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The American Journal of Managed Care September 2018
Food Insecurity, Healthcare Utilization, and High Cost: A Longitudinal Cohort Study
Seth A. Berkowitz, MD, MPH; Hilary K. Seligman, MD, MAS; James B. Meigs, MD, MPH; and Sanjay Basu, MD, PhD
Language Barriers and LDL-C/SBP Control Among Latinos With Diabetes
Alicia Fernandez, MD; E. Margaret Warton, MPH; Dean Schillinger, MD; Howard H. Moffet, MPH; Jenna Kruger, MPH; Nancy Adler, PhD; and Andrew J. Karter, PhD
Hepatitis C Care Cascade Among Persons Born 1945-1965: 3 Medical Centers
Joanne E. Brady, PhD; Claudia Vellozzi, MD, MPH; Susan Hariri, PhD; Danielle L. Kruger, BA; David R. Nerenz, PhD; Kimberly Ann Brown, MD; Alex D. Federman, MD, MPH; Katherine Krauskopf, MD, MPH; Natalie Kil, MPH; Omar I. Massoud, MD; Jenni M. Wise, RN, MSN; Toni Ann Seay, MPH, MA; Bryce D. Smith, PhD; Anthony K. Yartel, MPH; and David B. Rein, PhD
“Precision Health” for High-Need, High-Cost Patients
Dhruv Khullar, MD, MPP, and Rainu Kaushal, MD, MPH
From the Editorial Board: A. Mark Fendrick, MD
A. Mark Fendrick, MD
Health Literacy, Preventive Health Screening, and Medication Adherence Behaviors of Older African Americans at a PCMH
Anil N.F. Aranha, PhD, and Pragnesh J. Patel, MD
Early Experiences With the Acute Community Care Program in Eastern Massachusetts
Lisa I. Iezzoni, MD, MSc; Amy J. Wint, MSc; W. Scott Cluett III; Toyin Ajayi, MD, MPhil; Matthew Goudreau, BS; Bonnie B. Blanchfield, CPA, SM, ScD; Joseph Palmisano, MA, MPH; and Yorghos Tripodis, PhD
Economic Evaluation of Patient-Centered Care Among Long-Term Cancer Survivors
JaeJin An, BPharm, PhD, and Adrian Lau, PharmD
Fragmented Ambulatory Care and Subsequent Healthcare Utilization Among Medicare Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
High-Touch Care Leads to Better Outcomes and Lower Costs in a Senior Population
Reyan Ghany, MD; Leonardo Tamariz, MD, MPH; Gordon Chen, MD; Elissa Dawkins, MS; Alina Ghany, MD; Emancia Forbes, RDCS; Thiago Tajiri, MBA; and Ana Palacio, MD, MPH
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Adjusting Medicare Advantage Star Ratings for Socioeconomic Status and Disability
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; Cheryl L. Damberg, PhD; Ann Haas, MS, MPH; Mallika Kommareddi, MPH; Anagha Tolpadi, MS; Megan Mathews, MA; and Marc N. Elliott, PhD

Adjusting Medicare Advantage Star Ratings for Socioeconomic Status and Disability

Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; Cheryl L. Damberg, PhD; Ann Haas, MS, MPH; Mallika Kommareddi, MPH; Anagha Tolpadi, MS; Megan Mathews, MA; and Marc N. Elliott, PhD
CMS implemented the Categorical Adjustment Index as part of the Medicare Advantage and Part D Star Rating Program in 2017. These analyses informed its development.
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RESULTS

The analyses using the 2012 data included 620 MA and 76 PDP contracts. The number of MA contracts that met the denominator criteria for individual measures varied from 341 to 613 (Table 1). All PDP contracts met the denominator criteria for each of the included prescription drug event (PDE) measures. The average contract-level percentage of DE/LIS beneficiaries was 40.5% (SD = 38.7%), ranging from 0.4% to 100%, for MA contracts. PDP contracts averaged 22.1% DE/LIS (SD = 27.7%), ranging from 0.0% to 86.2%. Contracts with at least 1 SNP, which focus on specific subpopulations of Medicare beneficiaries, including those who are dual-eligible, have chronic conditions, or reside in institutions, had more DE/LIS beneficiaries than contracts without an SNP (59.0% vs 27.8%; P <.0001). Roughly one-third (34.4%) of MA contracts and one-fifth (21.1%) of PDP contracts had at least 50% beneficiaries who were DE/LIS. MA contracts averaged 19.8% (SD = 16.2%) disabled beneficiaries (ranging from 0.0% to 97.1%), whereas PDPs averaged 17.9% (SD = 15.2%) disabled beneficiaries (ranging from 0.0% to 54.7%). Contracts with SNPs enrolled more disabled beneficiaries than contracts without an SNP (29.4% vs 14.6%; P <.0001). Approximately one-fourth (23.2%) of MA contracts and one-third (31.6%) of PDP contracts had at least 25% disabled beneficiaries.

