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Al Faysal J, Noor-E-Alam M, Young GJ, Lo-Ciganic WH, Goodin AJ, Huang JL, Wilson DL, Park TW, Hasan MM. An explainable machine learning framework for predicting the risk of buprenorphine treatment discontinuation for opioid use disorder among commercially insured individuals. Comput Biol Med 2024; 177:108493. [PMID: 38833799 DOI: 10.1016/j.compbiomed.2024.108493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/22/2024] [Accepted: 04/17/2024] [Indexed: 06/06/2024]
Abstract
OBJECTIVES Buprenorphine is an effective evidence-based medication for opioid use disorder (OUD). Yet premature discontinuation undermines treatment effectiveness, increasing the risk of mortality and overdose. We developed and evaluated a machine learning (ML) framework for predicting buprenorphine care discontinuity within 12 months following treatment initiation. METHODS This retrospective study used United States (US) 2018-2021 MarketScan commercial claims data of insured individuals aged 18-64 who initiated buprenorphine between July 2018 and December 2020 with no buprenorphine prescriptions in the previous six months. We measured buprenorphine prescription discontinuation gaps of ≥30 days within 12 months of initiating treatment. We developed predictive models employing logistic regression, decision tree classifier, random forest, extreme gradient boosting, Adaboost, and random forest-extreme gradient boosting ensemble. We applied recursive feature elimination with cross-validation to reduce dimensionality and identify the most predictive features while maintaining model robustness. For model validation, we used several statistics to evaluate performance, such as C-statistics and precision-recall curves. We focused on two distinct treatment stages: at the time of treatment initiation and one and three months after treatment initiation. We employed SHapley Additive exPlanations (SHAP) analysis that helped us explain the contributions of different features in predicting buprenorphine discontinuation. We stratified patients into risk subgroups based on their predicted likelihood of treatment discontinuation, dividing them into decile subgroups. Additionally, we used a calibration plot to analyze the reliability of the models. RESULTS A total of 30,373 patients initiated buprenorphine and 14.98% (4551) discontinued treatment. C-statistic varied between 0.56 and 0.76 for the first-stage models including patient-level demographic and clinical variables. Inclusion of proportion of days covered (PDC) measured after one month and three months following treatment initiation significantly increased the models' discriminative power (C-statistics: 0.60 to 0.82). Random forest (C-statistics: 0.76, 0.79 and 0.82 with baseline predictors, one-month PDC and three-months PDC, respectively) outperformed other ML models in discriminative performance in all stages (C-statistics: 0.56 to 0.77). Most influential risk factors of discontinuation included early stage medication adherence, age, and initial days of supply. CONCLUSION ML algorithms demonstrated a good discriminative power in identifying patients at higher risk of buprenorphine care discontinuity. The proposed framework may help healthcare providers optimize treatment strategies and deliver targeted interventions to improve buprenorphine care continuity.
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Affiliation(s)
- Jabed Al Faysal
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, FL, USA
| | - Md Noor-E-Alam
- Department of Mechanical and Industrial Engineering, Northeastern University, Boston, MA, USA
| | - Gary J Young
- Center for Health Policy and Healthcare Research, Northeastern University, Boston, MA, USA; Bouve College of Health Sciences, Northeastern University, Boston, MA, USA; D'Amore-McKim School of Business, Northeastern University, Boston, MA, USA
| | - Wei-Hsuan Lo-Ciganic
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Pharmaceutical Policy & Prescribing, University of Pittsburgh, Pittsburgh, PA, USA; North Florida/South Georgia Veterans Health System; Geriatric Research Education and Clinical Center, Gainesville, FL, USA
| | - Amie J Goodin
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, FL, USA
| | - James L Huang
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, FL, USA
| | - Debbie L Wilson
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, FL, USA
| | - Tae Woo Park
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Md Mahmudul Hasan
- Department of Pharmaceutical Outcomes & Policy, University of Florida, Gainesville, FL, USA; Department of Information Systems and Operations Management, University of Florida, Gainesville, FL, USA; Center for Drug Evaluation and Safety, University of Florida, Gainesville, FL, USA.
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Chen XT, Glasgow AE, Haberman EB, Heckmann ND, Callaghan JJ, Lewallen DG, Berry DJ, Bedard NA. Is the Rise of Medicare Advantage Impacting the Fidelity of Traditional Medicare Claims Data? Implications for Reporting of Long-Term Total Hip Arthroplasty Survivorship. J Arthroplasty 2024:S0883-5403(24)00230-4. [PMID: 38493968 DOI: 10.1016/j.arth.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Arthroplasty registries often utilize traditional Medicare (TM) claims data to report long-term total hip arthroplasty (THA) survivorship. The purpose of this study was to determine whether the large number of patients leaving TM for Medicare Advantage (MA) has compromised the fidelity of TM data. METHODS We identified 10,962 THAs in 9,333 Medicare-eligible patients who underwent primary THA from 2000 to 2020 at a single institution. Insurance type was analyzed, and 83% of patients had TM at the time of THA. Survivorship free from any revision or reoperation were calculated for patients who have TM. The same survivorship endpoints was re-calculated with censoring performed when a patient transitioned to a MA plan after their primary THA to model the impact of losing patients from the TM dataset. Differences in survivorship were compared. The mean follow-up was 7 years. RESULTS From 2000 to 2020, there was a decrease in TM insurance (93 to 73%) and a corresponding increase in MA insurance (0 to 19%) among THA patients. Following THA, 23% of TM patients switched to MA. For patients who had TM at the time of surgery, 15-year survivorship free from any reoperation or revision was 90 and 93%, respectively. When censoring patients upon transition from TM to MA, survivorship free from any reoperation became significantly higher (92 versus 90% at 15 years; hazard ratio (HR) = 1.16, P = 0.033), and there was a trend towards higher survivorship free from any revision (95 versus 93% at 15-years; HR = 1.16, P = 0.074). CONCLUSION Approximately 1 in 4 patients left TM for MA after primary THA, effectively making them lost to follow-up within TM datasets. The mass exodus of patients out of TM appears to have led to a slight overestimation of survivorship free from any reoperation and trended toward overestimating survivorship free from any revision. If MA continues to grow, efforts to obtain MA data will become even more important.
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Affiliation(s)
- Xiao T Chen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Elizabeth B Haberman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - John J Callaghan
- Department of Orthopedic Surgery, University of Iowa, Iowa City, IA
| | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Wang N, Seale M, Chen J. Availability and use of telehealth services among patients with ADRD enrolled in traditional Medicare vs. Medicare advantage during the COVID-19 pandemic. Front Public Health 2024; 12:1346293. [PMID: 38476485 PMCID: PMC10927842 DOI: 10.3389/fpubh.2024.1346293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/02/2024] [Indexed: 03/14/2024] Open
Abstract
Background The objective of this study was to examine differences in availability and use of telehealth services among Medicare enrollees according to Alzheimer's disease and related dementias (ADRD) status and enrollment in Medicare Advantage (MA) versus Traditional Medicare (TM) during the period surrounding the COVID-19 pandemic. Methods This was a retrospective cross-sectional analysis of data from community-dwelling MA and TM enrollees with and without ADRD from the Medicare Current Beneficiary Survey (MCBS) Fall 2020 and Winter 2021 COVID-19 Supplement Public Use Files. We examined self-reported availability of telehealth service before and during the COVID-19 pandemic and use of telehealth services during COVID-19. We analyzed marginal effects under multivariable logistic regression. Results There were 13,700 beneficiaries with full-year enrollment in MA (6,046) or TM (7,724), 518 with ADRD and 13,252 without ADRD. Telehealth availability during COVID-19 was positively associated with having a higher income (2.81 pp. [percentage points]; 95% CI: 0.57, 5.06), having internet access (7.81 pp.; 95% CI: 4.96, 10.66), and owning telehealth-related technology (3.86; 95% CI: 1.36, 6.37); it was negatively associated with being of Black Non-Hispanic ethnicity (-8.51 pp.; 95% CI: -12.31, -4.71) and living in a non-metro area (-8.94 pp.; 95% CI: -13.29, -4.59). Telehealth availability before COVID-19 was positively associated with being of Black Non-Hispanic ethnicity (9.34 pp.; 95% CI: 3.74, 14.94) and with enrollment in MA (4.72 pp.; 95% CI: 1.63, 7.82); it was negatively associated having dual-eligibility (-5.59 pp.; 95% CI: -9.91, -1.26). Telehealth use was positively associated with being of Black Non-Hispanic ethnicity (6.47 pp.; 95% CI: 2.92, 10.01); it was negatively associated with falling into the age group of 75+ years (-4.98 pp.; 95% CI: -7.27, -2.69) and with being female (-4.98 pp.; 95% CI: -7.27, -2.69). Conclusion Telehealth services were available to and used by Medicare enrollees with ADRD to a similar extent compared to their non-ADRD counterparts. Telehealth services were available to MA enrollees to a greater extent before COVID-19 but not during COVID-19, and this group did not use telehealth services more than TM enrollees during COVID-19.
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Affiliation(s)
- Nianyang Wang
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, MD, United States
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Jafri FI, Patel VR, Xu J, Polsky D, Gupta A, Hussaini SMQ. Association of Medicare Program Type with Health Care Access, Utilization, and Affordability among Cancer Survivors. Cancers (Basel) 2023; 15:3964. [PMID: 37568779 PMCID: PMC10417052 DOI: 10.3390/cancers15153964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/17/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND The Medicare Advantage program provides care to nearly half of Medicare beneficiaries, including a rapidly growing population of cancer survivors. Despite its increased adoption, it is still unknown whether or not the program improves healthcare access, outcomes, and affordability for cancer survivors. METHODS We performed a cross-sectional study of Medicare beneficiaries aged ≥ 65 years with a self-reported history of cancer from the 2019 National Health Interview Survey. We used multivariable logistic regression to evaluate the association between Medicare program type (Medicare Advantage vs. traditional Medicare) and measures of healthcare access, acute care utilization, and affordability. RESULTS We identified 4451 beneficiaries with a history of cancer, corresponding to 26.6 million weighted cancer survivors in 2019. Of the beneficiaries, 35.8% were enrolled in Medicare Advantage, whereas 64.2% were enrolled in traditional Medicare. The age, sex, racial and ethnic composition, household income, primary site of cancer, and comorbidity burden of Medicare Advantage and traditional Medicare beneficiaries were similar. In the adjusted analysis, there were no differences in healthcare access or acute care utilization between traditional Medicare and Medicare Advantage beneficiaries. However, cancer survivors enrolled in Medicare Advantage were more likely to worry about (34.3% vs. 29.4%; aOR, 1.3 (95% CI, 1.1-1.5)) or have problems paying (13.6% vs. 11.1%; aOR, 1.4 (95% CI, 1.1-1.8)) medical bills. CONCLUSIONS We found no evidence that Medicare Advantage beneficiaries with cancer had better healthcare access, affordability, or acute care utilization than traditional Medicare beneficiaries did. Furthermore, Medicare Advantage beneficiaries were more likely to report financial strain and have difficulty paying for their medical bills than were those with traditional Medicare. Despite the generous benefits and attractive incentives, Medicare Advantage plans may not be more cost-effective than traditional Medicare is for cancer survivors. Our study informs ongoing congressional deliberations to re-evaluate the role of Medicare Advantage in promoting equity among beneficiaries with cancer.
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Affiliation(s)
- Faraz I. Jafri
- Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA;
| | - Vishal R. Patel
- Dell Medical School, The University of Texas at Austin, Austin, TX 78712, USA;
| | - Jianhui Xu
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (J.X.); (D.P.)
| | - Daniel Polsky
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; (J.X.); (D.P.)
- Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD 21224, USA
- Carey Business School, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Arjun Gupta
- Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455, USA;
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Achola EM, Stevenson DG, Keohane LM. Postacute Care Services Use and Outcomes Among Traditional Medicare and Medicare Advantage Beneficiaries. JAMA HEALTH FORUM 2023; 4:e232517. [PMID: 37594745 PMCID: PMC10439482 DOI: 10.1001/jamahealthforum.2023.2517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/13/2023] [Indexed: 08/19/2023] Open
Abstract
Importance Better evidence is needed on whether Medicare Advantage (MA) plans can control the use of postacute care services while achieving excellent outcomes. Objective To compare self-reported use of postacute care services and outcomes among traditional Medicare (TM) beneficiaries and MA enrollees. Design, Setting, and Participants This cohort study used data from the National Health and Aging Trends Study (NHATS) with linked Medicare enrollment data from 2015 to 2017. Participants were community-dwelling MA or TM beneficiaries 70 years and older; those with dual Medicare and Medicaid eligibility were also identified. Analyses were conducted from May 2022 to February 2023 and were weighted to account for the complex survey design. Exposures Enrollment in MA and dual eligibility for Medicare and Medicaid. Main Outcomes and Measures Postacute care service use including site of use, duration, primary indication, and whether participants met their goals or experienced improved functional status during or after services. Results Included in the analysis were 2357 Medicare beneficiaries who used postacute care. Of these beneficiaries, 815 (32.6%; 62.0% were females [weighted percentages]) had MA and 1542 (67.4%; 59.5% were females [weighted percentages]) had TM. Enrollees in MA reported using postacute care services across all NHATS survey rounds: between 16.2% (95% CI, 14.3%-18.4%) and 17.7% (95% CI, 15.4%-20.4%) of MA enrollees reported using postacute care services each round, vs 22.4% (95% CI, 20.9%-24.1%) to 24.1% (95% CI, 21.8%-26.6%) of TM beneficiaries (P for all rounds <.002). Enrollees in MA reported less functional improvement during postacute care use (63.1% [95% CI, 59.2%-66.8%] vs 71.7% [95% CI, 68.9%-74.3%], P < .001). Among beneficiaries who ended postacute service use, fewer MA enrollees than TM enrollees reported that they met their goals (70.5% [95% CI, 65.1%-75.3%] vs 76.2% [95% CI, 73.1%-79.1%]; P = .053) or had improved functional status (43.9% [95% CI, 38.9%-49.1%] vs 46.0% [95% CI, 42.5%-49.5%]; P = .42), but differences were not statistically significant. Differences in postacute care use and functional improvement were not statistically significant between MA and TM enrollees with dual eligibility. Conclusions and relevance In this cohort study of Medicare beneficiaries, we found that MA enrollees overall used less postacute care services than their TM counterparts. Among users of postacute care services, MA enrollees reported less favorable outcomes compared with TM enrollees. These findings highlight the importance of assessing patient-reported outcomes, especially as MA and other payment models seek to reduce inefficient use of postacute care services.
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Affiliation(s)
- Emma M. Achola
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David G. Stevenson
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville
| | - Laura M. Keohane
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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Figueroa JF, Dai D, Feyman Y, Garrido MM, Tsai TC, Orav EJ, Frakt AB. Use of High-Risk Medications Among Older Adults Enrolled in Medicare Advantage Plans vs Traditional Medicare. JAMA Netw Open 2023; 6:e2320583. [PMID: 37368399 DOI: 10.1001/jamanetworkopen.2023.20583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Importance Limiting the use of high-risk medications (HRMs) among older adults is a national priority to provide a high quality of care for older beneficiaries of both Medicare Advantage and traditional fee-for-service Medicare Part D plans. Objective To evaluate the differences in the rate of HRM prescription fills among beneficiaries of traditional Medicare vs Medicare Advantage Part D plans and to examine the extent to which these differences change over time and the patient-level factors associated with higher rates of HRMs. Design, Setting, and Participants This cohort study used a 20% sample of Medicare Part D data on filled drug prescriptions from 2013 to 2017 and a 40% sample from 2018. The sample comprised Medicare beneficiaries aged 66 years or older who were enrolled in Medicare Advantage or traditional Medicare Part D plans. Data were analyzed between April 1, 2022, and April 15, 2023. Main Outcomes and Measures The primary outcome was the number of unique HRMs prescribed to older Medicare beneficiaries per 1000 beneficiaries. Linear regression models were used to model the primary outcome, adjusting for patient characteristics and county characteristics and including hospital referral region fixed effects. Results The sample included 5 595 361 unique Medicare Advantage beneficiaries who were propensity score-matched on a year-by-year basis to 6 578 126 unique traditional Medicare beneficiaries between 2013 and 2018, resulting in 13 704 348 matched pairs of beneficiary-years. The traditional Medicare vs Medicare Advantage cohorts were similar in age (mean [SD] age, 75.65 [7.53] years vs 75.60 [7.38] years), proportion of males (8 127 261 [59.3%] vs 8 137 834 [59.4%]; standardized mean difference [SMD] = 0.002), and predominant race and ethnicity (77.1% vs 77.4% non-Hispanic White; SMD = 0.05). On average in 2013, Medicare Advantage beneficiaries filled 135.1 (95% CI, 128.4-142.6) unique HRMs per 1000 beneficiaries compared with 165.6 (95% CI, 158.1-172.3) HRMs per 1000 beneficiaries for traditional Medicare. In 2018, the rate of HRMs had decreased to 41.5 (95% CI, 38.2-44.2) HRMs per 1000 beneficiaries in Medicare Advantage and to 56.9 (95% CI, 54.1-60.1) HRMs per 1000 beneficiaries in traditional Medicare. Across the study period, Medicare Advantage beneficiaries received 24.3 (95% CI, 20.2-28.3) fewer HRMs per 1000 beneficiaries per year compared with traditional Medicare beneficiaries. Female, American Indian or Alaska Native, and White populations were more likely to receive HRMs than other groups. Conclusion and Relevance Results of this study showed that HRM rates were consistently lower among Medicare Advantage than traditional Medicare beneficiaries. Higher use of HRMs among female, American Indian or Alaska Native, and White populations is a concerning disparity that requires further attention.
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Affiliation(s)
- Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dannie Dai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Yevgeniy Feyman
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
| | - Melissa M Garrido
- Boston University School of Public Health, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Thomas C Tsai
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Center for Surgery and Public Health, Boston, Massachusetts
| | - E John Orav
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Austin B Frakt
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Boston University School of Public Health, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
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Drake C, Anderson D, Cai ST, Sacks DW. Financial transaction costs reduce benefit take-up evidence from zero-premium health insurance plans in Colorado. JOURNAL OF HEALTH ECONOMICS 2023; 89:102752. [PMID: 37001239 DOI: 10.1016/j.jhealeco.2023.102752] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 03/07/2023] [Accepted: 03/14/2023] [Indexed: 06/19/2023]
Abstract
With the passage of the American Recovery Plan Act of 2021, roughly 12 million Americans are eligible to purchase zero-premium Health Insurance Marketplace plans. Millions more are eligible for generously subsidized health plans with small, positive premiums. What difference does a premium of zero make, relative to a slightly positive premium? Using a regression discontinuity design and administrative data from Colorado, we find that zero-premium plans increase coverage, primarily by helping low-income households begin coverage sooner. The main mechanism is eliminating the transaction costs of having to make on-time payments to begin coverage. Transaction costs may be a meaningful barrier to subsidized insurance coverage take-up, particularly for low-income families.
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Affiliation(s)
| | | | - Sih-Ting Cai
- University of Pittsburgh, United States of America.
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Papageorge MV, Ng SC, Sachs TE, Kenzik KM. Exclusion criteria: Evaluating the impact of enrollment requirements in SEER-Medicare research. J Am Geriatr Soc 2022; 70:3593-3597. [PMID: 36040326 DOI: 10.1111/jgs.18017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Enrollment criteria are routinely utilized in patient selection in SEER-Medicare but little is known about how this may be impacting research outcomes. This study evaluated demographics and survival among pancreatic cancer patients who are included and excluded from SEER-Medicare analyses. METHODS Patients ≥66 years old with pancreatic cancer were identified (SEER-Medicare, 2008-2015). Two patient cohorts were compared: included (continuous enrollment in Medicare Parts A and B and no enrollment in Medicare Advantage), and excluded. Mortality was assessed using a Standardized Mortality Ratio. RESULTS Among 49,017 patients with pancreatic cancer, 59.5% were in the included cohort. The excluded cohort was younger (median age 74 vs. 77) with more male (49.9% vs. 47.8%), non-white (33.0% vs. 21.3%) and urban-dwelling patients (91.0% vs. 85.0%). Those excluded had a higher mortality risk (SMR 1.06, 95%CI 1.04-1.07). CONCLUSIONS There are significant differences in patient demographics and mortality among those who are and are not routinely included in SEER-Medicare analyses and our study provides a critical opportunity to quantify this potential bias.
