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BackgroundUnderstanding and addressing racial and ethnic disparities in the quality of post-acute care in skilled nursing facilities is an important health policy issue, particularly as the Medicare program initiates value-based payments for these institutions.MethodsOur final cohort included 649,187 Medicare beneficiaries in either the fee-for-service or Medicare Advantage programs, who were 65 and older and were admitted to a skilled nursing facility following an acute hospital stay, from 8,375 skilled nursing facilities. We examined the quality of care in skilled nursing facilities that disproportionately serve minority patients compared to non-Hispanic whites. Three measures, all calculated at the level of the facility, were used to assess quality of care in skilled nursing facilities: (a) 30-day rehospitalization rate; (b) successful discharge from the facility to the community; and (c) Medicare five-star quality ratings.ResultsWe found that African American post-acute patients are highly concentrated in a small number of institutions, with 28% of facilities accounting for 80% of all post-acute admissions for African American patients. Similarly, just 20% of facilities accounted for 80% of all admissions for Hispanics. Skilled nursing facilities with higher fractions of African American patients had worse performance for three publicly reported quality measures: rehospitalization, successful discharge to the community, and the star rating indicator.ConclusionsEfforts to address disparities should focus attention on institutions that disproportionately serve minority patients and monitor unintended consequences of value-based payments to skilled nursing facilities.

Objective: To quantify racial, ethnic, and income‐based disparities in home health (HH) patients' functional improvement within and between HH agencies (HHAs). Data Sources: 2016–2017 Outcome and Assessment Information Set, Medicare Beneficiary Summary File, and Census data. Data Collection/Extraction Methods: Not Applicable. Study Design: We use multinomial‐logit analyses with and without HHA fixed effects. The outcome is a mutually exclusive five‐category outcome: (1) any functional improvement, (2) no functional improvement, (3) death while a patient, (4) transfer to an inpatient setting, and (5) continuing HH as of December 31, 2017. The adjusted outcome rates are calculated by race, ethnicity, and income level using predictive margins. Principal Findings: Of the 3+ million Medicare beneficiaries with a HH start‐of‐care assessment in 2016, 77% experienced functional improvement at discharge, 8% were discharged without functional improvement, 0.6% died, 2% were transferred to an inpatient setting, and 12% continued using HH. Adjusting for individual‐level characteristics, Black, Hispanic, American Indian/Alaska Native (AIAN), and low‐income HH patients were all more likely to be discharged without functional improvement (1.3 pp [95% CI: 1.1, 1.5], 1.5 pp [95% CI: 0.8, 2.1], 1.2 pp [95% CI: 0.6, 1.8], 0.7 pp [95% CI:0.5, 0.8], respectively) compared to White and higher income patients. After including HHA fixed effects, the differences for Black, Hispanic, and AIAN HH patients were mitigated. However, income‐based disparities persisted within HHAs. Black‐White, Hispanic‐White, and AIAN‐White disparities were largely driven by between‐HHA differences, whereas income‐based disparities were mostly due to within‐HHA differences, and Asian American/Pacific Islander patients did not experience any observable disparities. Conclusions: Both within‐ and between‐HHA differences contribute to the overall disparities in functional improvement. Mitigating functional improvement inequities will require a diverse set of culturally appropriate and socially conscious interventions. Improving the quality of HHAs that serve more marginalized patients and incentivizing improved equity within HHAs are approaches that are imperative for ameliorating outcomes. [ABSTRACT FROM AUTHOR]

Background: Medicare Advantage plans, private managed care plans that enrolled 34% of Medicare beneficiaries in 2019, received $6 billion in annual bonus payments on the basis of their performance on a 5-star rating system. Little is known, however, as to the extent these ratings adequately capture enrollee experience. Objectives: To measure the effect of exposure to higher rated Medicare Advantage contracts on enrollee experience. Design: An instrumental variables analysis using MA contract consolidation as an exogenous shock to the quality of plan enrollees are exposed to. Participants: A total of 345,897 MA enrollees enrolled in non-consolidated contracts and 21,405 enrollees who were consolidated. Main Measures: The primary exposure was enrollee star rating, instrumented using contract consolidation. The primary outcomes were enrollee self-reported experience measures. Key Results: There were no significant effects on increased star ratings on 23 of 27 outcomes. A one-star increase in contract star rating leads to a 5.4 percentage point increase in reporting that pain does not interfere with daily activities (95%CI 2.4, 8.4), and a 4.4 percentage reduction in the likelihood that a physician would talk to the enrollee about physical activity (95%CI: −7.8, −1.1, all p<0.05). A one-star increase in contract star rating led to an 8.4 percentage point reduction in achieving the top score on the received needed information index (95%CI: −16.4, −0.4), and a 1.8 percentage point reduction in responding with the lowest score for the overall rating of care (95%CI: −3.5, −0.1). Conclusions: Exposure to a higher rated MA contract did not appreciably increase enrollee experience. Policymakers should consider reassessing how these ratings and associated bonus payments are currently calculated. [ABSTRACT FROM AUTHOR]

