The primary diagnoses on Medicare claims for the AD event were usually comorbidities rather than CI. A linear regression model adjusting for demographic factors, selected comorbidities, and overall frailty found that the transitional CI diagnoses were significant independent cost determinants. They increased Medicare expenditures by an estimated $4600 to $14,200 relative to patients whose initial CI diagnosis was AD.

Effects of home-based primary care on Medicare costs in high-risk elders.

OBJECTIVES: To determine the effect of home-based primary care (HBPC) on Medicare costs and mortality in frail elders. DESIGN: Case-control concurrent study using Medicare administrative data. SETTING: HBPC practice in Washington, District of Columbia. PARTICIPANTS: HBPC cases (n = 722) and controls (n = 2,161) matched for sex, age bands, race, Medicare buy-in status (whether Medicaid covers Part B premiums), long-term nursing home status, cognitive impairment, and frailty. Cases were eligible if enrolled in MedStar Washington Hospital Center's HBPC program during 2004 to 2008. Controls were selected from Washington, District of Columbia, and urban counties in Virginia, Maryland, and Pennsylvania. INTERVENTION: HBPC clinical service. MEASUREMENTS: Medicare costs, utilization events, mortality. RESULTS: Mean age was 83.7 for cases and 82.0 for controls (P < .001). A majority of both groups was female (77%) and African American (90%). During a mean 2-year follow-up, in univariate analysis, cases had lower Medicare ($44,455 vs $50,977, P = .01), hospital ($17,805 vs $22,096, P = .003), and skilled nursing facility care ($4,821 vs $6,098, P = .001) costs, and higher home health ($6,579 vs $4,169; P < .001) and hospice ($3,144 vs. $1,505; P = .005) costs. Cases had 23% fewer subspecialist visits (P = .001) and 105% more generalist visits (P < .001). In a multivariate model, cases had 17% lower Medicare costs, averaging $8,477 less per beneficiary (P = .003) over 2 years of follow-up. There was no difference between cases and controls in mortality (40% vs 36%, hazard ratio = 1.06, P = .44) or in average time to death (16.2 vs 16.8 months, P = .30). CONCLUSION: HBPC reduces Medicare costs for ill elders, with similar survival outcomes in cases and controls.

Using U.S. Medicare records to evaluate the indirect health effects on spouses: a case study in Alzheimer's disease patients.

BACKGROUND: The burden experienced by spouses of patients with Alzheimer's disease (AD) may have negative consequences for their physical health. We describe here a method for analyzing United States Medicare records to determine the changes in health service use and costs experienced by spouses after their marital partner receives an AD diagnosis. METHODS: We initially identified all beneficiaries in the 2001-2005 Medicare 5% sample who had multiple claims listing the ICD-9 diagnostic code for AD, 331.0. The 5% sample includes spouses who share a Medicare account with their marital partners because they lack a sufficient work history for full eligibility on their own. A matched cohort study assessed incremental health costs in the spouses of AD patients versus a control group of spouses of non-AD patients. Longitudinal and cross-sectional analyses tracked the impact of a patient's AD diagnosis on his or her spouse's healthcare costs. RESULTS: Our method located 54,593 AD patients of whom 11.5% had spouses identifiable via a shared Medicare account. AD diagnosis in one member of a couple was associated with significantly higher monthly Medicare payments for the other member's healthcare. The spouses' elevated costs commenced 2 to 3 months before their partners' AD diagnosis and persisted over the follow-up period. After 31 months, the cumulative additional Medicare reimbursements totaled a mean $4,600 in the spouses of AD patients. This excess was significant even after accounting for differences in baseline health status between the cohorts. CONCLUSION: The study methodology provides a framework for comprehensively evaluating medical costs of both chronically ill patients and their spouses. This method also provides monthly data, which makes possible a longitudinal evaluation of the cost effects of specific health events. The observed correlations provide a coherent demonstration of the interdependence between AD patients' and spouses' health. Future research should examine caregiving burden and other possible factors contributing to the AD spouses' health outcomes. It should also extend the method presented here to evaluations of other chronic diseases of the elderly.

The economic burden of Medicare-eligible patients by multiple sclerosis type.

OBJECTIVE: Although the global rate of multiple sclerosis (MS) is low, a few studies have documented high costs. Costs are highly variable depending on MS stage. This study was designed to assess the economic burden of Medicare-eligible patients by MS type in the United States using a claims-based classification algorithm to examine cost variation by disease stage. METHODS: A sample of 2003 to 2006 Medicare patients was selected. Cases were classified as pre-existing progressive MS or pre-existing relapsing-remitting MS (RRMS); the latter were further subdivided into relapsing, remitting, or stable. RESULTS: The sample had 5044 MS subjects, of whom 34.4% had prevalent progressive MS and 65.6% had prevalent RRMS. There were many chronic, comorbid conditions. The mean all-cause Medicare expenditures (not including self-administered medications) per person-year for MS in 2006 were $23,630 for prevalent progressive patients and $5887 for prevalent RRMS patients. Within the RRMS type, Medicare expenditures per person per month in 2006 were $1418 for relapsing patients, $608 for remitting patients, and $331 for stable patients. CONCLUSIONS: There are substantial cost advantages to Medicare for keeping RRMS patients in a stable health state and in keeping them from advancing in disability severity. The overall cost advantage would be diminished by the large cost burden of comorbidity, which would likely remain fixed with improved MS therapies.

Effect of an expenditure cap on low-income seniors' drug use and spending in a state pharmacy assistance program.

