Predictors of high-risk prescribing among elderly Medicare Advantage beneficiaries.
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ABSTRACT:
SUBMITTER: Cooper AL
PROVIDER: S-EPMC5402891 | biostudies-literature | 2014 Oct
REPOSITORIES: biostudies-literature
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Predictors of high-risk prescribing among elderly Medicare Advantage beneficiaries.
Cooper Alicia L AL Dore David D DD Kazis Lewis E LE Mor Vincent V Trivedi Amal N AN
The American journal of managed care 20141001 10
<h4>Objectives</h4>To examine patient, community, and insurance plan predictors of high-risk prescribing in the elderly Medicare Advantage population.<h4>Study design</h4>Cohort study.<h4>Methods</h4>Using a sample of 203 Medicare Advantage plans from the 2006-2008 Health Outcomes Survey, we compared patient, community, and insurance plan characteristics of 77,247 respondents with and without new Medicare Part D claims for high-risk medications from June 2006 to May 2007.<h4>Results</h4>Of the M ...[more]
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Project description:ImportanceA growing proportion of the population is enrolling in Medicare Advantage (MA), which typically offers additional benefits compared with traditional Medicare (TM).ObjectiveTo determine whether frailty and frailty trajectories differ between MA enrollees and TM enrollees.Design, setting, and participantsThis retrospective cohort study used data from the National Health and Aging Trends Study (2015-2016). Analyses were conducted from August 2023 to March 2024. Participants were community-dwelling Medicare beneficiaries aged 65 years and older.ExposureEnrollment in MA vs TM.Main outcomes and measuresFrailty was calculated by a frailty index (FI) (range, 0-1, with higher values indicating greater frailty) and the Fried Frailty Phenotype (FFP) score (range, 0-5, with higher values indicating greater frailty). Physical performance, including Short Physical Performance Battery (SPPB) score (range, 0-12, with higher values indicating better performance), and gait speed (meters per second) were measured. The primary outcome was the difference in FI and FFP scores from the 2015 baseline assessment to the 2016 follow-up assessment. Secondary outcomes include the 1-year changes in SPPB and gait speed.ResultsThe final cohort consisted of 7063 participants (2775 [23.1%] aged >80 years; 4040 [54.7%] female), representing a sample of the 38.8 million beneficiaries. There were 2583 (35.0%) MA enrollees (13.6 million) and 4480 (65.0%) TM enrollees (25.2 million). At baseline, the FI score was similar between MA and TM enrollees (mean [SD], 0.22 [0.15] vs 0.21 [0.14]), although MA enrollees had worse phenotypic frailty (496 participants [15.2%] vs 811 participants [13.7%] considered frail by FFP score), SPPB scores (mean [SD], 6.91 [3.34] vs 7.21 [3.27]), and gait speed (0.79 [0.24] m/s vs 0.82 [0.23] m/s) than TM enrollees. One year later, there were no differences between MA and TM enrollees in the 1-year change in FI score (mean [SD], 0.016 [0.071] vs 0.014 [0.066]; adjusted mean difference, 0.001 [95% CI, -0.004 to 0.005]), FFP score (mean [SD], 0.017 [1.004] vs 0.007 [0.958]; adjusted mean difference, -0.009 [95% CI, -0.067 to 0.049]), SPPB score (mean [SD], -0.144 [2.064] vs -0.211 [1.968]; adjusted mean difference, 0.068 [95% CI, -0.076 to 0.212]), and gait speed (mean [SD], -0.0160 [0.148] m/s vs -0.007 [0.148] m/s; adjusted mean difference, -0.010 m/s [95% CI, -0.067 to 0.049 m/s]).Conclusions and relevanceIn this cohort study of Medicare beneficiaries from 2015, MA enrollees experienced similar declines in frailty over 1 year compared with TM enrollees. Future work should examine whether the specific types of services covered by health insurance can impact frailty and health trajectories for older adults.
