Risk Adjustment In Medicare ACO Program Deters Coding Increases But May Lead ACOs To Drop High-Risk Beneficiaries.
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ABSTRACT:
SUBMITTER: Markovitz AA
PROVIDER: S-EPMC6394223 | biostudies-literature | 2019 Feb
REPOSITORIES: biostudies-literature
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Risk Adjustment In Medicare ACO Program Deters Coding Increases But May Lead ACOs To Drop High-Risk Beneficiaries.
Markovitz Adam A AA Hollingsworth John M JM Ayanian John Z JZ Norton Edward C EC Moloci Nicholas M NM Yan Phyllis L PL Ryan Andrew M AM
Health affairs (Project Hope) 20190201 2
The Medicare Shared Savings Program (MSSP) adjusts savings benchmarks by beneficiaries' baseline risk scores. To discourage increased coding intensity, the benchmark is not adjusted upward if beneficiaries' risk scores rise while in the MSSP. As a result, accountable care organizations (ACOs) have an incentive to avoid increasingly sick or expensive beneficiaries. We examined whether beneficiaries' exposure to the MSSP was associated with within-beneficiary changes in risk scores and whether ris ...[more]
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Project description:ObjectivesThere is wide variation in long-term acute care hospital (LTACH) use nationwide, the most intensive and expensive post-acute care setting, although appropriateness of use is uncertain. Therefore, we examined the appropriateness and reasons for transfer in a high-use region, and how Medicare criteria for LTACH payment identifies appropriate transfers.DesignMulticenter retrospective observational cohort.Setting and participantsConsecutive hospitalized Medicare beneficiaries transferred to an LTACH from 2017 to 2018 from an accountable care organization in Texas.MethodsThe primary outcome was clinical appropriateness of transfer ascertained by 2 physician reviewers. We abstracted patients' characteristics and primary reasons for transfer. We examined the positive predictive value (PPV) of meeting Medicare criteria for full LTACH payment [preceding intensive care unit (ICU) stay ≥3 days or prolonged mechanical ventilation] for identifying appropriate transfers, and how this differed if Medicare adopted an 8-day minimum ICU stay criterion recommended by the Medicare Payment Advisory Commission (MedPAC).ResultsOf 105 LTACH transfers, 33 (31.4%) were clinically appropriate. The most common reason among appropriate transfers was respiratory care (58%), but 42% had other indications. Inappropriate transfers most commonly were for wound care (28%), intravenous medication infusions (28%), or patient (17%) and physician preference (26%). The PPV for meeting Medicare LTACH payment criteria was 55%. The PPV improved to 77% if Medicare adopted the 8-day minimum ICU stay criterion, with only a modest absolute increase in appropriate transfers not meeting the more stringent criteria (12% to 17%).Conclusions and implicationsTwo-thirds of LTACH transfers in a high-LTACH-use region are clinically inappropriate, and are most commonly transferred for wound care, intravenous infusions, or patient and physician preference. Medicare payment criteria modestly distinguished between appropriate and inappropriate transfers. Adoption of MedPAC's recommended 8-day minimum ICU stay criterion could safely reduce inappropriate transfers, although generalizability to low LTACH-use regions is uncertain.
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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
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Project description:ObjectivesTo examine patient, community, and insurance plan predictors of high-risk prescribing in the elderly Medicare Advantage population.Study designCohort study.MethodsUsing 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.ResultsOf the Medicare Advantage enrollee respondents, 15.6% received a new prescription for a high-risk medication during 12 months of follow-up. In adjusted analyses, new users of high-risk medications were more likely to be women (OR = 1.35; 95% CI,1.28-1.42), and they reported poorer general health (Physical Component Summary score 37.3 vs 40.4, P <.05) than did individuals who never received a high-risk prescription. Being aged ≥ 85 years was protective against receipt of a high-risk medication (OR relative to persons aged 65-69 years = 0.69; 95% CI, 0.64-0.75). Incidence of high-risk prescribing varied by census division, with a 2-fold difference between regions with the lowest and highest rates (9% in New England vs 18% in the West South Central region). Muscle relaxants, antihistamines, and opiates accounted for over 71% of new dispensing of high-risk medications. Approximately 67% of new users of high-risk medications received only 1 dispensing.ConclusionsHigh-risk prescribing varies widely by geography and drug class in the Medicare Advantage population. Women, persons with poorer self-reported health, and those residing in the Southern regions of the United States more frequently receive high-risk medications. Variations may highlight areas for targeted interventions to reduce high-risk prescribing to the elderly.
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Project description:5.8 M living Americans have experienced a stroke at some time in their lives, 780K had either their first or a recurrent stroke this year, and 150K died from strokes this year. Stroke costs about $66B annually in the US, and also results in serious, long-term disability. Therefore, it is prudent to identify all possible risk factors and their effects so that appropriate intervention points may be targeted.Baseline (1993-1994) interview data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD) were linked to 1993-2005 Medicare claims. Participants were 5,511 self-respondents >or= 70 years old. Two ICD9-CM case-identification approaches were used. Two approaches to stroke case-identification based on ICD9-CM codes were used, one emphasized sensitivity and the other emphasized specificity. Participants were censored at death or enrollment into managed Medicare. Baseline risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting post-baseline non-stroke hospitalizations was included to reflect health shocks, and sensitivity analyses were conducted to identify its peak effect. Competing risk, proportional hazards regression was used.Post-baseline strokes occurred for 545 (9.9%; high sensitivity approach) and 374 (6.8%; high specificity approach) participants. The greatest static risks involved increased age, being widowed or never married, living in multi-story buildings, reporting a baseline history of diabetes, hypertension, or stroke, and reporting difficulty picking up a dime, refusing to answer the delayed word recall test, or having poor cognition. Risks were similar for both case-identification approaches and for recurrent and first-ever vs. only first-ever strokes. The time-dependent health shock (recent hospitalization) marker did not alter the static model effect estimates, but increased stroke risk by 200% or more.The effect of our health shock marker (a time-dependent recent hospitalization indicator) was large and did not mediate the effects of the traditional risk factors. This suggests an especially vulnerable post-hospital transition period from adverse effects associated with both their underlying health shock (the reasons for the recent hospital admission) and the consequences of their treatments.
