Laura M. Keohane

Quality of Care for White and Hispanic Medicare Advantage Enrollees in the United States and Puerto Rico

IMPORTANCE Geographic, racial, and ethnic variations in quality of care and outcomes have been well documented among the Medicare population. Few data exist on beneficiaries living in Puerto Rico, three-quarters of whom enroll in Medicare Advantage (MA). OBJECTIVE To determine the quality of care provided to white and Hispanic MA enrollees in the United States and Puerto Rico. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of MA enrollees in 2011 was conducted, including white enrollees in the United States (n = 6 289 374), Hispanic enrollees in the United States (n = 795 039), and Hispanic enrollees in Puerto Rico (n = 267 016). The study was conducted from January 1, 2011, to December 31, 2011; data analysis took place from January 19, 2015, to January 2, 2016. MAIN OUTCOMES AND MEASURES Seventeen performance measures related to diabetes mellitus (including hemoglobin A1c control, retinal eye examination, low-density lipoprotein cholesterol control, nephropathy screening, and blood pressure control), cardiovascular disease (including low-density lipoprotein cholesterol control, blood pressure control, and use of a β-blocker after myocardial infarction), cancer screening (colorectal and breast), and appropriate medications (including systemic corticosteroids and bronchodilators for chronic obstructive pulmonary disease [COPD] and disease-modifying antirheumatic drugs). RESULTS Of the 7.35 million MA enrollees in the United States and Puerto Rico in our study, 1.06 million (14.4%) were Hispanic. Approximately 25.1% of all Hispanic MA enrollees resided in Puerto Rico, which was more than those residing in any state. For 15 of the 17 measures assessed, Hispanic MA enrollees in Puerto Rico received worse care compared with Hispanics in the United States, with absolute differences in performance rates ranging from 2.2 percentage points for blood pressure control in diabetes mellitus (P = .03) to 31.3 percentage points for use of disease-modifying antirheumatic drug therapy (P < .01). Adjusted performance differences between Hispanic MA enrollees in Puerto Rico and Hispanic MA enrollees in the United States exceeded 20 percentage points for 3 measures: use of disease-modifying antirheumatic drug therapy (-23.8 percentage points [95% CI, -30.9 to -16.8]), use of systemic corticosteroid in COPD exacerbation (-21.3 percentage points [95% CI, -27.5 to -15.1]), and use of bronchodilator therapy in COPD exacerbation (-22.7 percentage points [95% CI, -27.7 to -17.6]). CONCLUSIONS AND RELEVANCE We found modest differences in care between white and Hispanic MA enrollees in the United States but substantially worse care for enrollees in Puerto Rico compared with their US counterparts. Major efforts are needed to improve care delivery on the island to a level equivalent to the United States.

Waiving The Three-Day Rule: Admissions And Length-Of-Stay At Hospitals And Skilled Nursing Facilities Did Not Increase

The traditional Medicare program requires an enrollee to have a hospital stay of at least three consecutive calendar days to qualify for coverage of subsequent postacute care in a skilled nursing facility. This long-standing policy, implemented to discourage premature discharges from hospitals, might now be inappropriately lengthening hospital stays for patients who could be transferred sooner. To assess the implications of eliminating the three-day qualifying stay requirement, we compared hospital and postacute skilled nursing facility utilization among Medicare Advantage enrollees in matched plans that did or did not eliminate that requirement in 2006-10. Among hospitalized enrollees with a skilled nursing facility admission, the mean hospital length-of-stay declined from 6.9 days to 6.7 days for those no longer subject to the qualifying stay but increased from 6.1 to 6.6 days among those still subject to it, for a net decline of 0.7 day when the three-day stay requirement was eliminated. The elimination was not associated with more hospital or skilled nursing facility admissions or with longer lengths-of-stay in a skilled nursing facility. These findings suggest that eliminating the three-day stay requirement conferred savings on Medicare Advantage plans and that study of the requirement in traditional Medicare plans is warranted.

Association of Cost Sharing With Use of Home Health Services Among Medicare Advantage Enrollees

Importance Several 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. Objective To determine the association of home health copayments with use of home health services. Design, Setting, and Participants A 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. Exposures Introduction of copayments for home health care between 2007 and 2011. Main Outcomes and Measures Proportion of enrollees receiving home health care, annual numbers of home health episodes, and days receiving home health care. Results Copayments for home health visits ranged from

Effects of Caps on Cost Sharing for Skilled Nursing Facility Services in Medicare Advantage Plans: Caps on Cost Sharing for SNF Services

5 to

Dual Eligibles: Challenges for Medicare and Medicaid Coordination

20 per visit, which were estimated to be associated with

Preferred Provider Relationships Between Medicare Advantage Plans and Skilled Nursing Facilities Reduce Switching Out of Plans: An Observational Analysis

165 (interquartile range [IQR],

States With Medically Needy Pathways: Differences in Long-Term and Temporary Medicaid Entry for Low-Income Medicare Beneficiaries

45-

High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare

180) to

Local Medicaid Home- and Community-Based Services Spending and Nursing Home Admissions of Younger Adults

660 (IQR,

Medicare Advantage Members’ Expected Out-Of-Pocket Spending For Inpatient And Skilled Nursing Facility Services

180-