Association Between Primary Care Payment Model and Telemedicine Use for Medicare Advantage Enrollees During the COVID-19 Pandemic.
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ABSTRACT:
SUBMITTER: Powers BW
PROVIDER: S-EPMC8796918 | biostudies-literature | 2021 Jul
REPOSITORIES: biostudies-literature
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Association Between Primary Care Payment Model and Telemedicine Use for Medicare Advantage Enrollees During the COVID-19 Pandemic.
Powers Brian W BW Drzayich Antol Dana D Zhao Yongming Y Haugh Gilbert S GS Roman Oraida O Shrank William H WH Choudhry Niteesh K NK
JAMA health forum 20210716 7
This cohort study examines the association between the primary care payment model and telemedicine use for Medicare Advantage enrollees during the COVID-19 pandemic. ...[more]
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Project description:Importance:In 2016, the Centers for Medicare & Medicaid Services introduced mandatory bundled payments for knee and hip replacement surgical procedures among traditional Medicare (TM) patients in randomly selected areas. The association of bundled payments with outcomes among patients enrolled in Medicare Advantage (MA) is not known. Objective:To determine the association of bundled payments for joint replacement surgical procedures with the use of postacute care (PAC) services among MA patients. Design, Setting, and Participants:This cohort study used difference-in-differences analysis to evaluate changes in PAC use among patients enrolled in Medicare who underwent joint replacement operations before and after the introduction of bundled payments (ie, from January 1, 2013, to September 30, 2017). A total of 75 metropolitan statistical areas were randomized to participate in the bundled payment program, with 121 areas serving as controls. Data were analyzed between September 15, 2018, and October 1, 2019. Exposure:Bundled payments for hip and knee joint replacement operations, in which hospitals received a single payment to cover all costs associated with a joint replacement and associated care for the 90 days after surgery. Main Outcomes and Measures:The primary outcomes were discharge to any institutional PAC setting and days spent in institutional PAC within 90 days after surgery. Secondary outcomes included discharge and days spent in specific PAC settings (ie, home health, skilled nursing facility, inpatient rehabilitation). Results:Of 1 536 387 individuals who underwent hip and knee join replacement surgery, 493 977 (32.2%) were enrolled in MA (mean [SD] age, 73.3 [8.4] years; 386 699 [63.5%] women; 55 078 [6.4%] black) and 1 042 410 (67.8%) were enrolled in TM (mean [SD] age, 73.3 [8.7] years, 829 014 [65.2%] women; 82 890 [9.4%] black). Among MA patients, bundled payments were associated with a reduction of 1.5 (95% CI, 1.0-2.0) percentage points in discharge to an institutional PAC setting (P < .001) and an estimated reduction of 0.3 (95% CI, 0.2-0.5) days spent in an institutional PAC setting (P < .001), a 5.6% relative reduction. Among TM patients, bundled payments were associated with a reduction of 2.6 (95% CI, 2.2-2.9) percentage points in institutional PAC discharge (P < .001) and a reduction of 0.8 (95% CI, 0.7-0.9) days spent in an institutional PAC setting (P < .001), a 2.5% relative reduction. These changes were larger in hospitals with greater proportions of TM patients. In hospitals with low concentrations of MA patients, time spent in institutional PAC settings decreased by 0.9 days among TM patients and 0.8 days among MA patients; in hospitals with high MA concentrations, time spent in institutional PAC settings decreased by 0.6 days for TM patients and 0.2 days for MA patients. Conclusions and Relevance:In this study, the first 18 months of the Centers for Medicare & Medicaid Services bundled payment program for joint replacement surgery were associated with reductions in the use of institutional PAC among MA patients. Past evaluations of bundled payments that focused on TM patients may not have measured the full consequences of this alternative payment model.
