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ABSTRACT BACKGROUND The Medicare Accountable Care Organization (ACO) programs encourage integration of providers into large groups and reward provider groups for improving quality, but not explicitly for reducing health care disparities. Larger group size and better overall quality may or may not be associated with smaller disparities. OBJECTIVE To examine differences in patient characteristics between provider groups sufficiently large to participate in ACO programs and smaller groups; the association between group size and racial disparities in quality; and the association between quality and disparities among larger groups. DESIGN AND PARTICIPANTS Using 2009 Medicare claims for 3.1 million beneficiaries with cardiovascular disease or diabetes and linked data on provider groups, we compared racial differences in quality by provider group size, adjusting for patient characteristics. Among larger groups, we used multilevel models to estimate correlations between group performance on quality measures for white beneficiaries and black–white disparities within groups. MAIN MEASURES Four process measures of quality, hospitalization for ambulatory care-sensitive conditions (ACSCs) related to cardiovascular disease or diabetes, and hospitalization for any ACSC. KEY RESULTS Beneficiaries served by larger groups were more likely to be white and live in areas with less poverty and more education. Larger group size was associated with smaller disparities in low-density lipoprotein (LDL) cholesterol testing and retinal exams, but not in other process measures or hospitalization for ACSCs. Among larger groups, better quality for white beneficiaries in one measure (hospitalization for ACSCs related to cardiovascular disease or diabetes) was correlated with smaller racial disparities ( r  = 0.28; P  = 0.02), but quality was not correlated with disparities in other measures. CONCLUSIONS Larger provider group size and better performance on quality measures were not consistently associated with smaller racial disparities in care for Medicare beneficiaries with cardiovascular disease or diabetes. ACO incentives rewarding better quality for minority groups and payment arrangements supporting ACO development in disadvantaged communities may be required for ACOs to promote greater equity in care.

Populations with intensive health care needs and high care costs may be attracted to insurance plans that have high quality ratings, but patients may be likely to disenroll from a plan if their care needs are not met. We assessed the association between publicly reported Medicare Advantage plan star ratings and voluntary disenrollment of incident dialysis patients in the following year over the period 2007-13. We found that Medicare Advantage (MA) plans with lower star ratings had significantly higher rates of disenrollment by incident dialysis patients in the following year. Compared to MA plans with 4.0 or more stars, adjusted disenrollment rates were 3.9 percentage points higher for plans with 3.5 stars, 5.0 percentage points higher for those with 3.0 stars, and 12.1 percentage points higher for those with 2.5 or fewer stars. These findings suggest that low plan quality may lead to increased expenditures, as this high-cost population generally must shift from Medicare Advantage to traditional Medicare upon disenrollment.

ABSTRACT Background A key goal of resident duty hour reform by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 was to improve patient outcomes. Objective To assess whether the reform led to a change in readmission rates. Design Observational study using multiple time series analysis with hospital discharge data from July 1, 2000 to June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of readmission in more versus less teaching-intensive hospitals before and after duty hour reform. Participants All unique Medicare patients (n = 8,282,802) admitted to acute-care nonfederal hospitals with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke (combined medical group), or a DRG classification of general, orthopedic, or vascular surgery (combined surgical group). Main measures Primary outcome was 30-day all-cause readmission. Secondary outcomes were (1) readmission or death within 30 days of discharge, and (2) readmission, death during the index admission, or death within 30 days of discharge. Key Results For the combined medical group, there was no evidence of a change in readmission rates in more versus less teaching-intensive hospitals [OR = 0.99 (95% CI 0.94, 1.03) in post-reform year 1 and OR = 0.99 (95% CI 0.95, 1.04) in post-reform year 2]. There was also no evidence of relative changes in readmission rates for the combined surgical group: OR = 1.03 (95% CI 0.98, 1.08) for post-reform year 1 and OR = 1.02 (95% CI 0.98, 1.07) for post-reform year 2. Findings for the secondary outcomes combining readmission and death were similar. Conclusions Among Medicare beneficiaries, there were no changes in hospital readmission rates associated with resident duty hour reform.

