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Medicare Beneficiaries (medicare + beneficiary)
Kinds of Medicare Beneficiaries Selected AbstractsRacial and Gender Trends in the Use of Implantable Cardioverter-Defibrillators Among Medicare Beneficiaries Between 1997 and 2003CONGESTIVE HEART FAILURE, Issue 2 2009Paul S. Chan MD Differences in the use of implantable cardioverter-defibrillators (ICDs) have been reported, but the extent to which they have widened after the publication of major clinical trials supporting their use is unclear. Using data on Medicare beneficiaries, the authors determined annual age-standardized population-based utilization rates of ICDs for white men, black men, white women, and black women from 1997 to 2003. During the study period, overall use of ICDs increased most for white men (81.7,254.7 procedures per 100,000 from 1997 to 2003) and black men (38.0,151.7 procedures per 100,000), with white women (28.9,98.4 procedures per 100,000) and black women (18.2,77.3 procedures per 100,000) showing smaller increases in comparison. After adjustment with multivariable regression models, differences in utilization rates between whites and men widened compared with blacks and women between 1997 and 2003, a period when indications for ICD therapy have expanded. [source] Trends in Inpatient Treatment Intensity among Medicare Beneficiaries at the End of LifeHEALTH SERVICES RESEARCH, Issue 2 2004Amber E. Barnato Objective. Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures. Data Source. The 1985,1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. Study Design. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services. Principal Findings. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission. Conclusions. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred. [source] Changing Patterns in Medication Use with Increasing Probability of Death for Older Medicare BeneficiariesJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2010Thomas Shaffer MHS OBJECTIVES: To determine whether use of symptom relief drugs (e.g., antidepressants, anxiolytics, opioid analgesics, sleep aids) rises and use of two commonly prescribed classes of chronic medications (statins and osteoporosis drugs) falls with greater probability of death for older Medicare beneficiaries. DESIGN: Pooled cross-sectional study. SETTING: Noninstitutionalized older Medicare population in 2000 to 2005. PARTICIPANTS: Community-dwelling Medicare beneficiaries aged 65 and older (N=20,233). MEASUREMENTS: Use of medications measured according to dichotomous flags; intensity of use by annual medication fills. Annual probability of death modeled using logistic regression and stratified into seven groups with predicted probabilities of death that range from less than 5% to greater than 50%. Prevalence of use and intensity (mean prescription fills per month) were computed for each class of medication. RESULTS: For symptom relief medications, there is relatively constant use with increasing probability of death, along with greater intensity of use. For the two chronic medications, there was a monotonic decrease in use but at a relatively constant intensity. Decline in statin use ranged from 34.4% in the lowest mortality stratum to 17.6% for those in the highest (P<.001). Use of osteoporosis drugs fell from 10.4% to 6.6% over the same range (P<.001). CONCLUSION: Greater intensity of use of symptom relief medications with increasing probability of death is consistent with hypothesized use. The different profile for chronic medications suggests that the time to benefit is being considered regarding therapy initiation, which results in lower use. [source] Treatment of Dementia in Community-Dwelling and Institutionalized Medicare BeneficiariesJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2007Ann L. Gruber-Baldini PhD OBJECTIVES: To establish nationally representative estimates of the use of agents to treat Alzheimer's disease and related dementias (ADRDs) and related behavioral symptoms in Medicare beneficiaries and to describe medication use according to residential status and other patient characteristics. DESIGN: Cross-sectional prevalence study. SETTING: Community and various long-term care (LTC) settings. PARTICIPANTS: Twelve thousand six hundred ninety-seven beneficiaries from the 2002 Medicare Current Beneficiary Survey (MCBS), of whom 11,593 were community dwelling and 1,104 resided in various LTC settings. MEASUREMENTS: ADRDs were identified according to International Classification of Diseases, Ninth Revision, codes in Medicare claims and self- and proxy reports. Medication use was derived from self-reports (community) and extracts of facility medication administration records (LTC). RESULTS: In 2002, an estimated 3.4 million Medicare beneficiaries were diagnosed with ADRDs (8.1%), of whom 58.9% resided in the community (prevalence rate=5.1%) and 41.1% resided in LTC facilities (prevalence rate=57.2%). Use of antidementia drugs was similar across settings, with 24.7% of subjects with dementia in the community and 26.3% of those in LTC receiving prescriptions for donepezil, galantamine, or rivastigmine. Use of haloperidol was comparable (and low) in both settings. Use of atypical antipsychotics, especially risperidone, olanzapine, and quetiapine, was much higher in LTC residents (21.0%, 11.9%, and 7.1%, respectively) than in the community (5.1%, 4.0%, and 2.3%). CONCLUSION: The prevalence of ADRDs in LTC settings is much larger than in the community, but there is little difference in the proportions receiving antidementia drugs, although LTC residents are more likely to be treated with atypical antipsychotics (risperidone, olanzapine, and quetiapine), presumably for behavioral symptoms. [source] The Effect of Dementia on Outcomes and Process of Care for Medicare Beneficiaries Admitted with Acute Myocardial InfarctionJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2004Frank A. Sloan PhD Objectives: To determine differences in mortality after admission for acute myocardial infarction (AMI) and in use of noninvasive and invasive treatments for AMI between patients with and without dementia. Design: Retrospective chart review. Setting: Cooperative Cardiovascular Project. Patients: Medicare patients admitted for AMI (N=129,092) in 1994 and 1995. Measurements: Dementia noted on medical chart as history of dementia, Alzheimer's disease, chronic confusion, or senility. Outcome measures included mortality at 30 days and 1-year