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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]

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]

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]

Contracts with higher market share tended to have larger networks, while the contracts with the highest star ratings more often had narrow primary care networks. Higher quality contracts had narrower networks (20% in 2-2.5-star and 23.6% in 3-3.5-star contracts had a narrow primary care network compared to 50.1% of enrollees in 5-star contracts). MA contracts may define provider networks, while the TM program does not restrict access to any provider. [Extracted from the article]

Objective: To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection. Data Sources: We utilized 2014–2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website. Data Collection/Extraction Methods: We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee‐for‐Service home health users. Study Design: This admission‐level assessment compared HHA selection before (July 2014–June 2015) and after (February–December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs. Principal Findings: The introduction of star ratings was associated with a 0.88‐percentage‐point increase in the probability of selecting a high‐quality HHA and a 0.81‐percentage‐point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare–Medicaid dual‐eligible beneficiaries experienced larger increases in their likelihood of selecting high‐rated agencies than inpatient, white, and nondual beneficiaries. Conclusions: The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection. [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]

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have become common in large nursing homes, placing not only residents but also staff and community members at risk for infection. However, the relationship between larger nursing homes and the community spread of SARS-CoV-2 has not yet been documented. Objective: To examine the association between county average nursing home bed size and presence of certificate of need (CON) laws, which influence nursing home size, with county-level SARS-CoV-2 prevalence over time. Design: Cross-sectional study using county-level data from March 11 through June 12, 2020. Participants: All US counties with at least one nursing home (n = 2,883). Main Measures: The main explanatory variables were county average nursing home bed size and presence of a CON law. The main outcome was the cumulative number of SARS-CoV-2 cases on each day of the study period adjusted for county population size and density, demographic and socioeconomic characteristics, total nursing home bed supply, other health care supply measures, epidemic stage, and census region. Key Results: By June 12, a between-county difference in average nursing home size equal to 1 bed was associated with 3.92 additional SARS-COV-2 cases (95% CI = 2.14 to 5.69; P < 0.001), on average, and counties subject to CON laws had 104.53 additional SARS-CoV-2 cases (95% CI = 7.68 to 201.38; P < 0.05), on average. Counties with larger nursing homes also demonstrated higher growth in the frequency of SARS-COV-2 throughout the study period. Conclusions: At the county level, average nursing home size and CON law presence was associated with a greater frequency of SARS-CoV-2 cases. Controlling the impact of the coronavirus 2019 pandemic may require additional resources for communities with larger nursing homes and more attention towards long-term care policies. [ABSTRACT FROM AUTHOR]

BACKGROUND: To quantify changes to the electronic health record (EHR) market in Rhode Island and to assess the degree of EHR market consolidation between 2009 and 2017. METHODS: The EHR market in Rhode Island is represented by three measures: the proportion of physicians who have adopted an EHR, the number of EHR vendors in use, and EHR market competitiveness, captured by the Herfindahl--Hirschman Index (HHI). RESULTS: The EHR market became more consolidated overall between 2009 and 2017. Among outpatient physicians, the market has remained competitive, despite ongoing consolidation. In contrast, the EHR market among inpatient physicians crossed into the "highly concentrated" zone in 2015. DISCUSSION: While consolidation in the EHR market may facilitate the exchange of data across health systems, potentially reducing duplicative testing and facilitating timely diagnosis, limiting competition may affect vendors' responsiveness to calls for improved usability and innovation. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Prior studies have reported mixed findings about the existence of racial disparities in readmission rates among Medicare Advantage beneficiaries, but these studies used data from one state, focused on black‐white disparities, and did not focus on patients discharged to skilled nursing facilities (SNFs). The objective of the study was to characterize racial and ethnic disparities in rates of 30‐day rehospitalization directly from SNFs among fee‐for‐service and Medicare Advantage patients. DESIGN: A cross‐sectional study of admissions to SNFs in 2015 was conducted. SETTING: SNFs across the United States. PARTICIPANTS: The sample included 1 500 334 white, 213 848 African American, and 99 781 Hispanic Medicare patients who were admitted to 13 375 SNFs. MEASUREMENTS: The main outcome of interest was readmission, identified as patients sent back to any hospital directly from the SNF within 30 days of admission, as indicated on the Minimum Data Set discharge assessment. RESULTS: Overall readmission rates for fee‐for‐service patients were 16.7% (95% confidence interval [CI] = 16.7%‐16.8%) for whites, 18.8% (95% CI = 18.7%‐19.0%) for African Americans, and 17.4% (95% CI = 17.1%‐17.7%) for Hispanics. Readmission rates in Medicare Advantage were 14.7% (95% CI = 14.5%‐14.8%) for whites, 16.8% (95% CI = 16.6%‐17.1%) for African Americans, and 15.3% (95% CI = 14.9%‐15.6%) for Hispanics. We also found that African Americans had about 1% higher readmission rates than whites, even when they received care within the same SNF. No statistically significant differences were found in the magnitude of within‐SNF racial disparities in Medicare Advantage compared with Medicare fee‐for‐service. CONCLUSION: We found racial disparities in readmission rates even within the same facility for both Medicare Advantage and fee‐for‐service beneficiaries. Intervention to reduce disparities in readmission rates, as well as more comprehensive quality measures that incorporate outcomes for Medicare Advantage enrollees, are needed. J Am Geriatr Soc 67:1672–1679, 2019 [ABSTRACT FROM AUTHOR]

