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Shirakura Y, Shobugawa Y, Saito R. Geographic variation in inpatient medical expenditure among older adults aged 75 years and above in Japan: a three-level multilevel analysis of nationwide data. Front Public Health 2024; 12:1306013. [PMID: 38481853 PMCID: PMC10933056 DOI: 10.3389/fpubh.2024.1306013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/18/2024] [Indexed: 05/07/2024] Open
Abstract
Introduction In Japan, a country at the forefront of population ageing, significant geographic variation has been observed in inpatient medical expenditures for older adults aged 75 and above (IMEP75), both at the small- and large-area levels. However, our understanding of how different levels of administrative (geographic) units contribute to the overall geographic disparities remains incomplete. Thus, this study aimed to assess the degree to which geographic variation in IMEP75 can be attributed to municipality-, secondary medical area (SMA)-, and prefecture-level characteristics, and identify key factors associated with IMEP75. Methods Using nationwide aggregate health insurance claims data of municipalities for the period of April 2018 to March 2019, we conducted a multilevel linear regression analysis with three levels: municipalities, SMA, and prefectures. The contribution of municipality-, SMA-, and prefecture-level correlates to the overall geographic variation in IMEP75 was evaluated using the proportional change in variance across six constructed models. The effects of individual factors on IMEP75 in the multilevel models were assessed by estimating beta coefficients with their 95% confidence intervals. Results We analysed data of 1,888 municipalities, 344 SMAs, and 47 prefectures. The availability of healthcare resources at the SMA-level and broader regions to which prefectures belonged together explained 57.3% of the overall geographic variance in IMEP75, whereas the effects of factors influencing healthcare demands at the municipality-level were relatively minor, contributing an additional explanatory power of 2.5%. Factors related to long-term and end-of-life care needs and provision such as the proportion of older adults certified as needing long-term care, long-term care benefit expenditure per recipient, and the availability of hospital beds for psychiatric and chronic care and end-of-life care support at home were associated with IMEP75. Conclusion To ameliorate the geographic variation in IMEP75 in Japan, the reallocation of healthcare resources across SMAs should be considered, and drivers of broader regional disparities need to be further explored. Moreover, healthcare systems for older adults must integrate an infrastructure of efficient long-term care and end-of-life care delivery outside hospitals to alleviate the burden on inpatient care.
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Affiliation(s)
- Yuki Shirakura
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
- Department of Active Ageing, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Yugo Shobugawa
- Department of Active Ageing, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Reiko Saito
- Division of International Health (Public Health), Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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2
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Loehrer AP. High-deductible Health Plans, Surgical Conditions, and a Different Moral Hazard. Ann Surg 2023; 278:e675-e676. [PMID: 37450695 DOI: 10.1097/sla.0000000000006010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Affiliation(s)
- Andrew P Loehrer
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Dartmouth Cancer Center, Lebanon, NH
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3
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Roberts ET, Kwon Y, Hames AG, McWilliams JM, Ayanian JZ, Tipirneni R. Racial and Ethnic Disparities in Health Care Use and Access Associated With Loss of Medicaid Supplemental Insurance Eligibility Above the Federal Poverty Level. JAMA Intern Med 2023; 183:534-543. [PMID: 37036727 PMCID: PMC10087092 DOI: 10.1001/jamainternmed.2023.0512] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/07/2023] [Indexed: 04/11/2023]
Abstract
Importance Medicaid supplemental insurance covers most cost sharing in Medicare. Among low-income Medicare beneficiaries, the loss of Medicaid eligibility above this program's income eligibility threshold (100% of federal poverty level [FPL]) may exacerbate racial and ethnic disparities in Medicare beneficiaries' ability to afford care. Objective To examine whether exceeding the income threshold for Medicaid, which results in an abrupt loss of Medicaid eligibility, is associated with greater racial and ethnic disparities in access to and use of care. Design, Setting, and Participants This cross-sectional study used a regression discontinuity design to assess differences in access to and use of care associated with exceeding the income threshold for Medicaid eligibility. We analyzed Medicare beneficiaries with incomes 0% to 200% of FPL from the 2008 to 2018 biennial waves of the Health and Retirement Study linked to Medicare administrative data. To identify racial and ethnic disparities associated with the loss of Medicaid eligibility, we compared discontinuities in outcomes among Black and Hispanic beneficiaries (n = 2885) and White beneficiaries (n = 5259). Analyses were conducted between January 1, 2022, and October 1, 2022. Main outcome measures