Assessment of Rural-Urban Differences in Health Care Use and Survival Among Medicare Beneficiaries With Alzheimer Disease and Related Dementia.

Importance: There is poor understanding as to how survival and health care use varies among older adults living with Alzheimer disease and related dementia (ADRD) in rural vs urban areas of the United States. Objective: To describe survival and trajectories of hospital, hospice, nursing home, and home health care use among rural and urban Medicare beneficiaries with ADRD in the 6 years after diagnosis. Design, Setting, and Participants: This retrospective cohort study linked Medicare claims data from January 1, 2009, to December 31, 2016, with nursing home and home health assessment data from all US counties. A total of 555 333 Medicare fee-for-service beneficiaries newly diagnosed with ADRD in 2010 were included. A total of 424 561 individuals (76.5%) resided in metropolitan counties, 75 001 (13.5%) in micropolitan counties, and 55 771 (10.0%) in rural counties. Exposures: Rurality of beneficiary's county of residence. Main Outcomes and Measures: Number of days survived after initial ADRD diagnosis; percent of survived days per month spent in the hospital, hospice nursing home, community with home health care services, and community without home health care services. Results: A total of 555 333 Medicare beneficiaries (mean [SD] age, 82.0 [7.5] years; 345 294 women [62.2%]; 480 286 White [86.5%]) were evaluated. Compared with metropolitan county residents, rural beneficiaries were younger (mean [SD] age, 81.6 [7.6] vs 82.1 [7.5] years), were less likely to be women (34 100 [61.1%] vs 264 688 [62.3%]), were more likely to be White (50 886 [91.2%] vs 361 205 [85.1%]) and Medicaid-eligible (14 264 [25.6%] vs 71 656 [16.9%]), and had fewer preexisting chronic conditions (mean [SD], 6.9 [2.8] vs 7.4 [2.9]). Medicare beneficiaries residing in metropolitan counties survived a mean (SD) of 1183.5 (826.0) days after diagnosis. Adjusting for individual demographic and clinical characteristics, rural and micropolitan county residents survived approximately 1.5 months less than metropolitan residents. The adjusted share of survived days spent in nursing homes was 5.7 (95% CI, 4.0-7.5) percentage points higher for rural vs metropolitan residents. The adjusted share of days in hospitals was 0.7 (95% CI, -0.9 to -0.4) percentage points lower, and the share of days in community without home health care was 4.6 (95% CI, -6.1 to -3.1) percentage points lower for rural vs metropolitan county residents. There were no statistically significant differences in home health or hospice use. Similar patterns were found for micropolitan vs metropolitan residents as for rural vs metropolitan residents, although the magnitude of the differences were smaller. Differences in time spent in community and nursing homes between rural vs metropolitan beneficiaries became more pronounced with further time from diagnosis. Conclusions and Relevance: Study results suggest that, after diagnosis, rural Medicare beneficiaries with ADRD spend more time in nursing homes and less time in the community, receive less home health care, and have shorter survival than their urban counterparts.

What Characteristics Influence Whether Rural Beneficiaries Receiving Care From Urban Hospitals Return Home for Skilled Nursing Care?

PURPOSE: Skilled nursing care (SNC) provides Medicare beneficiaries short-term rehabilitation from an acute event. The purpose of this study is to assess beneficiary, market, and hospital factors associated with beneficiaries receiving care near home. METHODS: The population includes Medicare beneficiaries who live in a rural area and received acute care from an urban facility in 2013. "Near home" was defined 3 different ways based on distances from the beneficiary's home to the nearest source of SNC. Results include unadjusted means and odds ratios from logistic regression. FINDINGS: About 69% of rural beneficiaries receiving acute care in an urban location returned near home for SNC. Beneficiaries returning home were white (odds ratio [OR] black: 0.69; other race: 0.79); male (OR: 1.07); older (OR age 85+ [vs 65-69]: 1.14); farther from SNC (OR: 1.01 per mile); closer to acute care (OR: 0.28, logged miles); and received acute care from hospitals that did not own a skilled nursing facility (owned OR: 0.77) and hospitals with: no swing bed (swing bed OR: 0.47), high case mix (OR: 3.04), and nonprofit status (for-profit OR: 0.85). Results varied somewhat across definitions of "near home." CONCLUSIONS: Rural Medicare beneficiaries who received acute care far from home were more likely to receive SNC far from home. Because Medicare beneficiaries have the choice of where to receive SNC, policy makers may consider ensuring that new payment models do not incentivize provision of SNC away from home.

Costs for Colon Cancer Treatment Comparing Benefit Types and Care Sources in the US Military Health System.

