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Objective: Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower-quality plans, measured by a 5-star quality rating system. We examine whether differential access to high-rated plans was associated with this differential enrollment in high-rated plans by race and ethnicity among MA enrollees. Data Sources: The Medicare Master Beneficiary Summary File and MA Landscape File for 2016. Study Design: We first examined county-level MA plan offerings by race and ethnicity. We then examined the association of racial and ethnic differences in enrollment by star rating by controlling for the following different sets of covariates: (1) individual-level characteristics only, and (2) individual-level characteristics and county-level MA plan offerings. Data Collection/Extraction Methods: Not applicable Principal Findings: Racial and ethnic minority enrollees had, on average, more MA plans available in their counties of residence compared to White enrollees (16.1, 20.8, 20.2, vs. 15.1 for Black, Asian/Pacific Islander, Hispanic, and White enrollees), but had fewer number of high-rated plans (4-star plans or higher) and/or more number of low-rated plans (3.5-star plans or lower). While racial and ethnic minority enrollees had lower enrollment in 4-4.5 star plans than White enrollees, this difference substantially decreased after accounting for county-level MA plan offerings (-9.1 to -0.5 percentage points for Black enrollees, -15.9 to -5.0 percentage points for Asian/Pacific Islander enrollees, and -12.7 to 0.6 percentage points for Hispanic enrollees). Results for Black enrollees were notable as the racial difference reversed when we limited the analysis to those who live in counties that offer a 5-star plan. After accounting for county-level MA plan offerings, Black enrollees had 3.2 percentage points higher enrollment in 5-star plans than White enrollees. Conclusions: Differences in enrollment in high-rated MA plans by race and ethnicity may be explained by limited access and not by individual characteristics or enrollment decisions. KEYWORDS access to care, health disparity, high-quality plan, Medicare Advantage, race, traditional Medicare, 1 | INTRODUCTION Enrollment in Medicare Advantage (MA), the segment of the Medicare program run by private insurance companies receiving capitated payments from the government, has been increasing over the [...]

Objective: To compare the outcomes of postacute care between home health (HH) and skilled nursing facilities (SNFs) following hospitalization among Medicare beneficiaries with a diagnosis of dementia. Data Sources: 100% MedPAR data, Minimum Data Set, and Outcome and Assessment Information Set assessment data from January 1, 2015 to December 31, 2016. Study Design: Retrospective cohort analysis using an instrumental variable design to compare outcomes (30-day readmission and mortality, 100-day mortality) of HH versus SNF following acute hospitalization. We used the differential distance between patients' home and the closest HH agency and SNF to instrument for nonrandom allocation of patients. Data Collection/Extraction Methods: We identified hospital discharges followed by SNF and HH stays for Medicare fee-for-service beneficiaries with dementia. We excluded beneficiaries younger than age 65, admitted to the hospital from a nursing home, or enrolled in hospice. We identified dementia using validated diagnostic codes with a 3-year look-back. Principal Findings: Our sample included 977,946 beneficiaries with a diagnosis of dementia; 297,732 (30.4%) received HH, while 680,214 (69.6%) went to SNF. Overall, 16.8% were readmitted to the hospital and 6.1% died within 30 days, while 15.4% died within 100 days of hospital discharge. In the instrumental variable analysis, there were no differences in any outcome between the two postacute care settings. Conclusions: Medicare beneficiaries with a diagnosis of dementia receiving postacute care in HH or SNF experienced similar rates of readmission and mortality across settings. This finding raises important questions about current postacute care referral patterns, given 7 in 10 patients with a diagnosis of dementia in our sample were discharged to SNF. KEYWORDS dementia, health policy, home health, postacute care, skilled nursing facility What is known on this topic * The prevalence of dementia and of postacute care use is rising in the United States. * No studies have compared outcomes of different postacute care settings for patients with dementia even though they vary significantly on cost and services provided. What this study adds * Medicare beneficiaries with a diagnosis of dementia receiving HH care had similar rates of hospital readmission and mortality to those receiving care in a SNF. * This finding raises questions about the appropriateness of postacute care referral patterns in beneficiaries without a diagnosis of dementia (where 50% of postacute care use is in SNF) and in beneficiaries with a diagnosis of dementia (where 70% of postacute care use in this sample is in SNF)., 1 | INTRODUCTION Currently, more than 40% of Medicare beneficiaries receive postacute care in a skilled nursing facility (SNF) or from a home health (HH) agency after hospital discharge, for [...]

