J. Michael McWilliams

Differences in control of cardiovascular disease and diabetes by race, ethnicity, and education: U.S. trends from 1999 to 2006 and effects of medicare coverage.

Context Acquiring health insurance and getting better quality of care could reduce health care disparities. The relative importance of these 2 factors is unknown. Contribution To measure changes in chronic disease control, the authors used blood pressure, hemoglobin A1c, and total cholesterol measurements that were obtained from participants in the 1999 to 2006 National Health and Nutrition Examination Survey. Disease control improved over 8 years, but gaps between white and nonwhite patients did not change. The gaps were smaller after age 65 years, when universal Medicare insurance begins. Caution Each annual National Health and Nutrition Examination Survey enrolled different persons. Implication Access to care through universal health insurance reduced disparities in chronic disease control; improved quality of care did not affect sociodemographic differences. The Editors In 3 comprehensive reports since 2001, the Institute of Medicine has advanced recommendations to expand access (1), improve quality (2), and eliminate disparities in health care (3). Although widespread deficits in the quality of care have been reported in the United States (4), some evidence suggests that quality of care has improved in the past decade (58). More consistent efforts to provide high-quality care may also reduce racial, ethnic, and socioeconomic differences in health (9). However, quality improvement may not necessarily lead to more equitable care (5, 10, 11), especially if improvements occur among providers who serve fewer disadvantaged patients (1218) or if new financial incentives to improve quality have unintended, detrimental consequences (1820). Furthermore, better performance and smaller racial differences in processes of care for cardiovascular disease and diabetes have not been consistently associated with reduced racial differences in clinical outcomes, such as control of cholesterol or glucose levels (8, 21, 22). Although overall disease control in the United States may be improving for some measures (2325), recent national trends in sociodemographic differences in control have not been comprehensively assessed. Insurance coverage may be an important mediator of sociodemographic differences in control of cardiovascular disease and diabetes (3, 26). Racial and ethnic minorities and adults of lower socioeconomic status are much more likely to be uninsured (27), and uninsured adults are much less likely to receive basic clinical services for these conditions (28). Near-universal Medicare coverage after age 65 years has been associated with decreased racial and socioeconomic differences in self-reported general health status and receipt of mammography (29, 30). Recent longitudinal studies also suggest that acquiring Medicare coverage increases use of health services and improves self-reported health outcomes for previously uninsured adults with cardiovascular disease or diabetes (3133). However, previous studies have not assessed the effects of increases in insurance coverage on racial, ethnic, and socioeconomic differences in clinical measures of disease control. Our primary objectives were to assess national trends from 1999 to 2006 in blood pressure control (for adults with hypertension), glycemic control (for adults with diabetes), and cholesterol level control (for adults with coronary heart disease, stroke, or diabetes); to analyze concomitant changes in differences by race, ethnicity, and education for each of these measures; and to evaluate whether these differences narrow after age 65 years with Medicare coverage. Methods Study Sample We analyzed serial cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), a nationally representative study designed to assess population health through interviews, physical examinations, and clinical testing (34). From 1999 to 2006, 41474 noninstitutionalized adults and children were enrolled (average response rate, 81.4%), including oversamples of black adults, Mexican Americans, and adults age 60 years or older. Data have been released in four 2-year increments. Among participants who completed a standardized interview in English or Spanish, 39352 (94.9%) had clinical examinations and testing, including 12079 participants age 40 to 85 years. We studied adults age 40 to 85 years who had at least 1 of the following conditions: diabetes, hypertension, coronary heart disease, or stroke (Table 1). If we assessed disease control only among those with self-reported diagnoses, improved diagnosis of less severe disease might bias estimates of time trends in disease control in a positive direction. Therefore, on the basis of relevant clinical testing, we identified and included adults with undiagnosed hypertension and diabetes so that disease control was consistently assessed among all prevalent cases (a detailed classification of conditions is in the Appendix). Table 1. Demographic Characteristics of Adults Age 40 to 85 Years With Cardiovascular Disease or Diabetes Because the proportion of immigrant Hispanic adults varies by age and has increased over time (35) and because Hispanic immigrants experience different patterns of chronic disease care and outcomes from those of U.S.-born Hispanic adults (36), we excluded 743 Hispanic adults (53.1%) who were born outside the United States, restricting all analyses to the U.S.-born Hispanic group (hereafter referred to as Hispanic). This restriction improved comparability of Hispanic samples over time and ensured that age-related differences in outcomes were not confounded by health differences between immigrant and U.S.-born Hispanic adults. In contrast, only 5.2% of white participants and 12.7% of black participants were born outside the United States. Results were similar when we excluded white and black immigrants in a sensitivity analysis. Finally, we excluded 202 participants who were not white, black, or Hispanic because samples for other groups were too small for statistical comparisons. The Human Studies Committee of Harvard Medical School approved our study protocol. Study Variables We used dichotomous and continuous measures of disease control to compare rates of control and mean levels, respectively, across groups. We assessed blood pressure control (average systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg) (37) and average systolic blood pressure readings among participants with hypertension; glycemic control (hemoglobin A1c levels <7.0%) (38) and hemoglobin A1c levels among participants with diabetes; and cholesterol level control (total cholesterol level <200 mg/dL [<5.2 mmol/L]) (39) and total cholesterol levels among participants with coronary heart disease, stroke, or diabetes. We defined comparison groups by race or ethnicity (non-Hispanic black and Hispanic each vs. non-Hispanic white) or education (high school graduates vs. nonhigh school graduates). We also determined age, sex, ratio of family income to poverty threshold, body mass index (BMI), current smoking status, and insurance coverage from NHANES data. Statistical Analysis We compared trends in disease control for each measure by using a linear model (E[Yi] = 0 + 1timei + 2groupi + 3timeigroupi), in which Yi is a dichotomous or continuous indicator of disease control for the ith individual; time is a chronologic index of the four 2-year survey periods ranging from 1 (1999 to 2000) to 4 (2005 to 2006); and group is an indicator of membership in a particular racial, ethnic, or educational comparison group. Thus, coefficients for the time-by-group interaction terms represent biennial trends (average change over 2-year periods between survey waves) in racial, ethnic, and educational differences in disease control from 1999 to 2006. We estimated overall trends by using simpler models without group variables. We also calculated rates of control and mean values for each of the four 2-year periods for reporting purposes. We adjusted all reported estimates of rates and trends for age and sex. To determine whether trends in disease control were related to changes in other population characteristics, we also estimated overall trends that were further adjusted for race, ethnicity, education, income, BMI, smoking status, and insurance coverage. We did not adjust analyses of racial, ethnic, or educational differences in disease control for factors other than age and sex, because we were interested in overall differences that could result from many individual and health care system factors, rather than attributing differences to specific mediators, such as discrimination (40). To estimate effects of near-universal Medicare coverage on sociodemographic differences, we compared racial, ethnic, and educational differences in systolic blood pressure, hemoglobin A1c levels, and total cholesterol levels before and after age 65 years. For example, to identify changes in racial differences in systolic blood pressure associated with Medicare eligibility, we fitted a linear model predicting mean systolic blood pressure as a function of black race, an indicator of age 65 years or older, and an interaction between these 2 predictors, with white adults serving as the reference group. We fitted similar models for each racial, ethnic, and educational comparison and for each outcome. We used measured values rather than dichotomous outcomes in these analyses to identify clinically important changes with greater sensitivity. In our study, differences in mortality rates, time-varying characteristics, and use of cross-sectional data posed several challenges to interpreting age-related changes in sociodemographic differences in disease control. Older groups may have differed from younger groups in predictors of disease control other than age or insurance coverage, and these differences between age groups may have differed by sociodemographic characteristics. Therefore, to estimate effects of Medicare coverage more robustly, we made several p