| S-EPMC11365002 | biostudies-literature
Project description:Background: Pain is common among patients with cardiopulmonary conditions; however, there are increasing concerns, but limited research, regarding use of opioids for pain in patients with noncancer conditions. Objective: To compare patterns of opioid prescribing among older adults reporting pain with cardiopulmonary conditions and/or cancer. Design: Observational study using data from the Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey resource linked to Medicare Part D prescription claims. Setting/Subjects: We identified patients who self-reported moderate-to-severe pain interference with daily activities. Patients were stratified by (1) self-reported history of cardiopulmonary conditions; (2) were within five years of cancer diagnosis; (3) had both conditions; or (4) neither. Measurements: We characterized opioid prescribing within 30 days of survey and one-year follow-up using logistic regression and Cox proportional hazard time-to-event analyses. Results: Of 10,516 patients with moderate-to-severe pain (1758 cardiopulmonary conditions, 3383 cancer, 2861 both, 2514 neither), 46% were aged ≥75 years, 65% were non-Hispanic white, and 10% non-Hispanic black. At survey, 1627 (15.5%) received opioids. Adjusted proportions of opioid use were lower for patients with cardiopulmonary conditions only (14%) compared with cancer only (17%; p < 0.001) and both conditions (17%; p < 0.001) but higher than patients with neither condition (13.1%; p < 0.001). There was no difference in time to initiation of opioids at follow-up among patients with cardiopulmonary conditions only, relative to cancer only (adjusted hazard ratio 1.03; 95% confidence interval 0.88-1.21). Conclusions: Opioid use is lower among patients with pain and cardiopulmonary conditions relative to patients with cancer. Findings emphasize the importance of pain assessment and management for patients with cardiopulmonary conditions.
| S-EPMC7840305 | biostudies-literature
Project description:BackgroundSince 2005, the Centers for Medicare and Medicaid Services (CMS) has required all Medicare Advantage (MA) plans to report prescribing rates of high risk medications (HRM).ObjectiveTo determine predictors of receipt of HRMs, as defined by the National Committee for Quality Assurance's "Drugs to Avoid in the Elderly" quality indicator, in a national sample of MA enrollees.Design and participantsRetrospective analysis of Healthcare Effectiveness Data and Information Set (HEDIS) data for 6,204,824 enrollees, aged 65 years or older, enrolled in 415 MA plans in 2009. To identify predictors of HRM use, we fit generalized linear models and modeled outcomes on the risk-difference scale.Main outcome measuresReceipt or non-receipt of one or two HRMs.Key resultsApproximately 21 % of MA enrollees received at least one HRM and 4.8 % received at least two. In fully adjusted models, females had a 10.6 (95 % CI: 10.0-11.2) higher percentage point rate of receipt than males, and residence in any of the Southern United States divisions was associated with a greater than 10 percentage point higher rate, as compared with the reference New England division. Higher rates were also observed among enrollees with low personal income (6.5 percentage points, 95 % CI: 5.5-7.5), relative to those without low income and those residing in areas in the lowest quintile of socioeconomic status (2.7 points, 95 % CI: 1.9-3.4) relative to persons residing in the highest quintile. Enrollees ? 85 years old, black enrollees, and other minority groups were less likely to receive these medications. Over 38 % of MA enrollees residing in the hospital referral region of Albany, Georgia received at least one HRM, a rate four times higher than the referral region with the lowest rate (Mason City, Iowa).ConclusionsUse of HRMs among MA enrollees varies widely by geographic region. Persons living in the Southern region of the U.S., whites, women, and persons of low personal income and socioeconomic status are more likely to receive HRMs.