Objective: The study aimed to assess whether individuals with Alzheimer's disease and related dementias (ADRD) experience restricted access to hospitals' high‐volume preferred skilled nursing facility (SNF) partners. Data Sources: The data source includes acute care hospital to SNF transitions identified using 100% Medicare Provider Analysis and Review files, 2017–2019. Study Design: We model and compare the estimated effect of facility "preferredness" on SNF choice for patients with and without ADRD. We use conditional logistic regression with a 1:1 patient sample otherwise matched on demographic and encounter characteristics. Data Collection: Our matched sample included 58,190 patients, selected from a total observed population of 3,019,260 Medicare hospitalizations that resulted in an SNF transfer between 2017 and 2019. Principal Findings: Overall, patients with ADRD have a lower probability of being discharged to a preferred SNF (52.0% vs. 54.4%, p < 0.001). Choice model estimation using our matched sample suggests similarly that the marginal effect of preferredness on a patient choosing a proximate SNF is 2.4 percentage points lower for patients with ADRD compared with those without (p < 0.001). The differential effect of preferredness based on ADRD status increases when considering (a) the cumulative effect of multiple SNFs in close geographic proximity, (b) the magnitude of the strength of hospital‐SNF relationship, and (c) comparing patients with more versus less advanced ADRD. Conclusions: Preferred relationships are significantly predictive of where a patient receives SNF care, but this effect is weaker for patients with ADRD. To the extent that these high‐volume relationships are indicative of more targeted transitional care improvements from hospitals, ADRD patients may not be fully benefiting from these investments. Hospital leaders can leverage integrated care relationships to reduce SNFs' perceived need to engage in selection behavior (i.e., enhanced resource sharing and transparency in placement practices). Policy intervention may be needed to address selection behavior and to support hospitals in making systemic improvements that can better benefit all SNF partners (i.e., more robust information sharing systems). [ABSTRACT FROM AUTHOR]

Background: Understanding 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.Methods: Our 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.Results: We 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.Conclusions: Efforts 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. [ABSTRACT FROM AUTHOR]

Objective. Determine the effect of Seguro Popular (SP) on preventive care utilization among low-income SP beneficiaries and uninsured elders in Mexico. Materials and methods. Fixed-effects instrumental-variable (FE-IV) pseudo-panel estimation from three rounds of the Mexican National Health and Nutrition Survey (2000, 2006 and 2012). Results. Our findings suggest that SP has no significant effect on the use of preventive services, including screening for diabetes, hypertension, breast cancer and cervical cancer, by adults aged 50 to 75 years. Conclusions. Despite the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in healthcare access and utilization still exist in Mexico. The Mexican government must keep working on extending health insurance coverage to vulnerable adults. Additional efforts to increase health care coverage and to support preventive care are needed to reduce persistent disparities in healthcare utilization. [ABSTRACT FROM AUTHOR]