postadmission; use of aspirin, beta-blocker, angiotensin-converting enzyme (ACE) inhibitor, thrombolytic therapy, cardiac catheterization, coronary angioplasty, and cardiac bypass surgery compared by dementia status. Results: Dementia was associated with higher mortality at 30 days (relative risk (RR)=1.16, 95% confidence interval (CI)=1.09,1.22) and at 1-year postadmission (RR=1.18, 95% CI=1.13,1.23). There were few to no differences in the use of aspirin and beta-blockers between patients with and without a history of dementia. Patients with a history of dementia were less likely to receive ACE inhibitors during the stay (RR=0.89, 95% CI=0.86,0.93) or at discharge (RR=0.90, 95% CI=0.86,0.95), thrombolytic therapy (RR=0.82, 95% CI=0.74,0.90), catheterization (RR=0.51, 95% CI=0.47,0.55), coronary angioplasty (RR=0.58, 95% CI=0.51,0.66), and cardiac bypass surgery (RR=0.41, 95% CI=0.33,0.50) than patients without a history of dementia. Conclusion: The results imply that the presence of dementia had a major effect on mortality and care patterns for this condition. [source] Predictors of Health Resource Use by Disabled Older Female Medicare Beneficiaries Living in the CommunityJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2003Michael Weiner MD OBJECTIVES: To identify specific clinical factors that could best predict resource use by disabled older women. DESIGN: Cross-sectional. SETTING: Urban community in Baltimore, Maryland. PARTICIPANTS: One thousand two community-dwelling, moderately to severely disabled, female Medicare beneficiaries aged 65 and older, from the Women's Health and Aging Study I (WHAS). MEASUREMENTS: WHAS data were merged with participants' 1992,1994 Medicare claims data for the year after baseline evaluation, reflecting inpatient, outpatient, home-based, and skilled-nursing services. The independent contributions of factors hypothesized to predict health expenditures were assessed, using chi-square and regression analyses, with the logarithm of Medicare expenditures as the primary outcome. RESULTS: Demographic factors were not associated with Medicare expenditures. Factors associated with expenditures in bivariate analyses included heart disease (1.4x), chronic obstructive pulmonary disease (1.3x), diabetes mellitus (1.1x), smoking, comorbidity, and severity of disability, as well as low creatinine clearance, serum albumin, caloric expenditure, or skinfold thickness. Heart disease, diabetes mellitus, and low skinfold thickness remained significant after adjustment for other factors. CONCLUSION: Heart disease, diabetes mellitus, and low skinfold thickness are important independent predictors of 1-year Medicare expenditures by disabled older women. Many other variables that reflect disease, disability, nutrition, or personal habits have less predictive ability. Most demographic factors are not predictors of expenditures in this population. Focusing on the best predictors may facilitate more-effective risk adjustment and creation of related health policies. [source] Choice of Personal Assistance Services Providers by Medicare Beneficiaries Using a Consumer-Directed Benefit: Rural-Urban DifferencesTHE JOURNAL OF RURAL HEALTH, Issue 4 2010Hongdao Meng PhD Abstract Purpose: To examine the impact of an experimental consumer-choice voucher benefit on the selection of independent and agency personal assistance services (PAS) providers among rural and urban Medicare beneficiaries with disabilities. Methods: The Medicare Primary and Consumer-Directed Care Demonstration enrolled 1,605 Medicare beneficiaries in 19 counties in New York State, West Virginia, and Ohio. A total of 839 participants were randomly assigned to receive a voucher benefit (up to $250 per month with a 20% copayment) that could be used toward PAS provided by either independent or agency workers. A bivariate probit model was used to estimate the probabilities of choosing either type of PAS provider while controlling for potential confounders. Findings: The voucher was associated with a 32.4% (P < .01) increase in the probability of choosing agency providers and a 12.5% (P= .03) increase in the likelihood of choosing independent workers. When the analysis was stratified by rural/urban status, rural voucher recipients had 36.8% higher probability of using independent workers compared to rural controls. Urban voucher recipients had 37.1% higher probability of using agency providers compared to urban controls. Conclusions: This study provided evidence that rural and urban Medicare beneficiaries with disabilities may have very different responses to a consumer-choice PAS voucher program. Offering a consumer-choice voucher option to rural populations holds the potential to significantly improve their access to PAS. [source] The State of Diabetes Care Provided to Medicare Beneficiaries Living in Rural AmericaTHE JOURNAL OF RURAL HEALTH, Issue 4 2006Joseph P. Weingarten Jr PhD ABSTRACT:,Context: Diabetes poses a growing health burden in the United States, but much of the research to date has been at the state and local level. Purpose: To present a national profile of diabetes care provided to Medicare beneficiaries living in urban, semirural, and rural communities. Methods: Medicare beneficiaries with diabetes aged 18-75 were identified from Part A and Part B claims data from 1999 to 2001. A composite of 3 diabetes care indicators was assessed (annual hemoglobin A1c test, biennial lipid profile, and biennial eye examination). Findings: Over 77% had a hemoglobin A1c test, 74% a lipid profile, and 69% an eye examination. Patterns of care were considerably different across the urban-rural continuum at the state, Census division, and regional levels. States in the northern and eastern portions of the country had higher indicator rates for rural than for urban residents. States in the South had much lower rates for rural residents than their urban counterparts. Despite these within-state differences, across-state comparisons found that several states tended to have low indicator rates in every level of the urban-rural continuum. A common feature of these states was the relatively high concentration of nonwhite beneficiaries. For example, southern states had much higher concentrations of nonwhite beneficiaries relative to other areas in the country and demonstrated low rates in every level of the urban-rural continuum. Conclusions: Urban-rural quality of care differences may be a function not just of geography but also of the presence of a large nonwhite