Background: Having knowledge of out-of-pocket cost and access to services constitutes an advanced level of health literacy within the Medicare population. The cost and services offered within Medicare change annually, yet less than 30% of beneficiaries compare their coverage options (between traditional or fee-for-service Medicare and Medicare Advantage)—an important application of health care knowledge. Failure to compare can expose the financing of the Medicare program and the beneficiary to financial risk if a beneficiary has not elected a coverage option that best suits their individual needs. The factors driving beneficiaries to compare are poorly understood. Objective: Our objective was to examine the association between different levels of information reviewed (exposure) and comparing coverage (outcome). Methods: This pooled cross-sectional study included 28,924 Medicare beneficiaries using data from the 2019−2021 Medicare Current Beneficiary Survey. Multivariable probit regressions were performed using Stata version 18. Key Results: Reviewing both cost and service information increased the probability of comparing coverage by 159% (44.4 percentage points). Exposure to service-only information increased the probability of comparing coverage by 97% (27.2 percentage points) and 68% (19.1 percentage points) for cost-only information, relative to those who reviewed neither cost nor service information. Forty-seven percent of beneficiaries did not review cost nor service information, followed by 39% who reviewed both, 8% cost-only, and 6% service-only. The probability of comparing coverage increased by 8.2% (2.3 percentage points) for beneficiaries who reviewed both cost and service information and those who had an education greater than high school. Conclusion: A targeted outreach and education campaign geared toward increasing the type of information reviewed could result in an increase in comparing Medicare coverage options. Plain Language Summary: We examined factors associated with beneficiaries comparing their option to elect either traditional Medicare or Medicare Advantage. In this study, review of both out-of-pocket cost and access to services increased the probability of comparing coverage options. These findings suggest policymakers and the Centers for Medicare & Medicaid Services should focus on crafting targeted campaigns to increase the level of health literacy for Medicare beneficiaries.

Background Availability of nursing home care has declined and national efforts have been initiated to improve the quality of nursing home care in the U.S. Yet, data are limited on whether there are geographic variations in declines of availability and quality of nursing home care, and whether variations persist over time. We sought to assess geographic variation in availability and quality of nursing home care. Methods Retrospective study using Medicaid/Medicare-certified nursing home data from the Centers for Medicare & Medicaid Services, 1996–2016. Outcomes were 1) availability of all nursing home care (1996–2016), measured by the number of Medicaid/Medicare-certified beds for a given county per 100,000 population aged ≥65 years, regardless of nursing home star rating; 2) availability of 5-star nursing home care, measured by the number of Medicaid/Medicare-certified beds provided by 5-star nursing homes; and 3) utilization of nursing home beds, defined as the rate of occupied Medicaid/Medicare-certified beds among the total Medicaid/Medicare-certified beds. Results From 1999 to 2016, availability of all nursing home care declined from 4882 (standard deviation: 931) to 3480 (912) beds, per 100,000 population aged ≥65 years. Persistent geographic variation in availability of nursing home care was observed; the correlation coefficient of county-specific availabilities from 1996 to 2016 was 0.78 (95% CI 0.77–0.79). From 2011 to 2016, availability of 5-star nursing home beds increased from 658 (303) to 895 (661) per 100,000 population aged ≥65 years. The correlation coefficient for county-specific availabilities from 2011 to 2016 was 0.54 (95% CI 0.51–0.56). Availability and quality of nursing home care were not highly correlated. In 2016, the correlation coefficient for county-specific availabilities between all nursing home and 5-star nursing home beds was 0.33 (95% CI 0.30–0.36). From 1996 to 2016, the utilization of certified beds declined from 78.5 to 72.2%. This decline was consistent across all census divisions, but most pronounced in the Mountain division and less in the South-Atlantic division. Conclusion We observed persistent geographic variations in availability and quality of nursing home care. Availability of all nursing home care declined but availability of 5-star nursing home care increased. Availability and quality of nursing home care were not highly correlated.

ABSTRACT BACKGROUND/OBJECTIVES The impact of co-morbid illnesses on adherence to guideline recommendations in chronic illness is of growing concern. We tested a framework [Piette and Kerr, Diabetes Care. 29(3):725–31, 2006 ] of provider adherence to guidelines in the presence of co-morbid conditions, which suggests that the effect of co-morbid conditions depends on treatment recommendations for the co-morbid conditions and how symptomatic they are. METHODS We conducted an exploratory analysis to assess the framework using chart audit data for 1,240 post-acute myocardial infarction (AMI) Medicare beneficiaries in Alabama. We assessed level of guideline-adherent post-AMI care from chart-based quality indicators and constructed scores reflecting how much care for the co-morbid condition was similar to post-AMI care (concordance) and how symptomatic the co-morbid condition is, based on expert opinion. RESULTS Patients had a mean age of 74 years, mean co-morbidities of 2, and 61% were white. Both concordance and symptomatic scores were positively associated with guideline compliance, with correlations of 0.32 and 0.14, respectively (p < 0.001 for each). We found positive correlations between highly concordant co-morbid conditions and post-AMI quality scores and negative correlations between highly symptomatic conditions and post-AMI quality scores; both findings support the framework. However, the framework performed less well for conditions that were not highly concordant or highly symptomatic, and the magnitudes of the associations were not large. CONCLUSIONS The framework was related to the association of co-morbid conditions with adherence by providers to guideline-recommended treatment for post-AMI patients. The framework holds promise for evaluating and possibly predicting guideline adherence.

