Background After an organizational transformation in the mid-1990s, the quality of care in the Veterans Affairs health-care system (VA) compared favorably with the quality of care in some private-sector settings. Whether this performance advantage has persisted, and also its relation to geographic and socioeconomic variations in care, is unknown. Objective We compared the quality and equity of care for older adults in the VA with that delivered in Medicare Advantage (MA) health plans using the same performance measures. Research Design Cross-sectional comparison. Subjects A total of 293,554 observations from enrollees in 142 VA medical centers (VAMCs) and 5,768,573 observations from enrollees in 305 MA plans. Measurements Adherence to quality measures assessing diabetes, cardiovascular, and cancer screening care from 2000 to 2007. Results The VA outperformed MA plans on 10 of 11 quality measures in the initial study year, and on all 12 measures in the final year. In 2006 and 2007, adjusted differences between the VA and MA ranged from 4.3 percentage points (95% CI, 3.2-5.4) for cholesterol testing in coronary heart disease to 30.8 percentage points (95% CI, 28.1-33.5) for colorectal cancer screening. For 9 of 12 measures, socioeconomic disparities (defined as the difference in performance rates between persons in the highest and lowest quartiles of area-level income and education) were lower in the VA than in MA. Across all measures, the mean interquartile range of performance was 6.7 percentage points for VAMCs and 14.5 percentage points for MA plans. Conclusions Among persons aged 65 years or older, the VA health-care system significantly outperformed private-sector MA plans and delivered care that was less variable by site, geographic region, and socioeconomic status.
Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients’ SNF length of stay. Using a set of fee-for-service beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid.
The Affordable Care Act Medicaid expansion may be associated with reduced mortality, but evidence to date is limited. Patients with end-stage renal disease (ESRD) are a high-risk group that may be particularly affected by Medicaid expansion.
Objective
To examine the association of Medicaid expansion with 1-year mortality among nonelderly patients with ESRD initiating dialysis.
Design, Setting, and Participants
Difference-in-differences analysis of nonelderly patients initiating dialysis in Medicaid expansion and nonexpansion states from January 2011 to March 2017.
Exposure
Living in a Medicaid expansion state.
Main Outcomes and Measures
The primary outcome was 1-year mortality. Secondary outcomes were insurance, predialysis nephrology care, and type of vascular access for hemodialysis.
Results
A total of 142 724 patients in expansion states (mean age, 50.2 years; 40.2% women) and 93 522 patients in nonexpansion states (mean age, 49.7; 42.4% women) were included. In Medicaid expansion states, 1-year mortality following dialysis initiation declined from 6.9% in the preexpansion period to 6.1% after expansion (change, −0.8 percentage points; 95% CI, −1.1 to −0.5). In nonexpansion states, mortality rates were 7.0% before expansion and 6.8% after expansion (change, −0.2 percentage points; 95% CI, −0.5 to 0.2), yielding an adjusted absolute reduction in mortality in expansion states of −0.6 percentage points (95% CI, −1.0 to −0.2). Mortality reductions were largest for black patients (−1.4 percentage points; 95% CI, −2.2, −0.7;P=.04 for interaction) and patients aged 19 to 44 years (−1.1 percentage points; 95% CI, −2.1 to −0.3;P=.01 for interaction). Expansion was associated with a 10.5-percentage-point (95% CI, 7.7-13.2) increase in Medicaid coverage at dialysis initiation, a −4.2-percentage-point (95% CI, −6.0 to −2.3) decrease in being uninsured, and a 2.3-percentage-point (95% CI, 0.6-4.1) increase in the presence of an arteriovenous fistula or graft. Changes in predialysis nephrology care were not significant.
Conclusions and Relevance
Among patients with ESRD initiating dialysis, living in a state that expanded Medicaid under the Affordable Care Act was associated with lower 1-year mortality. If this association is causal, further research is needed to understand what factors may have contributed to this finding.
Abstract The 30-Day All-Cause Readmission Measure is part of the Skilled Nursing Facility Value-Based Purchasing (SNFVBP) beginning 2019. The objective of the study was to characterize racial and ethnic disparities in 30-day rehospitalization rates from SNF among fee-for-service (FFS) and Medicare Advantage (MA) patients using the Minimum Data Set. The American Health Care Association risk-adjusted model was used. The primary independent variables were race/ethnicity and enrollment in FFS and MA. The sample included 1,813,963 patients from 15,412 SNFs across the US in 2015. Readmission rates were lower for whites. However, MA patients had readmission rates that were ~1 to 2 percentage points lower. In addition, we also found that African-Americans had higher readmission rates than whites, even when they received care within the same SNF. The inclusion of MA patients could change SNF penalties. Successful efforts to reduce rehospitalizations in SNF settings often require improving care coordination and care planning.