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Project description:BackgroundUnaffordability of medications is a barrier to effective treatment. Cost-related nonadherence (CRN) is a crucial, widely used measure of medications access.ObjectivesOur study examines the current national prevalence of and risk factors for CRN (eg, not filling, skipping or reducing doses) and companion measures in the US Medicare population.Research designSurvey-weighted analyses included logistic regression and trends 2006-2016.SubjectsMain analyses used the 2016 Medicare Current Beneficiary Survey. Our study sample of 12,625 represented 56 million community-dwelling beneficiaries.MeasuresAdditional outcome measures were spending less on other necessities in order to pay for medicines and use of drug cost reduction strategies such as requesting generics.ResultsIn 2016, 34.5% of enrollees under 65 years with disability and 14.4% of those 65 years and older did not take their medications as prescribed due to high costs; 19.4% and 4.7%, respectively, experienced going without other essentials to pay for medicines. Near-poor older beneficiaries with incomes $15-25K had 50% higher odds of CRN (vs. >$50K), but beneficiaries with incomes <$15K, more likely to be eligible for the Part D Low-Income Subsidy, did not have significantly higher risk. Three indicators of worse health (general health status, functional limits, and count of conditions) were all independently associated with higher risk of CRN.ConclusionsChanges in the risk profile for CRN since Part D reflect the effectiveness of targeted policies. The persistent prevalence of CRN and associated risks for sicker people in Medicare demonstrate the consequences of high cost-sharing for prescription fills.
| S-EPMC7735208 | biostudies-literature
Project description:BackgroundThe Medicare Accountable Care Organization (ACO) programs encourage integration of providers into large groups and reward provider groups for improving quality, but not explicitly for reducing health care disparities. Larger group size and better overall quality may or may not be associated with smaller disparities.ObjectiveTo examine differences in patient characteristics between provider groups sufficiently large to participate in ACO programs and smaller groups; the association between group size and racial disparities in quality; and the association between quality and disparities among larger groups.Design and participantsUsing 2009 Medicare claims for 3.1 million beneficiaries with cardiovascular disease or diabetes and linked data on provider groups, we compared racial differences in quality by provider group size, adjusting for patient characteristics. Among larger groups, we used multilevel models to estimate correlations between group performance on quality measures for white beneficiaries and black-white disparities within groups.Main measuresFour process measures of quality, hospitalization for ambulatory care-sensitive conditions (ACSCs) related to cardiovascular disease or diabetes, and hospitalization for any ACSC.Key resultsBeneficiaries served by larger groups were more likely to be white and live in areas with less poverty and more education. Larger group size was associated with smaller disparities in low-density lipoprotein (LDL) cholesterol testing and retinal exams, but not in other process measures or hospitalization for ACSCs. Among larger groups, better quality for white beneficiaries in one measure (hospitalization for ACSCs related to cardiovascular disease or diabetes) was correlated with smaller racial disparities (r?=?0.28; P?=?0.02), but quality was not correlated with disparities in other measures.ConclusionsLarger provider group size and better performance on quality measures were not consistently associated with smaller racial disparities in care for Medicare beneficiaries with cardiovascular disease or diabetes. ACO incentives rewarding better quality for minority groups and payment arrangements supporting ACO development in disadvantaged communities may be required for ACOs to promote greater equity in care.
| S-EPMC4139518 | biostudies-literature
Project description:ObjectiveTo understand the current role of urologists in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) and the organizational characteristics of ACOs with participating urologists.Materials and methodsUsing 2012-2013 Medicare data and the National Provider Identifier Database, we classified each urologist in the U.S. and Puerto Rico as either an MSSP ACO participant or nonparticipating provider. We then examined the distribution of ACO-participating urologists across the U.S. and among the first 220 MSSP ACOs. We also compared the characteristics of ACOs with and without participating urologists.ResultsAmong 11,084 identified urologists, 1118 (10%) were MSSP ACO participants. ACO-participating urologists practiced more frequently in the Northeast and Midwest (P < .001), and were more commonly female (10% vs 8%, P = .003). At an organizational level, only 110 (50%) of the initial MSSP ACOs included at least one urologist; among this group, the number of participating urologists ranged from 1 to 55. ACOs with one or more participating urologist were larger organizations, with respect to both the number of assigned beneficiaries and the number of providers per 1000 beneficiaries (P < .001 for each comparison). The patient populations served by ACOs with and without urologists were similar (P > .05 for each comparison).ConclusionA modest percentage of urologists participate in MSSP ACOs, although many of these organizations still lack any formal involvement by urological surgeons. Without such participation, improving the coordination, quality, and cost of urologic care for Medicare beneficiaries may be more challenging.
| S-EPMC4818669 | biostudies-literature