Rates of Disenrollment From Medicare Advantage Plans Are Higher for Racial/Ethnic Minority Beneficiaries.

BACKGROUND: Each year, about 10% of Medicare Advantage (MA) enrollees voluntarily switch to another MA contract, while another 2% voluntarily switch from MA to fee-for-service Medicare. Voluntary disenrollment from MA plans is related to beneficiaries' negative experiences with their plan, disrupts the continuity of care, and conflicts with goals to reduce Medicare costs. Little is known about racial/ethnic disparities in voluntary disenrollment from MA plans. OBJECTIVE: The objective of this study was to investigate differences in rates of voluntary disenrollment from MA plans by race/ethnicity. SUBJECTS: A total of 116,770,319 beneficiaries enrolled in 736 MA plans in 2015. METHODS: Differences in rates of disenrollment across racial/ethnic groups [Asian or Pacific Islander (API), Black, Hispanic, and White] were summarized using 4 types of logistic regression models: adjusted and unadjusted models estimating overall differences and adjusted and unadjusted models estimating within-plan differences. Unadjusted overall models included only racial/ethnic group probabilities as predictors. Adjusted overall models added age, sex, dual eligibility, disability, and state of residence as control variables. Between-plan differences were estimated by subtracting within-plan differences from overall differences. RESULTS: Adjusted rates of disenrollment were significantly (P<0.001) higher for Hispanic (+1.2 percentage points), Black (+1.2 percentage points), and API beneficiaries (+2.4 percentage points) than for Whites. Within states, all 3 racial/ethnic minority groups tended to be concentrated in higher disenrollment plans. Within plans, API beneficiaries voluntarily disenrolled considerably more often than otherwise similar White beneficiaries. CONCLUSION: These findings suggest the need to address cost, information, and other factors that may create barriers to racial/ethnic minority beneficiaries' enrollment in plans with lower overall disenrollment rates.

Imputation of race/ethnicity to enable measurement of HEDIS performance by race/ethnicity.

OBJECTIVE: To improve an existing method, Medicare Bayesian Improved Surname Geocoding (MBISG) 1.0 that augments the Centers for Medicare & Medicaid Services' (CMS) administrative measure of race/ethnicity with surname and geographic data to estimate race/ethnicity. DATA SOURCES/STUDY SETTING: Data from 284 627 respondents to the 2014 Medicare CAHPS survey. STUDY DESIGN: We compared performance (cross-validated Pearson correlation of estimates and self-reported race/ethnicity) for several alternative models predicting self-reported race/ethnicity in cross-sectional observational data to assess accuracy of estimates, resulting in MBISG 2.0. MBISG 2.0 adds to MBISG 1.0 first name, demographic, and coverage predictors of race/ethnicity and uses a more flexible data aggregation framework. DATA COLLECTION/EXTRACTION METHODS: We linked survey-reported race/ethnicity to CMS administrative and US census data. PRINCIPAL FINDINGS: MBISG 2.0 removed 25-39 percent of the remaining MBISG 1.0 error for Hispanics, Whites, and Asian/Pacific Islanders (API), and 9 percent for Blacks, resulting in correlations of 0.88 to 0.95 with self-reported race/ethnicity for these groups. CONCLUSIONS: MBISG 2.0 represents a substantial improvement over MBISG 1.0 and the use of CMS administrative data on race/ethnicity alone. MBISG 2.0 is used in CMS' public reporting of Medicare Advantage contract HEDIS measures stratified by race/ethnicity for Hispanics, Whites, API, and Blacks.

Associations of CAHPS Composites With Global Ratings of the Doctor Vary by Medicare Beneficiaries' Health Status.

