Cameron M. Kaplan

Geographic Variation in Outpatient Antibiotic Prescribing Among Older Adults

BACKGROUND Consequences of antibiotic overuse are substantial, especially among older adults, who are more susceptible to adverse reactions. Findings about variation in antibiotic prescribing can target policy efforts to focused areas; however, little is known about these patterns among older adults. METHODS Using Medicare Part D data from January 1, 2007, through December 31, 2009 (comprising 1.0-1.1 million patients per year), we examined geographic variation in antibiotic use among older adults in 306 Dartmouth Atlas of Health Care hospital referral regions, 50 states and the District of Columbia, and 4 national regions (South, West, Midwest, and Northeast). In addition, we examined the quarterly change in antibiotic use across the 4 regions. Differences in patient demographics, insurance status, and clinical characteristics were adjusted for across regions. RESULTS Substantial geographic and quarterly variation in outpatient antibiotic prescribing existed across regions after adjusting for population characteristics. This variation could not be explained by differences in the prevalences of the underlying conditions. For example, the ratios of the 75th percentile to the 25th percentile of adjusted annual antibiotic spending were 1.31 across states and 1.32 across regions. The highest antibiotic use was in the South, where 21.4% of patients per quarter used an antibiotic, whereas the lowest antibiotic use was in the West, where 17.4% of patients per quarter used an antibiotic (P < .01). Regardless of region, the rate of antibiotic use was highest in the first quarter (20.9% in January through March) and was lowest in the third quarter (16.9% in July through September) (P < .01). CONCLUSIONS Areas with high rates of antibiotic use may benefit from targeted programs to reduce unnecessary prescription. Quality improvement programs can set attainable targets using the low-prescribing areas as a reference, particularly targeting older adults.

Disability, race/ethnicity, and medication adherence among Medicare myocardial infarction survivors

BACKGROUND Long-term medication therapy for patients with post-myocardial infarction (MI) can prolong life. However, recent data on long-term adherence are limited, particularly among some subpopulations. We compared medication adherence among Medicare MI survivors by disability status, race/ethnicity, and income. METHODS We examined 100% of Medicare fee-for-service beneficiaries discharged post-MI in 2008. The outcomes were adherence to β-blockers, statins, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, for 1-year and 6-month postdischarge. Adherence was defined as having prescriptions in possession for ≥75% of days. RESULTS Among aged beneficiaries who survived 1-year adherence to β-blockers were 68%, 66%, 61%, 58%, and 57% for whites, Asians, Hispanics, Native Americans, and blacks, respectively; among persons with disability, 1-year adherence was worse for each group: 59%, 54%, 52%, 47%, and 43%, respectively. The racial/ethnic difference persisted after adjustment for age, gender, income, drug coverage, location, and health status. Patterns of adherence to statins and angiotensin-converting enzymes/angiotensin II receptor blockers were similar. Among beneficiaries with close-to-full drug coverage, minorities were still less likely to adhere relative to whites: odds ratio 0.70 (95% CI 0.65-0.75) for blacks and odds ratio 0.70 (95% CI 0.55-0.90) for Native Americans. CONCLUSIONS Although β-blockers at discharge has improved since the National Committee for Quality Assurance implemented quality measures, long-term adherence remains problematic, especially among persons with disability and minority beneficiaries. Quality measures for long-term adherence should be created to improve outcomes in patients with post-MI. Even among those with close-to-full drug coverage, racial differences remain, suggesting that policies simply relying on cost reduction cannot eliminate racial differences.

Community Oncology Medical Homes: Physician-Driven Change to Improve Patient Care and Reduce Costs

Although the patient-centered medical home is a well-established model of care for primary care providers, adoption by specialty providers has been relatively limited. Recently, there has been particular interest in developing specialty medical homes in medical oncology because of practice variation, care fragmentation, and high overall costs of care. In 2012, the Center for Medicare and Medicaid Innovation awarded Innovative Oncology Business Solutions a 3-year grant for their Community Oncology Medical Home (COME HOME) program to implement specialty medical homes in seven oncology practices across the country. We report our early experience and lessons learned.Through September 30, 2014, COME HOME has touched 16,353 unique patients through triage encounters, patient education visits, or application of clinical pathways. We describe the COME HOME model and implementation timeline, profile use of key services, and report patient satisfaction. Using feedback from practice sites, we highlight patient-centered innovations and overall lessons learned.COME HOME incorporates best practices care driven by triage and clinical pathways, team-based care, active disease management, enhanced access and care, as well as financial support for the medical home infrastructure. Information technology plays a central role, supporting both delivery of care and performance monitoring. Volume of service use has grown steadily over time, leveling out in second quarter 2014. The program currently averages 1,265 triage encounters, 440 extended hours visits, and 655 patient education encounters per month.COME HOME offers a patient-centered model of care to improve quality and continuity of care.

The January effect: medication reinitiation among Medicare Part D beneficiaries.

