Amresh D. Hanchate

Background: As Alzheimer's disease and related dementias (ADRD) progress, many people become homebound and depend on home‐based medical care (HBMC), but differences in HBMC, telemedicine, and office visits between Traditional Medicare (TM) and Medicare Advantage (MA) plans are not well understood. Methods: We analyzed 2021–2022 Medicare claims and encounter data to categorize 2022 outpatient visits for community‐living TM and MA enrollees with ADRD as HBMC, telemedicine, or office‐based. We summarized HBMC recipient characteristics by plan type and used Poisson regression with inverse weights of propensity of plan enrollment and regional fixed effects to compare TM and MA enrollees on visit counts, usage incidence, and visit intensity by visit modality. We also examined differences by comorbidity burden, frailty, dual Medicaid eligibility, race and ethnicity, and major MA plans. Results: Out of 49,194 TM and 47,830 MA enrollees with ADRD, MA enrollees had fewer overall visits (TM = 8.89; MA = 7.97) and HBMC visits (TM = 2.09; MA = 1.37) compared to TM enrollees. Adjusted analyses showed that the number of HBMC visits was 25% lower (IRR = 0.75; 95% CI, 0.69–0.81) in MA compared to TM, arising from 19% and 7% lower user incidence and visit intensity, respectively. Office visits were 6% lower (IRR = 0.94; 95% CI, 0.91–0.96), telemedicine visits were similar (IRR = 1.02; 95% CI, 0.95–1.10), and overall visits were 10% lower (IRR = 0.90; 95% CI, 0.88–0.93) in MA relative to TM. Relative to TM, HBMC visits were lower in MA by a larger margin among non‐Hispanic Black (47%), Hispanic (67%), and dual Medicaid‐eligible (42%) MA enrollees. Within MA, HBMC visits were 27% higher (IRR = 1.27; 95% CI, 1.09–1.48) in PPO plans relative to HMO plans. Conclusions: HBMC user incidence and visit intensity were higher in TM than MA among enrollees with ADRD. The findings underscore the need for research and targeted interventions to ensure adequate and equitable access to HBMC services.

Objectives: To assess differences in health care utilization, mortality, and incidence of health conditions nearly 2 years after a fertilizer plant fire near a residential area. Design: We performed a longitudinal cohort study. Participants: Residents who lived within a 1-mile radius of the fertilizer plant (exposed cohort, N = 2546) were compared to 2 matched control cohorts based on neighborhood (N = 10 043) or participant-level (N = 10 001) characteristics. Setting: We extracted electronic health record data from January 31, 2020, to November 21, 2023, comprising the “pre” time period from January 31, 2020, to January 31, 2022, and the “post” time period from February 1, 2022, to November 21, 2023. Main Outcome Measures: Outcomes included health care utilization (number of outpatient clinic visits, ED visits, and hospitalizations in the pre- and postfire periods), mortality (measured for each participant in each cohort in the postperiod only), and incidence of health conditions (development of asthma, cancer, chronic heart disease, diabetes, migraines, nausea, and neurocognitive disorders in the postperiod). Results: Health care utilization was highest among the cohort that was exposed to the fire in pre- and postfire periods and decreased over time for all cohorts. There were no significant differences between cohorts with respect to mortality or incidence of health conditions. Conclusions: We did not identify statistically significantly differences in health outcomes among the exposed, compared to neighborhood- and participant-level matched cohorts. Policymakers and funders should have mechanisms available for rapid funding opportunities for disaster evaluation to follow cohorts and assess long-term health effects.

Introduction: As Alzheimer's disease and related dementias (ADRD) progress, many individuals become homebound and increasingly depend on home-based medical care (HBMC), such as clinician house calls. The COVID-19 pandemic spurred a rapid expansion of telemedicine under Medicare, but its impact on outpatient care by modality—HBMC, telemedicine, and office-based—among enrollees with ADRD remains unclear. Methods: Using national Medicare claims, we examined changes in primary care visits—categorized as office-based, HBMC, and telemedicine—between the pre-expansion period (March 2019–February 2020) and the late post-expansion period (March–November 2021), when telemedicine use had stabilized. Analyses were stratified by regions with low vs high HBMC provider availability. Results: Regions with high HBMC availability saw a 13.6% greater increase in HBMC visits and a 5.0% greater increase in all visits compared to low-availability regions. Both groups had similar increases in telemedicine and declines in office-based visits. HBMC growth reflected broader access, with more beneficiaries receiving HBMC post-expansion. However, gains were concentrated among non-Hispanic White enrollees, with no significant changes for non-Hispanic Black or Hispanic enrollees. Conclusion: These findings suggest that Medicare's telemedicine waivers expanded, rather than replaced, HBMC. Sustaining these policies may support aging in place for individuals with dementia, though disparities in access remain a critical concern.

