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Trends in Postacute Care Use and Outcomes After Hip and Knee Replacements in Dual-Eligible Medicare and Medicaid Beneficiaries, 2013-2016.

ABSTRACT: Importance:Several Medicare alternative payment models were implemented in recent years, but their implications for socioeconomic gaps in postacute care (PAC) are unknown. Objectives:To determine the longitudinal trends in PAC use and outcomes after hip and knee replacements and in gaps among 3 groups: Medicare-only patients, dual-eligible patients with full Medicaid benefits, and dual-eligible patients with partial Medicaid benefits. Design, Setting, and Participants:A cohort study was conducted of PAC use and outcomes among Medicare fee-for-service patients undergoing hip or knee replacement surgery from January 1, 2013, to December 31, 2016, in approximately 3000 hospitals, using Medicare claims, assessment, hospital, and skilled nursing facility (SNF) files. Statistical analysis was performed from October 1, 2018, to December 17, 2019. Main Outcomes and Measures:Risk-adjusted differences among dual-eligible groups in institutional PAC use (SNF, inpatient rehabilitation, or long-term hospital care), readmission rate, and payment for readmissions; for patients discharged to a SNF, risk-adjusted differences in SNF quality measured by star ratings, proportion successfully discharged to the community, proportion transitioned to long-stay residence, and SNF length of stay and payments. Results:The sample included 1?302?256 patients (837?256 women [64.3%]; mean [SD] age, 75.4 [7.2] years) who underwent joint replacement. The proportion of patients discharged to institutional PAC and the 30-day and 90-day readmission rates decreased for all 3 groups during the period from 2013 to 2016. In 2013, institutional PAC use was 43.7% (95% CI, 43.5%-43.9%) for Medicare-only patients (n?=?1?182?555), 70.1% (95% CI, 69.4%-70.8%; n?=?60?461) for dual-eligible patients with full benefits, and 70.3% (95% CI, 69.6%-71.0%; n?=?59?240) for dual-eligible patients with partial benefits; in 2016, the rates decreased to 32.5% (95% CI, 32.4%-32.7%) for Medicare-only patients, 62.3% (95% CI, 61.5%-63.0%) for dual-eligible patients with full benefits, and 61.5% (95% CI, 60.7%-62.3%) for dual-eligible patients with partial benefits. Among patients discharged to SNFs, outcomes remained flat over time. For example, the proportion of patients successfully discharged to the community remained at 80.5% (95% CI, 80.4%-80.7%) for Medicare-only patients, 59.8% (95% CI, 59.3%-60.3%) for dual-eligible patients with full benefits, and 50.0% (95% CI, 49.4%-50.5%) for dual-eligible patients with partial benefits. Multivariable analyses with adjustment for patient, hospital (or SNF), and geographical covariates suggested maintained or enlarged gaps in all outcomes. Conclusions and Relevance:This study suggests that, during the period from 2013 to 2016, Medicare patients undergoing hip or knee replacement showed reduced institutional PAC use, reduced readmissions, and, among those discharged to SNFs, roughly unchanged outcomes. However, dual-eligible patients, especially those with partial Medicaid benefits, had persistently worse outcomes than Medicare-only patients.

SUBMITTER: Li Y

PROVIDER: S-EPMC7057132 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Trends in Postacute Care Use and Outcomes After Hip and Knee Replacements in Dual-Eligible Medicare and Medicaid Beneficiaries, 2013-2016.

