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Policy PointsPublic reporting is associated with both mitigating and exacerbating inequities in high‐quality home health agency use for marginalized groups.Ensuring equitable access to home health requires taking a closer look at potentially inequitable policies to ensure that these policies are not inadvertently exacerbating disparities as home health public reporting potentially does.Targeted federal, state, and local interventions should focus on raising awareness about the five‐star quality ratings among marginalized populations for whom inequities have been exacerbated. Context: Literature suggests that public reporting of quality may have the unintended consequence of exacerbating disparities in access to high‐quality, long‐term care for older adults. The objective of this study is to evaluate the impact of the home health five‐star ratings on changes in high‐quality home health agency use by race, ethnicity, income status, and place‐based factors. Methods: We use data from the Outcome and Assessment Information Set, Medicare Enrollment Files, Care Compare, and American Community Survey to estimate differential access to high‐quality home health agencies between July 2014 and June 2017. To estimate the impact of the home health five‐star rating introduction on the use of high‐quality home health agencies, we use a longitudinal observational pretest–posttest design. Findings: After the introduction of the home health five‐star ratings in 2016, we found that adjusted rates of high‐quality home health agency use increased for all home health patients, except for Hispanic/Latine and Asian American/Pacific Islander patients. Additionally, we found that the disparity in high‐quality home health agency use between low‐income and higher‐income home health patients was exacerbated after the introduction of the five‐star quality ratings. We also observed that patients within predominantly Hispanic/Latine neighborhoods had a significant decrease in their use of high‐quality home health agencies, whereas patients in predominantly White and integrated neighborhoods had a significant increase in high‐quality home health agency use. Other neighborhoods experience a nonsignificant change in high‐quality home health agency use. Conclusions: Policymakers should be aware of the potential unintended consequences for implementing home health public reporting, specifically for Hispanic/Latine, Asian American/Pacific Islander, and low‐income home health patients, as well as patients residing in predominantly Hispanic/Latine neighborhoods. Targeted interventions should focus on raising awareness around the five‐star ratings. [ABSTRACT FROM AUTHOR]

Purpose: Home health agencies delivering care in rural counties face unique challenges when providing care to older adults; long travel times between each visit can limit the number of patients seen each day. In 2010, Medicare began paying home health (HH) providers 3% more to serve rural beneficiaries without evaluating the policy's impact on patient outcomes. Methods: Using 100% Medicare data on postacute HH episodes from 2007 to 2014, we estimated the impact of higher payments on beneficiaries outcomes using difference‐in‐differences analysis, comparing rehospitalizations between rural and urban postacute HH episodes before and after 2010. Findings: Our sample included 5.6 million postacute HH episodes (18% rural). In the preperiod, the 30‐ and 60‐day rehospitalization rates for urban HH episodes were 11.30% and 18.23% compared to 11.38% and 18.39% for rural HH episodes. After 2010, 30‐ and 60‐day rehospitalization rates declined, 10.08% and 16.49% for urban HH episodes and 9.87% and 16.08% for rural HH episodes, respectively. The difference‐in‐difference estimate was 0.29 percentage points (P =.005) and 0.57 percentage points (P <.001) for 30‐ and 60‐day rehospitalization, respectively. Conclusions: Increasing payments resulted in a statistically significant reduction in rehospitalizations for rural postacute HH episodes. The add‐on payment is set to sunset in 2022 and its impact on access and quality to HH for rural older adults should be reconsidered. [ABSTRACT FROM AUTHOR]

Patients receiving home health services from high-quality home health agencies often experience fewer adverse outcomes (for example, hospitalizations) than patients receiving services from low-quality agencies. Using administrative data from 2016 and regression analysis, we examined individual- and neighborhood-level racial, ethnic, and socioeconomic factors associated with the use of high-quality home health agencies. We found that Black and Hispanic home health patients had a 2.2-percentage-point and a 2.5-percentage-point lower adjusted probability of high-quality agency use, respectively, compared with their White counterparts within the same neighborhoods. Low-income patients had a 1.2-percentage-point lower adjusted probability of high-quality agency use compared with their higher-income counterparts, whereas home health patients residing in neighborhoods with higher proportions of marginalized residents had a lower adjusted probability of high-quality agency use. Some 40-77 percent of the disparities in high-quality agency use were attributable to neighborhood-level factors. Ameliorating these inequities will require policies that dismantle structural and institutional barriers related to residential segregation. [ABSTRACT FROM AUTHOR]

