Medicare Advantage enrollees' reports of unfair treatment during health care encounters.

We investigated unfair treatment among 1863 Medicare Advantage (MA) enrollees from 21 MA plans using 2022 survey data (40% response rate) in which respondents indicated whether they were treated unfairly in a health care setting based on any of 10 personal characteristics. We calculated reported unfair treatment rates overall and by enrollee characteristics. Nine percent of respondents reported any unfair treatment, most often based on health condition (6%), disability (3%), or age (2%). Approximately 40% of those reporting any unfair treatment endorsed multiple categories. People who qualified for Medicare via disability reported unfair treatment by disability, age, income, race and ethnicity, sex, sexual orientation, and gender/gender identity more often than those who qualified via age. Enrollees dually eligible for Medicare and Medicaid or eligible for a Low-Income Subsidy (DE/LIS) reported unfair treatment by disability, income, language/accent, race and ethnicity, culture/religion, and sex more often than non-DE/LIS enrollees. Compared with White respondents, racial and ethnic minority respondents more often reported unfair treatment by race and ethnicity, language/accent, culture/religion, and income. Female respondents were more likely than male respondents to report unfair treatment based on age and sex.

Which medicare advantage enrollees are at highest one-year mortality risk?

BACKGROUND: While a number of tools exist to predict mortality among older adults, less research has described the characteristics of Medicare Advantage (MA) enrollees at higher risk for 1 year mortality. OBJECTIVES: To describe the characteristics of MA enrollees at higher mortality risk using patient survey data. RESEARCH DESIGN: Retrospective cohort. SUBJECTS: MA enrollees completing the 2019 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. MEASURES: Linked demographic, health, and mortality data from a sample of MA enrollees were used to predict 1-year mortality risk and describe enrollee characteristics across levels of predicted mortality risk. RESULTS: The mortality model had a 0.80 c-statistic. Mortality risks were skewed: 6 % of enrollees had a ≥ 10 % 1-year mortality risk, while 45 % of enrollees had 1 % to < 5 % 1-year mortality risk. Among the high-risk (≥10 %) group, 47 % were age 85+ versus 12 % among those with mortality risk <5 %. 79 % were in fair or poor self-rated health versus 29 % among those with mortality risk of <5 %. 71 % reported needing urgent care in the prior 6 months versus 40 % among those with a mortality risk of 1 to<5 %. CONCLUSIONS: Relatively few older adults enrolled in MA are at high 1-year mortality risk. Nonetheless, MA enrollees over age 85, in fair or poor health, or with recent urgent care needs are far more likely to be in a high mortality risk group.

Rural disparities in the quality of clinical care are notable and larger for males.

PURPOSE: To investigate whether rural-urban differences in quality of care for Medicare Advantage (MA) enrollees vary between females and males. METHODS: Data for this study came from the 2019 Healthcare Effectiveness Data and Information Set. Linear regression was used to investigate urban-rural differences in individual MA enrollee scores on 34 clinical care measures grouped into 7 categories, and how those differences varied by sex (through evaluation of statistical interactions). FINDINGS: Across all 7 categories of measures, scores for rural residents were worse than scores for urban residents. For 4 categories-care for patients with (suspected) chronic obstructive pulmonary disease, avoiding prescription misuse, behavioral health, and diabetes care-the average difference across measures in the category was greater than 3 percentage points. Across all 34 measures, there were 15 statistically significant rural-by-sex interactions that exceeded 1 percentage point. In 11 of those cases, the deficit associated with living in a rural area was greater for males than for females. In 3 cases, the deficit associated with living in a rural area was larger for females than for males. In 1 case involving Follow-up After Hospitalization for Mental Illness, rural residents had an advantage, and it was larger for males than for females. CONCLUSIONS: Interventions may help address patient- (eg, health literacy and patient activation), provider- (eg, workforce recruitment and retention), and structural-level issues contributing to these disparities, especially for rural males.

Income-related disparities in Medicare advantage behavioral health care quality.

