TY - JOUR T1 - Drivers of Community-Entry Home Health Care Utilization Among Older Adults. JF - Journal of the American Medical Directors Association Y1 - Forthcoming A1 - Burgdorf, Julia G A1 - Ritchie, Christine S A1 - Reckrey, Jennifer M A1 - Liu, Bian A1 - McDonough, Catherine A1 - Ornstein, Katherine A KW - community health care KW - home care KW - home care agencies KW - home health care services KW - Medicare AB -

OBJECTIVES: A growing proportion of Medicare home health (HH) patients are "community-entry," meaning referred to HH without a preceding hospitalization. We sought to identify factors that predict community-entry HH use among older adults to provide foundational information regarding care needs and circumstances that may prompt community-entry HH referral.

DESIGN: Nationally representative cohort study.

SETTING AND PARTICIPANTS: Health and Retirement Study (HRS) respondents who were aged ≥65 years, community-living, and enrolled in Medicare between 2012 and 2018 (n = 11,425 unique individuals providing 27,026 two-year observation periods).

METHODS: HRS data were linked with standardized HH patient assessments. Community-entry HH utilization was defined as incurring one or more HH episode with no preceding hospitalization or institutional post-acute care stay (determined via assessment item indicating institutional care within 14 days of HH admission) within 2 years of HRS interview. Weighted, multivariable logistic regression was used to model community-entry HH use as a function of individual, social support, and community characteristics.

RESULTS: The overall rate of community-entry HH utilization across observation periods was 13.4%. Older adults had higher odds of community-entry HH use if they were Medicaid enrolled [adjusted odds ratio (aOR) = 1.49, P = .001], had fair or poor overall health (aOR = 1.48, P < .001), 3+ activities of daily living limitations (aOR = 1.47, P = .007), and had fallen in the past 2 years (aOR = 1.43, P < .001). Compared with those receiving no caregiver help, individuals were more likely to use community-entry HH if they received family or unpaid help only (aOR = 1.81, P < .001), both family and paid help (aOR = 2.79, P < .001), or paid help only (aOR: 3.46, P < .001).

CONCLUSIONS AND IMPLICATIONS: Findings indicate that community-entry HH serves a population with long-term care needs and coexisting clinical complexity, making this an important setting to provide skilled care and prevent avoidable health care utilization. Results highlight the need for ongoing monitoring of community-entry HH accessibility as this service is a key component of home-based care for a high-need subpopulation.

ER - TY - JOUR T1 - End-of-life care discussions with healthcare providers and dying experiences: A latent class analysis using the health and retirement study. JF - Archives of Gerontology and Geriatrics Y1 - Forthcoming A1 - Lou, Yifan KW - Advance care planning KW - End-of-life health service utilization KW - Health care preferences KW - Health communication KW - Medicare AB -

BACKGROUND: The impact of provider-patient end-of-life care conversations on the dying experience as a multi-dimensional concept among non-White population is understudied. The study examines whether such discussions are effective at improving end-of-life experiences among U.S. older adults with diverse backgrounds.

METHODS: The analytic sample featured 9,733 older adults who died between 2002 and 2019 in the Health and Retirement Study. Latent class analysis was used with sixteen end-of-life indicators, including service utilization of seven aggressive and supportive care, symptom management, and quality of care. Multinomial logistic regression was conducted to estimate the effects of provider-patient end-of-life discussions on the predicted membership.

RESULTS: Three types of end-of-life experiences were identified. People in "minimum service user with good death" (44.54 %) were least likely to use any type of medical care, either aggressive or comforting, and had best end-of-life symptom management and quality of care. Intensive care users (20.70 %) are characterized by very high use of aggressive treatments and low use of supportive care. "Extensive service user with uncomfortable death" (34.76 %) had high likelihoods of using both aggressive and comforting care and had the worst dying experience. Older adults who discussed their end-of-life wishes with providers were 49 % and 51 % more likely to be an intensive care user and extensive service user with uncomfortable death, respectively, rather than a minimum service user with good death.

CONCLUSION: Discussing end-of-life care wishes with providers is associated with worse end-of-life experiences. Efforts are needed to facilitate early initiation and effectiveness of the provider-patient end-of-life care conversation.

VL - 119 ER - TY - JOUR T1 - Public spending on acute and long-term care for Alzheimer's disease and related dementias. JF - Alzheimer's & Dementia Y1 - Forthcoming A1 - Norma B Coe A1 - White, Lindsay A1 - Oney, Melissa A1 - Basu, Anirban A1 - Larson, Eric B KW - longitudinal costs KW - Medicaid KW - Medicare KW - Spending AB -

INTRODUCTION: We estimate the spending attributable to Alzheimer's disease and related dementias (ADRD) to the United States government for the first 5 years post-diagnosis.

METHODS: Using data from the Health and Retirement Study matched to Medicare and Medicaid claims, we identify a retrospective cohort of adults with a claims-based ADRD diagnosis along with matched controls.

RESULTS: The costs attributable to ADRD are $15,632 for traditional Medicare and $8833 for Medicaid per dementia case over the first 5 years after diagnosis. Seventy percent of Medicare costs occur in the first 2 years; Medicaid costs are concentrated among the longer-lived beneficiaries who are more likely to need long-term care and become Medicaid eligible.

DISCUSSION: Because the distribution of the incremental costs varies over time and between insurance programs, when interventions occur and the effect on the disease course will have implications for how much and which program reaps the benefits.

ER - TY - JOUR T1 - Using Medicare claims in identifying Alzheimer's disease and related dementias. JF - Alzheimer's & Dementia Y1 - Forthcoming A1 - Jain, Siddharth A1 - Rosenbaum, Paul R A1 - Reiter, Joseph G A1 - Geoffrey J Hoffman A1 - Small, Dylan S A1 - Ha, Jinkyung A1 - Hill, Alexander S A1 - Wolk, David A A1 - Timothy G. Gaulton A1 - Mark D Neuman A1 - Roderic G Eckenhoff A1 - Fleisher, Lee A A1 - Jeffrey H Silber KW - administrative data KW - Alzheimer's disease KW - cognitive impairment KW - Dementia KW - Medicare AB -

INTRODUCTION: This study develops a measure of Alzheimer's disease and related dementias (ADRD) using Medicare claims.

METHODS: Validation resembles the approach of the American Psychological Association, including (1) content validity, (2) construct validity, and (3) predictive validity.

RESULTS: We found that four items-a Medicare claim recording ADRD 1 year ago, 2 years ago, 3 years ago, and a total stay of 6 months in a nursing home-exhibit a pattern of association consistent with a single underlying ADRD construct, and presence of any two of these four items predict a direct measure of cognitive function and also future claims for ADRD.

DISCUSSION: Our four items are internally consistent with the measurement of a single quantity. The presence of any two items do a better job than a single claim when predicting both a direct measure of cognitive function and future ADRD claims.

ER - TY - JOUR T1 - The Prevalence of Cognitive Impairment Among Medicare Beneficiaries Who Use Outpatient Physical Therapy. JF - Physical Therapy Y1 - 2024 A1 - Miller, Matthew J A1 - Cenzer, Irena A1 - Barnes, Deborah E A1 - Kelley, Amy S A1 - Covinsky, Kenneth E KW - Aged KW - Cognitive Dysfunction KW - Cross-Sectional Studies KW - Dementia KW - Female KW - Humans KW - Male KW - Medicare KW - Mobility Limitation KW - Outpatients KW - pain KW - Physical Therapy Modalities KW - Prevalence KW - United States AB -

OBJECTIVE: The objective of this study was to estimate the prevalence of cognitive impairment (including cognitive impairment no dementia [CIND] and dementia) among Medicare fee-for-service beneficiaries who used outpatient physical therapy and to estimate the prevalence of cognitive impairment by measures that are relevant to rehabilitation practice.

METHODS: This cross-sectional analysis included 730 Medicare fee-for-service beneficiaries in the 2016 wave of the Health and Retirement Study with claims for outpatient physical therapy. Cognitive status, our primary variable of interest, was categorized as normal, CIND, or dementia using a validated approach, and population prevalence of cognitive impairment (CIND and dementia) was estimated by sociodemographic variables and Charlson comorbidity index score. Age-, gender- (man/woman), race-/ethnicity-adjusted population prevalence of CIND and dementia were also calculated for walking difficulty severity, presence of significant pain, self-reported fall history, moderate-vigorous physical activity (MVPA) ≤1×/week, and sleep disturbance frequency using multinomial logistic regression.

RESULTS: Among Medicare beneficiaries with outpatient physical therapist claims, the prevalence of any cognitive impairment was 20.3% (CIND:15.2%, dementia:5.1%). Cognitive impairment was more prevalent among those who were older, Black, had lower education attainment, or higher Charlson comorbidity index scores. The adjusted population prevalence of cognitive impairment among those who reported difficulty walking across the room was 29.8%, difficulty walking 1 block was 25.9%, difficulty walking several blocks was 20.8%, and no difficulty walking was 16.3%. Additionally, prevalence of cognitive impairment among those with MVPA ≤1×/week was 27.1% and MVPA >1×/week was 14.1%. Cognitive impairment prevalence did not vary by significant pain, self-reported fall history, or sleep disturbance.

CONCLUSION: One in 5 older adults who use outpatient physical therapist services have cognitive impairment. Furthermore, cognitive impairment is more common in older physical therapist patients who report worse physical function and less physical activity.

IMPACT: Physical therapists should consider cognitive screening for vulnerable older adults to inform tailoring of clinical practice toward a patient's ability to remember and process rehabilitation recommendations.

VL - 104 IS - 1 ER - TY - JOUR T1 - Variation in Home Healthcare Use by Dementia Status Among a National Cohort of Older Adults. JF - Journals of Gerontology. Series A Biological Sciences and Medical Sciences Y1 - 2024 A1 - Burgdorf, Julia G A1 - Ornstein, Katherine A A1 - Liu, Bian A1 - Leff, Bruce A1 - Brody, Abraham A A1 - McDonough, Catherine A1 - Ritchie, Christine S KW - Aged KW - Delivery of Health Care KW - Dementia KW - Home Care Services KW - Hospitalization KW - Humans KW - Medicare KW - United States AB -

BACKGROUND: Medicare-funded home healthcare (HHC) delivers skilled nursing, therapy, and related services through visits to the patient's home. Nearly one-third (31%) of HHC patients have diagnosed dementia, but little is currently known regarding how HHC utilization and care delivery differ for persons living with dementia (PLwD).

METHODS: We drew on linked 2012-2018 Health and Retirement Study and Medicare claims for a national cohort of 1 940 community-living older adults. We described differences in HHC admission, length of stay, and referral source by patient dementia status and used weighted, multivariable logistic and negative binomial models to estimate the relationship between dementia and HHC visit type and intensity while adjusting for sociodemographic characteristics, health and functional status, and geographic/community factors.

RESULTS: PLwD had twice the odds of using HHC during a 2-year observation period, compared to those without dementia (odds ratio [OR]: 2.03; p < .001). They were more likely to be referred to HHC without a preceding hospitalization (49.4% vs 32.1%; p < .001) and incurred a greater number of HHC episodes (1.4 vs 1.0; p < .001) and a longer median HHC length of stay (55.8 days vs 40.0 days; p < .001). Among post-acute HHC patients, PLwD had twice the odds of receiving social work services (unadjusted odds ratio [aOR]: 2.15; p = .008) and 3 times the odds of receiving speech-language pathology services (aOR: 2.92; p = .002).

CONCLUSIONS: Findings highlight HHC's importance as a care setting for community-living PLwD and indicate the need to identify care delivery patterns associated with positive outcomes for PLwD and design tailored HHC clinical pathways for this patient subpopulation.

VL - 79 IS - 3 ER - TY - JOUR T1 - Alzheimer's disease medication use and adherence patterns by race and ethnicity. JF - Alzheimer's & Dementia Y1 - 2023 A1 - Olchanski, Natalia A1 - Daly, Allan T A1 - Zhu, Yingying A1 - Breslau, Rachel A1 - Cohen, Joshua T A1 - Neumann, Peter J A1 - Jessica Faul A1 - Fillit, Howard M A1 - Freund, Karen M A1 - Lin, Pei-Jung KW - acetylcholinesterase inhibitors KW - Alzheimer's disease KW - anti-dementia medication KW - Cognitive health KW - Dementia KW - Health Disparities KW - Medicaid KW - Medicare AB -

BACKGROUND: We examined racial and ethnic differences in medication use for a representative US population of patients with Alzheimer's disease and related dementias (ADRD).

METHODS: We examined cholinesterase inhibitors and memantine initiation, non-adherence, and discontinuation by race and ethnicity, using data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims.

RESULTS: Among newly diagnosed ADRD patients (n = 1299), 26% filled an ADRD prescription ≤90 days and 36% ≤365 days after diagnosis. Among individuals initiating ADRD-targeted treatment (n = 1343), 44% were non-adherent and 24% discontinued the medication during the year after treatment initiation. Non-Hispanic Blacks were more likely than Whites to not adhere to ADRD medication therapy (odds ratio: 1.50 [95% confidence interval: 1.07-2.09]).

DISCUSSION: Initiation of ADRD-targeted medications did not vary by ethnoracial group, but non-Hispanic Blacks had lower adherence than Whites. ADRD medication non-adherence and discontinuation were substantial and may relate to cost and access to care.

HIGHLIGHTS: Initiation of anti-dementia medications among newly diagnosed Alzheimer's disease and related dementias (ADRD) patients was low in all ethnoracial groups. ADRD medication non-adherence and discontinuation were substantial and may relate to cost and access to care. Compared to Whites, Blacks and Hispanics had lower use, poorer treatment adherence, and more frequent discontinuation of ADRD medication, but when controlling for disease severity and socioeconomic factors, racial disparities diminish. Our findings demonstrate the importance of adjusting for socioeconomic characteristics and disease severity when studying medication use and adherence in ADRD patients.

ER - TY - JOUR T1 - Association Between Loneliness and Postoperative Mortality Among Medicare Beneficiaries. JF - JAMA Surgery Y1 - 2023 A1 - Shen, Mary R A1 - Suwanabol, Pasithorn A A1 - Howard, Ryan A A1 - Hu, Hsou Mei A1 - Levine, Deborah A A1 - Kenneth M. Langa A1 - Waljee, Jennifer F KW - Loneliness KW - Medicare VL - 158 IS - 2 ER - TY - JOUR T1 - Breast and prostate cancer screening rates by cognitive status in US older adults. JF - J Am Geriatr Soc Y1 - 2023 A1 - Schoenborn, Nancy L A1 - Cidav, Tom A1 - Boyd, Cynthia M A1 - Pollack, Craig E A1 - Sekhon, Vishaldeep Kaur A1 - Yasar, Sevil KW - Aged KW - Breast Neoplasms KW - Cognition KW - Dementia KW - Early Detection of Cancer KW - Humans KW - Male KW - Mass Screening KW - Medicare KW - Prostate-Specific Antigen KW - Prostatic Neoplasms KW - United States AB -

INTRODUCTION: For most older adults with dementia, the short-term harms and burdens of routine cancer screening likely outweigh the delayed benefits. We aimed to provide a more updated assessment of the extent that US older adults with dementia receive breast and prostate cancer screenings.

METHODS: Using the Health and Retirement Study (HRS) Wave 12 (2014-2015) linked to Medicare, we examine rates of breast and prostate cancer screenings in adults 65+ years by cognitive status. We used claims data to identify eligibility for screening and receipt of screening. We used a validated method using HRS data to define cognitive status.

RESULTS: The analytic sample included 2439 women in the breast cancer screening cohort and 1846 men in the prostate cancer screening cohort. Average ages were 76.8 years for women and 75.6 years for men, with 9.0% and 7.6% with dementia in each cohort, respectively. Among women with dementia, 12.3% were screened for breast cancer. When stratified by age, 10.6% of those 75+ and have dementia were screened for breast cancer. When stratified by predicted life expectancy, 10.4% of those with predicted life expectancy of <10 years and have dementia were screened for breast cancer. Among men with dementia, 33.9% were screened for prostate cancer. When stratified by age, 30.9% of those 75+ and have dementia were screened for prostate cancer. When stratified by predicted life expectancy, 34.4% of those with predicted life expectancy of <10 years and have dementia were screened for prostate cancer. Using multivariable logistic regression, dementia was associated with lower odds of receiving breast cancer screening (OR 0.36, 95% CI 0.23-0.57) and prostate cancer screening (OR 0.58, 95% CI 0.36-0.96).

DISCUSSION: Our results suggest potential over-screening in older adults with dementia. Better supporting dementia patients and caregivers to make informed cancer screening decisions is critical.

VL - 71 IS - 5 ER - TY - JOUR T1 - Can markers of disease severity improve the predictive power of claims-based multimorbidity indices? JF - Journal of the American Geriatrics Society Y1 - 2023 A1 - Rizzo, Anael A1 - Jing, Bocheng A1 - Boscardin, W John A1 - Shah, Sachin J A1 - Steinman, Michael A KW - Hospitalization KW - Medicare KW - multimorbidity KW - Patient Acuity AB -

BACKGROUND: Claims-based measures of multimorbidity, which evaluate the presence of a defined list of diseases, are limited in their ability to predict future outcomes. We evaluated whether claims-based markers of disease severity could improve assessments of multimorbid burden.

METHODS: We developed 7 dichotomous markers of disease severity which could be applied to a range of diseases using claims data. These markers were based on the number of disease-associated outpatient visits, emergency department visits, and hospitalizations made by an individual over a defined interval; whether an individual with a given disease had outpatient visits to a specialist who typically treats that disease; and ICD-9 codes which connote more versus less advanced or symptomatic manifestations of a disease. Using Medicare claims linked with Health and Retirement Study data, we tested whether including these markers improved ability to predict ADL decline, IADL decline, hospitalization, and death compared to equivalent models which only included the presence or absence of diseases.

RESULTS: Of 5012 subjects, median age was 76 years and 58% were female. For a majority of diseases tested individually, adding each of the 7 severity markers yielded minimal increase in c-statistic (≤0.002) for outcomes of ADL decline and mortality compared to models considering only the presence versus absence of disease. Gains in predictive power were more substantial for a small number of individual diseases. Inclusion of the most promising marker in multi-disease multimorbidity indices yielded minimal gains in c-statistics (<0.001-0.007) for predicting ADL decline, IADL decline, hospitalization, and death compared to indices without these markers.

CONCLUSIONS: Claims-based markers of disease severity did not contribute meaningfully to the ability of multimorbidity indices to predict ADL decline, mortality, and other important outcomes.

VL - 71 IS - 3 ER - TY - JOUR T1 - The Construction of a Multidomain Risk Model of Alzheimer's Disease and Related Dementias. JF - Journal of Alzheimer's Disease : JAD Y1 - 2023 A1 - Akushevich, Igor A1 - Yashkin, Arseniy A1 - Ukraintseva, Svetlana A1 - Yashin, Anatoliy I A1 - Kravchenko, Julia KW - Alzheimer disease KW - Comorbidity KW - Dementia KW - Humans KW - Hypertension KW - Medicare KW - United States AB -

BACKGROUND: Alzheimer's disease (AD) and related dementia (ADRD) risk is affected by multiple dependent risk factors; however, there is no consensus about their relative impact in the development of these disorders.

OBJECTIVE: To rank the effects of potentially dependent risk factors and identify an optimal parsimonious set of measures for predicting AD/ADRD risk from a larger pool of potentially correlated predictors.

METHODS: We used diagnosis record, survey, and genetic data from the Health and Retirement Study to assess the relative predictive strength of AD/ADRD risk factors spanning several domains: comorbidities, demographics/socioeconomics, health-related behavior, genetics, and environmental exposure. A modified stepwise-AIC-best-subset blanket algorithm was then used to select an optimal set of predictors.

RESULTS: The final predictive model was reduced to 10 features for AD and 19 for ADRD; concordance statistics were about 0.85 for one-year and 0.70 for ten-year follow-up. Depression, arterial hypertension, traumatic brain injury, cerebrovascular diseases, and the APOE4 proxy SNP rs769449 had the strongest individual associations with AD/ADRD risk. AD/ADRD risk-related co-morbidities provide predictive power on par with key genetic vulnerabilities.

CONCLUSION: Results confirm the consensus that circulatory diseases are the main comorbidities associated with AD/ADRD risk and show that clinical diagnosis records outperform comparable self-reported measures in predicting AD/ADRD risk. Model construction algorithms combined with modern data allows researchers to conserve power (especially in the study of disparities where disadvantaged groups are often grossly underrepresented) while accounting for a high proportion of AD/ADRD-risk-related population heterogeneity stemming from multiple domains.

VL - 96 IS - 2 ER - TY - JOUR T1 - The devil's in the details: Variation in estimates of late-life activity limitations across national cohort studies. JF - J of the American Geriatric Society Y1 - 2023 A1 - Ankuda, Claire K A1 - Covinsky, Kenneth A1 - Freedman, Vicki A A1 - Kenneth M. Langa A1 - Aldridge, Melissa D A1 - Yee, Cynthia A1 - Kelley, Amy S KW - Activities of Daily Living KW - Cohort Studies KW - Disabled Persons KW - Medicare KW - Self Care AB -

BACKGROUND: Assessing activity limitations is central to aging research. However, assessments of activity limitations vary, and this may have implications for the populations identified. We aim to compare measures of activities of daily living (ADLs) and their resulting prevalence and mortality across three nationally-representative cohort studies: the National Health and Aging Trends Study (NHATS), the Health and Retirement Survey (HRS), and the Medicare Current Beneficiary Survey (MCBS).

METHODS: We compared the phrasing and context of questions around help and difficulty with six self-care activities: eating, bathing, toileting, dressing, walking inside, and transferring. We then compared the prevalence and 1-year mortality for difficulty and help with eating and dressing.

RESULTS: NHATS, HRS, and MCBS varied widely in phrasing and framing of questions around activity limitations, impacting the proportion of the population found to experience difficulty or receive help. For example, in NHATS 12.4% [95% confidence interval (CI) 11.5%-13.4%] of the cohort received help with dressing, while in HRS this figure was 6.4% [95% CI 5.7%-7.2%] and MCBS 5.3% [95% CI 4.7%-5.8%]. When combined with variation in sampling frame and survey approach of each survey, such differences resulted in large variation in estimates of the older population of older adults with ADL disability.

CONCLUSIONS: In order to take late-life activity limitations seriously, we must clearly define the measures we use. Further, researchers and clinicians seeking to understand the experience of older adults with activity limitations should be careful to interpret findings in light of the framing of the question asked.

VL - 71 IS - 3 ER - TY - THES T1 - End-of-Life Care Discussions with Doctors: Evidence from the United States and China T2 - Social Work Y1 - 2023 A1 - Lou, Yifan KW - discrimination in medical care KW - health planning KW - Hospice Care KW - Medicare KW - minority older people-care KW - social service KW - Terminal Care AB - Chapter 1 presents the backgrounds and research questions of the dissertation project. Although everyone hopes to die with dignity, a “good death” is often privileged. Inequality in end-of-life care in the United States is striking; older minorities are 3 times more likely to receive intrusive care and experience hospital readmission and less likely to use hospice care and die at home. With the hope to address disparities in end-of-life outcomes, as part of the Affordable Care Act, Medicare expanded its benefit and started to reimburse end-of-life care planning services from 2016. This dissertation examines the roles of health insurance policy and its advocated intervention in ensuring person-centered dying experiences in the United States and the public readiness for establishing a similar end-of-life care policy in China. The second chapter examines whether physician–patient advance care planning (ACP) discussions, the “intervention” embedded in the policy, is effective at prompting end-of-life care planning behaviors and improving end-of-life experiences. I also studied the heterogenous effects by race and ethnicity. I used exit data about 7,282 deceased Medicare-eligible respondents from the Health and Retirement Study (HRS) from 2012 to 2020, a nationally representative biennial survey of U.S. older adults. I conducted latent class analysis to identify different end-of-life experiences and used multinomial logistic regression models to study the relationship between having ACP discussions with doctors and different end-of-life experiences in full and stratified samples by race and ethnicity. Then I used path analyses to test whether completing legal documentation initiated by ACP services explains the effectiveness of the intervention. The results show three types of end-of-life experiences among White, Black, and Hispanic older adults; significant effects of end-of-life care discussions with doctors on uncomfortable dying experiences and extensive use of invasive treatments in the older White population; and the partial mediating role of completion of legal health care documents on the relationship between ACP discussions and end-of-life outcomes. This study identified the limited effectiveness of physician–patient ACP discussions among minority older adults and emphasizes the importance of quality, content (e.g., to cover legal documentation during the conversation), and cultural appropriateness of ACP consultations led by doctors. The third chapter examines the heterogenous intent-to-treat effect of the Medicare policy on older adults’ motivation to plan for care by exploiting policy intervention as a natural experiment. Taking advantage of the longitudinal nature of the HRS, I used core data with 47,982 observations nested in 15,647 individuals across 9 years (2012–2020). I used two quasi-experimental models—interrupted time series analysis and difference-in-difference—to study the care-planning outcomes before and after the policy implementation between older adults eligible or not eligible for Medicare. I studied the heterogenous effects in stratified samples by race and ethnicity, immigration background, and socioeconomic status proxied by education and wealth. I used coarsened exact matching to address the potential bias of the comparison group not being the ideal counterfactual control unit. I found that in the total population, the Medicare policy was associated with a significant increase in the proportion of older adults who completed a living will and designated a durable power of attorney for health care, but not having an ACP conversation. Furthermore, although there were immediate positive policy effects, the increases in ACP outcomes driven by the ACA Medicare benefit expansion were not sustained. Finally, I found no evidence that the ACA Medicare benefit expansion was effective in improving the rates of ACP among Black, Hispanic, Asian, Native American, or non-U.S.-born older adults. I also identified heterogeneous policy effects by socioeconomic status. I discuss promising recommendations for health care policy and practice to improve the participation rate of end-of-life care planning. Chapter 4 explores the feasibility of encouraging physicians to discuss end-of-life care wishes with older patients in China. Knowledge of a medical diagnosis is critical for end-of-life decision making. However, a patient’s right to know their diagnosis is neither guaranteed nor protected by law in China. Doctors typically inform family members of the patient’s illness diagnosis and prognosis and let them decide whether to disclose this information to the patient. This study examined middle-aged and older Chinese adults’ preferences for disclosing their and significant others’ diagnoses and whether sociodemographic, economic, and cultural factors were associated with these preferences. The research team surveyed 571 adults aged 50 or older in Shanghai from 2021 to 2022. The outcome measures are preferences for diagnosis disclosures, including whether and to whom diagnoses should be disclosed. I characterized preference types using latent class analysis and estimated multinomial logistic regression to identify the covariates associated with each preference type. Three latent classes were identified. The transparent group (34%) believed patients, whether self or a significant other, should be informed of their diagnoses. The contradictory group (50%) held conflicting attitudes; they preferred to know their diagnosis but preferred that significant others not be informed of their diagnoses. The avoidant group (16%) preferred not to know their diagnosis or to disclose significant others’ diagnoses to them. Familism attitudes were positively associated with holding contradictory views. Experiences with hospitalization and medical decision-making for family members were associated with holding transparent views. I discuss the importance of illness disclosure for honoring patients’ autonomous decision-making. JF - Social Work PB - Columbia University CY - New York City VL - Ph.D ER - TY - JOUR T1 - Examining Medicaid Participation and Medicaid Entry Among Senior Medicare Beneficiaries With Linked Administrative and Survey Data. JF - Medical Care Research and Review Y1 - 2023 A1 - Garrow, Renee A1 - Mellor, Jennifer M A1 - McInerney, Melissa A1 - Sabik, Lindsay M KW - dual eligibles KW - Medicaid KW - Medicare KW - program enrollment AB -

Because Medicare beneficiaries can qualify for Medicaid through several pathways, duals who newly enroll in Medicaid may have experienced various financial and/or health changes that impact their Medicaid eligibility. Alternatively, new enrollment could reflect changes in awareness of the program among those previously eligible. Using monthly enrollment data linked to Health and Retirement Study survey data, we examine financial and health changes that occur around the time new Medicaid participants enter the program, and we compare those with changes experienced by both those continuously enrolled in Medicaid and those not enrolled. We find that Medicaid entry is often timed with a marked increase in out-of-pocket medical expenses, a substantial decrease in assets for some, and increases in activities of daily living (ADL) limitations. We also observe financial changes among persons continuously enrolled in Medicaid. Our results inform discussions about Medicaid eligibility policies and potential gaps in the protection that Medicaid offers from financial risk.

ER - TY - JOUR T1 - Expected and diagnosed rates of mild cognitive impairment and dementia in the U.S. Medicare population: observational analysis. JF - Alzheimers Res Ther Y1 - 2023 A1 - Mattke, Soeren A1 - Jun, Hankyung A1 - Chen, Emily A1 - Liu, Ying A1 - Becker, Andrew A1 - Wallick, Christopher KW - cognitive impairment KW - Medicare KW - United States AB -

BACKGROUND: With the emergence of disease-modifying Alzheimer's treatments, timely detection of early-stage disease is more important than ever, as the treatment will not be indicated for later stages. Contemporary population-level data for detection rates of mild cognitive impairment (MCI), the stage at which treatment would ideally start, are lacking, and detection rates for dementia are only available for subsets of the Medicare population. We sought to compare documented diagnosis rates of MCI and dementia in the full Medicare population with expected rates based on a predictive model.

METHODS: We performed an observational analysis of Medicare beneficiaries aged 65 and older with a near-continuous enrollment over a 3-year observation window or until death using 100% of the Medicare fee-for-service or Medicare Advantage Plans beneficiaries from 2015 to 2019. Actual diagnoses for MCI and dementia were derived from ICD-10 codes documented in those data. We used the 2000-2016 data of the Health and Retirement Study to develop a prediction model for expected diagnoses for the included population. The ratios between actually diagnosed cases of MCI and dementia over number of cases expected, the observed over expected ratio, reflects the detection rate.

RESULTS: Although detection rates for MCI cases increased from 2015 to 2019 (0.062 to 0.079), the results mean that 7.4 of 8 million (92%) expected MCI cases remained undiagnosed. The detection rate for MCI was 0.039 and 0.048 in Black and Hispanic beneficiaries, respectively, compared with 0.098 in non-Hispanic White beneficiaries. Individuals dually eligible for Medicare and Medicaid had lower estimated detection rates than their Medicare-only counterparts for MCI (0.056 vs 0.085). Dementia was diagnosed more frequently than expected (1.086 to 1.104) from 2015 to 2019, mostly in non-Hispanic White beneficiaries (1.367) compared with 0.696 in Black beneficiaries and 0.758 in Hispanic beneficiaries.

CONCLUSIONS: These results highlight the need to increase the overall detection rates of MCI and of dementia particularly in socioeconomically disadvantaged groups.

VL - 15 IS - 1 ER - TY - JOUR T1 - Life-Sustaining Treatments Among Medicare Beneficiaries with and without Dementia at the End of Life. JF - Journal of Alzheimer's Disease : JAD Y1 - 2023 A1 - Zhu, Yingying A1 - Olchanski, Natalia A1 - Cohen, Joshua T A1 - Freund, Karen M A1 - Jessica Faul A1 - Fillit, Howard M A1 - Neumann, Peter J A1 - Lin, Pei-Jung KW - Aged KW - Alzheimer disease KW - Cohort Studies KW - Death KW - Humans KW - Medicare KW - Terminal Care KW - United States AB -

BACKGROUND: Older adults with dementia including Alzheimer's disease may have difficulty communicating their treatment preferences and thus may receive intensive end-of-life (EOL) care that confers limited benefits.

OBJECTIVE: This study compared the use of life-sustaining interventions during the last 90 days of life among Medicare beneficiaries with and without dementia.

METHODS: This cohort study utilized population-based national survey data from the 2000-2016 Health and Retirement Study linked with Medicare and Medicaid claims. Our sample included Medicare fee-for-service beneficiaries aged 65 years or older deceased between 2000 and 2016. The main outcome was receipt of any life-sustaining interventions during the last 90 days of life, including mechanical ventilation, tracheostomy, tube feeding, and cardiopulmonary resuscitation. We used logistic regression, stratified by nursing home use, to examine dementia status (no dementia, non-advanced dementia, advanced dementia) and patient characteristics associated with receiving those interventions.

RESULTS: Community dwellers with dementia were more likely than those without dementia to receive life-sustaining treatments in their last 90 days of life (advanced dementia: OR = 1.83 [1.42-2.35]; non-advanced dementia: OR = 1.16 [1.01-1.32]). Advance care planning was associated with lower odds of receiving life-sustaining treatments in the community (OR = 0.84 [0.74-0.96]) and in nursing homes (OR = 0.68 [0.53-0.86]). More beneficiaries with advanced dementia received interventions discordant with their EOL treatment preferences.

CONCLUSIONS: Community dwellers with advanced dementia were more likely to receive life-sustaining treatments at the end of life and such treatments may be discordant with their EOL wishes. Enhancing advance care planning and patient-physician communication may improve EOL care quality for persons with dementia.

VL - 96 IS - 3 ER - TY - THES T1 - Medicaid and the Life Course: An Intersectional Mixed-Methods Approach T2 - ProQuest Dissertations and Theses Y1 - 2023 A1 - Petry,Sarah KW - 0573:Public health KW - 0626:Sociology KW - 0630:Public policy KW - Gender marginalization KW - Health Insurance KW - Medicaid policy KW - Medicare KW - Public Health KW - Public Policy KW - socioeconomic status KW - Sociology AB - Health insurance coverage is associated with better access to health care and better health outcomes at every age. The United States does not provide universal health insurance, and most people pay for private insurance that is linked to their job. Individuals whose jobs do not provide insurance have three choices: to remain uninsured, to buy their own insurance, or, in some cases, apply for public health insurance. Select populations in the US may be eligible for public health insurance coverage through Medicare and Medicaid. Medicare provides essentially universal insurance coverage for adults over 65, and, although enrollment is required, there is no application to determine eligibility. Alternately, Medicaid is a means-tested program with a stringent application process and recertification requirements, and take-up rates vary greatly across the US. In some states, individuals who do not have insurance through their employer can apply for and enroll in Medicaid. Individuals with Medicare coverage can also apply for Medicaid. Individuals who are “dually eligible” for Medicare and Medicaid, represent a uniquely vulnerable population due to their age, income, health, and life course exposures to marginalization, poverty, and other risk factors.Medicaid provides an essential health safety net for people in the United States living in poverty, particularly for individuals with high health care needs and costs. Many adults over 65 will need Medicaid to cover health and long-term care costs, yet the process by which older adults gain access to Medicaid is complex and burdensome. Chapter 1 includes the results of a qualitative study of Medicaid enrollment among residents of a skilled nursing facility (SNF). In interviews with caregivers and staff at the Department of Social Services (DSS) in a large, urban county in North Carolina, I find that family members are often applying their aging relatives, and that these applicants have difficulty navigating the Medicaid application process. In addition, I find that prior exposure to institutional care settings facilitates knowledge about Medicaid eligibility and enrollment criteria. Finally, all respondents commented on the costs associated with SNF care. In particular, respondents with higher incomes noted the long process of becoming eligible, while lower income respondents noted the inevitability of running out of funds. This qualitative study illustrates the distinct ways that older adults, marginalized due to their health and socioeconomic status, engage with social welfare programs in the US.Building on the results from Chapter 1, in Chapter 2 I employ an intersectional, life course approach to assess predictors of Medicaid enrollment in later life. In Chapter 1 I hypothesize that, for institutionalized individuals, having living kin facilitates Medicaid enrollment. In addition, I hypothesize that individuals who have experienced health events requiring a skilled nursing facility (SNF) or other institutional care stay, as well as individuals who have low incomes are more likely to enroll in Medicaid as older adults. Using data from 10 waves of the Health and Retirement Survey I test each hypothesis, accounting for other dimensions of social and health disparities. Alternate to my expectations, individuals without living kin are more likely to enroll in Medicaid than those with living family members. Results from discrete-time logit models confirm the second hypothesis, that individuals who have had a short-term SNF stay are more likely to enroll in Medicaid over a two-year period. In addition, as expected from both interviews and Medicaid policy, income is the single greatest predictor of enrollment in late life. Enrollment odds, though, are distinctly racialized and gendered: Black and Hispanic individuals are more likely to enroll than whites, women are at a greater risk than men, and women of color are at the highest risk. In addition, having a higher income is less protective for marginalized racial and ethnic groups than for white populations.In the third chapter, I examine late life health as an outcome of structural, state-level variations in Medicaid policy. Although every US state is required to provide some form of Medicaid coverage to “Aged, Blind, and Disabled” adults, each state establishes distinct requirements and benefits. In this study I use 10 waves of restricted data from the Health and Retirement Survey (HRS) to examine late life consequences of state-level Medicaid generosity. Using multistate life tables, this study demonstrates that Medicaid generosity is associated with more years dually covered by Medicare and Medicaid. In addition, I demonstrate that racial and gender marginalization, low income, and specific late life health risks contribute to inequitable health and mortality outcomes in late life. JF - ProQuest Dissertations and Theses SN - 9798379569433 UR - https://proxy.lib.umich.edu/login?url=https://www.proquest.com/dissertations-theses/medicaid-life-course-intersectional-mixed-methods/docview/2820001588/se-2 ER - TY - JOUR T1 - Out-of-Pocket Health Care Spending at Older Ages: Do Caregiving Arrangements Matter? JF - J Appl Gerontol Y1 - 2023 A1 - Friedman, Esther M A1 - Beach, Scott R A1 - Schulz, Richard KW - Aged KW - Delivery of Health Care KW - Health Expenditures KW - Humans KW - Medicare KW - Middle Aged KW - United States AB -

Identifying the correlates of out-of-pocket (OOP) health care spending is an important step for ensuring the financial security of older adults. Whether or not someone has a family member providing assistance is one such factor that could be associated with OOP spending. If family caregivers facilitate better health, health care spending could be reduced. On the other hand, costs would be higher if family members facilitate more (or more costly) care for loved ones. This paper explores the relationship between caregiving arrangements and OOP spending using data from 5045 individuals in the 2000-2016 Health and Retirement Study with Medicare coverage and caregiving needs. We do not find a relationship between family caregiving and OOP health care costs, overall. However, among those with Medicare HMO insurance, having a family caregiver is associated with more spending than having no helper. This is mainly due to differences in spending on prescription medications.

VL - 42 IS - 5 ER - TY - JOUR T1 - Racial and Ethnic Disparities in Health Care Use and Access Associated With Loss of Medicaid Supplemental Insurance Eligibility Above the Federal Poverty Level. JF - JAMA Intern Med Y1 - 2023 A1 - Roberts, Eric T A1 - Kwon, Youngmin A1 - Hames, Alexandra G A1 - McWilliams, J Michael A1 - Ayanian, John Z A1 - Tipirneni, Renuka KW - Aged KW - Cross-Sectional Studies KW - Female KW - Healthcare Disparities KW - Humans KW - Male KW - Medicaid KW - Medicare KW - Middle Aged KW - Poverty KW - United States AB -

IMPORTANCE: Medicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program's income eligibility threshold (100% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries' ability to afford care.

OBJECTIVE: To examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0% to 200% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022.

MAIN OUTCOME MEASURES: Patient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data.

RESULTS: This cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1% of beneficiaries were women, 14.8% were non-Hispanic Black, 13.6% were Hispanic, and 71.6% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95% CI, 2.0-9.4), lower outpatient use (-6.3 services per person-year; 95% CI, -10.4 to -2.2), and fewer medication fills (-6.9 fills per person-year; 95% CI, -11.4 to -2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: -6.2 services per person-year; 95% CI, -11.7 to -0.6; P = .03) and medication fills (disparity: -7.2 fills per person-year; 95% CI, -13.4 to -1.0; P = .02) among Black and Hispanic vs White beneficiaries.

CONCLUSIONS AND RELEVANCE: This cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.