Health Consequences of Uninsurance Among Adults in the United States: Recent Evidence and Implications

CONTEXT Uninsured adults have less access to recommended care, receive poorer quality of care, and experience worse health outcomes than insured adults do. The potential health benefits of expanding insurance coverage for these adults may provide a strong rationale for reform. However, evidence of the adverse health effects of uninsurance has been largely based on observational studies with designs that do not support causal conclusions. Although recent research using more rigorous methods may offer a better understanding of this important subject, it has not been comprehensively reviewed. METHODS The clinical and economic literature since 2002 was systematically searched. New research contributions were reviewed and evaluated based on their methodological strength. Because the effectiveness of medical care varies considerably by clinical risk and across conditions, the consistency of study findings with clinical expectations was considered in their interpretation. Updated conclusions were formulated from the current body of research. FINDINGS The quality of research has improved significantly, as investigators have employed quasi-experimental designs with increasing frequency to address limitations of earlier research. Recent studies have found consistently positive and often significant effects of health insurance coverage on health across a range of outcomes. In particular, significant benefits of coverage have now been robustly demonstrated for adults with acute or chronic conditions for which there are effective treatments. CONCLUSIONS Based on the evidence to date, the health consequences of uninsurance are real, vary in magnitude in a clinically consistent manner, strengthen the argument for universal coverage in the United States, and underscore the importance of evidence-based determinations in providing health care to a diverse population of adults.

