In this study, the authors estimated the direct health care costs attributable to ADRD among older adults within a large MA plan. A retrospective cohort design was used to estimate direct total, outpatient, inpatient, ambulatory pharmacy, and nursing home costs for 3 years before and after an incident ADRD diagnosis for 927 individuals diagnosed with ADRD relative to a sex-matched and birth year-matched set of 2945 controls. The authors found that greater total health care costs among individuals with ADRD are primarily driven by nursing home costs.
Fishman P; White L; Ingraham B; Larson EB; Crane PK; Coe NB: Health Care Costs of Alzheimer’s and Related Dementias within a Medicare Managed Care Provider. Medical Care. Sep 2020. 58(9) 833-841
Differences in Health Care Utilization, Process of Diabetes Care, Care Satisfaction and Health Status in Patients with Diabetes in Medicare Advantage vs Traditional Medicare. Medical Care
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. Using the 2010–2016 Medicare Current Beneficiary Survey, the authors identified MA and TM beneficiaries with and without diabetes. To address the endogenous plan choice between MA and TM, the authors used an instrumental variable approach. Using marginal effects, the authors estimated differences in the outcomes between MA and TM beneficiaries with and without diabetes. 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.
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, Medical Care: September 10, 2020 - Volume Publish Ahead of Print
Association of Medicare Advantage Penetration With Per Capita Spending, Emergency Department Visits, and Readmission Rates Among Fee-for-Service Medicare Beneficiaries With High Comorbidity Burden
Rapid growth of Medicare Advantage (MA) plans has the potential to change clinical practice for both MA and fee-for-service (FFS) beneficiaries, particularly for high-need, high-cost beneficiaries with multiple chronic conditions or a costly single condition. The authors assessed whether MA growth from 2010 to 2017 spilled over to county-level per capita spending, emergency department visits, and readmission rates among FFS beneficiaries, and how much this varied by the comorbidity burden of the beneficiary. The authors also examined whether the association between MA growth and per capita spending in FFS varied in beneficiaries with specific chronic conditions. MA growth was associated with decreased FFS spending and emergency department visits only among beneficiaries with six or more chronic conditions. MA growth was associated with decreased FFS spending among beneficiaries with 11 of the 20 chronic conditions. This suggests that MA growth may drive improvements in efficiency of health care delivery for high-need, high-cost beneficiaries.
Park S, Langellier BA, Burke RE, Figueroa JF, Coe NB. Association of Medicare Advantage Penetration With Per Capita Spending, Emergency Department Visits, and Readmission Rates Among Fee-for-Service Medicare Beneficiaries With High Comorbidity Burden. Medical Care Research and Review (MCRR). 2020 Aug 26: Epub ahead of print.
Sociodemographic trends in the United States may influence future dementia-associated mortality, yet there is little evidence about their potential impact. The study objective was to estimate the effect of dementia on survival in adults stratified by sex, education, and marital status. Methods: Using survey data from the Health and Retirement Study (HRS) linked to Medicare claims from 1991 to 2012, the authors identified a retrospective cohort of adults with at least one International Classification of Diseases—ninth revision—Clinical Modification (ICD-9-CM) dementia diagnosis code (n = 3,714). For each case, the authors randomly selected up to five comparators, matching on sex, birth year, education, and HRS entry year (n = 9,531), and assigned comparators the diagnosis date of their matched case. The authors estimated a survival function for the entire study population and then within successive strata defined by sex, education, and marital status. Both sex and level of education moderate the relationship between dementia diagnosis and length of survival.
White L, Fishman P, Basu A, Crane PK, Larson EB, Coe NB. Dementia Is Associated With Earlier Mortality for Men and Women in the United States. Gerontology and Geriatric Medicine, 2020 Aug.
Achieving effective, high-quality primary care for Medicare beneficiaries is a national priority as it encourages health promotion and maintenance, potentially reducing intensity of acute care services. Currently, there is ample data documenting intensity of primary care services, including rates of utilization and expenditures, for beneficiaries in fee-for-service Traditional Medicare (TM). However, less is known about the beneficiaries enrolled in Medicare Advantage (MA) plans, which now include 33% of the Medicare population. As managed care’s goal is to control costs while maintaining a high quality, MA plans may encourage greater primary care than is the case in TM. We examined whether this is the case by assessing primary care utilization and expenditures among beneficiaries in MA and TM.