population. [source] Racial and Gender Trends in the Use of Implantable Cardioverter-Defibrillators Among Medicare Beneficiaries Between 1997 and 2003CONGESTIVE HEART FAILURE, Issue 2 2009Paul S. Chan MD Differences in the use of implantable cardioverter-defibrillators (ICDs) have been reported, but the extent to which they have widened after the publication of major clinical trials supporting their use is unclear. Using data on Medicare beneficiaries, the authors determined annual age-standardized population-based utilization rates of ICDs for white men, black men, white women, and black women from 1997 to 2003. During the study period, overall use of ICDs increased most for white men (81.7,254.7 procedures per 100,000 from 1997 to 2003) and black men (38.0,151.7 procedures per 100,000), with white women (28.9,98.4 procedures per 100,000) and black women (18.2,77.3 procedures per 100,000) showing smaller increases in comparison. After adjustment with multivariable regression models, differences in utilization rates between whites and men widened compared with blacks and women between 1997 and 2003, a period when indications for ICD therapy have expanded. [source] Emergency Department Utilization by Noninstitutionalized EldersACADEMIC EMERGENCY MEDICINE, Issue 3 2001Manish N. Shah MD Abstract. Objectives: To the best of the authors knowledge, no nationally representative, population-based study has characterized the proportion of elders using the emergency department (ED) and factors associated with ED use by elders. This article describes the proportion of elder Medicare beneficiaries using the ED and identifies attributes associated with elder ED users as compared with nonusers. Methods: The 1993 Medicare Current Beneficiary Survey was used, a national, population-based, cross-sectional survey of Medicare beneficiaries linked with Medicare claims data. The study population was limited to 9,784 noninstitutionalized individuals aged 66 years or older. The Andersen model of health service utilization was used, which explains variation in ED use through a combination of predisposing (demographic and social), enabling (access to care), and need (comorbidity and health status) characteristics. Results: Eighteen percent of the sample used the ED at least once during 1993. Univariate analysis showed ED users were older; were less educated and lived alone; had lower income and higher Charlson Comorbidity Index scores; and were less satisfied with their ability to access care than nonusers (p < 0.01, chi-square). Logistic regression identified older age, less education, living alone, higher comorbidity scores, worse reported health, and increased difficulties with activities of daily living as factors associated with ED use (p < 0.05). Need characteristics predicted ED use with the greatest accuracy. Conclusions: The proportion of elder ED users is slightly higher than previously reported among Medicare beneficiaries. Need (comorbidity and health status) characteristics predict ED utilization with the greatest accuracy. [source] The impact of detection and treatment on lifetime medical costs for patients with precancerous polyps and colorectal cancerHEALTH ECONOMICS, Issue 12 2009David H. Howard Abstract Understanding the costs associated with early detection of disease is important for determining the fiscal implications of government-funded screening programs. We estimate the lifetime medical costs for patients with screen-detected versus undetected polyps and early-stage colorectal cancer. Typically, cost,effectiveness studies of screening account only for the direct costs of screening and cancer care. Our estimates include costs for unrelated conditions. We applied the Kaplan,Meier Smoothing Estimator to estimate lifetime costs for beneficiaries with screen-detected polyps and cancer. Phase-specific costs and survival probabilities were calculated from the Surveillance, Epidemiology, and End Results-Medicare database for Medicare beneficiaries aged ,65. We estimate costs from the point of detection onward; therefore, our results do not include the costs associated with screening. We used a modified version of the model to estimate what lifetime costs for these patients would have been if the polyps or cancer remained undetected, based on assumptions about the ,lead time' for polyps and early-stage cancer. For younger patients, polyp removal is cost saving. Treatment of early-stage cancer is cost increasing. Copyright © 2009 John Wiley & Sons, Ltd. [source] Use of instrumental variables in the presence of heterogeneity and self-selection: an application to treatments of breast cancer patientsHEALTH ECONOMICS, Issue 11 2007Anirban Basu Abstract Instrumental variable (IV) methods are widely used in the health economics literature to adjust for hidden selection biases in observational studies when estimating treatment effects. Less attention has been paid in the applied literature to the proper use of IVs if treatment effects are heterogeneous across subjects and individuals select treatments based on expected idiosyncratic gains or losses from treatments. In this paper we compare conventional IV analysis with alternative approaches that use IVs to estimate treatment effects in models with response heterogeneity and self-selection. Instead of interpreting IV estimates as the effect of treatment at an unknown margin of patients, we identify the marginal patients and we apply the method of local IVs to estimate the average treatment effect and the effect on the treated on 5-year direct costs of breast-conserving surgery and radiation therapy compared with mastectomy in breast cancer patients. We use a sample from the Outcomes and Preferences in Older Women, Nationwide Survey which is designed to be representative of all female Medicare beneficiaries (aged 67 or older) with newly diagnosed breast cancer between 1992 and 1994. Our results reveal some of the advantages and limitations of conventional and alternative IV methods in estimating mean treatment effect parameters. Copyright © 2007 John Wiley & Sons, Ltd. [source] Health care funding levels and patient outcomes: a national studyHEALTH ECONOMICS, Issue 4 2007Margaret M. Byrne Abstract Background: Health care funding levels differ significantly across geographic regions, but there is little correlation between regional funding levels and outcomes of elderly Medicare beneficiaries. Our goal was to determine whether this relationship holds true in a non-Medicare population