Patient-reported difficulty accessing care due to cost and outpatient service use, medication fills, and hospitalizations measured from Medicare administrative data. Results This cross-sectional study included 8144 participants (38 805 person-years), who when weighted represented 151 282 957 person-years in the community-dwelling population of Medicare beneficiaries aged 50 years and older and incomes less than 200% FPL. In the weighted sample, the mean (SD) age was 75.4 (9.4) years, 66.1% of beneficiaries were women, 14.8% were non-Hispanic Black, 13.6% were Hispanic, and 71.6% were White. Findings suggest that exceeding the Medicaid eligibility threshold was associated with a 43.8 percentage point (pp) (95% CI, 37.8-49.8) lower probability of Medicaid enrollment among Black and Hispanic Medicare beneficiaries and a 31.0 pp (95% CI, 25.4-36.6) lower probability of Medicaid enrollment among White beneficiaries. Among Black and Hispanic beneficiaries, exceeding the threshold was associated with increased cost-related barriers to care (discontinuity: 5.7 pp; 95% CI, 2.0-9.4), lower outpatient use (-6.3 services per person-year; 95% CI, -10.4 to -2.2), and fewer medication fills (-6.9 fills per person-year; 95% CI, -11.4 to -2.5), but it was not associated with a statistically significant discontinuity in hospitalizations. Discontinuities in these outcomes were smaller or nonsignificant among White beneficiaries. Consequently, exceeding the threshold was associated with widened disparities, including greater reductions in outpatient service use (disparity: -6.2 services per person-year; 95% CI, -11.7 to -0.6; P = .03) and medication fills (disparity: -7.2 fills per person-year; 95% CI, -13.4 to -1.0; P = .02) among Black and Hispanic vs White beneficiaries. Conclusions and Relevance This cross-sectional study found that loss of eligibility for Medicaid supplemental insurance above the federal poverty level, which increases cost sharing in Medicare, was associated with increased racial and ethnic health care disparities among low-income Medicare beneficiaries. Expanding eligibility for Medicaid supplemental insurance may narrow these disparities.
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Affiliation(s)
- Eric T. Roberts
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Youngmin Kwon
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Alexandra G. Hames
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - J. Michael McWilliams
- Department of Health Care Policy, Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts
| | - John Z. Ayanian
- Division of General Medicine, University of Michigan Medical School and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Renuka Tipirneni
- Division of General Medicine, University of Michigan Medical School and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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He W. Does the immediate reimbursement of medical insurance reduce the socioeconomic inequality in health among the floating population? Evidence from China. Int J Equity Health 2023; 22:96. [PMID: 37198632 DOI: 10.1186/s12939-023-01913-7] [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: 04/04/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Enhancing health intervention for floating populations has become an essential aspect of public health around the world. China launched a policy reform aimed at implementing immediate reimbursement for trans-provincial inpatient treatments. The objective of this study was to investigate the effects of this policy change on socioeconomic inequality in health among the floating population. METHODS This study used two waves of individual-level data from the China Migrants Dynamic Survey (CMDS) collected in 2017 and 2018 as well as administrative hospital data at the city level. The sample included 122061 individuals and 262 cities. Under a quasi-experimental research design, we built up the framework to employ the generalized and multi-period difference-in-differences estimation strategy. We used the number of qualified hospitals that could provide immediate reimbursement to represent the degree and intensity of the implementation of this policy change. We also calculated the Wagstaff Index (WI) to measure socioeconomic inequality in health. RESULTS This policy change and income level had a negative joint impact on the health status of floating population (odds ratio = 0.955, P < 0.01), that is, the lower the income, the better the number of qualified hospitals' effect on health improvement. Furthermore, as the number of qualified tertiary hospitals increased, the health inequality would decrease significantly on average at the city level (P < 0.05). In addition, inpatient utilization as well as total expenditure and reimbursement significantly improved after the policy change, and the magnitude of increase was greater in the relatively lower-income group (P < 0.01). Finally, only inpatient spending could obtain immediate reimbursement in the early stage, thus, compared with primary care, these impacts were greater in tertiary care. CONCLUSIONS Our study revealed that after the implementation of immediate reimbursement, the floating population could obtain greater and more timely reimbursement, which significantly increased its inpatient utilization, promoted health, and reduced the health inequality caused by socioeconomic factors. These results suggest that a more accessible and friendly medical insurance scheme should be promoted for this group.