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Affiliation(s)
- Marianna V Papageorge
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, Massachusetts, USA
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, Massachusetts, USA
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, Massachusetts, USA
| | - Kelly M Kenzik
- Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, Massachusetts, USA
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Park S, Werner RM, Coe NB. Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions. Med Care 2022; 60:872-879. [PMID: 36356289 PMCID: PMC9668368 DOI: 10.1097/mlr.0000000000001770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Enrollment in high-quality Medicare Advantage (MA) plans, measured by a 5-star quality rating system, was lower among racial and ethnic minority enrollees than White enrollees partly due to fewer high-quality plans available in their counties of residence. This may contribute to racial and ethnic disparities in ambulatory care sensitive condition (ACSC) hospitalizations. OBJECTIVE We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating. METHODS Using the Medicare enrollment and claims data for 2016, we identified White, Black, Hispanic, and Asian/Pacific Islander enrollees in MA plans. We estimated racial and ethnic disparities in ACSC hospitalizations (per 10,000 enrollees) overall and by star rating. RESULTS We found that the adjusted rates of ACSC hospitalizations were significantly higher among Black enrollees than White enrollees overall [39.4 (95% confidence interval: 36.3-42.5)]. However, no significant disparities were found among Hispanic and Asian/Pacific Islander enrollees. The adjusted rates of ACSC hospitalizations were higher in lower-rated plans than higher-rated plans in all racial and ethnic groups. The significant disparities in ACSC hospitalizations by star rating were the most pronounced between White and Black enrollees. We found suggestive evidence that enrollment in lower-rated plans was associated with higher disparities in ACSC hospitalizations between White and Black enrollees. CONCLUSIONS Substantial disparities in ACSC hospitalizations exist between White and Black enrollees in MA plans, especially for lower-rated plans. Policies aimed at reducing racial disparities in ACSC hospitalizations could include improving access to high-rated plans.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA
- Department of Health Policy and Management, College of Health Science, Korea University, Seoul, South Korea
| | - Rachel M Werner
- Department of Medicine, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennsylvania
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center
| | - Norma B Coe
- Leonard Davis Institute of Health Economics, University of Pennsylvania
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Layton TJ, Maestas N, Prinz D, Vabson B. Healthcare Rationing in Public Insurance Programs: Evidence from Medicaid. AMERICAN ECONOMIC JOURNAL. ECONOMIC POLICY 2022; 14:397-431. [PMID: 36824998 PMCID: PMC9945909 DOI: 10.1257/pol.20190628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
We study two mechanisms used by public health insurance programs for rationing health care: outsourcing to private managed care plans and quantity limits for prescription drugs. Leveraging a natural experiment in Texas’s Medicaid program, we find that the shift to managed care and the relaxation of a strict drug cap increased access to high-value drugs and outpatient services and reduced avoidable hospitalizations. Program costs increased significantly, indicating a trade-off between cost and quality. We provide suggestive evidence attributing the reduction in hospitalizations to the relaxation of the drug cap and much of the spending increase to the shift to managed care. (JEL G22, H75, I13, I18, I38)
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Parikh RB, Emanuel EJ, Brensinger CM, Boyle CW, Price-Haywood EG, Burton JH, Heltz SB, Navathe AS. Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program. JAMA Netw Open 2022; 5:e2228529. [PMID: 35997977 PMCID: PMC9399862 DOI: 10.1001/jamanetworkopen.2022.28529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
IMPORTANCE The 2 primary efforts of Medicare to advance value-based care are Medicare Advantage (MA) and the fee-for-service-based Medicare Shared Savings Program (MSSP). It is unknown how spending differs between the 2 programs after accounting for differences in patient clinical risk. OBJECTIVE To examine how spending and utilization differ between MA and MSSP beneficiaries after accounting for differences in clinical risk using data from administrative claims and electronic health records. DESIGN, SETTING, AND PARTICIPANTS This retrospective economic evaluation used data from 15 763 propensity score-matched beneficiaries who were continuously enrolled in MA or MSSP from January 1, 2014, to December 31, 2018, with diabetes, congestive heart failure (CHF), chronic kidney disease (CKD), or hypertension. Participants received care at a large nonprofit academic health system in the southern United States that bears risk for Medicare beneficiaries through both the MA and MSSP programs. Differences in beneficiary risk were mitigated by propensity score matching using validated clinical criteria based on data from administrative claims and electronic health records. Data were analyzed from January 2019 to May 2022. EXPOSURES Enrollment in MA or attribution to an accountable care organization in the MSSP program. MAIN OUTCOMES AND MEASURES Per-beneficiary annual total spending and subcomponents, including inpatient hospital, outpatient hospital, skilled nursing facility, emergency department, primary care, and specialist spending. RESULTS The sample of 15 763 participants included 12 720 (81%) MA and 3043 (19%) MSSP beneficiaries. MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]). The mean unadjusted per-member per-year spending difference between MSSP and MA disease-specific subcohorts was $2159 in diabetes, $4074 in CHF, $2560 in CKD, and $2330 in hypertension. After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2454; 95% CI, $1431-$3574), CHF ($3699; 95% CI, $1235-$6523), CKD ($2478; 95% CI, $1172-$3920), and hypertension ($2258; 95% CI, $1616-2,939). Higher MSSP spending among matched beneficiaries was consistent over time. In the matched cohort in 2018, MSSP total spending ranged from 23% (CHF) to 30% (CKD) higher than MA. Adjusting for differential trends in coding intensity did not affect these results. Higher outpatient hospital spending among MSSP beneficiaries contributed most to spending differences between MSSP and MA, representing 49% to 62% of spending differences across disease cohorts. CONCLUSIONS AND RELEVANCE In this study, utilization and spending were consistently higher for MSSP than MA beneficiaries within the same health system even after adjusting for granular metrics of clinical risk. Nonclinical factors likely contribute to the large differences in MA vs MSSP spending, which may create challenges for health systems participating in MSSP relative to their participation in MA.
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Affiliation(s)
- Ravi B. Parikh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Ezekiel J. Emanuel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | | | - Connor W. Boyle
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | | | | | - Amol S. Navathe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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12
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Moyo P, Bosco E, Bardenheier BH, Rivera-Hernandez M, van Aalst R, Chit A, Gravenstein S, Zullo AR. Variation in influenza vaccine assessment, receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes. Vaccine 2022; 40:1031-1037. [PMID: 35033387 PMCID: PMC8917469 DOI: 10.1016/j.vaccine.2021.12.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 12/22/2021] [Accepted: 12/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND More older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents. METHODS We analyzed 2014-2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination. RESULTS There were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.10 pp, 95% CL: -3.53 pp, -2.68 pp), or high (-4.63 pp, 95% CL: -5.11 pp, -4.15 pp) MA compared with NHs with the lowest prevalence of MA. CONCLUSION A higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings.
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Affiliation(s)
- Patience Moyo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA.
| | - Elliott Bosco
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA
| | - Barbara H Bardenheier
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA; Leslie Dan School of Pharmacy, University of Toronto, Ontario, Canada
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA
| | - Robertus van Aalst
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Department of Modelling, Epidemiology, and Data Science, Sanofi Pasteur, Lyon, France; Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Ayman Chit
- Sanofi Pasteur, Swiftwater, PA, USA; Leslie Dan School of Pharmacy, University of Toronto, Ontario, Canada
| | - Stefan Gravenstein
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA; Center for Gerontology and Health Care Research, School of Public Health, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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13
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Park S, Langellier BA, Meyers DJ. Association of Health Insurance Literacy With Enrollment in Traditional Medicare, Medicare Advantage, and Plan Characteristics Within Medicare Advantage. JAMA Netw Open 2022; 5:e2146792. [PMID: 35113164 PMCID: PMC8814909 DOI: 10.1001/jamanetworkopen.2021.46792] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Health insurance literacy helps individuals make informed choices. However, evidence suggests that Medicare beneficiaries experience low health insurance literacy, leading to high-cost or poor-quality coverage choices. OBJECTIVE To examine how health insurance literacy was associated with coverage choices between traditional Medicare (TM) and Medicare Advantage (MA), as well as within MA. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included 6627 TM and MA enrollees, using data from the 2015-2016 Medicare Current Beneficiary Survey. Data analyses were conducted between May 1 and June 30, 2021. EXPOSURES Three self-reported measures of health insurance literacy (presence of information to make an informed comparison, ease in reviewing and comparing coverage options, and annual review and comparison of coverage options). MAIN OUTCOMES AND MEASURES Enrollment in TM vs MA and enrollment in an MA plan with different characteristics (star rating, monthly plan premium, in-network maximum out-of-pocket limit, plan type, and provision of supplemental benefits). RESULTS We included 6627 Medicare beneficiaries (3578 women [54.0%]; mean [SD] age, 75.13 [7.12] years). A total of 77 individuals were Asian (1.2%), 696 were Black (10.5%), 488 were Hispanic (7.4%), 5277 were non-Hispanic White (79.6%), and 225 (3.4%) were single races not of Hispanic origin (including American Indian or Alaska Native and Native Hawaiian) or were 2 or more races. Medicare Advantage enrollment was higher among individuals with higher health insurance literacy than those with lower health insurance literacy, especially for those who reviewed or compared coverage options annually than among those who did not (38.0%; 95% CI, 36.0%-40.1% vs 27.8%; 95% CI, 25.8%-29.7%). Among MA beneficiaries, those who reviewed or compared coverage options annually were more likely to enroll in plans with 4 to 4.5 stars and plans with monthly premiums of $1 to $50 by 4.6 percentage points (95% CI, 0.1-9.2 percentage points) and 4.8 percentage points (95% CI, 0.6-9.0 percentage points), respectively. However, enrollment in plans with 5 stars was 3.8 percentage points lower (95% CI, -5.8 to -1.9 percentage points) among individuals who reviewed or compared coverage options annually than among those who did not. Among individuals with low socioeconomic status, the likelihood of reviewing or comparing coverage options annually was lower for those with Medicare and Medicaid dual eligibility than for those without it (odds ratio, 0.79; 95% CI, 0.63-0.99). CONCLUSIONS AND RELEVANCE Results of this study suggest that higher health insurance literacy-particularly, annual review and comparison of coverage choices-is associated with higher MA enrollment and choice of a particular MA plan. Policy makers should develop programs to encourage frequent review and comparison of coverage options for informed decision making.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Brent A. Langellier
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - David J. Meyers
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
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Jung J, Carlin C, Feldman R. Measuring resource use in Medicare Advantage using Encounter data. Health Serv Res 2022; 57:172-181. [PMID: 34510453 PMCID: PMC8763275 DOI: 10.1111/1475-6773.13879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To check the completeness of Medicare Advantage (MA) Encounter data and to illustrate a process to measure resource use among MA enrollees using Encounter data. DATA SOURCES 2015 Preliminary MA Encounter, Medicare Provider Analysis and Review (MedPAR), Healthcare Effectiveness Data and Information System (HEDIS), and 2013 Traditional Medicare (TM) claims data. STUDY DESIGN Secondary data analysis. DATA COLLECTION/EXTRACTION METHODS We calculated the percentage of each contract's total hospitalizations in Encounter data after identifying total inpatient stays from Encounter and MedPAR data. We constructed each contract's ambulatory visits and emergency department (ED) visits per 1000 enrollees using Encounter data and compared those visit counts with the counts from HEDIS. We defined high data completeness as having less than 10% missing hospital stays and less than ±10% difference in ambulatory and ED visits between Encounter and HEDIS data. We used TM payments as standardized prices of services to examine resource use among MA enrollees with cancer in the contracts with high data completeness. PRINCIPAL FINDINGS We identified 83 of 380 MA contracts with high data completeness. Total resource use per enrollee with cancer in the 83 contracts was $14,715 in 2015. Service-specific resource use was $5342 for inpatient care, $5932 for professional services and $3441 for outpatient facility services. These represent what an MA enrollee with cancer would have cost on average if MA plans paid providers at TM payment rates, holding the observed utilization constant. CONCLUSIONS Checking the completeness of Encounter data is an important step to ensure the validity of research on MA resource use. Using Encounter data to measure MA resource use is feasible. It can compensate for the lack of payment information in Encounter data. It will be important to identify and refine ways to best use Encounter data to learn about care provision to MA enrollees.
