Diagnosis of Behavioral Symptoms of Dementia and CNS-Active Drug Use Among Diverse Persons Living With Dementia

Approximately 90% of persons living with dementia (PLWD) experience behavioral and psychological symptoms of dementia (BPSD). Studies demonstrated high use of central nervous system (CNS) active drugs in nursing homes; one recent study documented high use among community-dwelling PLWD. Racial/ethnic disparities in BPSD diagnosis and CNS-active drug use, however, are unknown. We quantified disparities in BPSD diagnoses and CNS-active drug use using 100% Medicare Part A and B claims, 2017-2019, and Part D, 2018-2019. Beneficiaries were ages 65 and older in 2017, community-dwelling, and had a dementia diagnosis (n=801,597). We estimated models of CNS-active drug use to quantify racial/ethnic differences adjusting for confounders. Among PLWD, 66% had a BPSD diagnosis and 65% were taking a CNS-acting drug. Asians/Pacific Islanders were less likely to have a BPSD diagnosis (55%) than other groups, particularly affective diagnoses (40%). Whites were most likely to have any diagnosis (67%). Blacks were most likely to have hyperactivity diagnoses (7%). Antidepressants were most commonly used drug class (44%). Thirteen percent used an antipsychotic. Models adjusted for age, sex, comorbid conditions, dual-eligibility and BPSD diagnoses, showed non-Whites were less likely to use any CNS-active drug than Whites, but Blacks and Hispanics were slightly more likely to use antipsychotics. We found racial/ethnic differences in BPSD diagnoses and CNS-active drug use. Whether these disparities are due to differences in BPSD symptoms, health-care access or care-seeking remains an important question. Further study of disparity in outcomes associated with use will inform risk and benefit of CNS-active drugs use among PLWD.

Trends of ARNI and Other Heart Failure Medication Use in Older Adults

In 2015-2017, we identified 276,679 to 315,788 Medicare beneficiaries with HFrEF (mean age 76.6-76.7 years, 75.0-76.2% male, 82.0-83.4% Whites, and 44.8-50.9% frail). Since its approval in July 2015, ARNI use increased from 0.3% to 5.7%. ARNI uptake was lower in patients with older age (6.6% for 65-74 years vs 3.4% for ≥85 years), non-Hispanic race (7.3% for Hispanic vs 5.6-6.6% for other race), no dual eligibility (6.4% for dual eligibility vs 5.5% for no dual eligibility), frailty (5.1% for frailty vs 6.1% for non-frailty) and dementia (3.8% for dementia vs 6.1% for no dementia). Frail patients were less likely than non-frail patients to receive disease-modifying treatments, such as angiotensin-converting enzyme inhibitors (32.4% vs 38.9%), angiotensin receptor blockers (14.5% vs 17.5%), aldosterone antagonists (20.8% vs 23.4%), and beta-blockers (65.1% vs 68.3%), but more likely to receive symptomatic treatment with loop diuretics (56.4% vs 48.0%).

Trends in Acuity of Residents in Assisted Living

Assisted living serves as a substitute for nursing home residents with low care needs, especially in markets with a high proportion of dually eligible Medicare beneficiaries. This study examines trends in the acuity of residents in assisted living communities over time in comparison to nursing homes to characterize how substitution has affected the resident compositions of both settings. We also examine how trends in acuity are shaped by dual eligibility. Using Medicare claims data, we identify cross-sectional samples of beneficiaries in each setting from 2007-2017. The proportion of residents in assisted living with high care needs has increased 18% in assisted living communities compared to 8.7% in nursing homes. Acuity levels are higher among dually eligible assisted living residents compared to assisted living residents who are not dually eligible. Policy makers and administrators should examine whether assisted living is prepared to provide care for an increasingly acute population.