INTRODUCTION: Cancer is one of the leading causes of morbidity and mortality in the USA, contributing largely to US healthcare spending. Provision of services (direct or purchased) and insurance benefit type may impact cost for cancer care. As a common cause of cancer in both men and women, we aim to compare colon cancer treatment costs between insurance benefit types and care sources in the US Military Health System (MHS) to better understand whether and to what extent these system factors impact cancer care costs. MATERIALS AND METHODS: Department of Defense Central Cancer Registry records and MHS Data Repository administrative claims were used to identify MHS beneficiaries aged 18-64 who were diagnosed with primary colon adenocarcinoma and received treatment between 2003 and 2008. The data linkage was approved by the Institutional Review Boards of the Walter Reed National Military Medical Center, the Defense Health Agency, and the National Institutes of Health. Costs to the MHS for each claim related to cancer treatment were extracted from the linked data and adjusted to 2008 USD. We used quantile regression models to compare median cancer treatment costs between benefit types and care sources (direct, purchased, or both), adjusted for demographic, tumor, and treatment characteristics. RESULTS: The median per capita (n = 801) costs for colon cancer care were $60,321 (interquartile range $24,625, $159,729) over a median follow-up of 1.7 years. The model-estimated treatment costs were similar between benefit types. Patients using direct care had significantly lower estimated median costs [$34,145 (standard error $4,326)] than patients using purchased care [$106,395 ($10,559)] or both care sources [$82,439 ($13,330)], controlled for patient demographic, tumor, and treatment characteristics. Differences in cost by care source were noted for patients with later stage tumors and by treatment type. Relative costs were 2-3 times higher for purchased care compared to direct care for patients with late-stage tumors and for patients receiving chemotherapy or radiation treatment. CONCLUSIONS: In the MHS, median cost for colon cancer treatment was lower in direct care compared to purchased care or patients using a combination of direct and purchased care. The variation in cancer treatment costs between care sources may be due to differences in treatment incentives or capabilities. Additional studies on cost differences between direct and purchased services are needed to understand how provision of care affects cancer treatment costs and to identify possible targets for cost reduction.

The concept of underinsurance: a general typology.

In a 2002 speech, Mark McClellan, a member of the Council of Economic Advisors at the White House, said that "[I]n the president's vision, all Americans should have access to high-quality and affordable healthcare." However, many healthcare researchers believe that a growing number of Americans are underinsured. Because any characterization of underinsurance will refer to the value judgments of people about what counts as "adequate" and "inadequate" healthcare, the goal of characterizing and measuring the underinsured is difficult to achieve. In this article, I examine the various dimensions of underinsurance, and propose a typology incorporating those dimensions.

The coverage priorities of disabled adult Medi-Cal beneficiaries.

Medi-Cal, like other Medicaid programs around the U.S., has been pressed to cut its budget. We report the results of a project using the CHAT (Choosing Healthplans All Together) exercise, designed to ascertain the priorities of disabled adult Medi-Cal beneficiaries to inform any decisions regarding Medi-Cal benefits. Participants voiced greatest interest in maintaining a wide spectrum of benefits and access to a large pool of providers and were most willing to restrict pharmacy benefits. The resulting findings may be of value to legislators drafting Medicaid proposals that revise benefits for this vulnerable population.

Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.

OBJECTIVE: The aim of this study was to measure the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain. DESIGN: This study is a retrospective analysis of claims data from a managed-care health plan over a 4-year period. The use rates of advanced imaging, surgery, inpatient care, and plain-film radiographs were compared between employer groups with and without a chiropractic benefit. RESULTS: For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (-32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (-37.2%); plain-film radiography (-23.1%); and inpatient care (-40.1%). On a per-patient basis, the rates were reduced by the following: surgery (-13.7%); CT/MRI (-20.3%); plain-film radiography (-2.2%); and inpatient care (-24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (-49.4%); CT/MRI (-45.6%); plain-film radiography (-36.0%); and inpatient care (-49.5%). Per patient, the rates were surgery (-31.1%); CT/MRI (-25.7%); plain-film radiography (-12.5%); and inpatient care (31.1%). All group differences were statistically significant. CONCLUSION: For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Criteria and procedures for determining benefit packages in health care. A comparative perspective.

The legitimacy of procedures and criteria for determining benefit packages depends crucially on the representation of stakeholders in decision-making bodies, the transparency of procedures and the consistency of benefit decisions. Moreover, the assessment of the costs of healthcare services and its application as a decision criterion can be an important policy instrument in order to increase the overall efficiency of healthcare systems. Our analysis of procedures and criteria for determining benefit packages in England, Germany and Switzerland established potential for developing more legitimate procedures and criteria for benefits decisions. In Germany, representation of stakeholders and transparency of procedures can be improved. Consistency of decision-making is hindered by the veto positions of selected stakeholders. Moreover, benefit decisions are made for different healthcare sectors separately. In Switzerland, transparency of procedures is virtually non-existent at the moment. Thus, it is impossible to assess the consistency of decision-making. Only in England the costs of healthcare services influence the decision to include or exclude them.

How low can you go? The impact of reduced benefits and increased cost sharing.