Early Performance of Accountable Care Organizations in Medicare

BACKGROUND In the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) have financial incentives to lower spending and improve quality. We used quasi-experimental methods to assess the early performance of MSSP ACOs. METHODS Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared changes in spending and in performance on quality measures from before the start of ACO contracts to after the start of the contracts between beneficiaries served by the 220 ACOs entering the MSSP in mid-2012 (2012 ACO cohort) or January 2013 (2013 ACO cohort) and those served by non-ACO providers (control group), with adjustment for geographic area and beneficiary characteristics. We analyzed the 2012 and 2013 ACO cohorts separately because entry time could reflect the capacity of an ACO to achieve savings. We compared ACO savings according to organizational structure, baseline spending, and concurrent ACO contracting with commercial insurers. RESULTS Adjusted Medicare spending and spending trends were similar in the ACO cohorts and the control group during the precontract period. In 2013, the differential change (i.e., the between-group difference in the change from the precontract period) in total adjusted annual spending was -

Steps To Reduce Favorable Risk Selection In Medicare Advantage Largely Succeeded, Boding Well For Health Insurance Exchanges

144 per beneficiary in the 2012 ACO cohort as compared with the control group (P=0.02), consistent with a 1.4% savings, but only -

The Value of Low-Value Lists

3 per beneficiary in the 2013 ACO cohort as compared with the control group (P=0.96). Estimated savings were consistently greater in independent primary care groups than in hospital-integrated groups among 2012 and 2013 MSSP entrants (P=0.005 for interaction). MSSP contracts were associated with improved performance on some quality measures and unchanged performance on others. CONCLUSIONS The first full year of MSSP contracts was associated with early reductions in Medicare spending among 2012 entrants but not among 2013 entrants. Savings were greater in independent primary care groups than in hospital-integrated groups.

New Risk-Adjustment System Was Associated With Reduced Favorable Selection In Medicare Advantage

Within Medicare, the Medicare Advantage program has historically attracted better risks-healthier, lower-cost patients-than has traditional Medicare. The disproportionate enrollment of lower-cost patients and avoidance of higher-cost ones during the 1990s-known as favorable selection-resulted in Medicares spending more per beneficiary who enrolled in Medicare Advantage than if the enrollee had remained in traditional Medicare. We looked at two measures that can indicate whether favorable selection is taking place-predicted spending on beneficiaries and mortality-and studied whether policies that Medicare implemented in the past decade succeeded in reducing favorable selection in Medicare Advantage. We found that these policies-an improved risk adjustment formula and a prohibition on monthly disenrollment by beneficiaries-largely succeeded. Differences in predicted spending between those switching from traditional Medicare to Medicare Advantage relative to those who remained in traditional Medicare markedly narrowed, as did adjusted mortality rates. Because insurance exchanges set up under the Affordable Care Act will employ similar policies to combat risk selection, our results give reason for optimism about managing competition among health plans.

Implementation of Medicare Part D and nondrug medical spending for elderly adults with limited prior drug coverage.