Objective: The Medicare Modernization Act of 2004 allowed Medicare Advantage (MA) contracts to form provider networks in order to concentrate their patients among preferred providers. We focus on the skilled nursing facility (SNF) industry to assess patients' health when treating SNFs concentrate more patients from the same MA contract.Data Sources/study Setting: We use Medicare Beneficiary Summary File and Health, HEDIS, and the Minimum Data Set for patient attributes and OSCAR, LTCfocus.org, and Nursing Home Compare for SNF attributes. We include 1,069,436 MA enrollees newly admitted to SNF between 2012 and 2014.Study Design: Using a MA contract fixed-effect model, we examine the effect of prevalence of a patient's MA contract in the treating SNF on patient's health outcomes including 180-day survival, 30-day hospital readmission, 30-day home discharge, and nursing home length of stay. We use an Instrumental Variable (IV), the expected share of admissions in a SNF from patient's MA contract calculated using a McFadden choice model.Principal Findings: We find no relationship between SNF contract concentration and patients' outcomes after applying the IV.Conclusions: While MA plans appear to steer patients to specific SNFs, we do not observe significant returns to patient outcomes related to concentration. [ABSTRACT FROM AUTHOR]

Objective: To examine the effects of Medicare's Medical Review (MR) program on short-stay inpatient hospitalization.Data Sources/study Setting: One Hundred percent of Medicare Part A and Part B claims and the Master Beneficiary Summary File (2007-2010).Study Design: Retrospective observational study using a difference-in-differences approach. We examined six primary intake diagnoses, we believed likely to be targeted by MR. We stratified by hospital profit structure, bed size, system membership, and inpatient admission rate to test for differential effects. The comparison group was hospital visits occurring in those MACs that had yet to implement, as well as those that did not implement during the period of interest.Data Collection: None.Principal Findings: Medical Review significantly reduced the likelihood of inpatient admission for patients with an intake diagnosis of "Non-Specific Chest Pain" by 1.29 percentage points (p < .001). This effect was stronger in larger hospitals (-2.03, p < .001), nonsystem hospitals (-2.54, p < .001), and those with a lower inpatient rate (-1.86, p < .001).Conclusions: Short inpatient hospitalizations were emphasized by MR, and our results show that MR modestly reduced their prevalence among certain patients and certain hospitals. Future work should examine whether this resulted in adverse patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: To characterize the nature and degree of hospitals' efforts to collaborate with skilled nursing facilities (SNFs) and associated patient outcomes.Data Sources/study Setting: Qualitative data were collected through 138 interviews with staff in 16 hospitals and 25 SNFs in eight markets across the United States in 2015. Quantitative data include Medicare claims data for the 290,603 patients discharged from those 16 hospitals between 2008 and 2015.Study Design/data Collection: Semi-structured interviews with hospital and SNF staff were coded and used to classify hospitals' collaboration efforts with SNFs into high versus low collaboration hospitals, and risk-adjusted, claims-based hospital readmission rates from SNF were compared.Principal Findings: Hospital collaboration efforts were defined as establishing SNF partners, transition management initiatives, and hospital staff visits to SNFs. High collaboration hospitals were more likely to send patients to SNFs (as opposed to home, home with home health, or other PAC settings), sent a higher share of patients to high quality SNFs, and had fewer hospital readmissions from SNF sooner than did low collaboration hospitals.Conclusions: Although collaboration with SNF requires significant administrative and clinical time investment, it is associated with positive patient outcomes. [ABSTRACT FROM AUTHOR]

In the traditional Medicare program, the use of health care services--particularly postacute care--varies substantially across geographic regions. Less is known about such variations in Medicare Advantage (MA), which is growing rapidly. Insurers that are paid on a risk basis, as in MA, may have incentives and tools to restrain the use of services, which could attenuate geographic variations. In this study of fifty-four million Medicare beneficiaries in the period 2007-13, we found that geographic variations in the use of skilled nursing facility and hospital care in the MA population exceeded those in traditional Medicare, though variations in the use of home health care were greater in traditional Medicare. Within hospital referral regions, the correlations between the use of services in MA and traditional Medicare were moderate to strong. The findings suggest that regional variations in hospital and postacute care reflect local factors that influence beneficiaries' use of services irrespective of the way they obtain coverage. [ABSTRACT FROM AUTHOR]