OBJECTIVE: To inform efforts to improve equity in the quality of behavioral health care by examining income-related differences in performance on HEDIS behavioral health measures in Medicare Advantage (MA) plans. DATA SOURCES AND STUDY SETTING: Reporting Year 2019 MA HEDIS data were obtained and analyzed. STUDY DESIGN: Logistic regression models were used to estimate differences in performance related to enrollee income, adjusting for sex, age, and race-and-ethnicity. Low-income enrollees were identified by Dual Eligibility for Medicare and Medicaid or receipt of the Low-Income Subsidy (DE/LIS). Models without and with random effects for plans were used to estimate overall and within-plan differences in measure performance. Heterogeneity by race-and-ethnicity in the associations of low-income with behavioral health quality were examined using models with interaction terms. DATA COLLECTION/EXTRACTION METHODS: Data were included for all MA contracts in the 50 states and the District of Columbia that collect HEDIS data. PRINCIPAL FINDINGS: For six of the eight measures, enrollees with DE/LIS coverage were more likely to have behavioral health conditions that qualify for HEDIS measures than higher income enrollees. In mixed-effects logistic regression models, DE/LIS coverage was associated with statistically significantly worse overall performance on five measures, with four large (>5 percentage point) differences (-7.5 to -11.1 percentage points) related to follow-up after hospitalization and avoidance of drug-disease interactions. Where the differences were large, they were primarily within-plan rather than between-plan. Interactions between DE/LIS and race-and-ethnicity were statistically significant (p < 0.05) for all measures; income-based quality gaps were larger for White enrollees than for Black or Hispanic enrollees. CONCLUSIONS: Low income is associated with lower performance on behavioral health HEDIS measures in MA, but these associations differ across racial-and-ethnic groups. Improving care integration and addressing barriers to care for low-income enrollees may improve equity across income levels in behavioral health care.

Patient Experience for Hispanic Older Adults Varies by Language Preference.

BACKGROUND: Hispanic people with Medicare report worse patient experiences than non-Hispanic White counterparts. However, little research examines how these disparities may vary by language preference (English/Spanish). OBJECTIVES: Using Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data, assess whether 2014-2018 disparities in patient experiences for Hispanic people with Medicare vary by language preference. RESEARCH DESIGN: We fit a series of linear, case-mix adjusted models predicting Medicare CAHPS measures by race/ethnicity/language preference (Hispanic Spanish-respondents; Hispanic Spanish-preferring English-respondents; Hispanic English-preferring respondents; and non-Hispanic White English-respondents). SUBJECTS: A total of 1,006,543 Hispanic and non-Hispanic White respondents to the Medicare 2014-2018 CAHPS surveys. RESULTS: There were disparities for all Hispanic groups relative to non-Hispanic White English-respondents. Hispanic Spanish-preferring English-respondents reported worse experience than Hispanic Spanish-respondents for getting care quickly (-8 points), getting needed care (-5 points), doctor communication (-2 points), and customer service (-1 point), but better experiences for flu immunization (+2 points). Similarly, Hispanic Spanish-preferring English-respondents reported worse experience than Hispanic English-preferring respondents for getting care quickly (-4 points) and getting needed care (-2 points). Hispanic English-preferring respondents reported worse experience than Hispanic Spanish-respondents for getting care quickly (-4 points), getting needed care (-3 points), doctor communication and customer service (-2 points each), but better experience for flu immunization (+2 points). CONCLUSIONS: Regardless of language preference, Hispanic people with Medicare experience disparities in patient care relative to non-Hispanic White English-preferring counterparts. Hispanic Spanish-preferring English-respondents report the worse experiences, followed by Hispanic English-preferring respondents. Hispanic Spanish-respondents experienced the least disparities of the three Hispanic language subgroups.

Poor self-rated mental health and Medicare beneficiaries' routine care-seeking.