Amid escalating health care costs and a managed care backlash, employers are considering traditional cost control methods from the pre-managed care era. We use an actuarial model to estimate the premium-reducing effects of two such methods: increasing employee cost sharing and reducing benefits. Starting from a baseline plan with rich benefits and low cost sharing, estimated premium savings as a result of eliminating five specific benefits were about 22 percent. The same level of savings was also achieved by increasing cost sharing from a 15 dollars copayment with no deductible to 20 percent coinsurance and a 250 dollars deductible. Further increases in cost sharing produced estimated savings of up to 50 percent. We discuss possible market- and individual-level effects of the proliferation of plans with high cost sharing and low benefits.

Is German long-term care insurance a model for the United States?

German long-term care insurance, implemented in 1995, significantly extends the coverage of care-related risks. Given the similarities of German and U.S. institutional features, the German social insurance approach has been put forward as a possible model for long-term care in the United States. Using a political economy framework, the authors conducted a policy analysis that compares the main shortfalls of long-term care (LTC) provision in the United States and Germany, examines the responses provided by LTC insurance in Germany, and relates them to broader trends and proposals for change in welfare policy in both countries. German LTC insurance includes a high degree of consumer direction and compensation and protection for informal caregivers; it supports the extension of community-based services. Its shortfalls include the continued split between health and LTC insurance. In both countries, decentralization and institutional and financial fragmentation are some of the characteristics responsible for the failure to promote egalitarian social policy and substantially expand social protection to family- and care-related risks. The German LTC program is a good model for the United States. With a social insurance approach to LTC, costs are spread across the largest possible risk pool. Major goals that can be reached with such a program include establishment of universal entitlements to LTC benefits, consumer choice, and equitability and uniformity.

Revising a priority list based on cost-effectiveness: the role of the prominence effect and distorted utility judgments.

BACKGROUND: People sometimes object to the results of cost-effectiveness analysis when the analysis produces a ranking of options based on both cost and benefit. We suggest 2 new reasons for these objections: the prominence effect, in which people attend mostly to a more prominent attrbute (benefit as opposed to cost), and distortion of utility judgments. METHOD: We simulated the production of a cost-effectiveness ranking list in 3 experiments using questionnaires on the World Wide Web. Subjects rated the utility of 16 health benefits using either rating scale or person trade-off elicitation methods. In some experiments, subjects were asked to rate the utility of the health benefits with attention also to the cost of achieving the benefits. In all experiments, at the end, subjects were shown a priority list based on their own utility judgments and were asked whether they wanted to move any of the health benefits up or down the list. RESULTS: In all experiments, subjects wanted to give higher priority to treatments with higher benefit, even when they also had higher cost. They thus wanted to give less weight to high cost (which would, by itself, lead to lower ranking) and more weight to benefit than the weight implied by their own prior judgments. The desire for revision was reduced when subjects made their utility judgments after indicating whether the utility was above or below the midpoint of the scale (a manipulation previously found to reduce distortion). CONCLUSION: The desire to change cost-effectiveness rankings is in part a preference reversal phenomenon that occurs because people attend mainly to the benefit of health interventions as opposed to cost, when they examine the ranking. People should be wary of tinkering with priority lists by examining the lists themselves.

Measuring the "managedness" and covered benefits of health plans.

STUDY AIMS: (1) To develop indexes measuring the degree of managedness and the covered benefits of health insurance plans, (2) to describe the variation in these indexes among plans in one health insurance market, (3) to assess the validity of the health plan indexes, and (4) to examine the association between patient characteristics and the health plan indexes. Measures of the "managedness" and covered benefits of health plans are requisite for studying the effects of managed care on clinical practice and health system performance, and they may improve people's understanding of our complex health care system. DATA SOURCES/STUDY SETTING: As part of our larger Physician Referral Study, we collected health insurance information for 189 insurance product lines and 755 products in the Seattle, Washington metropolitan area, which we linked with the study's data for 2,277 patients recruited in local primary care offices. STUDY DESIGN: Managed care and benefit variables were constructed through content analysis of health plan information. Principal component analysis of the variables produced a managedness index, an in-network benefits index, and an out-of-network benefits index. Bivariable analyses examined associations between patient characteristics and the three indexes. PRINCIPAL FINDINGS: From the managed care variables, we constructed three provider-oriented indexes for the financial, utilization management, and network domains of health plans. From these, we constructed a single managedness index, which correlated as expected with the individual measures, with the domain indexes, with plan type (FFS, PPO, POS, HMO), with independent assessments of local experts, and with patients' attitudes about their health insurance. For benefits, we constructed an in-network benefits index and an out-of-network benefits index, which were correlated with the managedness index. The personal characteristics of study patients were associated with the managed care and benefit indexes. Study patients in more managed plans reported somewhat better health than patients in less managed plans. CONCLUSIONS: Indexes of the managedness and benefits of health plans can be constructed from publicly available information. The managedness and benefit indexes are associated with the personal characteristics and health status of study patients. Potential uses of the managed care and benefits indexes are discussed.