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Project description:ImportanceSeveral policy proposals advocate introducing copayments for home health care in the Medicare program. To our knowledge, no prior studies have assessed this cost-containment strategy.ObjectiveTo determine the association of home health copayments with use of home health services.Design, setting, and participantsA difference-in-differences case-control study of 18 Medicare Advantage (MA) plans that introduced copayments for home health care between 2007 and 2011 and 18 concurrent control MA plans. The study included 135 302 enrollees in plans that introduced copayment and 155 892 enrollees in matched control plans.ExposuresIntroduction of copayments for home health care between 2007 and 2011.Main outcomes and measuresProportion of enrollees receiving home health care, annual numbers of home health episodes, and days receiving home health care.ResultsCopayments for home health visits ranged from $5 to $20 per visit, which were estimated to be associated with $165 (interquartile range [IQR], $45-$180) to $660 (IQR, $180-$720) in out-of-pocket spending for the average user of home health care. The increased copayment for home health care was not associated with the proportion of enrollees receiving home health care (adjusted difference-in-differences, -0.15 percentage points; 95% CI, -0.38 to 0.09), the number of home health episodes per user (adjusted difference-in-differences, 0.01; 95% CI, -0.01 to 0.03), and home health days per user (adjusted difference-in-differences, -0.19; 95% CI, -3.02 to 2.64). In both intervention and control plans and across all levels of copayments, we observed higher disenrollment rates among enrollees with greater baseline use of home health care.Conclusions and relevanceWe found no evidence that imposing copayments reduced the use of home health services among older adults. More intensive use of home health services was associated with increased rates of disenrollment in MA plans. The findings raise questions about the potential effectiveness of this cost-containment strategy.
| S-EPMC5662935 | biostudies-literature
Project description:ImportanceDuring the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized.ObjectiveTo compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use.Design, setting, and participantsIn this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022.ExposurePractice-level use of telemedicine during the first year of the COVID-19 pandemic.Main outcomes and measuresThe primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization.ResultsThe pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were -0.4% (95% CI, -1.3% to 0.5%) and -0.1% (95% CI, -1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, -1.5% to 6.2%) and 2.8% (95% CI, -1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use.Conclusions and relevanceIn this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.
| S-EPMC10611994 | biostudies-literature
Project description:ImportanceMedicare Advantage (MA) plans receive capitated per enrollee payments that create financial incentives to provide care more efficiently than traditional Medicare (TM); however, incentives could be associated with MA plans reducing use of beneficial services. Postacute care can improve functional status, but it is costly, and thus may be provided differently to Medicare beneficiaries by MA plans compared with TM.ObjectiveTo estimate the association of MA compared with TM enrollment with postacute care use and postdischarge outcomes.Design, setting, and participantsThis was a cohort study using Medicare data on 4613 hospitalizations among retired Ohio state employees and 2 comparison groups in 2015 and 2016. The study investigated the association of a policy change with use of postacute care and outcomes. The policy changed state retiree health benefits in Ohio from a mandatory MA plan to subsidies for either supplemental TM coverage or an MA plan. After policy implementation, approximately 75% of retired Ohio state employees switched to TM. Hospitalizations for 3 high-volume conditions that usually require postacute rehabilitation were assessed. Data from the Medicare Provider Analysis and Review files were used to identify all hospitalizations in short-term acute care hospitals. Difference-in-difference regressions were used to estimate changes for retired Ohio state employees compared with other 2015 MA enrollees in Ohio and with Kentucky public retirees who were continuously offered a mandatory MA plan. Data analyses were performed from September 1, 2019, to November 30, 2023.ExposuresEnrollment in Ohio state retiree health benefits in 2015, after which most members shifted to TM.Main outcomes and measuresReceived care in an inpatient rehabilitation facility, skilled nursing facility, or home health, or any postacute care; the occurrence of any hospital readmission; the number of days in the community during the 30 days after hospital discharge; and mortality.ResultsThe study sample included 2373 hospitalizations for Ohio public retirees, 1651 hospitalizations for other Humana MA enrollees in Ohio, and 589 hospitalizations for public retirees in Kentucky. After the 2016 policy implementation, the percentage of hospitalizations covered by MA decreased by 70.1 (95% CI, -74.2 to -65.9) percentage points (pp), inpatient rehabilitation facility admissions increased by 9.7 (95% CI, 4.7 to 14.7) pp, use of only home health or skilled nursing facility care fell by 8.6 (95% CI, -14.6 to -2.6) pp, and days in the community fell by 1.6 (95% CI, -2.9 to -0.3) days for Ohio public retirees compared with other Humana MA enrollees in Ohio. There was no change in 30-day mortality or hospital readmissions; similar results were found by comparisons using Kentucky public retirees as a control group.Conclusions and relevanceThe findings of this cohort study indicate that after a change in retiree health benefits, most Ohio public retirees shifted from MA to TM and received more intensive postacute care with no significant change in measured short-term postdischarge outcomes. Future work should consider additional measures of postacute functional status over a longer follow-up period.