OBJECTIVES: To assess the relationship between self-rated mental health (SRMH) and infrequent routine care among Medicare beneficiaries and to investigate the roles of managed care and having a personal doctor. STUDY DESIGN: Cross-sectional analysis of data from the 2018 Medicare Consumer Assessment of Healthcare Providers and Systems survey. METHODS: Logistic regression was used to predict infrequent routine care (having not made an appointment for routine care in the last 6 months) from SRMH, Medicare coverage type (fee-for-service [FFS] vs Medicare Advantage [MA], the managed care version of Medicare), and the interaction of these variables. Models that did and did not include having a personal doctor were compared. All models controlled for demographics and physical health. RESULTS: Overall, 14.9% of beneficiaries did not make a routine care appointment in the last 6 months, with rates adjusted for demographics and physical health ranging from 14.5% for those with "excellent" SRMH to 19.2% for those with "poor" SRMH. Beneficiaries with poor SRMH were less likely to make a routine care appointment in FFS than in MA (20.1% vs 16.4%, respectively, had not done so in the last 6 months; P < .05). Accounting for having a personal doctor reduced the association between SRMH and infrequent routine care by about a third. CONCLUSIONS: Extra efforts are needed to ensure receipt of routine care by beneficiaries with poor mental health-particularly in FFS, where more should be done to ensure that beneficiaries have a personal doctor.

Sex differences in Medicare beneficiaries' experiences by low-income status.

OBJECTIVES: Medicare beneficiaries dually eligible for Medicaid are a low-income group who are often in poor health. Little research has examined sex differences in patient experience by dual/low-income subsidy (LIS) status. STUDY DESIGN: Cross-sectional comparison by sex and low-income status. METHODS: We used linear regression to compare 6 case mix-adjusted patient experience measures (on a 0-100 scale) by sex within non-dual/LIS and dual/LIS beneficiary groups among 549,603 respondents 65 years and older to the 2016-2017 Medicare Consumer Assessment of Healthcare Providers and Systems surveys of beneficiary experience with Medicare (mail with telephone follow-up of nonrespondents, 42% response rate). RESULTS: Dual/LIS male beneficiaries reported worse patient experiences on all 6 measures than female beneficiaries, with scores 1 to 2 percentage points lower for 3 measures and less than 1 percentage point lower for the other 3 measures. For 4 of the 6 measures, sex differences among dual/LIS beneficiaries were significantly larger than those among non-dual/LIS beneficiaries. In all 4 instances, the gaps between men and women among dual/LIS beneficiaries favored women; P < .05 for all differences discussed. CONCLUSIONS: Low-income male Medicare beneficiaries are more likely to report poor patient experiences, possibly because of lower health literacy, less patient activation, and smaller social networks, along with provider responses to these characteristics. Efforts to address these patient-level factors should happen in parallel with structural-level approaches to train and prepare providers to ensure attentive, respectful patient-centered care for all patients. Additionally, targeted use of ombudsmen and interventions may help reduce inequities.

The Contribution of First-name Information to the Accuracy of Racial-and-Ethnic Imputations Varies by Sex and Race-and-Ethnicity Among Medicare Beneficiaries.

BACKGROUND: Data on race-and-ethnicity that are needed to measure health equity are often limited or missing. The importance of first name and sex in predicting race-and-ethnicity is not well understood. OBJECTIVE: The objective of this study was to compare the contribution of first-name information to the accuracy of basic and more complex racial-and-ethnic imputations that incorporate surname information. RESEARCH DESIGN: We imputed race-and-ethnicity in a sample of Medicare beneficiaries under 2 scenarios: (1) with only sparse predictors (name, address, sex) and (2) with a rich set (adding limited administrative race-and-ethnicity, demographics, and insurance). SUBJECTS: A total of 284,627 Medicare beneficiaries who completed the 2014 Medicare Consumer Assessment of Healthcare Providers and Systems survey and reported race-and-ethnicity were included. RESULTS: Hispanic, non-Hispanic Asian/Pacific Islander, and non-Hispanic White racial-and-ethnic imputations are more accurate for males than females under both sparse-predictor and rich-predictor scenarios; adding first-name information increases accuracy more for females than males. In contrast, imputations of non-Hispanic Black race-and-ethnicity are similarly accurate for females and males, and first names increase accuracy equally for each sex in both sparse-predictor and rich-predictor scenarios. For all 4 racial-and-ethnic groups, incorporating first-name information improves prediction accuracy more under the sparse-predictor scenario than under the rich-predictor scenario. CONCLUSION: First-name information contributes more to the accuracy of racial-and-ethnic imputations in a sparse-predictor scenario than in a rich-predictor scenario and generally narrows sex gaps in accuracy of imputations.