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Affiliation(s)
- Jeah Jung
- Department of Health Policy and Administration, College of Health and Human DevelopmentPennsylvania State UniversityUniversity ParkPennsylvaniaUSA
| | - Caroline Carlin
- Department of Family Medicine and Community Health, School of MedicineUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Roger Feldman
- Division of Health Policy and Management, School of Public HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
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15
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Schwartz AL, Zlaoui K, Foreman RP, Brennan TA, Newhouse JP. Health Care Utilization and Spending in Medicare Advantage vs Traditional Medicare. JAMA HEALTH FORUM 2021; 2:e214001. [PMID: 35977297 PMCID: PMC8796939 DOI: 10.1001/jamahealthforum.2021.4001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/12/2021] [Indexed: 11/14/2022] Open
Abstract
Question Findings Meaning Importance Objective Design, Setting, and Participants Main Outcomes and Measures Results Conclusions and Relevance
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Affiliation(s)
- Aaron L. Schwartz
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | | | | | - Joseph P. Newhouse
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Harvard Kennedy School, Cambridge, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
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16
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Park S, Fishman P, Coe NB. Racial Disparities in Avoidable Hospitalizations in Traditional Medicare and Medicare Advantage. Med Care 2021; 59:989-996. [PMID: 34432767 PMCID: PMC8519483 DOI: 10.1097/mlr.0000000000001632] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IMPORTANCE Compared with traditional Medicare (TM), Medicare Advantage (MA) has the potential to reduce racial disparities in hospitalizations for ambulatory care sensitive conditions (ACSC). As racial disparities may be partly attributable to unequal treatment based on where people live, this suggests the need of examining geographic variations in racial disparities. OBJECTIVE The aim of this study was to examine differences in ACSC hospitalizations between White and Black beneficiaries in TM and MA and examine geographic variations in racial differences in ACSC hospitalizations in TM and MA. METHODS We analyzed the 2015-2016 Medicare Provider Analysis and Review files. We used propensity score matching to account for differences in characteristics between TM and MA beneficiaries. Then, we conducted linear regression and estimated adjusted outcomes for TM and MA beneficiaries by race. Also, we estimated racial differences in adjusted outcomes by insurance and hospital referral region (HRR). RESULTS While White beneficiaries in TM and MA had similar rates of ACSC hospitalizations (163.7 vs. 162.2/10,000 beneficiaries), Black beneficiaries in MA had higher rates of ACSC hospitalizations than Black beneficiaries in TM (221.2 vs. 209.3/10,000 beneficiaries). However, the racial differences were greater in MA than TM (59.0 vs. 45.6/10,000 beneficiaries). Racial differences in ACSC hospitalizations in MA were prevalent across almost all HRRs. 95.5% of HRRs had higher rates of ACSC hospitalizations among Black beneficiaries than White beneficiaries in MA relative to just 54.2% of HRRs in TM. CONCLUSION Our findings provide evidence of racial disparities in access to high-quality primary care, especially in MA.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA
| | - Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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17
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Kyle MA, Frakt AB. Patient administrative burden in the US health care system. Health Serv Res 2021; 56:755-765. [PMID: 34498259 DOI: 10.1111/1475-6773.13861] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To assess the prevalence of patient administrative tasks and whether they are associated with delayed and/or foregone care. DATA SOURCE March 2019 Health Reform Monitoring Survey. STUDY DESIGN We assess the prevalence of five common patient administrative tasks-scheduling, obtaining information, prior authorizations, resolving billing issues, and resolving premium problems-and associated administrative burden, defined as delayed and/or foregone care. Using multivariate logistic models, we examined the association of demographic characteristics with odds of doing tasks and experiencing burdens. Our outcome variables were five common types of administrative tasks as well as composite measures of any task, any delayed care, any foregone care, and any burden (combined delayed/foregone), respectively. DATA COLLECTION We developed and administered survey questions to a nationally representative sample of insured, nonelderly adults (n = 4155). PRINCIPAL FINDINGS The survey completion rate was 62%. Seventy-three percent of respondents reported performing at least one administrative task in the past year. About one in three task-doers, or 24.4% of respondents overall, reported delayed or foregone care due to an administrative task: Adjusted for demographics, disability status had the strongest association with administrative tasks (adjusted odds ratio [OR] 2.91, p < 0.001) and burden (adjusted OR 1.66, p < 0.001). Being a woman was associated with doing administrative tasks (adjusted OR 2.19, p < 0.001). Being a college graduate was associated with performing an administrative task (adjusted OR 2.79, p < 0.001), while higher income was associated with fewer subsequent burdens (adjusted OR 0.55, p < 0.01). CONCLUSIONS Patients frequently do administrative tasks that can create burdens resulting in delayed/foregone care. The prevalence of delayed/foregone care due to administrative tasks is comparable to similar estimates of cost-related barriers to care. Demographic disparities in burden warrant further attention. Enhancing measurement of patient administrative work and associated burdens may identify opportunities for assessing quality, value, and patient experience.
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Affiliation(s)
- Michael Anne Kyle
- Harvard Medical School, Boston, Massachusetts, USA.,Harvard Business School, Boston, Massachusetts, USA.,Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Austin B Frakt
- Boston VA Healthcare System, Boston, Massachusetts, USA.,Boston University School of Public Health, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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18
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Mukherjee K, Small W, Duszak R. Trends and variations in utilization and costs of radiotherapy for prostate cancer: A SEER medicare analysis from 2007 through 2016. Brachytherapy 2021; 21:12-21. [PMID: 34380592 DOI: 10.1016/j.brachy.2021.06.148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/15/2021] [Accepted: 06/24/2021] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To assess recent changes and disparities in utilization and costs of radiotherapy in Medicare beneficiaries with prostate cancer. METHODS Surveillance, Epidemiology and End Results (SEER) -Medicare linked data from 2006-2016 were used to identify continuously enrolled Medicare beneficiaries with a first-time diagnosis of prostate cancer who, within 12 months of diagnosis, underwent at least one radiotherapy related service. Trends in the utilization of different radiotherapy techniques over time, yearly changes in per-patient costs of radiotherapy, and effect of socio-demographic and clinical characteristics on total cost were measured. Per patient annual costs, annual incidence of prostate cancer, and utilization of radiotherapy were used to estimate total costs of radiotherapy to the Medicare program. RESULTS For Medicare beneficiaries with a first-time diagnosis of prostate cancer, the utilization of intensity modulated radiation therapy (IMRT), proton therapy, and stereotactic body radiation therapy (SBRT) increased 23.62%, 0.74% and 1.61% respectively (p <0.0001) while brachytherapy decreased 17.04% (p <0.0001). Cost per beneficiary decreased $340.24 (95% CI: $136.05 - $544.43) annually (p = 0.0065). Age, registry region, and Gleason score were all associated with expenditures. The total cost to the Medicare program was estimated at US $1.16 billion in the year 2016. DISCUSSION In Medicare beneficiaries with prostate cancer treated with radiotherapy, IMRT is the primary mode of treatment. Utilization of brachytherapy decreased significantly despite the efficacy and cost-effectiveness. Although per patient costs have decreased, the share of patient responsibility remained unaltered across years. The current costs to Medicare of radiotherapy for newly diagnosed prostate cancer patients is substantial.
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Affiliation(s)
- Kumar Mukherjee
- Philadelphia College of Osteopathic Medicine, Suwanee, GA 30024.
| | - William Small
- Loyola University Chicago, Stritch School of Medicine, Department of Radiation Oncology, Cardinal Bernardin Cancer Center, Maywood, IL, 60153 USA
| | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA 30322
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19
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Agarwal R, Connolly J, Gupta S, Navathe AS. Comparing Medicare Advantage And Traditional Medicare: A Systematic Review. Health Aff (Millwood) 2021; 40:937-944. [PMID: 34097516 DOI: 10.1377/hlthaff.2020.02149] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare Advantage enrollment has almost doubled since 2010 and now accounts for more than a third of all Medicare beneficiaries. We performed a systematic review to compare Medicare Advantage and traditional Medicare on key metrics. Evidence from forty-eight studies showed that in most or all comparisons, Medicare Advantage was associated with more preventive care visits, fewer hospital admissions and emergency department visits, shorter hospital and skilled nursing facility lengths-of-stay, and lower health care spending. Medicare Advantage outperformed traditional Medicare in most studies comparing quality-of-care metrics. However, the evidence on patient experience, readmission rates, mortality, and racial/ethnic disparities did not show a trend of better performance in Medicare Advantage. Evidence to date might not fully account for selection bias, unobserved differences in social determinants of health, or risk adjustment challenges, in part because of differences in data quality that limit the comparability of outcomes between Medicare Advantage and traditional Medicare. With Medicare Advantage plans expected to grow in popularity, policy makers should support policies to improve data completeness and comparability, and health plans should focus on improving patient experience.
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Affiliation(s)
- Rajender Agarwal
- Rajender Agarwal is director of the Center for Health Reform, in Southlake, Texas
| | - John Connolly
- John Connolly is a medical student in the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, in Philadelphia, Pennsylvania
| | - Shweta Gupta
- Shweta Gupta is the fellowship director of the Oncology Program, Department of Medicine, John H. Stroger Jr. Hospital of Cook County, in Chicago, Illinois
| | - Amol S Navathe
- Amol S. Navathe is a core investigator at the Corporal Michael J. Cresencz Veterans Affairs Medical Center; an assistant professor in the Department of Medical Ethics and Health Policy, Perelman School of Medicine; and a senior fellow at the Leonard Davis Institute of Health Economics, University of Pennsylvania, all in Philadelphia
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Abstract
PURPOSE The purpose of this article was to investigate the organizational and market-level variables associated with sustained superior hospital performance on Value-Based Purchasing total performance scores (TPS). METHODOLOGY TPS for 2014 through 2017 was obtained from the Centers for Medicare & Medicaid Services Hospital Compare website. Market-level data were from the 2017 Area Health Resource File, and hospital-level data were from the 2014 American Hospital Association Annual Survey database. We specified a logistic regression model to identify significant predictors of hospitals with sustained superior performance on TPS, that is, "sustainers." PRINCIPAL FINDINGS Only 8.4% of hospitals were classified as sustainers. Hospitals located in rural markets with a high Medicare Advantage penetration had a higher likelihood of being classified as sustainers. High RN staffing levels, lower Medicare share of inpatient days, not-for-profit ownership, and small size were all significant organizational predictors of sustained superior performance. CONCLUSIONS Both modifiable characteristics, such as nurse staffing levels, and nonmodifiable characteristics, such as rural markets and small hospital size, are associated with the likelihood of hospitals sustaining superior performance over time. PRACTICE IMPLICATIONS Managers need to carefully examine their staffing levels as they pursue interventions to sustain high TPS overtime. Moreover, factors such as Medicare share of inpatient days and size need to be considered when understanding barriers to sustained performance on Value-Based Purchasing domains.
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Park S, Meyers DJ, Langellier BA. Rural Enrollees In Medicare Advantage Have Substantial Rates Of Switching To Traditional Medicare. Health Aff (Millwood) 2021; 40:469-477. [PMID: 33646865 DOI: 10.1377/hlthaff.2020.01435] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicare beneficiaries in rural areas may face challenges to gaining access to care, particularly if enrolled in Medicare Advantage (MA) plans with limited benefits and restrictive provider networks. These barriers to care may, in turn, increase switching to traditional fee-for-service Medicare among rural MA enrollees. Using 2010-16 Medicare Current Beneficiary Survey data, we found that switching from traditional Medicare to Medicare Advantage was uncommon among enrollees, both rural (1.7 percent) and nonrural (2.2 percent). Switching from Medicare Advantage to traditional Medicare was more common in both settings, especially for rural enrollees (10.5 percent) compared with nonrural enrollees (5.0 percent). The differential was even greater among rural enrollees who were high cost or high need. Of eleven care satisfaction variables we examined, dissatisfaction with care access had the strongest association with switching from Medicare Advantage to traditional Medicare among rural enrollees. Our findings point to the importance of developing policies targeted at improving care access for rural MA enrollees.