| S-EPMC3599014 | biostudies-literature
Project description:Approximately 34% of all Medicare beneficiaries were enrolled in a Medicare Advantage (MA) plan in 2019. Quantitative evidence suggests that MA beneficiaries have low rates of switching plans, but that beneficiaries who are hospitalized or use postacute nursing home care are disproportionately more likely to exit their plan. This research sought to explore how MA enrollees choose plans and the factors involved in their decision to keep their current plan or switch plans. We conducted 25 semistructured interviews focusing on expectations and experiences preenrollment and postenrollment among MA beneficiaries. Overall, the beneficiaries interviewed reported being highly satisfied with their plans. After selecting a plan, there was little incentive to revisit their choice since they viewed their plan as "good enough." Confusion, health status, cost and benefits also contributed to many seniors keeping or switching their plans. These seniors were reluctant to switch plans unless they experienced a major health event.
| S-EPMC7903586 | biostudies-literature
Project description:Use of opioids during and shortly after an acute hospitalization is warranted in some clinical settings. However, given the potential of opioids for short-term adverse events and long-term physiologic tolerance, it is important to understand the frequency of opioid prescribing at hospital discharge, hospital variation, and patient and hospital factors associated with opioid prescribing, which is currently unknown in the United States.To estimate the frequency of opioid prescribing at hospital discharge among Medicare beneficiaries without an opioid prescription claim 60 days prior to hospitalization; to document hospital variation in prescribing; and to analyze patient and hospital factors associated with prescribing, including hospital average performance on pain-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures.Analysis of pharmacy claims of a 20% random sample of Medicare beneficiaries hospitalized in 2011 without an opioid prescription claim in the 60 days before hospitalization.Our main outcome was a new opioid claim within 7 days of hospital discharge. We estimated a multivariable linear probability model of patient factors associated with new opioid use and described hospital variation in adjusted rates of new opioid use. In multivariable linear regression analysis, we also analyzed hospital factors associated with average adjusted new opioid use at the hospital level, including the percentage of each hospital's patients who reported that their pain during hospitalization was always well controlled in the 2011 HCAHPS surveys.Among 623?957 hospitalizations, 92?882 (14.9%) were associated with a new opioid claim. Among those hospitalizations with an associated opioid claim within 7 days of hospital discharge, 32?731 (42.5%) of 77?092 were associated with an opioid claim after 90 days postdischarge. Across 2512 hospitals, the average adjusted rate of new opioid use within 7 days of hospitalization was 15.1% (interquartile range, 12.3%-17.4%; interdecile range, 10.5%-20.0%). A hospital's adjusted rate of new opioid use was modestly positively associated with the percentage of its inpatients reporting that their pain was always well managed (increase from 25th to the 75th percentile in the HCAHPS measure was associated with an absolute increase in new opioid use of 0.89 percentage points or a relative increase of 6.0%; P?<?.001).New opioid use after hospitalization is common among Medicare beneficiaries, with substantial variation across hospitals and a large proportion of patients using a prescription opioid 90 days after hospitalization. The degree to which observed hospital variation in short- and longer-term opioid use reflects variation in inappropriate prescribing at hospital discharge is unknown.
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Project description:ImportanceLow-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care.ObjectivesTo compare rates of low-value services between MA and TM beneficiaries and explore how elements of insurance design present in MA are associated with the delivery of low-value care.Design, setting, and participantsThis cross-sectional study analyzed beneficiaries enrolled in MA and TM using claims data from a large, national MA insurer and a random 5% sample of TM beneficiaries. The study period was January 1, 2017, through December 31, 2019. All analyses were conducted from July 2021 to March 2022.ExposuresEnrollment in MA vs TM.Main outcomes and measuresLow-value care was assessed using 26 claims-based measures. Regression models were used to estimate the association between MA enrollment and rates of low-value services while controlling for beneficiary characteristics. Stratified analyses explored whether network design, product design, value-based payment, or utilization management moderated differences in low-value care between MA and TM beneficiaries and among MA beneficiaries.ResultsAmong a study population of 2 470 199 Medicare beneficiaries (mean [SD] age, 75.6 [7.0] years; 1 346 777 [54.5%] female; 229 107 [9.3%] Black and 2 126 353 [86.1%] White individuals), 1 527 763 (61.8%) were enrolled in MA and 942 436 (38.2%) were enrolled in TM. Beneficiaries enrolled in MA received 9.2% (95% CI, 8.5%-9.8%) fewer low-value services in 2019 than TM beneficiaries (23.1 vs 25.4 total low-value services per 100 beneficiaries). Although MA beneficiaries enrolled in health management organization and preferred provider organization products received fewer low-value services than TM beneficiaries, the difference was largest for those enrolled in health management organization products (2.6 fewer [95% CI, 2.4-2.8] vs 2.1 fewer [95% CI, 1.9-2.3] services per 100 beneficiaries, respectively). Across primary care payment arrangements, MA beneficiaries received fewer low-value services than TM beneficiaries, with the largest difference observed for MA beneficiaries whose primary care physicians were reimbursed within 2-sided risk arrangements.Conclusions and relevanceIn this cross-sectional study of Medicare beneficiaries, those enrolled in MA had lower rates of low-value care than those enrolled in TM; elements of insurance design present in the MA program and absent in TM were associated with reduction in low-value care.
