Setting eligibility criteria for a care-coordination benefit

OBJECTIVES: To examine different clinically relevant eligibility criteria sets to determine how they differ in numbers and characteristics of individuals served. DESIGN: Cross-sectional analysis of the 2000 wave of the Health and Retirement Study (HRS), a nationally representative longitudinal health interview survey of adults aged 50 and older. SETTING: Population-based cohort of community-dwelling older adults, subset of an ongoing longitudinal health interview survey. PARTICIPANTS: Adults aged 65 and older who were respondents in the 2000 wave of the HRS (n=10,640, representing approximately 33.6 million Medicare beneficiaries). MEASUREMENTS: Three clinical criteria sets were examined that included different combinations of medical conditions, cognitive impairment, and activity of daily living/instrumental activity of daily living (ADL/IADL) dependency. RESULTS: A small portion of Medicare beneficiaries (1.3-5.8%) would be eligible for care coordination, depending on the criteria set chosen. A criteria set recently proposed by Congress (at least four severe complex medical conditions and one ADL or IADL dependency) would apply to 427,000 adults aged 65 and older in the United States. Criteria emphasizing cognitive impairment would serve an older population. CONCLUSION: Several criteria sets for a Medicare care-coordination benefit are clinically reasonable, but different definitions of eligibility would serve different numbers and population groups of older adults.     

Association Between Cognitive Function and Social Support with Glycemic Control in Adults with Diabetes Mellitus

OBJECTIVES: To examine whether cognitive impairment in adults with diabetes mellitus is associated with worse glycemic control and to assess whether level of social support for diabetes mellitus care modifies this relationship.
DESIGN: Cross-sectional analysis.
SETTING: The 2003 Health and Retirement Study (HRS) Mail Survey on Diabetes and the 2004 wave of the HRS.
PARTICIPANTS: Adults aged 50 and older with diabetes mellitus in the United States (N=1,097, mean age 69.2).
MEASUREMENTS: Glycosylated hemoglobin (HbA1c) level; cognitive function, measured with the 35-point HRS cognitive scale (HRS-cog); sociodemographic variables; duration of diabetes mellitus; depressed mood; social support for diabetes mellitus care; self-reported knowledge of diabetes mellitus; treatments for diabetes mellitus; components of the Total Illness Burden Index related to diabetes mellitus; and functional limitations.
RESULTS: In an ordered logistic regression model for the three ordinal levels of HbA1c (<7.0, 7.0–7.9, ≥8.0 mg/dL), respondents with HRS-cog scores in the lowest quartile had significantly higher HbA1c levels than those in the highest cognitive quartile (adjusted odds ratio=1.80, 95% confidence interval=1.11–2.92). A high level of social support for diabetes mellitus care modified this association; for respondents in the lowest cognitive quartile, those with high levels of support had significantly lower odds of having higher HbA1c than those with low levels of support (1.11 vs 2.87, P =.02).
CONCLUSION: Although cognitive impairment was associated with worse glycemic control, higher levels of social support for diabetes mellitus care ameliorated this negative relationship. Identifying the level of social support available to cognitively impaired adults with diabetes mellitus may help to target interventions for better glycemic control.     

Unhealthy drinking patterns in older adults: prevalence and associated characteristics

OBJECTIVES: To examine the prevalence of unhealthy drinking patterns in community-dwelling older adults and its association with sociodemographic and health characteristics.
DESIGN: Cross-sectional analysis of nationally representative survey data.
SETTING: The data source was the 2003 Access to Care file of the Medicare Current Beneficiary Survey, which represents the continuously enrolled Medicare population.
PARTICIPANTS: Community-dwelling Medicare beneficiaries aged 65 and older (N=12,413).
MEASUREMENTS: The prevalence of unhealthy alcohol use by older adults defined in relation to two parameters of recommended limits: monthly use exceeding 30 drinks per typical month and "heavy episodic" drinking of four or more drinks in any single day during a typical month in the previous year. Sociodemographic and health status variables were also included.
RESULTS: Nine percent of elderly Medicare beneficiaries reported unhealthy drinking, with higher prevalence in men (16%) than women (4%). In logistic regression analyses with the full sample, higher education and income; better health status; male sex; younger age; smoking; being white; and being divorced, separated, or single were associated with higher likelihood of unhealthy drinking. Among drinkers, in addition to sociodemographic variables, self-reported depressive symptoms were positively associated with unhealthy drinking. Among unhealthy drinkers, race and ethnicity variables were associated with likelihood of heavy episodic drinking.
CONCLUSION: Almost one in 10 elderly Medicare beneficiaries report exceeding recommended drinking limits. Several distinct unhealthy drinking patterns were identified and associated with sociodemographic and health characteristics, suggesting the value of additional targeted approaches within the context of universal screening to reduce alcohol misuse by older adults.     