Within-Contract SES and Disability Performance Disparities

Controlling for between-contract differences, DE/LIS beneficiaries received significantly worse care for 12 of 16 MA measures (Figure 1), with odds ratios (ORs) ranging from 0.68 (95% CI, 0.66-0.70) to 0.94 (95% CI, 0.93-0.95). DE/LIS beneficiaries were more likely to have an adult body mass index assessment (OR, 1.10; 95% CI, 1.06-1.14) and have better performance on the measure reducing risk of falling (OR, 1.67; 95% CI, 1.60-1.74) than non-DE/LIS beneficiaries; there were not significant overall differences between DE/LIS and other beneficiaries for 2 measures (controlling high blood pressure and monitoring physical activity). Within PDPs, DE/LIS beneficiaries received significantly lower-quality care than other beneficiaries on all 3 PDE measures, with ORs ranging from 0.67 (95% CI, 0.66-0.67) to 0.81 (95% CI, 0.81-0.81). These results were not sensitive to further adjustment for Census-based SES characteristics (block group–level education and income/poverty) (eAppendix).

Controlling for contract, disabled beneficiaries received significantly less care for 11 of 15 MA measures (Figure 1), with ORs ranging from 0.56 (95% CI, 0.51-0.62) to 0.93 (95% CI, 0.91-0.96). Disabled beneficiaries were more likely to receive rheumatoid arthritis management (OR, 1.13; 95% CI, 1.10-1.17) and have better performance on the measures reducing risk of falling (OR, 1.32; 95% CI, 1.22-1.42) and monitoring physical activity (OR, 1.33; 95% CI, 1.26-1.40) than other beneficiaries; there were not significant overall differences between disabled and other beneficiaries for 1 measure (controlling high blood pressure). Within PDPs, disabled beneficiaries received significantly lower-quality care than other beneficiaries on all 3 PDE measures, with ORs ranging from 0.61 (95% CI, 0.61-0.61) to 0.74 (95% CI, 0.74-0.75).

Consistency of Within-Contract Disparities Across Contracts

Figure 2 illustrates the heterogeneity of the within-contract difference in care received by DE/LIS beneficiaries relative to non-DE/LIS beneficiaries for each measure; Figure 3 provides analogous information for disability. DE/LIS beneficiaries receive, on average, lower-quality care than non-DE/LIS beneficiaries in contracts.

For 3 measures, DE/LIS beneficiaries received lower-quality care than non-DE/LIS beneficiaries in all MA contracts. DE/LIS beneficiaries received lower-quality care in at least 90% of contracts for an additional 3 measures, but higher-quality care in all contracts for 1 measure. For PDPs, DE/LIS beneficiaries received lower-quality care in all contracts for 1 PDE measure and lower-quality care in 90% or more of PDPs for the remaining 2 Part D measures.

Disabled beneficiaries received lower-quality care than nondisabled beneficiaries in all MA contracts for 6 measures and received lower-quality care in at least 90% of contracts for 3 additional measures. They received higher-quality care in at least 90% of MA contracts for 2 measures. For PDPs, disabled beneficiaries received lower-quality care in all contracts for the 3 PDE measures.

Contract Star Ratings Following Adjustment for SES Differences Using CAI

There are 7 measures (6 MA and 1 PDP) for which the contract-level median absolute DE/LIS disparity is at least 5 percentage points or there are no contracts with DE/LIS scores equal to or higher than their non-DE/LIS scores. Table 2 shows the simulation of the overall star ratings when applying the CAI based on these 7 measures, with large and consistent DE/LIS disparities across contracts. Adjustment with the CAI changed the overall star ratings for 8.5% of contracts with 50% or more DE/LIS beneficiaries (Table 2). Gains in overall star ratings were concentrated in the high-DE/LIS group; 9 of 10 contracts that had higher overall star ratings following CAI had 50% or more DE/LIS. One contract that had less than 50% DE/LIS lost one-half star, while no contracts with 50% or more DE/LIS lost stars. No contract gained or lost more than one-half star.

Adjustment with the CAI changed the Part D ratings for 20.3% of PDPs (16.3% of contracts with <50% DE/LIS and 33.3% with ≥50% DE/LIS; Table 2). No contract gained or lost more than one-half star. Gains only occurred among contracts with 50% or more DE/LIS beneficiaries (n = 5; 33.3%), while losses only occurred among contracts with less than 50% DE/LIS (n = 8; 16.3%).


 
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