Coverage Denials in Medicare Advantage-Balancing Access and Efficiency.

This essay compares Medicare Advantage's claim denials and reversals with traditional Medicare and questions whether coverage obligations are being met.

Taking Stock of Care Delivery Transformation.

This Viewpoint discusses how the same realism and rigor for evaluating biomedical innovations can be applied to the science of care delivery.

Cities as Platforms for Population Health: Past, Present, and Future.

Policy Points Cities have long driven innovation in public health in response to shifting trends in the burden of disease for populations. Today, the challenges facing municipal health departments include the persistent prevalence of chronic disease and deeply entrenched health inequities, as well as the evolving threats posed by climate change, political gridlock, and surging behavioral health needs. Surmounting these challenges will require generational investment in local public health infrastructure, drawn both from new governmental allocation and from innovative financing mechanisms that allow public health agencies to capture more of the value they create for society. Additional funding must be paired with the local development of public health data systems and the implementation of evidence-based strategies, including community health workers and the co-localization of clinical services and social resources as part of broader efforts to bridge the gap between public health and health care. Above all, advancing urban health demands transformational public policy to tackle inequality and reduce poverty, to address racism as a public health crisis, and to decarbonize infrastructure. One strategy to help achieve these ambitious goals is for cities to organize into coalitions that harness their collective power as a force to improve population health globally.

Association Between Community-Level Social Risk and Spending Among Medicare Beneficiaries: Implications for Social Risk Adjustment and Health Equity.

Importance: Payers are increasingly using approaches to risk adjustment that incorporate community-level measures of social risk with the goal of better aligning value-based payment models with improvements in health equity. Objective: To examine the association between community-level social risk and health care spending and explore how incorporating community-level social risk influences risk adjustment for Medicare beneficiaries. Design, Setting, and Participants: Using data from a Medicare Advantage plan linked with survey data on self-reported social needs, this cross-sectional study estimated health care spending health care spending was estimated as a function of demographics and clinical characteristics, with and without the inclusion of Area Deprivation Index (ADI), a measure of community-level social risk. The study period was January to December 2019. All analyses were conducted from December 2021 to August 2022. Exposures: Census block group-level ADI. Main Outcomes and Measures: Regression models estimated total health care spending in 2019 and approximated different approaches to social risk adjustment. Model performance was assessed with overall model calibration (adjusted R2) and predictive accuracy (ratio of predicted to actual spending) for subgroups of potentially vulnerable beneficiaries. Results: Among a final study population of 61 469 beneficiaries (mean [SD] age, 70.7 [8.9] years; 35 801 [58.2%] female; 48 514 [78.9%] White; 6680 [10.9%] with Medicare-Medicaid dual eligibility; median [IQR] ADI, 61 [42-79]), ADI was weakly correlated with self-reported social needs (r = 0.16) and explained only 0.02% of the observed variation in spending. Conditional on demographic and clinical characteristics, every percentile increase in the ADI (ie, more disadvantage) was associated with a $11.08 decrease in annual spending. Directly incorporating ADI into a risk-adjustment model that used demographics and clinical characteristics did not meaningfully improve model calibration (adjusted R2 = 7.90% vs 7.93%) and did not significantly reduce payment inequities for rural beneficiaries and those with a high burden of self-reported social needs. A postestimation adjustment of predicted spending for dual-eligible beneficiaries residing in high ADI areas also did not significantly reduce payment inequities for rural beneficiaries or beneficiaries with self-reported social needs. Conclusions and Relevance: In this cross-sectional study of Medicare beneficiaries, the ADI explained little variation in health care spending, was negatively correlated with spending conditional on demographic and clinical characteristics, and was poorly correlated with self-reported social risk factors. This prompts caution and nuance when using community-level measures of social risk such as the ADI for social risk adjustment within Medicare value-based payment programs.

Correction: The Story of #GetMePPE and GetUsPPE.org to Mobilize Health Care Response to COVID-19 : Rapidly Deploying Digital Tools for Better Health Care.

[This corrects the article DOI: 10.2196/20469.].

Return on Investment of the COVID-19 Vaccination Campaign in New York City.