VL - 183 IS - 6 ER - TY - JOUR T1 - Understanding Alzheimer's disease in the context of aging: Findings from applications of stochastic process models to the Health and Retirement Study. JF - Mech Ageing Dev Y1 - 2023 A1 - Arbeev, Konstantin G A1 - Bagley, Olivia A1 - Yashkin, Arseniy P A1 - Duan, Hongzhe A1 - Akushevich, Igor A1 - Ukraintseva, Svetlana V A1 - Yashin, Anatoliy I KW - Aged KW - Aging KW - Alzheimer disease KW - Apolipoproteins E KW - Humans KW - Medicare KW - Retirement KW - United States AB -

There is growing literature on applications of biodemographic models, including stochastic process models (SPM), to studying regularities of age dynamics of biological variables in relation to aging and disease development. Alzheimer's disease (AD) is especially good candidate for SPM applications because age is a major risk factor for this heterogeneous complex trait. However, such applications are largely lacking. This paper starts filling this gap and applies SPM to data on onset of AD and longitudinal trajectories of body mass index (BMI) constructed from the Health and Retirement Study surveys and Medicare-linked data. We found that APOE e4 carriers are less robust to deviations of trajectories of BMI from the optimal levels compared to non-carriers. We also observed age-related decline in adaptive response (resilience) related to deviations of BMI from optimal levels as well as APOE- and age-dependence in other components related to variability of BMI around the mean allostatic values and accumulation of allostatic load. SPM applications thus allow revealing novel connections between age, genetic factors and longitudinal trajectories of risk factors in the context of AD and aging creating new opportunities for understanding AD development, forecasting trends in AD incidence and prevalence in populations, and studying disparities in those.

VL - 211 ER - TY - JOUR T1 - Comparison of catastrophic out-of-pocket medical expenditure among older adults in the United States and South Korea: what affects the apparent difference? JF - BMC Health Services Research Y1 - 2022 A1 - Kim, Narae A1 - Jacobson, Mireille KW - Health Expenditures KW - Humans KW - KLoSA KW - Medicare KW - Poverty AB -

BACKGROUND: Medical spending rises sharply with age. Even with universal health insurance, older adults may be at risk of catastrophic out-of-pocket medical spending. We aimed to compare catastrophic out-of-pocket medical spending among adults ages 65 and older in the United States, where seniors have near-universal coverage through Medicare, versus South Korea, where all residents have national health insurance.

METHODS: We used the 2016 Health and Retirement Study and the Korean Longitudinal Study of Aging. The study population were adults ages 65 and over in the US (n = 9,909) and South Korea (n = 4,450; N = 14,359). The primary outcome of interest was older adults' exposure to catastrophic out-of-pocket medical expenditure, defined as out-of-pocket medical spending over the past two years that exceeded 50% of annual household income. To examine the factors affecting catastrophic out-of-pocket medical spending of older adults in both countries, we performed logistic regression analyses. To compare the contribution of demographic factors versus health system-level factors to catastrophic out-of-pocket medical spending, we performed a Blinder-Oaxaca decomposition.

RESULTS: The proportion of respondents with catastrophic out-of-pocket medical expenditure was 5.8% and 3.0% in the US and South Korea, respectively. A Blinder-Oaxaca decomposition showed that the difference in the rate of catastrophic out-of-pocket medical expenditure spending between the two countries was attributable largely to unobservable system-level factors, rather than observed differences in the sociodemographic characteristics.

CONCLUSIONS: Exposure to catastrophic out-of-pocket medical spending is considerably higher in the US than South Korea. Most of the difference can be attributed to unobserved health system-level factors.

VL - 22 IS - 1 ER - TY - JOUR T1 - Decreasing rates of cost-related medication non-adherence by age advancement among American generational cohorts 2004-2014: a longitudinal study. JF - BMJ Open Y1 - 2022 A1 - Zhang, James A1 - Bhaumik, Deepon A1 - Meltzer, David KW - Activities of Daily Living KW - Drug Costs KW - Medicare KW - Medication Adherence AB -

OBJECTIVES: The access barrier to medication has been a persistent and elusive challenge in the US healthcare system and around the globe. Cost-related medication non-adherence (CRN) is an important measure of medication non-adherence behaviours that aim to avoid costs. Longitudinal study of CRN behaviours for the ageing population is rare.

DESIGN: Longitudinal study using the Health and Retirement Study to evaluate self-reported CRN biennially.

SETTING: General population of older Americans.

PARTICIPANTS: Three cohorts of Americans aged between 50 and 54 (baby boomers), 65-69 (the silent generation) and 80 or above (the greatest generation) in 2004 who were followed to 2014.

INTERVENTION: Observational with no intervention.

PRIMARY AND SECONDARY OUTCOME MEASURES: Longitudinal CRN rates for three generational cohorts from 2004 to 2014. Population-averaged effects of a broad set of variables including sociodemographics, income, insurance status, limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and comorbid conditions on CRN were derived using generalised estimating equation by taking into account repeated measurements of CRN over time for the three cohorts, respectively.

RESULTS: The three cohorts of baby boomer, the silent generation and the greatest generation with 1925, 2839 and 2666 respondents represented 12.3 million, 8.2 million and 7.7 million people in 2004, respectively. Increasing age was associated with decreasing likelihood of reporting CRN in all three generational cohorts (p<0.05), controlling for demographics, income, insurance status, functional status and comorbid conditions. All three generational cohorts had a higher prevalence of diabetes, cancer, heart conditions, stroke, a higher percentage of respondents with Medicare-Medicaid dual eligibility and lower percentage with private insurance in 2014 compared with 2004 (p<0.05).

CONCLUSION: The paradox of decreasing CRN rates, independent of disease burden, income and insurance status, suggests populations' CRN behaviours change as Americans age, bearing implications to social policy.

VL - 12 IS - 5 ER - TY - ICOMM T1 - Dementia diagnosis can also make a big difference in health care costs Y1 - 2022 A1 - Henderson, Emily KW - dementia diagnosis KW - Health Care Costs KW - Medicare PB - News Medical Net UR - https://www.news-medical.net/news/20220531/Dementia-diagnosis-can-also-make-a-big-difference-in-health-care-costs.aspx ER - TY - JOUR T1 - End-of-life burdensome interventions among Medicare fee-for-service beneficiaries with no dementia, non-advanced dementia, and advanced dementia JF - Alzheimer's & Dementia Y1 - 2022 A1 - Zhu, Yingying A1 - Olchanski, Natalia A1 - Freund, Karen M A1 - Jessica Faul A1 - Fillit, Howard M A1 - Breslau, Rachel M A1 - Cohen, Joshua T A1 - Neumann, Peter J A1 - Lin, Pei-Jung KW - Alzheimer KW - Dementia KW - End-of-life planning KW - Medicare AB - Abstract Background Older adults with dementia have difficulties communicating their treatment preferences and experience end-of-life burdensome interventions with discomfort and limited benefits. This study compared utilization of burdensome interventions during the last 90 days of life among Medicare fee-for-service (FFS) beneficiaries with no dementia, non-advanced dementia, and advanced dementia. Method This study utilized data from 2000-2016 Health and Retirement Study (HRS) linked with Medicare and Medicaid claims, and HRS Exit Interviews. We quantified rates of imaging tests and life-sustaining treatments during the last 90 days of life among those with no dementia, non-advanced dementia, and advanced dementia. Life-sustaining treatments include tube feeding, intensive care unit care, cardiopulmonary resuscitation, and invasive mechanical ventilation. Among patients with a claims-based diagnosis of dementia, we classified them as having advanced dementia if they had three or more activities of daily living limitations and any diagnosis of malnutrition, pressure ulcer, incontinence, or aspiration pneumonia. We used logistic regression to examine factors associated with end-of-life imaging tests and life-sustaining treatments. Result A higher proportion of beneficiaries with non-advanced dementia (68%) and advanced dementia (79%) had end-of-life imaging tests, compared to those without dementia (57%) (p<0.01). Beneficiaries with dementia were more likely than non-dementia beneficiaries to receive these imaging tests, controlling for patient characteristics (non-advanced dementia: OR = 2.2 [95% CI 2.0-2.5]; advanced dementia: OR = 5.4 [4.5-6.5]). The proportion of receiving end-of-life life-sustaining treatments was lower among the non-advanced dementia cohort (23%), compared to non-dementia (27%) and advanced-dementia (27%) individuals (p<0.01). After adjusting for patient characteristics, beneficiaries with dementia were more likely than those without dementia to receive at least one life-sustaining treatment (non-advanced dementia: OR = 1.1 [1.0-1.2]; advanced dementia: OR = 1.9 [1.6-2.3]). Younger age, survey self-respondents, beneficiaries with fewer instrumental activities of daily living limitations and no advance care planning were more likely to have end-of-life imaging tests and life-sustaining treatments. Conclusion Our findings suggest that older adults with dementia, especially advanced dementia, are more likely to receive end-of-life burdensome interventions compared to individuals without dementia. Advance care planning involving patients with dementia, their families, and physicians about end-of-life treatment may improve the quality of care. VL - 18 SN - 1552-5260 IS - S9 ER - TY - JOUR T1 - End-of-life burdensome interventions among Medicare fee-for-service beneficiaries with no dementia, non-advanced dementia, and advanced dementia JF - Alzheimer's & Dementia Y1 - 2022 A1 - Yingying Zhu A1 - Natalia Olchanski A1 - Karen M Freund A1 - Jessica Faul A1 - Howard M Fillit A1 - Rachel M Breslau A1 - Joshua T Cohen A1 - Peter J Neumann A1 - Pei-Jung Lin KW - Dementia KW - end-of-life KW - Medicare AB - Background Older adults with dementia have difficulties communicating their treatment preferences and experience end-of-life burdensome interventions with discomfort and limited benefits. This study compared utilization of burdensome interventions during the last 90 days of life among Medicare fee-for-service (FFS) beneficiaries with no dementia, non-advanced dementia, and advanced dementia. Method This study utilized data from 2000-2016 Health and Retirement Study (HRS) linked with Medicare and Medicaid claims, and HRS Exit Interviews. We quantified rates of imaging tests and life-sustaining treatments during the last 90 days of life among those with no dementia, non-advanced dementia, and advanced dementia. Life-sustaining treatments include tube feeding, intensive care unit care, cardiopulmonary resuscitation, and invasive mechanical ventilation. Among patients with a claims-based diagnosis of dementia, we classified them as having advanced dementia if they had three or more activities of daily living limitations and any diagnosis of malnutrition, pressure ulcer, incontinence, or aspiration pneumonia. We used logistic regression to examine factors associated with end-of-life imaging tests and life-sustaining treatments. Result A higher proportion of beneficiaries with non-advanced dementia (68%) and advanced dementia (79%) had end-of-life imaging tests, compared to those without dementia (57%) (p<0.01). Beneficiaries with dementia were more likely than non-dementia beneficiaries to receive these imaging tests, controlling for patient characteristics (non-advanced dementia: OR = 2.2 [95% CI 2.0-2.5]; advanced dementia: OR = 5.4 [4.5-6.5]). The proportion of receiving end-of-life life-sustaining treatments was lower among the non-advanced dementia cohort (23%), compared to non-dementia (27%) and advanced-dementia (27%) individuals (p<0.01). After adjusting for patient characteristics, beneficiaries with dementia were more likely than those without dementia to receive at least one life-sustaining treatment (non-advanced dementia: OR = 1.1 [1.0-1.2]; advanced dementia: OR = 1.9 [1.6-2.3]). Younger age, survey self-respondents, beneficiaries with fewer instrumental activities of daily living limitations and no advance care planning were more likely to have end-of-life imaging tests and life-sustaining treatments. Conclusion Our findings suggest that older adults with dementia, especially advanced dementia, are more likely to receive end-of-life burdensome interventions compared to individuals without dementia. Advance care planning involving patients with dementia, their families, and physicians about end-of-life treatment may improve the quality of care. VL - 18 IS - S9 ER - TY - JOUR T1 - End-of-Life Health Care Use Among Socially Isolated Older Adults with Cognitive Impairment JF - Journal of Pain and Symptom Management Y1 - 2022 A1 - Ashwin Kotwal A1 - Irena Cenzer A1 - Alexander Smith KW - cognitive impairment KW - End-of-life care KW - Medicare KW - socially isolated AB - Outcomes 1. Understand how social isolation is defined and should be considered among older adults with cognitive impairment. 2. Understand how social isolation and cognitive impairment can lead to reduced healthcare use at the end of life and the role of clinicians in addressing social needs Original Research Background At the end of life, older adults may rely on others to access healthcare, particularly if they have impaired cognition. Research Objectives To determine whether socially isolated older adults with and without cognitive impairment have different patterns of end-of-life healthcare use. Methods We used nationally representative 2006-2016 Health and Retirement Study data linked to Medicare claims to examine adults age >50 interviewed once in the last 4 years of life (N = 2,073). We measured three self-report subscales of social relationships: household contacts, social network interaction, and community engagement. The three subscales were combined to create an overall social isolation measure. End-of-life health outcomes included emergency department (ED) visits, hospitalizations, ICU stays, and hospice use in the last months of life. Cognitive impairment (CI) included CIND or dementia. We used logistic regression to test the adjusted association of each social measure with each end-of-life outcome and tested for significant interactions with CI (p < 0.1). Results Our sample had a mean age of 82 (52% female, 9% Black, 5% Hispanic, 47% had CI). There were significant interactions between social isolation or network interaction and CI for all end-of-life outcomes; social isolation was associated with lower hospice use (aOR = 0.61, p = 0.05), ED use (aOR = 0.55, p = 0.03), ICU use (aOR = 0.62, p = 0.05), and hospitalizations (aOR = 0.63, p = 0.04) for patients with CI, whereas there was no association for those with no CI (hospice, aOR = 1.1; ED, aOR = 1.1; ICU, aOR = 1.0; hospitalizations, aOR = 1.1). Conclusion Cognitively impaired older adults who were socially isolated or had reduced social network interaction had fewer ED visits, hospitalizations, ICU stays, and hospice use at the end of life. Implications for Research, Policy, or Practice Cognitively impaired, isolated older adults may struggle to access end-of-life healthcare. Further research is needed to determine whether low rates of acute care and hospice are concordant with their wishes or are due to a lack of support in accessing health services. VL - 63 IS - 5 ER - TY - JOUR T1 - The Epidemiology of Pre-Existing Geriatric and Palliative Conditions in Older Adults with Poor Prognosis Cancers (GP712) JF - Journal of Pain and Symptom Management Y1 - 2022 A1 - Mazie Tsang A1 - Siqi Gan A1 - John Boscardin A1 - Melisa Wong A1 - Louise Walter A1 - Alexander Smith KW - Cancer KW - geriatric conditions KW - Medicare KW - palliative conditions AB - Outcomes 1. Explain how geriatric and palliative care principles are important in the care of older adults with poor prognosis cancers 2. Characterize the prevalence of preexisting geriatric and palliative care conditions for older adults with poor prognosis cancers Importance Older adults with poor prognosis cancers are vulnerable to toxicities from cancer-directed therapies. The benefits and burdens of treatment should be contextualized within their overall prognosis and their functional, social, and symptom experience. Due to lack of routine assessment, however, the geriatric and palliative are needs of this population are unclear. Objective(s) To characterize the prevalence of preexisting geriatric and palliative conditions among older adults with poor prognosis cancers. Method(s) We used the Health and Retirement Study linked with Medicare (1998-2016) to identify adults age ≥65 with poor prognosis cancers (median overall survival <1 year). Using the interview prior to the cancer diagnosis, we determined the presence of clinically significant geriatric and palliative conditions across multiple domains: functional impairment, mobility, falls, unintentional weight loss, self-rated health, social support, mentation, use of pain or sleep medications, and advance care planning. Results Of 2,105 participants, mean age was 76, 52.7% were female, 34.1% had lung cancer, and the median overall survival was 9 months. After adjusting for age and sex, the prevalence of preexisting geriatric and palliative conditions were as follows: 65% had difficulty climbing stairs (95% CI 63-67%), 49% had not completed an advance directive (95% CI 45-54%), 35% lived alone (95% CI 32.5-36.7%), 35% fell in the last 2 years (95% CI 33-37%), and 32% rated their memory as poor (95% CI 29-34%). Functional impairment, impaired mobility, and falls were highest among those age >85. Those aged 65-74 were less likely to have an advance directive. Women had a higher rate of preexisting physical impairments when compared with men (e.g., for difficulty climbing stairs, the adjusted RR 1.25 [95% CI 1.14-1.36]). Conclusion(s) Because of a high prevalence of preexisting conditions across multiple domains, all older adults with poor prognosis cancers should be screened for geriatric and palliative care conditions. Impact Geriatric and palliative care principles should be implemented for older adults with poor prognosis cancers. VL - 63 IS - 6 ER - TY - JOUR T1 - Estimated Annual Spending on Aducanumab in the US Medicare Program JF - JAMA Health Forum Y1 - 2022 A1 - Mafi, John N. A1 - Leng, Mei A1 - Arbanas, Julia Cave A1 - Tseng, Chi-Hong A1 - Damberg, Cheryl L. A1 - Catherine A Sarkisian A1 - Landon, Bruce E. KW - aducanumab KW - annual spending KW - Medicare AB - The US Food and Drug Administration’s June 2021 decision to approve aducanumab for treatment for Alzheimer dementia raised concerns that a drug with uncertain benefit and high cost could, in aggregate, threaten Medicare's solvency. In response to these concerns, Biogen recently announced a 50% annual drug price reduction from $56 000 to $28 200 per patient. Preliminary US spending estimates either used extrapolated Alzheimer dementia prevalence data from 2012 or did not explicitly quantify ancillary costs, such as additional diagnostic imaging to monitor the amyloid-associated imaging abnormalities (ARIAs) that occur in 41% of treated patients, and did not incorporate the recently announced price reduction.1-3 We estimated upper bound and lower bound annualized Medicare costs for administering aducanumab to beneficiaries with the approved indications of mild cognitive impairment (MCI) or mild dementia, focusing on the degree to which associated ancillary health services affect spending.1 VL - 3 SN - 2689-0186 IS - 1 ER - TY - JOUR T1 - Estimated wasteful spending on aducanumab dispensing in the U.S. Medicare population: A cross-sectional analysis. JF - Journal of the American Geriatrics Society Y1 - 2022 A1 - Oronce, Carlos Irwin A A1 - Arbanas, Julia Cave A1 - Leng, Mei A1 - Landon, Bruce E A1 - Damberg, Cheryl L A1 - Sarkisian, Catherine A1 - Mafi, John N KW - Alzheimer disease KW - drugs KW - Medicare KW - Spending AB - Aducanumab, a weight-dosed Alzheimer's drug with uncertain benefits and high cost, could strain Medicare's budget if approved for widespread use.1 In April 2022, Medicare issued a final determination restricting aducanumab's use to clinical trials. However, Medicare's coverage decision may still be overturned by legal challenges, potentially leading to much higher uptake.2 Moreover, several other Alzheimer's infusion drugs similar to aducanumab are currently in the development pipeline.3 Because aducanumab is available in two fixed-dose vial sizes, its use may result in large amounts of discarded drug and wasteful spending.4, 5 To quantify the amount of discarded drug and potential savings that could be generated from more efficient aducanumab vial sizes, we analyzed patient weight distributions from a nationally representative sample of Medicare beneficiaries with mild cognitive impairment (MCI) or mild dementia. VL - 70 IS - 9 ER - TY - ICOMM T1 - Fixed Vial Sizes For Alzheimer’s Drug Could Waste $605M In Medicare Spending Each Year Y1 - 2022 A1 - University of California, Los Angeles KW - Alzheimer's disease KW - drugs KW - Medicare KW - Spending PB - ScienceBlog UR - https://scienceblog.com/531622/fixed-vial-sizes-for-alzheimers-drug-could-waste-605m-in-medicare-spending-each-year/ ER - TY - JOUR T1 - Frequency and Implications of Co-occurring Serious Illness in Older Adults (S544) JF - Journal of Pain and Symptom Management Y1 - 2022 A1 - Stephanie Nothelle A1 - Cynthia Yee A1 - Evan Bollens-Lund A1 - Kenneth Covinsky A1 - Amy Kelley KW - Caregivers KW - Dementia KW - Medicare KW - serious illness AB - Outcomes 1. Describe how frequently the three categories of serious illness (dementia, functional impairment, advanced medical conditions) overlap in older adults 2. List two ways health service use or caregiving needs differ by type of serious illness Original Research Background Serious illness is a condition with high risk of mortality that negatively affects function or quality of life or excessively strains caregivers. In older adults, serious illness predominantly comprises three overlapping categories: dementia, functional impairment, and other advanced medical conditions. Research Objectives We estimate the frequency and co-occurrence of three categories of serious illness in older adults and describe differences in health service use and caregiving hours by category. Methods Using 2016 data from the nationally representative Health and Retirement Study, we selected those with 12 months of linked fee-for-service Medicare claims pre- and post-interview. Dementia status was determined by a survey-based algorithm, functional impairment by self-report of help with ≥1 activity of daily living, and advanced medical condition by claims-based ICD10 codes. Results We included 4,503 adults >65 years. Approximately 27% were seriously ill (9% dementia, 13% functional impairment, 16% advanced medical condition). Approximately 70% of persons with dementia (PWDs) and 65% with functional impairment had another category of serious illness, whereas only 31% with an advanced medical condition did. Functional impairment and advanced medical condition in combination increased prevalence of hospitalization compared to either alone (52% combined, 32% functional impairment, 30% advanced medical condition), but combining dementia with another serious illness category did not meaningfully change hospitalization (39% alone, 33% with functional impairment, 39% with advanced medical condition). PWDs and those with functional impairment reported more than twice the caregiving hours per month (113 and 130 hours, respectively) than those with an advanced medical condition (51 hours). Conclusion Older adults with serious illness due to dementia or functional impairment are more likely than those with an advanced medical condition to have another category of serious illness and have higher caregiving needs. Implications for Research, Policy, or Practice Caregiving policies and interventions for older adults with serious illness may need to be tailored by category of serious illness. VL - 63 UR - https://www.sciencedirect.com/science/article/pii/S088539242200252 IS - 5 ER - TY - ICOMM T1 - Glaucoma Not Linked to Change in Cognitive Function Y1 - 2022 A1 - HealthDay News KW - cognitive function KW - Glaucoma KW - Medicare PB - Physician's Weekly UR - https://www.physiciansweekly.com/glaucoma-not-linked-to-change-in-cognitive-function/ ER - TY - JOUR T1 - Hallucinations, Antipsychotic Use, and Mortality in Older Adults with Dementia: Retrospective Cohort Study of Two Medicare-Linked National Health Surveys. JF - Drugs & Aging Y1 - 2022 A1 - Hamedani, Ali G A1 - Weintraub, Daniel A1 - Willis, Allison W KW - Antipsychotic Agents KW - Dementia KW - Medicare KW - Retrospective Studies AB -

BACKGROUND: Hallucinations are associated with earlier death in older adults with dementia, but antipsychotic medications are also associated with mortality, and comparisons of their relative harms are lacking.

OBJECTIVE: To determine the individual and combined association between hallucinations, antipsychotic use, and mortality.

METHODS: We performed a retrospective cohort study using Medicare-linked survey data from two nationally representative studies (the National Health and Aging Trends Study and the Health and Retirement Study) containing validated dementia identification algorithms and a screening question for hallucinations. Using Medicare claims, we identified participants with dementia who had no history of antipsychotic use during the year of or prior to entry. We used extended Cox regression with time-varying covariates to analyze the association between hallucinations, antipsychotic use, and mortality adjusting for confounders.

RESULTS: We identified 1703 eligible subjects who contributed 4,819 person-years of follow-up. 555 (32.6%) had hallucinations at baseline, 705 (41.4%) reported hallucinations at least once during follow-up, and 284 (16.7%) received antipsychotics. Hallucinations were associated with an increased risk of death in unadjusted models (hazard ratio (HR) 1.36; 95% confidence interval (CI): 1.18-1.5), but antipsychotic use was not (HR 1.03; 95% CI 0.85-1.2). After adjusting for age, race, gender, dementia severity, and comorbidities, the HR for hallucinations attenuated and was no longer statistically significant (1.15, 95% CI 0.98-1.34). There was no significant interaction between hallucinations and antipsychotic use.

CONCLUSION: Hallucinations are associated with an increased risk of death that is greater than the risk associated with antipsychotic use, though this is partially confounded by dementia severity and comorbidities.

VL - 39 IS - 12 ER - TY - RPRT T1 - HOW MUCH DO RETIREES SPEND ON UNCERTAIN HEALTH COSTS? Y1 - 2022 A1 - Arapakis, Karolos KW - health cost KW - Medicaid KW - Medicare KW - out-of-pocket costs KW - Retirees AB - The brief’s key findings are: One risk that retirees face is uncertain out-of-pocket health costs, over and above predictable insurance premiums. The analysis shows that total spending on retirees’ health care – including long-term care and excluding premiums – is high. But insurers like Medicare and Medicaid cover about 80 percent of the costs. As a result, 65-year-old households, on average, are estimated to pay $67,000 out-of-pocket over their remaining lifetime. JF - Briefs PB - Center for Retirement Research at Boston College CY - Newton, MA UR - https://crr.bc.edu/briefs/how-much-do-retirees-spend-on-uncertain-health-costs/ ER - TY - RPRT T1 - How Redistributive Are Public Health Care Schemes? Evidence from Medicare and Medicaid in Old Age Y1 - 2022 A1 - Arapakis, Karolos A1 - Eric French A1 - John Bailey Jones A1 - McCauley, Jeremy KW - Medicaid KW - Medicare KW - public health care KW - Social Security earnings records AB - Most health care for the U.S. population 65 and older is publicly provided through Medicare and Medicaid. Despite the massive expenditures of these systems, little is known about how redistributive they are. Using data from the Health and Retirement Study matched to administrative Medicare, Medicaid, and Social Security earnings records, we estimate the distribution of lifetime Medicare and Medicaid benefits received and the distribution of lifetime taxes paid to finance these benefits. For the cohort who turned 65 between 1999 and 2004, we find that benefits are greater among those with high income, in large part because they live longer. Nonetheless, high-income people pay more in the way of taxes. Middle-income households gain the most from these programs as these people live long yet pay modest taxes. All income groups gain from these programs: This cohort’s lifetime tax contribution did not cover the medical benefits it received. This deficit is paid by younger cohorts. JF - MRDRC Working Paper PB - Michigan Retirement and Disability Research Center, University of Michigan CY - Ann Arbor, MI UR - https://mrdrc.isr.umich.edu/pubs/how-redistributive-are-public-health-care-schemes-evidence-from-medicare-and-medicaid-in-old-age/ ER - TY - JOUR T1 - The importance of chronic conditions for potentially avoidable hospitalizations among non-Hispanic Black and non-Hispanic White older adults in the US: a cross-sectional observational study. JF - BMC Health Services Research Y1 - 2022 A1 - Jørgensen, Terese Sara Høj A1 - Allore, Heather A1 - Elman, Miriam R A1 - Nagel, Corey A1 - Quiñones, Ana R KW - Aged KW - Asthma KW - chronic KW - Chronic Obstructive KW - Heart Failure KW - Hospitalization KW - Humans KW - Medicare KW - Pulmonary Disease KW - Renal Insufficiency AB -

BACKGROUND: Non-Hispanic (NH) Black older adults experience substantially higher rates of potentially avoidable hospitalization compared to NH White older adults. This study explores the top three chronic conditions preceding hospitalization and potentially avoidable hospitalization among NH White and NH Black Medicare beneficiaries in the United States.

METHODS: Data on 4993 individuals (4,420 NH White and 573 NH Black individuals) aged ≥ 65 years from 2014 Medicare claims were linked with sociodemographic data from previous rounds of the Health and Retirement Study. Conditional inference random forests were used to rank the importance of chronic conditions in predicting hospitalization and potentially avoidable hospitalization separately for NH White and NH Black beneficiaries. Multivariable logistic regression with the top three chronic diseases for each outcome adjusted for sociodemographic characteristics were conducted to quantify the associations.

RESULTS: In total, 22.1% of NH White and 24.9% of NH Black beneficiaries had at least one hospitalization during 2014. Among those with hospitalization, 21.3% of NH White and 29.6% of NH Black beneficiaries experienced at least one potentially avoidable hospitalization. For hospitalizations, chronic kidney disease, heart failure, and atrial fibrillation were the top three contributors among NH White beneficiaries and acute myocardial infarction, chronic obstructive pulmonary disease (COPD), and chronic kidney disease were the top three contributors among NH Black beneficiaries. These chronic conditions were associated with increased odds of hospitalization for both groups. For potentially avoidable hospitalizations, asthma, COPD, and heart failure were the top three contributors among NH White beneficiaries and fibromyalgia/chronic pain/fatigue, COPD, and asthma were the top three contributors among NH Black beneficiaries. COPD and heart failure were associated with increased odds of potentially avoidable hospitalization among NH White beneficiaries, whereas only COPD was associated with increased odds of potentially avoidable hospitalizations among NH Black beneficiaries.

CONCLUSION: Having at least one hospitalization and at least one potentially avoidable hospitalization was more prevalent among NH Black than NH White Medicare beneficiaries. This suggests greater opportunity for increasing prevention efforts among NH Black beneficiaries. The importance of COPD for potentially avoidable hospitalizations further highlights the need to focus on prevention of exacerbations for patients with COPD, possibly through greater access to primary care and continuity of care.

VL - 22 IS - 1 ER - TY - RPRT T1 - Integrating Medicare And Medicaid Data To Improve Care Quality And Advance Health Equity Among Dual-Eligible Beneficiaries Y1 - 2022 A1 - Brown-Podgorski, Brittany A1 - Roberts, Eric KW - dual-eligible beneficiaries KW - health equity KW - Medicaid KW - Medicare AB - Policy makers continue to test new models to integrate Medicare and Medicaid coverage for the dually eligible population, with the goal of improving quality of care and health equity. However, evaluations of these integrated models are limited by the fact that few data resources comprehensively measure need for, use of, or spending on care among dual eligibles. JF - Health Policy Brief PB - Health Affairs ER - TY - JOUR T1 - Medicare claims data underestimate hallucinations in older adults with dementia JF - The American Journal of Geriatric Psychiatry Y1 - 2022 A1 - Ali G Hamedani A1 - Weintraub, Daniel A1 - Allison W Willis KW - Dementia KW - Hallucinations KW - Medicare KW - sensitivity KW - specificity KW - validity AB - Objective Administrative claims data are used to study the incidence and outcomes of dementia-related hallucinations, but the validity of International Classification of Diseases (ICD) codes for identifying dementia-related hallucinations is unknown. Methods We analyzed Medicare-linked survey data from two nationally representative studies of U.S. older adults (the National Health and Aging Trends Study and the Health and Retirement Study) which contain validated cognitive assessments and a screening question for hallucinations. We identified older adults who had dementia or were permanent nursing home residents, and we combined this with questionnaire responses to define dementia-related hallucinations. Using Medicare claims data, we calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ICD codes for dementia-related hallucinations overall and within prespecified strata of age, neurologic comorbidity, and health care utilization. Results We included 2,337 older adults with dementia in our cohort. Among 3,789 person-years of data, 1,249 (33.0%) had hallucations, and of these 286 had a qualifying ICD code for dementia-related hallucinations or psychosis (sensitivity 22.9%). Of 2,540 person-years of dementia without hallucinations, 284 had a diagnosis code for hallucinations (specificity 88.8%). PPV was 50.2%, and NPV was 70.1%. Sensitivity was greatest (57.0%) among those seeing a psychiatrist. Otherwise, there were no significant differences in sensitivity, specificity, PPV, or NPV by age, neurologic diagnosis, or neurologist care. Conclusion Dementia-related hallucinations are poorly captured in administrative claims data, and estimates of their prevalence and outcomes using these data are likely to be biased. VL - 30 SN - 1064-7481 IS - 3 ER - TY - JOUR T1 - Medicare Coverage at the End of Life: Separate and Unequal? JF - Journal of Pain and Symptom Management Y1 - 2022 A1 - Claire Ankuda KW - end of life KW - Medicare KW - out-of-pocket costs AB - Outcomes 1. Contrast the pros and cons of different Medicare insurance types, from a patient perspective 2. Understand and describe out-of-pocket costs across Medicare Original Research Background Medicare coverage varies across beneficiaries, with some opting into Medicare Advantage (MA) versus traditional Medicare (TM); some are enrolled in supplementary insurance, and some are dually enrolled in Medicaid. It is unknown how variation affects those at the end of life and their families, Research Objectives We aim to characterize types of Medicare coverage at the end of life and assess how coverage type affects out-of-pocket spending in the last year of life. Methods We used the Health and Retirement Study, a nationally representative cohort study, to identify decedents between 1998 and 2016 with linked Medicare claims. Medicare insurance types were defined as TM alone, TM with supplementary insurance, MA, and dual eligible. We examined the sociodemographic and health characteristics of decedents across insurance groups and the reported out-of-pocket expenditures for hospitalizations in the last year of life. Results We identified 7,910 decedents, 8.5% who were enrolled in TM alone, 43.9% in TM with supplementary insurance, 27.2% in MA, and 20.5% duals. Although rates of MA grew over time, rates of TM with supplementary insurance fell. Compared to those with supplementary insurance or in MA, those in TM alone were younger, more likely to be male, in the lowest quartile of wealth, without a high school education, non-Hispanic Black, or Hispanic/Latino. Preliminary investigation of out-of-pocket costs showed that among those hospitalized in the last year of life, 31.4% of those with TM alone spent more than $2,000 out of pocket, compared to 14.9% in MA and 11.5% with supplementary insurance. Conclusion Across those enrolled in Medicare at the end of life but without Medicaid, those in TM alone are more likely to be from racial and ethnic minority groups and with lower education and wealth and yet face higher out-of-pocket spending. Implications for Research, Policy, or Practice Differences within Medicare create differential cost burdens at the end of life that may increase disparities for patients and their families. VL - 63 IS - 5 ER - TY - JOUR T1 - Medicare spending associated with a dementia diagnosis among older adults. JF - Journal of the American Geriatrics Society Y1 - 2022 A1 - Hoffman, Geoffrey J A1 - Donovan T Maust A1 - Harris, Melissa A1 - Ha, Jinkyung A1 - Davis, Matthew A KW - Dementia KW - Diagnosis KW - impairment KW - Medicare KW - utilization AB -

BACKGROUND: Over 6 million Americans have Alzheimer's Disease or Related Dementia (ADRD) but whether spikes in spending surrounding a new diagnosis reflect pre-diagnosis morbidity, diagnostic testing, or treatments for comorbidities is unknown.

METHODS: We used the 1998-2018 Health and Retirement Study and linked Medicare claims from older (≥65) adults to assess incremental quarterly spending changes just before versus just after a clinical diagnosis (diagnosis cohort, n = 2779) and, for comparative purposes, for a cohort screened as impaired based on the validated Telephone Interview for Cognitive Status (TICS) (impairment cohort, n = 2318). Models were adjusted for sociodemographic and health characteristics. Spending patterns were examined separately by sex, race, education, dual eligibility, and geography.

RESULTS: Among the diagnosis cohort, mean (SD) overall spending was $4773 ($9774) per quarter - 43% of which was spending on hospital care ($2048). In adjusted analyses, spending increased by $8400 (p < 0.001), or 156%, from $5394 in the quarter prior to $13,794 in the quarter including the diagnosis. Among the cohort in which impairment was incidentally detected using the TICS, adjusted spending did not change from just before to after detection of impairment, from $2986 before and $2962 after detection (p = 0.90). Incremental spending changes did not differ by sex, race, education, dual eligibility, or geography.

CONCLUSION: Large, transient spending increases accompany an ADRD diagnosis that may not be attributed to impairment or changes in functional status due to dementia. Further study may help reveal how treatment for comorbidities is associated with the clinical diagnosis of dementia, with potential implications for Medicare spending.

VL - 70 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/35583388?dopt=Abstract ER - TY - JOUR T1 - Racial and Ethnic Differences in Hospice Use and Hospitalizations at End-of-Life Among Medicare Beneficiaries With Dementia. JF - JAMA Network Open Y1 - 2022 A1 - Lin, Pei-Jung A1 - Zhu, Yingying A1 - Olchanski, Natalia A1 - Cohen, Joshua T A1 - Neumann, Peter J A1 - Jessica Faul A1 - Fillit, Howard M A1 - Freund, Karen M KW - Activities of Daily Living KW - Death KW - Dementia KW - Female KW - Hospice Care KW - Hospices KW - Hospitalization KW - Medicare AB -

Importance: The pool of studies examining ethnic and racial differences in hospice use and end-of-life hospitalizations among patients with dementia is limited and results are conflicting, making it difficult to assess health care needs of underresourced racial and ethnic groups.

Objective: To explore differences in end-of-life utilization of hospice and hospital services among patients with dementia by race and ethnicity.

Design, Setting, and Participants: This cohort study used national survey data from the Health and Retirement Study linked with Medicare and Medicaid claims that reflected a range of socioeconomic, health, and psychosocial characteristics. Eligible participants were Medicare fee-for-service beneficiaries aged 65 years or older diagnosed with dementia who died between 2000 and 2016. Analyses were performed from June to December 2021.

Exposures: Race and ethnicity.

Main Outcomes and Measures: We examined the frequency and costs of hospice care, emergency department (ED) visits, and hospitalizations during the last 180 days of life among Medicare decedents with dementia. We analyzed the proportion of dementia decedents with advance care planning and their end-of-life care preferences.

Results: The cohort sample included 5058 beneficiaries with dementia (mean [SD] age, 85.5 [8.0] years; 3038 women [60.1%]; 809 [16.0%] non-Hispanic Black, 357 [7.1%] Hispanic, and 3892 non-Hispanic White respondents [76.9%]). In adjusted analysis, non-Hispanic Black decedents (odds ratio [OR], 0.65; 95% CI, 0.55-0.78), nursing home residents (OR, 0.81; 95% CI, 0.71-0.93), and survey respondents represented by a proxy (OR, 0.84; 95% CI, 0.71-0.99) were less likely to use hospice, whereas older decedents (age 75-84 vs 65-74 years: OR, 1.39; 95% CI, 1.12-1.72; age ≥85 vs 65-74 years: OR, 1.39; 95% CI, 1.13-1.71), women (OR, 1.19; 95% CI, 1.05-1.35), and decedents with higher education (high school vs less than high school: OR, 1.17; 95% CI, 1.01-1.36; more than high school vs less than high school: OR, 1.32; 95% CI, 1.13-1.54), more severe cognitive impairment (OR, 1.51; 95% CI, 1.02-2.23), and more instrumental activities of daily living limitations (OR, 1.07; 95% CI, 1.01-1.12) were associated with higher hospice enrollment. A higher proportion of Black and Hispanic decedents with dementia used ED (645 of 809 [79.7%] and 274 of 357 [76.8%] vs 2753 of 3892 [70.7%]; P < .001) and inpatient services (625 of 809 [77.3%] and 275 of 357 [77.0%] vs 2630 of 3892 [67.5%]; P < .001) and incurred roughly 60% higher inpatient expenditures at the end of life compared with White decedents (estimated mean: Black, $23 279; 95% CI, $20 690-$25 868; Hispanic, $23 471; 95% CI, $19 532-$27 410 vs White, $14 609; 95% CI, $13 800-$15 418). A higher proportion of Black and Hispanic than White beneficiaries with dementia who were enrolled in hospice were subsequently admitted to the ED (56 of 309 [18.1%] and 22 of 153 [14.4%] vs 191 of 1967 [9.7%]; P < .001) or hospital (48 of 309 [15.5%] and 17 of 153 [11.1%] vs 119 of 1967 [6.0%]; P < .001) before death. The proportion of dementia beneficiaries completing advance care planning was lower among Black (146 of 704 [20.7%]) and Hispanic (66 of 308 [21.4%]) beneficiaries compared with White beneficiaries (1871 of 3274 [57.1%]). A higher proportion of Black and Hispanic decedents with dementia had written instructions choosing all care possible to prolong life (30 of 144 [20.8%] and 12 of 65 [18.4%] vs 72 of 1852 [3.9%]), whereas a higher proportion of White decedents preferred to limit care in certain situations (1708 of 1840 [92.8%] vs 114 of 141 [80.9%] and 51 of 64 [79.7%]), withhold treatments (1448 of 1799 [80.5%] vs 87 of 140 [62.1%] and 41 of 62 [66.1%]), and forgo extensive life-prolonging measures (1712 of 1838 [93.1%] vs 120 of 138 [87.0%] and 54 of 65 [83.1%]).