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Affiliation(s)
- Wen He
- School of Public Administration, Hunan University, Lushan Road (S), Yuelu District, Changsha, 410082, China.
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5
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Saxby K, Byrnes J, de New SC, Nghiem S, Petrie D. Does affirmative action reduce disparities in healthcare use by Indigenous peoples? Evidence from Australia's Indigenous Practice Incentives Program. HEALTH ECONOMICS 2023; 32:853-872. [PMID: 36609870 DOI: 10.1002/hec.4645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
Globally, Indigenous populations experience poorer health but use less primary healthcare than their non-Indigenous counterparts. In 2010, the Australian government introduced a targeted reform aimed at reducing these disparities. The reform reduced, or abolished prescription medicine co-payments and provided financial incentives for GPs to better manage chronic disease care for Indigenous peoples. Exploiting the framework of a natural experiment, we investigate how the reform affected these health disparities in primary and specialist healthcare utilization using longitudinal administrative data from 75,826 Australians, including 1896 Indigenous peoples, with cardiovascular disease. The differences-in-differences estimates indicate that the reform increased primary healthcare use among Indigenous peoples, including 12.9% more prescription medicines, 6.6% more GP services, and 34.0% more chronic disease services, but also reduced specialist attendances by 11.8%. Increases in primary care were larger for those who received the largest co-payment relief and lived in metropolitan regions, whereas the reduction in specialist attendances was concentrated among lower income Indigenous patients. Affirmative action can reduce inequalities in Indigenous use of primary healthcare, albeit careful design is required to ensure that benefits are equitable and do not lead to substitution away from valuable, or necessary, care.
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Affiliation(s)
- Karinna Saxby
- Centre for Health Economics, Monash Business School, Monash University, Victoria, Caulfield East, Australia
| | - Joshua Byrnes
- Centre for Applied Health Economics, Griffith University, Queensland, Nathan, Australia
| | - Sonja C de New
- Centre for Health Economics, Monash Business School, Monash University, Victoria, Caulfield East, Australia
- Institute for the Study of Labor (IZA Bonn), RWI Research Network, Essen, Germany
| | - Son Nghiem
- College of Health & Medicine, Australian National University, Australian Capital Territory, Canberra, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash Business School, Monash University, Victoria, Caulfield East, Australia
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Du W, Liu P, Xu W. Effects of decreasing the out-of-pocket expenses for outpatient care on health-seeking behaviors, health outcomes and medical expenses of people with diabetes: evidence from China. Int J Equity Health 2022; 21:162. [PMID: 36384591 PMCID: PMC9667616 DOI: 10.1186/s12939-022-01775-5] [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] [Received: 04/03/2022] [Revised: 09/18/2022] [Accepted: 10/16/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND To improve access to outpatient services and provide financial support in outpatient expenses for the insured, China has been establishing its scheme of decreasing the out-of-pocket expenses for outpatient care in recent years. There are 156 million diabetes patients in China which almost accounts for a quarter of diabetes population worldwide. Outpatient services plays an important role in diabetes treatment. The study aims to clarify the effects of decreasing the out-of-pocket expenses for outpatient care on health-seeking behaviors, health outcomes and medical expenses of people with diabetes. METHODS This study constructed a two-way fixed effect model, utilized 5,996 diabetes patients' medical visits records from 2019 to 2021, to ascertain the influence of decreasing the out-of-pocket expenses for outpatient care on diabetes patients. The dependent variables were diabetes patients' health-seeking behaviors, health outcomes, medical expenses and expenditure of the basic medical insurance funds for them; the core explanatory variable was the out-of-pocket expenses for outpatient care expressed by the annual outpatient reimbursement ratio. RESULTS With each increase of 1% in the annual outpatient reimbursement ratio: (1) for health-seeking behaviors, a diabetes patient's annual number of outpatient visits and annual number of medical visits increased by 0.021 and 0.014, while the annual number of hospitalizations decreased by 0.006; (2) for health outcomes, a diabetes patient's annual length of hospital stays and average length of a hospital stay decreased by 1.2% and 1.1% respectively, and the number of diabetes complications and Diabetes Complications Severity Index (DCSI) score both decreased by 0.001; (3) for medical expenses, a diabetes patient's annual outpatient expenses, annual inpatient expenses, annual medical expenses and annual out-of-pocket expenses decreased by 2.2%, 4.6%, 2.6% and 4.0%; (4) for expenditure of the basic medical insurance funds for a diabetes patient, the annual expenditure on outpatient services increased by 1.1%, and on inpatient services decreased by 4.4%, but on healthcare services didn't change. CONCLUSION Decreasing the out-of-pocket expenses for outpatient care appropriately among people with diabetes could make patients have a more rational health-seeking behaviors, a better health status and a more reasonable medical expenses while the expenditure of the basic medical insurance funds is stable totally.