We defined a contract as consolidated if over 75% of enrollees move into a different contract owned by the same insurer in the following year, with the previous contract terminated. Figure 1 plots the annual number of consolidated contracts and the percentage of those consolidations that were to a contract with 4+ stars. If a contract were terminated, and enrollees from that contract were not consolidated, that contract would be included in the Neither category. [Extracted from the article]

Background: Medicare Advantage (MA) and Medicare fee-for-service (FFS) plans have different financial incentives. Medicare pays predetermined rates per beneficiary to MA plans for providing care throughout the year, while providers serving FFS patients are reimbursed per utilization event. It is unknown how these incentives affect post-acute care in skilled nursing facilities (SNFs). The objective of this study was to examine differences in rehabilitation service use, length of stay, and outcomes for patients following hip fracture between FFS and MA enrollees.Methods and Findings: This was a retrospective cohort study to examine differences in health service utilization and outcomes between FFS and MA patients in SNFs following hip fracture hospitalization during the period January 1, 2011, to June 30, 2015, and followed up until December 31, 2015. We linked the Master Beneficiary Summary File, Medicare Provider and Analysis Review data, Healthcare Effectiveness Data and Information Set data, the Minimum Data Set, and the American Community Survey. The 6 primary outcomes of interest in this study included 2 process measures and 4 patient-centered outcomes. Process measures included length of stay in the SNF and average rehabilitation therapy minutes (physical and occupational therapy) received per day. Patient-centered outcomes included 30-day hospital readmission, changes in functional status as measured by the 28-point late loss MDS-ADL scale, likelihood of becoming a long-term resident, and successful discharge to the community. Successful discharge from a SNF was defined as being discharged to the community within 100 days of SNF admission and remaining alive in the community without being institutionalized in any acute or post-acute setting for at least 30 days. We analyzed 211,296 FFS and 75,554 MA patients with hip fracture admitted directly to a SNF following an index hospitalization who had not been in a nursing facility or hospital in the preceding year. We used inverse probability of treatment weighting (IPTW) and nursing facility fixed effects regression models to compare treatments and outcomes between MA and FFS patients. MA patients were younger and less cognitively impaired upon SNF admission than FFS patients. After applying IPTW, demographic and clinical characteristics of MA patients were comparable with those of FFS patients. After adjusting for risk factors using IPTW-weighted fixed effects regression models, MA patients spent 5.1 (95% CI -5.4 to -4.8) fewer days in the SNF and received 463 (95% CI to -483.2 to -442.4) fewer minutes of total rehabilitation therapy during the first 40 days following SNF admission, i.e., 12.1 (95% CI -12.7 to -11.4) fewer minutes of rehabilitation therapy per day compared to FFS patients. In addition, MA patients had a 1.2 percentage point (95% CI -1.5 to -1.1) lower 30-day readmission rate, 0.6 percentage point (95% CI -0.8 to -0.3) lower rate of becoming a long-stay resident, and a 3.2 percentage point (95% CI 2.7 to 3.7) higher rate of successful discharge to the community compared to FFS patients. The major limitation of this study was that we only adjusted for observed differences to address selection bias between FFS and MA patients with hip fracture. Therefore, results may not be generalizable to other conditions requiring extensive rehabilitation.Conclusions: Compared to FFS patients, MA patients had a shorter course of rehabilitation but were more likely to be discharged to the community successfully and were less likely to experience a 30-day hospital readmission. Longer lengths of stay may not translate into better outcomes in the case of hip fracture patients in SNFs. [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]