Conclusions and Relevance: The results of this cohort study highlight unique end-of-life care utilization and treatment preferences across racial and ethnic groups among patients with dementia. Medicare should consider alternative payment models to promote culturally competent end-of-life care and reduce low-value interventions and costs among the population with dementia.

VL - 5 IS - 6 ER - TY - ICOMM T1 - Reduction in Vial Size of Aducanumab Could Yield Savings Y1 - 2022 A1 - HealthDay News KW - Alzheimer's disease KW - cost KW - Medicare KW - Medication PB - Physician's Weekly UR - https://www.physiciansweekly.com/reduction-in-vial-size-of-aducanumab-could-yield-savings ER - TY - JOUR T1 - Regional variation in healthcare usage for Medicare beneficiaries: a cross-sectional study based on the health and retirement study. JF - BMJ Open Y1 - 2022 A1 - Luo, Dian KW - health KW - Health Expenditures KW - Insurance KW - Medicare KW - Retirement AB -

OBJECTIVES: To investigate whether regional variation changes with different beneficiary health insurance coverage types.

DESIGN: A cross-sectional study of the Health and Retirement Study (HRS) in 2018 was used.

SETTING: Medicare beneficiaries only covered by Medicare (group 1) are compared with those covered by Medicare and other health insurance (group 2). Outcomes included healthcare usage measures: (1) whether beneficiaries have a hospital stay and (2) the number for those with at least one stay; (3) whether beneficiaries have a doctor's visit and (4) the number for those with at least one visit. We compared healthcare usage in both groups across the five regions: (1) New England and Mid-Atlantic; (2) East North Central and West North Central; (3) South Atlantic; (4) East South Central and West South Central; (5) Mountain and Pacific. We used logistic regression for binary outcomes and negative binomial regression for count outcomes in each group.

PARTICIPANTS: We identified 8749 Medicare beneficiaries, of which 4098 in group 1 and 4651 in group 2.

RESULTS: Residents in all non-reference regions had a significantly lower probability of seeking a doctor's visit in group 1 (OR with 95% CI 0.606 (0.374 to 0.982), 0.619 (0.392 to 0.977), 0.472 (0.299 to 0.746) and 0.618 (0.386 to 0.990) in the order of above regions, respectively), which is not significant in group 2. Residents in most non-reference regions (except South Atlantic) had a significantly fewer number of seeking a hospital stay in group 2 (incident rate ratio (IRR) with 95% CI 0.797 (0.691 to 0.919), 0.740 (0.643 to 0.865), 0.726 (0.613 to 0.859) in the order of above regions, respectively), which is not significant in group 1.

CONCLUSION: Regional variation in the likelihood of having a doctor's visit was reduced in Medicare beneficiaries covered by supplemental health insurance. Regional variation in hospital stays was accentuated among Medicare beneficiaries covered by supplemental health insurance.

VL - 12 IS - 8 ER - TY - JOUR T1 - Time to dementia diagnosis by race: a retrospective cohort study. JF - Journal of the American Geriatrics Society Y1 - 2022 A1 - Davis, Matthew A A1 - Lee, Kathryn A A1 - Harris, Melissa A1 - Ha, Jinkyung A1 - Kenneth M. Langa A1 - Bynum, Julie P W A1 - Hoffman, Geoffrey J KW - Dementia KW - Diagnosis KW - Disparities KW - Medicare KW - race AB -

BACKGROUND: Non-Hispanic Black individuals may be less likely to receive a diagnosis of dementia compared to non-Hispanic White individuals. These findings raise important questions regarding which factors may explain this observed association and any differences in the time to which disparities emerge following dementia onset.

METHODS: We conducted a retrospective cohort study using survey data from the 1995 to 2016 Health and Retirement Study linked with Medicare fee-for-service claims. Using the Hurd algorithm (a regression-based approach), we identified dementia onset among older adult respondents (age ≥65 years) from the Telephone Interview for Cognitive Status and proxy respondents. We determined date from dementia onset to diagnosis using Medicare data up to 3 years following onset using a list of established diagnosis codes. Cox Proportional Hazards modeling was used to examine the association between an individual's reported race and likelihood of diagnosis after accounting for sociodemographic characteristics, income, education, functional status, and healthcare use.

RESULTS: We identified 3435 older adults who experienced a new onset of dementia. Among them, 30.1% received a diagnosis within 36 months of onset. In unadjusted analyses, the difference in cumulative proportion diagnosed by race continued to increase across time following onset, p-value <0.001. 23.8% of non-Hispanic Black versus 31.4% of non-Hispanic White participants were diagnosed within 36 months of dementia onset, Hazard Ratio = 0.73 (95% CI: 0.61, 0.88). The association persisted after adjustment for functional status and healthcare use; however, these factors had less of an impact on the strength of the association than income and level of education.

CONCLUSION: Lower diagnosis rates of dementia among non-Hispanic Black individuals persists after adjustment for sociodemographic characteristics, functional status, and healthcare use. Further understanding of barriers to diagnosis that may be related to social determinants of health is needed to improve dementia-related outcomes among non-Hispanic Black Americans.

ER - TY - JOUR T1 - Trends in the Use of Residential Settings Among Older Adults. JF - The Journals of Gerontology: Series B Y1 - 2022 A1 - Toth, Matt A1 - Palmer, Lauren A1 - Lawren E. Bercaw A1 - Voltmer, Helena A1 - Sarita Karon KW - Activities of Daily Living KW - Aged KW - Comorbidity KW - Cross-Sectional Studies KW - Dementia KW - Female KW - Health Status Disparities KW - Health Transition KW - Homes for the Aged KW - Humans KW - Independent Living KW - Male KW - Medicare KW - Nursing homes KW - United States AB -

OBJECTIVES: As the U.S. population ages, the prevalence of disability and functional limitations, and demand for long-term services and supports (LTSS), will increase. This study identified the distribution of older adults across different residential settings, and how their health characteristics have changed over time.

METHODS: A cross-sectional analysis of older adults residing in traditional housing, community-based residential facilities (CBRFs), and nursing facilities using 3 data sources: the Medicare Current Beneficiary Survey (MCBS), 2008 and 2013; the Health and Retirement Study (HRS), 2008 and 2014; and the National Health and Aging Trends Study, 2011 and 2015. We calculated the age-standardized prevalence of older adults by setting, functional limitations, and comorbidities and tested for health characteristics changes relative to the baseline year (2002).

RESULTS: The proportion of older adults in traditional housing increased over time, relative to baseline (p < .05), while the proportion of older adults in CBRFs was unchanged. The proportion of nursing facility residents declined from 2002 to 2013 in the MCBS (p < .05). The prevalence of dementia and functional limitations among traditional housing residents increased, relative to the baseline year in the HRS and MCBS (p < .05).

DISCUSSION: The proportion of older adults residing in traditional housing is increasing, while the nursing facility population is decreasing. This change may not be due to better health; rather, older adults may be relying on noninstitutional LTSS.

VL - 77 IS - 2 ER - TY - JOUR T1 - Validation of Claims Algorithms to Identify Alzheimer's Disease and Related Dementias. JF - The Journals of Gerontology, Series A Y1 - 2022 A1 - Ellen P McCarthy A1 - Chang, Chiang-Hua A1 - Tilton, Nicholas A1 - Mohammed U Kabeto A1 - Kenneth M. Langa A1 - Julie P W Bynum KW - Accuracy KW - algorithm KW - Dementia KW - Diagnosis KW - Medicare AB -

BACKGROUND: Using billing data generated through healthcare delivery to identify individuals with dementia has become important in research. To inform tradeoffs between approaches, we tested the validity of different Medicare claims-based algorithms.

METHODS: We included 5,784 Medicare-enrolled, Health and Retirement Study participants aged >65 years in 2012 clinically assessed for cognitive status over multiple waves and determined performance characteristics of different claims-based algorithms.

RESULTS: Positive predictive value (PPV) of claims ranged from 53.8-70.3% and was highest using a revised algorithm and 1-year of observation. The trade-off of greater PPV was lower sensitivity; sensitivity could be maximized using 3-years of observation. All algorithms had low sensitivity (31.3-56.8%) and high specificity (92.3-98.0%). Algorithm test performance varied by participant characteristics, including age and race.

CONCLUSIONS: Revised algorithms for dementia diagnosis using Medicare administrative data have reasonable accuracy for research purposes, but investigators should be cognizant of the trade-offs in accuracy among the approaches they consider.

VL - 77 IS - 6 ER - TY - JOUR T1 - Association Between Receipt of Cancer Screening and All-Cause Mortality in Older Adults. JF - JAMA Network Open Y1 - 2021 A1 - Schoenborn, Nancy L A1 - Sheehan, Orla C A1 - David L. Roth A1 - Cidav, Tansu A1 - Huang, Jin A1 - Chung, Shang-En A1 - Zhang, Talan A1 - Lee, Sei A1 - Xue, Qian-Li A1 - Cynthia Boyd KW - all-cause mortality KW - cancer screening KW - Medicare AB -

Importance: Guidelines recommend against routine breast and prostate cancer screenings in older adults with less than 10 years' life expectancy. One study using a claims-based prognostic index showed that receipt of cancer screening itself was associated with lower mortality, suggesting that the index may misclassify individuals when used to inform cancer screening, but this finding was attributed to residual confounding because the index did not account for functional status.

Objective: To examine whether cancer screening remains significantly associated with all-cause mortality in older adults after accounting for both comorbidities and functional status.

Design, Setting, and Participants: This cohort study included individuals older than 65 years who were eligible for breast or prostate cancer screening and who participated in the 2004 Health and Retirement Study. Data were linked to Medicare claims from 2001 to 2015. Data analysis was conducted from January to November 2020.

Main Outcomes and Measures: A Cox model was used to estimate the association between all-cause mortality over 10 years and receipt of screening mammogram or prostate-specific antigen (PSA) test, adjusting for variables in a prognostic index that included age, sex, comorbidities, and functional status. Potential confounders (ie, education, income, marital status, geographic region, cognition, self-reported health, self-care, and self-perceived mortality risk) of the association between cancer screening and mortality were also tested.

Results: The breast cancer screening cohort included 3257 women (mean [SD] age, 77.8 [7.5] years); the prostate cancer screening cohort included 2085 men (mean [SD] age, 76.1 [6.8] years). Receipt of screening mammogram was associated with lower hazard of all-cause mortality after accounting for all index variables (adjusted hazard ratio [aHR], 0.67; 95% CI, 0.60-0.74). A weaker, but still statistically significant, association was found for screening PSA (aHR 0.88; 95% CI, 0.78-0.99). None of the potential confounders attenuated the association between screening and mortality except for cognition, which attenuated the aHR for mammogram from 0.67 (95% CI, 0.60-0.74) to 0.73 (95% CI, 0.64-0.82) and the aHR for PSA from 0.88 (95% CI, 0.78-0.99) to 0.92 (95% CI, 0.80-1.05), making PSA screening no longer statistically significant.

Conclusions and Relevance: In this study, cognition attenuated the observed association between cancer screening and mortality among older adults. These findings suggest that existing mortality prediction algorithms may be missing important variables that are associated with receipt of cancer screening and long-term mortality. Relying solely on algorithms to determine cancer screening may misclassify individuals as having limited life expectancy and stop screening prematurely. Screening decisions need to be individualized and not solely dependent on life expectancy prediction.

VL - 4 IS - 6 ER - TY - RPRT T1 - Cognitive Impairment and Prevalence of Memory-Related Diagnoses among U.S. Older Adults Y1 - 2021 A1 - Qian, Yuting A1 - Chen, Xi A1 - Tang, Diwen A1 - Amy Kelley A1 - Li, Jing KW - cognitive aging KW - cognitive impairment KW - Dementia KW - Medicare KW - memory-related diagnosis AB - Cognitive impairment creates significant challenges to health and well-being of the fast-growing aging population. Early recognition of cognitive impairment may confer important advantages, allowing for diagnosis and appropriate treatment, education, psychosocial support, and improved decision-making regarding life planning, health care, and financial matters. Yet the prevalence of memory-related diagnoses among older adults with early symptoms of cognitive impairment is unknown. Using 2000-2014 Health and Retirement Survey - Medicare linked data, we leveraged within-individual variation in a longitudinal cohort design to examine the relationship between incident cognitive impairment and receipt of diagnosis among American older adults. Receipt of a memory-related diagnosis was determined by ICD-9-CM codes. Incident cognitive impairment was assessed using the modified Telephone Interview of Cognitive Status (TICS). We found overall low prevalence of early memory-related diagnosis, or high rate of underdiagnosis, among older adults showing symptoms of cognitive impairment, especially among non-whites and socioeconomically disadvantaged subgroups. Our findings call for targeted interventions to improve the rate of early diagnosis, especially among vulnerable populations. JF - GLO Discussion Paper PB - Global Labor Organization CY - Essen, Germany UR - https://www.econstor.eu/bitstream/10419/229436/1/GLO-DP-0777.pdf ER - TY - JOUR T1 - Development, Validation, and Performance of a New Physical Functioning–Weighted Multimorbidity Index for Use in Administrative Data JF - Journal of General Internal Medicine Y1 - 2021 A1 - Melissa Y Wei A1 - Jamie E Luster A1 - Ratz, David A1 - Kenneth J Mukamal A1 - Kenneth M. Langa KW - Medicaid KW - Medicare KW - multimorbidity index KW - physical functioning VL - 36 ER - TY - CONF T1 - On the Distribution and Dynamics of Medical Expenditure among the Elderly T2 - Retirement and Disability Research Consortium 23rd Annual Meeting Y1 - 2021 A1 - Arapakis, Karolos A1 - Eric French A1 - John Bailey Jones A1 - McCauley, Jeremy KW - dynamics KW - Medicaid KW - Medical spending KW - Medicare AB - Using data from the Health and Retirement Study (HRS), we estimate the stochastic process for total medical spending and its components. By focussing on dynamics, we consider not only the risk of catastrophic expenses in a single year, but also the risk of moderate but persistent expenses that accumulate into a catastrophic lifetime cost. We also assess the reduction in out-of-pocket medical spending risk provided by public insurance schemes such as Medicare or Medicaid. JF - Retirement and Disability Research Consortium 23rd Annual Meeting PB - Center for Financial Security, University of Wisconsin-Madison CY - Virtual Event UR - https://cfsrdrc.wisc.edu/files/2021-RDRC-Meeting-Booklet.pdf#page=7 ER - TY - THES T1 - Essays on the Value of Health and Longevity Y1 - 2021 A1 - Saha, Nirman KW - Affordable Care Act KW - consumption KW - health risk KW - Medicare AB - My dissertation investigates how individuals make tradeoffs between consumption and health risks, and the implications of their choices for the efficiency and equity of public policies. I study how these decisions can be used to infer their willingness to pay to reduce health risks, as well as the implications for dynamic complementarities between the quantity and the quality of life, and how decisions on health behavior affect educational attainment and workplace performance. Chapter 1 provides a brief preview of how I formalize these ideas, test them using micro data, and consider their policy implications in three interconnected essays. In Chapter 2 I provide the first revealed preference evidence on the willingness to pay to reduce mortality risks by US senior citizens. I derive this evidence from the rates at which they consume medical services and the effects of their choices on survival probabilities. Instrumental variable estimates provide robust evidence that their Value of a Statistical Life (VSL) is well below $1 million and declines with age. Conditional on age, the VSL increases in health, income, education and is higher for women and for people who never smoked. Chapter 3 develops a unified framework for valuing changes in health and longevity that explicitly allows for the complementarities between quantity and quality of life. I develop a dynamic life-cycle model of health investment, stochastic health and mortality, and use the model to characterize the VSL and the value of disease prevention for seniors. My results reinforce the qualitative variation in VSL with respect to age, health and income described in Chapter 2. I also document evidence of dynamic complementarity that implies there is increasing returns to health improvements. To demonstrate the policy implications of this complementarity, I use my calibrated model to calculate the benefits of mortality reductions in the 2000’s that the US Environmental Protection Agency attributed to the Clean Air Act. I find that these mortality reductions generated benefits, in part, by increasing the value of further health risk reductions due to increased life expectancy. The value of this improvement was equivalent to 6% of the total benefit of the Clean Air Act in 2010. In Chapter 4 I investigate the causal effect of depression on illicit drug use among young adults. Using the 9/11 terrorist attack as an instrument for depression, I show that depression triggers illicit drug use among young adults (age 18-28) with heterogeneous impacts on different drugs. This finding suggests that treating depression can help to reduce illicit drug use. Dynamic complementarity in health improvements therefore, imply that there are likely to be positive externalities from the Affordable Care Act and other policies that increase insurance coverage for mental health. PB - Arizona State University CY - Scottsdale, AZ VL - Ph.D. UR - https://www.proquest.com/openview/bbc9d256cd9306f631238ed0a440b135/1?pq-origsite=gscholar&cbl=18750&diss=y ER - TY - JOUR T1 - Identifying cohabiting couples in administrative data: evidence from Medicare address data JF - Health Services and Outcomes Research Methodology Y1 - 2021 A1 - Matta, Sasmira A1 - Joanne W. Hsu A1 - Theodore J Iwashyna A1 - Micah Y. Baum A1 - Kenneth M. Langa A1 - Lauren Hersch Nicholas KW - Cohabitation KW - Couples KW - Marriage KW - Medicare AB - Marital status is recognized as an important social determinant of health, income, and social support, but is rarely available in administrative data. We assessed the feasibility of using exact address data and zip code history to identify cohabiting couples using the 2018 Medicare Vital Status file and ZIP codes in the 2011–2014 Master Beneficiary Summary Files. Medicare beneficiaries meeting our algorithm displayed characteristics consistent with assortative mating and resembled known married couples in the Health and Retirement Study linked to Medicare claims. Address information represents a promising strategy for identifying cohabiting couples in administrative data including healthcare claims and other data types. VL - 21 SN - 1572-9400 IS - 2 ER - TY - JOUR T1 - Impact of Medicare Eligibility on Informal Caregiving for Surgery and Stroke JF - Health Services Research Y1 - 2021 A1 - DeRoo, Ana A1 - Ha, Jinkyung A1 - Norcott, Alexandra A1 - Regenbogen, Scott A1 - Geoffrey J Hoffman KW - Eligibility Determination KW - Informal caregiving KW - Medicare KW - Stroke KW - Surgery AB - Research Objective Over 40 million older Americans rely on informal care (unpaid assistance for personal care such and instrumental support, including toileting, bathing, and shopping). Prior work illustrates 68–230% greater spending on post-acute care after surgery for Medicare beneficiaries compared to older commercial insurance enrollees. Such enhanced access to post-acute care may reduce the need for family and friend caregiving support for rehabilitation following acute medical events. While use of informal care is substantial among older Americans, little is known about informal support for patients after acute medical events, and how formal post-acute care influences its use. Study Design We used 1998 to 2018 Health and Retirement Study (HRS) data to assess changes in weekly hours of informal care received by individuals experiencing acute events before and after Medicare eligibility. We created two similar cohorts of individuals near the Medicare eligibility age: pre-Medicare, or individuals ages 59–66 and not covered by Medicare; and Medicare, or individuals ages 67–74. We used a threshold of 67, rather than 65, for the Medicare cohort to account for the two-year lookback period used in HRS survey questions. The cohorts were matched using inverse probability treatment weights. A regression discontinuity design assessed three types of caregiving – the proportion of respondents receiving care, intensity of care among care recipients, and care intensity among all respondents – before and after Medicare eligibility. We estimated generalized linear models with a log link and gamma distribution that regressed informal care on Medicare status, a centered age variable, and an interaction between Medicare status and centered age. Sensitivity analyses included stratification by surgery type and by sex. Population Studied 4264 Health and Retirement Study participants near the age of Medicare eligibility in one of three self-reported acute medical cohorts: stroke, heart surgery, or joint surgery. Principal Findings Among near-retirement individuals, 2031 (47.6%) had a stroke, 1038 (24.3%) underwent heart surgery, and 1038 (28.0%) underwent joint surgery. Of the 937 (22.3%) of patients who reported receiving care from an informal caregiver, average care measured 34.0 (SD: 49.2) weekly hours. Mean (SD) weekly informal caregiving hours were 7.5 (27.0) overall, and 12.1 (34.7), 3.8 (18.5), and 2.9 (14.1) for stroke, heart surgery, and joint surgery patients, respectively. In adjusted analyses, the proportion of stroke patients receiving informal care decreased from 39.5% to 28.6% (or by 28%) and the average weekly amount of care decreased from 21.0 to 10.3 hours (or 51%) after Medicare enrollment. Non-significant decreases were observed for the other medical cohorts. There was a non-significant average decrease of 22.8 hours (or 40%) in the intensity of care received by men after one of three events. Conclusions Access to Medicare coverage was associated with a 51% reduction in informal care received by older Medicare stroke patients, potentially by increasing access to post-acute services. Implications for Policy or Practice Post-acute care is increasingly targeted for cost savings under Medicare policies, which may restrict access to post-acute care and rehabilitation, impacting demand for informal care for older adults with stroke. VL - 56 IS - S2 ER - TY - JOUR T1 - Increasing Medicaid's Stagnant Asset Test For People Eligible For Medicare And Medicaid Will Help Vulnerable Seniors. JF - Health Affairs Y1 - 2021 A1 - Cornelio, Noelle A1 - Melissa McInerney A1 - Jennifer M Mellor A1 - Roberts, Eric T A1 - Lindsay M Sabik KW - Eligibility Determination KW - Medicaid KW - Medicare AB -

Low-income Medicare beneficiaries rely on Medicaid for supplemental coverage but must meet income and asset tests to qualify. We examined states' income and asset tests for full-benefit Medicaid during the period 2006-18 and examined how alternative asset tests would affect eligibility for community-dwelling Medicare beneficiaries ages sixty-five and older. Most states have not updated the dollar limit of Medicaid's asset test since 1989, making the asset test increasingly restrictive in inflation-adjusted terms. We estimated that increasing Medicaid's asset limit by the Consumer Price Index, to Medicare Savings Program levels, or to $10,000 for individuals and $20,000 for couples would increase Medicaid eligibility by 1.7 percent, 4.4 percent, and 7.5 percent, respectively. Simplifying Medicaid's asset test to focus only on certain high-value assets would increase eligibility by 20.5 percent. Increasing asset limits would lessen restrictions on Medicaid eligibility that arise from stagnant asset tests, broadening eligibility for certain low-income Medicare beneficiaries and allowing them to retain higher, yet still modest, savings.

VL - 40 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/34871073?dopt=Abstract ER - TY - JOUR T1 - Medicaid Coverage 'Cliff' Increases Expenses And Decreases Care For Near-Poor Medicare Beneficiaries. JF - Health Affairs Y1 - 2021 A1 - Roberts, Eric T A1 - Glynn, Alexandra A1 - Cornelio, Noelle A1 - Donohue, Julie M A1 - Gellad, Walid F A1 - McWilliams, J Michael A1 - Lindsay M Sabik KW - Medicaid KW - Medicare AB -

Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100 percent but less than 200 percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8 percentage points just above the eligibility threshold for Medicaid (100 percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55 percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.

VL - 40 IS - 4 ER - TY - JOUR T1 - Pre-existing geriatric conditions in older adults with poor prognosis cancers. JF - Journal of Clinical Oncology Y1 - 2021 A1 - Tsang, Mazie A1 - Gan, Siqi A1 - Wong, Melisa L. A1 - Louise C Walter A1 - Alexander K Smith KW - Cancer KW - Geriatric Assessment KW - Medicare KW - Pre-existing Conditions AB - Background: Older adults with poor prognosis cancers are more likely to experience toxicity from cancer-directed therapies. Although geriatric assessment (GA) reduces chemotherapy toxicity by detecting pre-existing conditions, GA can be difficult for oncologists to perform because of limited time and resources. We aim to determine the prevalence of pre-existing geriatric conditions that could be detected if GA were performed during routine oncology care. Methods: We used the Health and Retirement Study (HRS) linked with Medicare (1998-2016) to identify adults age >65 with poor prognosis cancers (median overall survival < 1 year). The HRS is a biennial nationally representative survey that asks about pre-existing geriatric conditions. Using the interview prior to the cancer diagnosis, we determined the presence of conditions included in GA: functional status (i.e. difficulty with climbing stairs, walking one block, getting up from a chair, bathing or showering, taking medications, and managing money), falls and injurious falls, unintentional weight loss, self-rated health, social support, mentation, advanced care planning, use of pain or sleep medications, and mobility. To identify groups with the highest prevalence of pre-existing geriatric conditions, we stratified results by age (adjusted for gender) and gender (adjusted for age). Results: Our study included 2,121 participants. At the time of cancer diagnosis, mean age was 76, 51% were female, 79% were non-Hispanic White, 26% had lung cancer, 14% had a GI cancer, and 60% had other metastatic cancers. Mean time between the HRS interview and cancer diagnosis was 12.7 months. The median overall survival of the entire cohort was 9.6 months with a 45% 1-year survival rate. The adjusted prevalence of pre-existing geriatric concerns were as follows: 65% had difficulty with climbing several flights of stairs, 27% had difficulty with walking one block, 47% had difficulty getting up from a chair after sitting down, 12% had difficulty in bathing or showering, 6% had difficulty taking medications, 11% had difficulty in managing money, 35% had a fall in the last 2 years with 12% of participants reporting injury after their fall. Those who were aged 85+, vs those aged 65-74, had higher rates of conditions indicative of cognitive impairment (e.g. 12 vs 4% had difficulty taking medications, p = 0.000, 26% vs 6% had difficulty managing money, p = 0.000) and physical impairments (e.g. 54% vs 30% had falls, respectively, p = 0.000). Rates of geriatric conditions indicative of physical impairment were higher in women vs men (e.g. 72% vs 58% had difficulty climbing stairs, p = 0.000 and 52% vs 41% had difficulty getting up from a chair, p = 0.000). Conclusions: Patients with poor prognosis cancers have high rates of pre-existing geriatric conditions that can be detected by GA. Geriatric assessments could find important impairments that could be addressed prior to cancer therapy to reduce adverse effects.12044Background: Older adults with poor prognosis cancers are more likely to experience toxicity from cancer-directed therapies. Although geriatric assessment (GA) reduces chemotherapy toxicity by detecting pre-existing conditions, GA can be difficult for oncologists to perform because of limited time and resources. We aim to determine the prevalence of pre-existing geriatric conditions that could be detected if GA were performed during routine oncology care. Methods: We used the Health and Retirement Study (HRS) linked with Medicare (1998-2016) to identify adults age >65 with poor prognosis cancers (median overall survival < 1 year). The HRS is a biennial nationally representative survey that asks about pre-existing geriatric conditions. Using the interview prior to the cancer diagnosis, we determined the presence of conditions included in GA: functional status (i.e. difficulty with climbing stairs, walking one block, getting up from a chair, bathing or showering, taking medications, and managing money), falls and injurious falls, unintentional weight loss, self-rated health, social support, mentation, advanced care planning, use of pain or sleep medications, and mobility. To identify groups with the highest prevalence of pre-existing geriatric conditions, we stratified results by age (adjusted for gender) and gender (adjusted for age). Results: Our study included 2,121 participants. At the time of cancer diagnosis, mean age was 76, 51% were female, 79% were non-Hispanic White, 26% had lung cancer, 14% had a GI cancer, and 60% had other metastatic cancers. Mean time between the HRS interview and cancer diagnosis was 12.7 months. The median overall survival of the entire cohort was 9.6 months with a 45% 1-year survival rate. The adjusted prevalence of pre-existing geriatric concerns were as follows: 65% had difficulty with climbing several flights of stairs, 27% had difficulty with walking one block, 47% had difficulty getting up from a chair after sitting down, 12% had difficulty in bathing or showering, 6% had difficulty taking medications, 11% had difficulty in managing money, 35% had a fall in the last 2 years with 12% of participants reporting injury after their fall. Those who were aged 85+, vs those aged 65-74, had higher rates of conditions indicative of cognitive impairment (e.g. 12 vs 4% had difficulty taking medications, p = 0.000, 26% vs 6% had difficulty managing money, p = 0.000) and physical impairments (e.g. 54% vs 30% had falls, respectively, p = 0.000). Rates of geriatric conditions indicative of physical impairment were higher in women vs men (e.g. 72% vs 58% had difficulty climbing stairs, p = 0.000 and 52% vs 41% had difficulty getting up from a chair, p = 0.000). Conclusions: Patients with poor prognosis cancers have high rates of pre-existing geriatric conditions that can be detected by GA. Geriatric assessments could find important impairments that could be addressed prior to cancer therapy to reduce adverse effects. VL - 39 SN - 0732-183X IS - 15_suppl ER - TY - JOUR T1 - Skilled Nursing Facilities Modify the Relationship Between Depressive Symptoms and Hospital Readmissions but Not Health Outcomes Among Older Adults. JF - Journal of Aging and Health Y1 - 2021 A1 - Leah R. Abrams A1 - Geoffrey J Hoffman KW - depression KW - Medicare KW - post-acute care KW - Readmissions KW - Rehabilitation AB -

Despite detrimental effects of depressive symptoms on self-care and health, hospital discharge practices and the benefits of different discharge settings are poorly understood in the context of depression. This retrospective cohort study comprised 23,485 hospitalizations from Medicare claims linked to the Health and Retirement Study (2000-2014). Respondents with depressive symptoms were no more likely to be referred to home health, whereas the probability of discharge to skilled nursing facilities (SNFs) went up a half percentage point with each increasing symptom, even after adjusting for family support and health. Rehabilitation in SNFs, compared to routine discharges home, reduced the positive association between depressive symptoms and 30-day hospital readmissions (OR = 0.95, = 0.029) but did not prevent 30-day falls, 1-year falls, or 1-year mortality associated with depressive symptoms. Depressive symptoms were associated with discharges to SNFs, but SNFs do not appear to address depressive symptoms to enhance functioning and survival.

VL - 33 IS - 10 ER - TY - JOUR T1 - Validation of self-reported incident cancer diagnoses in the U.S. Health and Retirement Study: A tool for population-based cancer and aging research. JF - Journal of Clinical Oncology Y1 - 2021 A1 - Megan Mullins A1 - Jasdeep S Kler A1 - Eastman, Marissa A1 - Mohammed U Kabeto A1 - Lauren P Wallner A1 - Lindsay C Kobayashi KW - biomarker data KW - cancer diagnoses KW - Medicare KW - self-report AB - Background: Population aging and improving cancer survival rates are resulting in a growing population of older cancer survivors in the United States (US). As a result, there is an increasing need for longitudinal, population-representative data for interdisciplinary cancer research among older adults. The US Health Retirement Study (HRS) is an ongoing population-representative cohort of US adults over age 50 that contains rich interview and biomarker data on health during aging. Interviews have collected self-reported cancer diagnoses since 1998, but these self-reports have not been validated. We compared first incident cancer diagnoses self-reported in HRS interviews against diagnostic claims from linked Medicare records. Methods: We examined the validity of first incident cancer diagnoses self-reported in biennial HRS interviews from 2000 through 2016 against ICD-9 and ICD-10 diagnostic claim records among 8,242 HRS participants aged ≥65 with 90% continuous enrollment in fee-for-service Medicare, using the claim records as the gold standard. We calculated the sensitivity, specificity, and k for first incident cancer diagnoses (all cancers combined, excluding non-melanoma skin cancer, and each of bladder, breast, colorectal/anal, uterine, kidney/renal, lung/bronchus, and prostate cancers) cumulatively over the follow-up, and at each biennial study interview. Results: Self-reports of first incident cancer diagnosis (agnostic of site) between 2000 and 2016 had 73.2% sensitivity and 96.2% specificity against Medicare claims (k = 0.73). For site-specific self-reports, sensitivities ranged from 44.7% (kidney) to 75.0% (breast), and specificities ranged from 99.2% (prostate) to 99.9% (bladder, uterine, and kidney). Results were similar in sensitivity analyses restricting to individuals with 100% continuous fee-for-service Medicare enrollment and when restricting to individuals with at least 24 months of Medicare enrollment. Conclusions: Self-reported cancer diagnoses in the HRS have reasonable validity for population-based research on cancer and aging across cancer types. Apart from breast cancer, cancer site specific analyses will greatly benefit from the improved validity of self-report with Medicare claim linkage. VL - 39 IS - 28_suppl ER - TY - JOUR T1 - Cognition and Take-up of the Medicare Savings Programs. JF - JAMA Internal Medicine Y1 - 2020 A1 - Roberts, Eric T A1 - Brian E McGarry A1 - Glynn, Alexandra KW - Cognition KW - health care policy KW - Medicare AB - The Medicare Savings Programs (MSPs) are limited Medicaid benefits that reduce out-of-pocket costs in Medicare Parts A and B for individuals with low income and assets. Despite the substantial financial assistance the MSPs offer, fewer than one-half of eligible individuals are enrolled. The complexity of the application and reattestation process for the MSPs, which requires individuals to provide detailed documentation of their income and assets at least annually, has been identified as one explanation for the low take-up of these benefits.2 Individuals with cognitive impairments, such as dementia, which 6.5 million elderly Americans experience, may face particular challenges navigating the MSP benefit. Prior research identified poor cognition as a contributor to the low take-up of insurance benefits other than the MSPs. In this study, we examined the association between cognition and MSP enrollment among elderly Medicare beneficiaries who qualify for these programs. We also examined enrollment in the Low-Income Subsidy (LIS), a separate program that provides premium and cost-sharing assistance in Medicare Part D that Medicare beneficiaries automatically receive if they are enrolled in an MSP. ER - TY - JOUR T1 - Dementia Is Associated With Earlier Mortality for Men and Women in the United States. JF - Gerontology and Geriatric Medicine Y1 - 2020 A1 - White, Lindsay A1 - Fishman, Paul A1 - Basu, Anirban A1 - Paul K Crane A1 - Eric B Larson A1 - Norma B Coe KW - Dementia KW - gender KW - Medicare KW - Medicare administrative data AB -

Sociodemographic trends in the United States may influence future dementia-associated mortality, yet there is little evidence about their potential impact. Our study objective was to estimate the effect of dementia on survival in adults stratified by sex, education, and marital status. Using survey data from the Health and Retirement Study (HRS) linked to Medicare claims from 1991 to 2012, we identified a retrospective cohort of adults with at least one International Classification of Diseases-ninth revision-Clinical Modification (ICD-9-CM) dementia diagnosis code ( = 3,714). For each case, we randomly selected up to five comparators, matching on sex, birth year, education, and HRS entry year ( = 9,531), and assigned comparators the diagnosis date of their matched case. Participants were followed for up to 60 months following diagnosis. We estimated a survival function for the entire study population and then within successive strata defined by sex, education, and marital status. On average, dementia cases were 80.5 years old at diagnosis. Most were female, had less than college-level education, and approximately 40% were married at diagnosis. In multivariate analyses, dementia diagnosis was associated with earlier mortality for women (predicted median survival of 54.5 months vs. 62.5 months; dementia coefficient = -0.13; 95% confidence interval [CI] = [-0.22, -0.04]; = .003), but even more so among men (predicted median survival of 35.5 months vs. 54.5 months; dementia coefficient = -0.42; 95% CI = [-0.52, -0.31]; < .001). We found substantial heterogeneity in the relationship between dementia and survival, associated with both education and marital status. Both sex and level of education moderate the relationship between dementia diagnosis and length of survival.

VL - 6 ER - TY - ICOMM T1 - How the Affordable Care Act Is Helping Fight the Coronavirus Outbreak Y1 - 2020 A1 - Marc A Cohen A1 - Jane Tavares KW - Affordable Care Act KW - Coronavirus KW - COVID-19 KW - depression KW - Health Insurance KW - Medicare KW - Pandemic AB - Ten years after the passage of the Affordable Care Act, the Trump administration is now asking the Supreme Court to overturn it. Yet it’s now clear that the ACA has brought significant improvements to the lives of millions of Americans. Today, they enjoy more health care coverage, with greater access, better outcomes and less cost. JF - The Conversation: Health PB - The Conversation CY - Boston UR - https://theconversation.com/obamacares-unexpected-bonus-how-the-affordable-care-act-is-helping-middle-aged-americans-during-the-pandemic-139267 ER - TY - JOUR T1 - Implications of the Use of Algorithmic Diagnoses or Medicare Claims to Ascertain Dementia. JF - Neuroepidemiology Y1 - 2020 A1 - Melinda C Power A1 - Kan Z Gianattasio A1 - Ciarleglio, Adam KW - Algorithms KW - Dementia KW - Diagnosis KW - Medicare KW - Sensitivity and Specificity AB -

INTRODUCTION: Formal dementia ascertainment with research criteria is resource-intensive, prompting the growing use of alternative approaches. Our objective was to illustrate the potential bias and implications for study conclusions introduced through the use of alternate dementia ascertainment approaches.

METHODS: We compared dementia prevalence and risk factor associations obtained using criterion-standard dementia diagnoses to those obtained using algorithmic or Medicare-based dementia ascertainment in participants of the baseline visit of the Aging, Demographics, and Memory Study (ADAMS), a Health and Retirement Study (HRS) sub-study.

RESULTS: Estimates of dementia prevalence derived using algorithmic or Medicare-based ascertainment differ substantially from those obtained using criterion-standard ascertainment. Use of algorithmic or Medicare-based dementia ascertainment can, but does not always, lead to risk factor associations that substantially differ from those obtained using criterion-standard ascertainment.

DISCUSSION/CONCLUSIONS: Absolute estimates of dementia prevalence should rely on samples with formal dementia ascertainment. The use of multiple algorithms is recommended for risk factor studies when formal dementia ascertainment is not available.