Elderly Patients' Knowledge of Drug Benefit Caps and Communication with Providers About Exceeding Caps

OBJECTIVES: Many elderly persons have drug benefits with coverage gaps, such as in Medicare Part D. Because beneficiaries who have such gaps must pay all drug costs, an accurate knowledge of gap thresholds and communication with providers about exceeding caps is important for elderly persons to manage out-of-pocket drug costs.
DESIGN: Cross-sectional survey.
SETTING: Health plan.
PARTICIPANTS: One thousand three hundred eight health plan members aged 65 and older. The study was a 2002 cross-sectional survey of elderly persons with capped drug benefits in a managed care plan in one state. Participants were sampled so that half reached coverage caps and half did not.
METHODS: Participants reported cap levels, communication with providers about exceeding caps, and decreased medication use due to cost.
RESULTS: Of the 1,308 participants (65.4% response rate), 68.6% did not know their correct cap level. Rates were similar in those who exceeded caps (66.2%), reported difficulty paying for medications (63.9%), or decreased medication use (66%). For participants who exceeded caps, 59.1% did not know beforehand that they were close to exceeding caps and 50.2% did not tell providers afterward. In multivariate analyses accounting for demographics and health, the oldest participants (≥85 vs 65–74) were at greater risk for not knowing cap levels (odds ratio (OR)=2.0, 95% confidence interval (CI)=1.2–3.4) and not telling providers about exceeding caps (OR=2.2, 95% CI=1.1–4.5).
CONCLUSIONS: Elderly patients often did not know correct cap levels and did not tell providers about exceeding caps. Providers, plans, and policymakers should actively assess and improve Medicare beneficiaries' knowledge of Part D coverage gaps.     

Medicare Part D's effect on the under- and overuse of medications: a systematic review

OBJECTIVES: To evaluate the literature regarding the effect of Medicare Part D on the under‐ and overuse of specific medications and corresponding health outcomes. DESIGN: Systematic review. SETTING: Medline search of the peer‐reviewed literature from January 1, 2006, to October 8, 2010. PARTICIPANTS: Medicare beneficiaries who obtained drug insurance from the Part D program. MEASUREMENTS: The review evaluated changes in the use of specific drugs or drug classes after implementation of Part D, as described in original, peer‐reviewed articles. RESULTS: Nineteen articles met inclusion criteria. Part D's implementation was associated with greater use of essential medications such as clopidogrel and statins, especially in beneficiaries who had been previously uninsured, but increases in inappropriate antibiotic use for the treatment of acute respiratory tract infections and increases in claims for the often overused proton pump inhibitor drug class were also observed. In the Part D transition period, dually eligible beneficiaries' drug use remained largely unchanged. When beneficiary cost sharing increased in the coverage gap, use of essential and overused medications declined. CONCLUSION: Increasing drug coverage led to greater use of underused essential medications and inappropriate, or overused, medications under Medicare Part D. Despite efforts to have it do so, the Part D benefit did not sufficiently discriminate between essential and nonessential medication use.     

Prevalence,expenditures, and complications of multiple chronic conditions in the elderly

BACKGROUND: The prevalence, health care expenditures, and hospitalization experiences are important considerations among elderly populations with multiple chronic conditions. METHODS: A cross-sectional analysis was conducted on a nationally random sample of 1 217 103 Medicare fee-for-service beneficiaries aged 65 and older living in the United States and enrolled in both Medicare Part A and Medicare Part B during 1999. Multiple logistic regression was used to analyze the influence of age, sex, and number of types of chronic conditions on the risk of incurring inpatient hospitalizations for ambulatory care sensitive conditions and hospitalizations with preventable complications among aged Medicare beneficiaries. RESULTS: In 1999, 82% of aged Medicare beneficiaries had 1 or more chronic conditions, and 65% had multiple chronic conditions. Inpatient admissions for ambulatory care sensitive conditions and hospitalizations with preventable complications increased with the number of chronic conditions. For example, Medicare beneficiaries with 4 or more chronic conditions were 99 times more likely than a beneficiary without any chronic conditions to have an admission for an ambulatory care sensitive condition (95% confidence interval, 86-113). Per capita Medicare expenditures increased with the number of types of chronic conditions from $211 among beneficiaries without a chronic condition to $13 973 among beneficiaries with 4 or more types of chronic conditions. CONCLUSIONS: The risk of an avoidable inpatient admission or a preventable complication in an inpatient setting increases dramatically with the number of chronic conditions. Better primary care, especially coordination of care, could reduce avoidable hospitalization rates, especially for individuals with multiple chronic conditions.     