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Project description:BackgroundThe decision to screen for breast cancer among older adults with dementia is complex and must often be individualized, as these individuals have an elevated risk of harm from over-screening. Medicare beneficiaries with dementia are increasingly enrolling in Medicare Advantage plans, which typically promote receipt of preventive cancer screening among their enrollees. This study examined the utilization of breast cancer screening among Medicare enrollees with dementia, in Medicare Advantage and in fee-for-service Medicare.MethodsWe conducted a pooled cross-sectional study of women with Alzheimer's disease and related dementias or cognitive impairment who were eligible for mammogram screening. We used Medicare Current Beneficiary Survey data to identify utilization of biennial mammogram screening between 2012 and 2019. Poisson regression models were used to estimate prevalence ratios of mammogram utilization and to calculate adjusted mammogram rates for Medicare Advantage and fee-for-service Medicare enrollees with dementia, and further stratified by rurality and by dual eligibility for Medicare and Medicaid.ResultsMammogram utilization was 16% higher (Prevalence Ratio [PR] 1.16; 95% CI: 1.05, 1.29) among Medicare Advantage enrollees with dementia, compared to their counterparts in fee-for-service Medicare. Rural enrollees experienced no significant difference (PR 0.99; 95% CI: 0.72, 1.37) in mammogram use between Medicare Advantage and fee-for-service Medicare enrollees. Among urban enrollees, Medicare Advantage enrollment was associated with a 21% higher mammogram rate (PR 1.21; 95% CI: 1.09, 1.35). Dual-eligible Medicare Advantage enrollees had a 34% higher mammogram rate (PR 1.34; 95% CI: 1.10, 1.63) than dual-eligible fee-for-service Medicare enrollees. Among non-dual-eligible enrollees, adjusted mammogram rates were not significantly different (PR 1.11; 95% CI: 0.99, 1.24) between Medicare Advantage and fee-for-service Medicare enrollees.ConclusionsMedicare beneficiaries age 65-74 with Alzheimer's disease and related dementias or cognitive impairment had a higher mammogram use rate when they were enrolled in Medicare Advantage plans compared to fee-for-service Medicare, especially when they were dual-eligible or lived in urban areas. However, some Medicare Advantage enrollees with Alzheimer's disease and related dementias or cognitive impairment may have experienced over-screening for breast cancer.
| S-EPMC10916275 | biostudies-literature
Project description:ImportanceVarious policy proposals would reduce federal payments to Medicare Advantage (MA) plans. However, it is unclear whether payment reductions would compromise beneficiary access to the MA program.ObjectiveTo quantify the association between MA payment reductions under the Affordable Care Act (ACA) and MA enrollment growth.Design, setting, and participantsThis retrospective cohort study examined the MA market before and after the ACA, which mandated cuts to MA benchmark payment rates. Using 2008 to 2019 county-level enrollment and payment data, a difference-in-differences analysis was conducted comparing MA enrollment changes between counties with larger vs smaller benchmark reductions, before vs after the ACA.Main outcomes and measuresThe primary outcome was the MA enrollment rate, defined as the proportion of a county's Medicare beneficiaries enrolled in MA. A secondary analysis examined MA plan payments per member per month.ResultsAmong 3138 counties with 37 639 county-year observations, ACA-induced benchmark cuts were sizeable and varied, ranging from 0% to 42.9% (mean [SD], 5.9% [6.6%]). Counties with benchmark cuts above the 75th percentile had population-weighted average benchmark cuts of 14.9% compared with 4.4% in other counties. In the 8 years following the ACA, there was no differential change in MA enrollment between counties with larger vs smaller benchmark cuts (difference-in-differences estimate, 0.02 [95% CI, -1.18 to 1.21] percentage points; P = .98). Plan payments differentially fell in counties with larger benchmark cuts by $78.35 (95% CI, $62.21-$94.48) per member per month (P < .001).Conclusion and relevanceThis cohort study found no evidence that the MA benchmark and ensuing payment cuts imposed by the ACA were associated with reduced MA enrollment, compromising access to MA. This evidence can inform ongoing policy debates regarding the growth of MA, concerns about excess payments to MA plans, and proposed Medicare reforms, including further reductions in MA payments.