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Affiliation(s)
- Wenwen Du
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing,, 211198, Jiangsu, China
| | - Ping Liu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing,, 211198, Jiangsu, China
| | - Wei Xu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing,, 211198, Jiangsu, China.
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Nguyen KH, Lee Y, Thorsness R, Rivera-Hernandez M, Kim D, Swaminathan S, Mehrotra R, Trivedi AN. Medicaid Expansion and Medicare-Financed Hospitalizations Among Adult Patients With Incident Kidney Failure. JAMA HEALTH FORUM 2022; 3:e223878. [PMID: 36331442 PMCID: PMC9636522 DOI: 10.1001/jamahealthforum.2022.3878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Importance Although Medicare provides health insurance coverage for most patients with kidney failure in the US, Medicare beneficiaries who initiate dialysis without supplemental coverage are exposed to substantial out-of-pocket costs. The availability of expanded Medicaid coverage under the Patient Protection and Affordable Care Act (ACA) for adults with kidney failure may improve access to care and reduce Medicare-financed hospitalizations after dialysis initiation. Objective To examine the implications of the ACA's Medicaid expansion for Medicare-financed hospitalizations, health insurance coverage, and predialysis nephrology care among Medicare-covered adults aged 19 to 64 years with incident kidney failure in the first year after initiating dialysis. Design, Setting, and Participants This cross-sectional study used a difference-in-differences approach to assess Medicare-financed hospitalizations among adults aged 19 to 64 years who initiated dialysis between January 1, 2010, and December 31, 2018, while covered by Medicare Part A (up to 5 years postexpansion). Data on patients were obtained from the Renal Management Information System's End Stage Renal Disease Medical Evidence Report, which includes data for all patients initiating outpatient maintenance dialysis regardless of health insurance coverage, treatment modality, or citizenship status, and these data were linked with claims data from the Medicare Provider Analysis and Review. Data were analyzed from January to August 2022. Exposure Living in a Medicaid expansion state. Main Outcomes and Measures Primary outcomes were number of Medicare-financed hospitalizations and hospital days in the first 3 months, 6 months, and 12 months after dialysis initiation. Secondary outcomes included dual Medicare and Medicaid coverage at 91 days after dialysis initiation and the presence of an arteriovenous fistula or graft at dialysis initiation for patients undergoing hemodialysis. Results The study population included 188 671 adults, with 97 071 living in Medicaid expansion states (mean [SD] age, 53.4 [9.4] years; 58 329 men [60.1%]) and 91 600 living in nonexpansion states (mean [SD] age, 53.0 [9.6] years; 52 677 men [57.5%]). In the first 3 months after dialysis initiation, Medicaid expansion was associated with a significant decrease in Medicare-financed hospitalizations (-4.24 [95% CI, -6.70 to -1.78] admissions per 100 patient-years; P = .001) and hospital days (-0.73 [95% CI, -1.08 to -0.39] days per patient-year; P < .001), relative reductions of 8% for both outcomes. Medicaid expansion was associated with a 2.58-percentage point (95% CI, 0.88-4.28 percentage points; P = .004) increase in dual Medicare and Medicaid coverage at 91 days after dialysis initiation and a 1.65-percentage point (95% CI, 0.31-3.00 percentage points; P = .02) increase in arteriovenous fistula or graft at initiation. Conclusions and Relevance In this cross-sectional study with a difference-in-differences analysis, the ACA's Medicaid expansion was associated with decreases in Medicare-financed hospitalizations and hospital days and increases in dual Medicare and Medicaid coverage. These findings suggest favorable spillover outcomes of Medicaid expansion to Medicare-financed care, which is the primary payer for patients with kidney failure.