A small proportion of high-need (HN) Medicare beneficiaries account for a large share of medical expenditures in the United States. Identifying hospitals with the best outcomes for HN patients is central to identifying and spreading evidence-based practices to improve care for this population. The objective of this study was to identify and characterize top-performing hospitals for HN patients. Administrative claims data from 2013–2014 were used to identify HN beneficiaries and their treating hospital; hospitals were ranked based on their HN beneficiaries' outcomes in 2015. Hospitalization, mortality, and days spent in community were assessed, and all outcomes were risk standardized for age, sex, dual eligibility, and hospital referral region. American Hospital Association and aggregated inpatient claims data characterized hospitals. Logistic regression models estimated the odds of ranking in the top 20% on all outcomes. Of 2253 hospitals with at least 500 HN patients in the United States, 92 (4.1%) ranked in the top 20% across all outcomes. No hospital characteristics were associated with being top performing across all outcomes, but urban hospitals were significantly less likely to perform well on hospitalization and private, for-profit hospitals performed better on mortality. Small hospitals, Accountable Care Organization providers, and those providing palliative care services were more likely to rank highly on days spent in the community. Top-performing hospitals served fewer minority, dual eligible, and HN patients, suggesting that case mix may explain some of the differences in performance, and that additional work is needed to examine programs and practices at outstanding hospitals. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: As the national population of persons living with human immunodeficiency virus (HIV) ages, they will require greater postacute and long‐term care use. Little is known about the quality of nursing homes (NHs) to which patients with HIV are admitted. In this study, we assess the association between the number of persons with HIV admitted annually to a given NH (HIV concentration) and that NH's quality outcomes. DESIGN: A cross‐sectional comparative study. SETTING: NHs in nine states, from 2001 to 2012. PARTICIPANTS: A total of 46 918 NH‐years accounting for 67 301 admissions by patients with HIV. MEASUREMENTS: We used 100% Medicaid Analytic Extract, Minimum Dataset 2.0 and 3.0, and Medicare claims from 2001 to 2012 from nine states to examine the association between HIV concentration and NH quality. Persons were classified as HIV positive on the basis of all available data sources, and a NH's percentage of new admissions with HIV was calculated (HIV concentration). We then compared differences in star ratings, rehospitalization rates, NH survey deficiencies, and restraint use by a NH's percentage of admissions with HIV, using linear random effects models. RESULTS: After adjusting for NH characteristics, zip code characteristics, and state and year fixed effects, NHs with greater than 0% to 5% of admissions with HIV had a 0.6 lower star rating (P < .001), and a 0.4% percentage point higher 30‐day rehospitalization rate (P < .01), compared to those with no HIV admissions. NHs with 5% to 50% of admissions with HIV had 7.0 more deficiencies (P < .001), a 0.1 lower star rating (P < .001), and a 1.5 percentage point higher rehospitalization rate (P < .001). CONCLUSION: Persons with HIV were generally admitted to lower‐quality NHs compared to persons without HIV. More efforts are needed to ensure that persons with HIV have access to high‐quality NHs. J Am Geriatr Soc 67:2615–2621, 2019 [ABSTRACT FROM AUTHOR]

Objectives: To evaluate a federal regulation effective in 2011 that limited how much that Medicare Advantage (MA) plans could charge for the first 20 days of care in a skilled nursing facility (SNF). Design: Difference‐in‐differences retrospective analysis comparing SNF utilization trends from 2008–2012. Setting: Select MA plans. Participants: Members of 27 plans with mandatory cost sharing reductions (n=132,000) and members of 21 plans without such reductions (n=138,846). Measurements: Mean monthly number of SNF admissions and days per 1,000 members; annual proportion of MA enrollees exiting the plan. Results: In plans with mandated cost sharing reductions, cost sharing for the first 20 days of SNF care decreased from an average of $2,039 in 2010 to $992 in 2011. In adjusted analyses, plans with mandated cost‐sharing reductions averaged 158.1 SNF days (95% confidence interval (CI)=153.2–163.1 days) per 1,000 members per month before the cost sharing cap. This measure increased by 14.3 days (95% CI=3.8–24.8 days, p=0.009) in the 2 years after cap implementation. However, increases in SNF utilization did not significantly differ between plans with and without mandated cost‐sharing reductions (adjusted between‐group difference: 7.1 days per 1,000 members, 95% CI=–6.5–20.8, p=.30). Disenrollment patterns did not change after the cap took effect. Conclusions: When a federal regulation designed to protect MA members from high out‐of‐pocket costs for postacute care took effect, the use of SNF services did not change. [ABSTRACT FROM AUTHOR]