Objective: To examine the relative influence of hospital and skilled nursing facilities (SNFs) on 30-day rehospitalization.Data Sources/settings: Elderly Medicare beneficiaries newly admitted to a SNF following hospitalization.Study Design: We ranked hospitals and SNFs into quartiles based on previous years' adjusted rehospitalization rates (ARRs) and examined how rehospitalizations from a given hospital vary depending upon the admitting SNF ARR quartile. We examined whether the availability of SNFs with low rehospitalization rates influenced hospitals' SNF readmission rates and whether changes in a hospital's ARR over 3 years is associated with changes in the SNFs to which they discharge.Principal Findings: Hospital readmission rates from SNFs varied 5 percentage points between patients discharged to SNFs in the lowest and the highest rehospitalization quartiles. Low rehospitalization rate hospitals sent a larger fraction of their patients to the lowest rehospitalization SNFs available in the area. A 10 percent increase in hospital's share of discharges to the lowest rehospitalization quartile SNFs is associated with a 1 percentage point reduction in hospital's ARR.Conclusions: The SNF rehospitalization rate has greater influence on patients' risk of rehospitalization than the discharging hospital. Identifying high-performing SNFs may be a powerful strategy for hospitals to reduce rehospitalizations. [ABSTRACT FROM AUTHOR]

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the observed differences in the risk-adjusted rehospitalization rates across skilled nursing facilities (SNFs) reflect true differences or merely differences in patient severity.Settings: Elderly Medicare beneficiaries newly admitted to an SNF following hospitalization.Study Design: We used 2009-2012 Medicare data to calculate SNFs' risk-adjusted rehospitalization rate. We then estimated the effect of these rehospitalization rates on the rehospitalization of incident patients in 2013, using an instrumental variable (IV) method and controlling for patient's demographic and clinical characteristics and residential zip code fixed effects. We used the number of empty beds in a patient's proximate SNFs during hospital discharge to create the IV.Principal Findings: The risk-adjusted rehospitalization rate varies widely; about one-quarter of the SNFs have a rehospitalization rate lower than 17 percent, and for one-quarter, it is higher than 23 percent. All the IV models result in a robust finding that an increase in a SNF's rehospitalization rate of 1 percentage point over the period 2009-2012 leads to an increase in a patient's likelihood of rehospitalization by 0.8 percentage points in 2013.Conclusions: Treatment in SNFs with historically low rehospitalization causally reduces a patient's likelihood of rehospitalization. Observed differences in rehospitalization rates reflect true differences and are not an artifact of selection. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of Seguro Popular (Mexican social health insurance for the poor; SP) on diabetes and hypertension care, intermediate process indicators for older adults (>50 years): pharmacological treatment, blood glucose tests, the use of complementary and alternative medicine (CAM), and adherence to their nutrition and exercise program. (CAM was defined as products or practices that were not part of the medical standard of care.)Data Sources/study Setting: Repeated cross-sectional surveys from Encuesta Nacional de Salud y Nutrición (Mexican Health and Nutrition Survey, ENSANUT), a nationally representative health and nutrition survey sampling N = 45,294 older adults in 2000, N = 45,241 older adults in 2005-2006, and N = 46,277 older adults in 2011-2012.Study Design: Fixed-effects instrumental variable (FE-IV) repeated cross-sectional at the individual level with municipality fixed-effects estimation was performed.Principal Findings: We found a marginally significant effect of SP on the use of insulin and oral agents (40 percentage points). Contrary to that expected, no other significant differences were found for diabetes or hypertension treatment and care indicators.Conclusions: Social health insurance for the poor improved some but not all health care process indicators among diabetic and hypertensive older people in Mexico. [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]

Over the past two decades, nursing homes and home health care agencies have been influenced by several Medicare and Medicaid policy changes including the adoption of prospective payment for Medicare-paid postacute care and Medicaid-paid long-term home and community-based care reforms. This article examines how spending growth in these sectors was affected by state certificate-of-need (CON) laws, which were designed to limit the growth of providers and have remained unchanged for several decades. Compared with states without CON laws, Medicare and Medicaid spending in states with CON laws grew faster for nursing home care and more slowly for home health care. In particular, we observed the slowest growth in community-based care in states with CON for both the nursing home and home health industries. Thus, controlling for other factors, public postacute and long-term care expenditures in CON states have become dominated by nursing homes. [ABSTRACT FROM AUTHOR]

Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection. We examined the rates at which participants who used three high-cost services switched between Medicare Advantage and traditional Medicare. We found that the switching rate from 2010 to 2011 away from Medicare Advantage and to traditional Medicare exceeded the switching rate in the opposite direction for participants who used long-term nursing home care (17 percent versus 3 percent), short-term nursing home care (9 percent versus 4 percent), and home health care (8 percent versus 3 percent). These results were magnified among people who were enrolled in both Medicare and Medicaid. Our findings raise questions about the role of Medicare Advantage plans in serving high-cost patients with complex care needs, who account for a disproportionately high amount of total health care spending. [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 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]

In this paper, we examine the contributions of travel distance and preferences for racial homogeneity as sources of nursing home segregation and racial disparities in nursing home quality. We first theoretically characterize the distinctive implications of these mechanisms for nursing home racial segregation. We then use this model to structure an empirical analysis of nursing home sorting. We find little evidence of differential willingness to pay for quality by race among first-time nursing home entrants, but do find significant distance and race-based preference effects. Simulation exercises suggest that both effects contribute importantly to racial disparities in nursing home quality. [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]

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. [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 determine whether the rate of rehospitalization is lower among patients discharged to skilled nursing facilities (SNFs) with which a hospital has a strong linkage.Data Sources/collection: We used national Medicare enrollment, claims, and the Minimum Data Set to examine 2.8 million newly discharged patients to 15,063 SNFs from 2,477 general hospitals between 2004 and 2006.Study Design: We examined the relationship between the proportion of discharges from a hospital and alternative SNFs on the rehospitalization of patients treated by that hospital-SNF pair using an instrumental variable approach. We used distances to alternative SNFs from residence of the patients of the originating hospital as the instrument.Principal Findings: Our estimates suggest that if the proportion of a hospital's discharges to an SNF was to increase by 10 percentage points, the likelihood of patients treated by that hospital-SNF pair to be rehospitalized within 30 days would decline by 1.2 percentage points, largely driven by fewer rehospitalizations within a week of hospital discharge.Conclusions: Stronger hospital-SNF linkages, independent of hospital ownership, were found to reduce rehospitalization rates. As hospitals are held accountable for patients' outcomes postdischarge under the Affordable Care Act, hospitals may steer their patients preferentially to fewer SNFs. [ABSTRACT FROM AUTHOR]

Objective To determine whether the rate of rehospitalization is lower among patients discharged to skilled nursing facilities ( SNFs) with which a hospital has a strong linkage. Data Sources/Collection We used national Medicare enrollment, claims, and the Minimum Data Set to examine 2.8 million newly discharged patients to 15,063 SNFs from 2,477 general hospitals between 2004 and 2006. Study Design We examined the relationship between the proportion of discharges from a hospital and alternative SNFs on the rehospitalization of patients treated by that hospital- SNF pair using an instrumental variable approach. We used distances to alternative SNFs from residence of the patients of the originating hospital as the instrument. Principal Findings Our estimates suggest that if the proportion of a hospital's discharges to an SNF was to increase by 10 percentage points, the likelihood of patients treated by that hospital- SNF pair to be rehospitalized within 30 days would decline by 1.2 percentage points, largely driven by fewer rehospitalizations within a week of hospital discharge. Conclusions Stronger hospital- SNF linkages, independent of hospital ownership, were found to reduce rehospitalization rates. As hospitals are held accountable for patients' outcomes postdischarge under the Affordable Care Act, hospitals may steer their patients preferentially to fewer SNFs. [ABSTRACT FROM AUTHOR]