Background/Objectives: We sought to compare the post‐acute and long‐term care experience of Medicare beneficiaries with and without Alzheimer Disease and Related Dementias (ADRD), and whether differences changed from January 1, 2007 to September 30, 2015. Design Retrospective cross‐sectional trend study using Medicare claims linked to the Centers for Medicare & Medicaid Services' (CMS) Minimum Data Set. Setting: CMS‐certified skilled nursing facilities (skilled nursing facility (SNF), n = 17,043). Participants: Fee‐for‐service Medicare beneficiaries aged ≥66 years (n = 6,614,939) discharged from a hospital to a SNF who had not lived in a nursing home during the year before hospitalization. Measurements ADRD was defined by the Chronic Condition Data Warehouse. Outcome measures included: (1) successful discharge defined as being in SNF less than 90 days, then discharged back to the community, alive without subsequent inpatient health care for 30 continuous days; (2) became long‐stay resident in SNF; (3) death in SNF within 90 days; (4) hospital readmission within 30 days of entering SNF; and (5) transferred to another nursing home within 30 days of entering SNF. Results: Successful discharge of beneficiaries with ADRD increased from 43.4% in 2007 to 53.9% in 2015 (average annual percent change (AAPC) = 2.1 (95% CI = 2.0–2.2)); those without ADRD also increased (from 59.1% to 63.6%, AAPC = 0.9 (95% CI = 0.7–1.1)) but not as fast as those with ADRD (P <.01). The proportion of all beneficiaries who became long‐stay or were readmitted to the hospital decreased (P <.05). The proportion with ADRD who became long‐stay was nearly three times higher than those without throughout the study (15.0% vs 5.5% in 2007; 11.3% vs 4.3% in 2015). Conclusion: Though disparity in ADRD in becoming long‐stay residents remains, the increase in successful discharges among those with ADRD also stresses the increasing importance of community as a care setting for adults with ADRD. [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]

