Medicare Expenditures and Health Care Utilization in a Multiethnic Community-based Population With Dementia From Incidence to Death.
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ABSTRACT: Introduction
While individuals live with dementia for many years, utilization and expenditures from disease onset through the end-of-life period have not been examined in ethnically diverse samples.Methods
We used a multiethnic, population-based, prospective study of cognitive aging (Washington Heights-Inwood Columbia Aging Project) linked to Medicare claims to examine total Medicare expenditures and health care utilization among individuals with clinically diagnosed incident dementia from disease onset to death.Results
High-intensity treatment (hospitalizations, life-sustaining procedures) was common and mean Medicare expenditures per year after diagnosis was $69,000. Non-Hispanic blacks exhibited higher spending relative to Hispanics and non-Hispanic whites 1 year after diagnosis. Non-Hispanic blacks had higher total (mean=$205,000) Medicare expenditures from diagnosis to death compared with non-Hispanic whites (mean=$118,000). Hispanics' total expenditures and utilization after diagnosis was similar to non-Hispanic whites despite living longer with dementia.Discussion
Health care spending for patients with dementia after diagnosis through the end-of-life is high and varies by ethnicity.
SUBMITTER: Ornstein KA
PROVIDER: S-EPMC6215747 | biostudies-literature | 2018 Oct-Dec
REPOSITORIES: biostudies-literature
Publications
Medicare Expenditures and Health Care Utilization in a Multiethnic Community-based Population With Dementia From Incidence to Death.
Ornstein Katherine A KA Zhu Carolyn W CW Bollens-Lund Evan E Aldridge Melissa D MD Andrews Howard H Schupf Nicole N Stern Yaakov Y
Alzheimer disease and associated disorders 20181001 4
<h4>Introduction</h4>While individuals live with dementia for many years, utilization and expenditures from disease onset through the end-of-life period have not been examined in ethnically diverse samples.<h4>Methods</h4>We used a multiethnic, population-based, prospective study of cognitive aging (Washington Heights-Inwood Columbia Aging Project) linked to Medicare claims to examine total Medicare expenditures and health care utilization among individuals with clinically diagnosed incident dem ...[more]
Similar Datasets
Project description:ObjectiveTo estimate dementia's incremental cost to the traditional Medicare program.Data sourcesHealth and Retirement Study (HRS) survey-linked Medicare part A and B claims from 1991 to 2012.Study designWe compared Medicare expenditures for 60 months following a claims-based dementia diagnosis to those for a randomly selected, matched comparison group.Data collection/extraction methodsWe used a cost estimator that accounts for differential survival between individuals with and without dementia and decomposes incremental costs into survival and cost intensity components.Principal findingsDementia's five-year incremental cost to the traditional Medicare program is approximately $15 700 per patient, nearly half of which is incurred in the first year after diagnosis. Shorter survival with dementia mitigates the incremental cost by about $2650. Increased costs for individuals with dementia were driven by more intensive use of Medicare part A covered services. The incremental cost of dementia was about $7850 higher for females than for males because of sex-specific differential mortality associated with dementia.ConclusionsDementia's cost to the traditional Medicare program is significant. Interventions that target early identification of dementia and preventable inpatient and post-acute care services could produce substantial savings.
| S-EPMC6606539 | biostudies-literature
Project description:BackgroundClinical features of dementia (cognition, function, and behavioral/psychological symptoms [BPSD]) may differentially affect Medicare expenditures/health care utilization.MethodsWe linked cross-sectional data from the Aging, Demographics, and Memory Study to Medicare data to evaluate the association between dementia clinical features among those with dementia and Medicare expenditures/health care utilization (n = 234). Cognition was evaluated using the Mini-Mental State Examination (MMSE). Function was evaluated as the number of functional limitations (0-10). BPSD was evaluated as the number of symptoms (0-12). Expenditures were estimated with a generalized linear model (log-link and gamma distribution). Number of hospitalizations, institutional outpatient visits, and physician visits were estimated with a negative binomial regression. Medicare covered skilled nursing days were estimated with a zero-inflated negative binomial model.ResultsCognition and BPSD were not associated with expenditures. Among individuals with less than seven functional limitations, one additional limitation was associated with $123 (95% confidence interval: $19-$227) additional monthly Medicare spending. Better cognition and poorer function were associated with more hospitalizations among those with an MMSE less than three and less than six functional limitations, respectively. BPSD had no effect on hospitalizations. Poorer function and fewer BPSD were associated with more skilled nursing among individuals with one to seven functional limitations and more than four symptoms, respectively. Cognition had no effect on skilled nursing care. No clinical feature was associated with institutional outpatient care. Of individuals with an MMSE less than 15, poorer cognition was associated with fewer physician visits. Among those with more than six functional limitations, poorer function was associated with fewer physician visits.ConclusionsPoorer function, not cognition or BPSD, was associated with higher Medicare expenditures.