Objective To estimate the effect of a nursing home's share of residents with a serious mental illness ( SMI) on the quality of care. Data Sources Secondary nursing home level data over the period 2000 through 2008 obtained from the Minimum Data Set, OSCAR, and Medicare claims. Study Design We employ an instrumental variables approach to address the potential endogeneity of the share of SMI residents in nursing homes in a model including nursing home and year fixed effects. Principal Findings An increase in the share of SMI nursing home residents positively affected the hospitalization rate among non- SMI residents and negatively affected staffing skill mix and level. We did not observe a statistically significant effect on inspection-based health deficiencies or the hospitalization rate for SMI residents. Conclusions Across the majority of indicators, a greater SMI share resulted in lower nursing home quality. Given the increased prevalence of nursing home residents with SMI, policy makers and providers will need to adjust practices in the context of this new patient population. Reforms may include more stringent preadmission screening, new regulations, reimbursement changes, and increased reporting and oversight. [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]

The Patient Driven Payment Model (PDPM) was implemented in U.S. skilled nursing facilities (SNFs) in October 2019, shortly before COVID-19. This new payment model aimed to reimburse SNFs for patients' nursing needs rather than the previous model which reimbursed based on the volume of therapy received. Through 156 semi-structured interviews with 40 SNF administrators from July 2020 to December 2021, this qualitative study clarifies the impact of COVID-19 on the administration of PDPM at SNFs. Interview data were analyzed using modified grounded theory and thematic analysis. Our findings show that SNF administrators shifted focus from management of the PDPM to COVID-19-related delivery of care adaptations, staff shortfalls, and decreased admissions. As the pandemic abated, administrators re-focused their attention to PDPM. Policy makers should consider the continued impacts of the pandemic at SNFs, particularly on delivery of care, admissions, and staffing, on the ability of SNF administrators to administer a new payment model. [ABSTRACT FROM AUTHOR]

See related Editorial by Unroe and Towsley in this issue. [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]

Health systems have increasingly developed integrated Medicare Advantage (MA) plans to align financial incentives and improve coordination of care and services across payer and provider. However, little is known about integrated MA plans' effects on patient outcomes and care processes. We used 2015 MA hospitalization data to assess whether these new models are associated with differences in the processes that take place during hospitalizations and to differences in patient outcomes. We found that enrollees who received care in a fully integrated context were less likely to disenroll from Medicare Advantage or switch MA plans and had marginally lower adjusted mortality rates, compared to enrollees hospitalized in less integrated settings--with no differences in readmissions between the two groups. The fully integrated enrollees also acquired more diagnoses but were less often admitted to the ICU compared to other patients admitted to the same hospitals. As the number of these arrangements continues to grow, the potential advantages of coordination may need to be balanced against the increased cost to Medicare associated with apparently more diagnostic complexity. [ABSTRACT FROM AUTHOR]

Abstract Unstable housing, including homelessness, is a public policy concern for all populations, and more critically for people with a serious health condition such as HIV. We measure the effect of unstable housing on HIV treatment biomarkers: viral suppression (viral load < 200 HIV RNA copies per ml) and adequate CD4+ T-cell count (CD4>350 cells per μl). We use panel data (1995–2015) from 3082 participants of the Women's Interagency HIV Study (WIHS) sites in Bronx and Brooklyn (NY), Chicago (IL), Los Angeles and San Francisco (CA), and Washington (DC). The instrumental variable (IV) measures allocations for the Housing Opportunities for People with AIDS (HOPWA) per person newly infected with HIV, and it represents actual availability of housing assistance for HIV-positive persons at the metropolitan area level. Using an extended probit model with the IV, we find that unstable housing reduces the likelihood of viral suppression by 51 percentage points, and decreases the probability of having adequate CD4 cell count by 53 percentage points. The endogeneity-corrected results are larger than naïve probits, which show decreases of 8.1 and 7.8 percentage points, respectively. The hypothesized pathways for the effect are: decreased use of mental healthcare/counseling, any healthcare, and less continuity of care. Increasing efforts to improve housing assistance, including HOPWA, and other interventions to make housing more affordable for low-income populations, and HIV-positive populations in particular, may be warranted not only for the benefits of stable housing, but also to improve HIV-related biomarkers. Highlights • We measure the negative effect of unstable housing on objective health biomarkers. • We test specific pathways: mental health/healthcare use, and continuity of care. • We use instrumental variables allowing a causal interpretation of the effects. • We use panel data (1995–2015) for largest- & longest-running HIV + cohort in U.S. [ABSTRACT FROM AUTHOR]

