We examine how long-term care insurance (LTCI) affects informal care use and expectations among the insured individuals and co-residence and labor market outcomes of their adult children. We address the endogeneity of LTCI coverage by instrumenting for LTCI with changes in state tax treatment of LTCI insurance policies. We do not find evidence of reductions in informal care use over a horizon of approximately eight years. However, we find that LTCI coverage reduces parents' perceptions of the willingness of their children to care for them in the future and that the behavior of adult children changes, with LTCI resulting in lower likelihoods of adult children co-residing and stronger labor market attachment. These findings provide empirical support for the presence of spillovers of LTCI on the economic behaviors of family members.
Publications
Family spillovers and long-term care insurance
Coe, N. B., Goda, G. S., & Van Houtven, C. H. (2023). Family spillovers and long-term care insurance. Journal of health economics, 90, 102781. https://doi.org/10.1016/j.jhealeco.2023.102781
Can a Home-Based Collaborative Care Model Reduce Health Services Utilization for Older Medicaid Beneficiaries Living with Depression and Co-occurring Chronic Conditions? A Quasi-experimental Study
Depression remains a major public health issue for older adults, increasing risk of costly health services utilization. While home-based collaborative care models (CCM) like PEARLS have been shown to effectively treat depression in low-income older adults living with multiple chronic conditions, their economic impact is unclear. We conducted a quasi-experimental study to estimate PEARLS effect on health service utilization among low-income older adults. Our secondary data analysis merged de-identified PEARLS program data (N = 1106), home and community-based services (HCBS) administrative data (N = 16,096), and Medicaid claims and encounters data (N = 164) from 2011 to 2016 in Washington State. We used nearest neighbor propensity matching to create a comparison group of social service recipients similar to PEARLS participants on key determinants of utilization guided by Andersen's Model. Primary outcomes were inpatient hospitalizations, emergency room (ER) visits, and nursing home days; secondary outcomes were long-term supports and services (LTSS), mortality, depression and health. We used an event study difference-in-difference (DID) approach to compare outcomes. Our final dataset included 164 older adults (74% female, 39% people of color, mean PHQ-9 12.2). One-year post-enrollment, PEARLS participants had statistically significant improvements in inpatient hospitalizations (69 fewer hospitalizations per 1000 member months, p = 0.02) and 37 fewer nursing home days (p < 0.01) than comparison group participants; there were no significant improvements in ER visits. PEARLS participants also experienced lower mortality. This study shows the potential value of home-based CCM for participants, organizations and policymakers. Future research is needed to examine potential cost savings.
Steinman, L., Xing, J., Court, B., Coe, N. B., Yip, A., Hill, C., Rector, B., Baquero, B., Weiner, B. J., & Snowden, M. (2023). Can a Home-Based Collaborative Care Model Reduce Health Services Utilization for Older Medicaid Beneficiaries Living with Depression and Co-occurring Chronic Conditions? A Quasi-experimental Study. Administration and policy in mental health, 50(5), 712–724. https://doi.org/10.1007/s10488-023-01271-0
Addressing Serious Illness Care in Medicare Advantage
No abstract available
Ankuda, C. K., Aldridge, M. D., Braun, R. T., Coe, N. B., Grabowski, D. C., Meyers, D. J., Ryan, A., Stevenson, D., & Teno, J. M. (2023). Addressing Serious Illness Care in Medicare Advantage. The New England journal of medicine, 388(19), 1729–1732. https://doi.org/10.1056/NEJMp2302252
Patient Experience at US Hospitals Following the Caregiver Advise, Record, Enable (CARE) Act
In this cohort study of 2763 short-term, acute-care US hospitals from 2013 to 2019, differential improvements in patient experience were found across multiple measures, including communication with nurses and physicians and receipt of discharge information, among CARE Act states compared with non–CARE Act states after policy passage.
Lee, C. R., Taggert, E., Coe, N. B., & Chatterjee, P. (2023). Patient Experience at US Hospitals Following the Caregiver Advise, Record, Enable (CARE) Act. JAMA network open, 6(5), e2311253. https://doi.org/10.1001/jamanetworkopen.2023.11253
Let's Not Repeat History's Mistakes: Two Cautions to Scientists on the Use of Race in Alzheimer's Disease and Alzheimer's Disease Related Dementias Research
Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD) research has advanced gene and biomarker technologies to aid identification of individuals at risk for dementia. This innovation is a lynchpin in development of disease-modifying therapies. The emerging science could transform outcomes for patients and families. However, current limitations in the racial representation and inclusion of racial diversity in research limits the relevance of these technologies: AD/ADRD research cohorts used to define biomarker cutoffs are mostly White, despite clinical and epidemiologic research that shows Black populations are among those experiencing the greatest burdens of AD/ADRD. White cohorts alone are insufficient to characterize heterogeneity in disease and in life experiences that can alter AD/ADRD's courses. The National Institute on Aging (NIA) has called for increased racial diversity in AD/ADRD research. While scientists are working to implement NIA's plan to build more diverse research cohorts, they are also seeking out opportunities to consider race in AD/ADRD research. Recently, scientists have posed two ways of including race in AD/ADRD research: ancestry-based verification of race and race-based adjustment of biomarker test results. Both warrant careful examination for how they are impacting AD/ADRD science with respect to specific study objectives and the broader mission of the field. If these research methods are not grounded in pursuit of equity and justice, biases they introduce into AD/ADRD science could perpetuate, or even worsen, disparities in AD/ADRD research and care.
