OBJECTIVES:In January 2020, the Centers for Medicare & Medicaid Services implemented the Patient-Driven Groupings Model (PDGM), the most substantial revision to Medicare's home health (HH) prospective payment system since its introduction in 2000. PDGM shortened the payment period from 60 to 30 days and eliminated therapy visit thresholds from payment calculations. Because Medicare's HH payment policies have historically shaped patterns of service use, payment changes under PDGM were expected to influence service intensity and episode length. The aim of this study is to examine whether PDGM influences HH utilization among Medicare beneficiaries, particularly those with Alzheimer's disease and related dementias (ADRD). DESIGN:Cross-sectional cohort study. SETTINGS AND PARTICIPANTS:A 20% random sample of traditional Medicare beneficiaries who used HH services in 2019 (pre-PDGM) and 2021 (post-PDGM). METHODS:We compared total HH visits and length of stay (LOS) during a standardized 60-day episode in the pre- and post-PDGM periods. Generalized linear models were used to estimate changes in visit volume and LOS following PDGM implementation, comparing beneficiaries with ADRD and without ADRD. RESULTS:Beneficiaries with ADRD experienced a steeper decline in total visits (from 22.4 to 17.9) compared with those without ADRD (from 18.2 to 15.4), driven by reductions in therapy visits, which fell from 12.9 to 9.9 among beneficiaries with ADRD and from 9.8 to 8.3 among those without ADRD. The average LOS within a 60-day episode also decreased after PDGM implementation. Adjusting for patient-level characteristics, beneficiaries with ADRD in the post-PDGM period received 2.04 fewer total visits, including 1.4 fewer therapy visits, than those without ADRD. These patterns differed by the severity of ADRD. CONCLUSIONS AND IMPLICATIONS:PDGM's reimbursement changes and the shortening of the payment period may disproportionately affect Medicare beneficiaries with ADRD, underscoring the need to assess the implications for patient outcomes and future refinements of the payment policy.

Cognitive ability can impact older adults’ economic well-being. This study investigated the relationship between cognitive decline and switching financial responsibility within the household and its impacts on household wealth using the Health and Retirement Study (HRS) from 2006-2020. Cognitive decline and financial responsibility were measured for each HRS respondent aged 50 years or older. A decrease in objective test scores measured cognitive decline. Two primary outcomes included switching financial responsibility within the household and financial wealth. The analysis focused on the extent to which individuals’ cognitive decline was related to switching the financial responsibility within the household and if there was any impact on changes in financial wealth due to cognitive decline. Between two consecutive waves from 2006 to 2020, approximately 35% of respondents experienced cognitive decline, 35% improved, and 15% received the same cognitive score. Thirty-five percent did not switch to the role of financial responsibility within the household. Compared to those with no change in cognitive scores, those who experienced improvement or decreased scores were 26% and 27% more likely not to switch the financial responsibility role within the household. Further analysis examined if self-reported memory changes versus the objective value of cognitive scores influenced the switching decision within the household and its impacts on household wealth over time. This study provides an expanded profile of the variation in individual characteristics of a financial respondent within the household that leads to the switching decision of the financial responsibility role and its impact on household wealth.

OBJECTIVES:Historically, fee-for-service Medicare reimbursed long-term care hospital (LTCH) stays as a lump-sum payment, which was substantially reduced for discharges before the diagnosis-specific short-stay outlier (SSO) threshold day, leading to large spikes in discharges on the threshold day. The objective of this study was to examine if LTCHs similarly time discharge at the SSO threshold for blended site-neutral payment cases compared with standard payment cases. DESIGN:Cross sectional. SETTING AND PARTICIPANTS:Cohort of Medicare beneficiaries. METHODS:We used the national 100% LTCH Medicare Provider Analysis and Review Limited Data Set for fiscal year 2017 and exploited differences in prior ICU days using a multinomial model adjusting for patient demographics and case-mix. We only included stays where payment status was solely determined by prior ICU days. Our primary outcome was the discharge on the SSO threshold day. The exposure was an indicator variable for ≥3 intensive care unit days in the preceding acute care hospital, where yes equated to standard payment and no was a blended site-neutral case. RESULTS:Among 10,910 LTCH discharges (48% of cases were aged 65-74 years, 52% were female, 25% were non-white, 24% were blended site-neutral cases), we found that despite an approximately 50% reduction in payment increase, the spike in the adjusted probability of discharge on the SSO threshold day vs the day before was similar for blended site-neutral (20% vs 2%) and standard payment cases (16% vs 1%), with an adjusted difference of -3% (95% CI, -5% to 2%). CONCLUSIONS AND IMPLICATIONS:Unwarranted spikes in discharge on the SSO threshold persisted despite a 50% reduction in the payment increase, a crucial insight for policymakers and payers who seek to avoid incentives to strategically time discharges. LTCH stays should be reimbursed without meaningful payment increases based on length of stay thresholds.

