Standing Up For My Sister Van Houtven, Courtney H.
Health Affairs,
10/2022, Letnik:
41, Številka:
10
Journal Article
Recenzirano
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Integrating caregivers into the health care team could confer benefits to patients, families, and even health systems. Systems could benefit because caregiver interactions with the team likely affect ...the quality of care and patient outcomes. This seems particularly true in the case of patients with intellectual disabilities, such as my sister. Today health systems fail to recognize how essential caregivers are to providing the best care. Persistent challenges in communicating with family members are evidence of this failure.
Rates of informal home care use among older adults with disabilities increased from 2004 to 2016, such that in 2016 almost three-quarters of these adults received informal home care. Informal care ...remains the most common source of home care, even though formal home care use grew at almost twice the rate, with a 6-percentage-point increase to 36.9 percent in 2016.
Because of workforce needs and demographic and chronic disease trends, nurse practitioners (NPs) and physician assistants (PAs) are taking a larger role in the primary care of medically complex ...patients with chronic conditions. Research shows good quality outcomes, but concerns persist that NPs' and PAs' care of vulnerable populations could increase care costs compared to the traditional physician-dominated system. We used 2012-13 Veterans Affairs data on a cohort of medically complex patients with diabetes to compare health services use and costs depending on whether the primary care provider was a physician, NP, or PA. Case-mix-adjusted total care costs were 6-7 percent lower for NP and PA patients than for physician patients, driven by more use of emergency and inpatient services by the latter. We found that use of NPs and PAs as primary care providers for complex patients with diabetes was associated with less use of acute care services and lower total costs.
Hospices have been expected to reduce health expenditures since their addition to the US Medicare benefit package in the early-1980s, but the literature on their ability to do so is mixed. The ...contradictory findings noted in previous studies may be due to selection bias and the period of cost comparison used. Accounting for these, this study focuses on the length of hospice use that maximizes reductions in medical expenditures near death. We used a retrospective, case/control study of Medicare decedents (1993–2003, National Long Term Care Survey screening sample) to compare 1819 hospice decedents, with 3638 controls matched via their predicted likelihood of dying while using a hospice. Variables used to create matches were demographic, primary medical condition, cost of Medicare financed care prior to the last year of life, nursing home residence and Medicaid eligibility.
Hospice use reduced Medicare program expenditures during the last year of life by an average of $2309 per hospice user; expenditures after initiation of hospice were $7318 for hospice users compared to $9627 for controls (
P<0.001). On average, hospice use reduced Medicare expenditures during all but 2 of hospice users’ last 72 days of life; about $10 on the 72nd day prior to death, with savings increasing to more than $750 on the day of death. Maximum cumulative expenditure reductions differed by primary condition. The maximum reduction in Medicare expenditures per user was about $7000, which occurred when a decedent had a primary condition of cancer and used a hospice for their last 58–103 days of life. For other primary conditions, the maximum savings of around $3500 occurred when a hospice was used for the last 50–108 days of life. Given the length of hospice use observed in the Medicare program, increasing the length of hospice use for 7 in 10 Medicare hospice users would increase savings.
A number of OECD countries have implemented policies encouraging longer labour force participation in tandem with policies encouraging informal care provision in the community. To better understand ...how these policies may affect the available pool of caregivers and labour force participants, we need more evidence about how informal caregiving is related to retirement status and timing. We assessed the association between caregiving intensity and retirement status for individuals aged 55 to 69 using the Canadian 2007 General Social Survey, a cross-sectional survey with 23,404 individuals. We used multinomial logistic regressions to determine whether providing different intensities of informal care (i.e. hours of weekly care) was significantly associated with the likelihood that an individual was fully retired, had retired and returned to work, had never retired and was working part-time or full-time, or was a labour market non-participant. We found that higher intensity caregiving was associated with being fully retired (relative to working full-time) for men and women (relative risk ratios, 2.93 and 2.04, respectively). For women, high intensity caregiving was also associated with working part-time (1.84) and being a labour force non-participant (1.99). Male and female high intensity caregivers were more likely to be retired before age 65. Our results highlight the importance of measuring caregiving intensity and multiple paths to retirement, which are often overlooked in the caregiving and retirement literature. They also indicate that a policy context encouraging both later retirement and more informal care may not be reasonable without flexible work arrangement options.
•A cross-sectional analysis of the association between retirement status and caregiving intensity.•High intensity caregivers aged 55–69 are more likely to be retired and female caregivers more likely to work part-time.•Male and female high intensity caregivers are more likely to be retired before age 65.•Supporting high intensity caregivers is important in contexts encouraging later retirement and more community care.
Objective
To determine whether the Veterans Health Administration's (VHA) efforts to expand access to home‐ and community‐based services (HCBS) after the 2001 Millennium Act significantly changed ...Veterans' utilization of institutional, paid home, and unpaid home care relative to a non‐VHA user Medicare population that was not exposed to HCBS expansion efforts.