Li Yue Y Ying Meiling M Cai Xueya X Kim Yeunkyung Y Thirukumaran Caroline Pinto CP

JAMA network open 20200302 3

<h4>Importance</h4>Several Medicare alternative payment models were implemented in recent years, but their implications for socioeconomic gaps in postacute care (PAC) are unknown.<h4>Objectives</h4>To determine the longitudinal trends in PAC use and outcomes after hip and knee replacements and in gaps among 3 groups: Medicare-only patients, dual-eligible patients with full Medicaid benefits, and dual-eligible patients with partial Medicaid benefits.<h4>Design, setting, and participants</h4>A coh ...[more]

PMID: 32129866

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Project description:ImportanceThe Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown.ObjectiveTo determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status.Design, setting, and participantsObservational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs.Main outcome measuresRisk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident.ResultsThe CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities.ConclusionsThe CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

Project description:ImportanceThe Centers for Medicare & Medicaid Services is beginning to consider adjusting for social risk factors, such as dual eligibility for Medicare and Medicaid, when evaluating hospital performance under value-based purchasing programs. It is unknown whether dual eligibility represents a unique domain of social risk or instead represents clinical risk unmeasured by variables available in traditional Medicare claims.ObjectiveTo assess how dual eligibility for Medicare and Medicaid is associated with risk-adjusted readmission rates after surgery.Design, setting, and participantsA retrospective cohort study was conducted of 55 651 Medicare beneficiaries undergoing general, vascular, and gynecologic surgery at 62 hospitals in Michigan between January 1, 2014, and December 1, 2016. Representative cohorts were derived from traditional Medicare claims (n?=?29?710) and the Michigan Surgical Quality Collaborative (MSQC) clinical registry (n?=?25?941), which includes additional measures of clinical risk. Statistical analysis was conducted between April 10 and July 15, 2019. The association between dual eligibility and risk-adjusted 30-day readmission rates after surgery was compared between models inclusive and exclusive of additional measurements of clinical risk. The study also examined how dual eligibility is associated with hospital profiling using risk-adjusted readmission rates.ExposuresDual eligibility for Medicare and Medicaid.Main outcomes and measuresRisk-adjusted all-cause 30-day readmission after surgery.ResultsThere were a total of 3986 dual-eligible beneficiaries in the Medicare claims cohort (2554 women; mean [SD] age, 72.9 [6.9] years) and 1608 dual-eligible beneficiaries in the MSQC cohort (990 women; mean [SD] age, 72.9 [6.8] years). In both data sets, higher proportions of dual-eligible beneficiaries were younger, female, and nonwhite than Medicare-only beneficiaries (Medicare claims cohort: female, 2554 of 3986 [64.1%] vs 12?879 of 25?724 [50.1%]; nonwhite, 1225 of 3986 [30.7%] vs 2783 of 25?724 [10.8%]; MSQC cohort: female, 990 of 1608 [61.6%] vs 12?578 of 24?333 [51.7%]; nonwhite, 416 of 1608 [25.9%] vs 2176 of 24?333 [8.9%]). In the Medicare claims cohort, dual-eligible beneficiaries were more likely to be readmitted (15.5% [95% CI, 13.7%-17.3%]) than Medicare-only beneficiaries (13.3% [95% CI, 12.7%-13.9%]; difference, 2.2 percentage points [95% CI, 0.4-3.9 percentage points]). In the MSQC cohort, after adjustment for more granular measures of clinical risk, dual eligibility was not significantly associated with readmission (difference, 0.6 percentage points [95% CI, -1.0 to 2.2 percentage points]). In both the Medicare claims and MSQC cohorts, adding dual eligibility to risk-adjustment models had little association with hospital ranking using risk-adjusted readmission rates.Conclusions and relevanceThis study suggests that dual eligibility for Medicare and Medicaid may reflect unmeasured clinical risk of readmission in claims data. Policy makers should consider incorporating more robust measures of social risk into risk-adjustment models used by value-based purchasing programs.

Dataset Information

Trends in Postacute Care Use and Outcomes After Hip and Knee Replacements in Dual-Eligible Medicare and Medicaid Beneficiaries, 2013-2016.

Publications

Trends in Postacute Care Use and Outcomes After Hip and Knee Replacements in Dual-Eligible Medicare and Medicaid Beneficiaries, 2013-2016.

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