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Affiliation(s)
- Kevin H. Nguyen
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Rebecca Thorsness
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island,Chief Medical Office, Veterans Affairs New England Healthcare System, Bedford, Massachusetts
| | - Maricruz Rivera-Hernandez
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Daeho Kim
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Shailender Swaminathan
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island,Sapien Labs Centre for Human Brain and Mind, Krea University, India
| | - Rajnish Mehrotra
- Department of Medicine, University of Washington School of Medicine, Seattle
| | - Amal N. Trivedi
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island,Providence Veterans Affairs Medical Center, Providence, Rhode Island
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Xu M, Bittschi B. Does the abolition of copayment increase ambulatory care utilization?: a quasi-experimental study in Germany. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:1319-1328. [PMID: 35084631 DOI: 10.1007/s10198-022-01430-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 01/06/2022] [Indexed: 06/14/2023]
Abstract
Due to a problematic situation with public finances, Germany introduced a copayment scheme for ambulatory care visits in 2004. In 2012, Germany achieved a balanced budget, and copayment was abolished on the 1st of January 2013. This policy change offers a rare opportunity to explore the impact of the abolition of copayment, compared to the much more frequently studied introduction of copayment. We therefore investigate the development of ambulatory care and inpatient care utilization following this policy change among people over 50 in Germany, as well as the heterogeneous impacts among vulnerable people, such as the low-income population, the chronically ill and the elderly over the age of 65. We use data from the Survey of Health, Ageing and Retirement in Europe and adopt a difference-in-differences approach with matching. We found that the abolition of copayment only caused an increase in ambulatory care use in the shorter term, while leading to a significant reduction in the longer term. In addition, we find a negative effect on inpatient care use, i.e., the hospitalization offset effect. Finally, we demonstrate that vulnerable people were more sensitive to the abolition of copayment.
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Affiliation(s)
- Mingming Xu
- School of Public Health (Shenzhen), Sun Yat-sen University, Gongchang Road 66, Shenzhen, 518107, China.
- Department of Economics and Management, Karlsruhe Institute of Technology, Kronenstraβe 34, 76133, Karlsruhe, Germany.
| | - Benjamin Bittschi
- Austrian Institute of Economic Research (WIFO), Arsenal, Objekt 20, 1030, Vienna, Austria
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Rymer JA, Kaltenbach LA, Peterson ED, Cohen DJ, Fonarow GC, Choudhry NK, Henry TD, Cannon CP, Wang TY. Does the Effectiveness of a Medicine Copay Voucher Vary by Baseline Medication Out-Of-Pocket Expenses? Insights From ARTEMIS. J Am Heart Assoc 2022; 11:e026421. [PMID: 36250667 DOI: 10.1161/jaha.122.026421] [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] [Indexed: 11/16/2022]
Abstract
Background Persistence to P2Y12 inhibitors after myocardial infarction (MI) remains low. Out-of-pocket cost is cited as a factor affecting medication compliance. We examined whether a copayment intervention affected 1-year persistence to P2Y12 inhibitors and clinical outcomes. Methods and Results In an analysis of ARTEMIS (Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study), patients with MI discharged on a P2Y12 inhibitor were stratified by baseline out-of-pocket medication burden: low ($0-$49 per month), intermediate ($50-$149 per month), and high (≥$150 per month). The impact of the voucher intervention on 1-year P2Y12 inhibitor persistence was examined using a logistic regression model with generalized estimating equations. We assessed the rates of major adverse cardiovascular events among the groups using a Kaplan-Meier estimator. Among 7351 MI-treated patients at 282 hospitals, 54.2% patients were in the low copay group, 32.0% in the middle copay group, and 13.8% in the high copay group. Patients in higher copay groups were more likely to have a history of prior MI, heart failure, and diabetes compared with the low copay group (all P<0.0001). Voucher use was associated with a significantly higher likelihood of 1-year P2Y12 inhibitor persistence regardless of copayment tier (low copay with versus without voucher: adjusted odds ratio [OR], 1.44 [95% CI, 1.25-1.66]; middle copay: adjusted OR, 1.63 [95% CI, 1.37-1.95]; high copay group: adjusted OR, 1.41 [95% CI, 1.05-1.87]; P interaction=0.42). Patients in the high copay group without a voucher had similar risk of 1-year major adverse cardiovascular events compared with patients in the high copay group with a voucher (adjusted hazard ratio, 0.89 [95% CI, 0.66-1.21]). Conclusions Medication copayment vouchers were associated with higher medication persistence at 1 year following an MI, regardless of out-of-pocket medication burden. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02406677.