With Alzheimer’s Disease and Related Dementia (ADRD) increasing in the U.S., more research is needed to deliver patient-centered care. However, recruiting people with ADRD is challenging—this pilot study aimed to test the feasibility of collecting self-reported health data from people with ADRD. The primary data collection site was a geriatric clinic in eastern North Carolina. Potential patients were identified based on dementia diagnoses from the electronic medical record system (EPIC). After the clinic visits with the healthcare providers, we consented to those with “mild” or “moderate” dementia using a short portable mental status questionnaire. Participants self-reported (in person or over the phone) survey questions focused on their health and well-being. Thirty-five patients with ADRD consented to the study, and 25 participants completed the survey (>70% completion rate). The sample average age was 71; 62% were female, 42% were White, 56% were African American, and 54% had limitations in at least one daily activity. Participants were satisfied with their life circumstances, with an average score of 4.5 (range 0-5). Qualitative interviews indicated the need for improvements in dementia care, including better person-centered care and resources. None expressed difficulty with the survey completion. Although recruiting people with ADRD for healthcare research is challenging, it can be done. Partnering with healthcare providers and community support groups was an effective recruitment strategy. Our results indicate that community-dwelling individuals with ADRD can complete the surveys to report their health and well-being. Self-reporting was feasible and should be used in research to design person-centered care.

With Alzheimer’s Disease and Related Dementia (ADRD) increasing in the U.S., more research is needed to deliver patient-centered care. However, recruiting people with ADRD is challenging. This study examines what matters to individuals living with dementia in their community through the conceptual lens of person-centered care. We conducted seven qualitative interviews with individuals who have early or mid-stage dementia and live in the community. Two researchers used an inductive line-by-line approach to perform thematic data analysis independently and then as a team. The analysis revealed one overarching theme with four sub-themes. The overarching theme was holistic person-centeredness in dementia care. The four sub-themes were: (1) understanding the interplay between disease and daily-life activities; (2) participating in meaningful activities based on one’s preferences; (3) incongruence between the person with dementia’s preferences, needs, and the care received from healthcare providers; and (4) concerns of lost income due to job loss, burdening the family, and lack of comprehensive dementia care supports. There is a clear incongruence between individual preferences and needs and a demand to operationalize person-centeredness in dementia care, including the healthcare provider’s role. This group of participants wants the “incongruence” resolved to improve person-centered care. Healthcare providers should focus on encouraging individuals with dementia to participate in meaningful activities in daily routines. As a start to person-centeredness in care delivery, healthcare providers need to know and share resources based on their patients’ needs and preferences for care.

Enrollment in Medicare Advantage (MA) plans surpassed fee-for-service (FFS) Medicare beneficiaries in 2024. Still, little is known about how effectively these private plans impact Medicare beneficiaries' health and quality of life outcomes. The current study aimed to examine the associations of MA plans' characteristics with beneficiaries' health-related quality of life (EQ-5D) physical and mental health summary scores (PCS, MCS) using the Medicare Health Outcomes Survey (2015-2017). The study used two cross-sectional samples (2016 and 2018) and one repeated sample with baseline (2015) and follow-up (2017) data. I used propensity score matching analysis (PSM) and the instrumental variable approach to address the selection of MA plans. Findings suggest that PPO (Preferred Provider Organization) enrollment was significantly associated with higher EQ-5D, PCS, and MCS scores than HMO (Health Maintenance Organization) plans. Results from linear models with individual and time-fixed effects suggest that beneficiaries enrolled in PPO plans experienced an improvement in all three outcomes from baseline to follow-up compared to HMO plans. Other significant plan-level characteristics were plan enrollment, ownership status, and duration. Assessing health and quality-of-life outcomes is important for a better understanding how MA plans directly impact population health, the core of the value-based care model.