ER - TY - JOUR T1 - Multimorbidity in Medicare Beneficiaries: Performance of an ICD-Coded Multimorbidity-Weighted Index JF - Journal of the American Geriatrics Society Y1 - 2020 A1 - Melissa Y Wei A1 - Ratz, David A1 - Kenneth J Mukamal KW - administrative claims data KW - Comorbidity KW - Medicare KW - multimorbidity KW - physical functioning AB - OBJECTIVES Most older adults have multimorbidity that impairs physical functioning, but it is difficult to quantify using claims data. We previously developed and validated a multimorbidity-weighted index (MWI) that embeds physical functioning through disease weightings. We mapped these conditions to International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and compared them with existing indices. DESIGN Population-based prospective cohort. SETTING Respondents to the 2006-2016 waves of the Health and Retirement Study (HRS) with linked Medicare claims data and continuous enrollment in 2006. PARTICIPANTS Community-dwelling Medicare-eligible HRS participants (N = 9923; mean age = 75.5 ± 8.5 y). MEASUREMENTS Individuals were followed for future physical functioning (2006-2014) and mortality (2007-2016). MWI conditions were mapped to ICD-9-CM codes to produce an ICD-coded MWI (MWI-ICD). We compared MWI-ICD, simple disease count, Charlson, Elixhauser, and the health-related quality of life comorbidity index (HRQOL-CI) through distributions, hazard ratios for mortality, and relationships with future physical functioning. RESULTS MWI-ICD exhibited the broadest distribution and most unique values (5891). Left censoring was most pronounced for Charlson (34.3% score = 0) and Elixhauser (13.1% score = 0) vs MWI (5.0% score = 0). Hazard ratios and concordance (C)-statistics for mortality across extreme quartiles were similar for MWI-ICD, Elixhauser, and Charlson but lower for disease count and the HRQOL-CI. For physical functioning, MWI-ICD yielded the greatest contrast across extreme quartiles and overall coefficient of determination (R2). CONCLUSION MWI-ICD was significantly associated with mortality and future physical functioning and comparable with established metrics for mortality prediction although not weighted to mortality. MWI-ICD successfully captures diseases accumulation and functioning in claims data. VL - n/a UR - https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16310 ER - TY - JOUR T1 - Prehospital and Posthospital Fall Injuries in Older US Adults JF - JAMA Network Open Y1 - 2020 A1 - Geoffrey J Hoffman A1 - Mary Tinetti A1 - Ha, Jinkyung A1 - Neil B. Alexander A1 - Lillian C. Min KW - Fall injury KW - Hospitalization KW - Medicare AB - To date, measurement and treatment of older adult fall injury has been siloed within specific care settings, such as a hospital or within a nursing home or community. Little is known about changes in fall risk across care settings. Understanding the occurrence of falls across settings has implications for measuring and incentivizing high-value care across care settings.To estimate the risk of older adult fall injury within and across discrete periods during a 12-month care episode anchored by an acute hospitalization.This cohort study is a longitudinal analysis of 12-month periods that include an anchor hospital stay using national data from 2006 to 2014. Participants included older (aged ≥65 years) Medicare fee-for-service beneficiaries from the Health and Retirement Study. Weekly fall injury rates were computed for 4 periods compared with the anchor hospitalization: at baseline (1-6 months before hospitalization), just before (<1 month before hospitalization), just after (<1 month after hospitalization), and at follow-up (1-6 months after hospitalization). Piecewise logistic regression models estimated weekly marginal risk of fall injury within each period, adjusting for sociodemographic and health characteristics. Fall injury risks for high-risk beneficiaries with a fall injury during the anchor hospitalization were also estimated. Data analysis was performed from November 2019 to April 2020.Fall injuries.In total, 10 106 anchor hospitalizations for 4101 beneficiaries (mean [SD] age, 77.1 [7.6] years; 5912 hospitalizations among women [58.5%]) were identified. The overall fall injury risk was 0.77%. In adjusted models, marginal increases in weekly fall injury risk just before hospitalization (0.27 percentage points [95% CI, 0.22 to 0.33 percentage points], or 30.0%; P < .001) were 4 times greater than decreases just after hospitalization (−0.18 percentage points [95% CI, −0.23 to −0.13 percentage points], or −9.2%; P < .001)]. A greater risk differential before and after hospitalization was observed for patients with an inpatient fall injury (1.89 percentage points [95% CI, 1.37 to 2.40], or 309.8%; P < .001; vs −0.39 percentage points [95% CI, −0.73 to −0.04], or −11.6%; P = .03).An episode-based assessment of fall injury illustrates substantial variability in period-specific risks over an extended period including an anchor hospitalization. Risk transitions between periods include sizable increases just before hospitalization that do not fully subside after hospital discharge. Financial incentives to coordinate hospital and posthospital care for patients at risk for fall injury are needed. These could include bundled payments for fall injury episodes that incentivize coordination across settings. VL - 3 SN - 2574-3805 IS - 8 ER - TY - JOUR T1 - Welcome Mats and On-Ramps for Older Adults: The Impact of the Affordable Care Act's Medicaid Expansions on Dual Enrollment in Medicare and Medicaid JF - Journal of Policy Analysis and Management Y1 - 2020 A1 - Melissa McInerney A1 - Jennifer M Mellor A1 - Lindsay M Sabik KW - Affordable Care Act KW - Medicaid KW - Medicare AB - Abstract For many low-income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out-of-pocket costs and additional benefits. We examine whether Medicaid participation by low-income adults age 65 and up increased as a result of Medicaid expansions to working-age adults under the Affordable Care Act (ACA). Previous literature documents so-called ?welcome mat? effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working-age adults increased Medicaid participation among low-income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an ?on-ramp? effect; that is, low-income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non-expansion states. This on-ramp effect is an important mechanism behind welcome mat effects among some older adults. SN - 0276-8739 ER - TY - THES T1 - Essays in Macroeconomics and Labor Economics T2 - Economics Y1 - 2019 A1 - Tan,Fu KW - 0501:Economics KW - 0510:Labor economics KW - Economics KW - Information technology KW - Labor economics KW - Life-cycle KW - Long-term Care KW - Medicaid KW - Medicare KW - Occupational employment KW - Social Sciences AB - The first chapter studies the interaction between family insurance and social insurance. In particular, this paper assesses the value of Medicaid for recent retirees in insuring against long-term care risks while taking into account child-to-parent transfers. Parent retirees receive substantial transfers in the forms of informal care and financial transfers from children. To understand the role of upward intergenerational insurance for old-age health risks, I develop a dynamic model for parent-child pairs and childless retirees. A vital feature of the model is that a parent and her child interact strategically to make decisions about transfers in a non-cooperative game. I estimate and calibrate the model to match the Health and Retirement Study (HRS) data. Using the calibrated model, I calculate the insurance values of Medicaid relative to its cost for retirees and child households. Compensating variation calculations suggest that childless retirees value every dollar of Medicaid insurance at $2.20, which is twice the value for parent retirees ($1.10). Furthermore, I find that middle-income parent retirees value Medicaid insurance less than poor and wealthy parent retirees. An additional result of the paper is that child households also value Medicaid. This decomposition provides a new consideration for the efficient design of Medicaid benefits, particularly in light of a growing population aging without children. The second chapter studies the role of medical expenditure risks in elderly consumption choices. Old-age medical expenditure risks have been documented to have significant impacts on elderly savings. However, little is known about the consumption effects of elderly medical expenditure risks. In this study, we examine the effect of medical expenditure risk on elderly household consumption behaviors. We identify the causal effect by exploiting the exogenous reduction in prescription drug spending risk as a result of the introduction of Medicare Part D in the U.S. in 2006. Using the Health and Retirement Study (HRS) data during 2004–2010, we find that declining medical expenditure risks had little impact on total consumption, regardless of nondurable or durable consumption. The third chapter explores the reasons why the growth rate of non-routine cognitive occupations employment has significantly declined during 2000–2014, compared to 1985–2000. I propose and test the hypothesis that tasks related to information gathering and processing have been substituted by recent information technology after 2000. For that, I develop a model of production process. A novel feature of the model is that outputs are produced using a set of tasks, which combine occupation-specific labor and capital inputs. Recent information technological change is modeled as the declines in the occupation-specific cost of capital. I estimate the conditional labor and product demand using U.S. data. Results of the estimation show that the cost of capital, which is used with occupations related to information gathering and processing in production, has declined faster after 2000. My work contributes to the job polarization literature by documenting and exploring the new dynamics of technological change. JF - Economics PB - University of Wisconsin-Madison VL - PhD SN - 9781392287149 N1 - Copyright - Database copyright ProQuest LLC; ProQuest does not claim copyright in the individual underlying works; Last updated - 2019-07-24 ER - TY - JOUR T1 - The Impact of Income-Related Medicare Part B Premiums on Labor Supply JF - ILR Review: The Journal of Work and Policy Y1 - 2019 A1 - Padmaja Ayyagari A1 - Frank A Sloan KW - Labor KW - Labor Dynamics KW - Medicare KW - Medicare Part B AB - The 2003 Medicare Modernization Act introduced income-related premiums on Medicare coverage for professional services (Part B) for the first time. Beginning in 2007, higher-income households were required to pay higher premiums for Part B coverage, which raises the price of Medicare relative to employer-sponsored health insurance for these households. The authors exploit this exogenous change in Medicare policy to examine the impact of Part B premiums on the labor supply decisions of older adults. They find that higher Medicare premiums delay retirement. Findings have important implications for Medicare policy and labor markets. UR - https://doi.org/10.1177/0019793919891973 ER - TY - JOUR T1 - Out-of-pocket health spending among Medicare beneficiaries: Which chronic diseases are most costly? JF - PLoS One Y1 - 2019 A1 - Joelle H Fong KW - Chronic Diseases KW - Medicare KW - Medicare Beneficiaries KW - Out-of-pocket payments AB -

BACKGROUND: Little is known about the impact of different types of chronic diseases on older adults' out-of-pocket healthcare spending and whether certain diseases trigger higher spending needs than others.

METHODS: We use data from the 2014 Health and Retirement Study representing a weighted population of 35,939,270 Medicare beneficiaries aged 65+. Generalized linear models are applied to estimate the effect of different chronic diseases on total out-of-pocket expenditure, adjusted for demographics, socio-economic status, physical health, and other factors. We also decompose total spending by expenditure categories (inpatient, non-inpatient, and prescription drug spending). Sensitivity analysis is performed using a younger sample of older adults aged 50-64.

RESULTS: Cardiovascular disease, diabetes, hypertension and cancer, induce significantly higher adjusted out-of-pocket spending among older adults than other conditions. These results hold regardless how the spending differences are assessed (absolute or percentage terms). For Medicare beneficiaries, cardiovascular disease is associated with an excess out-of-pocket spending of $317 per year, followed by diabetes ($237), hypertension ($150), and cancer ($144). Prescription drug spending is singularly the most important driver of additional expenses for cardiovascular disease, diabetes and hypertension, while non-inpatient services spending accounts for the bulk of increased spending among those with cancer.

CONCLUSIONS: Our finding that major noncommunicable diseases impact individuals' out-of-pocket medical spending differentially-and that service drivers of increased spending may be heterogeneous across disease types-suggest that health professionals and policymakers should recognize that certain chronic diseases exert greater financial toll on the elderly. Interventions to promote more cost efficient healthcare services and consumer choices can help older adults better cope with these expensive long-lasting conditions and reduce the overall burden of noncommunicable diseases.

VL - 14 UR - https://www.ncbi.nlm.nih.gov/pubmed/31539389 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/31539389?dopt=Abstract ER - TY - JOUR T1 - Racial disparities and temporal trends in dementia misdiagnosis risk in the United States JF - Alzheimer's and Dementia: Translational Research and Clinical Interventions Y1 - 2019 A1 - Kan Z Gianattasio A1 - Prather, C. A1 - M. Maria Glymour A1 - Ciarleglio, A. A1 - Melinda C Power KW - Aged KW - algorithm KW - ancestry group KW - Article KW - Black person KW - Caucasian KW - Dementia KW - diagnostic error KW - ethnic group KW - Female KW - health disparity KW - human KW - ICD-9-CM KW - major clinical study KW - Male KW - Medicare KW - priority journal KW - Retirement KW - risk factor KW - sensitivity analysis KW - Sensitivity and Specificity KW - United States AB - Introduction: Systematic disparities in misdiagnosis of dementia across racial/ethnic groups have implications for health disparities. We compared the risk of dementia under- and overdiagnosis in clinical settings across racial/ethnic groups from 2000 to 2010. Methods: We linked fee-for-service Medicare claims to participants aged ≥70 from the nationally representative Health and Retirement Study. We classified dementia status using an algorithm with similar sensitivity and specificity across racial/ethnic groups and assigned clinical dementia diagnosis status using ICD-9-CM codes from Medicare claims. Multinomial logit models were used to estimate relative risks of clinical under- and overdiagnosis between groups and over time. Results: Non-Hispanic blacks had roughly double the risk of underdiagnosis as non-Hispanic whites. While primary analyses suggested a shrinking disparity over time, this was not robust to sensitivity analyses or adjustment for covariates. Risk of overdiagnosis increased over time in both groups. Discussion: Our results suggest that efforts to reduce racial disparities in underdiagnosis are warranted. © 2019 The Authors VL - 5 ER - TY - RPRT T1 - Recession vs Policy Shock: 2008, Medicare Part D & Grandparent Childcare Y1 - 2019 A1 - Michael Ewing Roberts KW - Economics KW - Medicare KW - Medicare Part D KW - Recession AB - Many studies have found grandparent provided childcare (GPCC) is of higher quality on average than center-based care, and that the availability of childcare itself increases the labor foce participation rates of women. This has led to this investigation into the influence of income and wealth on the supply of GPCC. Using restricted-use data from the Health and Retirement Survey, this investigation focuses on labor income, household wealth, age, health factors, family size, and period dummies to understand how the 2008 recession affected GPCC provision. This study is the first of its kind to include state fixed-effects and to focus on the 2008 recession. Results suggest that there is no difference between the recession and recovery periods themselves but that work income and wealth are significant predictors with small magnitude. Sub-sample regressions run by sex and coupled status suggest that work income influences female GPCC decisions more than male and coupled respondents more than single. This finding suggests that socially constructed systems of constraint may be present in the decision making studied. Finally, using an inverseprobability weighted regression adjusted estimator, the effect of Medicare Part D on providing any GPCC is tested. Limits to the data leaves the effect ambiguous but suggests confirmation of the fixed-effects model. UR - http://www.essentiallyeconomics.com/wp-content/uploads/2019/05/Job-Market-Paper.pdf ER - TY - JOUR T1 - Reducing Disparities in Healthy Aging Through an Enhanced Medicare Annual Wellness Visit JF - Public Policy & Aging Report Y1 - 2019 A1 - Tipirneni, Renuka A1 - Ganguli, Ishani A1 - John Z. Ayanian A1 - Kenneth M. Langa KW - Health Disparities KW - Medicare KW - Well-being AB - In its current form, the Medicare annual wellness visit (AWV) is not reaching most older Americans, particularly lower-income or minority adults and those served by safety-net providers (Ganguli, Souza, McWilliams, & Mehrotra, 2018). Yet these underserved seniors face disparities in healthy aging, likely due to individual, social, and behavioral determinants of health, such as low income, limited education, social isolation, food insecurity, poor housing quality, and difficulty affording medications. New AWV models should move beyond traditional assessments of cognition, balance, and vision to identify and address important root causes of poor health, such as individual, social, and behavioral determinants of health. Incorporating these key determinants of health into AWVs has the potential to promote healthy aging among underserved seniors. In this paper, we present local opportunities for AWV-related practice transformation, including screening tools, electronic health record templates, care team member roles, and workflows. At the national level, we suggest updates to Medicare’s current AWV policy guidelines with regard to visit elements and funding models. VL - 29 UR - https://academic.oup.com/ppar/advance-article/doi/10.1093/ppar/pry048/5251985http://academic.oup.com/ppar/advance-article-pdf/doi/10.1093/ppar/pry048/27184822/pry048.pdf IS - 1 ER - TY - RPRT T1 - Thoughts on Medicare for All Y1 - 2019 A1 - Kuziemko, Ilyana KW - Medicare JF - Policy Brief PB - Economics for Inclusive Prosperity UR - https://econfip.org/policy-briefs/thoughts-on-medicare-for-all/ ER - TY - RPRT T1 - Cumulative Out-of-Pocket Health Care Expenses After the Age of 70 Y1 - 2018 A1 - Sudipto Banerjee KW - Healthcare KW - Medicare KW - Out-of-pocket payments AB - This study estimates how much retirees spend on out-of-pocket health care expenses after age 70 until their death. Unlike many other studies, it includes only expenses for health care services actually used (i.e., Medicare and insurance premiums are not included), and it is based on self-reported expenses of actual retirees and not on projections for hypothetical individuals. The numbers are adjusted for medical inflation and reported in 2015 dollars. The self-reported expenses are from panel data from the Asset and Health Dynamics Among the Oldest Old (AHEAD) cohort of the Health and Retirement Study (HRS). JF - Issue Brief PB - Employee Benefit Research Institute CY - Washington, DC UR - https://www.ebri.org/pdf/briefspdf/EBRI_IB_446.pdf ER - TY - JOUR T1 - An Examination of Veteran Health Access Around the Medicare Eligibility Age JF - Contemporary Economic Policy Y1 - 2018 A1 - Stype, Amanda C. KW - Healthcare KW - Medicare KW - Preventative Care KW - Veterans AB - Recent news reports suggest that veterans' health care may be inadequate. We use Health and Retirement Study data to compare utilization rates for preventative care by male veterans and nonveterans before and after the near-universal health coverage at Medicare eligibility. Larger increases in utilization rates for preventative services upon reaching Medicare eligibility at age 65 are associated with less health care adequacy before Medicare eligibility. Results suggest that health care adequacy for male veterans between the ages of 56 and 64 is at least as good as that of nonveterans and may be better. (JEL I14, J14). © 2017 Western Economic Association International VL - 36 UR - http://doi.wiley.com/10.1111/coep.2018.36.issue-3http://doi.wiley.com/10.1111/coep.12259http://onlinelibrary.wiley.com/wol1/doi/10.1111/coep.12259/fullpdfhttps://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111%2Fcoep.12259 IS - 3 JO - Contemp Econ Policy ER - TY - JOUR T1 - High Burden of Palliative Care Needs of Older Adults During Emergency Major Abdominal Surgery JF - Journal of the American Geriatrics Society Y1 - 2018 A1 - Cooper, Zara A1 - Elizabeth J Lilley A1 - Bollens-Lund, Evan A1 - Susan L Mitchell A1 - Christine S Ritchie A1 - Stuart R Lipsitz A1 - Amy Kelley KW - Medicare KW - Mortality KW - Palliative care KW - Surgery AB - Objectives: To quantify preoperative illness burden in older adults undergoing emergency major abdominal surgery (EMAS), to examine the association between illness burden and postoperative outcomes, and to describe end-of-life care in the year after discharge. Design: Retrospective study using data from Health and Retirement Study interviews linked to Medicare claims (2000–2012). Setting: National population-based dataset. Participants: Medicare beneficiaries who underwent EMAS. Measurements: High illness burden, defined as ≥2 of the following vulnerabilities: functional dependence, dementia, use of helpers, multimorbidity, poor prognosis, high healthcare utilization. In-hospital outcomes were complications and mortality. Postdischarge outcomes included emergency department (ED) visits, hospitalization, intensive care unit (ICU) stay, and 365-day mortality. For individuals discharged alive who died within 365 days of surgery, outcomes included hospice use, hospitalization, ICU use, and ED use in the last 30 days of life. Multivariable regression was used to determine the association between illness burden and outcomes. Results: Of 411 participants, 57% had high illness burden. More individuals with high illness burden had complications (45% vs 28% p=0.00) and in-hospital death (20% vs 9%, p=0.00) than those without. After discharge (n=349), individuals with high illness burden experienced more ED visits (57% vs 46%, P=.04) and were more likely to die (35% vs 13%, p=0.00). Of those who died after discharge (n=86), 75% had high illness burden, median survival was 67 days (range 21–141 days), 48% enrolled in hospice, 32% died in the hospital, 23% were in the ICU in the last 30 days of life and 37% had an ED visit in the last 30 days of life. Conclusion: Most older adults undergoing EMAS have preexisting high illness burden and experience high mortality and healthcare use in the year after surgery, particularly near the end of life. Concurrent surgical and palliative care may improve quality of life and end-of-life care in these people. © 2018, Copyright the Author Journal compilation © 2018, The American Geriatrics Society UR - http://doi.wiley.com/10.1111/jgs.15516http://onlinelibrary.wiley.com/wol1/doi/10.1111/jgs.15516/fullpdfhttps://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111%2Fjgs.15516 JO - J Am Geriatr Soc ER - TY - JOUR T1 - Means Testing Federal Health Entitlement Benefits JF - Tax Policy and the Economy Y1 - 2018 A1 - Andrew A. Samwick KW - Affordable Care Act KW - Health Insurance KW - Income KW - Medicare KW - Poverty KW - Social Security linkage AB - Recent federal legislation has linked the price paid for health insurance benefits to current income. Under the Patient Protection and Affordable Care Act of 2010, individuals and families with income as high as 400% of the federal poverty level are eligible for premium tax credits that limit their health insurance premiums to under 10% of their income. Under the Medicare Modernization Act of 2003, higher-income beneficiaries face income-related premiums over three times the standard premium for Part B coverage. For workers at or near retirement age, means testing based on current income provides an incentive for early retirement, dissaving, and income manipulation, raising concerns about the efficiency of such means testing. Further, current income is subject to short-term fluctuations, making it a noisy predictor of ability to pay. Using the Health and Retirement Study and linked Social Security earnings histories, this paper introduces a measure of lifetime income that compares favorably to current income as a basis for means testing. It offers less short-term variation in premiums while improving incentives for preretirement work and saving. VL - 32 IS - 1 JO - Tax Policy and the Economy ER - TY - JOUR T1 - Pain and Hardship Among Older Men: Examining the Buffering Effect of Medicare Insurance Coverage JF - American Journal of Men's Health Y1 - 2018 A1 - Gillian L Marshall A1 - Tamara A. Baker A1 - Song, Chiho A1 - Miller, David B. KW - Insurance KW - Medicare KW - Men's health AB - To better understand the health status of men in the United States, this study aimed to assess the association of hardship on the presence of and pain severity among men 50 years of age and older. Cross-sectional multivariate logistic regression analyses were conducted using the 2010 wave of the Health and Retirement Study (N = 3,174) to assess the association between four hardship indicators and the presence of pain and pain severity among this sample of older men. Results suggest that the association between the presence of pain and hardship was statistically significant across all four indicators: ongoing financial hardship (CI [1.05, 1.63], p < .05), difficulty paying bills (CI [1.42, 3.02], p < .001), food insecurity (CI [1.46, 3.15], p < .001), and not taking medication due to cost (CI [1.06, 1.66], p < .05), even after adjusting for all demographic factors. The associations between pain severity and ongoing financial strain (CI [1.23, 2.83], p < .01) and difficulty paying bills (CI [1.02, 3.18], p < .05) were statistically significant. Results also indicate that education was a buffer at all levels. In addition, the interactive effect of hardship and Medicare insurance coverage on pain severity was significant only for ongoing financial strain (CI [1.74, 14.33], p > .001) and difficulty paying bills (CI [1.26, 7.05], p < .05). The evidence is clear that each hardship indicators is associated with the presence of pain and across some of the indicators in pain severity among men aged 50 and older. In addition, these findings stress the importance that Medicare insurance plays in acting as a buffer to alleviate some of the hardships experienced by older men. These findings also highlight the association between the presence of pain and pain severity for the overall quality of life, health outcomes, and financial position of men in later life. VL - 12 UR - http://journals.sagepub.com/doi/full/10.1177/1557988318765921http://journals.sagepub.com/doi/pdf/10.1177/1557988318765921http://journals.sagepub.com/doi/pdf/10.1177/1557988318765921http://journals.sagepub.com/doi/full-xml/10.1177/1557988318765921 IS - 5 JO - Am J Mens Health ER - TY - JOUR T1 - Social Exclusion and Switching Barriers in Medicare Part D Choices JF - Sustainability Y1 - 2018 A1 - Ko, Dong A1 - Bae, Young A1 - Han, Jayoung KW - Healthcare KW - Medicare KW - Medicare Part D KW - Prescription Medication AB - Previous studies have shown that Medicare beneficiaries do not tend to switch their prescription drug plans (Part D), even though they can greatly save on the money spent on drugs by switching plans. To explore this occurrence, the present study focused on the concept of social exclusion-one of the most important characteristics prevalent in the elderly. This study compared the impact of two types of social exclusion on the association between psychological cost and plan switching: active (or rejected) social exclusion and passive (or ignored) social exclusion. The study's aim was to examine the moderating effect of social exclusion on the relationship between the cost of switching and willingness to switch plan to build sustainable health care system. The Prescription Drug Study supplementary to the Health and Retirement Study (HRS) data were utilized for analysis by applying a Hierarchical Linear Model (HLM) (N = 1042). The findings suggest that active social exclusion moderates the relationship between the switching cost and willingness to switch plan. This study's findings will help policymakers better understand the elderly's decision-making process pertaining to plans and promote their informed plan decisions to build sustainable health care system. VL - 10 UR - http://www.mdpi.com/2071-1050/10/7/2419http://www.mdpi.com/2071-1050/10/7/2419/pdf IS - 7 JO - Sustainability ER - TY - JOUR T1 - The Costs of Fall-Related Injuries among Older Adults: Annual Per-Faller, Service Component, and Patient Out-of-Pocket Costs. JF - Health Serv Res Y1 - 2017 A1 - Geoffrey J Hoffman A1 - Hays, Ron D A1 - Martin F Shapiro A1 - Steven P Wallace A1 - Susan L Ettner KW - Accidental Falls KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Female KW - Financing, Personal KW - Health Expenditures KW - Health Services KW - Humans KW - Male KW - Medicare KW - Models, Econometric KW - Sex Factors KW - Socioeconomic factors KW - United States KW - Wounds and Injuries AB -

OBJECTIVE: To estimate expenditures for fall-related injuries (FRIs) among older Medicare beneficiaries.

DATA SOURCES: The 2007-2009 Medicare claims and 2008 Health and Retirement Study (HRS) data for 5,497 (228 FRI and 5,269 non-FRI) beneficiaries.

STUDY DESIGN: FRIs were indicated by inpatient/outpatient ICD-9 diagnostic codes for fractures, trauma, dislocations, and by e-codes. A pre-post comparison group design was used to estimate the differential change in pre-post expenditures for the FRI relative to the non-FRI cohort (FRI expenditures). Out-of-pocket (OOP) costs, service category total annual FRI-related Medicare expenditures, expenditures related to the type of initial FRI treatment (inpatient, ED, outpatient), and the risk of persistently high expenditures (4th quartile for each post-FRI quarter) were estimated.

PRINCIPAL FINDINGS: Estimated FRI expenditures were $9,389 (95 percent CI: $5,969-$12,808). Inpatient, physician/outpatient, skilled nursing facility, and home health comprised 31, 18, 39, and 12 percent of the total. OOP costs were $1,363.0 (95 percent CI: $889-$1,837). Expenditures for FRIs initially treated in inpatient/ED/outpatient settings were $21,424/$6,142/$8,622. The FRI cohort had a 64 percent increased risk of persistently high expenditures. Total Medicare expenditures were $13 billion (95 percent CI: $9-$18 billion).

CONCLUSIONS: FRIs are associated with substantial, persistent Medicare expenditures. Cost-effectiveness of multifactorial falls prevention programs should be assessed using these expenditure estimates.

VL - 52 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27581952?dopt=Abstract ER - TY - JOUR T1 - Genetic Predisposition to Obesity and Medicare Expenditures JF - The Journals of Gerontology: Series A Y1 - 2017 A1 - George L Wehby A1 - Benjamin W Domingue A1 - Fred A Ullrich A1 - Frederic D Wolinsky KW - genetic predisposition KW - Genetics KW - Medicare KW - Obesity AB - The relationship between obesity and health expenditures is not well understood. We examined the relationship between genetic predisposition to obesity measured by a polygenic risk score for body mass index (BMI) and Medicare expenditures.Biennial interview data from the Health and Retirement Survey for a nationally representative sample of older adults enrolled in fee-for-service Medicare were obtained from 1991 through 2010 and linked to Medicare claims for the same period and to Genome-Wide Association Study (GWAS) data. The study included 6,628 Medicare beneficiaries who provided 68,627 complete person-year observations during the study period. Outcomes were total and service-specific Medicare expenditures and indicators for expenditures exceeding the 75th and 90th percentiles. The BMI polygenic risk score was derived from GWAS data. Regression models were used to examine how the BMI polygenic risk score was related to health expenditures adjusting for demographic factors and GWAS-derived ancestry.Greater genetic predisposition to obesity was associated with higher Medicare expenditures. Specifically, a 1 SD increase in the BMI polygenic risk score was associated with a \\$805 (p \< .001) increase in annual Medicare expenditures per person in 2010 dollars ( 15\% increase), a \\$370 (p \< .001) increase in inpatient expenses, and a \\$246 (p \< .001) increase in outpatient services. A 1 SD increase in the polygenic risk score was also related to increased likelihood of expenditures exceeding the 75th percentile by 18\% (95\% CI: 10\%–28\%) and the 90th percentile by 27\% (95\% CI: 15\%–40\%).Greater genetic predisposition to obesity is associated with higher Medicare expenditures. VL - 73 UR - https://doi.org/10.1093/gerona/glx062 ER - TY - RPRT T1 - How much does Out-of-Pocket Medical Spending Eat Away at Retirement Income? Y1 - 2017 A1 - Melissa McInerney A1 - Matthew S. Rutledge A1 - Sara Ellen King KW - Gender Differences KW - Income KW - Medicare KW - Social Security AB - The adequacy of retirement income – from Social Security benefits and other sources – is substantially reduced by Medicare’s high out-of-pocket (OOP) costs. This project uses the 2002-2014 Health and Retirement Study to calculate post-OOP benefit ratios, defined as the share of either Social Security benefits or total income available for non-medical spending. The project decomposes the share of income that is going toward premium payments and services delivered and examines how these post-OOP benefit ratios differ by age, gender, income, supplemental insurance coverage, and health status. The project also updates previous studies’ estimates to document how OOP spending and the post-OOP income ratios changed following the introduction of Medicare Part D prescription drug coverage in 2006 and the closing of the “donut hole” coverage gap in 2010, which decreased OOP costs under Part D for those spending moderate amounts on prescriptions. JF - Working Papers PB - Center for Retirement Research at Boston College CY - Boston, MA UR - http://crr.bc.edu/working-papers/how-much-does-out-of-pocket-medical-spending-eat-away-at-retirement-income/ ER - TY - JOUR T1 - Identifying Older Adults with Serious Illness: A Critical Step toward Improving the Value of Health Care. JF - Health Serv Res Y1 - 2017 A1 - Amy Kelley A1 - Kenneth E Covinsky A1 - Rebecca Jean Gorges A1 - McKendrick, Karen A1 - Bollens-Lund, Evan A1 - R Sean Morrison A1 - Christine S Ritchie KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Critical Illness KW - Early Diagnosis KW - Female KW - Health Care Costs KW - Hospitalization KW - Humans KW - Male KW - Medicare KW - Nursing homes KW - Prospective Studies KW - Quality Improvement KW - United States AB -

OBJECTIVE: To create and test three prospective, increasingly restrictive definitions of serious illness.

DATA SOURCES: Health and Retirement Study, 2000-2012.

STUDY DESIGN: We evaluated subjects' 1-year outcomes from the interview date when they first met each definition: (A) one or more severe medical conditions (Condition) and/or receiving assistance with activities of daily living (Functional Limitation); (B) Condition and/or Functional Limitation and hospital admission in the last 12 months and/or residing in a nursing home (Utilization); and (C) Condition and Functional Limitation and Utilization. Definitions are increasingly restrictive, but not mutually exclusive.

DATA COLLECTION: Of 11,577 eligible subjects, 5,297 met definition A; 3,151 definition B; and 1,447 definition C.

PRINCIPAL FINDINGS: One-year outcomes were as follows: hospitalization 33 percent (A), 44 percent (B), 47 percent (C); total average Medicare costs $20,566 (A), $26,349 (B), and $30,828 (C); and mortality 13 percent (A), 19 percent (B), 28 percent (C). In comparison, among those meeting no definition, 12 percent had hospitalizations, total Medicare costs averaged $7,789, and 2 percent died.

CONCLUSIONS: Prospective identification of older adults with serious illness is feasible using clinically accessible criteria and may be a critical step toward improving health care value. These definitions may aid clinicians and health systems in targeting patients who could benefit from additional services.

VL - 52 UR - http://www.ncbi.nlm.nih.gov/pubmed/26990009 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26990009?dopt=Abstract U4 - Medicare; geriatrics; palliative medicine; population health ER - TY - JOUR T1 - Identifying Specific Combinations of Multimorbidity that Contribute to Health Care Resource Utilization: An Analytic Approach. JF - Med Care Y1 - 2017 A1 - Nicholas K Schiltz A1 - David F Warner A1 - Jiayang Sun A1 - Paul M Bakaki A1 - Avi Dor A1 - Charles W Given A1 - Kurt C Stange A1 - Siran M Koroukian KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Comorbidity KW - Female KW - Health Behavior KW - Health Expenditures KW - Health Status KW - Humans KW - Machine learning KW - Male KW - Medicare KW - Retrospective Studies KW - Self Report KW - Socioeconomic factors KW - United States AB -

BACKGROUND: Multimorbidity affects the majority of elderly adults and is associated with higher health costs and utilization, but how specific patterns of morbidity influence resource use is less understood.

OBJECTIVE: The objective was to identify specific combinations of chronic conditions, functional limitations, and geriatric syndromes associated with direct medical costs and inpatient utilization.

DESIGN: Retrospective cohort study using the Health and Retirement Study (2008-2010) linked to Medicare claims. Analysis used machine-learning techniques: classification and regression trees and random forest.

SUBJECTS: A population-based sample of 5771 Medicare-enrolled adults aged 65 and older in the United States.

MEASURES: Main covariates: self-reported chronic conditions (measured as none, mild, or severe), geriatric syndromes, and functional limitations. Secondary covariates: demographic, social, economic, behavioral, and health status measures.

OUTCOMES: Medicare expenditures in the top quartile and inpatient utilization.

RESULTS: Median annual expenditures were $4354, and 41% were hospitalized within 2 years. The tree model shows some notable combinations: 64% of those with self-rated poor health plus activities of daily living and instrumental activities of daily living disabilities had expenditures in the top quartile. Inpatient utilization was highest (70%) in those aged 77-83 with mild to severe heart disease plus mild to severe diabetes. Functional limitations were more important than many chronic diseases in explaining resource use.

CONCLUSIONS: The multimorbid population is heterogeneous and there is considerable variation in how specific combinations of morbidity influence resource use. Modeling the conjoint effects of chronic conditions, functional limitations, and geriatric syndromes can advance understanding of groups at greatest risk and inform targeted tailored interventions aimed at cost containment.

VL - 55 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27753745?dopt=Abstract ER - TY - JOUR T1 - Multimorbidity: constellations of conditions across subgroups of midlife and older individuals, and related Medicare expenditures. JF - J Comorbidity Y1 - 2017 A1 - Siran M Koroukian A1 - Nicholas K Schiltz A1 - David F Warner A1 - Jiayang Sun A1 - Kurt C Stange A1 - Charles W Given A1 - Avi Dor KW - Death KW - Medicare KW - Medicare claims data KW - multimorbidity AB -

INTRODUCTION: The Department of Health and Human Services' 2010 Strategic Framework on Multiple Chronic Conditions called for the identification of common constellations of conditions in older adults.

OBJECTIVES: To analyze patterns of conditions constituting multimorbidity (CCMM) and expenditures in a US representative sample of midlife and older adults (50-64 and ≥65 years of age, respectively).

DESIGN: A cross-sectional study of the 2010 Health and Retirement Study (HRS; =17,912). The following measures were used: (1) count and combinations of CCMM, including (i) chronic conditions (hypertension, arthritis, heart disease, lung disease, stroke, diabetes, cancer, and psychiatric conditions), (ii) functional limitations (upper body limitations, lower body limitations, strength limitations, limitations in activities of daily living, and limitations in instrumental activities of daily living), and (iii) geriatric syndromes (cognitive impairment, depressive symptoms, incontinence, visual impairment, hearing impairment, severe pain, and dizziness); and (2) annualized 2011 Medicare expenditures for HRS participants who were Medicare fee-for-service beneficiaries (=5,677). Medicaid beneficiaries were also identified based on their self-reported insurance status.

RESULTS: No large representations of participants within specific CCMM categories were observed; however, functional limitations and geriatric syndromes were prominently present with higher CCMM counts. Among fee-for-service Medicare beneficiaries aged 50-64 years, 26.7% of the participants presented with ≥10 CCMM, but incurred 48% of the expenditure. In those aged ≥65 years, these percentages were 16.9% and 34.4%, respectively.

CONCLUSION: Functional limitations and geriatric syndromes considerably add to the MM burden in midlife and older adults. This burden is much higher than previously reported.

VL - 7 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/29090187?dopt=Abstract ER - TY - JOUR T1 - Out-of-Pocket Spending and Financial Burden Among Medicare Beneficiaries With Cancer. JF - JAMA Oncol Y1 - 2017 A1 - Amol K Narang A1 - Lauren Hersch Nicholas KW - Aged KW - Cost of Illness KW - Female KW - Financing, Personal KW - Health Expenditures KW - Humans KW - Income KW - Insurance, Health KW - Male KW - Medicare KW - Neoplasms KW - Prospective Studies KW - Social Class KW - United States AB -

Importance: Medicare beneficiaries with cancer are at risk for financial hardship given increasingly expensive cancer care and significant cost sharing by beneficiaries.

Objectives: To measure out-of-pocket (OOP) costs incurred by Medicare beneficiaries with cancer and identify which factors and services contribute to high OOP costs.

Design, Setting, and Participants: We prospectively collected survey data from 18 166 community-dwelling Medicare beneficiaries, including 1409 individuals who were diagnosed with cancer during the study period, who participated in the January 1, 2002, to December 31, 2012, waves of the Health and Retirement Study, a nationally representative panel study of US residents older than 50 years. Data analysis was performed from July 1, 2014, to June 30, 2015.

Main Outcomes and Measures: Out-of-pocket medical spending and financial burden (OOP expenditures divided by total household income).

Results: Among the 1409 participants (median age, 73 years [interquartile range, 69-79 years]; 46.4% female and 53.6% male) diagnosed with cancer during the study period, the type of supplementary insurance was significantly associated with mean annual OOP costs incurred after a cancer diagnosis ($2116 among those insured by Medicaid, $2367 among those insured by the Veterans Health Administration, $5976 among those insured by a Medicare health maintenance organization, $5492 among those with employer-sponsored insurance, $5670 among those with Medigap insurance coverage, and $8115 among those insured by traditional fee-for-service Medicare but without supplemental insurance coverage). A new diagnosis of cancer or common chronic noncancer condition was associated with increased odds of incurring costs in the highest decile of OOP expenditures (cancer: adjusted odds ratio, 1.86; 95% CI, 1.55-2.23; P < .001; chronic noncancer condition: adjusted odds ratio, 1.82; 95% CI, 1.69-1.97; P < .001). Beneficiaries with a new cancer diagnosis and Medicare alone incurred OOP expenditures that were a mean of 23.7% of their household income; 10% of these beneficiaries incurred OOP expenditures that were 63.1% of their household income. Among the 10% of beneficiaries with cancer who incurred the highest OOP costs, hospitalization contributed to 41.6% of total OOP costs.

Conclusions and Relevance: Medicare beneficiaries without supplemental insurance incur significant OOP costs following a diagnosis of cancer. Costs associated with hospitalization may be a primary contributor to these high OOP costs. Medicare reform proposals that restructure the benefit design for hospital-based services and incorporate an OOP maximum may help alleviate financial burden, as can interventions that reduce hospitalization in this population.

VL - 3 UR - http://oncology.jamanetwork.com/article.aspx?doi=10.1001/jamaoncol.2016.4865 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27893028?dopt=Abstract JO - JAMA Oncol ER - TY - JOUR T1 - Smoking Response to Health and Medical Spending Changes and the Role of Insurance. JF - Health Econ Y1 - 2017 A1 - Marti, Joachim A1 - Michael R. Richards KW - Cardiovascular Diseases KW - Female KW - Health Behavior KW - Health Expenditures KW - Health Surveys KW - Humans KW - Insurance, Health KW - Male KW - Medically Uninsured KW - Medicare KW - Middle Aged KW - Risk Factors KW - Smoking KW - Socioeconomic factors KW - United States AB -

Severe health shocks provide new information about one's personal health and have been shown to influence smoking behaviors. In this paper, we suggest that they may also convey information about the hard to predict financial consequences of illnesses. Relevant financial risk information is idiosyncratic and unavailable to the consumer preceding illness, and the information search costs are high. However, new and salient information about the health as well as financial consequences of smoking after a health shock may impact smoking responses. Using variation in the timing of health shocks and two features of the US health care system (uninsured spells and aging into the Medicare program at 65), we test for heterogeneity in the post-shock smoking decision according to plausibly exogenous changes in financial risk exposure to medical spending. We also explore the relationship between smoking and the evolution of out-of-pocket costs. Individuals experiencing a cardiovascular health shock during an uninsured spell have more than twice the cessation effect of those receiving the illness while insured. For those uninsured prior to age 65 years, experiencing a cardiovascular shock post Medicare eligibility completely offsets the cessation effect. We also find that older adults' medical spending changes separate from health shocks influence their smoking behavior. Copyright © 2016 John Wiley & Sons, Ltd.