| S-EPMC6075208 | biostudies-literature
Project description:BackgroundFew studies have examined how dementia and comorbidities may interact to affect healthcare expenditures.ObjectiveTo examine whether effects of dementia severity on Medicare expenditures differed for individuals with different levels of comorbidities.MethodsData are drawn from the Washington Heights-Inwood Columbia Aging Project (WHICAP). Comprehensive clinical assessments of dementia severity were systematically carried out at ∼18 month intervals. Dementia severity was measured by Clinical Dementia Rating (CDR). Comorbidities were measured by a modified Elixhauser comorbidities index. Generalized linear models examined effects of dementia severity, comorbidities, and their interactions on Medicare expenditures (1999-2010).ResultsAt baseline, 1,280 subjects were dementia free (CDR = 0, 66.4%), 490 had very mild dementia (CDR = 0.5, 25.4%), 108 had mild dementia (CDR = 1, 5.6%), and 49 had moderate/severe dementia (CDR = 2/3, 2.5%). Average annual Medicare expenditures for individuals with moderate/severe dementia were more than twice as high as those who were dementia free (CDR = 0: $9,108, CDR = 0.5/1: $11,664, CDR≥2: $19,604, p < 0.01). Expenditures were approximately 10 times higher among those with≥3 comorbidities than among those with no comorbidities ($2,612 for those with no comorbidities, to $6,109 for those with 1, $10,656 for those with 2, and $30,244 for those with≥3 comorbidities, p < 0.001). Dementia severity was associated with higher expenditures, but comorbidities were the most important predictor of expenditures. We did not find strong interaction effects between number of comorbidities and dementia severity.ConclusionsIncreasing dementia severity and higher comorbidities are associated with higher Medicare expenditures. Care of individuals with dementia should focus on management of comorbidities.
| S-EPMC5461168 | biostudies-literature
Project description: Not available
| S-EPMC8390710 | biostudies-literature
Project description:ObjectiveTo examine the effect of Part D on 65-78-year-old noninstitutionalized dual eligibles' prescription utilization and expenditures.Data sourceRandom sample of unique pharmacy customers of a national retail pharmacy chain who filled at least one prescription during both 2005 and 2006. For each subject, we obtained claims data for every prescription filled between January 1, 2005, and April 31, 2007.Study designGeneralized estimating equations were used to examine the experience of a "treatment" group (dual eligibles between 65 and 78 years on January 1, 2005) with that of a "control" group (near-elderly patients with Medicaid coverage between 60 and 63 years on January 1, 2005) during the first 18 months after Part D implementation.Principal findingsExpenditures for the treatment and control groups tracked each other closely in the pre-Part D period. Immediately following the implementation of Part D, expenditures for both groups decreased and then leveled off. There were no significant changes in trends in the dual eligibles' out-of-pocket expenditures, total monthly expenditures, pill-days, or total number of prescriptions due to Part D.ConclusionsWe find no evidence that Part D adversely affected pharmaceutical utilization or out-of-pocket expenditures of dual eligibles during the transition period, nor during the 16 months subsequent to Part D implementation.