| S-EPMC10290750 | biostudies-literature
Project description:BackgroundDifferences in the control of blood pressure, cholesterol, and glucose among the various racial and ethnic groups of Medicare enrollees may contribute to persistent disparities in health outcomes.MethodsAmong elderly enrollees in Medicare Advantage health plans in 2011 who had hypertension (94,171 persons), cardiovascular disease (112,039), or diabetes (105,848), we compared the respective age-and-sex-adjusted proportions with blood pressure lower than 140/90 mm Hg, low-density lipoprotein cholesterol levels below 100 mg per deciliter (2.6 mmol per liter), and a glycated hemoglobin value of 9.0% or lower, according to race or ethnic group. Comparisons were made nationally and within regions and health plans, and changes since 2006 were assessed.ResultsBlack enrollees in 2006 and 2011 were substantially less likely than white enrollees to have adequate control of blood pressure (adjusted absolute differences in proportions of enrollees in the 2 years, 7.9 percentage points and 10.3 percentage points, respectively), cholesterol (11.4 percentage points and 10.2 percentage points, respectively), and glycated hemoglobin (10.1 percentage points and 9.4 percentage points, respectively) (P<0.001 for all comparisons). Differing distributions of enrollees among health plans accounted for 39 to 59% of observed disparities in 2011. These differences persisted in 2011 in the Northeast, Midwest, and South (6.9 to 14.1 percentage points, P<0.001 for all comparisons) but were eliminated in the West for all three measures (<1.5 percentage points, P≥0.15). Hispanic enrollees were less likely than whites in 2011 to have adequate control of blood pressure (adjusted difference, 1.6 percentage points), cholesterol (adjusted difference, 1.0 percentage points), and glycated hemoglobin (adjusted difference, 3.4 percentage points) (P≤0.02 for all comparisons). Asians and Pacific Islanders were more likely than whites to have adequate control of blood pressure (difference, 4.4 percentage points; P<0.001) and cholesterol (5.5 percentage points, P<0.001) and had similar control of glycated hemoglobin (0.3 percentage points, P=0.63).ConclusionsDisparities in control of blood pressure, cholesterol, and glucose have not improved nationally for blacks in Medicare Advantage plans, but these disparities were eliminated in the West in 2011. (Funded by the National Institute on Aging.).
| S-EPMC4381536 | biostudies-literature
Project description:ObjectiveTo assess relationships between changes in Medicare Advantage (MA) payment rates and Medicare beneficiary hospitalizations and to simulate the effects of scheduled payment cuts on ambulatory care sensitive (ACS) and elective hospitalization rates.DataState Inpatient Database discharge abstracts from Arizona, Florida, and New York merged with administrative Medicare enrollment and MA payment data.Study designRetrospective, fixed effect regression analysis of the relationship between MA payment rates and rates of ACS and elective hospitalizations among Medicare beneficiaries in counties with at least 10,000 Medicare beneficiaries and 3 percent MA penetration from 1999 to 2005.Principal findingsMA payment rates were negatively related to rates of ACS admissions. Simulations suggest that payment cuts could be associated with higher rates of ACS admissions. No relationship between MA payments and rates of elective hospitalizations was found.ConclusionsReductions in MA payment rates may result in a small increase in ACS admissions. Trends in ACS admissions among chronically ill Medicare beneficiaries should be tracked following MA payment cuts.
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