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Affiliation(s)
- Sungchul Park
- Sungchul Park is an assistant professor in the Department of Health Management and Policy at the Drexel Dornsife School of Public Health, in Philadelphia, Pennsylvania
| | - David J Meyers
- David J. Meyers is an assistant professor in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Brent A Langellier
- Brent A. Langellier is an assistant professor in the Department of Health Management and Policy at the Drexel Dornsife School of Public Health
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Nicholas LH, Langa KM, Bynum JPW, Hsu JW. Financial Presentation of Alzheimer Disease and Related Dementias. JAMA Intern Med 2021; 181:220-227. [PMID: 33252621 PMCID: PMC7851732 DOI: 10.1001/jamainternmed.2020.6432] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
IMPORTANCE Alzheimer disease and related dementias (ADRD), currently incurable neurodegenerative diseases, can threaten patients' financial status owing to memory deficits and changes in risk perception. Deteriorating financial capabilities are among the earliest signs of cognitive decline, but the frequency and extent of adverse financial events before and after diagnosis have not been characterized. OBJECTIVES To describe the financial presentation of ADRD using administrative credit data. DESIGN, SETTING, AND PARTICIPANTS This retrospective secondary data analysis of consumer credit report outcomes from 1999 to 2018 linked to Medicare claims data included 81 364 Medicare beneficiaries living in single-person households. EXPOSURES Occurrence of adverse financial events in those with vs without ADRD diagnosis and time of adverse financial event from ADRD diagnosis. MAIN OUTCOMES AND MEASURES Missed payments on credit accounts (30 or more days late) and subprime credit scores. RESULTS Overall, 54 062 (17 890 [33.1%] men; mean [SD] age, 74 [7.3] years) were never diagnosed with ADRD during the sample period and 27 302 had ADRD for at least 1 quarter of observation (8573 [31.4%] men; mean [SD] age, 79.4 [7.5] years). Single Medicare beneficiaries diagnosed with ADRD were more likely to miss payments on credit accounts as early as 6 years prior to diagnosis compared with demographically similar beneficiaries without ADRD (7.7% vs 7.3%; absolute difference, 0.4 percentage points [pp]; 95% CI, 0.07-0.70:) and to develop subprime credit scores 2.5 years prior to diagnosis (8.5% vs 8.1%; absolute difference, 0.38 pp; 95% CI, 0.04-0.72). By the quarter after diagnosis, patients with ADRD remained more likely to miss payments than similar beneficiaries who did not develop ADRD (7.9% vs 6.9%; absolute difference, 1.0 pp; 95% CI, 0.67-1.40) and more likely to have subprime credit scores than those without ADRD (8.2% vs 7.5%; absolute difference, 0.70 pp; 95% CI, 0.34-1.1). Adverse financial events were more common among patients with ADRD in lower-education census tracts. The patterns of adverse events associated with ADRD were unique compared with other medical conditions (eg, glaucoma, hip fracture). CONCLUSIONS AND RELEVANCE Alzheimer disease and related dementias were associated with adverse financial events years prior to clinical diagnosis that become more prevalent after diagnosis and were most common in lower-education census tracts.
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Affiliation(s)
- Lauren Hersch Nicholas
- Johns Hopkins School of Public Health & School of Medicine, Institute for Social Research, Baltimore, Maryland.,University of Colorado School of Public Health.,Institute for Social Research, University of Michigan Medical School, Ann Arbor, Michigan
| | - Kenneth M Langa
- Institute for Social Research, University of Michigan Medical School, Ann Arbor, Michigan.,University of Michigan Medical School, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.,Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan
| | - Julie P W Bynum
- University of Michigan Medical School, Ann Arbor.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Joanne W Hsu
- Federal Reserve Board of Governors & Howard University, Washington, DC.,Howard University
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23
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Alcusky M, Mick EO. Should Medicare Advantage Plans Receive Billions in Additional Risk-based Payments for Potentially Unmanaged Conditions? Med Care 2021; 59:93-95. [PMID: 33394895 DOI: 10.1097/mlr.0000000000001484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew Alcusky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
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24
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Meyers DJ, Trivedi AN. Medicare Advantage Chart Reviews Are Associated With Billions in Additional Payments for Some Plans. Med Care 2021; 59:96-100. [PMID: 32925467 PMCID: PMC7855237 DOI: 10.1097/mlr.0000000000001412] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In the Medicare Advantage (MA) program, private plans receive capitated payments that are adjusted based on their enrollees' number and type of clinical conditions. Plans have the ability to review charts to identify additional conditions that are not present in claims data, thereby increasing risk-adjusted payments. Recently the Government Accountability Office released a report raising concerns about the use of these chart reviews as a potential tool for upcoding. OBJECTIVES To measure the extent to which plans receive additional payments for chart reviews, and the variation in chart reviews across plans. RESEARCH DESIGN In this cross-sectional study we use 2015 MA Encounter data to calculate how many additional diagnoses codes were added for each enrollee using chart reviews. We then calculate how these additional diagnosis codes translate to additional reimbursements across plans. SUBJECTS A total of 14,021,692 beneficiaries enrolled in 510 MA contracts in 2015. MEASURES Individual and contract level hierarchical condition category codes, total plan reimbursement. RESULTS Chart reviews were associated with a $2.3 billion increase in payments to plans, a 3.7% increase in Medicare spending to MA plans. Just 10% of plans accounted for 42% of the $2.3 billion in additional spending attributed to chart review. Among these plans, the relative increase in risk score from chart review was 17.2%. For-profit plans engaged in chart reviews substantially more frequently than nonprofit plans. CONCLUSIONS Given the substantial and highly variable increase in payments attributable to chart review, further investigation of the validity of this practice and its implications for Medicare spending is needed.
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Affiliation(s)
- David J Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI
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25
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Abstract
OBJECTIVE The objective of this study was to analyze new telehealth benefits offered by Medicare Advantage (MA) plans in 2020 and examine plan characteristics associated with the provision of the new telehealth benefits. RESEARCH DESIGN Using publicly available data from the Centers for Medicare and Medicaid Services, we identified unique MA plans with at least 1 enrollee in January 2020. We examined whether plans offered any new telehealth benefits in 2020, the 20 most common types of telehealth services covered, and cost-sharing. Next, we used multivariable logistic regression to identify associations between offering any telehealth benefits and plan characteristics. We conducted a similar analysis for each of the 3 most commonly covered telehealth services. RESULTS Of 2992 unique MA plans, 58.1% offered new telehealth benefits in 2020. The most frequently covered services were primary care, mental health, and urgent care. Coverage for other types of services was limited. Our multivariable logistic regression showed that offering any new telehealth benefits was not more common among plans in rural areas, but was more likely among national plans, those with a monthly premium, those with >3540 enrollees, and those with a star rating of 4.0-4.5. The new telehealth benefits were less likely to be provided by for-profit plans. Overall, findings remained similar when analyzed according to the type of services. CONCLUSIONS MA plans are embracing new telehealth benefits, but there is room for improvement. Policymakers should consider how to accelerate the adoption curve of telehealth in MA plans.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University
| | - Brent A Langellier
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University
| | - Robert E Burke
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
- Research at the Hospital Medical Section, University of Pennsylvania, Philadelphia, PA
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26
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Levinson Z, Adler-Milstein J. A decade of experience for high-needs beneficiaries under Medicare Advantage. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100490. [PMID: 33129177 DOI: 10.1016/j.hjdsi.2020.100490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 09/19/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe the association between longitudinal enrollment in Medicare Advantage (MA) and utilization, access, quality of care, and health outcomes for beneficiaries with complex health needs. DATA SOURCES/STUDY SETTING Beneficiary characteristics, enrollment, and outcomes data from the 2004-2016 waves of the Health and Retirement Study (HRS). STUDY DESIGN Using the HRS panel structure, we identified beneficiaries consistently reporting high needs as well as enrollment in MA versus traditional Medicare (TM). We first evaluated a robust set of beneficiary characteristics to identify those that distinguish beneficiaries who consistently enrolled in MA versus TM. We then described adjusted differences in outcomes between high-needs beneficiaries who consistently enrolled in MA versus TM. PRINCIPAL FINDINGS Among high-needs beneficiaries, there was a modest amount of favorable selection into MA based on health. Controlling for several characteristics, MA enrollees used less care (with a 6.6 percentage point (pp) lower probability of hospitalization, 4.7 fewer physician visits, and a 5.1 pp lower probability of using home health care), had a 4.1 pp greater probability of being unable to afford their care, and had a 5.7 pp lower probability of reporting that they were very satisfied with their care. Compared to associations between MA and outcomes for high-needs beneficiaries, for non-high-needs beneficiaries MA enrollment was associated with smaller decreases in utilization and no statistically significant difference in the inability to afford care. CONCLUSIONS Our descriptive findings raise the possibility that high-needs beneficiaries may experience unique challenges in MA compared to their non-high-needs counterparts.
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Affiliation(s)
- Zachary Levinson
- RAND Corporation 1200 South Hayes Street Arlington, Virginia, 22202, USA.
| | - Julia Adler-Milstein
- Center for Clinical Informatics and Improvement Research, Department of Medicine University of California, San Francisco 3333 California St, Suite 265, San Francisco, CA, 94118, USA.
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27
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Park S, Larson EB, Fishman P, White L, Coe NB. Differences in Health Care Utilization, Process of Diabetes Care, Care Satisfaction, and Health Status in Patients With Diabetes in Medicare Advantage Versus Traditional Medicare. Med Care 2020; 58:1004-1012. [PMID: 32925471 PMCID: PMC7572707 DOI: 10.1097/mlr.0000000000001390] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The objective of this study was to determine differences in health care utilization, process of diabetes care, care satisfaction, and health status for Medicare Advantage (MA) and traditional Medicare (TM) beneficiaries with and without diabetes. METHODS Using the 2010-2016 Medicare Current Beneficiary Survey, we identified MA and TM beneficiaries with and without diabetes. To address the endogenous plan choice between MA and TM, we used an instrumental variable approach. Using marginal effects, we estimated differences in the outcomes between MA and TM beneficiaries with and without diabetes. RESULTS Our instrumental variable analysis showed that compared with TM beneficiaries with diabetes, MA beneficiaries with diabetes had less annual health care utilization, including -22.4 medical provider visits [95% confidence interval (CI): -23.6 to -21.1] and -3.4 outpatient hospital visits (95% CI: -3.8 to -3.0). A significant difference between MA and TM beneficiaries without diabetes was only observed in medical provider visits and the difference was greater among beneficiaries with diabetes than beneficiaries without diabetes (-12.5 medical provider visits; 95% CI: -15.9 to -9.2). While we did not detect significant differences in 5 measures of the process of diabetes care between MA and TM beneficiaries with diabetes, there were inconsistent results in the other 3 measures. There were no or marginal differences in care satisfaction and health status between MA and TM beneficiaries with and without diabetes. CONCLUSIONS MA enrollment was associated with lower health care utilization without compromising care satisfaction and health status, particularly for beneficiaries with diabetes. MA may have a more efficient care delivery system for beneficiaries with diabetes.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington
| | | | - Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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28
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Hooker K, Phibbs S, Irvin VL, Mendez-Luck CA, Doan LN, Li T, Turner S, Choun S. Depression Among Older Adults in the United States by Disaggregated Race and Ethnicity. THE GERONTOLOGIST 2020; 59:886-891. [PMID: 30561600 DOI: 10.1093/geront/gny159] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVES As the population becomes increasingly diverse, it is important to understand the prevalence of depression across a racially and ethnically diverse older population. The purpose of this study was to compare rates of depression by age and disaggregated racial and ethnic groups to inform practitioners and target resource allocation to high risk groups. RESEARCH DESIGN AND METHODS Data were from the Centers for Medicare and Medicaid Services Health Outcomes Survey, Cohorts 15 and 16, a national and annual survey of a racially diverse group of adults aged 65 and older who participate in Medicare Advantage plans (N = 175,956). Depression was operationalized by the Patient Health Questionnaire-2 (PHQ-2); we estimated a logistic regression model and adjusted standard errors to account for 403 Medicare Advantage Organizations. RESULTS Overall, 10.2% of the sample (n = 17,957) reported a PHQ-2 score of 3 or higher, indicative of a positive screen for depression. After adjusting for covariates, odds of screening positively for depression were higher among participants self-reporting as Mexican (odds ratio [OR] = 1.19), Puerto Rican (OR = 1.46), Cuban (OR = 1.57), another Hispanic/Latino (OR = 1.29), and multiple Hispanic/Latino (OR = 1.84) ethnicities, compared with non-Hispanic whites. Odds were also higher among participants reporting that their race was black/African American (OR = 1.20), Asian Indian (OR = 1.67), Filipino (OR = 1.30), Native Hawaiian/Pacific Islander (OR = 1.82), or two or more races (OR = 1.50), compared with non-Hispanic whites. DISCUSSION AND IMPLICATIONS Prevalence varied greatly across segments of the population, suggesting that certain racial/ethnic groups are at higher risk than others. These disparities should inform distribution of health care resources; efforts to educate and ameliorate depression should be culturally targeted.
