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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.

BackgroundNot much is known about nonelderly veterans and their reliance on care from the Veterans Affairs (VA) health care system when they have access to non-VA care.ObjectivesTo estimate VA reliance for nonelderly veterans enrolled in VA and Medicaid.Research designRetrospective, longitudinal analysis of Medicaid claims data and VA administrative data to compare patients' utilization of VA and Medicaid services 12 months before and for up to 12 months after Medicaid enrollment began.SubjectsNonelderly veterans (below 65 y) receiving VA care and newly enrolled in Medicaid, calendar years 2006-2010 (N=19,890).MeasuresVA reliance (proportion of care received in VA) for major categories of outpatient and inpatient care.ResultsPatients used VA outpatient care at similar levels after enrolling in Medicaid with the exceptions of emergency department (ED) and obstetrics/gynecology care, which decreased. VA inpatient utilization was similar after Medicaid enrollment for most types of care. VA-adjusted outpatient reliance was highest for mental health care (0.99) and lowest for ED care (0.02). VA-adjusted inpatient reliance was highest for respiratory (0.80) and cancer stays (0.80) and lowest for musculoskeletal stays (0.20). Associations between VA reliance and distance to VA providers varied by type of care.ConclusionsVeterans dually enrolled in Medicaid received most of their outpatient care from the VA except ED, obstetrics/gynecology, and dental care. Patients received most of their inpatient care from Medicaid except mental health, respiratory, and cancer care. Sensitivity to travel distance to VA providers explained some of these differences.

ObjectiveTo examine Veterans Health Administration (VA) enrollees' use of VA services for treatment of behavioral health conditions (BHCs) after gaining Medicaid, and if VA reliance varies by complexity of BHCs.Data sources/study settingVA and Medicaid Analytic eXtract utilization data from 31 states, 2006-2010.Study designA retrospective, longitudinal study of Veterans enrolled in VA care in the year before and year after enrollment in Medicaid among 7,249 nonelderly Veterans with serious mental illness (SMI), substance use disorder (SUD), posttraumatic stress disorder (PTSD), depression, or other BHCs.Data collection/extraction methodsUtilization and VA reliance (proportion of care received at VA) for BH outpatient and inpatient services in unadjusted and adjusted analyses.Principal findingsIn adjusted analyses, we found that overall Veterans did not significantly change their use of VA outpatient BH services after Medicaid enrollment. In beta-binomial models predicting VA BH outpatient reliance, veterans with SMI (IRR = 1.38, p

ObjectivesTo examine how dual coverage for nonelderly, low-income veterans by Veterans Affairs (VA) and Medicaid affects their demand for care.Data sourcesVeterans Affairs utilization data and Medicaid Analytic Extract Files.Study designA retrospective, longitudinal study of VA users prior to and following enrollment in Medicaid 2006-2010.Data collection/extraction methodsVeterans Affairs reliance, or proportion of care provided by VA, was estimated with beta-binomial models, adjusting for patient and state Medicaid program factors.Principal findingsIn a cohort of 19,890 nonelderly veterans, VA utilization levels were similar before and after enrolling in Medicaid. VA outpatient reliance was 0.65, and VA inpatient reliance was 0.53 after Medicaid enrollment. Factors significantly associated with greater VA reliance included sociodemographic factors, having a service-connected disability, comorbidity, and higher state Medicaid reimbursement. Factors significantly associated with less VA reliance included months enrolled in Medicaid, managed care enrollment, Medicaid eligibility type, longer drive time to VA care, greater Medicaid eligibility generosity, and better Medicaid quality.ConclusionVeterans Affairs utilization following new Medicaid enrollment remained relatively unchanged, and the VA continued to provide the large majority of care for dually enrolled veterans. There was variation among patients as Medicaid eligibility and other program factors influenced their use of Medicaid services.

BackgroundThe 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.MethodsWe 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.ResultsIn 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.ConclusionsAmong several strategies Medicare Advantage plans can employ to moderate SNF use, first-dollar SNF cost-sharing may be one influential factor.Trial registrationNot applicable.