Data Sources
We used linkages between the Health and Retirement Study and VHA administrative data from 1998 until 2012.
Study Design
We conducted a retrospective‐matched cohort study using coarsened exact matching to ensure balance on observable characteristics for VHA users (n = 943) and nonusers (n = 6106). We used a difference‐in‐differences approach with a person fixed‐effects estimator.
Data Collection/Extraction Methods
Individuals were eligible for inclusion in the analysis if they were age 65 or older and indicated that they were covered by Medicare insurance in 1998. Individuals were excluded if they were covered by Medicaid insurance at baseline. Individuals were considered exposed to VHA HCBS expansion efforts if they were enrolled in the VHA and used VHA services.
Principal Findings
Theory predicts that an increase in the public allocation of HCBS will decrease the utilization of its substitutes (e.g., institutional care and unpaid caregiving). We found that after the Millennium Act was passed, there were no observed differences between VHA users and nonusers in the probability of using institutional long‐term care (0.7% points, 95% CI: −0.009, 0.022) or in receiving paid help with activities of daily living (0.06% points, 95% CI: −0.011, 0.0125). VHA users received more hours of unpaid care post‐Millennium Act (1.48, 95% CI: −0.232, 3.187), though this effect was not significant once we introduced controls for mental health.
Conclusions
Our findings indicate that mandating access to HCBS services does not necessarily imply that access to these services will follow suit.
Objective
To examine the effect of rural hospital closures on EMS response time (minutes between dispatch notifying unit and arriving at scene); transport time (minutes between unit leaving the scene ...and arriving at destination); and total activation time (minutes between 9‐1‐1 call to responding unit returning to service), as longer EMS times are associated with worse patient outcomes.
Data Sources/Study Setting
We use secondary data from the National EMS Information System, Area Health Resource, and Center for Medicare & Medicaid Provider of Service files (2010‐2016).
Study Design
We examined the effects of rural hospital closures on EMS transport times for emergent 9‐1‐1 calls in rural areas using a pre‐post, retrospective cohort study with the matched comparison group using difference‐in‐difference and quantile regression models.
Principal Findings
Closures increased mean EMS transport times by 2.6 minutes (P = .09) and total activation time by 7.2 minutes (P = .02), but had no effect on mean response times. We also found closures had heterogeneous effects across the distribution of EMS times, with shorter response times, longer transport times, and median total activation times experiencing larger effects.
Conclusions
Rural hospital closures increased mean transport and total activation times with varying effects across the distribution of EMS response, transport, and total times. These findings illuminate potential barriers to accessing timely emergency services due to closures.
Caring for Caregivers During COVID‐19 Dang, Stuti; Penney, Lauren S.; Trivedi, Ranak ...
Journal of the American Geriatrics Society (JAGS),
October 2020, Letnik:
68, Številka:
10
Journal Article
Background:
Evaluation of Medicare-Medicaid integration models’ effects on patient-centered outcomes and costs requires multiple data sources and validated processes for linkage and reconciliation.
...Objective:
To describe the opportunities and limitations of linking state-specific Medicaid and Centers for Medicare & Medicaid Services administrative claims data to measure patient-centered outcomes for North Carolina dual-eligible beneficiaries.
Research Design:
We developed systematic processes to (1) validate the beneficiary ID linkage using sex and date of birth in a beneficiary ID crosswalk, (2) verify dates of dual enrollment, and (3) reconcile Medicare-Medicaid claims data to support the development and use of patient-centered outcomes in linked data.
Participants:
North Carolina Medicaid beneficiaries with full Medicaid benefits and concurrent Medicare enrollment (FBDE) between 2014 and 2017.
Measures:
We identified need-based subgroups based on service use and eligibility program requirements. We calculated utilization and costs for Medicaid and Medicare, matched Medicaid claims to Medicare service categories where possible, and reported outcomes by the payer. Some services were covered only by Medicaid or Medicare, including Medicaid-only covered home and community-based services (HCBS).
Results:
Of 498,030 potential dual enrollees, we verified the linkage and FBDE eligibility of 425,664 (85.5%) beneficiaries, including 281,174 adults enrolled in Medicaid and Medicare fee-for-service. The most common need-based subgroups were intensive behavioral health service users (26.2%) and HCBS users (10.8%) for adults under age 65, and HCBS users (20.6%) and nursing home residents (12.4%) for adults age 65 and over. Medicaid funded 42% and 49% of spending for adults under 65 and adults 65 and older, respectively. Adults under 65 had greater behavioral health service utilization but less skilled nursing facility, HCBS, and home health utilization compared with adults 65 and older.
Conclusions:
Linkage of Medicare-Medicaid data improves understanding of patient-centered outcomes among FBDE by combining Medicare-funded acute and ambulatory services with Medicaid-funded HCBS. Using linked Medicare-Medicaid data illustrates the diverse patient experience within FBDE beneficiaries, which is key to informing patient-centered outcomes, developing and evaluating integrated Medicare and Medicaid programs, and promoting health equity.
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