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Affiliation(s)
- Karen Hooker
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis
| | - Sandi Phibbs
- Department of Health Science and Recreation, College of Health and Human Sciences, San Jose State University, California
| | - Veronica L Irvin
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis
| | - Carolyn A Mendez-Luck
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis
| | - Lan N Doan
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis
| | - Tao Li
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis
| | - Shelbie Turner
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis
| | - Soyoung Choun
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis
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29
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Park S, White L, Fishman P, Larson EB, Coe NB. Health Care Utilization, Care Satisfaction, and Health Status for Medicare Advantage and Traditional Medicare Beneficiaries With and Without Alzheimer Disease and Related Dementias. JAMA Netw Open 2020; 3:e201809. [PMID: 32227181 PMCID: PMC7485599 DOI: 10.1001/jamanetworkopen.2020.1809] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Importance Compared with traditional Medicare (TM) fee-for-service plans, Medicare Advantage (MA) plans may provide more-efficient care for beneficiaries with Alzheimer disease and related dementias (ADRD) without compromising care quality. Objective To determine differences in health care utilization, care satisfaction, and health status for MA and TM beneficiaries with and without ADRD. Design, Setting, and Participants A cohort study was conducted of MA and TM beneficiaries with and without ADRD from all publicly available years of the Medicare Current Beneficiary Survey between 2010 and 2016. To address advantageous selection into MA plans, county-level MA enrollment rate was used as an instrument. Data were analyzed between July 2019 and December 2019. Exposures Enrollment in MA. Main Outcomes and Measures Self-reported health care utilization, care satisfaction, and health status. Results The sample included 47 100 Medicare beneficiaries (25 900 women [54.9%]; mean [SD] age, 72.2 [11.4] years). Compared with TM beneficiaries with ADRD, MA beneficiaries with ADRD had lower utilization across the board, including a mean of -22.3 medical practitioner visits (95% CI, -24.9 to -19.8 medical practitioner visits), -2.3 outpatient hospital visits (95% CI, -3.6 to -1.1 outpatient hospital visits), -0.2 inpatient hospital admissions (95% CI, -0.3 to -0.1 inpatient hospital admissions), and -0.1 long-term care facility stays (95% CI, -0.2 to -0.1 long-term care facility stays). A similar trend was observed among beneficiaries without ADRD, but the difference was greater between MA and TM beneficiaries with ADRD than between MA and TM beneficiaries without ADRD (mean, -15.0 medical practitioner visits [95% CI, -18.7 to -11.3 medical practitioner visits], -1.7 outpatient hospital visits [95% CI, -3.0 to -0.3 outpatient hospital visits], and -0.1 inpatient hospital admissions [95% CI, -1.0 to 0.0 inpatient hospital admissions]). Overall, no or negligible differences were detected in care satisfaction and health status between MA and TM beneficiaries with and without ADRD. Conclusions and Relevance Compared with TM beneficiaries, MA beneficiaries had lower health care utilization without compromising care satisfaction and health status. This difference was more pronounced among beneficiaries with ADRD. These findings suggest that MA plans may be delivering health care more efficiently than TM, especially for beneficiaries with ADRD.
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Affiliation(s)
- Sungchul Park
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Lindsay White
- RTI International, Research Triangle Park, North Carolina
| | - Paul Fishman
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - Eric B Larson
- Kaiser Permanent Washington Health Research Institute, Seattle, Washington
| | - Norma B Coe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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30
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Newhouse JP, Landrum MB, Price M, McWilliams JM, Hsu J, McGuire TG. The Comparative Advantage of Medicare Advantage. AMERICAN JOURNAL OF HEALTH ECONOMICS 2019; 5:281-301. [PMID: 31032383 PMCID: PMC6481953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We ascertain the degree of service-level selection in Medicare Advantage (MA) using individual level data on the 100 most frequent HCC's or combination of HCC's from two national insurers in 2012-2013. We find differences in the distribution of beneficiaries across HCC's between TM and MA, principally in the smaller share of MA enrollees with no coded HCC, consistent with greater coding intensity in MA. Among those with an HCC code, absolute differences between MA and TM shares of beneficiaries are small, consistent with little service-level selection. Variation in HCC margins does not predict differences between an HCC's share of MA and TM enrollees, although one cannot a priori sign a relationship between margin and service-level selection. Margins are negatively associated with the importance of post-acute care in the HCC. Margins among common chronic disease classes amenable to medical management and typically managed by primary care physicians are larger than among diseases typically managed by specialists. These margin differences by disease are robust against a test for coding effects and suggest that the average technical efficiency of MA relative to TM may vary by diagnosis. If so, service-level selection on the basis of relative technical efficiency could be welfare enhancing.
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Affiliation(s)
- Joseph P Newhouse
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston
| | - Mary Beth Landrum
- Department of Health Care Policy, Harvard Medical School, Harvard University, Boston
| | | | - J Michael McWilliams
- Department of Health Care Policy, Harvard Medical School, Harvard University and Department of Medicine, Brigham and Women's Hospital, Boston
| | - John Hsu
- Mongan Institute for Health Care Policy, Massachusetts General Hospital and Department of Health Care Policy, Harvard Medical School, Harvard University, Boston
| | - Thomas G McGuire
- Department of Health Care Policy, Harvard Medical School, Harvard University
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31
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Meyers DJ, Belanger E, Joyce N, McHugh J, Rahman M, Mor V. Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries. JAMA Intern Med 2019; 179:524-532. [PMID: 30801625 PMCID: PMC6450306 DOI: 10.1001/jamainternmed.2018.7639] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE How often enrollees with complex care needs leave the Medicare Advantage (MA) program and what might drive their decisions remain unknown. OBJECTIVE To characterize trends in switching to and from MA among high-need beneficiaries and to evaluate the drivers of disenrollment decisions. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study of MA and traditional Medicare (TM) enrollees from January 1, 2014, through December 31, 2015, used a multinomial logit regression stratified by Medicare-Medicaid eligibility status. All 14 589 645 non-high-need MA enrollees and 1 302 470 high-need enrollees in the United States who survived until the end of 2014 were eligible for the analysis. Data were analyzed from November 1, 2017, through August 1, 2018. EXPOSURES Enrollee dual eligibility and high-need status (based on complex chronic conditions, multiple morbidities, use of health care services, functional impairment, and frailty indicators), MA plan star rating, and cost sharing. MAIN OUTCOMES AND MEASURES The proportion of enrollees who disenrolled into TM, remained in the same MA plan, or who switched plans within the MA program. RESULTS A total of 13 901 816 enrollees were included in the analysis (56.2% women; mean [SD] age, 70.9 [9.9] years). Among the 1 302 470 high-need enrollees, an adjusted 4.6% (95% CI, 4.5%-4.6%) of Medicare-only and 14.8% (95% CI, 14.5%-15.0%) of Medicare-Medicaid members switched from MA to TM compared with 3.3% (95% CI, 3.3%-3.3%) and 4.6% (95% CI, 4.5%-4.7%), respectively, among non-high-need enrollees. Among enrollees in low-quality plans, 23.0% (95% CI, 22.3%-23.9%) of Medicare and 42.8% (95% CI, 40.5%-45.1%) of dual-eligible high-need enrollees left MA. Even in high-quality plans, high-need members disenrolled at higher rates than non-high-need members (4.9% [95% CI, 4.6%-5.2%] vs 1.8% [95% CI, 1.8%-1.9%] for Medicare-only enrollees and 11.3% vs 2.4% dual eligible enrollees). Enrollment in a 5.0-star rated plan was associated with a 30.1-percentage point reduction (95% CI, -31.7 to -28.4 percentage points) in the probability of disenrollment among high-need individuals. A $100 increase in monthly premiums was associated with a 33.9-percentage point increase (95% CI, -34.9 to -33.0 percentage points) in the likelihood of switching plans, and a small reduction in the likelihood of disenrolling (-2.7 percentage points; 95% CI, -3.2 to -2.2 percentage points). Among Medicare-Medicaid eligible participants, 14.1% (95% CI, 14.0%-14.2%) of high-need and 16.7% (95% CI, 16.6%-16.7%) of non-high-need enrollees switched from TM to MA. CONCLUSIONS AND RELEVANCE Results of this study suggest that substantially higher disenrollment from MA plans occurs among high-need and Medicare-Medicaid eligible enrollees. This study's findings suggest that star ratings have the strongest association with disenrollment trends, whereas increases in monthly premiums are associated with greater likelihood of switching plans.
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Affiliation(s)
- David J Meyers
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Emmanuelle Belanger
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Nina Joyce
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - John McHugh
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, New York
| | - Momotazur Rahman
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island.,Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island.,US Department of Veterans Affairs Medical Center, Providence, Rhode Island
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32
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Curto V, Einav L, Finkelstein A, Levin J, Bhattacharya J. Health Care Spending and Utilization in Public and Private Medicare. AMERICAN ECONOMIC JOURNAL. APPLIED ECONOMICS 2019; 11:302-332. [PMID: 31131073 PMCID: PMC6532061 DOI: 10.1257/app.20170295] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
We compare healthcare spending in public and private Medicare using newly available claims data from Medicare Advantage (MA) insurers. MA insurer revenues are 30 percent higher than their healthcare spending. Adjusting for enrollee mix, healthcare spending per enrollee in MA is 9 to 30 percent lower than in traditional Medicare (TM), depending on the way we define "comparable" enrollees. Spending differences primarily reflect differences in healthcare utilization, with similar reductions for "high value" and "low value" care, rather than healthcare prices. We present evidence consistent with MA plans encouraging substitution to less expensive care and engaging in utilization management. (JEL H11, H42, H51, I11, I13).