Disparities In The Quality Of Clinical Care Delivered To American Indian/Alaska Native Medicare Advantage Enrollees.

This study used data from the 2019 Healthcare Effectiveness Data and Information Set (HEDIS) to examine differences in the quality of care received by American Indian/Alaska Native beneficiaries versus care received by non-Hispanic White beneficiaries enrolled in Medicare Advantage (managed care) plans. American Indian/Alaska Native beneficiaries were more likely than White beneficiaries to receive care that meets clinical standards for eight of twenty-six HEDIS measures and were less likely than White beneficiaries to receive care that meets clinical standards for five of twenty-six measures. Measures for which American Indian/Alaska Native beneficiaries were less likely to receive care meeting clinical standards were mainly ones pertaining to appropriate treatment of diagnosed conditions. In all cases, differences in care for American Indian/Alaska Native and White beneficiaries were largely within-plan differences. These findings indicate the need for improved clinical care for all beneficiaries. For American Indian/Alaska Native beneficiaries, there is a particular need for improvement in the treatment of diagnosed conditions, including diabetes, chronic obstructive pulmonary disease, and alcohol and other forms of substance abuse.

Disparities in Care Experienced by Older Hispanic Medicare Beneficiaries in Urban and Rural Areas.

BACKGROUND: Hispanic older adults face substantial health disparities compared with non-Hispanic-White (hereafter "White") older adults. To the extent that these disparities stem from cultural and language barriers faced by Hispanic people, they may be compounded by residence in rural areas. OBJECTIVE: The objective of this study was to investigate possible interactions between Hispanic ethnicity and rural residence in predicting the health care experiences of older adults in the United States, and whether disparities in care for rural Hispanic older adults differ in Medicare Advantage versus Medicare Fee-for-Service. SUBJECTS: Medicare beneficiaries age 65 years and older who responded to the 2017-2018 nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. METHODS: We fit a series of linear, case-mix-adjusted models predicting Medicare CAHPS measures of patient experience (rescaled to a 0-100 scale) from ethnicity, place of residence, and Medicare coverage type. RESULTS: In all residential areas, Hispanic beneficiaries reported worse experiences with getting needed care (-3 points), getting care quickly (-4 points), and care coordination (-1 point) than White beneficiaries (all P's<0.001). In rural areas only, Hispanic beneficiaries reported significantly worse experiences than White beneficiaries on doctor communication and customer services (-3 and -9 points, respectively, P<0.05). Tests of a 3-way interaction between ethnicity, rural residence, and coverage type were nonsignificant. CONCLUSIONS: There is a need to improve access to care and care coordination for Hispanic beneficiaries overall and doctor-patient communication and customer service for rural Hispanic beneficiaries. Strategies for addressing deficits faced by rural Hispanics may involve cultural competency training and provision of language-appropriate services for beneficiaries (perhaps as telehealth services).

Patient-Reported Care Coordination is Associated with Better Performance on Clinical Care Measures.