cared for in a large integrated health care system with a capitated budget allocation system. Methods: We explored the association between health care funding and risk-adjusted mortality in the 22 Veterans Affairs (VA) geographic Networks over a six-year time period. Allocations to Networks were adjusted for illness burden using Diagnostic Cost Groups. To test the association between funding and risk-adjusted three-year mortality, we ran logistic regressions with single-year patient cohorts, as well as hierarchical regressions on a six year longitudinal data set, clustering on VA Network. Results: A $1000 increase in funding per unit of patient illness burden was associated with a 2,8% reduction in three-year mortality in cross sectional regressions. However, in longitudinal hierarchical regressions clustering on Network, the significant effect of funding level was eliminated. Conclusions: When longitudinal data are used, the significant cross sectional effect of funding levels on mortality disappear. Thus, the factors driving differences in mortality are Network effects, although part of the Network effect may be due to past levels of funding. Our results provide a caution for cross sectional examinations of the association between regional health care funding levels and health outcomes. Copyright © 2006 John Wiley & Sons, Ltd. [source] Health status and heterogeneity of cost-sharing responsiveness: how do sick people respond to cost-sharing?HEALTH ECONOMICS, Issue 4 2003Dahlia K. Remler Abstract This paper examines whether the responsiveness of health care utilization to cost-sharing varies by health status and the implications of such heterogeneity. First, we show theoretically that if health care utilization of those in poor health is less responsive to cost sharing, this, combined with the skewness of health expenditures in health status, leads to overestimates of the effect of cost sharing. This bias is exacerbated when elasticities are generalized to populations with greater expenditure skewness. Second, we show empirically that cost-sharing responsiveness does differ by health status using data from the Medicare Current Beneficiary Survey. Medicare beneficiaries are stratified into health status groups based on activity of daily living (ADL) impairments and self-reported health status. Separately, for each of the health status groups, we estimate the effect of Medigap insurance on Part B utilization using a two-part expenditure model. We find that the change in expenditures associated with Medigap is smaller for those in poorer health. For example, when stratified using ADLs, Medigap insurance increases expenditures for ,healthy' groups by 36.4%, while the increase for the ,sick' group is 12.7%. Results are qualitatively the same for different forms of supplemental insurance and different methods of health status stratification. We develop a test to demonstrate that adjusting our results for selection bias would result in estimates of greater heterogeneity. Our results imply that a lowerbound estimate of the bias from neglecting heterogeneity is about 2,7%. Copyright © 2002 John Wiley & Sons, Ltd. [source] Evaluation of Three Algorithms to Identify Incident Breast Cancer in Medicare Claims DataHEALTH SERVICES RESEARCH, Issue 5 2007Heather T. Gold Objective. To test the validity of three published algorithms designed to identify incident breast cancer cases using recent inpatient, outpatient, and physician insurance claims data. Data. The Surveillance, Epidemiology, and End Results (SEER) registry data linked with Medicare physician, hospital, and outpatient claims data for breast cancer cases diagnosed from 1995 to 1998 and a 5 percent control sample of Medicare beneficiaries in SEER areas. Study Design. We evaluate the sensitivity and specificity of three algorithms applied to new data compared with original reported results. Algorithms use health insurance diagnosis and procedure claims codes to classify breast cancer cases, with SEER as the reference standard. We compare algorithms by age, stage, race, and SEER region, and explore via logistic regression whether adding demographic variables improves algorithm performance. Principal Findings. The sensitivity of two of three algorithms is significantly lower when applied to newer data, compared with sensitivity calculated during algorithm development (59 and 77.4 percent versus 90 and 80.2 percent, p<.00001). Sensitivity decreases as age increases, and false negative rates are higher for cases with in situ, metastatic, and unknown stage disease compared with localized or regional breast cancer. Substantial variation also exists by SEER registry. There was potential for improvement in algorithm performance when adding age, region, and race to an indicator variable for whether the algorithm determined a subject to be a breast cancer case (p<.00001). Conclusions. Differential sensitivity of the algorithms by SEER region and age likely reflects variation in practice patterns, because the algorithms rely on administrative procedure codes. Depending on the algorithm, 3,5 percent of subjects overall are misclassified in 1998. Misclassification disproportionately affects older women and those diagnosed with in situ, metastatic, or unknown-stage disease. Algorithms should be applied cautiously to insurance claims databases to assess health care utilization outside SEER-Medicare populations because of uneven misclassification of subgroups that may be understudied already. [source] Access to Health Care Services for the Disabled ElderlyHEALTH SERVICES RESEARCH, Issue 3p1 2006Donald H. Taylor Jr. Objective. To determine whether difficulty walking and the strategies persons use to compensate for this deficit influenced downstream Medicare expenditures. Data Source. Secondary data analysis of Medicare claims data (1999,2000) for age-eligible Medicare beneficiaries (N=4,997) responding to the community portion of the 1999 National Long Term Care Survey (NLTCS). Study Design. Longitudinal cohort study. Walking difficulty and compensatory strategy were measured at the 1999 NLTCS, and used to predict health care use as measured in Medicare claims data from the survey date through year-end 2000. Data Extraction. Respondents to the 1999 community NLTCS with complete information on key explanatory variables (walking difficulty and compensatory strategy) were linked with Medicare claims to define outcome variables (health care use and cost). Principal Findings. Persons who reported