Research roundup: Managed care for dementia patients; bundled payments after the hospital; disparities among Medicare beneficiaries

Sep 30 2013

Each week, KHN compiles a selection of recently released health policy studies and briefs.

JAMA Internal Medicine: Health Insurance Status And The Care Of Nursing Home Residents With Advanced Dementia
Dementia is a leading cause of death in the United States; however, patients dying with this disease may not receive optimal end-of-life care. ... many of these [nursing home] residents commonly experience burdensome and costly interventions, such as hospital transfers, tube-feeding, and intravenous antibiotics. ... Nursing home reimbursement policies are among the factors that incentivize more aggressive care. ... This study linked unique prospective clinical data with Medicare claims to describe and compare patterns of care between nursing home residents with advanced dementia enrolled in a Medicare managed-care insurance plan and those with fee-for-service Medicare. Residents enrolled in Medicare managed care received more primary care visits (principally from NPs), were more likely to have a DNH order, and had fewer hospital transfers for acute illness compared with those who had traditional Medicare coverage. Our findings also suggest that managed-care residents may have been more likely to enter hospice and that family members may have been more satisfied with the level of care (Goldfield, Grabowski, Caudry, Mitchell, 9/23).

JAMA Internal Medicine: Growth In Medicare Expenditures for Patients With Acute Myocardial Infarction
We studied the cost to Medicare during 365 days of a well-defined cohort of beneficiaries hospitalized for [acute myocardial infarction or heart attacks]. Increased expenditures were not largely the result of price increases (DRG reimbursement stayed constant or even declined in real terms) or changes in the use of technology during the index admission. Instead, expenditures 31 to 365 days after the index admission rose by 28.0 percent because of increased use of home health agencies, hospices, durable medical equipment, skilled nursing facilities, and inpatient services. Although the first 30 days after admission are the focus of many bundled payment initiatives, care after the initial admission is still very much "fee for service." ... our findings suggest that although Medicare's current bundled payments may include expenditures for patients with AMI within 30 days of the event, they do not contain spending beyond 30 days, which accounted for most of the expenditure growth for such patients from 1998 through 1999 and 2008 (Likosky et al., 9/23).

Employee Benefit Research Institute: Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2013 Current Population Survey
The percentage of the nonelderly population (under age 65) with health insurance coverage increased to 82.3 percent in 2012, notable because increases in health insurance coverage have been recorded in only six years since 1994. The percentage of nonelderly individuals with health insurance coverage was 81.5 percent in 2010, the lowest level of that population with such coverage during the 1994–2012 period. ... Employment-based health benefits remain the most common form of health coverage in the United States. In 2012, 58.5 percent of the nonelderly population had employment-based health benefits, down from the peak of 69.3 percent in 2000, during the 1994–2012 period. However, the 2012 level was essentially the same as in 2011 (58.4 percent), meaning that the decline in the percentage of the nonelderly population with employment-based coverage that has occurred each year since 2000 ceased in 2012 (Fronstin, 9/26).

The Kaiser Family Foundation: Wide Disparities In The Income And Assets Of People On Medicare By Race And Ethnicity: Now And In The Future
This report provides insight into preparations in Maryland, Nevada, and Oregon -- three states that have established a State-based Marketplace, are moving forward with the Medicaid expansion, and are among the states leading the way in preparing for outreach and enrollment. ... Across the three states, the most significant challenge they have faced in preparing for the expansions has been developing the new integrated eligibility and enrollment systems. In all three states, time constraints have limited the capabilities they will be able to build into their systems by October 1st. ... All three states benefit from supportive political leadership and close, collaborative working relationships among key state agencies. Moreover, they have a strong network of community partners that are working closely with the states. Lastly, stakeholders in all three states have been creative and adaptable as they prepare for implementation (Artigua et al., 9/24). 

Congressional Budget Office: Medicare And Social Security Payroll Taxes And Benefits For People In Different Birth Cohorts
Different generations will pay different amounts of Medicare and Social Security payroll taxes and receive different amounts of Medicare and Social Security benefits during their lifetime -- as discussed in The 2013 Long-Term Budget Outlook released this week. Medicare benefits are expected to be higher for later generations primarily because of the growth of health care spending per person but also because increases in life expectancy will cause later generations to receive benefits for longer periods, on average. Social Security benefits are expected to be higher for later cohorts because of increased life expectancy and because real earnings generally grow over time. Payroll taxes will be higher for later cohorts because of that growth in real earnings (Meyerson and Topoleski, 9/20).

Here is a selection of news coverage of other recent research:

Reuters: Vets May Not Get Speedy Cancer Care
Adults diagnosed with colon or rectal cancer are experiencing longer wait times before receiving cancer treatment in Veterans Affairs (VA) Medical Centers across the U.S., according to a recent report. The growing treatment delays may not be specific to VA centers alone, and whether the delays are tied to worse outcomes, as previous studies have found for breast and other cancers, is unknown, researchers said (Huggins, 9/20).

MedPage Today: Docs' Role In ACO Leadership Remains Strong
Physicians have had a strong leadership role in the development and operation of the early accountable care organizations (ACOs) -- and that's a good omen for the future, a health reform expert said Monday. Physician-led ACOs outnumber their hospital-led counterparts, Elliott Fisher, MD, MPH, director of the Dartmouth Institute for Health Policy and Clinical Practice, noted at an Alliance for Health Reform briefing on the topic. He pointed to evidence from the health consulting firm Leavitt Partners of Salt Lake City (Pittman, 9/24).

Reuters: Kids' Race May Play A Role In ER Treatment For Pain
Black children who are brought to the emergency room for stomach pain and cramps are less likely than white children to be given painkillers, a new study suggests. Using records from more than 2,000 ER visits, researchers found that white children and teenagers more often received painkillers available over the counter, such as ibuprofen and acetaminophen (Tylenol), or more powerful opioids, including oxycodone. The difference remained after the severity of children's conditions and various hospital-related factors were taken into account (Pittman, 9/23).

Time: Overdoing Bone Density Testing
Among the many tests that doctors recommend as people get older is monitoring for bone mineral density (BMD) to keep track of how quickly bone is being broken down to make sure that the skeleton is strong enough to prevent fractures and other bone failures. People with low BMD readings could benefit from medications that shore up bone and lower the risk of hip and other fractures. So doctors recommend that people over age WHAT TK repeat BMD screening every two years. But the latest research suggests that all that testing may not be necessary (Sifferlin, 9/25).

Reuters: Drug Subsidy Failed To Close Racial Gap In Statin Use
Among older Americans with heart disease or diabetes, blacks are still less likely to be on cholesterol medication than whites, despite federal prescription drug subsidies that lowered costs, according to a new study. Older blacks are also less likely than whites to have their cholesterol under control, researchers found. Because black patients are more likely to skip doses or to not take expensive medications at all for cost reasons, the Medicare Part D program that started in 2006 was expected to close a racial gap in the number of Americans with heart disease taking statins (Doyle, 9/25).

Medpage Today: Team-Based Care Doesn't Defuse Burnout
Practicing in a team-based delivery model did not improve burnout rates for physicians after a year, a small study found. Doctors who meet the criteria of "burned out" were higher (35 percent) for physicians a year after practicing in a team model compared with those practicing a more traditional model (30t statistically significant, Spinelli, of Allina Health in Minneapolis, told MedPage Today during a poster presentation (Pittman, 9/26).