BACKGROUND: Prior studies using aggregated data suggest that better care coordination is associated with higher performance on measures of clinical care process; it is unclear whether this relationship reflects care coordination activities of health plans or physician practices. OBJECTIVE: Estimate within-plan relationships between beneficiary-reported care coordination measures and HEDIS measures of clinical process for the same individuals. DESIGN: Mixed-effect regression models in cross-sectional data. PARTICIPANTS: 2013 Medicare Advantage CAHPS respondents (n=152,069) with care coordination items linked to independently collected HEDIS data on clinical processes. MAIN MEASURES: Care coordination measures assessed follow-up, whether doctors had medical records during visits, whether doctors discussed medicines being taken, how informed doctors seemed about specialist care, and help received with managing care among different providers. HEDIS measures included mammography, colorectal cancer screening, cardiovascular LDL-C screening, controlling blood pressure, 5 diabetes care measures (LDL-C screening, retinal eye exam, nephropathy, blood sugar/HbA1c <9%, LCL-C<100 mg/dL), glaucoma screening in older adults, BMI assessment, osteoporosis management for women with a fracture, and rheumatoid arthritis therapy. KEY RESULTS: For 9 of the 13 HEDIS measures, within health plans, beneficiaries who reported better care coordination also received better clinical care (p<0.05) and none of the associations went in the opposite direction; HEDIS differences between those with excellent and poor coordination exceeded 5 percentage points for 7 measures. Nine measures had positive associations (breast cancer screening, colorectal cancer screening, cardiovascular care LDL-C screening, 4 of 5 diabetes care measures, osteoporosis management, and rheumatoid arthritis therapy). CONCLUSIONS: Within health plans, beneficiaries who report better care coordination also received higher-quality clinical care, particularly for care processes that entail organizing patient care activities and sharing information among different healthcare providers. These results extend prior research showing that health plans with better beneficiary-reported care coordination achieved higher HEDIS performance scores.

Associations of Mail Survey Length and Layout With Response Rates.

We assess the association between survey layout and response rates (RRs) in the 2017 Medicare Advantage Consumer Assessment of Healthcare Providers and Systems mail survey. Among 438 Medicare Advantage plans surveyed by six vendors, there was latitude in survey layout, and plans could add up to 12 supplemental items. Regression models predicted survey response from survey characteristics (page count, number of supplemental items, and survey attractiveness), and beneficiary sociodemographics. Beneficiary-age-by-survey-characteristic interactions assessed whether survey characteristics were more strongly related to RRs among older beneficiaries. We found that surveys with more supplemental items and less attractive layouts had lower adjusted odds of response. RRs were more sensitive to format among older beneficiaries. The difference in adjusted RRs for the most favorable versus the least favorable survey design was 14.5%. For a 65-year-old, this difference was 13.6%; for an 80-year-old, it was 21.0%. These findings suggest that even within a relatively standardized survey, formatting can substantially influence RRs.

Gender Differences in Patient Experience Across Medicare Advantage Plans.

BACKGROUND: Medicare beneficiaries annually select fee-for-service Medicare or a private Medicare insurance (managed care) plan; information about plan performance on quality measures can inform their decisions. Although there is drill-down information available regarding quality variation by race and ethnicity, there remains a dearth of evidence regarding the extent to which care varies by other key beneficiary characteristics, such as gender. We measured gender differences for six patient experience measures and how gender gaps differ across Medicare plans. METHODS: We used data from 300,979 respondents to the 2015-2016 Medicare Advantage Consumer Assessment of Healthcare Providers and Systems surveys. We fit case mix-adjusted linear mixed-effects models to estimate gender differences and evaluate heterogeneity in differences across health plans. RESULTS: Nationally, women's experiences were better than men's (p < .05) by 1 percentage point on measures involving interactions with administrative staff (+1.6 percentage point for customer service) and timely access to care (+1.1 percentage point for getting care quickly), but worse on a measure that may involve negotiation with physicians (getting needed care). Gender gaps varied across plans, particularly for getting care quickly and getting needed care, where plan-level differences of up to 5 to 6 percentage points were observed. CONCLUSIONS: Although the average national differences in patient experience by gender were generally small, gender gaps were larger in some health plans and for specific measures. This finding indicates opportunities for health plans with larger gender gaps to implement quality improvement efforts.

Disparities in Care Experienced by American Indian and Alaska Native Medicare Beneficiaries.