Importance Sex differences may contribute to disparities in dementia outcomes. Objective To understand the association between sex and mortality and health care services use after dementia diagnosis. Design, Setting, and Participants This nationwide cohort study used Medicare enrollment data and took place from 2014 to 2021 with up to 8 years of follow-up. Analysis was performed from April 2024 to April 2025. This study included 5 721 711 patients 65 years or older with International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes for dementia with at least 1 year of prior fee-for-service Medicare enrollment. Exposures Sex, determined from Medicare enrollment data, derived from Social Security Administration records. Main Outcomes and Measures The primary outcome was hazard of all-cause mortality, estimated with Cox proportional hazard regression. Secondary outcomes included hazards of use of common health care services, such as all-cause hospitalizations, skilled nursing facility stays, receipt of neuroimaging services, and physical/occupational therapy. Results A total of 5 721 711 patients (3 302 579 female and 2 419 132 male) with incident dementia between 2014 and 2021 were included in the study. Female patients had lower crude 1-year mortality rates (21.8% vs 27.2% for male patients; P < .001) and lower rates of all-cause hospitalizations (46.9% vs 50.5%; P < .001). The unadjusted hazard of death associated with male sex was 1.30 (95% CI, 1.29-1.31; P < .001). After adjustment for age, race and ethnicity, Medicaid dual eligibility, medical comorbidity burden, and access to health care resources, the association was modestly attenuated (adjusted hazard ratio, 1.24; 95% CI, 1.23-1.26; P < .001). Similarly, the unadjusted hazard ratio of all-cause hospitalization associated with male sex was 1.13 (95% CI, 1.12-1.14; P < .001); the adjusted hazard ratio was 1.08 (95% CI, 1.08-1.09; P < .001). Male patients also had increased hazards of hospice stay, neuroimaging services, and hospitalization for neurodegenerative disease diagnosis or behavioral disturbance. Conclusions and Relevance In this study, male patients with dementia had higher mortality rates and higher use of many health care services, especially hospital stays, than comparable female patients. Strategies to slow mortality and decrease health care use among male patients with dementia may be particularly impactful in limiting the burden of dementia. Given higher incidence of dementia among women, a focus on efforts to prevent dementia is necessary to achieve population-level health equity in dementia-attributable mortality by sex.

Abstract This study examines the difference in functional outcomes among Traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries with Alzheimer’s disease and related dementias (ADRD) during a home health admission, which is unknown. This cohort study used data from the 2019 Outcome and Assessment Information Set (OASIS) and Medicare claims (Home Health (HH) and inpatient), enrollment, and Chronic Condition Warehouse (CCW) files from the CMS. Functional outcome was measured as a change in the composite ADL score (grooming, bathing, toileting, dressing, walking, transferring, ambulation, and hygiene) from HH admission to discharge. A binary logistic model with an outcome variable (1/0: if the composite score was ≤0 (improvement or static) at discharge (1), and 0 if score >0 (decline) from HH admission to discharge) was estimated. The independent predictor was a binary indicator of MA enrollment (if enrolled ≥1 month in 2019). The ADRD cohort was identified based on CCW criteria and ICD-10 codes from inpatient and HH claims. The analysis included 81,735 Medicare beneficiaries; 30.5% had MA, and 69.5% had TM. There was no difference in the number of HH visits between TM and MA enrollees (2.14 vs. 2.13; P=0.39). Adjusting for patients’ demographics, total number of diagnoses, and availability of caregiving support, MA enrollees were 26% less likely to report improvement or maintenance of ADL composite score (95% CI: 0.71-0.77) than TM. A less favorable outcome for MA enrollees highlights the importance of addressing the inefficient use of home health services among people with ADRD in MA.

Informal or family caregivers (ICGs) are unpaid individuals who assist those with various diagnoses or conditions with their health and/or living-related needs. In 2020, there were an estimated 53 million individuals in the United States who provided informal care, which research indicates can negatively impact physiological and psychological health. Music therapy is a promising nonpharmacological intervention for psychosocial needs, including many that ICGs experience. The purpose of this study was to pilot a single, virtually delivered, music-based wellness workshop to examine feasibility and acceptability amongst ICGs of adults over 50. Additionally, the study aimed to establish the appropriateness of the measurement tools in addressing the research questions. Results of the study (N = 24) revealed a significant reduction in perceived stress score from pre to the post intervention t(23) = 5.71, p < .001. Slight positive increases were also observed from pre- to two weeks post intervention for wellbeing (14.75 vs. 14.79) and quality of life (6.00 vs. 6.08) measures. Additionally, 93.1% of participants completed the study from pre to two-week post-intervention, indicating a high feasibility of the intervention design. Themes emerged related to perceived value of the intervention and resource provided, including positive perception of music and mindfulness techniques along with themes related to difficulty with delivery and future needs of ICGs.