Compared with traditional Medicare (TM), Medicare Advantage (MA) plans typically offer supplemental benefits and lower copayments for in-network services and must include an out-of-pocket spending limit. The authors used Medical Expenditure Panel Survey data to examine whether persons switching from TM to MA had a decrease in the financial burden of care relative to those remaining in TM. Visual Abstract. Association of Medicare Advantage Enrollment With Financial Burden of Care: Compared with traditional Medicare (TM), Medicare Advantage (MA) plans typically offer supplemental benefits and lower copayments for in-network services and must include an out-of-pocket spending limit. The authors used Medical Expenditure Panel Survey data to examine whether persons switching from TM to MA had a decrease in the financial burden of care relative to those remaining in TM. Background: Compared with traditional Medicare (TM), Medicare Advantage (MA) plans typically offer supplemental benefits and lower copayments for in-network services and must include an out-of-pocket spending limit. Objective: To examine whether the financial burden of care decreased for persons switching from TM to MA (TM-to-MA switchers) relative to those remaining in TM (TM stayers). Design: Retrospective longitudinal cohort study comparing changes in financial outcomes between TM-to-MA switchers and TM stayers. Setting: Population-based. Participants: 7054 TM stayers and 1544 TM-to-MA switchers from the Medical Expenditure Panel Survey, 2014 to 2021. Measurements: Individual health care costs (out-of-pocket spending and cost sharing), financial burden (high and catastrophic), and subjective financial hardship (difficulty paying medical bills, paying medical bills over time, and inability to pay medical bills). Results: Compared with TM stayers, TM-to-MA switchers had small differences in out-of-pocket spending ($168 [95% CI, −$133 to $469]) and proportions of total health expenses paid out of pocket (cost sharing) (0.2 percentage point [CI, −1.3 to 1.7 percentage points]), families with out-of-pocket spending greater than 20% of their income (high financial burden) (0.3 percentage point [CI, −2.5 to 3.0 percentage points]), families reporting out-of-pocket spending greater than 40% of their income (catastrophic financial burden) (0.7 percentage point [CI, −0.1 to 1.6 percentage points]), families reporting paying medical bills over time (−0.2 percentage point [CI, −1.7 to 1.4 percentage points]), families having problems paying medical bills (−0.4 percentage point [CI, −2.7 to 1.8 percentage points]), and families reporting being unable to pay medical bills (0.4 percentage point [CI, −1.3 to 2.0 percentage points]). Limitation: Inability to account for all medical care and cost needs and variations across MA plans, small baseline differences in out-of-pocket spending, and potential residual confounding. Conclusion: Differences in financial outcomes between beneficiaries who switched from TM to MA and those who stayed with TM were small. Differences in financial burden ranged across outcomes and did not have a consistent pattern. Primary Funding Source: The National Research Foundation of Korea. [ABSTRACT FROM AUTHOR]

Medicare Advantage (MA) plans and the Veterans Affairs (VA) health care system assess quality of care using standardized Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. Little is known, however, about the relative accuracy of quality indicators for persons receiving care in more than one health care system. Among Veterans dually enrolled in an MA plan, we examined the agreement between MA and VA HEDIS assessments. Our study tested the hypothesis that private health plans underreport quality of care relative to a fully integrated delivery system utilizing a comprehensive electronic health record. Despite assessing the same individuals using identical measure specifications, reported VA performance was significantly better than reported MA performance for all 12 HEDIS measures. The VA's performance advantage ranged from 9.8% (glycosylated hemoglobin [HbA1c] < 7.0% in diabetes) to 54.7% (blood pressure < 140/90 mm Hg in diabetes). The overall agreement between VA and MA HEDIS assessments ranged from 38.5% to 62.6%. Performance rates derived from VA and MA aggregate data were 1.6% to 14.3% higher than those reported by VA alone. This analysis suggests that neither MA plans nor the VA fully capture quality of care information for dually enrolled persons. However, the VA's system-wide electronic health record may allow for more complete capture of quality information across multiple providers and settings.