BACKGROUND: Little is known about the health care experiences of American Indians and Alaska Natives (AIANs) due to limited data. OBJECTIVE: The objective of this study was to investigate the health care experiences of AIAN Medicare beneficiaries relative to non-Hispanic Whites using national survey data pooled over 5 years. SUBJECTS: A total of 1,193,248 beneficiaries who responded to the nationally representative 2012-2016 Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. METHODS: Linear regression models predicted CAHPS measures from race and ethnicity. Scores on the CAHPS measures were linearly transformed to a 0-100 range and case-mix adjusted. Three AIAN groups were compared with non-Hispanic Whites: single-race AIANs (n=2491; 0.4% of the total sample), multiple-race AIANs (n=15,502; 1.3%), and Hispanic AIANs (n=2264; 0.2%). RESULTS: Among AIAN groups, single-race AIANs were most likely to live in rural areas and areas served by the Indian Health Service; Hispanic AIANs were most likely to be Spanish-language-preferring (P's<0.05). Compared with non-Hispanic Whites, single-race AIANs reported worse experiences with getting needed care (adjusted disparity of -5 points; a "large" difference), getting care quickly (-4 points; a "medium" difference), doctor communication (-2 points; a "small" difference), care coordination (-2 points), and customer service (-7 points; P<0.001 for all comparisons). Disparities were similar for Hispanic AIANs but more limited for multiple-race AIANs. CONCLUSIONS: Quality improvement efforts are needed to reduce disparities faced by older AIANs. These findings may assist in developing targeted efforts to address cultural, communication, and health system factors presumed to underlie disparities in health care access and customer service.

Educational Attainment and Perceived Need for Urgent Care.

While lower educational attainment is associated with worse health status, education may also affect one's ability to identify need for urgent care. Using data from the 2010 Medicare CAHPS survey, we estimated multivariate logistic models to test the relationship between self-reported educational attainment and the perceived need for urgent care, controlling for health status and other factors. As expected, lower educational attainment was associated with greater reported need for urgent care in bivariate analyses because of poorer health. However, lower educational attainment was associated with less perceived need for urgent care after controlling for health status, particularly for those in poor health. These findings suggest the need for interventions to improve the likelihood that people with less education recognize the need for urgent care, particularly those in poor health and in most need of urgent care.

The effects of survey version on patient experience scores and plan rankings.

OBJECTIVE: To assess the effect of changing survey questions on plan-level patient experience measures and ratings. DATA SOURCE: 2015 Medicare Advantage CAHPS Survey respondents. STUDY DESIGN: Ninety three randomly selected beneficiaries in each of 40 MA plans received a revised (5.0) CAHPS survey; 38 832 beneficiaries received version 4.0. Linear mixed-effect regression predicted CAHPS measures from fixed effects for survey version and beneficiary characteristics and random effects for plan and plan-by-version random slope. PRINCIPAL FINDINGS: Response rates were 42 percent for both versions. Removal of "try to" from screeners increased the percentage of respondents eligible for follow-up questions. Version 5.0 caused a small increase (1-3 points on a 0-100 scale, P < 0.05) in the mean of three altered measures and a moderate increase (>3 points) in one. There was a small statistically significant increase in two unaltered measures. These changes were uniform across plans, so there would be no expected change compared to results using the legacy survey in the score distributions other than uniform mean shifts, and no expected effect on summary measures. CONCLUSIONS: These analyses illustrate how to assess the impact of seemingly minor survey modifications for other national surveys considering changes and highlight the importance of screeners in instrument design.

Exploring Disparities in Influenza Immunization for Older Women.