Observation Status,Poverty, and High Financial Liability Among Medicare Beneficiaries

Background

Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries.

Minority disparities in disability between Medicare beneficiaries

OBJECTIVES: To examine racial and ethnic disparities in mobility limitation, activities of daily living (ADLs), and instrumental activities of daily living (IADLs) in older adults enrolled in Medicare.
DESIGN: Longitudinal national survey.
PARTICIPANTS: Community-dwelling respondents in the Medicare Current Beneficiaries Survey from 1992 to 2004 (10,180–16,788 respondents per year).
MEASUREMENTS: Disability-related outcomes included mobility limitation, difficulty in six ADLs and six IADLs. Explanatory variables included age, sex, racial or ethnic group, living situation, and income level.
RESULTS: From 1992 to 2004, proportions of Medicare beneficiaries with mobility limitations were stable across racial and ethnic groups, improving slightly for ADLs and IADLs. Blacks reported more limitations in all three disability-related measures. In a longitudinal analysis, the probability of developing mobility limitation was consistently higher for blacks, followed by white Hispanics, white non-Hispanics, and Asians, after adjusting for age, sex, socioeconomic status, and living situation. For ADL and IADL difficulties, the number of reported difficulties increased with age for all ethnic and racial groups. At approximately age 75, Asians and white Hispanics reported difficulties with much higher numbers of ADLs and IADLs than the other groups.
CONCLUSION: Across all ethnic and racial groups, self-reported disability has declined in the past decade, but even after adjusting for age, sex, socioeconomic status, and living situation, racial and ethnic disparities in disability outcomes persist. Race and ethnicity may influence the reporting of disability, potentially affecting measures of prevalence. Further research is needed to understand whether these differences are a result of perceptions related to disablement or true differences in disability between racial and ethnic groups.     

Primary care quality in the Medicare Program: comparing the performance of Medicare health maintenance organizations and traditional fee-for-service medicare

BACKGROUND: Since 1972, Medicare beneficiaries have had the option of enrolling in a Medicare-qualified health maintenance organization (HMO). Little information exists to inform beneficiaries' choices between the traditional fee-for-service (FFS) Medicare program and an HMO. OBJECTIVES: To compare the primary care received by seniors in Medicare HMOs with that of seniors in the traditional FFS Medicare program, and among HMOs, and to examine performance differences associated with HMO model-type and profit status. METHODS: Data were derived from a cross-sectional observational survey of Medicare beneficiaries 65 years or older in the 13 states with mature, substantial Medicare HMO markets. Only beneficiaries continuously enrolled for 12 months or more in traditional FFS Medicare or a qualified Medicare HMO were eligible. Data were obtained using a 5-stage protocol involving mail and telephone (64% response rate). Analyses included respondents who identified a primary physician and had all required data elements (N = 8828). We compared FFS and HMO performance on 11 summary scales measuring 7 defining characteristics of primary care: (1) access, (2) continuity, (3) integration, (4) comprehensiveness, (5) "whole-person" orientation, (6) clinical interaction, and (7) sustained clinician-patient partnership. RESULTS: For 9 of 11 indicators, performance favored traditional FFS Medicare over HMOs (P<.001). Financial access favored HMOs (P<.001). Preventive counseling did not differ by system. Network-model HMOs performed more favorably than staff/group-model HMOs on 9 of 11 indicators (P<.001). Few differences were associated with HMO profit status. CONCLUSIONS: The findings are consistent with previous comparisons of indemnity insurance and network-model and staff/group-model HMOs in elderly and nonelderly populations. The stability of results across time, geography, and populations suggests that the relative strengths and weaknesses of each system are enduring attributes of their care. Medicare enrollees seem to face the perennial cost-quality trade-off: that is, deciding whether the advantages of primary care under traditional FFS Medicare are worth the higher out-of-pocket costs.     