it was very difficult to walk had more downstream home health visits (1.1/month, p<.001), but fewer outpatient physician visits (,0.16/month, p<.001) after controlling for overall disease burden. Those using a compensatory strategy for walking also had increased home health visits/month (0.55 for equipment, 1.0 for personal assistance, p<.001 for both) but did not have significantly reduced outpatient visits. Persons reporting difficulty walking had increased downstream Medicare costs ranging from $163 to $222/month (p<.001) depending upon how difficult walking was. Less than half of the persons who used equipment to adapt to walking difficulty had their difficulty fully compensated by the use of equipment. Persons using equipment that fully compensated their difficulty used around $300/month less in Medicare-financed costs compared with those with residual difficulty. Conclusions. Difficulty walking and use of compensatory strategies are correlated with the use of Medicare-financed services. The potential impact on the Medicare program is large, given how common such limitations are among the elderly. [source] Trends in Inpatient Treatment Intensity among Medicare Beneficiaries at the End of LifeHEALTH SERVICES RESEARCH, Issue 2 2004Amber E. Barnato Objective. Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures. Data Source. The 1985,1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. Study Design. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services. Principal Findings. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission. Conclusions. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred. [source] The Costs of Decedents in the Medicare Program: Implications for Payments to Medicare+Choice PlansHEALTH SERVICES RESEARCH, Issue 1 2004Melinda Beeuwkes Buntin Objective. To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life,a group that accounts for more than one-quarter of Medicare's annual expenditures. Data Source. Medicare administrative claims for 1994 and 1995. Study Design. We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. Data Extraction Methods. The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. Principal Findings. Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. Conclusions. More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries. [source] Medical Expenditures during the Last Year of Life: Findings from the 1992,1996 Medicare Current Beneficiary SurveyHEALTH SERVICES RESEARCH, Issue 6 2002Donald R Hoover Objective. To compare medical expenditures for the elderly (65 years old) over the last year of life with those for nonterminal years. Data Source. From the 1992,1996 Medicare Current Beneficiary Survey (MCBS) data from about ten thousand elderly persons each year. Study Design. Medical expenditures for the last year of life and nonterminal years by source of payment and type of care were estimated using robust covariance linear model approaches applied to MCBS data. Data Collection. The MCBS is a panel survey of a complex weighted multilevel random sample of Medicare beneficiaries. A structured questionnaire is administered at four-month intervals to collect all medical costs by payer and service. Medicare costs are validated by claims records. Principal Findings. From 1992 to 1996, mean annual medical expenditures (1996 dollars) for persons aged 65 and older were $37,581 during the last year of life versus $7,365 for nonterminal years. Mean total last-year-of-life expenditures did not differ greatly by age at death. However, non-Medicare last-year-of-life expenditures were higher and Medicare last-year-of-life expenditures were lower for those dying at older ages. Last-year-of-life expenses constituted 22 percent of all medical, 26 percent of Medicare, 18 percent of all non-Medicare expenditures, and 25 percent of Medicaid expenditures. Conclusions. While health services delivered near the end of life will continue to consume large portions of medical dollars, the portion paid by non-Medicare sources will likely rise as the population ages. Policies promoting improved allocation of resources for end-of-life care may not affect non-Medicare expenditures, which disproportionately support chronic and custodial care. [source] Early life risk factors in cancer: The relation of birth weight to adult obesityINTERNATIONAL JOURNAL OF CANCER, Issue 6 2003Nicole M. Leong Abstract The intrauterine environment appears to play a role in the development of adult diseases, including several prominent cancers. Our study aims to characterize the relationship between birth weight, a measure of the intrauterine environment, and adult obesity. A population-based sample of women aged 50,79, living in the states of Massachusetts, New Hampshire or Wisconsin, were randomly selected from lists of licensed drivers and Medicare beneficiaries to participate as controls in a case-control study of breast cancer. Information on birth weight, adult height and adult weight were collected through structured telephone interviews from 1992,1995. Our analysis was based on 1,850 interviews. A U-shaped relationship between birth weight and adult BMI was observed. Median adult BMI for the birth weight categories (in kilograms) <2.3, 2.3<2.5, 2.5<3.2, 3.2<3.9, 3.9<4.5 and ,4.5 were 26.6, 24.4, 25.1, 25.5, 25.4 and 26.6 kg/m respectively. Compared to women 2.5<3.2 kg at birth, women in highest birth weight category (,4.5 kg) had an odds ratio of 1.99 (95% CI 1.13,3.48) of being obese (,30 kg/m2) as adults. The odds ratio for women in the <2.3 kg birth weight category was 1.67 (95% CI 1.01,2.76). These data suggest that both low and high birth weights are associated with higher adult BMI and support the hypothesis that fetal experience may influence adult obesity with potential consequences for risk of several major cancers. © 2002 Wiley-Liss, Inc. [source] Changing Patterns in Medication Use with Increasing Probability of Death for Older Medicare BeneficiariesJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2010Thomas Shaffer MHS OBJECTIVES: To determine whether use of symptom relief drugs (e.g., antidepressants, anxiolytics, opioid analgesics, sleep aids) rises and use of two commonly prescribed classes of chronic medications (statins and osteoporosis drugs) falls with greater probability of death for older Medicare beneficiaries. DESIGN: Pooled cross-sectional study. SETTING: Noninstitutionalized older Medicare population in 2000 to 2005. PARTICIPANTS: Community-dwelling Medicare beneficiaries