Abstract With growing demands for better and cost-effective care delivery by Medicare Advantage (MA) plans, comparison of self-reported health outcomes is more important because those outcomes capture patients’ experiences and perspectives. The purpose of the study is to examine the characteristics of MA plans on Medicare beneficiaries’ physical and mental health status. Methods: I used the Medicare Health Outcomes (HOS) survey, a random sample of Medicare beneficiaries surveyed from each MA plan with a minimum of 500 enrollees conducted by the CMS. The current study included 3 baseline cohorts from 2015 (n=195,800), 2016 (n=178,973), and 2017 (n=172,047). I used physical component summary (PCS) and mental component summary (MCS) scores as two outcomes which include various domains of physical (exercise, pain, activity limitation) and mental health (social functioning, emotional status, depression) status. Plan characteristics include plan ownership status (for-profit (FP) vs. not-for-profit (NFP), plan types (PPO vs. HMO/cost contract), and the number of plan members. I used the linear regression method with clustering at the plan contract level due to the correlation of multiple beneficiaries within the same plan. Results: Adjusted for beneficiary level characteristics, beneficiaries in PPO plans experienced greater physical and mental health scores than HMO or cost contract plans. MA plan with less than 5k beneficiaries is associated with a lower physical health score than plans with more than 100k beneficiaries. For-profit ownership was significantly associated with lower mental health scores. Discussion: The characteristics of MA plan insurers are important factors for beneficiaries’ enrollment decisions and quality improvement efforts.

Objective: Medicare beneficiaries in rural areas may face challenges in access to dental care. This study assessed rural–urban differences in the use of dental services and dental procedures by Medicare beneficiaries. Methods: We obtained data from the 2018 Medicare Current Beneficiary Survey cost and use files. Outcome variables examined in this study were (1) dental visits (yes/no), whether the Medicare beneficiary had ≥1 dental visit in the past year, and (2) dental procedures—preventive (yes/no), restorative (yes/no), and surgical procedures (yes/no)—whether the beneficiary had the procedure in a dental visit. The independent variable was the beneficiary’s residence (rural vs urban). We used multiple logistic regression to analyze data and accounted for the survey design of the Medicare Current Beneficiary Survey. The analytic sample included 7377 respondents aged ≥65 years. Results: Approximately 57.0% (95% CI, 54.9%-59.0%) and 46.4% (95% CI, 41.6%-51.2%) of Medicare beneficiaries in urban and rural communities in the United States had a dental visit in 2018, respectively. Rural beneficiaries were significantly less likely than their urban counterparts to have preventive procedures (adjusted odds ratio = 0.51; 95% CI, 0.36-0.72) but significantly more likely to have restorative procedures (adjusted odds ratio = 1.30; 95% CI, 1.05-1.62). Conclusion: We found significant disparities in use of dental services by Medicare beneficiaries in rural communities. When Medicare beneficiaries in rural areas used dental care, they were less likely than beneficiaries in urban areas to have preventive procedures but more likely to have restorative procedures, suggesting a greater burden of oral health needs among them. Policy research is needed to identify models that can incentivize prevention and improve access to dental care for Medicare beneficiaries in rural communities.

Growing research recognizes the importance of evaluating life satisfaction in promoting psychological well-being (PWB) among middle-aged and older adults due to its heightened importance for public health relevance. The current study assessed the relationship between life satisfaction and living arrangement among U.S. adults aged 50 years or older and whether this relationship varies by gender. We used the Health and Retirement Study data from 2010-2014 (7,163 respondents), a nationally representative cohort of U.S. adults aged 50 years or older. The outcome variable was the measure of satisfaction with life on a continuous scale (1-7). The categorical independent variable was individuals’ living arrangements status (living with a spouse/partners (reference category), living alone, living with others; measured in the 2012 wave. We conducted a Generalized linear model in our regression analysis. Controlling for demographic, socioeconomic, and health-related factors, individuals who lived alone or lived with others had significantly lower life satisfaction (β = -0.21, 95% CI [-0.31, -0.11]) and (β = -0.23, 95% CI [-0.38, 0.08]) respectively, compared to those who lived with a spouse/partner. These findings suggest public health policies and programs may need to find ways to increase supportive resources for people living alone or living with others to promote life satisfaction, which is a protective factor for good health.