VL - 26 UR - http://dx.doi.org/10.1002/hec.3309 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26778716?dopt=Abstract U4 - smoking/health insurance/health shocks/moral hazard/Medicare ER - TY - JOUR T1 - Age Differences in the Association Between Body Mass Index Class and Annualized Medicare Expenditures. JF - J Aging Health Y1 - 2016 A1 - Daniel O. Clark A1 - Kathleen A Lane A1 - Ambuehl, Roberta A1 - Tu, Wanzhu A1 - Chiung-Ju Liu A1 - Kathleen T. Unroe A1 - Christopher M. Callahan KW - Age Factors KW - Aged KW - Body Mass Index KW - Female KW - Health Expenditures KW - Humans KW - Male KW - Medicare KW - Obesity KW - United States AB -

OBJECTIVE: The aim of the study is to assess the relationship between body mass index (BMI) class and Medicare claims among young-old (65-69), old (70-74), and old-old (75+) adults over a 10-year period.

METHOD: We assessed costs by BMI class and age group among 9,300 respondents to the 1998 Health and Retirement Study (HRS) with linked 1998-2008 Medicare claims data. BMI was classified as normal (18.5-24.9), overweight (25-29.9), mild obesity (30-34.9), or severe obesity (35 or above).

RESULTS: Annualized total Medicare claims adjusted for age, gender, ethnicity, education, and smoking history were 109% greater for severely obese young-old adults in comparison with normal weight young-old adults (US$9,751 vs. US$4,663). Total annualized claim differences between the normal weight and severely obese in the old and old-old groups were not statistically significant.

DISCUSSION: Excess Medicare expenditures related to obesity may be concentrated among severely obese young-old adults. Preventing severe obesity among middle and older aged adults may have large cost implications for society.

PB - 28 VL - 28 UR - http://jah.sagepub.com/content/28/1/165 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26112066?dopt=Abstract U2 - PMC4691214 ER - TY - JOUR T1 - Claims-based Identification Methods and the Cost of Fall-related Injuries Among US Older Adults. JF - Med Care Y1 - 2016 A1 - Geoffrey J Hoffman A1 - Hays, Ron D A1 - Martin F Shapiro A1 - Steven P Wallace A1 - Susan L Ettner KW - Accidental Falls KW - Aged KW - Aged, 80 and over KW - Cross-Over Studies KW - Female KW - Humans KW - Insurance Claim Review KW - Male KW - Medicare KW - United States KW - Wounds and Injuries AB -

OBJECTIVES: Compare expenditures of fall-related injuries (FRIs) using several methods to identify FRIs in administrative claims data.

RESEARCH DESIGN: Using 2007-2009 Medicare claims and 2008 Health and Retirement Survey data, FRIs were identified using external-cause-of-injury (e-codes 880/881/882/884/885/888) only, e-codes plus a broad set of primary diagnosis codes, and a newer approach using e-codes and diagnostic and procedural codes. Linear regression models adjusted for sociodemographic, health, and geographic characteristics were used to estimate per-FRI, service component, patient cost share, expenditures by type of initial FRI treatment (inpatient, emergency department only, outpatient), and total annual FRI-related Medicare expenditures.

SUBJECTS: The analysis included 5497 community-dwelling adults ≥65 (228 FRI, 5269 non-FRI individuals) with continuous Medicare coverage and alive during the 24-month study.

RESULTS: The 3 FRI identification methods produced differing distributions of index FRI type and varying estimated expenditures: $12,171 [95% confidence interval (CI), $4662-$19,680], $5648 (95% CI, $3819-$7476), and $9388 (95% CI, $5969-$12,808). In all models, most spending occurred in hospital, outpatient, and skilled nursing facility (SNF) settings, but greater proportions of SNF and outpatient spending were observed with commonly used FRI identification methods. Patient cost-sharing was estimated at $691-$1900 across the 3 methods. Inpatient-treated index FRIs were more expensive than emergency department and outpatient-treated FRIs across all methods, but were substantially higher when identifying FRI using only e-codes. Estimated total FRI-related Medicare expenditures were highly variable across methods.

CONCLUSIONS: FRIs are costly, with implications for Medicare and its beneficiaries. However, expenditure estimates vary considerably based on the method used to identify FRIs.

VL - 54 UR - http://www.ncbi.nlm.nih.gov/pubmed/27057747 IS - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27057747?dopt=Abstract ER - TY - JOUR T1 - Does the Relationship of the Proxy to the Target Person Affect the Concordance between Survey Reports and Medicare Claims Measures of Health Services Use? JF - Health Serv Res Y1 - 2016 A1 - George L Wehby A1 - Michael P Jones A1 - Fred A Ullrich A1 - Yiyue Lou A1 - Frederic D Wolinsky KW - Ambulatory Surgical Procedures KW - Female KW - Hospitalization KW - Humans KW - Insurance Claim Review KW - Male KW - Medicare KW - Patient Acceptance of Health Care KW - Proxy KW - Self Report KW - Socioeconomic factors KW - Spouses KW - United States AB -

OBJECTIVES: To compare concordance of survey reports of health service use versus claims data between self respondents and spousal and nonspousal relative proxies.

DATA SOURCES: 1995-2010 data from the Survey on Assets and Health Dynamics among the Oldest Old and 1993-2010 Medicare claims for 3,229 individuals (13,488 person-years).

STUDY DESIGN: Regression models with individual fixed effects were estimated for discordance of any hospitalizations and outpatient surgery and for the numbers of under- and over-reported physician visits.

PRINCIPAL FINDINGS: Spousal proxies were similar to self respondents on discordance. Nonspousal proxies, particularly daughters/daughters-in-law and sons/sons-in-law, had less discordance, mainly due to reduced under-reporting.

CONCLUSIONS: Survey reports of health services use from nonspousal relatives are more consistent with Medicare claims than spousal proxies and self respondents.

VL - 51 UR - https://www.ncbi.nlm.nih.gov/pubmed/26059195 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26059195?dopt=Abstract ER - TY - JOUR T1 - Functional status in older women diagnosed with pelvic organ prolapse. JF - Am J Obstet Gynecol Y1 - 2016 A1 - Tatiana V D Sanses A1 - Nicholas K Schiltz A1 - Bruna M. Couri A1 - Sangeeta T Mahajan A1 - Holly E Richter A1 - David F Warner A1 - Jack M. Guralnik A1 - Siran M Koroukian KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Aging KW - Cross-Sectional Studies KW - Female KW - Health Status KW - Health Surveys KW - Humans KW - Medicare KW - Middle Aged KW - Mobility Limitation KW - Muscle Strength KW - Pelvic Organ Prolapse KW - United States KW - Upper Extremity AB -

BACKGROUND: Functional status plays an important role in the comprehensive characterization of older adults. Functional limitations are associated with an increased risk of adverse treatment outcomes, but there are limited data on the prevalence of functional limitations in older women with pelvic floor disorders.

OBJECTIVE: The aim of the study was to describe the prevalence of functional limitations based on health status in older women with pelvic organ prolapse (POP).

STUDY DESIGN: This pooled, cross-sectional study utilized data from the linked Health and Retirement Study and Medicare files from 1992 through 2008. The analysis included 890 women age ≥65 years with POP. We assessed self-reported functional status, categorized in strength, upper and lower body mobility, activities of daily living (ADL), and instrumental ADL (IADL) domains. Functional limitations were evaluated and stratified by respondents self-reported general health status. Descriptive statistics were used to compare categorical and continuous variables, and logistic regression was used to measure differences in the odds of functional limitation by increasing age.

RESULTS: The prevalence of functional limitations was 76.2% in strength, 44.9% in upper and 65.8% in lower body mobility, 4.5% in ADL, and 13.6% in IADL. Limitations were more prevalent in women with poor or fair health status than in women with good health status, including 91.5% vs 69.9% in strength, 72.9% vs 33.5% in upper and 88.0% vs 56.8% in lower body mobility, 11.6% vs 0.9% in ADL, and 30.6% vs 6.7% in IADL; all P < .01. The odds of all functional limitations also increased significantly with advancing age.

CONCLUSION: Functional limitations, especially in strength and body mobility domains, are highly prevalent in older women with POP, particularly in those with poor or fair self-reported health status. Future research is necessary to evaluate if functional status affects clinical outcomes in pelvic reconstructive and gynecologic surgery and whether it should be routinely assessed in clinical decision-making when treating older women with POP.

PB - 214 VL - 214 UR - http://www.sciencedirect.com/science/article/pii/S0002937815024783 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26704893?dopt=Abstract U2 - PMC4851569 U4 - activities of daily living/functional status/limitations/mobility/pelvic organ prolapse/strength ER - TY - JOUR T1 - Late mortality after sepsis: propensity matched cohort study. JF - BMJ Y1 - 2016 A1 - Hallie C Prescott A1 - Osterholzer, John J A1 - Kenneth M. Langa A1 - Angus, Derek C A1 - Theodore J Iwashyna KW - Aged KW - Aged, 80 and over KW - Case-Control Studies KW - Cause of Death KW - Female KW - Hospital Mortality KW - Hospitalization KW - Humans KW - Longitudinal Studies KW - Male KW - Medicare KW - Propensity Score KW - Prospective Studies KW - Sepsis KW - Time Factors KW - United States AB -

OBJECTIVES:  To determine whether late mortality after sepsis is driven predominantly by pre-existing comorbid disease or is the result of sepsis itself.

DEIGN:  Observational cohort study.

SETTING:  US Health and Retirement Study.

PARTICIPANTS:  960 patients aged ≥65 (1998-2010) with fee-for-service Medicare coverage who were admitted to hospital with sepsis. Patients were matched to 777 adults not currently in hospital, 788 patients admitted with non-sepsis infection, and 504 patients admitted with acute sterile inflammatory conditions.

MAIN OUTCOME MEASURES:  Late (31 days to two years) mortality and odds of death at various intervals.

RESULTS:  Sepsis was associated with a 22.1% (95% confidence interval 17.5% to 26.7%) absolute increase in late mortality relative to adults not in hospital, a 10.4% (5.4% to 15.4%) absolute increase relative to patients admitted with non-sepsis infection, and a 16.2% (10.2% to 22.2%) absolute increase relative to patients admitted with sterile inflammatory conditions (P<0.001 for each comparison). Mortality remained higher for at least two years relative to adults not in hospital.

CONCLUSIONS:  More than one in five patients who survives sepsis has a late death not explained by health status before sepsis.

VL - 353 UR - https://www.ncbi.nlm.nih.gov/pubmed/27189000 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27189000?dopt=Abstract ER - TY - JOUR T1 - Neuroimaging overuse is more common in Medicare compared with the VA. JF - Neurology Y1 - 2016 A1 - James F. Burke A1 - Eve A Kerr A1 - Ryan J McCammon A1 - Holleman, Rob A1 - Kenneth M. Langa A1 - Brian C. Callaghan KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Female KW - Headache Disorders, Primary KW - Humans KW - Male KW - Medicare KW - Neuroimaging KW - Peripheral Nervous System Diseases KW - United States KW - United States Department of Veterans Affairs KW - Unnecessary Procedures AB -

OBJECTIVE: To inform initiatives to reduce overuse, we compared neuroimaging appropriateness in a large Medicare cohort with a Department of Veterans Affairs (VA) cohort.

METHODS: Separate retrospective cohorts were established in Medicare and in VA for headache and neuropathy from 2004 to 2011. The Medicare cohorts included all patients enrolled in the Health and Retirement Study (HRS) with linked Medicare claims (HRS-Medicare; n = 1,244 for headache and 998 for neuropathy). The VA cohorts included all patients receiving services in the VA (n = 93,755 for headache and 183,642 for neuropathy). Inclusion criteria were age over 65 years and an outpatient visit for incident neuropathy or a primary headache. Neuroimaging use was measured with Current Procedural Terminology codes and potential overuse was defined using published criteria for use with administrative data. Increasingly specific appropriateness criteria excluded nontarget conditions for which neuroimaging may be appropriate.

RESULTS: For both peripheral neuropathy and headache, potentially inappropriate imaging was more common in HRS-Medicare compared with the VA. Forty-nine percentage of all headache patients received neuroimaging in HRS-Medicare compared with 22.1% in the VA (p < 0.001) and differences persist when analyzing more specific definitions of overuse. A total of 23.7% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9.0% in the VA (p < 0.001), and the difference persisted after excluding nontarget conditions.

CONCLUSIONS: Overuse of neuroimaging is likely less common in the VA than in a Medicare population. Better understanding the reasons for the more selective use of neuroimaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing.

VL - 87 UR - http://www.ncbi.nlm.nih.gov/pubmed/27402889 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27402889?dopt=Abstract ER - TY - JOUR T1 - A pilot study among older adults of the concordance between their self-reports to a health survey and spousal proxy reports on their behalf. JF - BMC Health Serv Res Y1 - 2016 A1 - Frederic D Wolinsky A1 - Ayres, Lioness A1 - Michael P Jones A1 - Yiyue Lou A1 - George L Wehby A1 - Fred A Ullrich KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Epidemiologic Methods KW - Female KW - Health Status KW - Hospitalization KW - Humans KW - Iowa KW - Male KW - Medicare KW - Middle Aged KW - Patient Acceptance of Health Care KW - Physicians KW - Proxy KW - Spouses KW - United States AB -

BACKGROUND: Proxy respondents are frequently used in health surveys, and the proxy is most often the spouse. Longstanding concerns linger, however, about the validity of using spousal proxies, especially for older adults. The purpose of this pilot study was to evaluate the concordance between self-reports and spousal proxy reports to a standard health survey in a small convenience sample of older married couples.

METHODS: We used the Seniors Together in Aging Research (STAR) volunteer registry at the University of Iowa to identify and consent a cross-sectional, convenience sample of 28 married husband and wife couples. Private, personal interviews with each member of the married couple using a detailed health survey based on the 2012 Health and Retirement Study (HRS) instrument were conducted using computer assisted personal interviewing software. Within couples, each wife completed the health survey first for herself and then for her husband, and each husband completed the health survey first for himself and then for his wife. The health survey topics included health ratings, health conditions, mobility, instrumental activities of daily living (IADLs), health services use, and preventative services. Percent of agreement and prevalence and bias adjusted kappa statistics (PABAKs) were used to evaluate concordance.

RESULTS: PABAK coefficients indicated moderate to excellent concordance (PABAKs >0.60) for most of the IADL, health condition, hospitalization, surgery, preventative service, and mobility questions, but only slight to fair concordance (PABAKs = -0.21 to 0.60) for health ratings, and physician and dental visits.

CONCLUSIONS: These results do not allay longstanding concerns about the validity of routinely using spousal proxies in health surveys to obtain health ratings or the number of physician and dental visits among older adults. Further research is needed in a nationally representative sample of older couples in which each wife completes the health survey first for herself and then for her husband, each husband completes the health survey first for himself and then for his wife, and both spouses' Medicare claims are linked to their health survey responses to determine not just the concordance between spousal reports, but the concordance of those survey responses to the medical record.

VL - 16 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27612571?dopt=Abstract ER - TY - JOUR T1 - Predictors of bone mineral density testing among older women on Medicare. JF - Osteoporos Int Y1 - 2016 A1 - Yiyue Lou A1 - Edmonds, S. W. A1 - Michael P Jones A1 - Fred A Ullrich A1 - George L Wehby A1 - Cram, P. A1 - Frederic D Wolinsky KW - Absorptiometry, Photon KW - Aged KW - Bone density KW - Delivery of Health Care KW - Female KW - Humans KW - Medicare KW - Osteoporosis KW - Prospective Studies KW - United States AB -

Although dual-energy X-ray absorptiometry (DXA) is recommended for all women ≥65 and is covered by Medicare, 40 % of women on Medicare report never having had a DXA. In a longitudinal cohort of 3492 women followed for two decades, we identified several risk factors that should be targeted to improve DXA testing rates.

INTRODUCTION: DXA is used to measure bone mineral density, screen for osteoporosis, and assess fracture risk. DXA is recommended for all women ≥65 years old. Although Medicare covers DXA every 24 months for women, about 40 % report never having had a DXA test, and little is known from prospective cohort studies about which subgroups of women have low use rates and should be targeted for interventions. Our objective was to identify predictors of DXA use in a nationally representative cohort of women on Medicare.

METHODS: We used baseline and biennial follow-up survey data (1993-2012) for 3492 women ≥70 years old from the nationally representative closed cohort known as the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). The survey data for these women were then linked to their Medicare claims (1991-2012), yielding 17,345 person years of observation. DXA tests were identified from the Medicare claims, and Cox proportional hazard regression models were used with both fixed and time-dependent predictors from the survey interviews including demographic characteristics, socioeconomic factors, health status, health habits, and the living environment.

RESULTS: DXA use was positively associated with being Hispanic American, better cognition, higher income, having arthritis, using other preventative services, and living in Florida or other southern states. DXA use was negatively associated with age, being African-American, being overweight or obese, having mobility limitations, and smoking.

CONCLUSIONS: Interventions to increase DXA use should target the characteristics that were observed here to be negatively associated with such screening.

VL - 27 UR - http://link.springer.com/10.1007/s00198-016-3688-2 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/27358177?dopt=Abstract JO - Osteoporos Int ER - TY - JOUR T1 - Racial and Ethnic Differences in End-of-Life Medicare Expenditures. JF - Journal of the American Geriatrics Society Y1 - 2016 A1 - Byhoff, Elena A1 - Tamara B Harris A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - African Continental Ancestry Group KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Comorbidity KW - Cross-Cultural Comparison KW - Ethnic Groups KW - European Continental Ancestry Group KW - Female KW - Health Care Surveys KW - Health Expenditures KW - Hispanic Americans KW - Humans KW - Life Support Care KW - Longitudinal Studies KW - Male KW - Medicare KW - Rate Setting and Review KW - Social Support KW - Socioeconomic factors KW - Terminal Care KW - United States AB -

OBJECTIVES: To determine to what extent demographic, social support, socioeconomic, geographic, medical, and End-of-Life (EOL) planning factors explain racial and ethnic variation in Medicare spending during the last 6 months of life.

DESIGN: Retrospective cohort study.

SETTING: Health and Retirement Study (HRS).

PARTICIPANTS: Decedents who participated in HRS between 1998 and 2012 and previously consented to survey linkage with Medicare claims (N = 7,105).

MEASUREMENTS: Total Medicare expenditures in the last 180 days of life according to race and ethnicity, controlling for demographic factors, social supports, geography, illness burden, and EOL planning factors, including presence of advance directives, discussion of EOL treatment preferences, and whether death had been expected.

RESULTS: The analysis included 5,548 (78.1%) non-Hispanic white, 1,030 (14.5%) non-Hispanic black, and 331 (4.7%) Hispanic adults and 196 (2.8%) adults of other race or ethnicity. Unadjusted results suggest that average EOL Medicare expenditures were $13,522 (35%, P < .001) more for black decedents and $16,341 (42%, P < .001) more for Hispanics than for whites. Controlling for demographic, socioeconomic, geographic, medical, and EOL-specific factors, the Medicare expenditure difference between groups fell to $8,047 (22%, P < .001) more for black and $6,855 (19%, P < .001) more for Hispanic decedents than expenditures for non-Hispanic whites. The expenditure differences between groups remained statistically significant in all models.

CONCLUSION: Individuals-level factors, including EOL planning factors do not fully explain racial and ethnic differences in Medicare spending in the last 6 months of life. Future research should focus on broader systemic, organizational, and provider-level factors to explain these differences.

VL - 64 IS - 9 ER - TY - JOUR T1 - Spousal Characteristics and Older Adults' Hospice Use: Understanding Disparities in End-of-Life Care. JF - J Palliat Med Y1 - 2016 A1 - Katherine A Ornstein A1 - Melissa D. Aldridge A1 - Christine A Mair A1 - Rebecca Jean Gorges A1 - Albert L Siu A1 - Amy Kelley KW - Hospice Care KW - Hospices KW - Humans KW - Medicare KW - Prospective Studies KW - Quality of Life KW - Terminal Care KW - United States AB -

BACKGROUND: Hospice use has been shown to benefit quality of life for patients with terminal illness and their families, with further evidence of cost savings for Medicare and other payers. While disparities in hospice use by patient diagnosis, race, and region are well documented and attention to the role of family members in end-of-life decision-making is increasing, the influence of spousal characteristics on the decision to use hospice is unknown.

OBJECTIVES: To determine the association between spousal characteristics and hospice use.

DESIGN: We used data from the Health and Retirement Study (HRS), a prospective cohort study, linked to the Dartmouth Atlas of Health Care and Medicare claims.

SETTING: National study of 1567 decedents who were married or partnered at the time of death (2000-2011).

MEASURES: Hospice use at least 1 day in the last year of life as measured via Medicare claims data. Spousal factors (e.g., education and health status) measured via survey.

RESULTS: In multivariate models controlling for patient factors and regional variation, spouses with lower educational attainment than their deceased spouse had decreased likelihood of hospice use (odds ratio [OR] = 0.58; 95% confidence interval [CI] = 0.40-0.82). Health of the spouse was not significantly associated with likelihood of decedent hospice use in adjusted models.

IMPLICATIONS: Although the health of the surviving spouse was not associated with hospice use, their educational level was a predictor of hospice use. Spousal and family characteristics, including educational attainment, should be examined further in relation to disparities in hospice use. Efforts to increase access to high-quality end-of-life care for individuals with serious illness must also address the needs and concerns of caregivers and family.

PB - 19 VL - 19 UR - http://dx.doi.org/10.1089/jpm.2015.0399 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26991831?dopt=Abstract U2 - PMC4860657 U4 - hospice/medicare/Public Policy/end of life/caregiver burden ER - TY - JOUR T1 - The burden of health care costs for patients with dementia in the last 5 years of life. JF - Ann Intern Med Y1 - 2015 A1 - Amy Kelley A1 - Kathleen McGarry A1 - Rebecca Jean Gorges A1 - Jonathan S Skinner KW - Aged KW - Aged, 80 and over KW - Cost of Illness KW - Dementia KW - Female KW - Health Expenditures KW - Humans KW - Insurance, Health KW - Male KW - Medicaid KW - Medicare KW - Retrospective Studies KW - Socioeconomic factors KW - Terminal Care KW - United States AB -

BACKGROUND: Common diseases, particularly dementia, have large social costs for the U.S. population. However, less is known about the end-of-life costs of specific diseases and the associated financial risk for individual households.

OBJECTIVE: To examine social costs and financial risks faced by Medicare beneficiaries 5 years before death.

DESIGN: Retrospective cohort.

SETTING: The HRS (Health and Retirement Study).

PARTICIPANTS: Medicare fee-for-service beneficiaries, aged 70 years or older, who died between 2005 and 2010 (n = 1702), stratified into 4 groups: persons with a high probability of dementia or those who died because of heart disease, cancer, or other causes.

MEASUREMENTS: Total social costs and their components, including Medicare, Medicaid, private insurance, out-of-pocket spending, and informal care, measured over the last 5 years of life; and out-of-pocket spending as a proportion of household wealth.

RESULTS: Average total cost per decedent with dementia ($287 038) was significantly greater than that of those who died of heart disease ($175 136), cancer ($173 383), or other causes ($197 286) (P < 0.001). Although Medicare expenditures were similar across groups, average out-of-pocket spending for patients with dementia ($61 522) was 81% higher than that for patients without dementia ($34 068); a similar pattern held for informal care. Out-of-pocket spending for the dementia group (median, $36 919) represented 32% of wealth measured 5 years before death compared with 11% for the nondementia group (P < 0.001). This proportion was greater for black persons (84%), persons with less than a high school education (48%), and unmarried or widowed women (58%).

LIMITATION: Imputed Medicaid, private insurance, and informal care costs.

CONCLUSION: Health care expenditures among persons with dementia were substantially larger than those for other diseases, and many of the expenses were uncovered (uninsured). This places a large financial burden on families, and these burdens are particularly pronounced among the demographic groups that are least prepared for financial risk.

PRIMARY FUNDING SOURCE: National Institute on Aging.

PB - 163 VL - 163 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26502320?dopt=Abstract U4 - Care and treatment/Public Policy/Financial risk/Dementia/Medicare/Palliative care/Health care expenditures ER - TY - JOUR T1 - Cognitive function and the concordance between survey reports and Medicare claims in a nationally representative cohort of older adults. JF - Med Care Y1 - 2015 A1 - Frederic D Wolinsky A1 - Michael P Jones A1 - Fred A Ullrich A1 - Yiyue Lou A1 - George L Wehby KW - Aged KW - Aging KW - Cognition Disorders KW - Data collection KW - Female KW - Humans KW - Insurance Claim Review KW - Male KW - Medicare KW - Mental Health KW - Psychiatric Status Rating Scales KW - Self Report KW - United States AB -

BACKGROUND: While age-related cognitive decline may affect all stages in the response process--comprehension, retrieval, judgment, response selection, and response reporting--the associations between objective cognitive tests and the agreement between self-reports and Medicare claims has not been assessed. We evaluate those associations using the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD).

METHODS: Eight waves of reinterviews (1995-2010) were linked to Medicare claims for 3661 self-respondents yielding 12,313 person-period observations. Cognitive function was measured by 2 episodic memory tests (immediate and delayed recall of 10 words) and 1 mental status test (backward counting, dates, and names). Survey reports on 12 diseases and 4 health services were mapped to Medicare claims to derive counts of concordant reports, underreports, and overreports, as were the numbers of hospital episodes and physician visits. GEE negative binomial and logistic regression models were used.

RESULTS: Better mental status was associated with more concordant reporting and less underreporting on disease history and the number of hospital episodes. Better mental status and delayed word recall were associated with more concordant reporting and less underreporting on health services use. Better delayed recall was significantly associated with less underreporting on the number of physician visits. These associations were not appreciably altered by adjustment for demographic characteristics, socioeconomic status, self-rated health, or secular trends.

CONCLUSION: We recommend that future surveys of older adults include an objective measure of mental status (rather than memory), especially when those survey reports cannot be verified by access to Medicare claims or chart review.

VL - 53 UR - https://www.ncbi.nlm.nih.gov/pubmed/25793268 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25793268?dopt=Abstract ER - TY - JOUR T1 - Functional impairment and hospital readmission in Medicare seniors. JF - JAMA Intern Med Y1 - 2015 A1 - S. Ryan Greysen A1 - Irena Cenzer A1 - Andrew D. Auerbach A1 - Kenneth E Covinsky KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Comorbidity KW - Female KW - Heart Failure KW - Humans KW - Income KW - Logistic Models KW - Male KW - Medicare KW - Myocardial Infarction KW - Patient Readmission KW - Pneumonia KW - Risk Assessment KW - Risk Factors KW - Sex Factors KW - United States AB -

IMPORTANCE: Medicare currently penalizes hospitals for high readmission rates for seniors but does not account for common age-related syndromes, such as functional impairment.

OBJECTIVE: To assess the effects of functional impairment on Medicare hospital readmissions given the high prevalence of functional impairments in community-dwelling seniors.

DESIGN, SETTING, AND PARTICIPANTS: We created a nationally representative cohort of 7854 community-dwelling seniors in the Health and Retirement Study, with 22,289 Medicare hospitalizations from January 1, 2000, through December 31, 2010.

MAIN OUTCOMES AND MEASURES: Outcome was 30-day readmission assessed by Medicare claims. The main predictor was functional impairment determined from the Health and Retirement Study interview preceding hospitalization, stratified into the following 5 levels: no functional impairments, difficulty with 1 or more instrumental activities of daily living, difficulty with 1 or more activities of daily living (ADL), dependency (need for help) in 1 to 2 ADLs, and dependency in 3 or more ADLs. Adjustment variables included age, race/ethnicity, sex, annual income, net worth, comorbid conditions (Elixhauser score from Medicare claims), and prior admission. We performed multivariable logistic regression to adjust for clustering at the patient level to characterize the association of functional impairments and readmission.

RESULTS: Patients had a mean (SD) age of 78.5 (7.7) years (range, 65-105 years); 58.4% were female, 84.9% were white, 89.6% reported 3 or more comorbidities, and 86.0% had 1 or more hospitalizations in the previous year. Overall, 48.3% had some level of functional impairment before admission, and 15.5% of hospitalizations were followed by readmission within 30 days. We found a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased: 13.5% with no functional impairment, 14.3% with difficulty with 1 or more instrumental activities of daily living (odds ratio [OR], 1.06; 95% CI, 0.94-1.20), 14.4% with difficulty with 1 or more ADL (OR, 1.08; 95% CI, 0.96-1.21), 16.5% with dependency in 1 to 2 ADLs (OR, 1.26; 95% CI, 1.11-1.44), and 18.2% with dependency in 3 or more ADLs (OR, 1.42; 95% CI, 1.20-1.69). Subanalysis restricted to patients admitted with conditions targeted by Medicare (ie, heart failure, myocardial infarction, and pneumonia) revealed a parallel trend with larger effects for the most impaired (16.9% readmission rate for no impairment vs 25.7% for dependency in 3 or more ADLs [OR, 1.70; 95% CI, 1.04-2.78]).

CONCLUSIONS AND RELEVANCE: Functional impairment is associated with increased risk of 30-day all-cause hospital readmission in Medicare seniors, especially those admitted for heart failure, myocardial infarction, or pneumonia. Functional impairment may be an important but underaddressed factor in preventing readmissions for Medicare seniors.

PB - 175 VL - 175 IS - 4 N1 - Times Cited: 0 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25642907?dopt=Abstract U2 - PMC4388787 U4 - Medicare/Functional impairment/hospital readmission/ADL and IADL Impairments ER - TY - JOUR T1 - Hospitalization Type and Subsequent Severe Sepsis. JF - Am J Respir Crit Care Med Y1 - 2015 A1 - Hallie C Prescott A1 - Dickson, R. P. A1 - Mary A M Rogers A1 - Kenneth M. Langa A1 - Lwashyna, T. J. KW - Aged KW - Aged, 80 and over KW - Anti-Bacterial Agents KW - Clostridioides difficile KW - Dysbiosis KW - Enterocolitis, Pseudomembranous KW - Female KW - Hospitalization KW - Humans KW - Incidence KW - Information Storage and Retrieval KW - Longitudinal Studies KW - Male KW - Medicare KW - Patient Readmission KW - Retrospective Studies KW - Risk Factors KW - Sepsis KW - United States AB -

RATIONALE: Hospitalization is associated with microbiome perturbation (dysbiosis), and this perturbation is more severe in patients treated with antimicrobials.

OBJECTIVES: To evaluate whether hospitalizations known to be associated with periods of microbiome perturbation are associated with increased risk of severe sepsis after hospital discharge.

METHODS: We studied participants in the U.S. Health and Retirement Study with linked Medicare claims (1998-2010). We measured whether three hospitalization types associated with increasing severity of probable dysbiosis (non-infection-related hospitalization, infection-related hospitalization, and hospitalization with Clostridium difficile infection [CDI]) were associated with increasing risk for severe sepsis in the 90 days after hospital discharge. We used two study designs: the first was a longitudinal design with between-person comparisons and the second was a self-controlled case series design using within-person comparison.

MEASUREMENTS AND MAIN RESULTS: We identified 43,095 hospitalizations among 10,996 Health and Retirement Study-Medicare participants. In the 90 days following non-infection-related hospitalization, infection-related hospitalization, and hospitalization with CDI, adjusted probabilities of subsequent admission for severe sepsis were 4.1% (95% confidence interval [CI], 3.8-4.4%), 7.1% (95% CI, 6.6-7.6%), and 10.7% (95% CI, 7.7-13.8%), respectively. The incidence rate ratio (IRR) of severe sepsis was 3.3-fold greater during the 90 days after hospitalizations than during other observation periods. The IRR was 30% greater after an infection-related hospitalization versus a non-infection-related hospitalization. The IRR was 70% greater after a hospitalization with CDI than an infection-related hospitalization without CDI.

CONCLUSIONS: There is a strong dose-response relationship between events known to result in dysbiosis and subsequent severe sepsis hospitalization that is not present for rehospitalization for nonsepsis diagnoses.

PB - 192 VL - 192 IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26016947?dopt=Abstract U4 - humans/microbiota/self-controlled case series/patient readmission/dysbiosis/CLOSTRIDIUM-DIFFICILE INFECTION/RESPIRATORY SYSTEM/COMMUNITY/PNEUMONIA/CRITICAL CARE MEDICINE/METAANALYSIS/INTESTINAL MICROBIOTA/GUT MICROBIOTA/ANTIBIOTIC-TREATMENT/DISEASE/PREMATURE-INFANTS/FECAL MICROBIOTA TRANSPLANTATION/Enterocolitis, Pseudomembranous - epidemiology/Dysbiosis - epidemiology/Sepsis - epidemiology/Anti-Bacterial Agents - therapeutic use/Hospitalization - statistics/numerical data/Patient Readmission - statistics/numerical data ER - TY - JOUR T1 - Longitudinal patient-oriented outcomes in neuropathy: Importance of early detection and falls. JF - Neurology Y1 - 2015 A1 - Brian C. Callaghan A1 - Kevin Kerber A1 - Kenneth M. Langa A1 - Banerjee, Mousumi A1 - Rodgers, Ann A1 - Ryan J McCammon A1 - James F. Burke A1 - Eva L Feldman KW - Accidental Falls KW - Aged KW - Aged, 80 and over KW - Early Diagnosis KW - Female KW - Humans KW - International Classification of Diseases KW - Longitudinal Studies KW - Male KW - Medicare KW - Patient-Centered Care KW - Peripheral Nervous System Diseases KW - Treatment Outcome KW - United States AB -

OBJECTIVE: To evaluate longitudinal patient-oriented outcomes in peripheral neuropathy over a 14-year time period including time before and after diagnosis.

METHODS: The 1996-2007 Health and Retirement Study (HRS)-Medicare Claims linked database identified incident peripheral neuropathy cases (ICD-9 codes) in patients ≥65 years. Using detailed demographic information from the HRS and Medicare claims, a propensity score method identified a matched control group without neuropathy. Patient-oriented outcomes, with an emphasis on self-reported falls, pain, and self-rated health (HRS interview), were determined before and after neuropathy diagnosis. Generalized estimating equations were used to assess differences in longitudinal outcomes between cases and controls.

RESULTS: We identified 953 peripheral neuropathy cases and 953 propensity-matched controls. The mean (SD) age was 77.4 (6.7) years for cases, 76.9 (6.6) years for controls, and 42.1% had diabetes. Differences were detected in falls 3.0 years before neuropathy diagnosis (case vs control; 32% vs 25%, p = 0.008), 5.0 years for pain (36% vs 27%, p = 0.002), and 5.0 years for good to excellent self-rated health (61% vs 74%, p < 0.0001). Over time, the proportion of fallers increased more rapidly in neuropathy cases compared to controls (p = 0.002), but no differences in pain (p = 0.08) or self-rated health (p = 0.9) were observed.

CONCLUSIONS: In older persons, differences in falls, pain, and self-rated health can be detected 3-5 years prior to peripheral neuropathy diagnosis, but only falls deteriorates more rapidly over time in neuropathy cases compared to controls. Interventions to improve early peripheral neuropathy detection are needed, and future clinical trials should incorporate falls as a key patient-oriented outcome.

PB - 85 VL - 85 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/26019191?dopt=Abstract U2 - PMC4501944 U4 - Peripheral neuropathy/Peripheral neuropathy/Medicare/Propensity score ER - TY - JOUR T1 - Chiropractic use in the Medicare population: prevalence, patterns, and associations with 1-year changes in health and satisfaction with care. JF - J Manipulative Physiol Ther Y1 - 2014 A1 - Paula A Weigel A1 - Jason Hockenberry A1 - Frederic D Wolinsky KW - Aged KW - Aged, 80 and over KW - Female KW - Humans KW - Male KW - Manipulation, Chiropractic KW - Medicare KW - Patient Satisfaction KW - Time Factors KW - Treatment Outcome KW - United States AB -

OBJECTIVE: The purpose of this study was to examine how chiropractic care compares to medical treatments on 1-year changes in self-reported function, health, and satisfaction with care measures in a representative sample of Medicare beneficiaries.

METHODS: Logistic regression using generalized estimating equations is used to model the effect of chiropractic relative to medical care on decline in 5 functional measures and 2 measures of self-rated health among 12170 person-year observations. The same method is used to estimate the comparative effect of chiropractic on 6 satisfaction with care measures. Two analytic approaches are used, the first assuming no selection bias and the second using propensity score analyses to adjust for selection effects in the outcome models.

RESULTS: The unadjusted models show that chiropractic is significantly protective against 1-year decline in activities of daily living, lifting, stooping, walking, self-rated health, and worsening health after 1 year. Persons using chiropractic are more satisfied with their follow-up care and with the information provided to them. In addition to the protective effects of chiropractic in the unadjusted model, the propensity score results indicate a significant protective effect of chiropractic against decline in reaching.

CONCLUSION: This study provides evidence of a protective effect of chiropractic care against 1-year declines in functional and self-rated health among Medicare beneficiaries with spine conditions, and indications that chiropractic users have higher satisfaction with follow-up care and information provided about what is wrong with them.

VL - 37 UR - https://www.ncbi.nlm.nih.gov/pubmed/25233887 IS - 8 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25233887?dopt=Abstract ER - TY - JOUR T1 - Cumulative inequality and racial disparities in health: private insurance coverage and black/white differences in functional limitations. JF - J Gerontol B Psychol Sci Soc Sci Y1 - 2014 A1 - Ben Lennox Kail A1 - Miles G Taylor KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Black or African American KW - Cross-Sectional Studies KW - Female KW - Health Status Disparities KW - Hispanic or Latino KW - Humans KW - Insurance Coverage KW - Insurance, Health KW - Longitudinal Studies KW - Male KW - Medicare KW - Socioeconomic factors KW - United States AB -

OBJECTIVES: To test different forms of private insurance coverage as mediators for racial disparities in onset, persistent level, and acceleration of functional limitations among Medicare age-eligible Americans.

METHOD: Data come from 7 waves of the Health and Retirement Study (1996-2008). Onset and progression latent growth models were used to estimate racial differences in onset, level, and growth of functional limitations among a sample of 5,755 people aged 65 and older in 1996. Employer-provided insurance, spousal insurance, and market insurance were next added to the model to test how differences in private insurance mediated the racial gap in physical limitations.

RESULTS: In baseline models, African Americans had larger persistent level of limitations over time. Although employer-provided, spousal provided, and market insurances were directly associated with lower persistent levels of limitation, only differences in market insurance accounted for the racial disparities in persistent level of limitations.

DISCUSSION: Results suggest private insurance is important for reducing functional limitations, but market insurance is an important mediator of the persistently larger level of limitations observed among African Americans.

PB - 69 VL - 69 UR - http://psychsocgerontology.oxfordjournals.org/content/early/2014/02/24/geronb.gbu005.abstract IS - 5 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24569001?dopt=Abstract U2 - PMC4189650 U4 - Cumulative inequality/Insurance/Functional limitations/Private insurance ER - TY - JOUR T1 - Death certificates underestimate infections as proximal causes of death in the U.S. JF - PLoS One Y1 - 2014 A1 - Govindan, Sushant A1 - Shapiro, Letitia A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Cause of Death KW - Death Certificates KW - Hospitalization KW - Humans KW - Infections KW - Medicare KW - United States AB -

BACKGROUND: Death certificates are a primary data source for assessing the population burden of diseases; however, there are concerns regarding their accuracy. Diagnosis-Related Group (DRG) coding of a terminal hospitalization may provide an alternative view. We analyzed the rate and patterns of disagreement between death certificate data and hospital claims for patients who died during an inpatient hospitalization.

METHODS: We studied respondents from the Health and Retirement Study (a nationally representative sample of older Americans who had an inpatient death documented in the linked Medicare claims from 1993-2007). Causes of death abstracted from death certificates were aggregated to the standard National Center for Health Statistics List of 50 Rankable Causes of Death. Centers for Medicare and Medicaid Services (CMS)-DRGs were manually aggregated into a parallel classification. We then compared the two systems via 2×2, focusing on concordance. Our primary analysis was agreement between the two data sources, assessed with percentages and Cohen's kappa statistic.