aged 65 and older (N=20,233). MEASUREMENTS: Use of medications measured according to dichotomous flags; intensity of use by annual medication fills. Annual probability of death modeled using logistic regression and stratified into seven groups with predicted probabilities of death that range from less than 5% to greater than 50%. Prevalence of use and intensity (mean prescription fills per month) were computed for each class of medication. RESULTS: For symptom relief medications, there is relatively constant use with increasing probability of death, along with greater intensity of use. For the two chronic medications, there was a monotonic decrease in use but at a relatively constant intensity. Decline in statin use ranged from 34.4% in the lowest mortality stratum to 17.6% for those in the highest (P<.001). Use of osteoporosis drugs fell from 10.4% to 6.6% over the same range (P<.001). CONCLUSION: Greater intensity of use of symptom relief medications with increasing probability of death is consistent with hypothesized use. The different profile for chronic medications suggests that the time to benefit is being considered regarding therapy initiation, which results in lower use. [source] Psychometric Properties of the Activities-Specific Balance Confidence Scale and the Survey of Activities and Fear of Falling in Older WomenJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 2 2008Kristine M.C. Talley MS OBJECTIVES: To compare the psychometric properties of the Activities-specific Balance Confidence Scale (ABC) and the Survey of Activities and Fear of Falling in the Elderly (SAFE). DESIGN: Secondary analysis using baseline and 12-week data from a randomized, controlled trial on fall prevention. SETTING: Upper Midwest metropolitan area with assessments conducted in participants' homes. PARTICIPANTS: Population-based sample of 272 noninstitutionalized female Medicare beneficiaries aged 70 and older at risk of falling. MEASUREMENTS: Participants self-administered the ABC, SAFE, Geriatric Depression Scale, and Medical Outcomes Study 36-item Short Form Survey. During a home visit, a nurse practitioner administered the Berg Balance Test and Timed Up and Go, measured gait speed, and asked about falls and chronic illnesses. RESULTS: Baseline internal consistency measured using Cronbach alpha was 0.95 for the ABC and 0.82 for the SAFE. Baseline concurrent validity between the ABC and SAFE measured using a correlation coefficient was ,0.65 (P<.001). ABC and SAFE scores were significantly correlated at baseline with physical performance tests and self-reported health status. The ABC had stronger baseline correlations than the SAFE with most measures. Neither instrument demonstrated responsiveness to change at 12 weeks. CONCLUSION: The ABC and SAFE demonstrated strong internal-consistency reliability and validity when self-administered. The ABC had stronger associations with physical functioning and may be more appropriate for studies focused on improving physical function. Both instruments demonstrated ceiling effects, which may explain the lack of responsiveness to change in relatively nonfrail older women. Instruments sensitive to measuring lower levels of fear of falling are needed to capture the full range of this phenomenon in this population. [source] Treatment of Dementia in Community-Dwelling and Institutionalized Medicare BeneficiariesJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 10 2007Ann L. Gruber-Baldini PhD OBJECTIVES: To establish nationally representative estimates of the use of agents to treat Alzheimer's disease and related dementias (ADRDs) and related behavioral symptoms in Medicare beneficiaries and to describe medication use according to residential status and other patient characteristics. DESIGN: Cross-sectional prevalence study. SETTING: Community and various long-term care (LTC) settings. PARTICIPANTS: Twelve thousand six hundred ninety-seven beneficiaries from the 2002 Medicare Current Beneficiary Survey (MCBS), of whom 11,593 were community dwelling and 1,104 resided in various LTC settings. MEASUREMENTS: ADRDs were identified according to International Classification of Diseases, Ninth Revision, codes in Medicare claims and self- and proxy reports. Medication use was derived from self-reports (community) and extracts of facility medication administration records (LTC). RESULTS: In 2002, an estimated 3.4 million Medicare beneficiaries were diagnosed with ADRDs (8.1%), of whom 58.9% resided in the community (prevalence rate=5.1%) and 41.1% resided in LTC facilities (prevalence rate=57.2%). Use of antidementia drugs was similar across settings, with 24.7% of subjects with dementia in the community and 26.3% of those in LTC receiving prescriptions for donepezil, galantamine, or rivastigmine. Use of haloperidol was comparable (and low) in both settings. Use of atypical antipsychotics, especially risperidone, olanzapine, and quetiapine, was much higher in LTC residents (21.0%, 11.9%, and 7.1%, respectively) than in the community (5.1%, 4.0%, and 2.3%). CONCLUSION: The prevalence of ADRDs in LTC settings is much larger than in the community, but there is little difference in the proportions receiving antidementia drugs, although LTC residents are more likely to be treated with atypical antipsychotics (risperidone, olanzapine, and quetiapine), presumably for behavioral symptoms. [source] Setting Eligibility Criteria for a Care-Coordination BenefitJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 12 2005Christine T. Cigolle MD Objectives: To examine different clinically relevant eligibility criteria sets to determine how they differ in numbers and characteristics of individuals served. Design: Cross-sectional analysis of the 2000 wave of the Health and Retirement Study (HRS), a nationally representative longitudinal health interview survey of adults aged 50 and older. Setting: Population-based cohort of community-dwelling older adults, subset of an ongoing longitudinal health interview survey. Participants: Adults aged 65 and older who were respondents in the 2000 wave of the HRS (n=10,640, representing approximately 33.6 million Medicare beneficiaries). Measurements: Three clinical criteria sets were examined that included different combinations of medical conditions, cognitive impairment, and activity of daily living/instrumental activity of daily living (ADL/IADL) dependency. Results: A small portion of Medicare beneficiaries (1.3,5.8%) would be eligible for care coordination, depending