Albumin, Apolipoprotein E-ɛ4 and Cognitive Decline in Community-Dwelling Chinese Older Adults

OBJECTIVES: To examine the association between serum albumin and cognitive impairment and decline in community-living older adults.
DESIGNS: Population-based cohort study, followed up to 2 years; serum albumin, apolipoprotein E (APOE)-ɛ4, and cognitive impairment measured at baseline and cognitive decline (≥2-point drop in Mini-Mental State Examination (MMSE) score). Odds ratios were controlled for age, sex, education, medical comorbidity, hypertension, diabetes mellitus, cardiac disease, stroke, smoking, alcohol drinking, depression, APOE-ɛ4, nutritional status, body mass index, anemia, glomerular filtration rate, and baseline MMSE.
SETTINGS: Local area whole population.
PARTICIPANTS: One thousand six hundred sixty-four Chinese older adults aged 55 and older.
RESULTS: The mean age of the cohort was 66.0±7.3, 65% were women, mean serum albumin was 42.3±3.1 g/L, and mean MMSE score was 27.2±3.2. Lower albumin tertile was associated with greater risk of cognitive impairment in cross-sectional analysis (low, odds ratio (OR)=2.30, 95% confidence interval (CI)=1.31–4.03); medium, OR=1.59, 95% CI=0.88–2.88) versus high ( P for trend=.002); and with cognitive decline in longitudinal analyses: low, OR=1.73, 95% CI=1.18–2.55; medium, OR=1.32, 95% CI=0.89–1.95, vs high ( P for trend=.004). In cognitively unimpaired respondents at baseline (MMSE≥24), similar associations with cognitive decline were observed ( P for trends <.002). APOE-ɛ4 appeared to modify the association, due mainly to low rates of cognitive decline in subjects with the APOE-ɛ4 allele and high albumin.
CONCLUSION: Low albumin was an independent risk marker for cognitive decline in community-living older adults.     

Impact of medicare part D on access to and cost sharing for specialty biologic medications for beneficiaries with rheumatoid arthritis

Objective

Many worry that the use of specialty tiering for biologic disease‐modifying antirheumatic drugs (DMARDs) by Medicare Part D plans imposes a heavy financial burden on beneficiaries with rheumatoid arthritis (RA). To date, no one has examined the cost‐sharing structures for biologic DMARDs in Part D plans or the resulting cost burden for patients.

Methods

We followed 14,929 vulnerable, low‐income patients with RA who were enrolled in the Medicare Replacement Drug Demonstration (MRDD) in 2005. As the MRDD population transitioned into Part D in 2006, we examined correlates of Part D enrollment and compared the cost‐sharing provisions for biologic DMARDs in the Medicare Advantage and stand‐alone plans. We simulated the out‐of‐pocket costs of beneficiaries under 3 cost‐sharing scenarios.

Results

Eighty‐one percent of MRDD beneficiaries with RA enrolled in Part D. Enrollment predictors were female sex (odds ratio [OR] 1.48, 95% confidence interval [95% CI] 1.32–1.67), prior MRDD benefit use (OR 2.29, 95% CI 2.04–2.58), other self‐reported drug coverage (OR 1.53, 95% CI 1.36–1.71), and receiving an MRDD subsidy (OR 2.00, 95% CI 1.74–2.30). Compared with stand‐alone plans, Medicare Advantage plans had lower deductibles, lower premiums, and fewer prior authorization, step therapy, and quantity limit restrictions. However, ～75% of all plans used coinsurance as the preferred form of cost sharing. Out‐of‐pocket costs exceeded $4,000 annually in all cost‐sharing scenarios.

Conclusion

Most MRDD beneficiaries with RA enrolled in Part D. Although plans assume some costs for biologic DMARDs, the majority of costs are shifted to beneficiaries and to Medicare. Such cost shifting may place these medications out of the beneficiary's financial reach and expose Medicare to high financial liability.     