RESULTS: 2074 inpatient deaths were included in our analysis. 36.6% of death certificate cause-of-death codes agreed with the reason for the terminal hospitalization in the Medicare claims at the broad category level; when re-classifying DRGs without clear alignment as agreements, the concordance only increased to 61%. Overall Kappa was 0.21, or "fair." Death certificates in this cohort redemonstrated the conventional top 3 causes of death as diseases of the heart, malignancy, and cerebrovascular disease. However, hospitalization claims data showed infections, diseases of the heart, and cerebrovascular disease as the most common diagnoses for the same terminal hospitalizations.

CONCLUSION: There are significant differences between Medicare claims and death certificate data in assigning cause of death for inpatients. The importance of infections as proximal causes of death is underestimated by current death certificate-based strategies.

PB - 9 VL - 9 IS - 5 N1 - Times Cited: 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24878897?dopt=Abstract U2 - PMC4039437 U4 - Medicare claims/Infection/death certificate/cause of death/survey methods ER - TY - JOUR T1 - Geographic variation in out-of-pocket expenditures of elderly Medicare beneficiaries. JF - J Am Geriatr Soc Y1 - 2014 A1 - Lena M. Chen A1 - Edward C Norton A1 - Kenneth M. Langa A1 - Le, Sidney A1 - Arnold M. Epstein KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Female KW - Geography KW - Health Care Costs KW - Health Expenditures KW - Humans KW - Male KW - Medicare KW - Retrospective Studies KW - United States AB -

OBJECTIVES: To examine whether out-of-pocket expenditures (OOPEs) exhibit the same geographic variation as Medicare claims, given wide variation in the costs of U.S. health care, but no information on how that translates into OOPEs or financial burden for older Americans.

DESIGN: Retrospective cohort study.

SETTING: Data from the Health and Retirement Study linked to Medicare claims.

PARTICIPANTS: A nationally representative cohort of 4,657 noninstitutionalized, community-dwelling, fee-for-service elderly Medicare beneficiaries interviewed in 2006 and 2008.

MEASUREMENTS: The primary predictor was per capita Medicare spending quintile according to hospital referral region. The primary outcome was a self-reported, validated measure of annual OOPEs excluding premiums.

RESULTS: Mean and median adjusted per capita Medicare payments were $5,916 and $2,635, respectively; mean and median adjusted OOPEs were $1,525 and $779, respectively. Adjusted median Medicare payments were $3,474 in the highest cost quintile and $1,942 in the lowest cost quintile (ratio 1.79, P < .001 for difference). In contrast, adjusted median OOPEs were not higher in the highest than in the lowest Medicare cost quintile ($795 vs $764 for a Q5:Q1 ratio of 1.04, P = .42). The Q5:Q1 ratio was 1.48 for adjusted mean Medicare payments and 1.04 for adjusted mean OOPEs (both P < .001).

CONCLUSION: Medicare payments vary widely between high- and low-cost regions, but OOPEs do not.

PB - 62 VL - 62 IS - 6 N1 - Times Cited: 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24852182?dopt=Abstract U4 - Medicare/geographic variation/out-of-pocket expenditures ER - TY - JOUR T1 - Identifying diabetics in Medicare claims and survey data: implications for health services research. JF - BMC Health Serv Res Y1 - 2014 A1 - Joseph W Sakshaug A1 - David R Weir A1 - Lauren Hersch Nicholas KW - Aged KW - Aged, 80 and over KW - Algorithms KW - Diabetes Mellitus KW - Female KW - Glycated Hemoglobin KW - Health Services Research KW - Humans KW - Insurance Claim Review KW - Male KW - Medicare KW - Prevalence KW - United States AB -

BACKGROUND: Diabetes health services research often utilizes secondary data sources, including survey self-report and Medicare claims, to identify and study the diabetic population, but disagreement exists between these two data sources. We assessed agreement between the Chronic Condition Warehouse diabetes algorithm for Medicare claims and self-report measures of diabetes. Differences in healthcare utilization outcomes under each diabetes definition were also explored.

METHODS: Claims data from the Medicare Beneficiary Annual Summary File were linked to survey and blood data collected from the 2006 Health and Retirement Study. A Hemoglobin A1c reading, collected on 2,028 respondents, was used to reconcile discrepancies between the self-report and Medicare claims measures of diabetes. T-tests were used to assess differences in healthcare utilization outcomes for each diabetes measure.

RESULTS: The Chronic Condition Warehouse (CCW) algorithm yielded a higher rate of diabetes than respondent self-reports (27.3 vs. 21.2, p < 0.05). A1c levels of discordant claims-based diabetics suggest that these patients are not diabetic, however, they have high rates of healthcare spending and utilization similar to diabetics.

CONCLUSIONS: Concordance between A1c and self-reports was higher than for A1c and the CCW algorithm. Accuracy of self-reports was superior to the CCW algorithm. False positives in the claims data have similar utilization profiles to diabetics, suggesting minimal bias in some types of claims-based analyses, though researchers should consider sensitivity analysis across definitions for health services research.

PB - 14 VL - 14 N1 - Export Date: 21 April 2014 Source: Scopus Article in Press U1 - http://www.ncbi.nlm.nih.gov/pubmed/24693862?dopt=Abstract U2 - PMC3975984 U4 - Diabetes/Survey data/Medicare claims/Chronic condition warehouse ER - TY - JOUR T1 - Increased 1-year healthcare use in survivors of severe sepsis. JF - Am J Respir Crit Care Med Y1 - 2014 A1 - Hallie C Prescott A1 - Kenneth M. Langa A1 - Liu, Vincent A1 - Gabriel J. Escobar A1 - Theodore J Iwashyna KW - Aged KW - Female KW - Health Facilities KW - Humans KW - Insurance Claim Review KW - Long-term Care KW - Male KW - Medical Record Linkage KW - Medicare KW - Mortality KW - Outcome Assessment, Health Care KW - Patient Readmission KW - Prospective Studies KW - Sepsis KW - Skilled Nursing Facilities KW - Survivors KW - United States AB -

RATIONALE: Hospitalizations for severe sepsis are common, and a growing number of patients survive to hospital discharge. Nonetheless, little is known about survivors' post-discharge healthcare use.

OBJECTIVES: To measure inpatient healthcare use of severe sepsis survivors compared with patients' own presepsis resource use and the resource use of survivors of otherwise similar nonsepsis hospitalizations.

METHODS: This is an observational cohort study of survivors of severe sepsis and nonsepsis hospitalizations identified from participants in the Health and Retirement Study with linked Medicare claims, 1998-2005. We matched severe sepsis and nonsepsis hospitalizations by demographics, comorbidity burden, premorbid disability, hospitalization length, and intensive care use.

MEASUREMENTS AND MAIN RESULTS: Using Medicare claims, we measured patients' use of inpatient facilities (hospitals, long-term acute care hospitals, and skilled nursing facilities) in the 2 years surrounding hospitalization. Severe sepsis survivors spent more days (median, 16 [interquartile range, 3-45] vs. 7 [0-29]; P < 0.001) and a higher proportion of days alive (median, 9.6% [interquartile range, 1.4-33.8%] vs. 1.9% [0.0-7.9%]; P < 0.001) admitted to facilities in the year after hospitalization, compared with the year prior. The increase in facility-days was similar for nonsepsis hospitalizations. However, the severe sepsis cohort experienced greater post-discharge mortality (44.2% [95% confidence interval, 41.3-47.2%] vs. 31.4% [95% confidence interval, 28.6-34.2%] at 1 year), a steeper decline in days spent at home (difference-in-differences, -38.6 d [95% confidence interval, -50.9 to 26.3]; P < 0.001), and a greater increase in the proportion of days alive spent in a facility (difference-in-differences, 5.4% [95% confidence interval, 2.8-8.1%]; P < 0.001).

CONCLUSIONS: Healthcare use is markedly elevated after severe sepsis, and post-discharge management may be an opportunity to reduce resource use.

PB - 190 VL - 190 IS - 1 N1 - Times Cited: 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24872085?dopt=Abstract U4 - healthcare facilities/sepsis/hospitalization/patient outcomes assessment/patient readmission/skilled nursing facility ER - TY - JOUR T1 - Mortality and cardiovascular disease among older live kidney donors. JF - Am J Transplant Y1 - 2014 A1 - P. P. Reese A1 - R. D. Bloom A1 - H. I. Feldman A1 - Rosenbaum, P A1 - Wang, W A1 - P. Saynisch A1 - Tarsi, N M A1 - Mukherjee, N A1 - Garg, A X A1 - A. Mussell A1 - J. Shults A1 - Even-Shoshan, O A1 - R. R. Townsend A1 - J. H. Silber KW - Age Factors KW - Aged KW - Cardiovascular Diseases KW - Female KW - Follow-Up Studies KW - Humans KW - Kidney Transplantation KW - Living Donors KW - Longitudinal Studies KW - Male KW - Medicare KW - Middle Aged KW - Nephrectomy KW - Quality of Life KW - Renal Insufficiency KW - Time Factors KW - Treatment Outcome KW - United States AB -

Over the past two decades, live kidney donation by older individuals (≥55 years) has become more common. Given the strong associations of older age with cardiovascular disease (CVD), nephrectomy could make older donors vulnerable to death and cardiovascular events. We performed a cohort study among older live kidney donors who were matched to healthy older individuals in the Health and Retirement Study. The primary outcome was mortality ascertained through national death registries. Secondary outcomes ascertained among pairs with Medicare coverage included death or CVD ascertained through Medicare claims data. During the period from 1996 to 2006, there were 5717 older donors in the United States. We matched 3368 donors 1:1 to older healthy nondonors. Among donors and matched pairs, the mean age was 59 years; 41% were male and 7% were black race. In median follow-up of 7.8 years, mortality was not different between donors and matched pairs (p = 0.21). Among donors with Medicare, the combined outcome of death/CVD (p = 0.70) was also not different between donors and nondonors. In summary, carefully selected older kidney donors do not face a higher risk of death or CVD. These findings should be provided to older individuals considering live kidney donation.

PB - 14 VL - 14 IS - 8 N1 - Times Cited: 0 U1 - http://www.ncbi.nlm.nih.gov/pubmed/25039276?dopt=Abstract U2 - PMC4105987 U4 - public policy/health services and outcomes research/kidney transplantation/nephrology/living donor/organ procurement/cardiovascular disease ER - TY - JOUR T1 - Obesity and 1-year outcomes in older Americans with severe sepsis. JF - Crit Care Med Y1 - 2014 A1 - Hallie C Prescott A1 - Virginia W Chang A1 - James M. O'Brien Jr A1 - Kenneth M. Langa A1 - Theodore J Iwashyna KW - Aged KW - Aged, 80 and over KW - Body Mass Index KW - Cohort Studies KW - Comorbidity KW - Critical Illness KW - Delivery of Health Care KW - Female KW - Health Expenditures KW - Hospitalization KW - Humans KW - Male KW - Medicare KW - Middle Aged KW - Obesity KW - Sepsis KW - Survival Rate KW - Survivors KW - United States AB -

OBJECTIVES: Although critical care physicians view obesity as an independent poor prognostic marker, growing evidence suggests that obesity is, instead, associated with improved mortality following ICU admission. However, this prior empirical work may be biased by preferential admission of obese patients to ICUs, and little is known about other patient-centered outcomes following critical illness. We sought to determine whether 1-year mortality, healthcare utilization, and functional outcomes following a severe sepsis hospitalization differ by body mass index.

DESIGN: Observational cohort study.

SETTING: U.S. hospitals.

PATIENTS: We analyzed 1,404 severe sepsis hospitalizations (1999-2005) among Medicare beneficiaries enrolled in the nationally representative Health and Retirement Study, of which 597 (42.5%) were normal weight, 473 (33.7%) were overweight, and 334 (23.8%) were obese or severely obese, as assessed at their survey prior to acute illness. Underweight patients were excluded a priori.

INTERVENTIONS: None.

MEASUREMENTS AND MAIN RESULTS: Using Medicare claims, we identified severe sepsis hospitalizations and measured inpatient healthcare facility use and calculated total and itemized Medicare spending in the year following hospital discharge. Using the National Death Index, we determined mortality. We ascertained pre- and postmorbid functional status from survey data. Patients with greater body mass indexes experienced lower 1-year mortality compared with nonobese patients, and there was a dose-response relationship such that obese (odds ratio = 0.59; 95% CI, 0.39-0.88) and severely obese patients (odds ratio = 0.46; 95% CI, 0.26-0.80) had the lowest mortality. Total days in a healthcare facility and Medicare expenditures were greater for obese patients (p < 0.01 for both comparisons), but average daily utilization (p = 0.44) and Medicare spending were similar (p = 0.65) among normal, overweight, and obese survivors. Total function limitations following severe sepsis did not differ by body mass index category (p = 0.64).

CONCLUSIONS: Obesity is associated with improved mortality among severe sepsis patients. Due to longer survival, obese sepsis survivors use more healthcare and result in higher Medicare spending in the year following hospitalization. Median daily healthcare utilization was similar across body mass index categories.

PB - 42 VL - 42 IS - 8 N1 - Export Date: 21 April 2014 Source: Scopus Article in Press U1 - http://www.ncbi.nlm.nih.gov/pubmed/24717466?dopt=Abstract U2 - PMC4205159 U4 - body mass index/critical care/outcomes assessment/prognosis/sepsis/utilization ER - TY - JOUR T1 - Chiropractic use and changes in health among older medicare beneficiaries: a comparative effectiveness observational study. JF - J Manipulative Physiol Ther Y1 - 2013 A1 - Paula A Weigel A1 - Jason Hockenberry A1 - Suzanne E Bentler A1 - Frederic D Wolinsky KW - Activities of Daily Living KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Databases, Factual KW - Disability Evaluation KW - Female KW - Geriatric Assessment KW - Humans KW - Low Back Pain KW - Male KW - Manipulation, Chiropractic KW - Medicare KW - Mobility Limitation KW - Musculoskeletal Diseases KW - Patient Satisfaction KW - Quality of Life KW - Risk Assessment KW - Sex Factors KW - Treatment Outcome KW - United States AB -

OBJECTIVE: The purpose of this study was to investigate the effect of chiropractic on 5 outcomes among Medicare beneficiaries: increased difficulties performing activities of daily living (ADLs), instrumental ADLs (IADLs), and lower body functions, as well as lower self-rated health and increased depressive symptoms.

METHODS: Among all beneficiaries, we estimated the effect of chiropractic use on changes in health outcomes among those who used chiropractic compared with those who did not, and among beneficiaries with back conditions, we estimated the effect of chiropractic use relative to medical care, both during a 2- to 15-year period. Two analytic approaches were used--one assumed no selection bias, whereas the other adjusted for potential selection bias using propensity score methods.

RESULTS: Among all beneficiaries, propensity score analyses indicated that chiropractic use led to comparable outcomes for ADLs, IADLs, and depressive symptoms, although there were increased risks associated with chiropractic for declines in lower body function and self-rated health. Propensity score analyses among beneficiaries with back conditions indicated that chiropractic use led to comparable outcomes for ADLs, IADLs, lower body function, and depressive symptoms, although there was an increased risk associated with chiropractic use for declines in self-rated health.

CONCLUSION: The evidence in this study suggests that chiropractic treatment has comparable effects on functional outcomes when compared with medical treatment for all Medicare beneficiaries, but increased risk for declines in self-rated health among beneficiaries with back conditions.

VL - 36 UR - https://www.ncbi.nlm.nih.gov/pubmed/24636108 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/24144425?dopt=Abstract ER - TY - JOUR T1 - Cognition and take-up of subsidized drug benefits by Medicare beneficiaries. JF - JAMA Intern Med Y1 - 2013 A1 - Ifedayo Kuye A1 - Richard G Frank A1 - J. Michael McWilliams KW - Cognition KW - Comprehension KW - Cost Sharing KW - Eligibility Determination KW - Health Care Surveys KW - Humans KW - Medicare KW - Medicare Part D KW - Poverty KW - United States AB -

IMPORTANCE: Take-up of the Medicare Part D low-income subsidy (LIS) by eligible beneficiaries has been low despite the attractive drug coverage it offers at no cost to beneficiaries and outreach efforts by the Social Security Administration.

OBJECTIVE: To examine the role of beneficiaries' cognitive abilities in explaining this puzzle.

DESIGN AND SETTING: Analysis of survey data from the nationally representative Health and Retirement Study.

PARTICIPANTS: Elderly Medicare beneficiaries who were likely eligible for the LIS, excluding Medicaid and Supplemental Security Income recipients who automatically receive the subsidy without applying.

MAIN OUTCOMES AND MEASURES: Using survey assessments of overall cognition and numeracy from 2006 to 2010, we examined how cognitive abilities were associated with self-reported Part D enrollment, awareness of the LIS, and application for the LIS. We also compared out-of-pocket drug spending and premium costs between LIS-eligible beneficiaries who did and did not report receipt of the LIS. Analyses were adjusted for sociodemographic characteristics, household income and assets, health status, and presence of chronic conditions.

RESULTS: Compared with LIS-eligible beneficiaries in the top quartile of overall cognition, those in the bottom quartile were significantly less likely to report Part D enrollment (adjusted rate, 63.5% vs 52.0%; P = .002), LIS awareness (58.3% vs 33.3%; P = .001), and LIS application (25.5% vs 12.7%; P < .001). Lower numeracy was also associated with lower rates of Part D enrollment (P = .03) and LIS application (P = .002). Reported receipt of the LIS was associated with significantly lower annual out-of-pocket drug spending (adjusted mean difference, -$256; P = .02) and premium costs (-$273; P = .02).

CONCLUSIONS AND RELEVANCE: Among Medicare beneficiaries likely eligible for the Part D LIS, poorer cognition and numeracy were associated with lower reported take-up. Current educational and outreach efforts encouraging LIS applications may not be sufficient for beneficiaries with limited abilities to process and respond to information. Additional policies may be needed to extend the financial protection conferred by the LIS to all eligible seniors.

PB - 173 VL - 173 IS - 12 N1 - Copyright - Copyright American Medical Association Jun 24, 2013 Last updated - 2013-07-12 SubjectsTermNotLitGenreText - United States--US U1 - http://www.ncbi.nlm.nih.gov/pubmed/23649604?dopt=Abstract U2 - PMC3692587 U4 - Self assessed health/Medicare/Medicare Part D/Out of pocket costs/Beneficiaries/Government subsidies/Cognitive ability/Eligibility/Health care expenditures/Health care policy ER - TY - JOUR T1 - Monetary costs of dementia in the United States. JF - N Engl J Med Y1 - 2013 A1 - Michael D Hurd A1 - Martorell, Paco A1 - Delavande, Adeline A1 - Kathleen J Mullen A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Cost of Illness KW - Dementia KW - Female KW - Health Care Costs KW - Home Care Services KW - Home Nursing KW - Humans KW - Longitudinal Studies KW - Male KW - Medicare KW - Middle Aged KW - Nursing homes KW - United States AB -

BACKGROUND: Dementia affects a large and growing number of older adults in the United States. The monetary costs attributable to dementia are likely to be similarly large and to continue to increase.

METHODS: In a subsample (856 persons) of the population in the Health and Retirement Study (HRS), a nationally representative longitudinal study of older adults, the diagnosis of dementia was determined with the use of a detailed in-home cognitive assessment that was 3 to 4 hours in duration and a review by an expert panel. We then imputed cognitive status to the full HRS sample (10,903 persons, 31,936 person-years) on the basis of measures of cognitive and functional status available for all HRS respondents, thereby identifying persons in the larger sample with a high probability of dementia. The market costs associated with care for persons with dementia were determined on the basis of self-reported out-of-pocket spending and the utilization of nursing home care; Medicare claims data were used to identify costs paid by Medicare. Hours of informal (unpaid) care were valued either as the cost of equivalent formal (paid) care or as the estimated wages forgone by informal caregivers.

RESULTS: The estimated prevalence of dementia among persons older than 70 years of age in the United States in 2010 was 14.7%. The yearly monetary cost per person that was attributable to dementia was either $56,290 (95% confidence interval [CI], $42,746 to $69,834) or $41,689 (95% CI, $31,017 to $52,362), depending on the method used to value informal care. These individual costs suggest that the total monetary cost of dementia in 2010 was between $157 billion and $215 billion. Medicare paid approximately $11 billion of this cost.

CONCLUSIONS: Dementia represents a substantial financial burden on society, one that is similar to the financial burden of heart disease and cancer. (Funded by the National Institute on Aging.).

PB - 386 VL - 368 UR - http://www.nejm.org/doi/full/10.1056/NEJMsa1204629 IS - 14 U1 - http://www.ncbi.nlm.nih.gov/pubmed/23550670?dopt=Abstract U3 - 23550670 U4 - ADAMS/Dementia/Cognitive Impairment/cognitive assessment/PREVALENCE/Medicare/Out of pocket costs/nursing homes/Informal care/public policy ER - TY - JOUR T1 - Out-of-pocket spending in the last five years of life. JF - J Gen Intern Med Y1 - 2013 A1 - Amy Kelley A1 - Kathleen McGarry A1 - Sean Fahle A1 - Samuel M Marshall A1 - Qingling Du A1 - Jonathan S Skinner KW - Aged KW - Cause of Death KW - Female KW - Health Expenditures KW - Health Services for the Aged KW - Humans KW - Male KW - Marital Status KW - Medicare KW - Retrospective Studies KW - Socioeconomic factors KW - Terminal Care KW - United States AB -

BACKGROUND: A key objective of the Medicare program is to reduce risk of financial catastrophe due to out-of-pocket healthcare expenditures. Yet little is known about cumulative financial risks arising from out-of-pocket healthcare expenditures faced by older adults, particularly near the end of life.

DESIGN: Using the nationally representative Health and Retirement Study (HRS) cohort, we conducted retrospective analyses of Medicare beneficiaries' total out-of-pocket healthcare expenditures over the last 5 years of life.

PARTICIPANTS: We identified HRS decedents between 2002 and 2008; defined a 5 year study period using each subject's date of death; and excluded those without Medicare coverage at the beginning of this period (n = 3,209).

MAIN MEASURES: We examined total out-of-pocket healthcare expenditures in the last 5 years of life and expenditures as a percentage of baseline household assets. We then stratified results by marital status and cause of death. All measurements were adjusted for inflation to 2008 US dollars.

RESULTS: Average out-of-pocket expenditures in the 5 years prior to death were $38,688 (95 % Confidence Interval $36,868, $40,508) for individuals, and $51,030 (95 % CI $47,649, $54,412) for couples in which one spouse dies. Spending was highly skewed, with the median and 90th percentile equal to $22,885 and $89,106, respectively, for individuals, and $39,759 and $94,823, respectively, for couples. Overall, 25 % of subjects' expenditures exceeded baseline total household assets, and 43 % of subjects' spending surpassed their non-housing assets. Among those survived by a spouse, 10 % exceeded total baseline assets and 24 % exceeded non-housing assets. By cause of death, average spending ranged from $31,069 for gastrointestinal disease to $66,155 for Alzheimer's disease.

CONCLUSION: Despite Medicare coverage, elderly households face considerable financial risk from out-of-pocket healthcare expenses at the end of life. Disease-related differences in this risk complicate efforts to anticipate or plan for health-related expenditures in the last 5 years of life.

PB - 28 VL - 28 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22948931?dopt=Abstract U2 - PMC3614143 U4 - Public policy/Medicare/End of life/health expenditures/out of pocket costs ER - TY - JOUR T1 - Burden of cirrhosis on older Americans and their families: analysis of the health and retirement study. JF - Hepatology Y1 - 2012 A1 - M. O. Rakoski A1 - Ryan J McCammon A1 - John D Piette A1 - Theodore J Iwashyna A1 - J. A. Marrero A1 - Lok, Anna S A1 - Kenneth M. Langa A1 - Volk, Michael L KW - Aged KW - Black People KW - Caregivers KW - Comorbidity KW - Cost of Illness KW - Databases, Factual KW - Disability Evaluation KW - Female KW - Health Care Costs KW - Health Status KW - Hispanic or Latino KW - Humans KW - Incidence KW - Liver Cirrhosis KW - Male KW - Medicaid KW - Medicare KW - Prevalence KW - Prospective Studies KW - Retirement KW - United States KW - White People AB -

UNLABELLED: Prevalence of cirrhosis among older adults is expected to increase; therefore, we studied the health status, functional disability, and need for supportive care in a large national sample of individuals with cirrhosis. A prospective cohort of individuals with cirrhosis was identified within the longitudinal, nationally representative Health and Retirement Study. Cirrhosis cases were identified in linked Medicare data via ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes and compared to an age-matched cohort without cirrhosis. Two primary outcome domains were assessed: (1) patients' health status (perceived health status, comorbidities, health care utilization, and functional disability as determined by activities of daily living and instrumental activities of daily living), and (2) informal caregiving (hours of caregiving provided by a primary informal caregiver and associated cost). Adjusted negative binomial regression was used to assess the association between cirrhosis and functional disability. A total of 317 individuals with cirrhosis and 951 age-matched comparators were identified. Relative to the comparison group, individuals with cirrhosis had worse self-reported health status, more comorbidities, and used significantly more health care services (hospitalizations, nursing home stays, physician visits; P < 0.001 for all bivariable comparisons). They also had greater functional disability (P < 0.001 for activities of daily living and instrumental activities of daily living), despite adjustment for covariates such as comorbidities and health care utilization. Individuals with cirrhosis received more than twice the number of informal caregiving hours per week (P < 0.001), at an annual cost of US $4700 per person.

CONCLUSION: Older Americans with cirrhosis have high rates of disability, health care utilization, and need for informal caregiving. Improved care coordination and caregiver support is necessary to optimize management of this frail population.

PB - 55 VL - 55 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21858847?dopt=Abstract U2 - PMC3462487 U4 - alcohol Abuse/cirrhosis/cirrhosis/Self assessed health/COMORBIDITY/health care/HOSPITALIZATION/physician visits/physician visits ER - TY - JOUR T1 - Disability and decline in physical function associated with hospital use at end of life. JF - J Gen Intern Med Y1 - 2012 A1 - Amy Kelley A1 - Susan L Ettner A1 - R Sean Morrison A1 - Qingling Du A1 - Catherine A Sarkisian KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Chronic disease KW - Dementia KW - Disability Evaluation KW - Disabled Persons KW - Female KW - Frail Elderly KW - Geriatric Assessment KW - Hospitalization KW - Humans KW - Length of Stay KW - Longitudinal Studies KW - Male KW - Medicare KW - Socioeconomic factors KW - Terminal Care KW - United States AB -

BACKGROUND: Hospital use near the end of life is often undesirable to patients, represents considerable Medicare cost, and varies widely across regions.

OBJECTIVE: To concurrently examine regional and patient factors, including disability and functional decline, associated with end-of-life hospital use.

DESIGN/PARTICIPANTS: We sampled decedents aged 65 and older (n = 2,493) from the Health and Retirement Study (2000-2006), and linked data from individual Medicare claims and the Dartmouth Atlas of Health Care. Two-part regression models estimated the relationship between total hospital days in the last 6 months and patient characteristics including physical function, while adjusting for regional resources and hospital care intensity (HCI).

KEY RESULTS: Median hospital days was 7 (range = 0-183). 53% of respondents had functional decline. Compared with decedents without functional decline, those with severe disability or decline had more regression-adjusted hospital days (range 3.47-9.05, depending on category). Dementia was associated with fewer days (-3.02); while chronic kidney disease (2.37), diabetes (2.40), stroke or transient ischemic attack (2.11), and congestive heart failure (1.74) were associated with more days. African Americans and Hispanics had more days (5.91 and 4.61, respectively). Those with family nearby had 1.62 fewer days and hospice enrollees had 1.88 fewer days. Additional hospital days were associated with urban residence (1.74) and residence in a region with more specialists (1.97) and higher HCI (2.27).

CONCLUSIONS: Functional decline is significantly associated with end-of-life hospital use among older adults. To improve care and reduce costs, health care programs and policies should address specific needs of patients with functional decline and disability.

PB - 27 VL - 27 IS - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22382455?dopt=Abstract U2 - PMC3378753 U4 - Public Policy/Medicare/end of life/Functional decline/Functional decline/Hospital Care Intensity Index/Hospital Care Intensity Index/end-of-life ER - TY - JOUR T1 - Health service use among the previously uninsured: is subsidized health insurance enough? JF - Health Econ Y1 - 2012 A1 - Decker, Sandra L A1 - Jalpa A Doshi A1 - Amy E. Knaup A1 - Daniel Polsky KW - Aged KW - Female KW - Health Care Surveys KW - Health Services KW - Health Status KW - Humans KW - Insurance Coverage KW - Insurance, Health KW - Male KW - Medically Uninsured KW - Medicare KW - Middle Aged KW - Socioeconomic factors KW - United States AB -

Although it has been shown that gaining Medicare coverage at age 65 years increases health service use among the uninsured, difficulty in changing habits or differences in the characteristics of previously uninsured compared with insured individuals may mean that the previously uninsured continue to use the healthcare system differently from others. This study uses Medicare claims data linked to two different surveys--the National Health Interview Survey and the Health and Retirement Study--to describe the relationship between insurance status before age 65 years and the use of Medicare-covered services beginning at age 65 years. Although we do not find statistically significant differences in Medicare expenditures or in the number of hospitalizations by previous insurance status, we do find that individuals who were uninsured before age 65 years continue to use the healthcare system differently from those who were privately insured. Specifically, they have 16% fewer visits to office-based physicians but make 18% and 43% more visits to hospital emergency and outpatient departments, respectively. A key question for the future may be why the previously uninsured seem to continue to use the healthcare system differently from the previously insured. This question may be important to consider as health coverage expansions are implemented.

PB - 21 VL - 21 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22945812?dopt=Abstract U3 - 22945812 U4 - Medicare/health Services/ utilization/health Services/ utilization/health Insurance/Uninsured people/Public policy ER - TY - JOUR T1 - Predictors of self-report of heart failure in a population-based survey of older adults. JF - Circ Cardiovasc Qual Outcomes Y1 - 2012 A1 - Tanya R Gure A1 - Ryan J McCammon A1 - Christine T Cigolle A1 - Todd M Koelling A1 - Caroline S Blaum A1 - Kenneth M. Langa KW - Age Factors KW - Aged KW - Aged, 80 and over KW - Algorithms KW - Awareness KW - Chi-Square Distribution KW - Comorbidity KW - Female KW - Health Knowledge, Attitudes, Practice KW - Health Status KW - Health Surveys KW - Heart Failure KW - Humans KW - Insurance Claim Review KW - Logistic Models KW - Male KW - Medicare KW - Odds Ratio KW - Patients KW - Predictive Value of Tests KW - Self Report KW - Socioeconomic factors KW - United States AB -

BACKGROUND: Little research has been conducted on the predictors of self-report or patient awareness of heart failure (HF) in a population-based survey. The objective of this study was to (1) test the agreement between Medicare administrative and Health and Retirement Study (HRS) survey data and (2) determine predictors associated with self-report of HF, using a validated Medicare claims algorithm as the reference standard. We hypothesized that those who self-reported HF were more likely to have a higher number of HF-related claims.

METHODS AND RESULTS: Secondary data analysis was conducted using the 2004 wave of the HRS linked to 2002 to 2004 Medicare claims (n=5573 respondents aged ≥ 67 years). Concordance between self-report of HF in the HRS and Medicare claims was calculated. Logistic regression was performed to identify predictors associated with self-report HF. HF prevalence by self-report was 4.6%. Self-report of HF and claims agreement was 87% (κ=0.34). The presence of >1 HF inpatient claims was associated with greater odds of self-report (odds ratio [OR], 1.92; 95% CI, 1.23-3.00). Greater odds of self-reporting HF was also associated with ≥ 4 HF claims (OR, 2.74; 95% CI, 1.36-5.52). Blacks (OR, 0.28; 95% CI, 0.14-0.55) and Hispanics (OR, 0.30; 95% CI, 0.11-0.83) were less likely to self-report HF compared with whites in the final model.

CONCLUSIONS: Self-report of HF is an insensitive method for accurately identifying HF cases, especially in those with less-severe disease and who are nonwhite. There may be limited awareness of HF among older minority patients despite having clinical encounters during which HF is coded as a diagnosis.

PB - 5 VL - 5 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22592753?dopt=Abstract U2 - PMC3370939 U4 - medicare claims/heart disease/self-reported health ER - TY - JOUR T1 - Prevalence of cognitive impairment in older adults with heart failure. JF - J Am Geriatr Soc Y1 - 2012 A1 - Tanya R Gure A1 - Caroline S Blaum A1 - Bruno J Giordani A1 - Todd M Koelling A1 - Andrzej T Galecki A1 - Susan J Pressler A1 - Scott L Hummel A1 - Kenneth M. Langa KW - Aged KW - Aged, 80 and over KW - Algorithms KW - Chi-Square Distribution KW - Cognition Disorders KW - Cross-Sectional Studies KW - Demography KW - Female KW - Heart Failure KW - Humans KW - Logistic Models KW - Male KW - Medicare KW - Prevalence KW - United States AB -

OBJECTIVES: To determine the prevalence of cognitive impairment in older adults with heart failure (HF).

DESIGN: Cross-sectional analysis of the 2004 wave of the nationally representative Health and Retirement Study linked to 2002 to 2004 Medicare administrative claims.

SETTING: United States, community.

PARTICIPANTS: Six thousand one hundred eighty-nine individuals aged 67 and older.

MEASUREMENTS: An algorithm was developed using a combination of self- and proxy report of a heart problem and the presence of one or more Medicare claims in administrative files using standard HF diagnostic codes. On the basis of the algorithm, three categories were created to characterize the likelihood of a HF diagnosis: high or moderate probability of HF, low probability of HF, and no HF. Cognitive function was assessed using a screening measure of cognitive function or according to proxy rating. Age-adjusted prevalence estimates of cognitive impairment were calculated for the three groups.

RESULTS: The prevalence of cognitive impairment consistent with dementia in older adults with HF was 15%, and the prevalence of mild cognitive impairment was 24%. The odds of dementia in those with HF were significantly higher, even after adjustment for age, education level, net worth, and prior stroke (odds ratio = 1.52, 95% confidence interval = 1.14-2.02).

CONCLUSION: Cognitive impairment is common in older adults with HF and is independently associated with risk of dementia. A cognitive assessment should be routinely incorporated into HF-focused models of care.

PB - 60 VL - 60 IS - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22882000?dopt=Abstract U2 - PMC3445700 U4 - Cognition/Cognitive impairment/Cardiovascular disease/heart Diseases/epidemiology/dementia/PREVALENCE ER - TY - JOUR T1 - Spurring enrollment in Medicare savings programs through a substitute for the asset test focused on investment income. JF - Health Aff (Millwood) Y1 - 2012 A1 - Dorn, Stan A1 - Shang, Baoping KW - Cost Savings KW - Eligibility Determination KW - Financing, Personal KW - Humans KW - Medicare KW - Poverty KW - United States AB -

Fewer than one-third of eligible Medicare beneficiaries enroll in Medicare savings programs, which pay premiums and, in some cases, eliminate out-of-pocket cost sharing for poor and near-poor enrollees. Many beneficiaries don't participate in savings programs because they must complete a cumbersome application process, including a burdensome asset test. We demonstrate that a streamlined alternative to the asset test-allowing seniors to qualify for Medicare savings programs by providing evidence of limited assets or showing a lack of investment income-would permit 78 percent of currently eligible seniors to bypass the asset test entirely. This simplified approach would increase the number of beneficiaries who qualify for Medicare savings programs from the current 3.6 million seniors to 4.6 million. Such an alternative would keep benefits targeted to people with low assets, eliminate costly administrative expenses and obstacles to enrollment associated with the asset test, and avoid the much larger influx of seniors that would occur if the asset test were eliminated entirely.

PB - 31 VL - 31 IS - 2 N1 - Copyright - Copyright The People to People Health Foundation, Inc., Project HOPE Feb 2012 Language of summary - English Location - United States--US Pages - 367-75 ProQuest ID - 921992803 Document feature - Tables; References SubjectsTermNotLitGenreText - United States--US Last updated - 2012-06-05 Place of publication - Chevy Chase Corporate institution author - Dorn, Stan; Shang, Baoping DOI - 2588825981; 67448192; 15986; HAF; 22323167; INNNHAF0000865869 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22323167?dopt=Abstract U3 - 22323167 U4 - Financing, Personal/Cost Savings/Medicare/public policy/assets/medicare savings programs/socioeconomic factors ER - TY - JOUR T1 - Tests and expenditures in the initial evaluation of peripheral neuropathy. JF - Arch Intern Med Y1 - 2012 A1 - Brian C. Callaghan A1 - Ryan J McCammon A1 - Kevin Kerber A1 - Xiao Xu A1 - Kenneth M. Langa A1 - Eva L Feldman KW - Aged KW - Antibodies, Antinuclear KW - Blood Cell Count KW - Blood Protein Electrophoresis KW - Blood Sedimentation KW - Brain KW - Diagnostic Tests, Routine KW - Electromyography KW - Female KW - Glucose Tolerance Test KW - Glycated Hemoglobin KW - Health Expenditures KW - Humans KW - International Classification of Diseases KW - Magnetic Resonance Imaging KW - Male KW - Medicare KW - Neural Conduction KW - Peripheral Nervous System Diseases KW - Quality Assurance, Health Care KW - Spine KW - Thyrotropin KW - United States KW - Vitamin B 12 AB -

BACKGROUND: Peripheral neuropathy is a common disorder in which an extensive evaluation is often unrevealing.

METHODS: We sought to define diagnostic practice patterns as an early step in identifying opportunities to improve efficiency of care. The 1996-2007 Health and Retirement Study Medicare claims-linked database was used to identify individuals with an incident diagnosis of peripheral neuropathy using International Classification of Diseases, Ninth Revision, codes and required no previous neuropathy diagnosis during the preceding 30 months. Focusing on 15 relevant tests, we examined the number and patterns of tests and specific test utilization 6 months before and after the incident neuropathy diagnosis. Medicare expenditures were assessed during the baseline, diagnostic, and follow-up periods.

RESULTS: Of the 12, 673 patients, 1031 (8.1%) received a new International Classification of Diseases, Ninth Revision, diagnosis of neuropathy and met the study inclusion criteria. Of the 15 tests considered, a median of 4 (interquartile range, 2-5) tests were performed, with more than 400 patterns of testing. Magnetic resonance imaging of the brain or spine was ordered in 23.2% of patients, whereas a glucose tolerance test was rarely obtained (1.0%). Mean Medicare expenditures were significantly higher in the diagnostic period than in the baseline period ($14,362 vs $8067, P < .001).

CONCLUSIONS: Patients diagnosed as having peripheral neuropathy typically undergo many tests, but testing patterns are highly variable. Almost one-quarter of patients receiving neuropathy diagnoses undergo high-cost, low-yield magnetic resonance imaging, whereas few receive low-cost, high-yield glucose tolerance tests. Expenditures increase substantially in the diagnostic period. More research is needed to define effective and efficient strategies for the diagnostic evaluation of peripheral neuropathy.

PB - 172 VL - 172 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/22271119?dopt=Abstract U2 - PMC3694340 U4 - Peripheral neuropathy/Peripheral neuropathy/diagonistic practice patterns/health Services/Medicare/Medicare claims/glucose tolerance test ER - TY - JOUR T1 - Triggers of hospitalization for venous thromboembolism. JF - Circulation Y1 - 2012 A1 - Mary A M Rogers A1 - Deborah A Levine A1 - Neil Blumberg A1 - Scott A Flanders A1 - Vineet Chopra A1 - Kenneth M. Langa KW - Aged KW - Ambulatory Care Facilities KW - Comorbidity KW - Cross-Over Studies KW - Emergency Service, Hospital KW - Female KW - Hematinics KW - Home Care Services KW - Hospitalization KW - Humans KW - Immobilization KW - Incidence KW - Infections KW - Male KW - Medicare KW - Middle Aged KW - Office Visits KW - Postoperative Complications KW - Pulmonary Embolism KW - Risk Factors KW - Skilled Nursing Facilities KW - Transfusion Reaction KW - United States KW - Venous Thrombosis AB -

BACKGROUND: The rate of hospitalization for venous thromboembolism (VTE) is increasing in the United States. Although predictors of hospital-acquired VTE are well-known, triggers of VTE before hospitalization are not as clearly defined. The objective of this study was to evaluate triggers of hospitalization for VTE.

