Expansion of the Medicare Advantage program during 2009-18 saw greater enrollment among racial/ethnic minorities and other traditionally marginalized groups. Growth was more rapid among Black, ...Hispanic, and dually enrolled beneficiaries than among White and nondual beneficiaries. The implications of greater heterogeneity in the program for enrollee outcomes are uncertain.
Unlike fee-for-service (FFS) Medicare, most Medicare Advantage (MA) plans have a preferred network of care providers that serve most of a plan's enrollees. Little is known about how the quality of ...care MA enrollees receive differs from that of FFS Medicare enrollees. This article evaluates the differences in the quality of skilled nursing facilities (SNFs) that Medicare Advantage and FFS beneficiaries entered in the period 2012-14. After we controlled for patients' clinical, demographic, and residential neighborhood effects, we found that FFS Medicare patients have substantially higher probabilities of entering higher-quality SNFs (those rated four or five stars by Nursing Home Compare) and those with lower readmission rates, compared to MA enrollees. The difference between MA and FFS Medicare SNF selections was less for enrollees in higher-quality MA plans than those in lower-quality plans, but Medicare Advantage still guided patients to lower-quality facilities.
Abstract Purpose We sought to project the number of primary care physicians required to meet US health care utilization needs through 2025 after passage of the Affordable Care Act. Methods In this ...projection of workforce needs, we used the Medical Expenditure Panel Survey to calculate the use of office-based primary care in 2008. We used US Census Bureau projections to account for demographic changes and the American Medical Association's Masterfile to calculate the number of primary care physicians and determine the number of visits per physician. The main outcomes were the projected number of primary care visits through 2025 and the number of primary care physicians needed to conduct those visits. Results Driven by population growth and aging, the total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025. After incorporating insurance expansion, the United States will require nearly 52,000 additional primary care physicians by 2025. Population growth will be the largest driver, accounting for 33,000 additional physicians, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion will require more than 8,000 additional physicians, a 3% increase in the current workforce. Conclusions Population growth will be the greatest driver of expected increases in primary care utilization. Aging and insurance expansion will also contribute to utilization, but to a smaller extent.
A systematic review and a meta-analysis were performed to determine the association between public smoking bans and risk for hospital admission for acute myocardial infarction (AMI).
Secondhand smoke ...(SHS) is associated with a 30% increase in risk of AMI, which might be reduced by prohibiting smoking in work and public places.
PubMed, EMBASE, and Google Scholar databases plus bibliographies of relevant studies and reviews were searched for peer-reviewed original articles published from January 1, 2004, through April 30, 2009, using the search terms "smoking ban" and "heart" or "myocardial infarct." Investigators supplied additional data. All published peer-reviewed original studies identified were included. Incidence rates of AMI per 100,000 person-years before and after implementation of the smoking bans and incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated. Random effects meta-analyses estimated the overall effect of the smoking bans. Funnel plot and meta-regression assessed heterogeneity among studies.
Using 11 reports from 10 study locations, AMI risk decreased by 17% overall (IRR: 0.83, 95% CI: 0.75 to 0.92), with the greatest effect among younger individuals and nonsmokers. The IRR incrementally decreased 26% for each year of observation after ban implementation.
Smoking bans in public places and workplaces are significantly associated with a reduction in AMI incidence, particularly if enforced over several years.
Transcriptionally silent genes can be marked by histone modifications and regulatory proteins that indicate the genes' potential to be activated. Such marks have been identified in pluripotent cells, ...but it is unknown how such marks occur in descendant, multipotent embryonic cells that have restricted cell fate choices. We isolated mouse embryonic endoderm cells and assessed histone modifications at regulatory elements of silent genes that are activated upon liver or pancreas fate choices. We found that the liver and pancreas elements have distinct chromatin patterns. Furthermore, the histone acetyltransferase P300, recruited via bone morphogenetic protein signaling, and the histone methyltransferase Ezh2 have modulatory roles in the fate choice. These studies reveal a functional "prepattern" of chromatin states within multipotent progenitors and potential targets to modulate cell fate induction.
Health systems have increasingly developed integrated Medicare Advantage (MA) plans to align financial incentives and improve coordination of care and services across payer and provider. However, ...little is known about integrated MA plans' effects on patient outcomes and care processes. We used 2015 MA hospitalization data to assess whether these new models are associated with differences in the processes that take place during hospitalizations and to differences in patient outcomes. We found that enrollees who received care in a fully integrated context were less likely to disenroll from Medicare Advantage or switch MA plans and had marginally lower adjusted mortality rates, compared to enrollees hospitalized in less integrated settings-with no differences in readmissions between the two groups. The fully integrated enrollees also acquired more diagnoses but were less often admitted to the ICU compared to other patients admitted to the same hospitals. As the number of these arrangements continues to grow, the potential advantages of coordination may need to be balanced against the increased cost to Medicare associated with apparently more diagnostic complexity.
To assess the validity of race/ethnicity coding in Medicare data and whether misclassification errors lead to biased outcome reporting by race/ethnicity among Medicare Advantage beneficiaries.
In ...this national study of Medicare Advantage beneficiaries, we analyzed individual-level data from the Health Outcomes Survey (HOS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS), race/ethnicity codes from the Medicare Master Beneficiary Summary File (MBSF), and outcomes from the Medicare Provider Analysis and Review (MedPAR) files from 2015 to 2017.
We used self-reported beneficiary race/ethnicity to validate the Medicare Enrollment Database (EDB) and Research Triangle Institute (RTI) race/ethnicity codes. We measured the sensitivity, specificity, and positive and negative predictive values of the Medicare EDB and RTI codes compared to self-report. For outcomes, we compared annualized hospital admission, 30-day, and 90-day readmission rates.
Data for Medicare Advantage beneficiaries who completed either the HOS or CAHPS survey were linked to MBSF and MedPAR files. Validity was assessed for both self-reported multiracial and single-race beneficiaries.
For beneficiaries enrolled in Medicare Advantage, the EDB and RTI race/ethnicity codes have high validity for identifying non-Hispanic White or Black beneficiaries, but lower sensitivity for beneficiaries self-reported Hispanic any race (EDB: 28.3%, RTI: 85.9%) or non-Hispanic Asian American or Native Hawaiian Pacific Islander (EDB: 56.1%, RTI: 72.1%). Only 8.7% of beneficiaries self-reported non-Hispanic American Indian Alaska Native are correctly identified by either Medicare code, resulting in underreported annualized hospitalization rates (EDB: 31.5%, RTI: 31.6% vs. self-report: 34.6%). We find variation in 30-day readmission rates for Hispanic beneficiaries across race categories, which is not measured by Medicare race/ethnicity coding.
Current Medicare race/ethnicity codes misclassify and bias outcomes for non-Hispanic AIAN beneficiaries, who are more likely to select multiple racial identities. Revisions to race/ethnicity categories are needed to better represent multiracial/ethnic identities among Medicare Advantage beneficiaries.
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