on the criteria set chosen. A criteria set recently proposed by Congress (at least four severe complex medical conditions and one ADL or IADL dependency) would apply to 427,000 adults aged 65 and older in the United States. Criteria emphasizing cognitive impairment would serve an older population. Conclusion: Several criteria sets for a Medicare care-coordination benefit are clinically reasonable, but different definitions of eligibility would serve different numbers and population groups of older adults. [source] Evaluation of Nationally Mandated Drug Use Reviews to Improve Patient Safety in Nursing Homes: A Natural ExperimentJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 6 2005Becky Briesacher PhD Objectives: To test whether nationally required drug use reviews reduce exposure to inappropriate medications in nursing homes. Design: Quasi-experimental, longitudinal study. Setting: Data source is the 1997,2000 Medicare Current Beneficiary Survey, a nationally representative survey of Medicare beneficiaries. Participants: Nationally representative population sample of 8 million nursing home (NH) residents (unweighted n=2,242) and a comparative group of 2 million assisted living facility (ALF) residents (unweighted n=664). Measurements: Prevalence and incident use of 38 potentially inappropriate medications compared before and after the policy: 32 restricted for all NH residents and six for residents with certain conditions. Inappropriate medications were stratified by potential for legitimate exceptions: always avoid, rarely appropriate, or some acceptable indications. Results: In July 1999, the Centers for Medicare and Medicaid Services (CMS) mandated expansions to the drug use review policy for nursing home certification. Using explicit criteria, surveyors and consultant pharmacists must evaluate resident records for potentially inappropriate medication exposures and related adverse drug reactions. Nursing homes in noncompliance may receive citations for deficient care. Before the CMS policy, 28.8% (95% confidence interval (CI)=27.3,30.3) of Medicare beneficiaries in NHs and 22.4% (95% CI=19.8,25.0) in ALFs received potentially inappropriate medications. Nearly all prepolicy use came from medications with some acceptable indications: 23.4% in NHs (95% CI=20.4,26.4) and 18.0% in ALFs (95% CI=15.6,20.4). After the policy, exposures in NHs declined to 25.6% (95% CI=24.1,27.1, P<.05), but similar declines occurred in ALFs (19.0%, 95% CI=16.7,21.3, nonsignificant). Postpolicy use of inappropriate medications with exempted indications remained high, and more than half was incident use: 20.6% of NH residents (95% CI=19.0,22.0) and 15.6% of ALF residents (95% CI=15.2,15.7). Use of drugs that are restricted with certain diseases increased 33% in NHs between 1997 and 2000 (from 9.3% to 13.2%; P<.05). Multivariate results detected no postpolicy differences in inappropriate drug use between long-term care facilities with mandatory drug use reviews and those without. Conclusion: Some postpolicy declines were noted in NH use of potentially inappropriate medications, but the decrease was uneven and could not be attributed to the national drug use reviews. This study is the first evaluation of the CMS policy, and it highlights the unclear effectiveness of drug use reviews to improve patient safety in NHs even though state and federal agencies have widely adopted this strategy. [source] Do Rural Elders Have Limited Access to Medicare Hospice Services?JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2004Beth A. Virnig PhD Objectives:, To examine whether there are urban-rural differences in use of the Medicare hospice benefit before death and whether those differences suggest that there is a problem with access to hospice care for rural Medicare beneficiaries. Design:, Observational study using 100% of Medicare enrollment, hospice, and hospital claims data. Setting:, Inpatient hospitals and hospices. Participants:, Persons aged 65 and older in the Medicare program who died in 1999. Measurements:, Rates of hospice use before death and in-hospital death rates were calculated. Results:, In 1999, there were 1.76 million deaths of Medicare beneficiaries aged 65 and older. Hospice services were used by 365,700 of these beneficiaries. Rates of hospice care before death were negatively associated with degree of rurality. The lowest rate of hospice use, 15.2% of deaths, was seen in rural areas not adjacent to an urban area. The highest rate of use, 22.2% of deaths, was seen in urban areas. Rural areas adjacent to urban areas had an intermediate level of hospice use (17.0% of deaths). Hospices based in rural areas had a smaller number of elderly patients each year than hospices based in urban areas (P<.001) and were more likely to have very low volumes (average daily census of three patients or less). Conclusion:, The consistently lower use of Medicare hospice services before death and smaller sizes of rural hospices suggest that the combination of Medicare hospice payment policies and hospice volumes are problematic for rural hospices. Adjusting Medicare payment policies might be a critical step to assure availability of hospice services forterminally ill beneficiaries regardless of where they live. [source] Income-Related Differences in the Use of Evidence-Based Therapies in Older Persons with Diabetes Mellitus in For-Profit Managed CareJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2003Arleen F. Brown MD OBJECTIVES: To determine whether income influences evidence-based medication use by older persons with diabetes mellitus in managed care who have the same prescription drug benefit. DESIGN: Observational cohort design with telephone interviews and clinical examinations. SETTING: Managed care provider groups that contract with one large network-model health plan in Los Angeles County. PARTICIPANTS: A random sample of community-dwelling Medicare beneficiaries with diabetes mellitus aged 65 and older covered by the same pharmacy benefit. MEASUREMENTS: Patients reported their sociodemographic and clinical characteristics. Annual household income (,$20,000 or <$20,000) was the primary predictor. The outcome variable was use of evidence-based therapies determined by a review of all current medications brought to the clinical examination. The medications studied included use of any cholesterol-lowering medications, use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) for cholesterol lowering, aspirin for primary and secondary