Stites, S. D., & Coe, N. B. (2023). Let's Not Repeat History's Mistakes: Two Cautions to Scientists on the Use of Race in Alzheimer's Disease and Alzheimer's Disease Related Dementias Research. Journal of Alzheimer's disease : JAD, 92(3), 729–740. https://doi.org/10.3233/JAD-220507
Racial and Ethnic Disparities in Access to and Enrollment in High-quality Medicare Advantage Plans
Racial and ethnic minority enrollees in Medicare Advantage (MA) plans tend to be in lower-quality plans, measured by a 5-star quality rating system. We examine whether differential access to high-rated plans was associated with this differential enrollment in high-rated plans by race and ethnicity among MA enrollees.
Park, S., Werner, R. M., & Coe, N. B. (2023). Racial and ethnic disparities in access to and enrollment in high-quality Medicare Advantage plans. Health services research, 58(2), 303–313. https://doi.org/10.1111/1475-6773.13977
Rural Disparities in Use of Family and Formal Caregiving for Older Adults with Disabilities.
Older adults residing in rural areas are more likely to receive any family care than those in urban areas. From 2004 to 2016, a higher proportion of older adults in rural areas receive care from family caregivers exclusively while a lower proportion receive care from formal caregivers exclusively. When examining older adults in urban areas, we find the opposite — a higher proportion of urban adults rely exclusively on formal care and a lower proportion rely exclusively on family care in 2016 compared to 2004.
Miller, K. E. M., Ornstein, K. A., & Coe, N. B. (2023). Rural disparities in use of family and formal caregiving for older adults with disabilities. Journal of the American Geriatrics Society., 71(9), 2865–2870. https://doi.org/10.1111/jgs.18376
Medicaid Integrated Purchasing for Physical and Behavioral Health: Early Adopters' Perceptions of Payment Reform Implementation in Washington State.
The Centers for Medicare and Medicaid Innovation (CMMI) gave rise to the State Innovation Models (SIMs). Medicaid Integrated Purchasing for Physical and Behavioral Health, referred to as Payment Model 1 (PM1), was a core payment redesign area of the Washington State SIM project under which our research team was contracted to provide an evaluation. In doing so, we leveraged an open systems conceptual model to assess qualitatively Early Adopter stakeholders’ perceived effects of implementation. Between 2017 and 2019, we conducted three rounds of interviews, examining themes of care coordination, common facilitators and barriers to integration, and potential concerns for sustaining the initiative into the future. Further, we noted the initiative’s complexity may require the establishment of enduring partnerships, secure funding sources, and committed regional leadership to ensure longer-term success.
Park, Sungchul PhD*,†; Werner, Rachel M. PhD, MD‡,§,∥; Coe, Norma B. PhD§,¶. Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions. Medical Care 60(12):p 872-879, December 2022. | DOI: 10.1097/MLR.0000000000001770
Public spending on acute and long-term care for Alzheimer's disease and related dementias
We estimate the spending attributable to Alzheimer's disease and related dementias (ADRD) to the United States government for the first 5 years post-diagnosis. Using data from the Health and Retirement Study matched to Medicare and Medicaid claims, we identify a retrospective cohort of adults with a claims-based ADRD diagnosis along with matched controls. The costs attributable to ADRD are $15,632 for traditional Medicare and $8833 for Medicaid per dementia case over the first 5 years after diagnosis. Seventy percent of Medicare costs occur in the first 2 years; Medicaid costs are concentrated among the longer-lived beneficiaries who are more likely to need long-term care and become Medicaid eligible. Because the distribution of the incremental costs varies over time and between insurance programs, when interventions occur and the effect on the disease course will have implications for how much and which program reaps the benefits.
Coe, N. B., White, L., Oney, M., Basu, A., & Larson, E. B. (2023). Public spending on acute and long-term care for Alzheimer's disease and related dementias. Alzheimer's & dementia : the journal of the Alzheimer's Association, 19(1), 150–157. https://doi.org/10.1002/alz.12657
Association of Medicare Advantage Star Ratings With Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions
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. We examined whether there were racial and ethnic disparities in ACSC hospitalizations among MA enrollees overall and by star rating.
Park S, Werner RM, Coe NB: Association of Medicare Advantage Star Ratings with Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive Conditions. Medical Care 60(12): 872-879, Dec 2022.