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Affiliation(s)
- Vilsa Curto
- Curto: Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA 02115 ; Einav: Department of Economics, Stanford University, 579 Serra Mall, Stanford, CA 94305-6072 and NBER; Finkelstein: Department of Economics, MIT, 50 Memorial Drive, Cambrdige, MA 02142-1347 and NBER; Levin: Graduate School of Business, Stanford University, 655 Knight Way, Stanford, CA 94305-7298 and NBER; Bhattacharya: School of Medicine, Stanford University, 616 Serra Street, Stanford, CA 94305-6019 . We are grateful to Diego Jimenez, Andelyn Russell, Daniel Salmon, and Martina Uccioli for excellent research assistance. We thank the Editor, three anonymous referees, and numerous seminar participants for helpful comments. We gratefully acknowledge support from the NSF (SES-1527942, Bhattacharya, Einav, and Levin), the NIA (R01 AG032449, Einav and Finkelstein; R37 AG036791, Bhattacharya), and the Sloan Foundation (Bhattacharya, Einav, Finkelstein, and Levin). The authors acknowledge the assistance of the Health Care Cost Institute (HCCI) and its data contributors, Aetna, Humana, and UnitedHealthcare, in providing the claims data analyzed in this study
| | - Liran Einav
- Curto: Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA 02115 ; Einav: Department of Economics, Stanford University, 579 Serra Mall, Stanford, CA 94305-6072 and NBER; Finkelstein: Department of Economics, MIT, 50 Memorial Drive, Cambrdige, MA 02142-1347 and NBER; Levin: Graduate School of Business, Stanford University, 655 Knight Way, Stanford, CA 94305-7298 and NBER; Bhattacharya: School of Medicine, Stanford University, 616 Serra Street, Stanford, CA 94305-6019 . We are grateful to Diego Jimenez, Andelyn Russell, Daniel Salmon, and Martina Uccioli for excellent research assistance. We thank the Editor, three anonymous referees, and numerous seminar participants for helpful comments. We gratefully acknowledge support from the NSF (SES-1527942, Bhattacharya, Einav, and Levin), the NIA (R01 AG032449, Einav and Finkelstein; R37 AG036791, Bhattacharya), and the Sloan Foundation (Bhattacharya, Einav, Finkelstein, and Levin). The authors acknowledge the assistance of the Health Care Cost Institute (HCCI) and its data contributors, Aetna, Humana, and UnitedHealthcare, in providing the claims data analyzed in this study
| | - Amy Finkelstein
- Curto: Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA 02115 ; Einav: Department of Economics, Stanford University, 579 Serra Mall, Stanford, CA 94305-6072 and NBER; Finkelstein: Department of Economics, MIT, 50 Memorial Drive, Cambrdige, MA 02142-1347 and NBER; Levin: Graduate School of Business, Stanford University, 655 Knight Way, Stanford, CA 94305-7298 and NBER; Bhattacharya: School of Medicine, Stanford University, 616 Serra Street, Stanford, CA 94305-6019 . We are grateful to Diego Jimenez, Andelyn Russell, Daniel Salmon, and Martina Uccioli for excellent research assistance. We thank the Editor, three anonymous referees, and numerous seminar participants for helpful comments. We gratefully acknowledge support from the NSF (SES-1527942, Bhattacharya, Einav, and Levin), the NIA (R01 AG032449, Einav and Finkelstein; R37 AG036791, Bhattacharya), and the Sloan Foundation (Bhattacharya, Einav, Finkelstein, and Levin). The authors acknowledge the assistance of the Health Care Cost Institute (HCCI) and its data contributors, Aetna, Humana, and UnitedHealthcare, in providing the claims data analyzed in this study
| | - Jonathan Levin
- Curto: Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA 02115 ; Einav: Department of Economics, Stanford University, 579 Serra Mall, Stanford, CA 94305-6072 and NBER; Finkelstein: Department of Economics, MIT, 50 Memorial Drive, Cambrdige, MA 02142-1347 and NBER; Levin: Graduate School of Business, Stanford University, 655 Knight Way, Stanford, CA 94305-7298 and NBER; Bhattacharya: School of Medicine, Stanford University, 616 Serra Street, Stanford, CA 94305-6019 . We are grateful to Diego Jimenez, Andelyn Russell, Daniel Salmon, and Martina Uccioli for excellent research assistance. We thank the Editor, three anonymous referees, and numerous seminar participants for helpful comments. We gratefully acknowledge support from the NSF (SES-1527942, Bhattacharya, Einav, and Levin), the NIA (R01 AG032449, Einav and Finkelstein; R37 AG036791, Bhattacharya), and the Sloan Foundation (Bhattacharya, Einav, Finkelstein, and Levin). The authors acknowledge the assistance of the Health Care Cost Institute (HCCI) and its data contributors, Aetna, Humana, and UnitedHealthcare, in providing the claims data analyzed in this study
| | - Jay Bhattacharya
- Curto: Department of Health Policy and Management, T.H. Chan School of Public Health, Harvard University, 677 Huntington Avenue, Boston, MA 02115 ; Einav: Department of Economics, Stanford University, 579 Serra Mall, Stanford, CA 94305-6072 and NBER; Finkelstein: Department of Economics, MIT, 50 Memorial Drive, Cambrdige, MA 02142-1347 and NBER; Levin: Graduate School of Business, Stanford University, 655 Knight Way, Stanford, CA 94305-7298 and NBER; Bhattacharya: School of Medicine, Stanford University, 616 Serra Street, Stanford, CA 94305-6019 . We are grateful to Diego Jimenez, Andelyn Russell, Daniel Salmon, and Martina Uccioli for excellent research assistance. We thank the Editor, three anonymous referees, and numerous seminar participants for helpful comments. We gratefully acknowledge support from the NSF (SES-1527942, Bhattacharya, Einav, and Levin), the NIA (R01 AG032449, Einav and Finkelstein; R37 AG036791, Bhattacharya), and the Sloan Foundation (Bhattacharya, Einav, Finkelstein, and Levin). The authors acknowledge the assistance of the Health Care Cost Institute (HCCI) and its data contributors, Aetna, Humana, and UnitedHealthcare, in providing the claims data analyzed in this study
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Differences in Hospitalizations Between Fee-for-Service and Medicare Advantage Beneficiaries. Med Care 2019; 57:8-12. [DOI: 10.1097/mlr.0000000000001000] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lipschutz DA. Commentary: Don’t Further Privatize Medicare. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2019; 56:46958019867612. [PMID: 31382843 PMCID: PMC6685114 DOI: 10.1177/0046958019867612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Medicare program is quietly becoming privatized through increasing enrollment in Medicare Advantage (MA) plans, even though MA has not lived up to its promise of delivering better care at lower cost. Policymakers must reverse this trend and ensure parity between traditional Medicare and MA rather than encourage it through legislation that only benefits MA. Furthermore, as discussions of expanding health insurance coverage through Medicare intensify, policymakers should explore what version of Medicare they wish to expand.
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Bergquist SL, McGuire TG, Layton TJ, Rose S. Sample Selection for Medicare Risk Adjustment Due to Systematically Missing Data. Health Serv Res 2018; 53:4204-4223. [PMID: 30277560 PMCID: PMC6232496 DOI: 10.1111/1475-6773.13046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To assess the issue of nonrepresentative sampling in Medicare Advantage (MA) risk adjustment. DATA SOURCES Medicare enrollment and claims data from 2008 to 2011. DATA EXTRACTION Risk adjustment predictor variables were created from 2008 to 2010 Part A and B claims and the Medicare Beneficiary Summary File. Spending is based on 2009-2011 Part A and B, Durable Medical Equipment, and Home Health Agency claims files. STUDY DESIGN A propensity-score matched sample of Traditional Medicare (TM) beneficiaries who resembled MA enrollees was created. Risk adjustment formulas were estimated using multiple techniques, and performance was evaluated based on R2 , predictive ratios, and formula coefficients in the matched sample and a random sample of TM beneficiaries. PRINCIPAL FINDINGS Matching improved balance on observables, but performance metrics were similar when comparing risk adjustment formula results fit on and evaluated in the matched sample versus fit on the random sample and evaluated in the matched sample. CONCLUSIONS Fitting MA risk adjustment formulas on a random sample versus a matched sample yields little difference in MA plan payments. This does not rule out potential improvements via the matching method should reliable MA encounter data and additional variables become available for risk adjustment.
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Affiliation(s)
| | | | | | - Sherri Rose
- Department of Health Care PolicyHarvard Medical SchoolBostonMA
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36
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Affiliation(s)
- Patricia Neuman
- From the Kaiser Family Foundation, Washington office, Washington, DC
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37
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Jung HY, Li Q, Rahman M, Mor V. Medicare Advantage enrollees' use of nursing homes: trends and nursing home characteristics. THE AMERICAN JOURNAL OF MANAGED CARE 2018; 24:e249-e256. [PMID: 30130025 PMCID: PMC6225776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To examine temporal trends in the prevalence of nursing home (NH) patients participating in Medicare Advantage (MA) and to identify the characteristics of both these patients and the NHs that provide care for them. STUDY DESIGN Retrospective cohort study. METHODS Data sources included the Medicare enrollment file, Minimum Data Set, and facility-level data from the Certification and Survey Provider Enhanced Reporting system. Longitudinal trends of NH use by MA enrollees were examined over the period 2000 to 2013 and logistic regression models were used to identify facility characteristics associated with having a high proportion of MA patients. RESULTS The proportion of MA enrollees in NHs more than doubled between 2000 and 2013, increasing 125% during this period. Notable differences in facility characteristics were found between NHs that serve high proportions of MA enrollees and other NHs. High-MA NHs tended to be larger facilities affiliated with chains. These NHs also had better quality indicators, such as higher staffing levels, lower use of antipsychotics, and lower odds of rehospitalization. Additionally, high-MA NHs were more likely to be in counties with higher Medicare managed care penetration and less market concentration. CONCLUSIONS MA plans may be selectively contracting with NHs, as evidenced by the larger shares of MA patients who have been placed in facilities with better performance on quality measures. This may reflect MA plans concentrating enrollees in specific facilities and building "networks" of postacute and long-term care providers that provide better and more efficient care.
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Affiliation(s)
- Hye-Young Jung
- Department of Healthcare Policy and Research, Weill Cornell Medical College, 402 E 67th St, New York, NY 10065.
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Hayford TB, Burns AL. Medicare Advantage Enrollment and Beneficiary Risk Scores: Difference-in-Differences Analyses Show Increases for All Enrollees On Account of Market-Wide Changes. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2018; 55:46958018788640. [PMID: 30052104 PMCID: PMC6077888 DOI: 10.1177/0046958018788640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Medicare adjusts payments to Medicare Advantage (MA) insurers using risk scores that summarize the relationship between fee-for-service (FFS) Medicare spending and beneficiaries’ demographic characteristics and documented health conditions. Research shows that MA insurers have increasingly documented conditions more thoroughly than traditional Medicare—resulting in higher payments to insurers—but little is known about what factors contribute to diverging risk scores. We apportion that divergence between market-wide increases and increases that vary with length of MA enrollment. We also examine whether effects vary across plan types and whether the enrollment duration effect is contingent upon remaining with the same insurer. Using Medicare administrative data from 2008 to 2013, we employ a difference-in-differences model to compare the growth in risk scores of Medicare beneficiaries who switch from FFS to MA to that of beneficiaries who remain in FFS. We find that the effect of MA enrollment on risk scores increased from 5% in 2009 to 8% in 2012 and that continuous enrollment in MA was associated with an additional 1.2% increase per year, regardless of continuous enrollment with an insurer. Thus, even among those who switched to MA in 2009, enrollment duration comprised less than one-third of the coding intensity difference in 2012. We also find that risk scores grew faster in areas with greater MA penetration and among Health Maintenance Organization enrollees. Overall, our findings suggest that market-wide factors contributed most to the increasing divergence between FFS and MA risk scores.
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Geruso M, Layton TJ. Selection in Health Insurance Markets and Its Policy Remedies. THE JOURNAL OF ECONOMIC PERSPECTIVES : A JOURNAL OF THE AMERICAN ECONOMIC ASSOCIATION 2018; 31:23-50. [PMID: 29465215 PMCID: PMC10898225 DOI: 10.1257/jep.31.4.23] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Selection (adverse or advantageous) is the central problem that inhibits the smooth, efficient functioning of competitive health insurance markets. Even—and perhaps especially—when consumers are well-informed decision makers and insurance markets are highly competitive and offer choice, such markets may function inefficiently due to risk selection. Selection can cause markets to unravel with skyrocketing premiums and can cause consumers to be under- or overinsured. In its simplest form, adverse selection arises due to the tendency of those who expect to incur high health care costs in the future to be the most motivated purchasers. The costlier enrollees are more likely to become insured rather than to remain uninsured, and conditional on having health insurance, the costlier enrollees sort themselves to the more generous plans in the choice set. These dual problems represent the primary concerns for policymakers designing regulations for health insurance markets. In this essay, we review the theory and evidence concerning selection in competitive health insurance markets and discuss the common policy tools used to address the problems it creates. We emphasize the two markets that seem especially likely to be targets of reform in the short and medium term: Medicare Advantage (the private plan option available under Medicare) and the state-level individual insurance markets.
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40
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Affiliation(s)
- J Michael McWilliams
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts (J.M.M.)
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41
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Baker LC, Bundorf MK, Devlin AM, Kessler DP. Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays. Health Aff (Millwood) 2018; 35:1444-51. [PMID: 27503970 DOI: 10.1377/hlthaff.2015.1553] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines.