OBJECTIVES: While women obtain most recommended preventive health interventions more often than men, evidence is mixed regarding influenza vaccination for older adults. Therefore, we evaluated sex differences in influenza vaccination among older adults. DESIGN: Nationally representative cross-sectional survey. SETTING: United States. PARTICIPANTS: A total of 1 252 705 adults, aged 65 years and older, responding to 2013 to 2017 Medicare Consumer Assessment of Healthcare Providers and Systems surveys. MEASUREMENTS: The dependent variable was Healthcare Effectiveness Data and Information Set self-reported influenza immunization. The primary predictor was sex. Covariates included general health status, education, race/ethnicity, and Medicare Advantage (MA; managed care) vs Fee-for-Service (FFS) coverage. RESULTS: After adjusting for health status and other sociodemographic factors, women's immunization was 2% lower than men's immunization in MA, with no significant overall sex difference in FFS. Women were immunized less often than men in 95% of MA health plans, with the largest gaps in low-immunizing plans. Further analyses revealed variation in sex differences by health status, education, and race/ethnicity in both MA and FFS. Notably in MA, women in poor health were immunized less often than men in similar health (-4%; P < .001). Black women were immunized much less often than black men in both MA and FFS (-5%; P < .001 for each). Hispanic women were immunized less often than Hispanic men in MA (-4%; P < .001) but not within FFS. CONCLUSION: Women in MA experience small disparities overall in influenza immunization, with larger disparities for black and Hispanic women. Providers and MA plans should increase efforts to recommend and monitor immunization for older women, especially black and Hispanic women and those in poor health. Given the potential to reduce morbidity and mortality, equitable access to a critical preventive health service, such as influenza immunization, is crucial for all older adults.

Medicare Beneficiaries With a Specialist as Their Personal Doctor Report Better Experiences With Care.

BACKGROUND: Health plans often require that patients have a personal doctor. Older adults rely on specialists for much of their care and may use a specialist in this role, but little is known about how many or which Medicare beneficiaries use specialists as their personal doctor and how their care experiences differ from others'. OBJECTIVE: To examine the prevalence and characteristics of Medicare beneficiaries with a specialist as a personal doctor and compare their patient experiences and immunization to other beneficiaries'. RESEARCH DESIGN: Logistic regression predicted having a specialist as a personal doctor from beneficiary characteristics. Doubly-robust models compared 7 patient experience and 2 immunization measures for beneficiaries with and without a specialist as their personal doctor. Interactions of a specialist indicator and beneficiary characteristics tested for moderators. STUDY POPULATION: A total of 227,642 Medicare beneficiaries aged 65+ who reported having a personal doctor on the 2014 Medicare CAHPS survey. RESULTS: In total, 20% of beneficiaries reported that their personal doctor was a specialist, fewer than previously reported for the most frequently visited physician (43%); beneficiaries who were older, less healthy, less educated, racial/ethnic minorities, had fee-for-service coverage, or had lower income were more likely to do so. They also reported better patient experiences than those with nonspecialist personal physicians on 6 of 7 measures and more immunizations; the largest difference was for care coordination. Having a specialist personal doctor was associated with particularly positive patient experience for low income, Black, Hispanic, and less healthy beneficiaries. CONCLUSION: Future research should investigate whether specialists as personal doctors may reduce patient-experience disparities for vulnerable patients.

Differences in Hospitalizations Between Fee-for-Service and Medicare Advantage Beneficiaries.

BACKGROUND: Previous studies found lower hospitalization rates for enrollees in Medicare Advantage (MA) plans than for beneficiaries with fee-for-service (FFS) coverage. MA enrollment is increasing, especially for those newly eligible for Medicare, but little is known about how service use in FFS or MA differs for new beneficiaries. OBJECTIVE: To compare differences in rates of hospitalization between MA and FFS. RESEARCH DESIGN: A retrospective study of hospitalization among FFS and MA respondents to the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey. Differences in hospitalization rates were assessed using multivariable logistic regression models that controlled for patient sociodemographic and health characteristics. Models included an interaction between age and coverage type to determine whether patterns of care were distinct for enrollees recently eligible for Medicare. STUDY POPULATION: In total, 259,335 respondents to the 2013 MCAHPS survey. RESULTS: In total, 14% of FFS and 12% of MA enrollees had ≥1 hospitalization in the 6 months before survey administration. Models adjusted for enrollee demographics found that MA enrollees had 0.81 the odds of being hospitalized relative to those with FFS coverage (95% confidence interval, 0.78-0.84). Differences between groups were substantially reduced and no longer statistically significant when they were fully adjusted (adjusted odds ratio 1.01, 95% confidence interval, 0.97-1.08). Models with interactions indicated no significant age differences in the MA/FFS hospitalization gap. CONCLUSION: Differences in hospital admissions between those with MA and FFS coverage appear to be primarily related to differences in health status.