Objective: To characterize the experiences of nursing home administrators as they manage facilities across the United States during the COVID‐19 pandemic. Data Sources and Study Setting: We conducted 156 interviews, consisting of four repeated interviews with administrators from 40 nursing homes in eight health care markets across the country from July 2020 through December 2021. Study Design: We subjected the interview transcripts to a rigorous qualitative analysis to identify overarching themes using a modified grounded theory approach to applied thematic analysis. Data Collection Methods: In‐depth, semi‐structured qualitative interviews were conducted virtually or by phone, and audio‐recorded, with participants' consent. Audio recordings were transcribed. Principal Findings: Interviews with nursing home administrators revealed a number of important cross‐cutting themes. In interviewing each facility's administrator four times over the course of the pandemic, we heard perspectives regarding the stages of the pandemic, and how they varied by the facility and changed over time. We also heard how policies implemented by federal, state, and local governments to respond to COVID‐19 were frequently changing, confusing, and conflicting. Administrators described the effect of COVID‐19 and efforts to mitigate it on residents, including how restrictions on activities, communal dining, and visitation resulted in cognitive decline, depression, and weight loss. Administrators also discussed the impact of COVID‐19 on staff and staffing levels, reporting widespread challenges in keeping facilities staffed as well as strategies used to hire and retain staff. Administrators described concerns for the sustainability of the nursing home industry resulting from the substantial costs and pressures associated with responding to COVID‐19, the reductions in revenue, and the negative impact of how nursing homes appeared in the media. Conclusions: Findings from our research reflect nursing home administrator perspectives regarding challenges operating during COVID‐19 and have substantial implications for policy and practice. [ABSTRACT FROM AUTHOR]

Unlike fee-for-service (FFS) Medicare, most Medicare Advantage (MA) plans have a preferred network of care providers that serve most of a plan's enrollees. Little is known about how the quality of care MA enrollees receive differs from that of FFS Medicare enrollees. This article evaluates the differences in the quality of skilled nursing facilities (SNFs) that Medicare Advantage and FFS beneficiaries entered in the period 2012-14. After we controlled for patients' clinical, demographic, and residential neighborhood effects, we found that FFS Medicare patients have substantially higher probabilities of entering higher-quality SNFs (those rated four or five stars by Nursing Home Compare) and those with lower readmission rates, compared to MA enrollees. The difference between MA and FFS Medicare SNF selections was less for enrollees in higher-quality MA plans than those in lower-quality plans, but Medicare Advantage still guided patients to lower-quality facilities. [ABSTRACT FROM AUTHOR]

Background: The initial days of a Medicare-covered skilled nursing facility (SNF) stay may have no cost-sharing or daily copayments depending on beneficiaries' enrollment in traditional Medicare or Medicare Advantage. Some policymakers have advocated imposing first-dollar cost-sharing to reduce post-acute expenditures. We examined the relationship between first-dollar cost-sharing for a SNF stay and use of inpatient and SNF services.Methods: We identified seven Medicare Advantage plans that introduced daily SNF copayments of $25-$150 in 2009 or 2010. Copays began on the first day of a SNF admission. We matched these plans to seven matched control plans that did not introduce first-dollar cost-sharing. In a difference-in-differences analysis, we compared changes in SNF and inpatient utilization for the 172,958 members of intervention and control plans.Results: In intervention plans the mean annual number of SNF days per 100 continuously enrolled inpatients decreased from 768.3 to 750.6 days when cost-sharing changes took effect. Control plans experienced a concurrent increase: 721.7 to 808.1 SNF days per 100 inpatients (adjusted difference-in-differences: -87.0 days [95% CI (-112.1,-61.9)]). In intervention plans, we observed no significant changes in the probability of any SNF service use or the number of inpatient days per hospitalized member relative to concurrent trends among control plans.Conclusions: Among several strategies Medicare Advantage plans can employ to moderate SNF use, first-dollar SNF cost-sharing may be one influential factor.Trial Registration: Not applicable. [ABSTRACT FROM AUTHOR]