| S-EPMC2813441 | biostudies-literature
Project description:Importance:An estimated 4 to 5 million Americans have Alzheimer disease or another dementia. Objective:To determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-for-service beneficiaries. Design, Setting, and Participants:In this case-control study, we used a quasiexperimental design to compare health care utilization and costs for 1083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2166 similar patients with dementia not participating in the program. Patients in the comparison cohort were selected using the zip code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. We used Medicare claims data to compare utilization and cost outcomes for the 2 groups. Interventions:Patients in the dementia care program were comanaged by nurse practitioners and physicians, and the program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, 7 days per week. Main Outcomes and Measures:Admissions to long-term care facilities; average difference-in-differences per quarter over the 3-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates. Results:Program participants (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a long-term care facility (hazard ratio, 0.60; 95% CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits, or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95% CI, -$1198 to -$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of -$284 (95% CI, -$881 to $312) per program participant per quarter. Conclusions and Relevance:Comprehensive dementia care may reduce the number of admissions to long-term care facilities, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help people with dementia stay in their communities.
| S-EPMC6439653 | biostudies-literature
Project description:ObjectiveTo disentangle the relationships among food insecurity, health care utilization, and health care expenditures.Data sources/study settingWe use national data on 13 465 adults (age ≥ 18) from the 2016 Medical Expenditure Panel Survey (MEPS), the first year of the food insecurity measures.Study designWe employ two-stage empirical models (probit for any health care use/expenditure, ordinary least squares, and generalized linear models for amount of utilization/expenditure), controlling for demographics, health insurance, poverty status, chronic conditions, and other predictors.Principal findingsOur results show that the likelihood of any health care expenditure (total, inpatient, emergency department, outpatient, and pharmaceutical) is higher for marginal, low, and very low food secure individuals. Relative to food secure households, very low food secure households are 5.1 percentage points (P < .001) more likely to have any health care expenditure, and have total health care expenditures that are 24.8 percent higher (P = .011). However, once we include chronic conditions in the models (ie, high blood pressure, heart disease, stroke, emphysema, high cholesterol, cancer, diabetes, arthritis, and asthma), these underlying health conditions mitigate the differences in expenditures by food insecurity status (only the likelihood of any having any health care expenditure for very low food secure households remains statistically significant).ConclusionsPolicy makers and government agencies are focused on addressing deficiencies in social determinants of health and the resulting impacts on health status and health care utilization. Our results indicate that chronic conditions are strongly associated with food insecurity and higher health care spending. Efforts to alleviate food insecurity should consider the dual burden of chronic conditions. Finally, future research can address specific mechanisms underlying the relationships between food security, health, and health care.
| S-EPMC7518817 | biostudies-literature
Project description:ImportancePoor continuity of care may contribute to high health care spending and adverse patient outcomes in dementia.ObjectiveTo examine the association between medical clinician continuity and health care utilization, testing, and spending in older adults with dementia.Design, setting, and participantsThis was a study of an observational retrospective cohort from the 2012 national sample in fee-for-service Medicare, conducted from July to December 2015, using inverse probability weighted analysis. A total of 1 416 369 continuously enrolled, community-dwelling, fee-for-service Medicare beneficiaries 65 years or older with a claims-based dementia diagnosis and at least 4 ambulatory visits in 2012 were included.ExposuresContinuity of care score measured on patient visits across physicians over 12 months. A higher continuity score is assigned to visit patterns in which a larger share of the patient's total visits are with fewer clinicians. Score range from 0 to 1 was examined in low-, medium-, and high-continuity tertiles.Main outcomes and measuresOutcomes include all-cause hospitalization, ambulatory care sensitive condition hospitalization, emergency department visit, imaging, and laboratory testing (computed tomographic [CT] scan of the head, chest radiography, urinalysis, and urine culture), and health care spending (overall, hospital and skilled nursing facility, and physician).ResultsBeneficiaries with dementia who had lower levels of continuity of care were younger, had a higher income, and had more comorbid medical conditions. Almost 50% of patients had at least 1 hospitalization and emergency department visit during the year. Utilization was lower with increasing level of continuity. Specifically comparing the highest- vs lowest-continuity groups, annual rates per beneficiary of hospitalization (0.83 vs 0.88), emergency department visits (0.84 vs 0.99), CT scan of the head (0.71 vs 0.83), urinalysis (0.72 vs 1.09), and health care spending (total spending, $22 004 vs $24 371) were higher with lower continuity even after accounting for sociodemographic factors and comorbidity burden (P < .001 for all comparisons). The rate of ambulatory care sensitive condition hospitalization was similar across continuity groups.Conclusions and relevanceAmong older fee-for-service Medicare beneficiaries with a dementia diagnosis, lower continuity of care is associated with higher rates of hospitalization, emergency department visits, testing, and health care spending. Further research into these relationships, including potentially relevant clinical, clinician, and systems factors, can inform whether improving continuity of care in this population may benefit patients and the wider health system.