METHODS AND RESULTS: A case-crossover study was conducted. Subjects were participants in the Health and Retirement Study, a nationally representative sample of older Americans. Data were linked to Medicare files for hospital and nursing home stays, emergency department visits, outpatient visits including physician visits, and home health visits from years 1991 to 2007 (n=16 781). The outcome was hospitalization for venous thromboembolism (n=399). Exposures during the 90-day period before hospitalization for VTE were compared with exposures occurring in 4 comparison periods. Infection was the most common trigger of hospitalization for VTE, occurring in 52.4% of the risk periods before hospitalization. The adjusted incidence rate ratios (IRRs; 95% confidence interval) were 2.90 (2.13, 3.94) for all infection, 2.63 (1.90, 3.63) for infection without a previous hospital or skilled nursing facility stay, and 6.92 (4.46, 10.72) for infection with a previous hospital or skilled nursing facility stay. Erythropoiesis-stimulating agents and blood transfusion were also associated with VTE hospitalization (IRR=9.33, 95% confidence interval: 1.19, 73.42; IRR=2.57, 95% confidence interval: 1.17, 5.64; respectively). Other predictors included major surgeries, fractures (IRR=2.81), immobility (IRR=4.23), and chemotherapy (IRR=5.70). These predictors, combined, accounted for a large proportion (69.7%) of exposures before VTE hospitalization as opposed to 35.3% in the comparison periods.

CONCLUSIONS: Risk prediction algorithms for VTE should be reevaluated to include infection, erythropoiesis-stimulating agents, and blood transfusion.

PB - 125 VL - 125 UR - http://www.ncbi.nlm.nih.gov/pubmed/22474264 IS - 17 N1 - Rogers, Mary A M Levine, Deborah A Blumberg, Neil Flanders, Scott A Chopra, Vineet Langa, Kenneth M 5R21HL093129-02/HL/NHLBI NIH HHS/ R01 HL095467/HL/NHLBI NIH HHS/ U01AG009740/AG/NIA NIH HHS/ Circulation. 2012 May 1;125(17):2092-9. Epub 2012 Apr 3. U1 - http://www.ncbi.nlm.nih.gov/pubmed/22474264?dopt=Abstract U2 - PMC3342773 U4 - medicare claims/HOSPITALIZATION/venous thromboembolism/pulmonary embolism ER - TY - JOUR T1 - Anticipatory ex ante moral hazard and the effect of Medicare on prevention. JF - Health Econ Y1 - 2011 A1 - de Preux, Laure B KW - Age Factors KW - Aged KW - Alcohol Drinking KW - Female KW - Health Behavior KW - Health Services KW - Humans KW - Insurance Coverage KW - Male KW - Medically Uninsured KW - Medicare KW - Middle Aged KW - Morals KW - Motor Activity KW - Proportional Hazards Models KW - Regression Analysis KW - Smoking KW - United States AB -

This paper extends the ex ante moral hazard model to allow healthy lifestyles to reduce the probability of illness in future periods, so that current preventive behaviour may be affected by anticipated changes in future insurance coverage. In the United States, Medicare is offered to almost all the population at the age of 65. We use nine waves of the US Health and Retirement Study to compare lifestyles before and after 65 of those insured and not insured pre 65. The double-robust approach, which combines propensity score and regression, is used to compare trends in lifestyle (physical activity, smoking, drinking) of the two groups before and after receiving Medicare, using both difference-in-differences and difference-in-differences-in-differences. There is no clear effect of the receipt of Medicare or its anticipation on alcohol consumption nor smoking behaviour, but the previously uninsured do reduce physical activity just before receiving Medicare.

PB - 20 VL - 20 IS - 9 N1 - de Preux, Laure B Comparative Study England Health economics Health Econ. 2011 Sep;20(9):1056-72. doi: 10.1002/hec.1778. U1 - http://www.ncbi.nlm.nih.gov/pubmed/21830252?dopt=Abstract U3 - 21830252 U4 - Age Factors/Alcohol Drinking/epidemiology/Alcohol Drinking/epidemiology/Female/Health Behavior/Health Services/economics/ethics/ utilization/Health Services/economics/ethics/ utilization/Humans/Insurance Coverage/economics/ethics/ statistics/Insurance Coverage/economics/ethics/ statistics/numerical data/Medically Uninsured/ statistics/Medically Uninsured/ statistics/numerical data/Medicare/economics/ statistics/Medicare/economics/ statistics/numerical data/Middle Aged/moral hazard/Motor Activity/Motor Activity/Proportional Hazards Models/Regression Analysis/Smoking/epidemiology/Smoking/epidemiology/United States/epidemiology/United States/epidemiology ER - TY - JOUR T1 - Can Food Stamps help to reduce Medicare spending on diabetes? JF - Econ Hum Biol Y1 - 2011 A1 - Lauren Hersch Nicholas KW - Aged KW - Aged, 80 and over KW - Biomarkers KW - Confidence Intervals KW - Cross-Sectional Studies KW - Diabetes Mellitus KW - Female KW - Glycated Hemoglobin KW - Health Care Costs KW - Humans KW - Longitudinal Studies KW - Male KW - Medicare KW - Middle Aged KW - Odds Ratio KW - Outpatients KW - Poverty KW - Prevalence KW - Public Assistance KW - Regression Analysis KW - Social Welfare KW - Treatment Outcome KW - United States AB -

Diabetes is rapidly escalating amongst low-income, older adults at great cost to the Medicare program. We use longitudinal survey data from the Health and Retirement Study linked to administrative Medicare records and biomarker data to assess the relationship between Food Stamp receipt and diabetes health outcomes. We find no significant difference in Medicare spending, outpatient utilization, diabetes hospitalizations and blood sugar (HbA1c) levels between recipients and income-eligible non-recipients after controlling for a detailed set of covariates including individual fixed effects and measures of diabetes treatment compliance. As one-third of elderly Food Stamp recipients are currently diabetic, greater coordination between the Food Stamp, Medicare, and Medicaid programs may improve health outcomes for this group.

PB - 9 VL - 9 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21112260?dopt=Abstract U2 - PMC3032985 U4 - Diabetes/Food Stamps/biomarker data/elderly/Medicare spending/HbA1c/Public Policy ER - TY - JOUR T1 - Complex Medicare Advantage Choices May Overwhelm Seniors—Especially Those With Impaired Decision Making JF - Health Affairs Y1 - 2011 A1 - J. Michael McWilliams A1 - Afendulis, Christopher C. A1 - McGuire, Thomas G. A1 - Landon, Bruce E. KW - Decision making KW - Medicare KW - Medicare claims data AB - The proliferation of Medicare Advantage plans has given Medicare enrollees more choices, but these could be overwhelming for some, especially for those with impaired decision-making capabilities. We analyzed national survey data and linked Medicare enrollment data for the period 2004–07 to examine the effects on enrollment of expanded choices and benefits in the Medicare Advantage program. The availability of more plan options was associated with increased enrollment in Medicare Advantage when elderly Medicare beneficiaries chose from a limited number of plans—for example, fewer than fifteen plans. Enrollment was unchanged or decreased in Medicare Advantage when beneficiaries chose from larger numbers of plans—for example, fifteen to thirty, or more than thirty. Elderly adults with low cognitive function were less responsive to the generosity of available benefits than those with high cognitive function when choosing between traditional Medicare and Medicare Advantage. Simplifying choices in Medicare Advantage could improve beneficiaries’ enrollment decisions, strengthen value-based competition among plans, and extend the benefits of choice to seniors with impaired cognition. It could also lower their out-of-pocket costs. VL - 30 IS - 9 ER - TY - JOUR T1 - Determinants of medical expenditures in the last 6 months of life. JF - Annals of Internal Medicine Y1 - 2011 A1 - Amy Kelley A1 - Susan L Ettner A1 - R Sean Morrison A1 - Qingling Du A1 - Neil S. Wenger A1 - Catherine A Sarkisian KW - Aged KW - Aged, 80 and over KW - Chronic disease KW - Ethnic Groups KW - Female KW - Health Expenditures KW - Humans KW - Income KW - Independent Living KW - Male KW - Medicare KW - Regression Analysis KW - Social Support KW - Socioeconomic factors KW - Terminal Care KW - United States AB -

BACKGROUND: End-of-life medical expenditures exceed costs of care during other years, vary across regions, and are likely to be unsustainable. Identifying determinants of expenditure variation may reveal opportunities for reducing costs.

OBJECTIVE: To identify patient-level determinants of Medicare expenditures at the end of life and to determine the contributions of these factors to expenditure variation while accounting for regional characteristics. It was hypothesized that race or ethnicity, social support, and functional status are independently associated with treatment intensity and controlling for regional characteristics, and that individual characteristics account for a substantial proportion of expenditure variation.

DESIGN: Using data from the Health and Retirement Study, Medicare claims, and The Dartmouth Atlas of Health Care, relationships were modeled between expenditures and patient and regional characteristics.

SETTING: United States, 2000 to 2006.

PARTICIPANTS: 2394 Health and Retirement Study decedents aged 65.5 years or older.

MEASUREMENTS: Medicare expenditures in the last 6 months of life were estimated in a series of 2-level multivariable regression models that included patient, regional, and patient and regional characteristics.

RESULTS: Decline in function (rate ratio [RR], 1.64 [95% CI, 1.46 to 1.83]); Hispanic ethnicity (RR, 1.50 [CI, 1.22 to 1.85]); black race (RR, 1.43 [CI, 1.25 to 1.64]); and certain chronic diseases, including diabetes (RR, 1.16 [CI, 1.06 to 1.27]), were associated with higher expenditures. Nearby family (RR, 0.90 [CI, 0.82 to 0.98]) and dementia (RR, 0.78 CI, 0.71 to 0.87]) were associated with lower expenditures, and advance care planning had no association. Regional characteristics, including end-of-life practice patterns (RR, 1.09 [CI, 1.06 to 1.14]) and hospital beds per capita (RR, 1.01 [CI, 1.00 to 1.02]), were associated with higher expenditures. Patient characteristics explained 10% of overall variance and retained statistically significant relationships with expenditures after regional characteristics were controlled for.

LIMITATION: The study limitations include the decedent sample, proxy informants, and a large proportion of unexplained variation.

CONCLUSION: Patient characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby family, are important determinants of expenditures at the end of life, independent of regional characteristics.

PRIMARY FUNDING SOURCE: The Brookdale Foundation.

VL - 154 IS - 4 ER - TY - JOUR T1 - The evolution of advance directives. JF - JAMA Y1 - 2011 A1 - Douglas B. White A1 - Robert M. Arnold KW - Advance directives KW - Cost Savings KW - Decision making KW - Health Expenditures KW - Humans KW - Medicare KW - Palliative care KW - Terminal Care KW - United States PB - 306 VL - 306 IS - 13 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21972313?dopt=Abstract U3 - 21972313 U4 - Medicare/Advance directives/Medical technology/Health care expenditures ER - TY - JOUR T1 - Long-term declines in ADLs, IADLs, and mobility among older Medicare beneficiaries. JF - BMC Geriatr Y1 - 2011 A1 - Frederic D Wolinsky A1 - Suzanne E Bentler A1 - Jason Hockenberry A1 - Michael P Jones A1 - Maksym Obrizan A1 - Paula A Weigel A1 - Kaskie, Brian A1 - Robert B Wallace KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Disabled Persons KW - Female KW - Follow-Up Studies KW - Geriatric Assessment KW - Health Surveys KW - Humans KW - Insurance Benefits KW - Longitudinal Studies KW - Male KW - Medicare KW - Mobility Limitation KW - Prospective Studies KW - Time Factors KW - United States AB -

BACKGROUND: Most prior studies have focused on short-term (≤ 2 years) functional declines. But those studies cannot address aging effects inasmuch as all participants have aged the same amount. Therefore, the authors studied the extent of long-term functional decline in older Medicare beneficiaries who were followed for varying time lengths, and the authors also identified the risk factors associated with those declines.

METHODS: The analytic sample included 5,871 self- or proxy-respondents who had complete baseline and follow-up survey data that could be linked to their Medicare claims for 1993-2007. Functional status was assessed using activities of daily living (ADLs), instrumental ADLs (IADLs), and mobility limitations, with declines defined as the development of two of more new difficulties. Multiple logistic regression analysis was used to focus on the associations involving respondent status, health lifestyle, continuity of care, managed care status, health shocks, and terminal drop.

RESULTS: The average amount of time between the first and final interviews was 8.0 years. Declines were observed for 36.6% on ADL abilities, 32.3% on IADL abilities, and 30.9% on mobility abilities. Functional decline was more likely to occur when proxy-reports were used, and the effects of baseline function on decline were reduced when proxy-reports were used. Engaging in vigorous physical activity consistently and substantially protected against functional decline, whereas obesity, cigarette smoking, and alcohol consumption were only associated with mobility declines. Post-baseline hospitalizations were the most robust predictors of functional decline, exhibiting a dose-response effect such that the greater the average annual number of hospital episodes, the greater the likelihood of functional status decline. Participants whose final interview preceded their death by one year or less had substantially greater odds of functional status decline.

CONCLUSIONS: Both the additive and interactive (with functional status) effects of respondent status should be taken into consideration whenever proxy-reports are used. Encouraging exercise could broadly reduce the risk of functional decline across all three outcomes, although interventions encouraging weight reduction and smoking cessation would only affect mobility declines. Reducing hospitalization and re-hospitalization rates could also broadly reduce the risk of functional decline across all three outcomes.

PB - 11 VL - 11 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21846400?dopt=Abstract U2 - PMC3167753 U4 - SELF-RATED HEALTH/Medicare/Functional decline/Functional decline/ADL/IADL/risk Factors ER - TY - JOUR T1 - A prospective cohort study of long-term cognitive changes in older Medicare beneficiaries. JF - BMC Public Health Y1 - 2011 A1 - Frederic D Wolinsky A1 - Suzanne E Bentler A1 - Jason Hockenberry A1 - Michael P Jones A1 - Paula A Weigel A1 - Kaskie, Brian A1 - Robert B Wallace KW - Aged KW - Aged, 80 and over KW - Aging KW - Cognition KW - Cognition Disorders KW - Cohort Studies KW - Female KW - Humans KW - Interviews as Topic KW - Male KW - Medicare KW - Mental Health KW - Outcome Assessment, Health Care KW - Prospective Studies KW - Regression Analysis KW - Risk Factors KW - United States AB -

BACKGROUND: Promoting cognitive health and preventing its decline are longstanding public health goals, but long-term changes in cognitive function are not well-documented. Therefore, we first examined long-term changes in cognitive function among older Medicare beneficiaries in the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD), and then we identified the risk factors associated with those changes in cognitive function.

METHODS: We conducted a secondary analysis of a prospective, population-based cohort using baseline (1993-1994) interview data linked to 1993-2007 Medicare claims to examine cognitive function at the final follow-up interview which occurred between 1995-1996 and 2006-2007. Besides traditional risk factors (i.e., aging, age, race, and education) and adjustment for baseline cognitive function, we considered the reason for censoring (entrance into managed care or death), and post-baseline continuity of care and major health shocks (hospital episodes). Residual change score multiple linear regression analysis was used to predict cognitive function at the final follow-up using data from telephone interviews among 3,021 to 4,251 (sample size varied by cognitive outcome) baseline community-dwelling self-respondents that were ≥ 70 years old, not in managed Medicare, and had at least one follow-up interview as self-respondents. Cognitive function was assessed using the 7-item Telephone Interview for Cognitive Status (TICS-7; general mental status), and the 10-item immediate and delayed (episodic memory) word recall tests.

RESULTS: Mean changes in the number of correct responses on the TICS-7, and 10-item immediate and delayed word recall tests were -0.33, -0.75, and -0.78, with 43.6%, 54.9%, and 52.3% declining and 25.4%, 20.8%, and 22.9% unchanged. The main and most consistent risks for declining cognitive function were the baseline values of cognitive function (reflecting substantial regression to the mean), aging (a strong linear pattern of increased decline associated with greater aging, but with diminishing marginal returns), older age at baseline, dying before the end of the study period, lower education, and minority status.

CONCLUSIONS: In addition to aging, age, minority status, and low education, substantial and differential risks for cognitive change were associated with sooner vs. later subsequent death that help to clarify the terminal drop hypothesis. No readily modifiable protective factors were identified.

PB - 11 VL - 11 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21933430?dopt=Abstract U2 - PMC3190354 U4 - Cognition/Cognitive decline/public policy/Medicare/cognitive Function/TICS Scale ER - TY - JOUR T1 - Regional variation in the association between advance directives and end-of-life Medicare expenditures. JF - JAMA Y1 - 2011 A1 - Lauren Hersch Nicholas A1 - Kenneth M. Langa A1 - Theodore J Iwashyna A1 - David R Weir KW - Advance directives KW - Aged KW - Aged, 80 and over KW - Data collection KW - Female KW - Health Expenditures KW - Hospice Care KW - Hospital Mortality KW - Hospitals KW - Humans KW - Kidney Failure, Chronic KW - Male KW - Medicare KW - Palliative care KW - Prospective Studies KW - Regression Analysis KW - Terminal Care KW - United States AB -

CONTEXT: It is unclear if advance directives (living wills) are associated with end-of-life expenditures and treatments.

OBJECTIVE: To examine regional variation in the associations between treatment-limiting advance directive use, end-of-life Medicare expenditures, and use of palliative and intensive treatments.

DESIGN, SETTING, AND PATIENTS: Prospectively collected survey data from the Health and Retirement Study for 3302 Medicare beneficiaries who died between 1998 and 2007 linked to Medicare claims and the National Death Index. Multivariable regression models examined associations between advance directives, end-of-life Medicare expenditures, and treatments by level of Medicare spending in the decedent's hospital referral region.

MAIN OUTCOME MEASURES: Medicare expenditures, life-sustaining treatments, hospice care, and in-hospital death over the last 6 months of life.

RESULTS: Advance directives specifying limits in care were associated with lower spending in hospital referral regions with high average levels of end-of-life expenditures (-$5585 per decedent; 95% CI, -$10,903 to -$267), but there was no difference in spending in hospital referral regions with low or medium levels of end-of-life expenditures. Directives were associated with lower adjusted probabilities of in-hospital death in high- and medium-spending regions (-9.8%; 95% CI, -16% to -3% in high-spending regions; -5.3%; 95% CI, -10% to -0.4% in medium-spending regions). Advance directives were associated with higher adjusted probabilities of hospice use in high- and medium-spending regions (17%; 95% CI, 11% to 23% in high-spending regions, 11%; 95% CI, 6% to 16% in medium-spending regions), but not in low-spending regions.

CONCLUSION: Advance directives specifying limitations in end-of-life care were associated with significantly lower levels of Medicare spending, lower likelihood of in-hospital death, and higher use of hospice care in regions characterized by higher levels of end-of-life spending.

PB - 112 VL - 306 UR - http://proquest.umi.com.proxy.lib.umich.edu/pqdweb?did=2590187421andFmt=7andclientId=17822andRQT=309andVName=PQD IS - 13 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21972306?dopt=Abstract U2 - PMC3332047 U4 - Advance directives/Palliative care/Health care expenditures/Medicare ER - TY - JOUR T1 - Defining emergency department episodes by severity and intensity: A 15-year study of Medicare beneficiaries. JF - BMC Health Serv Res Y1 - 2010 A1 - Kaskie, Brian A1 - Maksym Obrizan A1 - Elizabeth A Cook A1 - Michael P Jones A1 - Li Liu A1 - Suzanne E Bentler A1 - Robert B Wallace A1 - John F Geweke A1 - Kara B Wright A1 - Elizabeth A Chrischilles A1 - Claire E Pavlik A1 - Robert L. Ohsfeldt A1 - Gary E Rosenthal A1 - Frederic D Wolinsky KW - Aged KW - Aged, 80 and over KW - Cohort Studies KW - Emergency Service, Hospital KW - Humans KW - Insurance Claim Review KW - Medicare KW - Prospective Studies KW - Severity of Illness Index KW - United States AB -

BACKGROUND: Episodes of Emergency Department (ED) service use among older adults previously have not been constructed, or evaluated as multi-dimensional phenomena. In this study, we constructed episodes of ED service use among a cohort of older adults over a 15-year observation period, measured the episodes by severity and intensity, and compared these measures in predicting subsequent hospitalization.

METHODS: We conducted a secondary analysis of the prospective cohort study entitled the Survey on Assets and Health Dynamics among the Oldest Old (AHEAD). Baseline (1993) data on 5,511 self-respondents >or=70 years old were linked to their Medicare claims for 1991-2005. Claims then were organized into episodes of ED care according to Medicare guidelines. The severity of ED episodes was measured with a modified-NYU algorithm using ICD9-CM diagnoses, and the intensity of the episodes was measured using CPT codes. Measures were evaluated against subsequent hospitalization to estimate comparative predictive validity.

RESULTS: Over 15 years, three-fourths (4,171) of the 5,511 AHEAD participants had at least 1 ED episode, with a mean of 4.5 episodes. Cross-classification indicated the modified-NYU severity measure and the CPT-based intensity measure captured different aspects of ED episodes (kappa = 0.18). While both measures were significant independent predictors of hospital admission from ED episodes, the CPT measure had substantially higher predictive validity than the modified-NYU measure (AORs 5.70 vs. 3.31; p < .001).

CONCLUSIONS: We demonstrated an innovative approach for how claims data can be used to construct episodes of ED care among a sample of older adults. We also determined that the modified-NYU measure of severity and the CPT measure of intensity tap different aspects of ED episodes, and that both measures were predictive of subsequent hospitalization.

PB - 8 VL - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20565949?dopt=Abstract U2 - PMC2903585 U4 - HOSPITALIZATION/emergency department service use/emergency department service use/medicare/predictive validity/predictive validity ER - TY - JOUR T1 - Impact of cognitive impairment on screening mammography use in older US women. JF - Am J Public Health Y1 - 2010 A1 - Kala M. Mehta A1 - Kathy Z Fung A1 - Christine E Kistler A1 - Chang, Anna A1 - Louise C Walter KW - Aged KW - Aged, 80 and over KW - Cognition Disorders KW - Female KW - Humans KW - Incidence KW - Longitudinal Studies KW - Mammography KW - Medicare KW - Patient Acceptance of Health Care KW - Social Class KW - United States AB -

OBJECTIVES: We evaluated mammography rates for cognitively impaired women in the context of their life expectancies, given that guidelines do not recommend screening mammography in women with limited life expectancies because harms outweigh benefits.

METHODS: We evaluated Medicare claims for women aged 70 years or older from the 2002 wave of the Health and Retirement Study to determine which women had screening mammography. We calculated population-based estimates of 2-year screening mammography prevalence and 4-year survival by cognitive status and age.

RESULTS: Women with severe cognitive impairment had lower rates of mammography (18%) compared with women with normal cognition (45%). Nationally, an estimated 120,000 screening mammograms were performed among women with severe cognitive impairment despite this group's median survival of 3.3 years (95% confidence interval = 2.8, 3.7). Cognitively impaired women who had high net worth and were married had screening rates approaching 50%.

CONCLUSIONS: Although severe cognitive impairment is associated with lower screening mammography rates, certain subgroups with cognitive impairment are often screened despite lack of probable benefit. Given the limited life expectancy of women with severe cognitive impairment, guidelines should explicitly recommend against screening these women.

PB - 100 VL - 100 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20075325?dopt=Abstract U2 - PMC2936976 U4 - Cognition Disorders/Mammography/Medicare ER - TY - JOUR T1 - Prior hospitalization and the risk of heart attack in older adults: a 12-year prospective study of Medicare beneficiaries. JF - J Gerontol A Biol Sci Med Sci Y1 - 2010 A1 - Frederic D Wolinsky A1 - Suzanne E Bentler A1 - Li Liu A1 - Michael P Jones A1 - Kaskie, Brian A1 - Jason Hockenberry A1 - Elizabeth A Chrischilles A1 - Kara B Wright A1 - John F Geweke A1 - Maksym Obrizan A1 - Robert L. Ohsfeldt A1 - Gary E Rosenthal A1 - Robert B Wallace KW - Aged KW - Educational Status KW - Female KW - Hospitalization KW - Humans KW - Male KW - Marital Status KW - Medicare KW - Myocardial Infarction KW - Patient Discharge KW - Proportional Hazards Models KW - Prospective Studies KW - Risk Factors KW - Sex Factors KW - United States AB -

BACKGROUND: We investigated whether prior hospitalization was a risk factor for heart attacks among older adults in the survey on Assets and Health Dynamics among the Oldest Old.

METHODS: Baseline (1993-1994) interview data were linked to 1993-2005 Medicare claims for 5,511 self-respondents aged 70 years and older and not enrolled in managed Medicare. Primary hospital International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 410.xx discharge codes identified postbaseline hospitalizations for acute myocardial infarctions (AMIs). Participants were censored at death or postbaseline managed Medicare enrollment. Traditional risk factors and other covariates were included. Recent postbaseline non-AMI hospitalizations (ie, prior hospitalizations) were indicated by a time-dependent marker, and sensitivity analyses identified their peak effect.

RESULTS: The total number of person-years of surveillance was 44,740 with a mean of 8.1 (median = 9.1) per person. Overall, 483 participants (8.8%) suffered postbaseline heart attacks, with 423 participants (7.7%) having their first-ever AMI. As expected, significant traditional risk factors were sex (men); race (whites); marital status (never being married); education (noncollege); geography (living in the South); and reporting a baseline history of angina, arthritis, diabetes, and heart disease. Risk factors were similar for both any postbaseline and first-ever postbaseline AMI analyses. The time-dependent recent non-AMI hospitalization marker did not alter the effects of the traditional risk factors but increased AMI risk by 366% (adjusted hazards ratio = 4.66, p < .0001). Discussion. Our results suggest that some small percentage (<3%) of heart attacks among older adults might be prevented if effective short-term postdischarge planning and monitoring interventions were developed and implemented.

PB - 65 VL - 65 IS - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20106961?dopt=Abstract U2 - PMC2904597 U4 - HOSPITALIZATION/heart disease/risk Factors/Medicare/Public Policy ER - TY - JOUR T1 - Reforming beneficiary cost sharing to improve Medicare performance. JF - Inquiry Y1 - 2010 A1 - Zuckerman, Stephen A1 - Shang, Baoping A1 - Timothy A Waidmann KW - Aged KW - Aged, 80 and over KW - Cost Sharing KW - Health Expenditures KW - Humans KW - Medicare KW - Middle Aged KW - Models, Economic KW - United States AB -

This paper explores options for reforming Medicare cost sharing in an effort to provide better financial protection for those beneficiaries with the greatest health care needs. Using data from the Health and Retirement Study (HRS) and the Medicare Current Beneficiary Survey (MCBS), we consider how unified annual deductibles, alternative coinsurance rates, and a limit on out-of-pocket spending would alter program spending, beneficiary cost sharing, and premiums for supplemental coverage. We show that adding an out-of-pocket limit and raising deductibles and coinsurance slightly would provide better safeguards to beneficiaries with high costs than the current Medicare benefit structure. Our estimates also suggest that policies protecting these beneficiaries could be structured in a way that would add little to overall program costs.

PB - 47 VL - 47 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/21155416?dopt=Abstract U4 - Medicare/out of pocket costs/Beneficiaries ER - TY - JOUR T1 - Untreated poor vision: a contributing factor to late-life dementia. JF - Am J Epidemiol Y1 - 2010 A1 - Mary A M Rogers A1 - Kenneth M. Langa KW - Aged, 80 and over KW - Cognition Disorders KW - Dementia KW - Female KW - Humans KW - Logistic Models KW - Male KW - Medicare KW - Ophthalmology KW - Patient Acceptance of Health Care KW - Risk Factors KW - United States KW - Vision Disorders AB -

Ophthalmologic abnormalities have been described in patients with dementia, but the extent to which poor vision and treatment for visual disorders affect cognitive decline is not well defined. Linked data from the Health and Retirement Study and Medicare files (1992-2005) were used to follow the experiences of 625 elderly US study participants with normal cognition at baseline. The outcome was a diagnosis of dementia, cognitively impaired but no dementia, or normal cognition. Poor vision was associated with development of dementia (P = 0.0048); individuals with very good or excellent vision at baseline had a 63% reduced risk of dementia (95% confidence interval (CI): 20, 82) over a mean follow-up period of 8.5 years. Participants with poorer vision who did not visit an ophthalmologist had a 9.5-fold increased risk of Alzheimer disease (95% CI: 2.3, 39.5) and a 5-fold increased risk of cognitively impaired but no dementia (95% CI: 1.6, 15.9). Poorer vision without a previous eye procedure increased the risk of Alzheimer disease 5-fold (95% CI: 1.5, 18.8). For Americans aged 90 years or older, 77.9% who maintained normal cognition had received at least one previous eye procedure compared with 51.7% of those with Alzheimer disease. Untreated poor vision is associated with cognitive decline, particularly Alzheimer disease.

PB - 171 VL - 171 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/20150357?dopt=Abstract U2 - PMC2842219 U4 - Alzheimer disease/delirium/dementia/amnestic/cognitive disorders/health services research/Medicare/memory disorders/ophthalmology/vision disorders ER - TY - JOUR T1 - A 12-year prospective study of stroke risk in older Medicare beneficiaries. JF - BMC Geriatr Y1 - 2009 A1 - Frederic D Wolinsky A1 - Suzanne E Bentler A1 - Elizabeth A Cook A1 - Elizabeth A Chrischilles A1 - Li Liu A1 - Kara B Wright A1 - John F Geweke A1 - Maksym Obrizan A1 - Claire E Pavlik A1 - Robert L. Ohsfeldt A1 - Michael P Jones A1 - Robert B Wallace A1 - Gary E Rosenthal KW - Aged KW - Aged, 80 and over KW - Female KW - Humans KW - Insurance Benefits KW - Male KW - Medicare KW - Prospective Studies KW - Risk Factors KW - Socioeconomic factors KW - Stroke KW - United States AB -

BACKGROUND: 5.8 M living Americans have experienced a stroke at some time in their lives, 780K had either their first or a recurrent stroke this year, and 150K died from strokes this year. Stroke costs about $66B annually in the US, and also results in serious, long-term disability. Therefore, it is prudent to identify all possible risk factors and their effects so that appropriate intervention points may be targeted.

METHODS: Baseline (1993-1994) interview data from the nationally representative Survey on Assets and Health Dynamics among the Oldest Old (AHEAD) were linked to 1993-2005 Medicare claims. Participants were 5,511 self-respondents >or= 70 years old. Two ICD9-CM case-identification approaches were used. Two approaches to stroke case-identification based on ICD9-CM codes were used, one emphasized sensitivity and the other emphasized specificity. Participants were censored at death or enrollment into managed Medicare. Baseline risk factors included sociodemographic, socioeconomic, place of residence, health behavior, disease history, and functional and cognitive status measures. A time-dependent marker reflecting post-baseline non-stroke hospitalizations was included to reflect health shocks, and sensitivity analyses were conducted to identify its peak effect. Competing risk, proportional hazards regression was used.

RESULTS: Post-baseline strokes occurred for 545 (9.9%; high sensitivity approach) and 374 (6.8%; high specificity approach) participants. The greatest static risks involved increased age, being widowed or never married, living in multi-story buildings, reporting a baseline history of diabetes, hypertension, or stroke, and reporting difficulty picking up a dime, refusing to answer the delayed word recall test, or having poor cognition. Risks were similar for both case-identification approaches and for recurrent and first-ever vs. only first-ever strokes. The time-dependent health shock (recent hospitalization) marker did not alter the static model effect estimates, but increased stroke risk by 200% or more.

CONCLUSION: The effect of our health shock marker (a time-dependent recent hospitalization indicator) was large and did not mediate the effects of the traditional risk factors. This suggests an especially vulnerable post-hospital transition period from adverse effects associated with both their underlying health shock (the reasons for the recent hospital admission) and the consequences of their treatments.

PB - 9 VL - 9 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19426528?dopt=Abstract U2 - PMC2683849 U4 - Stroke/risk factors/DISABILITY/DISABILITY/Health Shocks ER - TY - JOUR T1 - The accuracy of Medicare claims as an epidemiological tool: the case of dementia revisited. JF - J Alzheimers Dis Y1 - 2009 A1 - Donald H. Taylor Jr. A1 - Østbye, Truls A1 - Kenneth M. Langa A1 - David R Weir A1 - Brenda L Plassman KW - Aged KW - Aged, 80 and over KW - Alzheimer disease KW - Cohort Studies KW - Dementia KW - Female KW - Health Care Costs KW - Humans KW - Insurance Claim Reporting KW - Male KW - Medicare KW - Prevalence KW - Sensitivity and Specificity KW - United States AB -

Our study estimates the sensitivity and specificity of Medicare claims to identify clinically-diagnosed dementia, and documents how errors in dementia assessment affect dementia cost estimates. We compared Medicare claims from 1993-2005 to clinical dementia assessments carried out in 2001-2003 for the Aging Demographics and Memory Study (ADAMS) cohort (n = 758) of the Health and Retirement Study. The sensitivity and specificity of Medicare claims was 0.85 and 0.89 for dementia (0.64 and 0.95 for AD). Persons with dementia cost the Medicare program (in 2003) $7,135 more than controls (P < 0.001) when using claims to identify dementia, compared to $5,684 more when using ADAMS (P < 0.001). Using Medicare claims to identify dementia results in a 110% increase in costs for those with dementia as compared to a 68% increase when using ADAMS to identify disease, net of other variables. Persons with false positive Medicare claims notations of dementia were the most expensive group of subjects ($11,294 versus $4,065, for true negatives P < 0.001). Medicare claims overcount the true prevalence of dementia, but there are both false positive and negative assessments of disease. The use of Medicare claims to identify dementia results in an overstatement of the increase in Medicare costs that are due to dementia.

PB - 17 VL - 17 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19542620?dopt=Abstract U2 - PMC3697480 U4 - Medicare/dementia/Cost of Illness ER - TY - JOUR T1 - The aftermath of hip fracture: discharge placement, functional status change, and mortality. JF - Am J Epidemiol Y1 - 2009 A1 - Suzanne E Bentler A1 - Li Liu A1 - Maksym Obrizan A1 - Elizabeth A Cook A1 - Kara B Wright A1 - John F Geweke A1 - Elizabeth A Chrischilles A1 - Claire E Pavlik A1 - Robert B Wallace A1 - Robert L. Ohsfeldt A1 - Michael P Jones A1 - Gary E Rosenthal A1 - Frederic D Wolinsky KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - depression KW - Female KW - Health Status KW - Health Status Indicators KW - Hip Fractures KW - Humans KW - Interviews as Topic KW - Iowa KW - Length of Stay KW - Logistic Models KW - Medicare KW - Patient Discharge KW - Prospective Studies KW - Psychometrics KW - Socioeconomic factors KW - Time Factors KW - Treatment Outcome KW - United States AB -

The authors prospectively explored the consequences of hip fracture with regard to discharge placement, functional status, and mortality using the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). Data from baseline (1993) AHEAD interviews and biennial follow-up interviews were linked to Medicare claims data from 1993-2005. There were 495 postbaseline hip fractures among 5,511 respondents aged >or=69 years. Mean age at hip fracture was 85 years; 73% of fracture patients were white women, 45% had pertrochanteric fractures, and 55% underwent surgical pinning. Most patients (58%) were discharged to a nursing facility, with 14% being discharged to their homes. In-hospital, 6-month, and 1-year mortality were 2.7%, 19%, and 26%, respectively. Declines in functional-status-scale scores ranged from 29% on the fine motor skills scale to 56% on the mobility index. Mean scale score declines were 1.9 for activities of daily living, 1.7 for instrumental activities of daily living, and 2.2 for depressive symptoms; scores on mobility, large muscle, gross motor, and cognitive status scales worsened by 2.3, 1.6, 2.2, and 2.5 points, respectively. Hip fracture characteristics, socioeconomic status, and year of fracture were significantly associated with discharge placement. Sex, age, dementia, and frailty were significantly associated with mortality. This is one of the few studies to prospectively capture these declines in functional status after hip fracture.

PB - 170 VL - 170 IS - 10 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19808632?dopt=Abstract U2 - PMC2781759 U4 - Functional Status/Mortality/Nursing Homes ER - TY - JOUR T1 - Changes in functional status among persons over age sixty-five undergoing total knee arthroplasty. JF - Med Care Y1 - 2009 A1 - Frank A Sloan A1 - Ruiz, David A1 - Alyssa C Platt KW - Activities of Daily Living KW - Aged KW - Arthroplasty, Replacement, Knee KW - Attitude to Health KW - Geriatric Assessment KW - Health Care Surveys KW - Health Status KW - Health Surveys KW - Humans KW - Insurance Claim Reporting KW - Logistic Models KW - Longitudinal Studies KW - Medicare KW - Mobility Limitation KW - Multivariate Analysis KW - Muscle Weakness KW - Osteoarthritis, Knee KW - pain KW - Sensitivity and Specificity KW - Surveys and Questionnaires KW - Treatment Outcome KW - United States AB -

BACKGROUND: This study assessed changes in physical functional status following receipt of total knee arthroplasty (TKA) for patients diagnosed with osteoarthritis (OA) of the knee in a national sample of persons aged 65+ in the United States relative to a sample of similar OA patients who did not receive TKA.

METHODS: Data from the Health Retirement Survey (HRS) and linked Medicare claims from 1994 to 2006 were used to identify persons with diagnoses of OA of the lower leg who received a TKA (n = 516) and those who did not receive TKA (n = 1756). Predicted probabilities of receiving total knee arthroplasty from logit analysis were used for matching TKA and comparison groups on demographic, socioeconomic, and baseline functional status factors. Functional status measures were: mobility, gross motor function, large muscle, and limitations in activities of daily living (ADL). Average treatment effects of the treated (ATT), which compares changes in functional status between those who received TKA with similar individuals who did not receive TKA, were computed using propensity score matching.

RESULTS: Mobility (average treatment effect of the treated (ATT = 0.315; 95% CI: 0.118-0.512), gross motor function (ATT = 0.314; 95% CI: 0.156-0.472), and ADL limitations (ATT = 0.174; 95% CI: 0.055-0.293), improved among persons receiving TKA relative to the comparison group. Relative to the mean values of the physical function at baseline, mobility, gross motor function, and ADL limitations persons receiving TKA had better functional outcomes than the comparison group by 17.5, 39.3, and 46.9 percent, respectively.

CONCLUSIONS: TKA is effective in improving functional status in elderly persons.

PB - 47 VL - 47 IS - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19536027?dopt=Abstract U3 - 19536027 U4 - Activities of Daily Living/Arthroplasty/Knee Replacement/Attitude to Health/Geriatric Assessment/Insurance Claim Reporting/Logistic Models/Medicare/Mobility Limitation/Multivariate Analysis/Muscle Weakness/Osteoarthritis/Treatment Outcome ER - TY - JOUR T1 - Effect of Medicare home health care payment on informal care. JF - Inquiry Y1 - 2009 A1 - Ezra Golberstein A1 - David C Grabowski A1 - Kenneth M. Langa A1 - M.E. Chernew KW - Caregivers KW - Confidence Intervals KW - Female KW - Health Care Surveys KW - Home Care Services KW - Humans KW - Male KW - Medicare KW - Organizational Policy KW - Reimbursement Mechanisms KW - United States AB -

This paper assesses the effect of payment caps for Medicare home health care on the use of informal care by older adults with functional limitations. We find that individuals exposed to more restrictive payment caps offset reductions in Medicare home health care with increased informal care, although we only observe this effect for lower-income individuals. This suggests that home care payment restrictions may have increased the caregiving burden on some low-income families, but that many higher-income families were able to either forgo the care or finance it privately. Home care payment policies should recognize these effects, balancing costs of the program with the desire to protect families from the burdens associated with providing informal home care.