| S-EPMC9463603 | biostudies-literature
Project description:IntroductionHospitalization increases the risk of a subsequent diagnosis of dementia. We aimed to identify diagnoses or events during a hospitalization requiring critical care that are associated with a subsequent dementia diagnosis in the elderly.MethodsA cohort study of a random 5% sample of Medicare beneficiaries who received intensive care in 2005 and survived to hospital discharge, with three years of follow-up (through 2008) was conducted using Medicare claims files. We defined dementia using the International Classification of Diseases, 9th edition, clinical modification (ICD-9-CM) codes and excluded patients with any prior diagnosis of dementia or cognitive impairment in the year prior to admission. We used an extended Cox model to examine the association between diagnoses and events associated with the critical illness and a subsequent diagnosis of dementia, adjusting for known risk factors for dementia.ResultsOver the three years of follow-up, dementia was newly diagnosed in 4,519 (17.8%) of 25,368 patients who received intensive care and survived to hospital discharge. After accounting for known risk factors, having an infection (adjusted hazard ratio (AHR) = 1.25; 95% CI, 1.17 to 1.35), or a diagnosis of severe sepsis (AHR = 1.40; 95% CI, 1.28 to 1.53), acute neurologic dysfunction (AHR = 2.06; 95% CI, 1.72 to 2.46), and acute dialysis (AHR = 1.70; 95% CI, 1.30 to 2.23) were all independently associated with a subsequent diagnosis of dementia. No other measured ICU factors, such as need for mechanical ventilation, were independently associated.ConclusionsAmong ICU events, infection or severe sepsis, neurologic dysfunction, and acute dialysis were independently associated with a subsequent diagnosis of dementia. Patient prognostication, as well as future research into post-ICU cognitive decline, should focus on these higher-risk subgroups.
