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Objective: Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower-quality plans, measured by a 5-star quality rating system. We examine whether differential access to high-rated plans was associated with this differential enrollment in high-rated plans by race and ethnicity among MA enrollees. Data Sources: The Medicare Master Beneficiary Summary File and MA Landscape File for 2016. Study Design: We first examined county-level MA plan offerings by race and ethnicity. We then examined the association of racial and ethnic differences in enrollment by star rating by controlling for the following different sets of covariates: (1) individual-level characteristics only, and (2) individual-level characteristics and county-level MA plan offerings. Data Collection/Extraction Methods: Not applicable Principal Findings: Racial and ethnic minority enrollees had, on average, more MA plans available in their counties of residence compared to White enrollees (16.1, 20.8, 20.2, vs. 15.1 for Black, Asian/Pacific Islander, Hispanic, and White enrollees), but had fewer number of high-rated plans (4-star plans or higher) and/or more number of low-rated plans (3.5-star plans or lower). While racial and ethnic minority enrollees had lower enrollment in 4-4.5 star plans than White enrollees, this difference substantially decreased after accounting for county-level MA plan offerings (-9.1 to -0.5 percentage points for Black enrollees, -15.9 to -5.0 percentage points for Asian/Pacific Islander enrollees, and -12.7 to 0.6 percentage points for Hispanic enrollees). Results for Black enrollees were notable as the racial difference reversed when we limited the analysis to those who live in counties that offer a 5-star plan. After accounting for county-level MA plan offerings, Black enrollees had 3.2 percentage points higher enrollment in 5-star plans than White enrollees. Conclusions: Differences in enrollment in high-rated MA plans by race and ethnicity may be explained by limited access and not by individual characteristics or enrollment decisions. KEYWORDS access to care, health disparity, high-quality plan, Medicare Advantage, race, traditional Medicare, 1 | INTRODUCTION Enrollment in Medicare Advantage (MA), the segment of the Medicare program run by private insurance companies receiving capitated payments from the government, has been increasing over the [...]

Objective: To examine the effects of Medicare Advantage (MA) enrollment on patterns of end-of-life care. Data sources: We used data from the Master Beneficiary Summary File, the Medicare Provider Analysis and Review, hospice claims, the Minimum Data Set, the Outcome and Assessment Information Set, the Area Health Resources File, and Geographic Variation Public Use File for 2012-2014. Study design: To address selective enrollment into MA, we exploited a discontinuity in payment rates by county population (urban floor payments) as an instrument. Data collection/extraction methods: We identified Medicare beneficiaries continuously enrolled in MA or TM during their last year of life between 2012 and 2014 using Medicare administrative data. Principal findings: We did not find evidence that MA enrollment led to a change in hospital admissions in the last 30 days of life, but MA enrollment decreased hospital as the site of death by 11.0 (95% CI: -13.9 to -8.1) percentage points. Once hospitalized, however, MA enrollment increased use of intensive care by 6.7 (95% CI: 0.3 to 13.1) percentage points and non-invasive mechanical ventilation by 9.2 (95% CI: 5.5 to 12.9) percentage points. MA enrollment increased hospice use by 6.2 (95% CI: 2.3 to 10.1) percentage points at time of death and 7.7 (95% CI: 3.8 to 11.6) percentage points in the last 30 days of life. Particularly, MA enrollment increased hospice admissions among those who were admitted to the hospital within 30 days prior to hospice admission by 18.8 (95% CI: 13.8 to 23.8) percentage points. However, MA enrollment decreased hospice admissions among those who were admitted to home health within 30 days prior to hospice admission by 18.6 (95% CI: -21.9 to -15.2) percentage points. Conclusions: MA plans may improve end-of-life care by reducing hospital death while also improving access to hospice, especially among recently hospitalized persons. KEYWORDS end-of-life care, hospice, Medicare advantage, traditional Medicare What is known on this topic * Prior research has found that compared to traditional Medicare enrollees, Medicare Advantage (MA) enrollees had lower hospital admissions and higher hospice use at the end of life. * However, the prior research did not fully account for selective enrollment into MA, possibly leading to biased estimates. What this study adds * This study examined the effects of MA on end-of-life care patterns among decedents while accounting for selective enrollment, * MA enrollment decreased hospital as the site of death, however once hospitalized MA was not associated with decreased care intensity. * We also found that MA enrollment increased hospice use, but only among those who were admitted to the hospital within 30 days prior to hospice admission., 1 | INTRODUCTION Research has shown that costs for end-of-life care are substantial. Mean per-person Medicare spending for decedents was estimated to be $34,529 in 2014, more than triple the [...]

Objective: To estimate the impact of a new, two-sided risk model accountable care network (ACN) on Washington State employees and their families. Data Sources/Study Setting: Administrative data (January 2013-December 2016) on Washington State employees. Study Design: We compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0-5, 6-18,19-26,18-64). Data Collection/Extraction Methods: We used difference-in-difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children. Principal Findings: We estimate a 1-2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: -1.8, P < .01; age 0-5: -1.2, P = .07; age 6-18: -1.2, P = .06; age 19-26; -1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19-26 were also responsive with inpatient admissions declines (-0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures. Conclusions: Washington's state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality. KEYWORDS accountable care network, health insurance, quality, utilization, value-based contract, Washington, 1 | INTRODUCTION Employers continue to seek new ways to manage rising health care costs and improve employee health. (1) One such method the adoption of value-based contracts, in which [...]

Objective: To investigate the impact of Medicare's skilled nursing facility (SNF) co-payment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. Data Sources and Study Setting: Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee-for-service beneficiaries. Study Design: We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment. Principal Findings: From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1-day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4-1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8-1.0), lower total Medicare payment for the 90-day episode after hospital discharge ($396; 95% CI 361-431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149-210, P < .001), offsetting the lower payment for the shorter index SNF stay. Conclusions: Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes. KEYWORDS Medicare payment, postacute care, skilled nursing facility, 1 | INTRODUCTION Use of skilled nursing facilities (SNFs) for postacute care is common and costly. Institutional postacute care incurs enormous costs to Medicare (1) and is a large contributor [...]

Objective: To estimate dementia's incremental cost to the traditional Medicare program. Data Sources: Health and Retirement Study (HRS) survey-linked Medicare part A and B claims from 1991 to 2012. Study Design: We compared Medicare expenditures for 60 months following a claims-based dementia diagnosis to those for a randomly selected, matched comparison group. Data Collection/Extraction Methods: We used a cost estimator that accounts for differential survival between individuals with and without dementia and decomposes incremental costs into survival and cost intensity components. Principal Findings: Dementia's five-year incremental cost to the traditional Medicare program is approximately $15 700 per patient, nearly half of which is incurred in the first year after diagnosis. Shorter survival with dementia mitigates the incremental cost by about $2650. Increased costs for individuals with dementia were driven by more intensive use of Medicare part A covered services. The incremental cost of dementia was about $7850 higher for females than for males because of sex-specific differential mortality associated with dementia. Conclusions: Dementia's cost to the traditional Medicare program is significant. Interventions that target early identification of dementia and preventable inpatient and post-acute care services could produce substantial savings. KEYWORDS aging, Alzheimer's disease, dementia, health care costs, Medicare, 1 | INTRODUCTION An estimated four to five million older adults in the United States are living with dementia, (1) a chronic, progressive condition characterized by cognitive decline of sufficient [...]