Medicare Advantage (MA) plans and the Veterans Affairs (VA) health care system assess quality of care using standardized Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. Little is known, however, about the relative accuracy of quality indicators for persons receiving care in more than one health care system. Among Veterans dually enrolled in an MA plan, we examined the agreement between MA and VA HEDIS assessments. Our study tested the hypothesis that private health plans underreport quality of care relative to a fully integrated delivery system utilizing a comprehensive electronic health record. Despite assessing the same individuals using identical measure specifications, reported VA performance was significantly better than reported MA performance for all 12 HEDIS measures. The VAs performance advantage ranged from 9.8% (glycosylated hemoglobin [HbA1c] < 7.0% in diabetes) to 54.7% (blood pressure < 140/90 mm Hg in diabetes). The overall agreement between VA and MA HEDIS assessments ranged from 38.5% to 62.6%. Performance rates derived from VA and MA aggregate data were 1.6% to 14.3% higher than those reported by VA alone. This analysis suggests that neither MA plans nor the VA fully capture quality of care information for dually enrolled persons. However, the VAs system-wide electronic health record may allow for more complete capture of quality information across multiple providers and settings.

ObjectiveThe concurrent use of multiple health care systems may duplicate or fragment care. We assessed the characteristics of veterans who were dually enrolled in both the Veterans Affairs (VA) health care system and a Medicare Advantage (MA) plan, and compared intermediate quality outcomes among those exclusively receiving care in the VA with those receiving care in both systems.Data sources/study settingVA and MA quality and administrative data from 2008 to 2009.Study designWe used propensity score methods to test the association between dual use and five intermediate outcome quality measures. Outcomes included control of cholesterol, blood pressure, and glycosylated hemoglobin among persons with coronary heart disease (CHD), hypertension, and diabetes.Data collection/extraction methodsVA and MA data were merged to identify VA-only users (n = 1,637) and dual-system users (n = 5,006).Principal findingsWe found no significant differences in intermediate outcomes between VA-only and dual-user populations. Differences ranged from a 3.2 percentage point (95 percent CI: -1.8 to 8.2) greater rate of controlled cholesterol among VA-only users with CHD to a 2.2 percentage point (95 percent CI: -2.4 to 6.6) greater rate of controlled blood pressure among dual users with diabetes.ConclusionsFor the five measures studied, we did not find evidence that veterans with dual use of VA and MA care experienced improved or worsened outcomes as compared with veterans who exclusively used VA care.

This study assesses veterans' dual enrollment in the Veterans Health Administration (VHA) and Medicare Advantage and VHA spending from 2011 through 2020. [ABSTRACT FROM AUTHOR]

ObjectiveUsing disease-modifying antirheumatic drugs (DMARDs) improves outcomes in rheumatoid arthritis (RA) and is a nationally endorsed quality measure. We investigated the prevalence and predictors of receiving glucocorticoids alone for the treatment of RA in a nationwide sample of Medicare beneficiaries.MethodsAmong individuals ages ≥65 years with RA enrolled in the Part D prescription drug benefit in 2009, we compared those with ≥1 DMARD claim to those receiving glucocorticoid monotherapy, defined as no DMARD claim and an annual glucocorticoid supply of ≥180 days or an annual dose of ≥900 mg of prednisone or equivalent. We fit multivariable models to determine the sociodemographic and clinical factors associated with glucocorticoid monotherapy.ResultsOf 8,125 beneficiaries treated for RA, 10.2% (n = 825) received glucocorticoids alone. Beneficiaries with low incomes were more likely to receive glucocorticoids alone (12.3%; 95% confidence interval [95% CI] 10.9-13.8% versus 9.4%; 95% CI 8.6-10.1%), as were those living in certain US regions. More physician office visits and hospitalizations were associated with glucocorticoid monotherapy. Individuals who had no contact with a rheumatologist were significantly more likely to receive glucocorticoids alone (17.5%; 95% CI 16.0-19.0% versus 8.5%; 95% CI 7.4-9.5% for those with no rheumatology visits versus 1-4 visits).ConclusionApproximately 1 in 10 Medicare beneficiaries treated for RA received glucocorticoids without DMARDs in 2009. Compared to DMARD users, glucocorticoid users were older, had lower incomes, were more likely to live in certain US regions, and were less likely to have seen a rheumatologist, suggesting persistent gaps in quality of care despite expanded drug coverage under Part D.