Background: As more older adults become homebound, home‐based medical care (HBMC) has increased, but little is known about the HBMC workforce. This study analyzes national data on the size and structural features of HBMC providers from 2016 to 2022. Methods: We analyzed annual primary care data for all traditional Medicare enrollees, classifying visits as HBMC (private residence or assisted living facility [ALF]) or non‐HBMC (office or telemedicine). We evaluated trends in HBMC providers and visits by HBMC practice exclusivity (only‐HBMC or both HBMC and non‐HBMC), care setting (private residence, ALF), provider type (physician, nurse practitioner [NP], physician assistant [PA]), and visit volume. We assessed geographic variation in HBMC's share of primary care and payment differences between HBMC and non‐HBMC services. Results: In 2022, 16,125 of 304,326 (5%) primary care clinicians delivered 5.6 million HBMC visits, with most visits (66%) in ALFs. From 2016 to 2022, HBMC providers increased by 40% and visits by 29%. The proportion of only‐HBMC providers rose from 50.2% to 61.7%, whereas providers with volume > 1000 visits/year fell from 46.8% to 38.9%. The increase in providers was higher in private residences (49%) than ALFs (33%), though average provider volume decreased in private residences (−24%) and rose in ALFs (7%). NPs among HBMC providers increased from 42.2% to 63.0%, PAs from 6.6% to 8.2%, and physicians dropped from 51.3% to 28.9%. HBMC's share of all visits increased from 3.9% to 5.4%, driven more by ALF visits. Non‐HBMC service payments grew faster than those for HBMC services. Conclusions: Against the backdrop of an expanding HBMC workforce and rising visit volumes from 2016 to 2022, our findings highlight significant shifts in the structural composition of providers. These shifts emphasize the need for ongoing research to address their implications for access, quality, and outcomes in homebound older adults.

Depression is a well-established risk factor for impaired cognitive function, but the mechanisms underlying this relationship remain poorly understood. In this study, we utilized data from the 2017-18 Wave 1 of the Longitudinal Aging Study in India to examine the potentially causal association between depressive symptoms and cognitive performance in middle-aged and older adults using alternative estimation methods to account for observed and unobserved confounding. We also investigated the mediating roles of activities of daily living (ADL), instrumental activities of daily living (IADL), and sleep problems in the pathway linking depressive symptoms to cognitive decline. Our findings indicated significant decline in cognitive function associated with depression, particularly in the domains of language, immediate memory, and orientation. Moreover, we identified substantial mediation effects, with IADL accounting for 26.3%, ADL for 15.5%, and sleep problems for 10.8% of the relationship between depression and cognitive performance. These results suggest that interventions aimed at improving mental health in aging populations could enhance both performance in daily functioning and cognitive outcomes.

Introduction: Medicare Merit-based Incentive Payment System (MIPS), established by Centers for Medicare & Medicaid Services to transition Medicare reimbursement toward value-based care, has faced criticism for its administrative complexity and potential inequities affecting safety-net providers (SNPs). Methods: This study analyzed 5-year data (2018-2022) to evaluate the performance and financial outcomes of clinicians consistently participating in MIPS, focusing on disparities between SNPs and non-SNPs. Results: We found that safety-net specialists were 31% more likely than non–safety-net specialists to consistently receive positive payment adjustments and earned modestly higher average adjustment rates (0.35% points). However, despite this superior performance, safety-net specialists did not achieve greater cumulative financial rewards due to MIPS's percentage-based adjustment structure, which disadvantages clinicians with smaller billing volumes. Our analysis also showed that MIPS financial incentives were generally modest—ranging from $300 to $4000 over 5 years—far below the estimated $12 000 in annual administrative compliance costs per physician reported in prior research. Conclusion: To address these disparities and inefficiencies, policymakers should consider alternative models such as the American Medical Association's proposed Data-Driven Performance Payment System, which reduces administrative burden by simplifying the reporting process and ensures fairer financial rewards by uncoupling incentive payments from billing volume—thereby improving equity for safety-net clinicians.