Importance In the Medicare Advantage (MA) program, Medicare enrollees may be steered by their health plan to specific hospitals. Little is known about the quality of hospitals that serve MA enrollees. Objective To compare the quality of hospitals that admit MA enrollees with the quality of those that admit traditional Medicare enrollees. Design, Setting, and Participants This cross-sectional study used data from the 2012 to 2016 Medicare Provider Analysis and Review to compare quality of care, as measured by the star rating given by the Centers for Medicare and Medicaid Services and readmission rates, in hospitals that serve MA enrollees and traditional Medicare enrollees using multinomial logit models. Participants were 7 130 610 Medicare beneficiaries admitted to 2994 acute care hospitals across the United States in 2016. Data were analyzed between August 2018 and August 2019. Exposures The exposure was MA enrollment. Adjusters included demographic and clinical characteristics and zip code fixed effects. Main Outcomes and Measures Hospital Compare star ratings and quintiles of performance in 30-day readmission rates. Results The sample included 7 130 610 Medicare beneficiaries in 2016 (54.3% female; mean [SD] age, 72.7 [13.2] years). Of 12 190 270 total hospitalizations, 1 211 293 traditional Medicare and 494 352 MA patients were admitted to 718 low-readmission hospitals and 1 205 586 traditional Medicare and 526 955 MA patients were admitted to 597 high-readmission hospitals. Accounting for observed patient characteristics, MA enrollees less often entered either low- or high-quality hospitals and were more often admitted to average-quality hospitals. For nonemergent hospitalizations, MA enrollees were 1.9 percentage points (95% CI, 1.5-2.2 percentage points) less likely to enter a low-readmissions hospital, 5.1 percentage points (95% CI, 4.6-5.6 percentage points) more likely to enter an average-readmissions hospital, and 3.2 percentage points (95% CI, 2.9-3.5 percentage points) less likely to enter a high-readmissions hospital compared with traditional Medicare enrollees. Patients with MA were also 2.6 percentage points (95% CI, 2.2-2.9 percentage points) less likely to enter a 1- to 2-star hospital, 5.5 percentage points (95% CI, 4.9-5.9 percentage points) more likely to enter a 3-star hospital, and 2.8 percentage points (95% CI, 2.5-3.2 percentage points) less likely to enter a 4- to 5-star hospital compared with traditional Medicare enrollees. The differences were less pronounced for emergency admissions. Conclusions and Relevance This study found that enrollees in MA plans were more likely to be admitted to average-quality hospitals instead of either high- or low-quality hospitals, suggesting that MA plans may be steering their enrollees to specific hospitals. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Developing a definition of what constitutes high need among Medicare beneficiaries using administrative data is an important prerequisite to evaluating value-based payment reforms. While various definitions of high need exist, their predictive validity for different patient outcomes in the following year has not been systematically assessed for both fee-for-service (FFS) and Medicare Advantage (MA) beneficiaries.Objective: To develop a definition of high need using administrative data in 2014 and to examine its predictive validity for patient outcomes in 2015 as compared to alternative definitions for both FFS and MA beneficiaries.Design: Retrospective cohort study of national Medicare claims and post-acute assessment data.Participants: All Medicare beneficiaries in 2014 who survived until the end of the year (n = 54,717,039).Main Measures: Two or more complex conditions, 6 or more chronic conditions, acute or post-acute health services utilization, indicators of frailty, complete dependency in mobility or in any activities of daily living in post-acute care assessments, hospitalization, mortality, days in community, Medicare expenditures.Key Results: Based on our definition of high-need patients, 13.17% of FFS and 8.85% of MA beneficiaries were identified as high need in 2014. High-need FFS patients had mortality rates 7.1 times higher (16.23% vs. 2.27%) and hospitalization rates 3.4 times higher (40.69 vs. 12.03) in 2015 compared to other beneficiaries. Competing high-need definitions all had good specificity (≥ 0.88). Having 3 or more Hierarchical Chronic Conditions yielded a good positive predictive value for hospitalization, at 0.50, but only identified 19.71% of FFS beneficiaries hospitalized and 28.46% of FFS decedents that year as high need, as opposed to 33.92% and 51.98% for the new definition. Results were similar for MA beneficiaries.Conclusions: The proposed high-need definition has better sensitivity and yields a sample of almost 5 million FFS and 1.5 million MA beneficiaries, facilitating outcome performance comparisons across health systems. [ABSTRACT FROM AUTHOR]

The 2003 Medicare Modernization Act (MMA) increased payments to Medicare Advantage plans and instituted a new risk-adjustment payment model to reduce plans' incentives to enroll healthier Medicare beneficiaries and avoid those with higher costs. Whether the MMA reduced risk selection remains debatable. This study uses mortality differences, nursing home utilization, and switch rates to assess whether the MMA successfully decreased risk selection from 2000 to 2012. We found no decrease in the mortality difference or adjusted difference in nursing home use between plan beneficiaries pre- and post the MMA. Among beneficiaries with nursing home use, disenrollment from Medicare Advantage plans declined from 20% to 12%, but it remained 6 times higher than the switch rate from traditional Medicare to Medicare Advantage. These findings suggest that the MMA was not associated with reductions in favorable risk selection, as measured by mortality, nursing home use, and switch rates. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether aligning the Part D low-income subsidy and Medicaid program enrollment pathways in 2010 increased Medicaid participation among new Medicare beneficiaries.Data Sources: Medicare enrollment records for years 2007-2011.Study Design: We used a multinomial logistic model with state fixed effects to examine the annual change in limited and full Medicaid enrollment among new Medicare beneficiaries for 2 years before and after the reforms (2008-2011).Data Extraction Methods: We identified new Medicare beneficiaries in the years 2008-2011 and their participation in Medicaid based on Medicare enrollment records.Principal Findings: The percentage of beneficiaries enrolling in limited Medicaid at the start of Medicare coverage increased in 2010 by 0.3 percentage points for individuals aging into Medicare and by 1.3 percentage points for those qualifying due to disability (p < .001). There was no significant difference in the size of enrollment increases between states with and without concurrent limited Medicaid eligibility expansions.Conclusions: Our findings suggest that streamlining financial assistance programs may improve Medicare beneficiaries' access to benefits. [ABSTRACT FROM AUTHOR]