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Affiliation(s)
- Laurence C Baker
- Laurence C. Baker is a professor of health research and policy at Stanford University, in California, and a research associate at the National Bureau of Economic Research, in Cambridge, Massachusetts
| | - M Kate Bundorf
- M. Kate Bundorf is a professor of health research and policy at Stanford University and a faculty research fellow at the National Bureau of Economic Research
| | - Aileen M Devlin
- Aileen M. Devlin is a research fellow at the Stanford Law School
| | - Daniel P Kessler
- Daniel P. Kessler is a professor in the Law School and the Graduate School of Business, a professor (by courtesy) in the Department of Health Research and Policy, and a senior fellow at the Hoover Institution, all at Stanford University. He is also a research associate at the National Bureau of Economic Research
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42
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Goldberg EM, Keohane LM, Mor V, Trivedi AN, Jung HY, Rahman M. Preferred Provider Relationships Between Medicare Advantage Plans and Skilled Nursing Facilities Reduce Switching Out of Plans: An Observational Analysis. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2018; 55:46958018797412. [PMID: 30175669 PMCID: PMC6122232 DOI: 10.1177/0046958018797412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/03/2018] [Accepted: 08/07/2018] [Indexed: 12/03/2022]
Abstract
Unlike traditional Medicare, Medicare Advantage (MA) plans contract with specific skilled nursing facilities (SNFs). Patients treated in an MA plan's preferred SNF may benefit from enhanced coordination and have a lower likelihood of switching out of their plan. Using 2011-2014 Medicare enrollment data, the Medicare Healthcare Effectiveness Data and Information Set, and the Minimum Data Set, we examined Medicare enrollees who were newly admitted to SNFs in 2012-2013. We used the Centers for Medicare & Medicaid Services star rating to distinguish between MA plans and show how SNF concentration experienced by patients varies between patients in plans with different star ratings. We found that highly rated MA plans steer their patients to a smaller number of SNFs, and these patients are less likely to switch out of their plans. Strengthening the MA plan-SNF relationship may lower disenrollment rates for SNF beneficiaries, imparting benefits to both patients and payers.
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Affiliation(s)
| | | | - Vincent Mor
- Brown University, Providence, RI,
USA
- Providence VA Medical Center, RI,
USA
| | - Amal N. Trivedi
- Brown University, Providence, RI,
USA
- Providence VA Medical Center, RI,
USA
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43
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Cotton P, Newhouse JP, Volpp KG, Fendrick AM, Oesterle SL, Oungpasuk P, Aggarwal R, Wilensky G, Sebelius K. Medicare Advantage: Issues, Insights, and Implications for the Future. Popul Health Manag 2017; 19:S1-S8. [PMID: 27834576 PMCID: PMC5107672 DOI: 10.1089/pop.2016.29013.pc] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Medicare Advantage: Issues, Insights, and Implications for the Future Paul Cotton, Joseph P. Newhouse, PhD, Kevin G. Volpp, MD, PhD, A. Mark Fendrick, MD, Susan Lynne Oesterle, Pat Oungpasuk, Ruchi Aggarwal, Gail Wilensky, PhD, and Kathleen Sebelius Editorial S-2 D.B. Nash, and A.Y. Schwartz The History, Impact, and Future of the Medicare Advantage Star Ratings System S-3 P. Cotton Medicare Advantage and Traditional Fee-For-Service Medicare S-4 J.P. Newhouse Behavioral Economics: Key to Effective Care Management Programs for Patients, Payers, and Providers S-5 K.G. Volpp Value-Based Insurance Design: A Promising Strategy for Medicare Advantage S-6 A.M. Fendrick, S.L. Oesterle, P. Oungpasuk, and R. Aggarwal Two Perspectives on the Future of Medicare Advantage S-7 G. Wilensky and K. Sebelius
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Glazer J, McGuire TG. Paying Medicare Advantage plans: To level or tilt the playing field. JOURNAL OF HEALTH ECONOMICS 2017; 56:281-291. [PMID: 28318667 PMCID: PMC5548660 DOI: 10.1016/j.jhealeco.2016.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 12/08/2016] [Accepted: 12/12/2016] [Indexed: 05/29/2023]
Abstract
Medicare beneficiaries are eligible for health insurance through the public option of traditional Medicare (TM) or may join a private Medicare Advantage (MA) plan. Both are highly subsidized but in different ways. Medicare pays for most of costs directly in TM, and subsidizes MA plans based on a "benchmark" for each beneficiary choosing a private plan. The level of this benchmark is arguably the most important policy decision Medicare makes about the MA program. Many analysts recommend equalizing Medicare's subsidy across the options - referred to in policy circles as a "level playing field." This paper studies the normative question of how to set the level of the benchmark, applying the versatile model developed by Einav and Finkelstein (EF) to Medicare. The EF framework implies unequal subsidies to counteract risk selection across plan types. We also study other reasons to tilt the field: the relative efficiency of MA vs. TM, market power of MA plans, and institutional features of the way Medicare determines subsidies and premiums. After review of the empirical and policy literature, we conclude that in areas where the MA market is competitive, the benchmark should be set below average costs in TM, but in areas characterized by imperfect competition in MA, it should be raised in order to offset output (enrollment) restrictions by plans with market power. We also recommend specific modifications of Medicare rules to make demand for MA more price elastic.
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Affiliation(s)
- Jacob Glazer
- Tel Aviv University, Israel and University of Warwick, UK.
| | - Thomas G McGuire
- Department of Health Care Policy, Harvard Medical School and NBER, United States
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45
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Newhouse JP. Risk adjustment with an outside option. JOURNAL OF HEALTH ECONOMICS 2017; 56:256-258. [PMID: 29248055 PMCID: PMC5739068 DOI: 10.1016/j.jhealeco.2017.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/19/2016] [Accepted: 01/09/2017] [Indexed: 05/29/2023]
Abstract
Much of the risk adjustment literature has focused on how persons should be classified and given weights. It has given less attention to the amount of funds in the risk adjustment pool. If, however, there is an outside option, as there is in the principal American risk adjustment systems, there can be favorable or adverse selection in the risk pool. To address any such selection requires that the risk adjustment system not be zero sum; the main American risk adjustment systems differ in this respect.
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46
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Decarolis F, Guglielmo A. Insurers' response to selection risk: Evidence from Medicare enrollment reforms. JOURNAL OF HEALTH ECONOMICS 2017; 56:383-396. [PMID: 29248062 DOI: 10.1016/j.jhealeco.2017.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 02/24/2017] [Accepted: 02/27/2017] [Indexed: 06/07/2023]
Abstract
Evidence on insurers' behavior in environments with both risk selection and market power is largely missing. We fill this gap by providing one of the first empirical accounts of how insurers adjust plan features when faced with potential changes in selection. Our strategy exploits a 2012 reform allowing Medicare enrollees to switch to 5-star contracts at anytime. This policy increased enrollment into 5-star contracts, but without risk selection worsening. Our findings show that this is due to 5-star plans lowering both premiums and generosity, thus becoming more appealing for most beneficiaries, but less so for those in worse health conditions.
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47
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Kauer L. Long-term Effects of Managed Care. HEALTH ECONOMICS 2017; 26:1210-1223. [PMID: 27510575 DOI: 10.1002/hec.3392] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 06/28/2016] [Accepted: 07/06/2016] [Indexed: 06/06/2023]
Abstract
Managed care (MC) plans have been introduced to curb the ever increasing health care costs. Many previous studies on effectiveness lacked a long-term perspective; hence, the sustainability of (possible) savings remains unclear. Moreover, because of their incentives, MC plans are susceptible to under-provision of care. Most of these possibly negative effects can only be observed in the long-term. This paper analyzes the long-term effects of MC plans on cost savings, mortality, and the use of service, using administrative data from a large Swiss health insurer. The identification is based on a propensity-score matching approach, where individuals who enter an MC plan are compared over 10 years to individuals who remain in a standard fee-for-service plan. Cost savings are substantial and sustainable, and the mortality rate is lower in MC plans. Cost savings are driven by fewer consultations and fewer days in hospital care, although the probability of visiting a provider at least once per year is similar or even higher for persons in MC plans. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Lukas Kauer
- CSS Institute for Empirical Health Economics, Lucerne, Switzerland
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48
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Affiliation(s)
- Bruce E Landon
- From the Department of Health Care Policy, Harvard Medical School, and the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston (B.E.L.), and the Heller School for Social Policy and Management, Brandeis University, Waltham (R.E.M.) - both in Massachusetts
| | - Robert E Mechanic
- From the Department of Health Care Policy, Harvard Medical School, and the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston (B.E.L.), and the Heller School for Social Policy and Management, Brandeis University, Waltham (R.E.M.) - both in Massachusetts
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49
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Frank RG, McGuire TG. Regulated Medicare Advantage And Marketplace Individual Health Insurance Markets Rely On Insurer Competition. Health Aff (Millwood) 2017; 36:1578-1584. [PMID: 28874484 DOI: 10.1377/hlthaff.2017.0613] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Two important individual health insurance markets-Medicare Advantage and the Marketplaces-are tightly regulated but rely on competition among insurers to supply and price health insurance products. Many local health insurance markets have little competition, which increases prices to consumers. Furthermore, both markets are highly subsidized in ways that can exacerbate the impact of market power-that is, the ability to set price above cost-on health insurance prices. Policy makers need to foster robust competition in both sectors and avoid designing subsidies that make the market-power problem worse.
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Affiliation(s)
- Richard G Frank
- Richard G. Frank is the Margaret T. Morris Professor of Health Economics in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Thomas G McGuire
- Thomas G. McGuire is a professor of health economics in the Department of Health Care Policy, Harvard Medical School
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50
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Beveridge RA, Mendes SM, Caplan A, Rogstad TL, Olson V, Williams MC, McRae JM, Vargas S. Mortality Differences Between Traditional Medicare and Medicare Advantage: A Risk-Adjusted Assessment Using Claims Data. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2017; 54:46958017709103. [PMID: 28578605 PMCID: PMC5798747 DOI: 10.1177/0046958017709103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Medicare Advantage (MA) has grown rapidly since the Affordable Care Act; nearly one-third of Medicare beneficiaries now choose MA. An assessment of the comparative value of the 2 options is confounded by an apparent selection bias favoring MA, as reflected in mortality differences. Previous assessments have been hampered by lack of access to claims diagnosis data for the MA population. An indirect comparison of mortality as an outcome variable was conducted by modeling mortality on a traditional fee-for-service (FFS) Medicare data set, applying the model to an MA data set, and then evaluating the ratio of actual-to-predicted mortality in the MA data set. The mortality model adjusted for clinical conditions and demographic factors. Model development considered the effect of potentially greater coding intensity in the MA population. Further analysis calculated ratios for subpopulations. Predicted, risk-adjusted mortality was lower in the MA population than in FFS Medicare. However, the ratio of actual-to-predicted mortality (0.80) suggested that the individuals in the MA data set were less likely to die than would be predicted had those individuals been enrolled in FFS Medicare. Differences between actual and predicted mortality were particularly pronounced in low income (dual eligibility), nonwhite race, high morbidity, and Health Maintenance Organization (HMO) subgroups. After controlling for baseline clinical risk as represented by claims diagnosis data, mortality differences favoring MA over FFS Medicare persisted, particularly in vulnerable subgroups and HMO plans. These findings suggest that differences in morbidity do not fully explain differences in mortality between the 2 programs.
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Affiliation(s)
| | | | | | | | | | | | | | - Stefan Vargas
- 2 Thomas Jefferson University, Philadelphia, PA, USA
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