Importance: New York City, an early epicenter of the pandemic, invested heavily in its COVID-19 vaccination campaign to mitigate the burden of disease outbreaks. Understanding the return on investment (ROI) of this campaign would provide insights into vaccination programs to curb future COVID-19 outbreaks. Objective: To estimate the ROI of the New York City COVID-19 vaccination campaign by estimating the tangible direct and indirect costs from a societal perspective. Design, Setting, and Participants: This decision analytical model of disease transmission was calibrated to confirmed and probable cases of COVID-19 in New York City between December 14, 2020, and January 31, 2022. This simulation model was validated with observed patterns of reported hospitalizations and deaths during the same period. Exposures: An agent-based counterfactual scenario without vaccination was simulated using the calibrated model. Main Outcomes and Measures: Costs of health care and deaths were estimated in the actual pandemic trajectory with vaccination and in the counterfactual scenario without vaccination. The savings achieved by vaccination, which were associated with fewer outpatient visits, emergency department visits, emergency medical services, hospitalizations, and intensive care unit admissions, were also estimated. The value of a statistical life (VSL) lost due to COVID-19 death and the productivity loss from illness were accounted for in calculating the ROI. Results: During the study period, the vaccination campaign averted an estimated $27.96 (95% credible interval [CrI], $26.19-$29.84) billion in health care expenditures and 315 724 (95% CrI, 292 143-340 420) potential years of life lost, averting VSL loss of $26.27 (95% CrI, $24.39-$28.21) billion. The estimated net savings attributable to vaccination were $51.77 (95% CrI, $48.50-$55.85) billion. Every $1 invested in vaccination yielded estimated savings of $10.19 (95% CrI, $9.39-$10.87) in direct and indirect costs of health outcomes that would have been incurred without vaccination. Conclusions and Relevance: Results of this modeling study showed an association of the New York City COVID-19 vaccination campaign with reduction in severe outcomes and avoidance of substantial economic losses. This significant ROI supports continued investment in improving vaccine uptake during the ongoing pandemic.

Complications of Cardiac Resynchronization Therapy: Comparison of Safety Outcomes from Real-world Studies and Clinical Trials.

Cardiac resynchronization therapy (CRT) is an important intervention in heart failure. Whether real-world complication rates mirror those reported in randomized clinical trials (RCTs) is unknown. We sought to compare rates of procedural complications between major RCTs of CRT with "real-world" complication rates reported in registries and administrative claims database studies. We conducted a PubMed search to identify all relevant publications on CRT and classified them into RCTs and registry studies. Pooled procedural complication rates were analyzed. Differences between groups were compared using the chi-squared test. We identified a total of 6 RCTs, 2 administrative claims database studies, and 4 CRT registry studies. RCTs included a total of 4,442 patients and "real-world" studies included a total of 72,554 patients. The overall rates of procedural complications with CRT were significantly higher in RCTs compared to the real world (8.1% vs. 6.9%, P = .002). Lead-related complications were higher in the real-world studies compared to RCTs (11.3% vs. 6.5%, P = .0001). This could represent a follow-up bias with patients in registries being followed up for longer durations that would compound lead complication rates. Interestingly, RCTs had a higher incidence of pocket hematomas (2.1% vs. 0.4%, P = .001). In conclusion, real-world procedural complication rates of CRT appear to be significantly lower than those reported in RCTs.

Association Between Self-reported Health-Related Social Needs and Acute Care Utilization Among Older Adults Enrolled in Medicare Advantage.

Importance: There is increased focus on identifying and addressing health-related social needs (HRSNs). Understanding how different HRSNs relate to different health outcomes can inform targeted, evidence-based policies, investments, and innovations to address HRSNs. Objective: To examine the association between self-reported HRSNs and acute care utilization among older adults enrolled in Medicare Advantage. Design Setting and Participants: This cross-sectional study used data from a large, national survey of Medicare Advantage beneficiaries to identify the presence of HRSNs. Survey data were linked to medical claims, and regression models were used to estimate the association between HRSNs and rates of acute care utilization from January 1, 2019, through December 31, 2019. Exposures: Self-reported HRSNs, including food insecurity, financial strain, loneliness, unreliable transportation, utility insecurity, housing insecurity, and poor housing quality. Main Outcomes and Measures: All-cause hospital stays (inpatient admissions and observation stays), avoidable hospital stays, all-cause emergency department (ED) visits, avoidable ED visits, and 30-day readmissions. Results: Among a final study population of 56 155 Medicare Advantage beneficiaries (mean [SD] age, 74.0 [5.8] years; 32 779 [58.4%] women; 44 278 [78.8%] White; and 7634 [13.6%] dual eligible for Medicaid), 27 676 (49.3%) reported 1 or more HRSNs. Health-related social needs were associated with statistically significantly higher rates of all utilization measures, with the largest association observed for avoidable hospital stays (incident rate ratio for any HRSN, 1.53; 95% CI, 1.35-1.74; P < .001). Compared with beneficiaries without HRSNs, beneficiaries with an HRSN had a 53.3% higher rate of avoidable hospitalization (incident rate ratio, 1.53; 95% CI, 1.35-1.74; P < .001). Financial strain and unreliable transportation were each independently associated with increased rates of hospital stays (marginal effects of 26.5 [95% CI, 14.2-38.9] and 51.2 [95% CI, 30.7-71.8] hospital stays per 1000 beneficiaries, respectively). All HRSNs, except for utility insecurity, were independently associated with increased rates of ED visits. Unreliable transportation had the largest association with increased hospital stays and ED visits, with marginal effects of 51.2 (95% CI, 30.7-71.8) and 95.5 (95% CI, 65.3-125.8) ED visits per 1000 beneficiaries, respectively. Only unreliable transportation and financial strain were associated with increased rates of 30-day readmissions, with marginal effects of 3.3% (95% CI, 2.0%-4.0%) and 0.4% (95% CI, 0.2%-0.6%), respectively. Conclusions and Relevance: In this cross-sectional study of older adults enrolled in Medicare Advantage, self-reported HRSNs were common and associated with statistically significantly increased rates of acute care utilization, with variation in which HRSNs were associated with different utilization measures. These findings provide evidence of the unique association between certain HRSNs and different types of acute care utilization, which could help refine the development and targeting of efforts to address HRSNs.