Objective To examine outcomes associated with dual eligibility (Medicare and Medicaid) of patients who are admitted to skilled nursing facility ( SNF) care and whether differences in outcomes are related to states' Medicaid long-term care policies. Data Sources/Collection We used national Medicare enrollment data and claims, and the Minimum Data Set for 890,922 community-residing Medicare fee-for-service beneficiaries who were discharged to an SNF from a general hospital between July 2008 and June 2009. Study Design We estimated the effect of dual eligibility on the likelihood of 30-day rehospitalization, becoming a long-stay nursing home resident, and 180-day survival while controlling for clinical, demographic, socio-economic, residential neighborhood characteristics, and SNF-fixed effects. We estimated the differences in outcomes by dual eligibility status separately for each state and showed their relationship with state policies: the average Medicaid payment rate; presence of nursing home certificate-of-need ( CON) laws; and Medicaid home and community-based services ( HCBS) spending. Principal Findings Dual-eligible patients are equally likely to experience 30-day rehospitalization, 12 percentage points more likely to become long-stay residents, and 2 percentage points more likely to survive 180 days compared to Medicare-only patients. This longer survival can be attributed to longer nursing home length of stay. While higher HCBS spending reduces the length-of-stay gap without affecting the survival gap, presence of CON laws reduces both the length-of-stay and survival gaps. Conclusions Dual eligibles utilize more SNF care and experience higher survival rates than comparable Medicare-only patients. Higher HCBS spending may reduce the longer SNF length of stay of dual eligibles without increasing mortality and may save money for both Medicare and Medicaid. [ABSTRACT FROM AUTHOR]

Background Dual eligibles, persons who qualify for both Medicare and Medicaid coverage, often receive poorer quality care relative to other Medicare beneficiaries. Objectives To determine whether dual eligibles are discharged to lower quality post-acute skilled nursing facilities ( SNFs) compared with Medicare-only beneficiaries. Research Design Following the random utility maximization model, we specified a discharge function using a conditional logit model and tested how this discharge rule varied by dual-eligibility status. Subjects A total of 692,875 Medicare fee-for-service patients (22% duals) who were discharged for Medicare paid SNF care between July 2004 and June 2005. Measures Medicare enrollment and the Medicaid Analytic Extract files were used to determine dual eligibility. The proportion of Medicaid patients and nursing staff characteristics provided measures of SNF quality. Results Duals are more likely to be discharged to SNFs with a higher share of Medicaid patients and fewer nurses. These results are robust to estimation with an alternative subsample of patients based on primary diagnoses, propensity of being dual eligible, and likelihood of remaining in the nursing home. Conclusions Disparities exist in access to quality SNF care for duals. Strategies to improve discharge planning processes are required to redirect patients to higher quality providers, regardless of Medicaid eligibility. [ABSTRACT FROM AUTHOR]

Objective To examine the effect of reductions in hospital- based ( HB) skilled nursing facility ( SNF) bed supply on the rate of rehospitalization of patients discharged to any SNF from zip codes that lost HB beds. Data Source We used Medicare enrollment records, Medicare hospital and SNF claims, and nursing home Minimum Dataset assessments and characteristics ( OSCAR) to examine nearly 10 million Medicare fee-for-service hospital discharges to SNFs between 1999 and 2006. Study Design We calculated the number of HB and freestanding ( FS) SNF beds within a 22 km radius from the centroid of all zip codes in which Medicare beneficiaries reside in all years. We examined the relationship between HB and FS bed supply and the rehospitalization rates of the patients residing in corresponding zip codes in different years using zip code fixed effects and instrumental variable methods including extensive sensitivity analyses. Principal Findings Our estimated coefficients suggest that closure of 882 HB homes during our study period resulted in 12,000-18,000 extra rehospitalizations within 30 days of discharge. The effect was largely concentrated among the most acutely ill, high-need patients. Conclusions SNF patient-based prospective payment resulted in closure of higher cost HB facilities that had served most postacute patients. As other, less experienced SNFs replaced HB facilities, they were less able to manage high acuity patients without rehospitalizing them. [ABSTRACT FROM AUTHOR]