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Project description:Importance:Descriptive population-level health data are critical components of the evidence base for population health policy. Human populations often display marked heterogeneity in their health status among subgroups of the population. The recent widespread adoption of electronic health records provides opportunities to use routine real-world health care data to examine population health. Objective:To report population sociodemographic characteristics, health conditions, health care utilization, and health care costs for different population segments of a multiethnic Asian population divided according to a modified British Columbia Population Segmentation Framework. Design, Setting, and Participants:This population-based cross-sectional study used 2016 data from the Singapore Eastern Regional Health System, the largest Regional Health System in Singapore. Data were obtained from deidentified national-level electronic health records at the Ministry of Health Singapore. Participants included all residents in the Singapore Eastern Regional Health System catchment area in 2016. The descriptive analysis was conducted in August 2018. Main Outcomes and Measures:Socioeconomic profiles, disease prevalence, health care utilization, and cost patterns of population segments. Results:The total size of the study population in 2016 was 1?181?024 residents (576 663 [48.83%] male; median [interquartile range] age, 40 [22-57] years). The population was divided into 8 segments: healthy with no outpatient utilization (493?483 residents), healthy with outpatient utilization (259?909 residents), healthy with inpatient admissions (49?588 residents), low complex (215?134 residents), medium complex (79?350 residents), high complex (44?445 residents), cancer (34?217 residents), and end of life (4898 residents). Overall, the 3 most prevalent conditions were chronic kidney disease (31.89%), hypertension (18.52%), and lipid disorders (18.33%). Distributions of chronic conditions differed across the segments. Different segments had varying health care utilization patterns: the high-complex segment had the highest number of primary care clinic visits (mean [SD], 4.25 [5.46] visits), the cancer segment had the highest number of specialist outpatient clinic visits (mean [SD], 5.55 [8.49] visits), and the end-of-life segment had the highest numbers of accident and emergency department visits (mean [SD], 1.80 [1.88] visits) and inpatient admissions (mean [SD], 1.99 [1.89] admissions) during 2016. For health care costs, specialist outpatient clinic and inpatient care together made up more than 85% of the total cost of nearly 2 billion Singapore dollars. The end-of-life segment contributed approximately 50% of the health care cost per capita of 60?000 Singapore dollars. Conclusions and Relevance:Different population segments displayed heterogeneity in sociodemographic characteristics, health conditions, health care utilization, and health care cost patterns. This critical health information can be used as baseline data to inform regional and national health priorities for health services research and policy.
| S-EPMC6735407 | biostudies-literature
Project description:BackgroundThe purpose of this study was to examine the extent to which patterns of intensive end-of-life care explain geographic variation in end-of-life care expenditures among cancer decedents.MethodsUsing the SEER-Medicare database, we identified 90,465 decedents who were diagnosed with cancer in 2004-2011. Measures of intensive end-of-life care included chemotherapy received within 14 days of death; more than 1 emergency department visit, more than 1 hospitalization, or 1 or more intensive care unit (ICU) admissions within 30 days of death; in-hospital death; and hospice enrollment less than 3 days before death. Using hierarchical generalized linear models, we estimated risk-adjusted expenditures in the last month of life for each hospital referral region and identified key contributors to variation in expenditures.ResultsThe mean expenditure per cancer decedent in the last month of life was $10,800, ranging from $8,300 to $15,400 in the lowest and highest expenditure quintile areas, respectively. There was considerable variation in the percentage of decedents receiving intensive end-of-life care intervention, with 41.7% of decedents receiving intensive care in the lowest quintile of expenditures versus 57.9% in the highest quintile. Regional patterns of late chemotherapy or late hospice use explained only approximately 1% of the expenditure difference between the highest and lowest quintile areas. In contrast, the proportion of decedents who had ICU admissions within 30 days of death was a major driver of variation, explaining 37.6% of the expenditure difference.ConclusionsPromoting appropriate end-of-life care has the potential to reduce geographic variation in end-of-life care expenditures.
| S-EPMC5577560 | biostudies-literature