Research Objective Medicaid managed care (MMC) has become the dominant method of delivering health services for low‐income Americans enrolled in Medicaid. Following state decisions to extend Medicaid eligibility through the Affordable Care Act, MMC plans enrolled nearly 80% of newly eligible beneficiaries. Many states are adopting performance measurement systems to hold MMC plans accountable for quality of care. Despite the growing importance of measured quality of care in MMC payment and delivery, there is limited understanding of changes in MMC enrollee characteristics or performance measures associated with Medicaid expansion. We examined changes in plan composition among nonelderly MMC enrollees and measured quality of care associated with Medicaid expansion. Study Design We used 2012–2018 National Committee on Quality Assurance Adult Medicaid Consumer Assessment of Healthcare Providers and Systems (CAHPS) data, which are enrollee‐level surveys submitted by state Medicaid agencies and individual MMC plans. Enrollee characteristics included age, gender, race/ethnicity, educational attainment, and self‐reported health status. Our four outcomes measured patient experience of care: whether a respondent answered that it was “always or usually” easy to get needed care, had a personal doctor, had timely access to a checkup or routine care, and had timely access to specialty care. We estimated multivariable linear probability models comparing pre‐ versus post‐expansion changes in plan composition and measured quality in expansion versus non‐expansion states. The post‐expansion period was modeled as an event‐study regression to account for changes over time, where the coefficient of interest was a Medicaid expansion‐by‐year term. Models adjusted for sociodemographic characteristics, self‐reported health, and included state, year, and plan fixed effects. Standard errors were clustered at the state level. Population Studied 315,563 adult MMC enrollees age 18–64 in the 39 states with comprehensive MMC plans. Principal Findings Medicaid expansion was associated with statistically significant decreases in the proportion of female MMC enrollees (−8.4 percentage points [PP], p < 0.01), and increases in the proportion of MMC enrollees who were age 55–64 (6.8 PP, p < 0.01), White non‐Hispanic (4.4 PP, p < 0.01), and with a college degree or higher (2.3 PP, p < 0.01). Relative to MMC enrollees in non‐expansion states, enrollees in expansion states were significantly less likely to report access to a personal doctor (−1.6 PP, 95% CI ‐3.0 to −0.1 PP, p < 0.05) and less likely to report timely access to specialty care (−2.1 PP, 95% CI ‐3.4 to −0.8 PP, p < 0.01) in the first year after expansion. Differences were not statistically significant by the second year post‐expansion. Conclusions Medicaid expansion was associated with substantial changes in MMC plan composition, and there were modest, but temporary, reductions in measured quality of care in the first year post‐expansion. Implications for Policy or Practice States use MMC performance data to assign bonus payments based on meeting or exceeding quality targets, withhold capitated payments, and auto‐assign enrollees to plans. State policymakers should recognize that expansions of Medicaid eligibility may change the composition of plan enrollees, with implications for measured quality of care. Particularly for states that compare a plan's performance on measured quality to national benchmarks, accounting for a state's decision to expand Medicaid may mitigate unfair penalization.
Some research suggests that risk adjustment plays a substantial role in explaining the high levels of government spending on Medicare Advantage (MA). We studied whether the reliance on diagnosis codes to risk-adjust payments to MA plans leads to the inflation of submitted diagnoses. Our approach relied on a comparison among diagnoses included in hospital claims, health status measures from similarly timed health assessments completed by skilled nursing facility (SNF) clinicians, and short-term mortality data. SNF assessments are completed for both MA and traditional Medicare enrollees and, in contrast to diagnoses in claims, cannot be directly manipulated by MA plans or inform their payments. We found that among patients with the same assessment-based health status discharged to the same SNF, claims-based disease scores were 4.1 percent higher for MA enrollees, on average, relative to traditional Medicare enrollees. However, short-term mortality risk was, on average, 8.8 percent lower for MA enrollees. About 60 percent of the payer-based difference in disease scores was attributable to MA chart review updates to diagnoses, and additional codes from chart reviews were unrelated to assessment-based health status. Given the growth of MA and current spending on the program, which reached $321 billion in 2021, this evidence of potential coding inflation may have large fiscal implications.