Background Specialty societies in the United States identified low-value tests and procedures that contribute to waste and poor health care quality via implementation of the American Board of Internal Medicine Foundation’s Choosing Wisely initiative. Objective To develop claims-based algorithms, to use them to estimate the prevalence of select Choosing Wisely services and to examine the demographic, health and health care system correlates of low-value care at a regional level. Design Using Medicare data from 2006 to 2011, we created claims-based algorithms to measure the prevalence of 11 Choosing Wisely-identified low-value services and examined geographic variation across hospital referral regions (HRRs). We created a composite low-value care score for each HRR and used linear regression to identify regional characteristics associated with more intense use of low-value services. Patients Fee-for-service Medicare beneficiaries over age 65. Main Measures Prevalence of selected Choosing Wisely low-value services. Key Results The national average annual prevalence of the selected Choosing Wisely low-value services ranged from 1.2% (upper urinary tract imaging in men with benign prostatic hyperplasia) to 46.5% (preoperative cardiac testing for low-risk, non-cardiac procedures). Prevalence across HRRs varied significantly. Regional characteristics associated with higher use of low-value services included greater overall per capita spending, a higher specialist to primary care ratio and higher proportion of minority beneficiaries. Conclusions Identifying and measuring low-value health services is a prerequisite for improving quality and eliminating waste. Our findings suggest that the delivery of wasteful and potentially harmful services may be a fruitful area for further research and policy intervention for HRRs with higher per-capita spending. These findings should inform action by physicians, health systems, policymakers, payers and consumer educators to improve the value of health care by targeting services and areas with greater use of potentially inappropriate care.

ABSTRACT BACKGROUND Pay-for-performance programs could worsen health disparities if providers who care for disadvantaged patients face systematic barriers to providing high-quality care. Risk adjustment that includes sociodemographic factors could mitigate the financial incentive to avoid disadvantaged patients. OBJECTIVE To test for associations between quality of care and the composition of a physician’s patient panel. DESIGN Repeat cross-sectional analysis PARTICIPANTS Nationally representative sample of US primary care physicians responding to a panel telephone survey in 2000–2001 and 2004–2005 MAIN MEASURES Quality of primary care as measured by provision of eight recommended preventive services (diabetic monitoring [hemoglobin A1c testing, eye examinations, cholesterol testing and urine protein analysis], cancer screening [screening colonoscopy/sigmoidoscopy and mammography], and vaccinations against influenza and pneumococcus) documented in Medicare claims data and the association between quality and the sociodemographic composition of physicians’ patient panels. KEY RESULTS Across eight quality measures, physicians’ quality of care was not consistently associated with the composition of their patient panel either in a single year or between time periods. For example, a substantial number (seven) of the eighteen significant associations seen between sociodemographic characteristics and the delivery of preventive services in the first time period were no longer seen in the second time period. Among sociodemographic characteristics, panel Medicaid eligibility was most consistently associated with differences in the delivery of preventive services between time points; among preventive services, the delivery of influenza vaccine was most likely to demonstrate disparities in both time points. CONCLUSIONS In a Medicare pay-for-performance program, a better understanding of the effect of effect of patient panel composition on physicians’ quality of care may be necessary before implementing routine statistical adjustment, since the association of quality and sociodemographic composition is small and inconsistent. In addition, we observed improvements between time periods among physicians with varying panel composition.

We examined Medicare national coverage determinations for medical interventions to determine whether or not they have become more restrictive over time. National coverage determinations address whether particular big-ticket medical items, services, treatment procedures, and technologies can be paid for under Medicare. We found that after we adjusted for the strength of evidence and other factors known to influence the determinations of the Centers for Medicare and Medicaid Services (CMS), the evidentiary bar for coverage has risen. More recent coverage determinations (from mid-March 2008 through August 2012) were twenty times less likely to be positive than earlier coverage determinations (from February 1999 through January 2002). Furthermore, coverage during the study period was increasingly and positively associated both with the degree of consistency of favorable findings in the CMS reviewed clinical evidence and with recommendations made in clinical guidelines. Coverage policy is an important payer tool for promoting the appropriate use of medical interventions, but CMS's rising evidence standards also raise questions about patients' access to new technologies and about hurdles for the pharmaceutical and device industries as they attempt to bring innovations to the market.

The Centers for Medicare and Medicaid Services launched the 4-year Comprehensive Primary Care Initiative to support transformations in primary care delivery. After 2 years, practices have changed care delivery but have not yet reduced costs or substantially improved quality. Fee-for-service payments give providers the incentive to favor volume over value in the delivery of health care and can produce fragmented care that often lacks coordination, is not patient-centered, and is not proactive in population health management. 1 – 3 Although efforts to improve the delivery of care through changes in primary care (e.g., the use of patient-centered medical homes [PCMHs]) have expanded rapidly in recent years, 4 , 5 early evidence of their effect on the quality and cost of health care is mixed. 6 In October 2012, the Centers for Medicare and Medicaid Services (CMS), in collaboration with 39 private and public payers, . . .