Objective: To investigate the impact of Medicare's skilled nursing facility (SNF) co-payment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. Data Sources and Study Setting: Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee-for-service beneficiaries. Study Design: We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment. Principal Findings: From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1-day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4-1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8-1.0), lower total Medicare payment for the 90-day episode after hospital discharge ($396; 95% CI 361-431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149-210, P < .001), offsetting the lower payment for the shorter index SNF stay. Conclusions: Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes. KEYWORDS Medicare payment, postacute care, skilled nursing facility, 1 | INTRODUCTION Use of skilled nursing facilities (SNFs) for postacute care is common and costly. Institutional postacute care incurs enormous costs to Medicare (1) and is a large contributor [...]

Objective: To measure the association between clinician specialization in nursing home (NH) practice and outcomes of patients who received postacute care in skilled nursing facilities (SNFs). Data Sources: Medicare claims and NH assessments for 2 118 941 hospital discharges to 14 526 SNFs in January 2012-October 2014 and MD-PPAS data for 52 379 clinicians. Study Design: Generalist physicians and advanced practitioners with > 90 percent of claims for NH-based care were considered NH specialists. The primary clinician during each SNF stay was determined based on plurality of claims during that stay. We estimated the effect of being treated by a NH specialist on 30-day rehospitalizations, successful discharge to community, and 60-day episode-of-care Medicare payments (Parts A and B). All models included patient demographics, clinical variables, and SNF fixed effects. Principal Findings: Nursing home specialists' patients were less likely to be rehospitalized (14.71 percent vs 16.23 percent; adjusted difference, -1.51 percent, 95% CI -1.78 to -1.24), more likely to be successfully discharged to community (56.33 percent vs 55.49 percent; adjusted difference, 0.84 percent, 95% CI 0.54 to 1.14), but had higher 60-day Medicare payments ($31 628 vs $31 292; adjusted difference, $335; 95% CI $242 to $429). Conclusions: Clinicians who specialize in NH practice may achieve better postacute care outcomes at slightly higher costs. KEYWORDS care quality, hospitalization, nursing home, postacute care, specialization, 1 | INTRODUCTION One in five Medicare beneficiaries discharged from the hospital receives postacute care in nursing homes (NH), or skilled nursing facilities (SNFs), which provide nearly half (47 percent) [...]

Objective. To test for differences in patient outcomes when hospital and post-acute care (PAC) providers participate in accountable care organizations (ACOs).Data/Setting. Using Medicare claims, we examined changes in readmission, Medicare spending, and length of stay among patients admitted to ACO-participating hospitals and PAC providers.Design. We compared changes in outcomes among patients discharged from ACO-participating hospitals/PACs before and after participation to changes among patients discharged from non-participating hospitals/PACs over the same time period.Results. Patients discharged from an ACO-participating hospitals and skilled nursing facilities (SNF) had lower readmission rates (--1.7 percentage points, p-value = .03) than before ACO participation and non-participants; and lower per-discharge Medicare spending (--$940, p-value = .001), and length of stay (--3.1 days, p-value Conclusions. Hospital and SNF participation in an ACO was associated with lower readmission rates, Medicare spending on SNF, and SNF length of stay. These results lend support to the ACO payment model.Key Words. Post-acute care, hospitals, accountable care organizations, Medicare, By creating incentives to manage the health of their members across health care settings, accountable care organizations (ACOs) have the potential to induce providers to work together to improve coordination [...]

In recent years, there has been substantial policy interest in the relationship between acute and postacute care providers and patients' transitions between them. This focus was precipitated by growing recognition [...]