The Medicare prescription drug program (Part D) standard benefit includes deductible, initial coverage, coverage gap and catastrophic coverage phases. As beneficiaries enter each phase, their out-of-pocket medication costs change discontinuously. The benefit cycle restarts on 1 January of the next year. Taking advantage of variation in drug coverage, we study how individuals reinitiate discontinued medications in response to the non-linear price schedule. Because some beneficiaries who receive low-income subsidies (LIS) have zero or fixed small copayments throughout the year, we perform a difference-in-difference analysis by using the LIS group as a comparison. We find that individuals delay reinitiating important medications in December and are significantly more likely to reinitiate in January than in other months. Although we find some evidence that reinitiation is lower in the final months of the year, it is mostly driven by those who face higher prices due to the coverage gap. Our study suggests that individuals respond more to the current price of medications and do not anticipate future prices as well as theory would suggest.

Most Exchange Plans Charge Lower Tobacco Surcharges Than Allowed, But Many Tobacco Users Lack Affordable Coverage

Beginning in 2014, federal guidelines for health plans sold to people in the individual market allow insurers to charge tobacco users up to 50 percent more for premiums, compared to nonusers. We examined variations in tobacco surcharges for plans offered through the state and federal health insurance exchanges, or Marketplaces. The plan with the median surcharge had only 10 percent higher premiums for tobacco users compared to nonusers, and nine in ten plans charged a lower surcharge than allowed. Even with such lower-than-allowed surcharges, tobacco users lacked affordable coverage-defined as access to at least one plan with premiums of less than 8 percent of income after subsidies-in more states than did nonusers. Higher premiums could encourage tobacco users to opt out of coverage. Our results also suggest that the variation in tobacco surcharges may result in the sorting of tobacco users and nonusers into different plans.

Tobacco Surcharges on 2015 Health Insurance Plans Sold in Federally Facilitated Marketplaces: Variations by Age and Geography and Implications for Health Equity

In 2014, few health insurance plans sold in the Affordable Care Acts Federally Facilitated Marketplaces had age-dependent tobacco surcharges, possibly because of a system glitch. The 2015 tobacco surcharges show wide variation, with more plans implementing tobacco surcharges that increase with age. This underscores concerns that older tobacco users will find postsubsidy health insurance premiums difficult to afford. Future monitoring of enrollment will determine whether tobacco surcharges cause adverse selection by dissuading tobacco users, particularly older users, from buying health insurance.

The U.S. Health Insurance Marketplace: Are Premiums Truly Affordable?

Starting in 2014, the Patient Protection and Affordable Care Act (ACA) requires that individuals have health insurance or pay a penalty; however, those without access to affordable coverage are exempt from this mandate. The decision to purchase insurance depends on many complex factors, including the individuals perceived need for health care services, the affordability of premiums and out-of-pocket expenses, and the cost of potential penalties for lack of coverage. For those with a low perceived need for health care services, the cost of premiums relative to the penalty may play a pivotal role in coverage decisions. To examine how premium affordability varies according to age, income, and geographic area, we analyzed premium data for all health plans offered on state and federal health insurance marketplaces, commonly referred to as health insurance exchanges, for every county in the United States. Marketplace Overview The ACA established a modified community rating system, allowing insurance premiums to vary within strict limits on the basis of 4 factors: geographic region, family size, age, and tobacco use. For age-based premium variation, most plans follow the federally established standard age curve, where premiums for each age are determined by a schedule of fixed ratios such that the premium for a 64-year-old is 3 times greater than the base premium (that is, the premium for a 21-year-old) (1). Four states and the District of Columbia established their own age curves, which also increase with age but at different ratios than those specified by the standard age curve. Two states imposed a pure community rating, which prohibits variation in insurance premiums based on age. Marketplace health plans are categorized into 4 metal levels on the basis of the percentage of health care costs that the plan will pay for the average enrollee: 60% (bronze), 70% (silver), 80% (gold), and 90% (platinum). All plans available provide financial protection for unforeseen costly medical events and access to many preventive services free of charge; however, out-of-pocket costs vary substantially across plans. Bronze plans have lower premiums than other levels but higher out-of-pocket costs. Individual Mandate The ACA requires individuals to have health insurance or pay a yearly penalty. However, those without access to affordable coverage, for whom the cost of the least-expensive bronze plan available is greater than 8% of their income, are exempt from this penalty. The penalty for 2014 is

Anticipatory Behavior in Response to Medicare Part D's Coverage Gap.

95 per person or 1% of total household income, whichever is higher. It will increase to

Trends over time in enrollment in non-group health insurance plans by tobacco use in the United States

695 per person or 2.5% of income, whichever is higher, by 2016. Subsidy Overview Households with incomes between 100% and 400% of the federal poverty level (FPL)

Economic Analyses of an Alcohol Misconduct Prevention Program in a Military Setting

11670 and