Comparison of Medicare Advantage vs Traditional Medicare for Health Care Access, Affordability, and Use of Preventive Services Among Adults With Low Income.

Importance: The Medicare Advantage (MA) program has doubled in size during the past decade, and enrollment among adults with low income has increased rapidly. Such adults face significant barriers in accessing care, leading to poorer health outcomes. Therefore, understanding how health care access, preventive care, and care affordability compare for adults with low income who are enrolled in MA vs traditional Medicare (TM) is critically important. Objective: To compare measures of health care access, preventive care use, and affordability of care between adults with low income who are enrolled in MA vs TM. Design, Setting, and Participants: This nationally representative cross-sectional study used the 2019 National Health Interview Survey to compare 2622 adults aged 65 years or older with low income who were enrolled in MA vs TM. Data were analyzed from December 5, 2021, to April 10, 2022. Main Outcomes and Measures: Measures of health care access, preventive care use, and health care affordability. Results: The study cohort included 2622 adults aged 65 years or older with low income, resulting in a weighted cohort of 14 222 243 adults, of whom 5 641 049 (39.7%) were enrolled in MA and 8 581 194 (60.3%) in TM. The overall age of the cohort was 74.6 years (95% CI, 74.3-74.9). Between the MA and TM groups, the mean age (74.5 years [95% CI, 74.1-75.0] vs 74.7 years [95% CI, 74.3-75.1]; P = .63) and sex distribution (63.6% women [95% CI, 59.8%-67.3%] vs 60.4% women [95% CI, 57.4%-63.3%]; P = .17) were similar, but adults with low income in MA were more likely to be non-Hispanic Asian (7.6% [95% CI, 5.0%-10.1%] vs 3.8% [95% CI, 2.4%-5.3%]; P = .01) or Hispanic (18.1% [95% CI, 14.3%-21.9%] vs 9.4% [95% CI, 7.2%-11.7%]; P < .001). Adults with low income in MA compared with those enrolled in TM were more likely to have a usual place of care (97.7% vs 94.9%; adjusted odds ratio [aOR], 2.37 [95% CI, 1.38-4.07]), but similarly likely to have a recent physician visit (95.5% vs 93.5%; aOR, 1.39 [95% CI, 0.88-2.17]) and to delay medical care (5.3% vs 5.7%; aOR, 0.83 [95% CI, 0.56-1.24]) or not seek medical care (5.6% vs 5.9%; aOR, 0.86 [95% CI, 0.56-1.30]) due to costs. For preventive care measures, adults with low income in MA were more likely than those in TM to have undergone a recent cholesterol screening (98.7% vs 96.6%; aOR, 2.58 [95% CI, 1.27-5.22]). However, there were no significant differences between the MA and TM groups in the likelihood of diabetes screening (90.6% vs 87.6%; aOR, 1.21 [95% CI, 0.87-1.66]), blood pressure screening (96.8% vs 95.2%; aOR, 1.37 [95% CI, 0.84-2.23]), or receipt of an influenza vaccination in the past year (66.3% vs 63.8%; aOR, 1.16 [95% CI, 0.93-1.45]). Adults with low income in MA or TM were similarly likely to be concerned about paying medical bills (47.3% vs 44.2%; aOR, 1.09 [95% CI, 0.88-1.35]) or have problems paying medical bills (17.1% vs 17.2%; aOR, 0.94 [95% CI, 0.69-1.27]) and were also similarly likely to delay filling prescriptions (7.4% vs 6.2%; aOR, 1.22 [95% CI, 0.78-1.92]) or to not fill prescriptions (7.8% vs 7.4%; aOR, 1.01 [95% CI, 0.70-1.45]) due to costs. Conclusions and Relevance: In this study of Medicare beneficiaries with low income, key measures of health care access, preventive care use, and health care affordability generally did not differ between those enrolled in MA vs TM.

A Community Partnership to House and Care for Complex Patients with Unstable Housing.

Rising homelessness, especially among older adults, has significant ramifications for our health care system. People experiencing homelessness tend to experience worse health and poorer access to needed health care than people with stable housing. Commonwealth Care Alliance (CCA), a not-for-profit payer and provider that offers health plans to people dually eligible for Medicare and Medicaid, sought to address homelessness among its beneficiaries through a partnership with a local community-based housing organization, Hearth. This partnership led to many CCA members gaining access to permanent supportive housing in a setting in which CCA and Hearth could monitor and address their medical, social, and behavioral needs. It also provided an opportunity to examine health care utilization and cost trends associated with permanent supportive housing. Our experience demonstrates that a community-based partnership can effectively address homelessness among older adults with significant medical needs and may be associated with reduced health care expenditures.