OBJECTIVE: To estimate the impact of a soft cap (a ceiling on utilization beyond which insured enrollees pay a higher copayment) on low-income elders' use of prescription drugs. DATA SOURCES AND SETTING: Claims and enrollment files for the first year ( June 2002 through May 2003) of the Illinois SeniorCare program, a state pharmacy assistance program, and Medicare claims and enrollment files, 2001 through 2003. SeniorCare enrolled non-Medicaid-eligible elders with income less than 200 percent of Federal Poverty Level. Minimal copays increased by 20 percent of prescription cost when enrollee expenditures reached $1,750. RESEARCH DESIGN: Models were estimated for three dependent variables: enrollees' average monthly utilization (number of prescriptions), spending, and the proportion of drugs that were generic rather than brand. Observations included all program enrollees who exceeded the cap and covered two periods, before and after the cap was exceeded. PRINCIPLE FINDINGS: On average, enrollees exceeding the cap reduced the number of drugs they purchased by 14 percent, monthly expenditures decreased by 19 percent, and the proportion generic increased by 4 percent, all significant at p<.01. Impacts were greater for enrollees with greater initial spending, for enrollees without one of five chronic illness diagnoses in the previous calendar year, and for enrollees with lower income. CONCLUSIONS: Near-poor elders enrolled in plans with caps or coverage gaps, including Part D plans, may face sharp declines in utilization when they exceed these thresholds.

Managing Medicare's HIV caseload in the era of suppressive therapy.

OBJECTIVES: The 1996 introduction of antiretroviral medications changed Medicare's role in providing HIV care. We analyzed Medicare's patient database in an effort to document the new HIV therapies' effects on expenditures and outcomes. METHODS: We examined the medical billing records of a 5% national Medicare sample from 1997 through 2003. The cohort was stratified by year and categorized by age, race/ethnicity, gender, and Medicare status. Population summaries were categorized according to presence of major chronic diseases and HIV-related conditions. RESULTS: The number of Medicare beneficiaries with HIV increased from 42520 in 1997 to 76500 in 2003, whereas mortality among this group fell by 35%. HIV-associated infections declined by as much as 43% (mycoses). Heart and liver disease and diabetes increased by more than 50%. Adjusted annual per person Medicare expenditures fell 28%; expenditures were 49% higher for Blacks than for Whites. CONCLUSIONS: Improved HIV medical management has led to fewer deaths and has shifted treatment toward chronic care. However, successful management is complicated by conditions that have not been historically linked to HIV and whose effects vary according to race/ethnicity.

Injury prevalence among children and adolescents with mental retardation.

Childhood injuries lead to increased morbidity and result in significant costs to public insurance programs. People with mental retardation, most of whom are covered by Medicaid, are at high risk for injury, which has implications for community inclusion, a central policy goal. Medicaid data from inpatient, outpatient, and long-term care settings represent an important new resource for injury surveillance in this population. Injury prevalence for 8.4 million Medicaid-eligible children in 26 states was measured using 1999 eligibility and claims data; 36.9% Medicaid beneficiaries ages 1 to 20 with mental retardation had at least one injury claim as compared with 23.5% of those without mental retardation. Prevalence rates are reported by gender and age for a variety of injury types.

Medicare spending for injured elders: are there opportunities for savings?

Claims for injury care provided to aged fee-for-service (FFS) beneficiaries cost Medicare more than $8 billion in 1999, almost 6 percent of Medicare claims spending for elders. More than one-fifth of aged FFS beneficiaries had an injury that resulted in a claim. Fractures, which were experienced by one in seventeen aged beneficiaries, were responsible far 67 percent of total injury claims expenses. Medicare could realize substantial savings if these injuries could be prevented; the program should consider underwriting effective prevention activities.

Delivery of ipratropium and albuterol combination therapy for chronic obstructive pulmonary disease: effectiveness of a two-in-one inhaler versus separate inhalers.

OBJECTIVE: To determine whether a combined formulation consisting of ipratropium and an inhaled beta2 agonist (2-in-1 therapy) leads to lower respiratory-related healthcare use and charges and improved compliance compared with treatment with separate ipratropium and beta2-agonist inhalers (separate inhaler therapy). STUDY DESIGN: Retrospective inception cohort study. PATIENTS AND METHODS: Healthcare use, charges, and treatment compliance were examined for adults age 38 years or older who initiated ipratropium therapy on or after July 1997, based on health claims data for United Healthcare enrollees from 5 health plans from July 1997 through December 1998. A total of 428 patients received 2-in-1 therapy, and 658 patients received separate inhaler therapy. To adjust for disease severity and other confounders, the following were determined for the preinitiation period: age; sex; use of oral steroids, antibiotics, or albuterol; respiratory-related healthcare use; and respiratory diagnoses. Compliance was defined as not interrupting or discontinuing therapy during the follow-up period. RESULTS: After adjusting for baseline covariates, 2-in-1 therapy users had a significantly lower risk of emergency department use or hospitalization (relative risk = 0.58, 95% confidence interval [CI] = 0.36, 0.94), lower mean monthly healthcare charges (P= .015), shorter hospital stays (2.05 vs 4.61 days, P = .040), and greater likelihood of compliance (odds ratio = 1.77, 95% CI = 1.46, 2.14). CONCLUSION: A single inhaler containing both ipratropium and albuterol can increase compliance and decrease respiratory morbidity and charges over and above the effects achieved with separate inhalers for these 2 agents.