Park S, Figueroa JF, Fishman P, Coe NB: Primary Care Utilization and Expenditures in Traditional Medicare and Medicare Advantage, 2007-2016. Journal of General Internal Medicine,35(8):2480-2481 May 2020.
Health Care Utilization, Care Satisfaction, and Health Status for Medicare Advantage and Traditional Medicare Beneficiaries With and Without Alzheimer Disease and Related Dementias
The purpose of this study was to determine differences in health care utilization, care satisfaction, and health status for Medicare Advantage (MA) and Traditional Medicare (TM) beneficiaries with and without Alzheimer’s Disease and Related Dementias (ADRD). 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. 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.
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 Network Open 3(3), Mar 2020.
The Impact of Medicare Copayments for Skilled Nursing Facilities on Length of Stay, Outcomes, and Costs
The purpose of this article was to investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. The authors used retrospective cohort study from 2012 to 2016 including Medicare claims and SNF assessment data, including SNF admissions for Medicare fee-for-service beneficiaries. The authors first estimated how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. They then then used benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment. Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes.
Werner RM, Konetzka RT, Qi M, Coe NB: The Impact of Medicare Copayments for Skilled Nursing Facilities on Length of Stay, Outcomes, and Costs. Health Services Research 54(6): 1184-1192, Dec 2019.
This article uses the 2006 to 2012 Medicare Current Beneficiary Survey, to examine disease-specific switching rates between TM and MA and disease-specific ratios of mean baseline total Medicare expenditures of beneficiaries remaining in the same plan (stayers) vs those switching to another plan (switchers), respectively. We focused on beneficiaries with 1 or more of 10 incident diagnoses. Beneficiaries with a new diagnosis of Alzheimer disease and related dementias, hypertension, and psychiatric disorders had relatively high rates of switching into MA plans and low rates of switching out of MA plans. Among those with new diagnoses of psychiatric disorders and diabetes, more costly beneficiaries (those with higher costs) switched into MA plans. For cancer, more costly beneficiaries remained in MA plans.
Park S, Fishman P, White L, Larson EB, Coe NB: Disease-Specific Plan Switching Between Traditional Medicare and Medicare Advantage. Kaiser Permanente Journal 24, Nov 2019.
Association Between High Discharge Rates of Vulnerable Patients and Skilled Nursing Facility Copayments
Medicare pays for 100% of postacute care provided by skilled nursing facilities (SNFs) during the first 20 days within a benefit period. However, on the 21st day, most patients become responsible for a daily copayment of more than $150. This copayment may present a significant financial burden for some patients—particularly those with limited economic means—and motivate them to discharge from SNFs on the 20th day of care based on their financial resources rather than their recovery status. In this article, the researchers examine whether patterns of SNF discharge are associated with this change in Medicare payment responsibility on day 20.
P Chatterjee, M Qi, NB Coe, RT Konetzka, RM Werner. “Association of High Discharge Rates of Vulnerable Patients with Skilled Nursing Facility Copayments.” JAMA Internal Medicine. 2019. May. doi:10.1001/jamainternmed.2019.1209
The State of Washington, as part of a State Innovation Model (SIM) grant, is changing the payment model within state employee health insurance plans. The system is moving away from traditional fee-for-service reimbursement to value-based payment, through insurance design (the creation of accountable care network insurance products) and bundled payment strategies. New plans were rolled out in January 2016 (enrollment occurred in late 2015), with the stated goal of getting 80% of state employees covered by plans that contain value-based purchasing within the next 5 years. The goal of payment reform is to improve member experience, member health, and cut costs. However, changing health insurance during employment can, directly and indirectly, change labor market outcomes. Decreasing costs of insurance could lead people to remain in the state-employment sector longer. However, it could also influence retirement timing, by changing the relative costs of insurance through improving health.
This paper examines who switches to value-based insurance, where the insurance explicitly decreases premiums without changing out-of-pocket costs. We find that the peak age for switching insurance plans is 35–45, even among the subsample of individuals who would not need to change their usual sources of care. Second, we look at the labor market activity – both leaving the state-employee sector and retiring from state-employment – and find that younger workers with value-based insurance plans are less likely to leave state employment. Further, we find evidence of value-based insurance, available at a reduced cost to both employees and retirees, leads to a shifting downward in the distribution of retirement age. While these findings support the existence of both the price and income effects, the effect sizes are rather small.
Coe, NB, “Impact of Health Plan Reforms in Washington on Employment Decisions.” Journal of Pension Economics and Finance. 2019, 1-15, DOI: 10.1017/S1474747219000143