Objectives To estimate the effect of influenza vaccination on hospitalization and mortality in nursing home ( NH) residents. Design Retrospective cohort study. Setting Medicare claims data linked to NH Minimum Data Set assessments and Centers for Disease Control and Prevention ( CDC) surveillance data from 122 U.S. cities. Participants More than 1 million Medicare fee-for-service, long-stay NH residents between 2000 and 2009. Measurements Weekly facility outcome aggregates of NH resident pneumonia and influenza (P&I) hospitalizations and all-cause mortality and city-level P&I mortality as reported by the CDC were created. The seasonal vaccine match rate for influenza A/H1N1, A/H3N2, and B strains was calculated, and each outcome was compared in seasons of high and low match rates using facility fixed-effects regression models separately for full-year and nonsummer months. Results Average weekly all-cause mortality varied across seasons from 3.74 to 4.13 per 1,000 NH residents per week, and hospitalization for P&I varied from 2.05 to 2.43. Vaccine match rates were invariably high for H1N1 but variable across seasons for the other two types. The association between vaccine match and reduction in overall mortality and P&I hospitalizations was strongest for A/H3N2, the influenza strain typically responsible for the most-severe influenza cases. Given the approximately 130,000 deaths and 77,000 P&I hospitalizations of long-stay NH residents during the 32 nonsummer weeks, the model estimated that a 50-percentage-point increase in the A/H3N2 match rate (from <25% to >75%) reduced long-stay NH resident deaths by 2.0% and P&I hospitalizations by 4.2%. Conclusion Well-matched influenza vaccine prevents P&I hospitalizations and mortality in NH residents. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to determine whether the Minimum Data Set (MDS) 3.0 discharge record accurately identifies hospitalizations and deaths of nursing home residents. Design We merged date of death from Medicare enrollment data and hospital inpatient claims with MDS discharge records to check whether the same information can be verified from both the sources. We examined the association of 30-day rehospitalization rates from nursing homes calculated only from MDS and only from claims. We also examined how correspondence between these 2 data sources varies across nursing homes. Settings All fee-for-service (FFS) Medicare beneficiaries admitted for Medicare-paid (with prospective payment system) skilled nursing facility (SNF) care in 2011. Results Some 94% of hospitalization events in Medicare claims can be identified using MDS discharge records and 87% of hospitalization events detected in MDS data can be verified by Medicare hospital claims. Death can be identified almost perfectly from MDS discharge records. More than 99% of the variation in nursing home–level 30-day rehospitalization rate calculated using claims data can be explained by the same rates calculated using MDS. Nursing home structural characteristics explain only 5% of the variation in nursing home–level sensitivity and 3% of the variation in nursing home–level specificity. Conclusion The new MDS 3.0 discharge record matches Medicare enrollment and hospitalization claims events with a high degree of accuracy, meaning that hospitalization rates calculated based on MDS offer a good proxy for the “gold standard” Medicare data. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To compare the use of top-ranked cancer hospitals for complex cancer surgery between Medicare Advantage (MA) and traditional Medicare fee-for-service (FFS) enrollees. STUDY DESIGN: Cross-sectional analysis of Medicare claims and enrollment data. METHODS: The study used Medicare Provider Analysis and Review files to compare differences in use of top-ranked cancer hospitals for complex cancer surgery (lobectomy, esophagectomy, gastrectomy, colectomy, and the Whipple procedure [pancreaticoduodenectomy]) between MA and FFS enrollees 65 years and older who underwent the surgery in 2015 to 2017. RESULTS: After adjusting for demographic characteristics and county fixed effects, MA enrollees were less likely to use top-ranked cancer hospitals than FFS enrollees by 6.0 percentage points (95% CI, 4.7-7.2) overall; the difference varied from 3.5 percentage points (95% CI, 2.5-4.6) for colectomy to 14.3 percentage points (95% CI, 10.9-17.8) for the Whipple procedure. The difference in cancer surgery rate at a top-ranked cancer hospital between MA and FFS enrollees was larger for MA plans without out-of-network (OON) benefits (--7.5 percentage points; 95% CI, --9.1 to --5.9) than for MA plans with OON benefits (--2.3 percentage points; 95% CI, --2.9 to --1.7). CONCLUSIONS: MA enrollees were less likely to use top-ranked cancer hospitals for complex cancer surgery than FFS enrollees. This difference was larger for MA plans with more restrictive OON policies. These findings suggest that MA enrollees, particularly those with lower OON benefits, may have restricted access to top-ranked hospitals for cancer care compared with FFS enrollees. [ABSTRACT FROM AUTHOR]