OBJECTIVES:To assess (1) the willingness to get a COVID-19 vaccine among Medicare beneficiaries, (2) the associated factors, and (3) the reasons for vaccine hesitancy.METHODS:Data were taken from the Medicare Current Beneficiary Survey (MCBS) 2020 Fall COVID-19 Supplement, conducted October-November 2020. Willingness to get a COVID-19 vaccine was measured by respondents' answer to whether they would get a COVID-19 vaccine when available. We classified responses of "definitely" and "probably" as "willing to get," and responses "probably not," "definitely not," and "not sure" as "vaccine hesitancy." Reasons for vaccine hesitancy were assessed by a series of yes/no questions focusing on 10 potential reasons. The analytical sample included 6715 adults 65 years and older. We conducted a logistic regression model to assess demographic factors and other factors associated with the willingness to get a COVID-19 vaccine. All analyses were conducted in Stata 14 and accounted for the complex survey design of MCBS.RESULTS:Overall, 61.0% (95% confidence interval [CI], 59.1-63.0) of Medicare beneficiaries would be willing to get a vaccine when available. Among those who were hesitant, more than 40% reported that mistrust of the government and side effects as the main reasons. Logistic regression model results showed that non-Hispanic Blacks (adjusted odds ratio [AOR] = 0.33; 95% CI, 0.24-0.44) and Hispanics (AOR = 0.60; 95% CI, 0.47-0.77) were less willing to get a vaccine than non-Hispanic Whites; beneficiaries with an income of less than $25 000 (AOR = 0.71; 95% CI, 0.62-0.81) were less willing to get the vaccine than those with an income of $25 000 or more; those who did not think that the COVID-19 virus was more contagious (AOR = 0.53; 95% CI, 0.41-0.69) or more deadly (AOR = 0.51; 95% CI, 0.41-0.65) were also less willing to get the vaccine than those who thought that the virus was more contagious or more deadly than the influenza virus.CONCLUSIONS:The 2020 MCBS survey data showed that close to 40% of Medicare beneficiaries were hesitant about getting a COVID-19 vaccine, and the hesitancy was greater in racial/ethnic minorities. Medicare beneficiaries were concerned about the safety of the vaccine, and some appeared to be misinformed. Evidence-based educational and policy-level interventions need to be implemented to further promote COVID-19 vaccination.

Informal care is a major source of long-term services and supports (LTSS) for older adults in the U.S. However, the increasing gap between available family caregivers and those needing LTSS in coming years warrants better understanding of the balance between informal and formal home or community-based LTSS to meet the growing demand. The current study aimed to 1) identify patterns of informal and formal LTSS use among community-dwelling individuals, and 2) examine if the supply of formal LTSS predicts the use of informal care. These aims were investigated by linking the market supply of formal LTSS at the state-level to the Health and Retirement Survey data (N = 7,781). Results provide important empirical evidence that patterns of informal and formal LTSS use among older adults are heterogeneous and market supply of formal home and community-based services (HCBS) significantly predicts the use of informal care. Most older adults rely on informal care in combination with some formal supports, suggesting that the two systems work in tandem to meet the growing needs of LTSS. This offers important implications for states allocating resources to meet the LTSS needs of older adults and individuals with disabilities since states play key roles in U.S. long-term care policies.

To investigate the association of ownership status, discharge rate and length of stay (LOS) of home health care (HH) services under the prospective payment system (PPS). We used 2016-2018 Outcome Assessment and Information Set (OASIS) data sets for Medicare beneficiaries. Two outcome variables were investigated: rate of discharge from an HH agency and LOS. Our main independent variable was ownership status: for-profit (FP) versus not-for-profit (NFP). FP agencies were 4.2% (p <.01) less likely to discharge patients to the community but more likely (7.3%; p <.001) to have longer LOS (>99 days) compared to NFPs. Findings that FP agencies were less likely to discharge patients to the community and more likely to have a longer length of stay than NFP agencies have implications for quality of care initiatives by the Medicare Post-Acute Transformation Act 2014.