| S-EPMC3672622 | biostudies-literature
Project description:Approximately one-fifth of Medicare Advantage (MA) contracts terminated their participation in the MA program between 2011 and 2020. Little is known about subsequent insurance choices following a termination. To examine the insurance destinations of MA enrollees and the characteristics of enrollees who switch into traditional Medicare (TM) after a contract termination. This cross-sectional study examined MA program data of MA beneficiaries in the Medicare Master Beneficiary File from 2016 to 2018. Statistical analysis was performed from June 2023 to April 2024. Beneficiary characteristics, including age, sex, race and ethnicity, dual eligibility; hospital, nursing home, and home health utilization; and contract characteristics, including plan type, vertical integration, premium, and MA star rating. The main outcome was switching to TM in the year immediately after termination. We also evaluated the characteristics of contracts among those who remained in MA. A total of 117 681 beneficiaries were included in this analysis (64 654 [54.9%] female; 409 [0.4%] American Indian or Alaska Native; 2817 [2.4%] Asian; 76 725 [16.8%] Black; 11 131 [9.5%] Hispanic; 81 226 [69.0%] White; and 2373 [2.0%] other race or ethnicity; 27 078 [23.0%] dual-eligible; mean [SD] age, 71.2 [10.4] years). Following a contract termination, 20.1% (95% CI, 19.9%-20.4%) of enrollees switched to TM, including 32.7% (95% CI, 32.4%-33.1%) of dual-eligible beneficiaries and 16.4% (95% CI, 16.2%-16.5%) of non-dual-eligible beneficiaries. In nonterminated contracts, the concurrent switch rate was 6.2% (95% CI, 6.2%-6.2%) for all, 10.4% (95% CI, 10.4%-10.4%) for dual-eligible beneficiaries and 5.1% (95% CI, 5.1%-5.1%) for non-dual-eligible enrollees. The highest switch rates to TM were among Black enrollees (32.3% [95% CI, 31.7%-32.8%]) and those with prior use of hospital (31.3% [95% CI, 30.7%-31.9%], nursing home, 41.4% [95% CI, 40.4%-42.4%], or home health care (28.3% [95% CI, 27.4%-29.2%]). Beneficiaries who stayed in MA selected higher-rated star plans (mean posttermination contract star rating of 3.8 [95% CI, 3.8-3.8] stars compared with 3.3 [95% CI, 3.3-3.3] stars in the terminated year), but did not pay more in monthly premiums with 66.5% (95% CI, 66.2%-66.8%) paying the same or lower premiums. In this cross-sectional study, 1 in 5 MA beneficiaries switched to TM after a contract termination, with Black beneficiaries and those with more intensive health needs having the highest switch rates. These findings highlight the need to examine consequences of contract terminations and subsequent insurance destinations on access to care and health outcomes, especially among those with marginalized race and ethnicity, those who are dual-eligible, and beneficiaries with higher health care needs.
| S-EPMC11337069 | biostudies-literature
Project description:ImportanceBetter evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes.ObjectiveTo compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees.Design, setting, and participantsThis cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design.ExposuresEnrollment in MA and dual eligibility for Medicare and Medicaid.Main outcomes and measuresPostacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services.ResultsIncluded in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility.Conclusions and relevanceIn this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.
| S-EPMC10439482 | biostudies-literature
Project description:Critical illness is likely associated with an increased risk of dementia, but the magnitude remains uncertain.The cohort was a random 2.5% sample of Medicare beneficiaries who received intensive care in 2005 and survived to hospital discharge. Patients were matched with general population controls (age, sex, and race) with 3 yr of follow-up. The authors used an extended Cox model to assess the risk of a diagnosis of dementia, adjusting for the known risk factors for dementia, and the competing risk of death.Among 10,348 intensive care patients who survived to hospital discharge, dementia was newly diagnosed in 1,648 (15.0%) over the 3 yr of follow-up versus 12.2% in controls (incidence per 1,000 person-years, 73.6; 95% CI, 70.0 to 77.1 vs. 45.8; 95% CI, 43.2 to 48.3; hazard ratio [HR], 1.61; 95% CI, 1.50 to 1.74; P < 0.001). After accounting for the known risk factors in the year before the index hospitalization, the risk of receiving a diagnosis of dementia remained increased in patients who received intensive care (adjusted HR, 1.43; 95% CI, 1.32 to 1.54; P < 0.001). Inclusion of identifiable risk factors accrued during the quarter of critical illness accounted for almost all of the increased risks (adjusted HR, 1.09; 95% CI, 1.00 to 1.20; P = 0.06).Elderly critical care survivors have a 60% increased relative risk, but only 3% increased absolute risk, of receiving a diagnosis of dementia in the subsequent 3 yr compared with the general population. This increased risk is not accounted for by risk factors preexisting the critical illness. Surveillance bias, which increases the likelihood of receiving a diagnosis of dementia, could account for some or all of these additional risks.
| S-EPMC4618156 | biostudies-literature