The article reports on the increase in enrollment in the Medicare Advantage (MA) program among racial/ethnic minorities and traditionally marginalized groups in the U.S., particularly African Americans and Hispanics, in 2009-2018. The number of enrollees and their demographic information were determined using the Medicare Master Beneficiary Summary File. Also cited are the use of the Centers for Medicare and Medicaid Services (CMS) data for MA plan characteristics.

Hospitals and skilled nursing facilities (SNFs) face increasing pressure to improve care coordination and reduce unnecessary readmissions. One strategy to accomplish this is to share physicians and advanced practice clinicians, so that the same providers see patients in both settings. Using 2008-16 Medicare claims, we found that as SNFs moved increasingly toward using SNF specialists, there was a steady decline in the number of facilities sharing medical providers and in the proportion of SNF primary care delivered by provider practices with both hospital and SNF clinicians (hospital-SNF practices). In SNF fixed effects analyses, we found that SNFs that increased primary care visits by hospital-SNF practices had slightly fewer readmissions, shorter lengths-of-stay, and increased successful community discharges. These findings suggest that SNFs that share medical providers with hospitals may see some benefit from that linkage, although the magnitude of the benefit may be small. [ABSTRACT FROM AUTHOR]

Medicare's more than 420 accountable care organizations (ACOs) provide care for a considerable percentage of the elderly in the United States. One goal of ACOs is to improve care coordination and thereby decrease rates of rehospitalization. We examined whether ACO-affiliated hospitals were more effective than other hospitals in reducing rehospitalizations from skilled nursing facilities. We found a general reduction in rehospitalizations from 2007 to 2013, which suggests that all hospitals made efforts to reduce rehospitalizations. The ACO-affiliated hospitals, however, were able to reduce rehospitalizations more quickly than other hospitals. The reductions suggest that ACO-affiliated hospitals are either discharging to the nursing facilities more effectively compared to other hospitals or targeting at-risk patients better, or enhancing information sharing and communication between hospitals and skilled nursing facilities. Policy makers expect that reducing readmissions to hospitals will generate major savings and improve the quality of life for the frail elderly. However, further work is needed to investigate the precise mechanisms that underlie the reduction of readmissions among ACO-affiliated hospitals. [ABSTRACT FROM AUTHOR]

Little is known about emergency department (ED) utilization among the nearly 1 million older adults residing in assisted living (AL) settings. Unlike federally regulated nursing homes, states create and enforce AL regulations with great variability, which may affect the quality of care provided. The objective of this study was to examine state variability in all-cause and injury-related ED use among residents in AL. Observational retrospective cohort study. We identified a cohort of 293,336 traditional Medicare beneficiaries residing in larger AL communities (25+ beds). With Medicare enrollment and claims data, we identified ED visits and classified those because of injury. We present rates of all-cause and injury-related ED use per 100 person-years in AL, by state, adjusting for age, sex, race, dual-eligibility, and chronic conditions. Risk-adjusted state rates of all-cause ED visits ranged from 100.9 visits/100 AL person-years [95% confidence interval (CI) 92.8, 109.9] in New Mexico to 162.3 visits/100 AL person-years (95% CI 154.0, 174.7) in Rhode Island. The risk-adjusted rate of injury-related ED visits ranged from 18.7 visits/100 AL person-years (95% CI 17.2, 20.3) in New Mexico to 35.7 visits/100 AL person-years (95% CI 34.7, 36.8) in North Carolina. We observed significant variability among states in all-cause and injury-related ED use among AL residents. There is an urgent need to better understand why this variability is occurring to prevent avoidable visits to the ED. [ABSTRACT FROM AUTHOR]