RESEARCH OBJECTIVE: Care coordination among health care providers is essential for high-quality care and it is strongly associated with overall ratings of doctors. Care coordination may be especially important for sicker and chronically ill patients because of the multiple providers involved in their care. This study examines whether the association of care coordination with global ratings of one's personal doctor varies by number of chronic conditions and self-rated health. STUDY DESIGN: We used nationally representative Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data to evaluate care coordination, doctor communication, getting needed care, getting care quickly, count of 6 chronic conditions (angina, cancer, chronic obstructive pulmonary disease, diabetes, heart attack, stroke), self-rated general health (5-point scale, poor to excellent, scored linearly), and interactions among them as predictors of the CAHPS global rating of personal doctor (scored 0-100 with 100 being best possible personal doctor) using linear regression models. The analytic sample included 242,871 Medicare fee-for-service and managed care beneficiaries in 2013: 56% female; 14% 18-64, 47% 65-74, 27% 75-84, and 11% 85 and older; and 48% high school education or less. RESULTS: The CAHPS composites (of care coordination, doctor communication, getting needed care, and getting care quickly) and number of chronic conditions were significantly positively associated with ratings of personal doctor (P<0.05). Care coordination and doctor communication had a stronger association with positive ratings of the personal doctor among those with worse self-rated health (P<0.001). DISCUSSION: Results were consistent with the hypothesis that patients in worse health weigh care coordination more heavily in global physician assessments than patients in better health. Emphasis on improving care coordination, especially for patients in poorer health, may improve patients' overall assessments of their providers. The study provides further evidence for the importance of care coordination experiences in the era of patient-centered care.

Speaking Up and Walking Out: Are Vulnerable Patients Less Likely to Disagree With or Change Doctors?

BACKGROUND: Disparities in clinical process-of-care and patient experiences are well documented for Medicare beneficiaries with ≥1 social risk factors. If such patients are less willing to express disagreement with their doctors or change doctors when dissatisfied, these behaviors may play a role in observed disparities. OBJECTIVE: To investigate the association between social risk factors and self-reported likelihood of disagreeing with or changing doctors if dissatisfied among the Medicare fee-for-service population. SUBJECTS: Fee-for-service beneficiaries (N=96,317) who responded to the 2014 Medicare Consumer Assessment of Healthcare Providers and Systems survey. Subgroups were defined based on age, education, income, and race/ethnicity. METHODS: Respondents reported how likely they would be to express disagreement with their doctors and change doctors if dissatisfied (1=very unlikely to 4=very likely; rescaled to 0-100 points). We fit mixed-effect linear regression models predicting these outcomes from social risk factors, controlling for health status and geographic location. RESULTS: Beneficiaries who were older, less educated, and had lower incomes were least inclined to express disagreement or change doctors (P<0.001). Compared with non-Hispanic whites, Asian/Pacific Islander (-9.5) and Hispanic (-3.6) beneficiaries said they would be less likely, and black (+2.8) beneficiaries more likely, to express disagreement. Asian/Pacific Islander (-8.7), Hispanic (-5.9), and American Indian/Alaska Native (-3.8) beneficiaries were less inclined than non-Hispanic whites to change doctors (P<0.01). DISCUSSION: Reduction in health care disparities may be achieved if doctors and advocates encourage vulnerable patients to express their concerns and perspectives and if communities and caregivers provide support for changing providers when care is poor.

Performance of the Medicare Consumer Assessment of Health Care Providers and Systems (CAHPS) Physical Functioning Items.

BACKGROUND: Physical functioning is an important health domain for adults. OBJECTIVE: Evaluate physical functioning items in Medicare beneficiaries. RESEARCH DESIGN: Survey data from the 2010 Consumer Assessment of Healthcare Providers and Systems Medicare survey. SUBJECTS: The 366,701 respondents were 58% female; 38% were 75 or older; 57% had high school education or less. MEASURES: Walking, getting in or out of chairs, bathing, dressing, toileting, and eating assessed with 3 response choices: unable to do, have difficulty, do not have difficulty. RESULTS: Pearson correlations among the 6 items ranged from 0.515 to 0.835 (coefficient α=0.92). A single factor categorical factor analytic model fit the data well (comparative fit index=0.998; root mean square error of approximation=0.083). The item with the highest percentage of respondents reporting no difficulty was eating, followed by toileting, dressing, bathing, getting in and out of a chair, and walking. Threshold parameters from an item response theory-graded response model ranged from -1.983 (between unable to do and have difficulty eating) to -0.551 (between have difficulty and no difficulty walking). Item discrimination parameters ranged from 4.632 (walking) to 8.228 (dressing). IRT-scored physical functioning scores correlated with self-rated general health (r=0.389, n=344,843, P<0.0001) mental health (r=0.296, n=351,254, P<0.0001) and number of chronic conditions (r=-0.229, n=284,507, P<0.0001). CONCLUSIONS: The physical functioning items target relatively easy activities, providing information for a minority of people in the sample with the lowest levels of physical functioning. Items representing higher levels of physical functioning are needed for the majority of the Medicare beneficiaries.