Depression is a well-established risk factor for impaired cognitive function, but the mechanisms underlying this relationship remain poorly understood. In this study, we utilized data from the 2017-18 Wave 1 of the Longitudinal Aging Study in India to examine the potentially causal association between depressive symptoms and cognitive performance in middle-aged and older adults using alternative estimation methods to account for observed and unobserved confounding. We also investigated the mediating roles of activities of daily living (ADL), instrumental activities of daily living (IADL), and sleep problems in the pathway linking depressive symptoms to cognitive decline. Our findings indicated significant decline in cognitive function associated with depression, particularly in the domains of language, immediate memory, and orientation. Moreover, we identified substantial mediation effects, with IADL accounting for 26.3%, ADL for 15.5%, and sleep problems for 10.8% of the relationship between depression and cognitive performance. These results suggest that interventions aimed at improving mental health in aging populations could enhance both performance in daily functioning and cognitive outcomes.

Objective: To investigate the relationship between physician–hospital integration within accountable care organizations (ACOs) and inpatient care utilization and expenditure.Data Sources: The primary data were Massachusetts All‐Payer Claims Database (2009–2013).Study Setting: Fifteen provider organizations that entered a commercial ACO contract with a major private payer in Massachusetts between 2009 and 2013.Study Design: Using an instrumental variable approach, the study compared inpatient care delivery between patients of ACOs demonstrating high versus low integration. We measured physician–hospital integration within ACOs by the proportion of primary care physicians in an ACO who billed for outpatient services with a place‐of‐service code indicating employment or practice ownership by a hospital. The study sample comprised non‐elderly adults who had continuous insurance coverage and were attributed to one of the 15 ACOs. Outcomes of interest included total medical expenditure during an episode of inpatient care, length of stay (LOS) of the index hospitalization, and 30‐day readmission. An inpatient episode was defined as 30, 45, and 60 days from the admission date.Data Collection/Extraction Methods: Not applicable.Principal Findings: The study examined 33,535 admissions from patients served by the 15 ACOs. Average medical expenditure within 30 days of admission was $24,601, within 45 days was $26,447, and within 60 days was $28,043. Average LOS was 3.5 days, and 5.4% of patients were readmitted within 30 days. Physician–hospital integration was associated with a 10.6% reduction in 30‐day expenditure (95% CI, −15.1% to −5.9%). Corresponding estimates for 45 and 60 days were − 9.7% (95%CI, −14.2% to −4.9%) and − 9.6% (95%CI, −14.3% to −4.7%). Integration was associated with a 15.7% decrease in LOS (95%CI, −22.6% to −8.2%) but unrelated to 30‐day readmission rate.Conclusions: Our instrumental variable analysis shows physician–hospital integration with ACOs was associated with reduced inpatient spending and LOS, with no evidence of elevated readmission rates.

Background: The extent to which sex, racial, and ethnic groups receive advanced heart therapies equitably is unclear. We estimated the population rate of left ventricular assist device (LVAD) and heart transplant (HT) use among (non‐Hispanic) White, Hispanic, and (non‐Hispanic) Black men and women who have heart failure with reduced ejection fraction (HFrEF). Methods and Results: We used a retrospective cohort design combining counts of LVAD and HT procedures from 19 state inpatient discharge databases from 2010 to 2018 with counts of adults with HFrEF. Our primary outcome measures were the number of LVAD and HT procedures per 1000 adults with HFrEF. The main exposures were sex, race, ethnicity, and age. We used Poisson regression models to estimate procedure rates adjusted for differences in age, sex, race, and ethnicity. In 2018, the estimated population of adults aged 35 to 84 years with HFrEF was 69 736, of whom 44% were women. Among men, the LVAD rate was 45.6, and the HT rate was 26.9. Relative to men, LVAD and HT rates were 72% and 62% lower among women ( P P 0.05) or higher ( P <0.01) than among their White counterparts. Conclusions: Among adults with HFrEF, the use of LVAD and HT is lower among women and Black men. Health systems and policymakers should identify and ameliorate sources of sex and racial inequities.