PB - 46 VL - 46 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19489484?dopt=Abstract U2 - PMC3092523 U4 - Medicare/Home Care Services/Caregiver Status/home health care ER - TY - JOUR T1 - The health effects of Medicare for the near-elderly uninsured. JF - Health Serv Res Y1 - 2009 A1 - Daniel Polsky A1 - Jalpa A Doshi A1 - José J Escarce A1 - Manning, Willard A1 - Susan M Paddock A1 - Cen, Liyi A1 - Jeannette Rogowski KW - Aged KW - Attitude to Health KW - Female KW - Follow-Up Studies KW - Health Services Accessibility KW - Health Services Research KW - Health Status KW - Health Surveys KW - Humans KW - Insurance Coverage KW - Logistic Models KW - Male KW - Medically Uninsured KW - Medicare KW - Mortality KW - Multivariate Analysis KW - Program Evaluation KW - Retirement KW - Socioeconomic factors KW - Statistics, Nonparametric KW - United States AB -

OBJECTIVE: To determine whether Medicare enrollment at age 65 has an effect on the health trajectory of the near-elderly uninsured.

DATA SOURCES: Eight biennial waves (1992-2006) of the Health and Retirement Study, a nationally representative panel survey of noninstitutionalized 51-61 year olds and their spouses.

STUDY DESIGN: We use a quasi-experimental approach to compare the health effects of insurance for the near-elderly uninsured with previously insured contemporaneous controls. The primary outcome measure is overall self-reported health status combined with mortality (i.e., excellent to very good, good, fair to poor, dead).

RESULTS: The change in the trajectory of overall health status for the previously uninsured that can be attributed to Medicare is small and not statistically significant. For every 100 persons in the previously uninsured group, joining Medicare is associated with 0.6 fewer in excellent or very good health (95 percent CI: -4.8, 3.3), 0.3 more in good health (95 percent CI: -3.8, 4.1), 2.5 fewer in fair or poor health (95 percent CI: -7.4, 2.3), and 2.8 more dead (-4.0, 10.0) by age 73. The health trajectory patterns from physician objective health measures are similarly small and not statistically significant.

CONCLUSIONS: Medicare coverage at age 65 for the previously uninsured is not linked to improvements in overall health status.

PB - 44 VL - 44 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/19674430?dopt=Abstract U2 - PMC2699915 U4 - Medicare/health status/Health Insurance/Health Benefits ER - TY - JOUR T1 - Medicare savings programs: analyzing options for expanding eligibility. JF - Inquiry Y1 - 2009 A1 - Zuckerman, Stephen A1 - Shang, Baoping A1 - Timothy A Waidmann KW - Aged KW - Demography KW - Disabled Persons KW - Eligibility Determination KW - Female KW - Health Status KW - Humans KW - Income KW - Male KW - Medical Assistance KW - Medicare KW - Medicare Part D KW - Public Policy KW - United States AB -

The Medicare Savings Programs (MSPs) are designed to provide financial assistance to Medicare beneficiaries who do not qualify for full Medicaid coverage. This paper considers changes in eligibility that would better align MSP program rules with those related to receiving low-income subsidies for the Medicare Part D drug benefit. These changes would make more people eligible for the MSPs and could encourage greater participation; similar changes were incorporated in recently passed legislation. Our analysis, based on 2006 data from the Health and Retirement Study, shows there is a trade-off between making larger numbers of beneficiaries eligible by eliminating resource requirements and better targeting of individuals with greater health care needs by expanding income standards.

PB - 46 VL - 46 UR - URL:http://www.inquiryjournal.org Publisher's URL IS - 4 N1 - Journal Article U1 - http://www.ncbi.nlm.nih.gov/pubmed/20184166?dopt=Abstract U3 - 20184166 U4 - Analysis of Health Care Markets/Health: Government Policy,/Public Health/Medicare Savings Programs/Health Care/Medicare/Medicare Part D ER - TY - JOUR T1 - Emergency department utilization patterns among older adults. JF - J Gerontol A Biol Sci Med Sci Y1 - 2008 A1 - Frederic D Wolinsky A1 - Li Liu A1 - Thomas R Miller A1 - An, Hyonggin A1 - John F Geweke A1 - Kaskie, Brian A1 - Kara B Wright A1 - Elizabeth A Chrischilles A1 - Claire E Pavlik A1 - Elizabeth A Cook A1 - Robert L. Ohsfeldt A1 - Kelly K Richardson A1 - Gary E Rosenthal A1 - Robert B Wallace KW - Aged KW - Emergency Service, Hospital KW - Factor Analysis, Statistical KW - Female KW - Humans KW - Logistic Models KW - Male KW - Medicare KW - Risk Factors KW - United States AB -

BACKGROUND: We identified 4-year (2 years before and 2 years after the index [baseline] interview) ED use patterns in older adults and the factors associated with them.

METHODS: A secondary analysis of baseline interview data from the nationally representative Survey on Assets and Health Dynamics Among the Oldest Old linked to Medicare claims data. Participants were 4310 self-respondents 70 years old or older. Current Procedural Terminology (CPT) codes 99281 and 99282 identified low-intensity use, and CPT codes 99283-99285 identified high-intensity use. Exploratory factor analysis and multivariable multinomial logistic regression were used.

RESULTS: The majority (56.6%) of participants had no ED visits during the 4-year period. Just 5.7% had only low-intensity ED use patterns, whereas 28.9% used the ED only for high-intensity visits, and 8.7% had a mixture of low-intensity and high-intensity use. Participants with lower immediate word recall scores and those who did not live in major metropolitan areas were more likely to be low-intensity-only ED users. Older individuals, those who did not live in rural counties, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to be high-intensity-only ED users. Participants who were older, did not live in major cities, had lower education levels, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to have mixed ED use patterns.

CONCLUSIONS: Nearly half of these older adults used the ED at least once over a 4-year period, with a mean annual ED use percentage of 18.4. Few, however, used the ED only for visits that may have been avoidable. This finding suggests that triaging Medicare patients would not decrease ED overcrowding, although continued surveillance is necessary to detect potential changes in ED use patterns among older adults.

PB - 63A VL - 63 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18314459?dopt=Abstract U2 - PMC2923576 U4 - Medicare/Health Care Utilization/Elderly ER - TY - JOUR T1 - End-of-life medical treatment choices: do survival chances and out-of-pocket costs matter? JF - Med Decis Making Y1 - 2008 A1 - Chao, Li-Wei A1 - José A Pagán A1 - Beth J Soldo KW - Aged KW - Choice Behavior KW - Female KW - Financing, Personal KW - Health Care Costs KW - Humans KW - Life Expectancy KW - Male KW - Medicare KW - Neoplasms KW - Socioeconomic factors KW - Terminal Care KW - United States AB -

BACKGROUND: Out-of-pocket medical expenditures incurred prior to the death of a spouse could deplete savings and impoverish the surviving spouse. Little is known about the public's opinion as to whether spouses should forego such end-of-life (EOL) medical care to prevent asset depletion.

OBJECTIVES: To analyze how elderly and near elderly adults assess hypothetical EOL medical treatment choices under different survival probabilities and out-of-pocket treatment costs.

METHODS: Survey data on a total of 1143 adults, with 589 from the Asset and Health Dynamics Among the Oldest Old (AHEAD) and 554 from the Health and Retirement Study (HRS), were used to study EOL cancer treatment recommendations for a hypothetical anonymous married woman in her 80s.

RESULTS: Respondents were more likely to recommend treatment when it was financed by Medicare than by the patient's own savings and when it had 60% rather than 20% survival probability. Black and male respondents were more likely to recommend treatment regardless of survival probability or payment source. Treatment uptake was related to the order of presentation of treatment options, consistent with starting point bias and framing effects.

CONCLUSIONS: Elderly and near elderly adults would recommend that the hypothetical married woman should forego costly EOL treatment when the costs of the treatment would deplete savings. When treatment costs are covered by Medicare, respondents would make the recommendation to opt for care even if the probability of survival is low, which is consistent with moral hazard. The sequence of presentation of treatment options seems to affect patient treatment choice.

PB - 28 VL - 28 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18441252?dopt=Abstract U2 - PMC2587497 U4 - Economics of the Elderly/Medical Expenditures/Survival/Survivors/Saving ER - TY - JOUR T1 - Health insurance coverage as people approach and pass age-eligibility for Medicare. JF - J Aging Soc Policy Y1 - 2008 A1 - Caffrey, Christine A1 - Christine L Himes KW - Aged KW - Eligibility Determination KW - Female KW - Humans KW - Insurance Coverage KW - Insurance, Health KW - Male KW - Medicare KW - Middle Aged KW - United States AB -

This study uses six waves of the Health and Retirement Study (HRS) to measure dynamics of health insurance coverage as people approach and pass age-eligibility for Medicare. Thirteen percent of 59- to 64-year-olds were uninsured and 13% of 65- to 70-year-olds relied solely on Medicare. Those unmarried, in good health, and in poor health had an increased likelihood of being uninsured before age-eligibility for Medicare, while non-whites and those in good health had an increased likelihood of having Medicare-only coverage after age-eligibility for Medicare. Although only a small percentage was continually without coverage or with Medicare-only coverage, a substantial percentage had these coverage types at some point. Limitations and policy implications are included.

PB - 20 VL - 20 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18198158?dopt=Abstract U3 - 18198158 U4 - Health Insurance Coverage/Medicare ER - TY - JOUR T1 - Identification of dementia: agreement among national survey data, medicare claims, and death certificates. JF - Health Serv Res Y1 - 2008 A1 - Truls Ostbye A1 - Donald H. Taylor Jr. A1 - Elizabeth C. Clipp A1 - Lynn Van Scoyoc A1 - Brenda L Plassman KW - Aged KW - Consensus KW - Data Interpretation, Statistical KW - Death Certificates KW - Dementia KW - Female KW - Health Surveys KW - Humans KW - Incidence KW - Insurance Claim Review KW - Male KW - Mass Screening KW - Medicare KW - Research Design KW - United States AB -

OBJECTIVE: To estimate the proportion of seniors with dementia from three independent data sources and their agreement.

DATA SOURCES: The longitudinal Asset and Health Dynamics among the Oldest Old (AHEAD) study (n=7,974), Medicare claims, and death certificate data.

STUDY DESIGN: Estimates of the proportion of individuals with dementia from: (1) self- or proxy-reported cognitive status measures from surveys, (2) Medicare claims, and (3) death certificates. Agreement using Cohen's kappa; multivariate logistic regression.

PRINCIPAL FINDINGS: The proportion varied substantially among the data sources. Agreement was poor (kappa: 0.14-0.46 depending upon comparison assessed); the individuals identified had relatively modest overlap.

CONCLUSIONS: Estimates of dementia occurrence based on cognitive status measures from three independent data sources were not interchangeable. Further validation of these sources is needed. Caution should be used if policy is based on only one data source.

PB - 43 VL - 43 IS - 1 Pt 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18211532?dopt=Abstract U2 - PMC2323140 U4 - Dementia/Incidence/Cognitive Function/Survey questions/Medicare/Death Certificates ER - TY - JOUR T1 - Informal care and Medicare expenditures: testing for heterogeneous treatment effects. JF - J Health Econ Y1 - 2008 A1 - Courtney Harold Van Houtven A1 - Edward C Norton KW - Adult KW - Aged KW - Caregivers KW - Health Expenditures KW - Humans KW - Medicare KW - Models, Econometric KW - United States AB -

We estimate the effect of informal care on Medicare expenditures not only for care provided by children but also by the source of informal care (sons versus daughters, children versus others) and recipient characteristics (marital status). Our conceptual framework predicts heterogeneous effectiveness by source and recipient of informal care. We estimate two-part expenditure models as a function of informal care, controlling for endogeneity. We find that informal care by children reduces Medicare long-term care and inpatient expenditures of single elderly. We find that children are less effective caregivers among recipients who are married. For single elderly, child caregivers are more effective than other types. Gender of a child caregiver does not matter.

PB - 27 VL - 27 IS - 1 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17462764?dopt=Abstract U3 - 17462764 U4 - Caregivers/Medicare and Medicaid spending/Marital Status ER - TY - JOUR T1 - Exploring the association of dual use of the VHA and Medicare with mortality: separating the contributions of inpatient and outpatient services. JF - BMC Health Serv Res Y1 - 2007 A1 - Frederic D Wolinsky A1 - An, Hyonggin A1 - Li Liu A1 - Thomas R Miller A1 - Gary E Rosenthal KW - Aged KW - Aged, 80 and over KW - Ambulatory Care KW - Cluster Analysis KW - Continuity of Patient Care KW - Emergency Service, Hospital KW - Episode of Care KW - Hospital Mortality KW - Hospitals, Veterans KW - Humans KW - Male KW - Medicare KW - Proportional Hazards Models KW - United States KW - Veterans AB -

BACKGROUND: Older veterans may use both the Veterans Health Administration (VHA) and Medicare, but the association of dual use with health outcomes is unclear. We examined the association of indirect measures of dual use with mortality.

METHODS: Our secondary analysis used survey, claims, and National Death Index data from the Survey on Assets and Health Dynamics among the Oldest Old. The analytic sample included 1,521 men who were Medicare beneficiaries. Veterans were classified as dual users when their self-reported number of hospital episodes or physician visits exceeded that in their Medicare claims. Veterans reporting inpatient or outpatient visits but having no Medicare claims were classified as VHA-only users. Proportional hazards regression was used.

RESULTS: 897 (59%) of the men were veterans, of whom 134 (15%) were dual users. Among dual users, 60 (45%) met the criterion based on inpatient services, 54 (40%) based on outpatient services, and 20 (15%) based on both. 766 men (50%) died. Adjusting for covariates, the independent effect of any dual use was a 38% increased mortality risk (AHR = 1.38; p = .02). Dual use based on outpatient services marginally increased mortality risk by 45% (AHR = 1.45; p = .06), and dual use based on both inpatient and outpatient services increased the risk by 98% (AHR = 1.98; p = .02).

CONCLUSION: Indirect measures of dual use were associated with increased mortality risk. New strategies to better coordinate care, such as shared medical records, should be considered.

PB - 7 VL - 7 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17490488?dopt=Abstract U2 - PMC1884152 U4 - Veterans: statistics/numerical/medicare/mortality/Physician visits/Physician visits/HOSPITALIZATION ER - TY - JOUR T1 - Health of previously uninsured adults after acquiring Medicare coverage. JF - JAMA Y1 - 2007 A1 - J. Michael McWilliams A1 - Meara, Ellen A1 - Alan M. Zaslavsky A1 - John Z. Ayanian KW - Aged KW - Cardiovascular Diseases KW - depression KW - Diabetes Mellitus KW - Female KW - Health Status KW - Health Surveys KW - Humans KW - Longitudinal Studies KW - Male KW - Medically Uninsured KW - Medicare KW - Middle Aged KW - Outcome Assessment, Health Care KW - United States AB -

CONTEXT: Uninsured near-elderly adults, particularly those with cardiovascular disease or diabetes, experience worse health outcomes than insured adults. However, the health benefits of providing insurance coverage for uninsured adults have not been clearly demonstrated.

OBJECTIVE: To assess the effect of acquiring Medicare coverage on the health of previously uninsured adults.

DESIGN AND SETTING: We conducted quasi-experimental analyses of longitudinal survey data from 1992 through 2004 from the nationally representative Health and Retirement Study. We compared changes in health trends reported by previously uninsured and insured adults after they acquired Medicare coverage at age 65 years.

PARTICIPANTS: Five thousand six adults who were continuously insured and 2227 adults who were persistently or intermittently uninsured from ages 55 to 64 years.

MAIN OUTCOME MEASURES: Differential changes in self-reported trends after age 65 years in general health, change in general health, mobility, agility, pain, depressive symptoms, and a summary measure of these 6 domains; and adverse cardiovascular outcomes (all trend changes reported in health scores per year).

RESULTS: Compared with previously insured adults, previously uninsured adults reported significantly improved health trends after age 65 years for the summary measure (differential change in annual trend, +0.20; P = .002) and several component measures. Relative to previously insured adults with cardiovascular disease or diabetes, previously uninsured adults with these conditions reported significantly improved trends in summary health (differential change in annual trend, +0.26; P = .006), change in general health (+0.02; P = .03), mobility (+0.04; P = .05), agility (+0.08; P = .003), and adverse cardiovascular outcomes (-0.015; P = .02) but not in depressive symptoms (+0.04; P = .32). Previously uninsured adults without these conditions reported differential improvement in depressive symptoms (+0.08; P = .002) but not in summary health (+0.10; P = .17) or any other measure. By age 70 years, the expected difference in summary health between previously uninsured and insured adults with cardiovascular disease or diabetes was reduced by 50%.

CONCLUSION: In this study, acquisition of Medicare coverage was associated with improved trends in self-reported health for previously uninsured adults, particularly those with cardiovascular disease or diabetes.

PB - 298 VL - 298 IS - 24 U1 - http://www.ncbi.nlm.nih.gov/pubmed/18159058?dopt=Abstract U4 - Medicare/Insured Status/SELF-RATED HEALTH ER - TY - JOUR T1 - Risk of nursing home admission among older americans: does states' spending on home- and community-based services matter? JF - J Gerontol B Psychol Sci Soc Sci Y1 - 2007 A1 - Muramatsu, Naoko A1 - yin, Hongjun A1 - Richard T. Campbell A1 - Ruby L Hoyem A1 - Martha A. Jacob A1 - Christopher Ross KW - Aged KW - Aged, 80 and over KW - Caregivers KW - Cohort Studies KW - Cost Savings KW - Cost-Benefit Analysis KW - Female KW - Financing, Government KW - Health Expenditures KW - Home Care Services KW - Homes for the Aged KW - Humans KW - Insurance Coverage KW - Long-term Care KW - Male KW - Medicaid KW - Medicare KW - Nursing homes KW - Patient Admission KW - Patient Readmission KW - Risk Assessment KW - Risk Factors KW - State Health Plans KW - United States AB -

OBJECTIVE: States vary greatly in their support for home- and community-based services (HCBS) that are intended to help disabled seniors live in the community. This article examines how states' generosity in providing HCBS affects the risk of nursing home admission among older Americans and how family availability moderates such effects.

METHODS: We conducted discrete time survival analysis of first long-term (90 or more days) nursing home admissions that occurred between 1995 and 2002, using Health and Retirement Study panel data from respondents born in 1923 or earlier.

RESULT: State HCBS effects were conditional on child availability among older Americans. Living in a state with higher HCBS expenditures was associated with lower risk of nursing home admission among childless seniors (p <.001). However, the association was not statistically significant among seniors with living children. Doubling state HCBS expenditures per person aged 65 or older would reduce the risk of nursing home admission among childless seniors by 35%.

DISCUSSION: Results provided modest but important evidence supportive of increasing state investment in HCBS. Within-state allocation of HCBS resources, however, requires further research and careful consideration about fairness for individual seniors and their families as well as cost effectiveness.

PB - 62B VL - 62 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17507592?dopt=Abstract U4 - Home Care Services/Nursing Homes/Health Policy/Elderly ER - TY - JOUR T1 - Use of health services by previously uninsured Medicare beneficiaries. JF - N Engl J Med Y1 - 2007 A1 - J. Michael McWilliams A1 - Meara, Ellen A1 - Alan M. Zaslavsky A1 - John Z. Ayanian KW - Aged KW - Cardiovascular Diseases KW - Diabetes Mellitus KW - Female KW - Health Expenditures KW - Health Services KW - Hospitalization KW - Humans KW - Insurance, Health KW - Logistic Models KW - Longitudinal Studies KW - Male KW - Medically Uninsured KW - Medicare KW - Middle Aged KW - Socioeconomic factors KW - United States AB -

BACKGROUND: Previously uninsured adults who enroll in the Medicare program at the age of 65 years may have greater morbidity, requiring more intensive and costlier care over subsequent years, than they would if they had been previously insured.

METHODS: We used longitudinal data from the nationally representative Health and Retirement Study to assess self-reported health care use and expenditures from 1992 through 2004 among 5158 adults who were privately insured or uninsured before Medicare coverage began at the age of 65 years. We used propensity-score methods to compare health care use and expenditures for previously insured and uninsured beneficiaries who were similar across numerous characteristics at 59 to 60 years of age and adjusted for differences in supplemental and prescription-drug coverage after 65 years of age.

RESULTS: Among 2951 adults with hypertension, diabetes, heart disease, or stroke diagnosed before 65 years of age, previously uninsured adults who acquired Medicare coverage at the age of 65 reported significantly greater increases in the numbers of doctor visits (P<0.001) and hospitalizations (P=0.001) and in total medical expenditures (P=0.02) than did previously insured adults. Significant differential increases were not evident among the 2207 adults without these conditions (P>0.12 for all comparisons). In analyses adjusted for supplemental and prescription-drug coverage, previously uninsured adults with these conditions reported more doctor visits (13% relative difference, P=0.04), more hospitalizations (20% relative difference, P=0.04), and higher total medical expenditures (51% relative difference, P=0.09) from ages 65 to 72 years than did previously insured adults.

CONCLUSIONS: The costs of expanding health insurance coverage for uninsured adults before they reach the age of 65 years may be partially offset by subsequent reductions in health care use and spending for these adults after the age of 65, particularly if they have cardiovascular disease or diabetes before the age of 65 years.

PB - 357 VL - 357 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17625126?dopt=Abstract U4 - Medicare/Health Insurance Coverage/Health Care Utilization ER - TY - JOUR T1 - Changes in health for the uninsured after reaching age-eligibility for Medicare. JF - J Gen Intern Med Y1 - 2006 A1 - David W. Baker A1 - Joseph Feinglass A1 - Durazo-Arvizu, Ramon A1 - Whitney P. Witt A1 - Joseph J Sudano A1 - Jason A. Thompson KW - Age Factors KW - Aged KW - Cohort Studies KW - Eligibility Determination KW - Female KW - Health Status KW - Humans KW - Male KW - Medically Uninsured KW - Medicare KW - Middle Aged KW - Prospective Studies KW - United States AB -

BACKGROUND: Uninsured adults in late middle age are more likely to have a health decline than individuals with private insurance.

OBJECTIVE: To determine how health and the risk of future adverse health outcomes changes after the uninsured gain Medicare.

DESIGN: Prospective cohort study.

PARTICIPANTS: Participants (N=3,419) in the Health and Retirement Study who transitioned from private insurance or being uninsured to having Medicare coverage at the 1996, 1998, 2000, or 2002 interview.

MEASUREMENTS: We analyzed risk-adjusted changes in self-reported overall health and physical functioning during the transition period to Medicare (t(-2) to t(0)) and the following 2 years (t(0) to t(2)).

RESULTS: Between the interview before age 65 (t(-2)) and the first interview after reaching age 65 (t(0)), previously uninsured individuals were more likely than those who had private insurance to have a major decline in overall health (adjusted relative risk [ARR] 1.46; 95% confidence interval [CI] 1.03 to 2.04) and to develop a new physical difficulty affecting mobility (ARR 1.24; 95% CI 0.96 to 1.56) or agility (ARR 1.33; 95% CI 1.12 to 1.54). Rates of improvement were similar between the 2 groups. During the next 2 years (t(0) to t(2)), adjusted rates of declines in overall health and physical functioning were similar for individuals who were uninsured and those who had private insurance before gaining Medicare.

CONCLUSIONS: Gaining Medicare does not lead to immediate health benefits for individuals who were uninsured before age 65. However, after 2 or more years of continuous coverage, the uninsured no longer have a higher risk of adverse health outcomes.

PB - 21 VL - 21 IS - 11 U1 - http://www.ncbi.nlm.nih.gov/pubmed/16879704?dopt=Abstract ER - TY - JOUR T1 - Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes? JF - BMC Health Serv Res Y1 - 2006 A1 - Frederic D Wolinsky A1 - Thomas R Miller A1 - An, Hyonggin A1 - Paul R Brezinski A1 - Thomas E Vaughn A1 - Gary E Rosenthal KW - Aged KW - Aged, 80 and over KW - Deductibles and Coinsurance KW - Episode of Care KW - Health Services Research KW - Hospitals, Veterans KW - Humans KW - Male KW - Medicare KW - Mortality KW - Outcome Assessment, Health Care KW - Proportional Hazards Models KW - Quality Indicators, Health Care KW - Risk Assessment KW - Selection Bias KW - Surveys and Questionnaires KW - United States KW - United States Department of Veterans Affairs KW - Veterans AB -

BACKGROUND: Millions of veterans are eligible to use the Veterans Health Administration (VHA) and Medicare because of their military service and age. This article examines whether an indirect measure of dual use based on inpatient services is associated with increased mortality risk.

METHODS: Data on 1,566 self-responding men (weighted N = 1,522) from the Survey of Assets and Health Dynamics among the Oldest Old (AHEAD) were linked to Medicare claims and the National Death Index. Dual use was indirectly indicated when the self-reported number of hospital episodes in the 12 months prior to baseline was greater than that observed in the Medicare claims. The independent association of dual use with mortality was estimated using proportional hazards regression.

RESULTS: 96 (11%) of the veterans were classified as dual users. 766 men (50.3%) had died by December 31, 2002, including 64.9% of the dual users and 49.3% of all others, for an attributable mortality risk of 15.6% (p < .003). Adjusting for demographics, socioeconomics, comorbidity, hospitalization status, and selection bias at baseline, as well as subsequent hospitalization for ambulatory care sensitive conditions, the independent effect of dual use was a 56.1% increased relative risk of mortality (AHR = 1.561; p = .009).

CONCLUSION: An indirect measure of veterans' dual use of the VHA and Medicare systems, based on inpatient services, was associated with an increased risk of death. Further examination of dual use, especially in the outpatient setting, is needed, because dual inpatient and dual outpatient use may be different phenomena.

PB - 6 VL - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/17029643?dopt=Abstract U2 - PMC1617101 U4 - Veterans: statistics/numerical/Medicare/public Policy/Mortality ER - TY - JOUR T1 - Setting eligibility criteria for a care-coordination benefit. JF - J Am Geriatr Soc Y1 - 2005 A1 - Christine T Cigolle A1 - Kenneth M. Langa A1 - Mohammed U Kabeto A1 - Caroline S Blaum KW - Activities of Daily Living KW - Aged KW - Aged, 80 and over KW - Case Management KW - Chronic disease KW - Cognition Disorders KW - Comorbidity KW - Cross-Sectional Studies KW - Disability Evaluation KW - Disease Management KW - Eligibility Determination KW - Female KW - Geriatric Assessment KW - Health Surveys KW - Humans KW - Longitudinal Studies KW - Male KW - Medicare KW - Middle Aged KW - Retirement KW - United States AB -

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.

PB - 53 VL - 53 IS - 12 U1 - http://www.ncbi.nlm.nih.gov/pubmed/16398887?dopt=Abstract U4 - Chronic Disease/Cognition Disorders/ADL and IADL Impairments/Caregiving ER - TY - JOUR T1 - Elders who delay medication because of cost: health insurance, demographic, health, and financial correlates. JF - Gerontologist Y1 - 2004 A1 - Klein, Dawn A1 - Carolyn L. Turvey A1 - Robert B Wallace KW - Aged KW - Aged, 80 and over KW - Cross-Sectional Studies KW - Drug Therapy KW - Fees, Pharmaceutical KW - Female KW - Health Status KW - Humans KW - Insurance, Pharmaceutical Services KW - Logistic Models KW - Male KW - Medicare KW - Multivariate Analysis KW - Patient Compliance KW - Self Administration KW - Socioeconomic factors KW - United States AB -

PURPOSE: Prescription medication use is essential to the health and well-being of many elderly persons. However, the cost of medications may be prohibitive and contribute to noncompliance with medical recommendations. This study identifies community-dwelling elders who reported a delay in medication use because of prescription medication cost.

DESIGN AND METHODS: This was a cross-sectional study of a nationwide sample of 6,535 elders participating in the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. Participants reported if they had taken less medication than prescribed or if they had not filled prescriptions because of cost in the past 2 years. This response was then compared with the self-report of multiple variables, including demographic, health status, health insurance coverage, and financial variables.

RESULTS: Elders who were most vulnerable to medication delay as a result of cost included those with Medicare coverage only, low income, high out-of-pocket prescription costs, and poor health as well as African American elders and those aged 65-80 years.

IMPLICATIONS: This study provides important information about community-dwelling elders that reported a delay in medication use because of cost. As a Medicare prescription benefit has been passed, it will be important to monitor how these changes affect the elders identified at risk for medication delay.

PB - 44 VL - 44 IS - 6 U1 - http://www.ncbi.nlm.nih.gov/pubmed/15611214?dopt=Abstract U4 - Prescription Fees/Elderly/Medicine/COSTS ER - TY - JOUR T1 - Out-of-pocket health-care expenditures among older Americans with cancer. JF - Value Health Y1 - 2004 A1 - Kenneth M. Langa A1 - A. Mark Fendrick A1 - M.E. Chernew A1 - Mohammed U Kabeto A1 - Paisley, Kerry L. A1 - Hayman, James A. KW - Aged KW - Aged, 80 and over KW - Cost of Illness KW - Family Characteristics KW - Female KW - Financing, Personal KW - Health Expenditures KW - Health Services Research KW - Humans KW - Insurance, Health KW - Longitudinal Studies KW - Male KW - Medicaid KW - Medicare KW - Michigan KW - Neoplasms AB -

OBJECTIVE: There is currently limited information regarding the out-of-pocket expenditures (OOPE) for medical care made by elderly individuals with cancer. We sought to quantify OOPE for community-dwelling individuals age 70 or older with: 1) no cancer (No CA), 2) a history of cancer, not undergoing current treatment (CA/No Tx), and 3) a history of cancer, undergoing current treatment (CA/Tx).

METHODS: We used data from the 1995 Asset and Health Dynamics Study, a nationally representative survey of community-dwelling elderly individuals. Respondents identified their cancer status and reported OOPE for the prior 2 years for: 1) hospital and nursing home stays, 2) outpatient services, 3) home care, and 4) prescription medications. Using a multivariable two-part regression model to control for differences in sociodemographics, living situation, functional limitations, comorbid chronic conditions, and insurance coverage, the additional cancer-related OOPE were estimated.

RESULTS: Of the 6370 respondents, 5382 (84%) reported No CA, 812 (13%) reported CA/No Tx, and 176 (3%) reported CA/Tx. The adjusted mean annual OOPE for the No CA, CA/No Tx, and CA/Tx groups were 1210 dollars, 1450 dollars, and 1880 dollars, respectively (P < .01). Prescription medications (1120 dollars per year) and home care services (250 dollars) accounted for most of the additional OOPE associated with cancer treatment. Low-income individuals undergoing cancer treatment spent about 27% of their yearly income on OOPE compared to only 5% of yearly income for high-income individuals with no cancer history (P < .01).

CONCLUSIONS: Cancer treatment in older individuals results in significant OOPE, mainly for prescription medications and home care services. Economic evaluations and public policies aimed at cancer prevention and treatment should take note of the significant OOPE made by older Americans with cancer.

PB - 7 VL - 7 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/15164808?dopt=Abstract U4 - Health Care Costs/Health Expenditures ER - TY - JOUR T1 - High out-of-pocket health care spending by the elderly. JF - Health Aff (Millwood) Y1 - 2003 A1 - Dana P Goldman A1 - Julie M Zissimopoulos KW - Aged KW - Drug Costs KW - Drug Prescriptions KW - Financing, Personal KW - Health Care Surveys KW - Health Expenditures KW - Health Maintenance Organizations KW - Health Services for the Aged KW - Humans KW - Insurance, Health KW - Medicare KW - Poverty KW - United States AB -

We use data from the Health and Retirement Study to examine the elderly's out-of-pocket health care spending. We find that Medicare HMOs, employer supplements, and Medicaid effectively insulate against the risk of high expenditures. At the ninetieth percentile, Medicare beneficiaries with employer supplements or enrolled in Medicare HMOs spend 1,600 dollars less out of pocket than beneficiaries with traditional Medicare spend. For the poor elderly, Medicaid offers similar protection. Among the near-poor elderly, there is little employer coverage, so Medicare HMOs provide most of the protection against financial risk. There is evidence that Medicare HMO benefits have eroded since 1998, raising the question of whether the near-poor have lost financial protection since then.

PB - 22 VL - 22 IS - 3 U1 - http://www.ncbi.nlm.nih.gov/pubmed/12757285?dopt=Abstract U4 - Health Expenditures/Medicaid/Medicare ER - TY - JOUR T1 - Medication costs, adherence, and health outcomes among Medicare beneficiaries. JF - Health Aff (Millwood) Y1 - 2003 A1 - Ramin Mojtabai A1 - Mark Olfson KW - Aged KW - Aged, 80 and over KW - Chronic disease KW - Continuity of Patient Care KW - Family Characteristics KW - Female KW - Financing, Personal KW - Health Services Research KW - Humans KW - Income KW - Insurance, Pharmaceutical Services KW - Longitudinal Studies KW - Male KW - Medicare KW - Patient Compliance KW - Prevalence KW - Probability KW - Self Administration KW - Treatment Outcome KW - United States AB -

In a two-year period more than two million elderly Medicare beneficiaries did not adhere to drug treatment regimens because of cost. This poor adherence tended to be more common among beneficiaries with no or partial medication coverage and was associated with poorer health and higher rates of hospitalization. The risk for cost-related poor adherence was especially pronounced among lower-income beneficiaries with high out-of-pocket drug spending. We argue that this pattern of cost-related poor medication adherence should inform the design of Medicare prescription drug benefit legislation.

PB - 22 VL - 22 IS - 4 U1 - http://www.ncbi.nlm.nih.gov/pubmed/12889771?dopt=Abstract U4 - Medicare ER - TY - JOUR T1 - Life transitions and health insurance coverage of the near elderly. JF - Med Care Y1 - 1998 A1 - Frank A Sloan A1 - Conover, C.J. KW - Death KW - Employment KW - health policy KW - Health Services Research KW - Health Status Indicators KW - Humans KW - Insurance Coverage KW - Life Change Events KW - Medicaid KW - Medically Uninsured KW - Medicare KW - Middle Aged KW - Retirement KW - Spouses KW - United States AB -

OBJECTIVES: This study addresses three issues. (1) What are demographic wealth, employment, and health characteristics of near-elderly persons losing or acquiring health insurance coverage? Specifically, (2) what are the effects of life transitions, including changes in employment status, health, and marital status? (3) To what extent do public policies protect such persons against coverage loss, including various state policies recently implemented to increase access to insurance?

METHODS: The authors used the 1992 and 1994 waves of the Health and Retirement Study to analyze coverage among adults aged 51 to 64 years.

RESULTS: One in five near-elderly persons experienced a change in insurance coverage from 1992 to 1994. Yet, there was no significant change in the mix of coverage as those losing one form of coverage were replaced by others acquiring similar coverage.

CONCLUSIONS: Individuals whose health deteriorated significantly were not more likely than others to suffer a subsequent loss of coverage, due to substitution of retiree or individual coverage for those losing private coverage and acquisition of Medicaid and Medicare coverage for one in five uninsured. State policies to increase access to private health insurance generally did not prevent individuals from losing coverage or allow the uninsured to gain coverage. Major determinants of the probability of being insured were education, employment status of person and spouse, and work disability status. Other measures of health and functional status did not affect the probability of being insured, but had important impacts on the probability of having public coverage, conditional on being insured.

PB - 36 VL - 36 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/9475467?dopt=Abstract U4 - Socioeconomic Factors/Wealth/Health Status/Health Insurance Coverage/Employment/Marital Status/Disability/Disability/Medicare/Medicaid/Public Policy ER - TY - JOUR T1 - Employee benefits, retirement patterns, and implications for increased work life. JF - EBRI Issue Brief Y1 - 1997 A1 - Fronstin, Paul KW - Age Factors KW - Aged KW - Employment KW - Female KW - Health Benefit Plans, Employee KW - Health Status Indicators KW - Humans KW - Male KW - Medicare KW - Middle Aged KW - Pensions KW - Private Sector KW - Retirement KW - Social Security KW - United States AB -

This Issue Brief examines why policymakers are concerned about the trend toward early retirement and how it relates to Social Security, Medicare, and employee health and retirement benefits. It reviews the rationale for the effects of economic incentives on early retirement decisions and includes a summary of empirical literature on the retirement process. It presents data on how employee benefits influence workers' expected retirement patterns. Finally, it examines the implications of public policies to reverse early-retirement trends and raise the eligibility age for Social Security and Medicare. An employee Benefit Research Institute/Gallup survey indicates that there is a direct link between a worker's decision to retire early and the availability of retiree health benefits. In 1993, 61 percent of workers reported that they would not retire before becoming eligible for Medicare if their employer did not provide retiree health benefits. Participation in a pension plan can be an important determinant of retirement. Twenty-one percent of pension plan participants planned to stop working before age 65, compared with 12 percent among nonparticipants. Workers whose primary pension plan was a defined benefit plan were more likely to expect to stop working before age 65 (23 percent) than workers whose primary plan was a defined contribution plan (18 percent). Expected income replacement rates effect retirement patterns, indicating that as the expected replacement increases, the probability of expecting to stop working before age 65 increases. Twenty-two percent of workers with an expected income replacement rate below 60 percent expected to stop working before age 65, compared with 29 percent for those in the 60-69 percent replacement range, and 30 percent for those in the 70-79 percent replacement range. Workers expecting to receive retiree health insurance are more likely to expect to stop working before age 65 than workers who do not expect to have retiree health insurance. Twenty-one percent of workers with retiree health insurance expected to stop working before age 65, compared with 12 percent of workers not expecting to receive retiree health insurance. The Social Security Old-Age and Survivors Insurance (OASI) program depends on obtaining sufficient revenue from active workers' payroll taxes to fund the benefits received by retired beneficiaries. Funding the program in the past was in large part effortless because of the relatively large number of workers per retiree. Today, funding the program is a greater challenge because the ratio of workers to retirees has fallen. Policymakers have been able to agree that reform of the program is necessary for its survival; however, the debate over options to reform the program is just beginning, and it is likely to be a long time before a consensus emerges.

PB - No. 184 UR - https://www.ncbi.nlm.nih.gov/pubmed/10166809 IS - 184 U1 - http://www.ncbi.nlm.nih.gov/pubmed/10166809?dopt=Abstract U4 - Labor Force/Net Worth/Health Insurance Coverage/Retirement Behavior/Economic Status/Public Policy ER - TY - JOUR T1 - Medical insurance and the use of health care services by the elderly. JF - J Health Econ Y1 - 1997 A1 - Michael D Hurd A1 - Kathleen McGarry KW - Activities of Daily Living KW - Aged KW - Health Care Surveys KW - Health Services for the Aged KW - Health Status Indicators KW - Hospitalization KW - Humans KW - Insurance, Health KW - Medicare KW - Office Visits KW - Patient Acceptance of Health Care KW - Private Sector KW - Probability KW - United States AB -

The objective of this paper is to find how health insurance influences the use of health care services by the elderly. On the basis of the first wave of the Asset and Health Dynamics Survey, we find that those who are the most heavily insured use the most health care services. Because our data show little relationship between observable health measures and either the propensity to hold or to purchase private insurance, we interpret this as an effect of the incentives embodied in the insurance, rather than as the result of adverse selection in the purchase of insurance.

PB - 16 VL - 16 UR - https://www.ncbi.nlm.nih.gov/pubmed/10169091 IS - 2 U1 - http://www.ncbi.nlm.nih.gov/pubmed/10169091?dopt=Abstract U4 - Health Status/Health Services/Economic Status ER -