Another look at aggregate changes in severe cognitive impairment: further investigation into the cumulative effects of three survey design issues

OBJECTIVES: This study explored whether previously reported declines in severe cognitive impairment were robust to cumulative effects of potentially confounding survey design issues. METHODS: Using the 1993 Asset and Health Dynamics of the Oldest Old study (n = 7,443) and 1998 Health and Retirement Survey (HRS; n = 7,624) the proportion of persons ages 70 and older with severe cognitive impairment was calculated under various assumptions about item nonresponse, differential loss to follow-up, and the size and composition of the nursing home population. Impairment was measured for self-respondents using a modified version of the Telephone Interview Cognitive Screen; for proxy respondents ratings of memory and judgment were used. Chi-square tests were adjusted to account for complex survey designs. RESULTS: Ignoring loss to follow-up, excluding nursing home residents, and assigning a low score to those refusing subscales yielded a statistically significant decline in severe cognitive impairment from 5.8% in 1993 to 3.8% in 1998, or an average annual decline of 6.9%. When cumulative effects of survey design issues were considered and design effects incorporated into statistical tests, statistically significant declines persisted, albeit at a reduced average annual rate, ranging from 2.5% to 6.9% per year. DISCUSSION: Previously reported improvements in severe cognitive impairment appear to be robust to a variety of specifications. Replication with future waves of the HRS and other data is warranted.     

Preferences for patient cost sharing among medicare beneficiaries after HMO plan withdrawals

OBJECTIVE: To assess Medicare beneficiaries' willingness to cost share in order to minimize disruptions in coverage from HMO plan withdrawals. DESIGN: Cross-sectional survey of Medicare beneficiaries from February 1999 to March 1999. SETTING: Ten U.S. counties with the highest HMO plan withdrawal rates. PATIENTS/PARTICIPANTS: Seven hundred one Medicare beneficiaries for response rate of 69%. MEASUREMENTS AND MAIN RESULTS: Percentage of respondents willing to accept more out-of-pocket costs in order to continue their Medicare HMO coverage. Most respondents (67%) were willing to pay more out-of-pocket costs so that their HMO could have continued Medicare coverage. Those who were white (P =.03), had higher incomes (P =.01), and returned to traditional fee-for-service Medicare (P =.004) were more likely than other respondents to accept increased patient cost sharing. Most beneficiaries preferred Medicare policies requiring HMOs to sign longer-term Health Care Financing Administration (HCFA) contracts (72%) and to offer coverage to beneficiaries regardless of where they lived in a given state (87%). However, respondents' preferences for such policy options were not associated with the amount of cost sharing that respondents were willing to accept. CONCLUSIONS: Most Medicare beneficiaries are willing to accept increased patient cost sharing in order to reduce disruptions in their HMO coverage. Policies intended to reduce HMO plan withdrawals, such as requiring health plans to sign longer-term HCFA contracts, are supported by many Medicare beneficiaries, but these policy preferences were not related to willingness to cost share. In light of an apparent willingness to pay more out-of-pocket medical costs, Medicare beneficiaries in general may accept increased cost sharing in order to retain their HMO coverage.     

Survival of Community-Dwelling Older People: The Effect of Cognitive Impairment and Social Engagement

OBJECTIVES: To examine the association and interaction between cognitive impairment and social support and mortality.
DESIGN: Prospective cohort study.
SETTING: Fifty-three family practices in the United Kingdom.
PARTICIPANTS: Community-dwelling people (aged ≥75) participating in the Medical Research Council Trial of the Assessment and Management of Older People in the Community (10,720 individual subjects analyzed).
MEASUREMENTS: Cognition was measured using the Mini-Mental State Examination. Social engagement was assessed using categorical data on marital status, living situation, availability of assistance, availability of a confidant, and frequency of social contact. The primary outcome was all-cause mortality.
RESULTS: The prevalence of cognitive impairment was 13.0% (mild) and 2.0% (moderate to severe). In Cox survival models (fully adjusted for physical health, lifestyle, daily function, and depression), there was a consistent association between greater cognitive impairment and mortality risk (mild cognitive impairment, hazard ratio (HR)=1.31, 95% confidence interval (CI)=1.21–1.40; moderate to severe cognitive impairment, HR=1.64, 95% CI=1.41–1.93. Mortality risk was greater in the medium (HR=1.09, 95% CI=1.02–1.16) and low social engagement groups (HR=1.17, 95% CI=1.05–1.29) than in those with the highest level of social engagement. Lower social engagement did not increase mortality risk in those who were more cognitively impaired.
CONCLUSION: Cognitive impairment and social support are independent risk factors for mortality. Interventions that promote early identification and management of cognitive impairment and enhance social support for older people may decrease mortality and produce public health benefits.