AN INTERNATIONAL GROUNDSWELL OF ACTIVITY IS seeking to identify and reduce the use of health care services that provide little or no benefit— whether through overuse or misuse. There are strong imperatives for identifying such waste: (1) an ethical imperative to ensure patient safety and thus avoid tests and treatments that cause harm directly or indirectly without providing commensurate benefit; (2) a quality imperative to measure and reward best practices; and (3) an economic imperative to reduce spending and enhance the diffusion of cost-effective innovations. England’s National Institute for Health and Clinical Excellence (NICE) commenced a formal agenda in this area in 2005. The most recent initiative garnering attention is Choosing Wisely, a US campaign led by the ABIM Foundation. Other countries are implementing similar approaches. A major challenge faced by these initiatives has been how to identify and prioritize candidate services for consideration in a reasoned and transparent manner. Today, several lists compiled by prominent organizations have identified numerous services as potentially low value in certain clinical circumstances (eTable, available at http://www.jama.com). The challenge facing payers and health care service providers such as physicians and hospitals is to develop and implement strategies to reduce the use of services that are identified in these lists, many of which are discretionary, if not potentially harmful. The intent of the evidence-informed lists is to provide sets of specific services used in defined clinical scenarios that payers and health care professionals can target directly in rewarding value and limiting inappropriate care. As suggested by the lists, services that are ineffective, unsafe, or both for all patients andindicationsarerare.Typically,aservicedemonstratessafety and effectiveness profiles that depend on the characteristics of the population to whom it is provided. In essence, a service that is low value in some clinical circumstances might be high value in others. This clinical heterogeneity makes it difficult to develop simple approaches for identifying low-value services. For instance, although routine stress testing in asymptomatic patients is clearly of low value, stress tests can be very high value in those presenting with symptoms of ischemic heart disease. The main challenge is that interventions proven to be effective for specific clinical populations are often inappropriately applied to patients for whom benefit has never been demonstrated (indication or scope creep). In the United States in particular, extrapolation of evidence is encouraged by financial incentives embedded in physician payment systemsandcoveragedesignswith limitedcostsharingforpatients. Just as the development of low-value lists is beset with clinical complexity, so too is their implementation. Although evidence-based assessments of individual health services often focus on use in specific populations and indications, the presumption of detailed clinical data is often at odds with the nature of existing data sources such as administrative claims. For instance, imaging for acute back pain usually is considered of low value, but this may not be the case in certain cases such as trauma or evidence of neurologic compromise. Although this information might be present in medical records, it typically is not captured well in claims. These data deficiencies present fundamental obstacles to translating comparative effectiveness research into effective policies because often the lack of detailed information on the clinical context (ie, indications) limits the usefulness of claims data for identifying and measuring the use of these low-value services. One strategy to reduce waste is to deny coverage for wasteful services. Yet because of the aforementioned clinical heterogeneity that cannot always or easily be observed with current claims systems, the effectiveness of using coverage design to discourage use of low-value services is likely to be limited in scope. Similarly, value-based insurance design and related supply-side strategies (eg, not paying for never events) are fraught with measurement and data issues when applied to services of heterogeneous value. For example, developing benefit-based co-payments for automatic implantable cardiac defibrillators or for coronary revascularization procedures (higher co-payments for lower-value uses) would require the incorporation of complex and evolving guide-

Medicare spending for previously uninsured adults.

Health plans participating in the Medicare managed care program, called Medicare Advantage since 2003, have historically attracted healthier enrollees than has the traditional fee-for-service program. Medicare Advantage plans have gained financially from this favorable risk selection since their payments have traditionally been adjusted only minimally for clinical characteristics of enrollees, causing overpayment for healthier enrollees and underpayment for sicker ones. As a result, a new risk-adjustment system was phased in from 2004 to 2007, and a lock-in provision instituted to limit midyear disenrollment by enrollees experiencing health declines whose exodus could benefit plans financially. To determine whether these reforms were associated with intended reductions in risk selection, we compared differences in self-reported health care use and health between Medicare Advantage and traditional Medicare beneficiaries before versus after these reforms were implemented. We similarly compared differences between those who switched into or out of Medicare Advantage and nonswitchers. Most differences in 2001-03 were substantially narrowed by 2006-07, suggesting reduced selection. Similar risk-adjustment methods may help reduce incentives for plans competing in health insurance exchanges and accountable care organizations to select patients with favorable clinical risks.

Association of Financial Integration Between Physicians and Hospitals With Commercial Health Care Prices

CONTEXT Implementation of Medicare Part D was followed by increased use of prescription medications, reduced out-of-pocket costs, and improved medication adherence. Its effects on nondrug medical spending remain unclear. OBJECTIVE To assess differential changes in nondrug medical spending following the implementation of Part D for traditional Medicare beneficiaries with limited prior drug coverage. DESIGN, SETTING, AND PARTICIPANTS Nationally representative longitudinal survey data and linked Medicare claims from 2004-2007 were used to compare nondrug medical spending before and after the implementation of Part D by self-reported generosity of prescription drug coverage before 2006. Participants included 6001 elderly Medicare beneficiaries from the Health and Retirement Study, including 2538 with generous and 3463 with limited drug coverage before 2006. Comparisons were adjusted for sociodemographic and health characteristics and checked for residual confounding by conducting similar comparisons for a control cohort from 2002-2005. MAIN OUTCOME MEASURE Nondrug medical spending assessed from claims, in total and by type of service (inpatient and skilled nursing facility vs physician services). RESULTS Total nondrug medical spending was differentially reduced after January 1, 2006, for beneficiaries with limited prior drug coverage (-

HOW MUCH FAVORABLE SELECTION IS LEFT IN MEDICARE ADVANTAGE

306/quarter [95% confidence interval {CI}, -