Predictors of Disenrollment Among Medicare Fee-for-Service Beneficiaries With Dementia

Medicare enrollment among people with Alzheimer’s Disease and Related Dementias (ADRD) has reached an all-time high with about 12% of beneficiaries having an ADRD diagnosis. The federal government has special interest in providing healthcare alternatives for Medicare beneficiaries. However, limited studies have focused on understanding disenrollment from fee-for-service, especially among those with high-needs. In this study we identified predictors of disenrollment among beneficiaries with ADRD. We used the 2017-2018 Medicare Master Beneficiary Summary File to determine enrollment, sociodemographic, clinical characteristics and healthcare utilization. We included all fee-for-service beneficiaries enrolled in 2017 who survived the first quarter of 2018. Our primary outcome was disenrollment from fee-for-service between 2017 and 2018. Regression models included age, sex, race/ethnicity, dually eligibility to Medicare and Medicaid, chronic and disabling conditions (categorized by quartiles), total health care costs including outpatient, inpatient, post-acute care and other costs (categorized by quartiles) and county fixed-effects. There were 1,797,047 beneficiaries enrolled in fee-for-service with an ADRD diagnosis. Stronger predictors of disenrollment included race/ethnicity and dual eligibility. Disenrollment rates were 7.9% (95% CI, 7.2 – 8.5) among African Americans, 6.6 (95% CI, 6.2 – 7.0) among Hispanics and 4.3 (95% CI, 4.2 – 4.3) among Whites. Duals were 1.9% (95% CI, 1.4 – 2.3) more likely to disenroll from fee-for-service to Medicare Advantage (MA). The inclusion of MA special need plans and additional benefits for those with ADRD and complex chronic conditions may be valuable for those beneficiaries with ADRD, and who may not have Medigap coverage when enrolling in fee-for-service.

Effects of Global Budget Payments on Vulnerable Medicare Subpopulations in Maryland

There is little evidence regarding population equity in alternative payment models (APMs). We aimed to determine whether one such APM, the Maryland All-Payer Model (MDAPM), had differential effects on subpopulations of vulnerable Medicare beneficiaries. We utilized Medicare fee-for-service claims for beneficiaries living in Maryland and 48 comparison hospital market areas between 2011 and 2018. We used doubly robust difference-in-difference-in-differences regression models to estimate the differential effects of MDAPM on Medicare beneficiaries by dual eligibility for Medicare and Medicaid, disability as original reason for Medicare entitlement, presence of multiple chronic conditions (MCC), race, and rural residency status. Dual, disabled, and beneficiaries with MCC had greater reductions in expenditures and utilization than their counterparts. Hospitals may have prioritized high-cost, high-need patients as they changed their care delivery practices. The percentage of hospital discharges with 14-day follow-up was significantly lower for disadvantaged subpopulations, including duals, disabled, and non-White.

Health Care Use and Outcomes in Assisted Living Communities: Race, Ethnicity, and Dual Eligibility

Assisted Living (AL) has become an important residential long-term care option in the United States, yet very little is known about the nature and quality of care received in this setting by racial/ethnic minorities or residents dually eligible for Medicare and Medicaid. Using calendar year 2018 Medicare data, we identified 255,564 fee-for-service Medicare beneficiaries age 55+ who resided in 24,108 ALs across the United States. We fit several logistic regression models with individual-level covariates and AL-level fixed effects, to examine the association between race/ethnicity and dual status with inpatient hospital admission, 30-day readmission, emergency room use, and nursing home placement. Significant variations in these measures were found both within and across ALs for racial/ethnic minority and dual residents. Our results suggest that disparities in outcomes are most significant by dual eligibility status rather than by race/ethnicity alone. These findings provide important implications for providers, policy makers, and researchers.

State Medicaid Financing and Access to Large Assisted Living Settings for Medicare–Medicaid Dual-Eligibles

Assisted living has become more widely used by dual-eligible Medicare beneficiaries as states try to rebalance their long-term services and supports away from institutional (nursing home) care. In an analysis of 2014 Medicare data for 506,193 adults who live in large (25+ beds) assisted living communities, we found wide variability among states in the share of assisted living residents who were dual-eligible, ranging from 6% in New Hampshire to over 40% in New York. This variation is strongly correlated with the Medicaid support for assisted living care: In states with a Medicaid state plan option covering services in assisted living or both a state plan and waiver, the percent of assisted living residents with dual-eligibility was more than 10 percentage points higher than in states with neither a state plan nor waiver. Findings provide a basis for understanding the role of Medicaid financing in access to assisted living for duals.