prevention of cardiovascular disease, and angiotensin-converting enzyme (ACE) inhibitors in those with diabetic nephropathy. The influence of income on evidence-based medication use was adjusted for other patient characteristics. RESULTS: The cohort consisted of 301 persons with diabetes mellitus, of whom 53% had annual household income under $20,000. In unadjusted analyses, there were lower rates of use of all evidence-based therapies and lower rates of statin use for persons with annual income under $20,000 than for higher-income persons. In multivariate models, statin use was observed in 57% of higher-income versus 30% of lower-income respondents with a history of hyperlipidemia (P = .01) and 66% of higher-income versus 29% of lower-income respondents with a history of myocardial infarction (P = .03). There were no differences by income in the rates of aspirin or ACE inhibitor use. CONCLUSION: Among these Medicare managed care beneficiaries with diabetes mellitus, all of whom had the same pharmacy benefit, there were low rates of use of evidence-based therapies overall and substantially lower use of statins by poorer persons. [source] Predictors of Health Resource Use by Disabled Older Female Medicare Beneficiaries Living in the CommunityJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 3 2003Michael Weiner MD OBJECTIVES: To identify specific clinical factors that could best predict resource use by disabled older women. DESIGN: Cross-sectional. SETTING: Urban community in Baltimore, Maryland. PARTICIPANTS: One thousand two community-dwelling, moderately to severely disabled, female Medicare beneficiaries aged 65 and older, from the Women's Health and Aging Study I (WHAS). MEASUREMENTS: WHAS data were merged with participants' 1992,1994 Medicare claims data for the year after baseline evaluation, reflecting inpatient, outpatient, home-based, and skilled-nursing services. The independent contributions of factors hypothesized to predict health expenditures were assessed, using chi-square and regression analyses, with the logarithm of Medicare expenditures as the primary outcome. RESULTS: Demographic factors were not associated with Medicare expenditures. Factors associated with expenditures in bivariate analyses included heart disease (1.4x), chronic obstructive pulmonary disease (1.3x), diabetes mellitus (1.1x), smoking, comorbidity, and severity of disability, as well as low creatinine clearance, serum albumin, caloric expenditure, or skinfold thickness. Heart disease, diabetes mellitus, and low skinfold thickness remained significant after adjustment for other factors. CONCLUSION: Heart disease, diabetes mellitus, and low skinfold thickness are important independent predictors of 1-year Medicare expenditures by disabled older women. Many other variables that reflect disease, disability, nutrition, or personal habits have less predictive ability. Most demographic factors are not predictors of expenditures in this population. Focusing on the best predictors may facilitate more-effective risk adjustment and creation of related health policies. [source] Quality of Care of Nursing Home Residents Hospitalized With Heart FailureJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 11 2002Ali Ahmed MD, FACP OBJECTIVES: To determine whether the quality of heart failure (HF) care of hospitalized nursing home (NH) residents is different from that of patients admitted from other locations. DESIGN: Retrospective chart review. SETTING: Nursing home residents discharged from hospitals. PARTICIPANTS: Medicare beneficiaries aged 65 and older. MEASUREMENTS: Subjects were discharged with a primary discharge diagnosis of HF in Alabama in 1994. They were categorized as having been admitted from a NH or other locations. Bivariate logistic regression analysis was used to estimate crude odds ratios (ORs) and 95% confidence intervals (CIs) for left ventricular function (LVF) evaluation and angiotensin-converting enzyme (ACE) inhibitor use for NH residents relative to nonresidents. Multivariate generalized linear models were developed to determine independence of associations. RESULTS: Subjects (N = 1,067 years) had a mean age ± standard deviation of 79 ± 7.4, 60% were female, and 18% were African Americans. Fewer NH residents (n = 95) received LVF evaluation (39% vs 60%, P < .001) and ACE inhibitors (50% vs 72%, P = .111). NH residents had lower odds for LVF evaluation (OR = 0.42, 95% CI = 0.27,0.64). The odds for ACE inhibitor use, although of similar magnitude, did not reach statistical significance (OR = 0.40, 95% CI = 0.12,1.28). After adjustment of patient and care characteristics, admission from a NH was significantly associated with lower LVF evaluation (adjusted OR = 0.64, 95% CI = 0.49,0.82) but not with ACE inhibitor use (adjusted OR = 0.59, 95% CI = 0.16,2.14). CONCLUSIONS: Quality of HF care received by hospitalized NH residents was lower than that received by others. Further studies are needed to determine reasons for the lack of appropriate evaluation and treatment of NH patients with HF who are admitted to hospitals. [source] Prescription Drug Costs for Dually Eligible People in a Medicaid Home- and Community-Based Services ProgramJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2002Victoria L. Phillips Dphil This study examined the prescription drug costs of Medicare beneficiaries participating in a Medicaid home- and community-based services (HCBS) program and discussed possible implications of providing a prescription drug benefit under Medicare. The study examined Medicaid pharmaceutical claims data using two random samples (n = 766) of dually eligible Medicare beneficiaries in a HCBS program from four regions in Georgia. The average total monthly Medicaid prescription drug expenditure was determined. Annual prescription expenditures for this group averaged more than $1,500 per person. Prescription drugs intended for the treatment of cancer and circulatory disorders combined to account for 61% of total program drug expenditures. Multivariate analysis found that drug expenditures were higher for those who died during the observation period, the young-old, Caucasians, and those who self-selected into the program. Higher drug expenditures for the self-selected group, even after frailty adjustments, suggest the presence of adverse selection. Medicare prescription drug benefit proposals that rely on voluntary enrollment may also experience adverse selection from frail, low-income beneficiaries. [source] | ||||||||||