PURPOSE To assess rural-urban differences in participation rates of diabetes self-management education and associated factors among Medicare beneficiaries with type 2 diabetes (T2DM). METHODS Data were from the 2016 to 2018 Medicare Current Beneficiary Survey (MCBS). Participation in diabetes self-management education was self-reported. The study sample included 3,799 beneficiaries aged 65 years and older with self-reported T2DM. Logistic regression was used to assess the association of participation in diabetes self-management education and residential location. Sampling weights embedded in the MCBS were incorporated into all analyses. FINDINGS Overall, the participation rate of diabetes self-management education was 46.8% (95% CI: 44.4%-49.2%). The rate was 40.3% for beneficiaries in rural areas, 48.0% for suburban areas, and 47.3% for urban areas. About 31% of beneficiaries newly diagnosed with diabetes did not participate within the past year. Controlling for other covariates, beneficiaries in rural areas were less likely to have participated in diabetes self-management education (AOR = 0.73, 95% CI: 0.55-0.95) than those living in urban areas. Asian Americans were less likely to have participated (AOR = 0.49, 95% CI: 0.28-0.84) than Whites. Those who were older, with lower education, and lower income levels were less likely to have participated (P < .05). CONCLUSIONS Recent MCBS data indicate that more than half of Medicare beneficiaries with T2DM did not participate in diabetes self-management education, and the participation rate in rural areas was 7 percentage points lower than that ​in urban areas. The study findings highlight challenges to maximize the benefits of participating in diabetes self-management education, particularly in rural areas.

Abstract Despite growing attention to the association between living arrangements and health outcomes, less is known about how emotional well-being and life satisfaction vary by living arrangements. Using data from the 2014 and 2016 Leave Behind Questionnaires from the Health and Retirement Survey (N=13,275), we estimated generalized linear regression models comparing emotional well-being (a ratio of positive to negative emotion) and life satisfaction (the satisfaction with life scale, SWLS) by living alone versus living with others, controlling for socioeconomic and other health-related characteristics. Overall, individuals who lived alone had lower emotional well-being (β=-0.11; p<0.01), and SWLS score (β=-0.42; p<0.001), compared to those living with others. The direction of these relationships stratified by the cognitive status was the same. Policies and programs designed to support the growing population of older adults living alone should focus on improvement in these positive outcomes to enhance the quality of life.

Abstract Medicare restructured home healthcare reimbursement from a cost-basis to a 60- day risk-based prospective payment system (PPS) in 2000 to implement the value-based payment model for home healthcare services. Currently home healthcare market in the U.S. is dominated by the presence of for-profit (FP) agencies instead of being primarily served by not-for-profit (NFP) agencies. Using data from the 2016-2018 OASIS for beneficiaries participated in the Medicare Current Beneficiary Survey (MCBS) (N=6,115), the current study examines whether home health agency ownership status is associated with length of stay (LOS) and discharge outcome Medicare home health care patients. Our first outcome variable is discharge status (modeled via ordered probit) with three categories: discharge to the community, inpatient hospital and other long-term care facilities. The second outcome variable is LOS and two dummy variables LOS ≤ 30 days and LOS ≥ 99 days were modeled via binary probit. The key independent variable was the ownership status of the agency (FP vs. NFP). Patient level covariates includes demographics (age, gender, race/ethnicity, marital status), comorbidity index, agency characteristics (metropolitan statistical area, hospital-based). Patients in FP agencies were 5.1% (p<0.01) less likely to discharge to community, 15.3% (p<0.001) less likely to have LOS ≤ 30 days but 7.5% (p<0.001) more likely to have LOS ≥ 99 higher compared to patients from NFP agencies under the PPS. Our results have important implications for clinicians, patients and healthcare professionals to be cognizant about the influence of agency ownership on the delivery of healthcare services in home healthcare sector.

While Medicare is the universal source of health care coverage for Americans aged 65 years or older, the program requires significant cost sharing in terms of out-of-pocket (OOP) spending. We conducted a retrospective study using data from 2016 to 2018 Medicare Current Beneficiary Surveys of elderly community-dwelling beneficiaries ( n = 10,431) linked with administrative data to estimate OOP spending associated with the “big four” chronic diseases (cardiovascular disease, cancer, diabetes, and chronic lung disease). We estimated a generalized linear model adjusting for predisposing, enabling, and need factors to estimate annual OOP spending. We found that beneficiaries with any of the “big four” chronic conditions spent 15% ( p < .001) higher OOP costs and were 56% more likely to spend ≥20% of annual income on OOP expenditure (adjusted odds ratio = 1.56; p < .001) compared with those without any of those conditions. OOP spending appears to be heterogeneous across disease types and changing by conditions over time.