The availability of dialysis facilities and distance traveled to receive care can impact health outcomes for patients with newly onset kidney failure. We examined recent changes in county-level number of dialysis facilities between 2012 and 2019 and assessed the association between county-level dialysis facility supply and the distance incident kidney failure patients travel to receive care. We conducted a cross-sectional study of 828,427 adult patients initiating in-center hemodialysis for incident kidney failure between January 1, 2012, and December 31, 2019. We calculated the annual county-level number of dialysis facilities, and counties were categorized as having zero, one, two, or three or more dialysis facilities at the time of treatment initiation. We then measured the distance traveled between a patient's home address and dialysis facility at treatment initiation (in miles) and evaluated the association between county-level number of dialysis facilities and distance traveled to initiate treatment. The average annual county-level number of facilities increased from 1.8 to 2.3 between 2012 and 2019. In our study period, 5% of incident adult kidney failure patients resided in a county that had zero dialysis facilities between 2012 and 2019. Compared with counties with three or more dialysis facilities, patients living in counties with no facilities in our study period traveled 14.3 miles (95% CI, 13.4 to 15.2) further for treatment. Kidney failure patients in counties that had no dialysis facilities traveled further, limiting their access to dialysis. Counties with no dialysis facilities at the end of the study period were more rural and had higher poverty than other counties.
Importance Before 2021, most Medicare beneficiaries with end-stage renal disease (ESRD) were unable to enroll in private Medicare Advantage (MA) plans. The 21st Century Cures Act permitted these beneficiaries to enroll in MA plans effective January 2021. Objective To examine changes in MA enrollment among Medicare beneficiaries with ESRD after enactment of the 21st Century Cures Act overall and by race or ethnicity and dual-eligible status. Design, Setting, and Participants This cross-sectional time-trend study used data from Medicare beneficiaries with ESRD (both kidney transplant recipients and those undergoing dialysis) between January 2019 and December 2021. Data were analyzed between June and October 2022. Exposures 21st Century Cures Act. Main Outcomes and Measures Primary outcomes were the proportion of Medicare beneficiaries with prevalent ESRD who switched from traditional Medicare to MA between 2020 and 2021 and those with incident ESRD who newly enrolled in MA in 2021. Individuals who stayed in traditional Medicare were enrolled in 2020 and 2021 and those who switched to MA were enrolled in traditional Medicare in 2020 and MA in 2021. Results Among 575 797 beneficiaries with ESRD in 2020 or 2021 (mean [SD] age, 64.7 [14.2] years, 42.2% female, 34.0% Black, and 7.7% Hispanic or Latino), the proportion of beneficiaries enrolled in MA increased from 24.8% (December 2020) to 37.4% (December 2021), a relative change of 50.8%. The largest relative increases in MA enrollment were among Black (72.8% relative increase), Hispanic (44.8%), and dual-eligible beneficiaries with ESRD (73.6%). Among 359 617 beneficiaries with TM and prevalent ESRD in 2020, 17.6% switched to MA in 2021. Compared with individuals who stayed in traditional Medicare, those who switched to MA had modestly more chronic conditions (6.3 vs 6.1; difference, 0.12 conditions [95% CI, 0.10-0.16]) and similar nondrug spending in 2020 (difference, $509 [95% CI, −$58 to $1075]) but were more likely to be Black (difference, 19.5 percentage points [95% CI, 19.1-19.9]) and have dual Medicare-Medicaid eligibility (difference, 20.8 percentage points [95% CI, 20.4-21.2]). Among beneficiaries who were newly eligible for Medicare ESRD benefits in 2021, 35.2% enrolled in MA. Conclusions and Relevance Results suggest that increases in MA enrollment among Medicare beneficiaries with ESRD were substantial the first year after the 21st Century Cures Act, particularly among Black, Hispanic, and dual-eligible individuals. Policy makers and MA plans may need to assess network adequacy, disenrollment, and equity of care for beneficiaries who enrolled in MA.
Objective. This study analyzes what design elements inhibited enrollment in HEALTHpact. Study Setting. HEALTHpact is a high deductible plan with a premium capped at 10 percent of the average Rhode Island wage. Deductibles are reduced if enrollees meet wellness criteria. Study Design. Qualitative case study. Data Collection. Archival documents and 23 interviews. Principal Findings. Inclusion of a subsidy would have led to lower premiums and more generous coverage. Although priced lower than other plans, HEALTHpact still did not offer good value for most firms. Wellness incentives also were too complex. Conclusions. Subsidies for purchase of insurance coverage are critical to national reform of the small group market. Designers also will need to carefully balance program complexity with innovation in encouraging wellness and product appeal.