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Affiliation(s)
- Jennifer A Rymer
- Duke University School of Medicine Durham NC.,Duke Clinical Research Institute Durham NC
| | | | | | - David J Cohen
- Cardiovascular Research Foundation New York NY.,St. Francis Hospital Roslyn NY
| | - Gregg C Fonarow
- University of California Los Angeles Medical Center Los Angeles CA
| | | | | | | | - Tracy Y Wang
- Duke University School of Medicine Durham NC.,Duke Clinical Research Institute Durham NC
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10
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Xu M, Pei X. Does coinsurance reduction influence informer-sector workers' and farmers' utilization of outpatient care? A quasi-experimental study in China. BMC Health Serv Res 2022; 22:914. [PMID: 35836258 PMCID: PMC9281155 DOI: 10.1186/s12913-022-08301-x] [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: 03/28/2022] [Accepted: 07/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background In recent years, the Chinese government has been trying to improve informal-sector workers’ and farmers’ access to healthcare and reduce their financial burdens by introducing a plan of cost-sharing reduction, but the effect on outpatient care utilization remains unknown. Furthermore, scarce evidence has been provided to help understand the impact of cost-sharing reduction on healthcare use in low- and middle-income countries. The policy change of the coinsurance reduction for outpatient care from 75 to 55% for the enrollees of the Urban and Rural Residents Basic Medical Insurance in Taizhou, China in 2015 provides us a good quasi-experimental setting to explore such an impact. Methods We do a quasi-experimental study to explore the impact of coinsurance reduction on outpatient care use among the informal-sector workers and farmers aged 45 and above by estimating a fixed-effects negative binomial model with the difference-in-differences approach and the matching method. Heterogeneous effects in primary care clinics and for the older people aged 60 and above are also examined. Our data is from the China Health and Retirement Longitudinal Study 2013 and 2015. Results We find neither statistically significant impact of coinsurance reduction on outpatient care utilization in all health facilities for informal-sector workers and farmers aged 45 and above, nor heterogeneous effects in primary care clinics and for older people aged 60 and above. Conclusions We conclude that the coinsurance reduction cannot effectively improve the informal-sector workers’ and farmers’ utilization of healthcare if the cost-sharing undertaken by patients remains high even after the reduction. Besides, improving healthcare quality in primary care clinics may play a more important role than merely introducing a cost-sharing reduction plan in enhancing the role of primary care clinics as gatekeepers. We propose that only a substantial coinsurance reduction may help influence the utilization of healthcare for informal-sector workers and farmers, and enhancing the healthcare quality in primary care clinics should be given priority in low- and middle-income countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08301-x.
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Affiliation(s)
- Mingming Xu
- School of Public Health (Shenzhen), Sun Yat-sen University, Gongchang Road 66, Shenzhen, 518107, China. .,Department of Economics and Management, Karlsruhe Institute of Technology, Kronenstraβe 34, 76133, Karlsruhe, Germany.
| | - Xingtong Pei
- School of Public Health (Shenzhen), Sun Yat-sen University, Gongchang Road 66, Shenzhen, 518107, China
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11
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Kato H, Goto R, Tsuji T, Kondo K. The effects of patient cost-sharing on health expenditure and health among older people: Heterogeneity across income groups. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:847-861. [PMID: 34779932 PMCID: PMC9170661 DOI: 10.1007/s10198-021-01399-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 10/25/2021] [Indexed: 06/13/2023]
Abstract
Despite rapidly rising health expenditure associated with population aging, empirical evidence on the effects of cost-sharing on older people is still limited. This study estimated the effects of cost-sharing on the utilization of healthcare and health among older people, the most intensive users of healthcare. We employed a regression discontinuity design by exploiting a drastic reduction in the coinsurance rate from 30 to 10% at age 70 in Japan. We used large administrative claims data as well as income information at the individual level provided by a municipality. Using the claims data with 1,420,252 person-month observations for health expenditure, we found that reduced cost-sharing modestly increased outpatient expenditure, with an implied price elasticity of - 0.07. When examining the effects of reduced cost-sharing by income, we found that the price elasticities for outpatient expenditure were almost zero, - 0.08, and - 0.11 for lower-, middle-, and higher-income individuals, respectively, suggesting that lower-income individuals do not have more elastic demand for outpatient care compared with other income groups. Using large-scale mail survey data with 3404 observations for self-reported health, we found that the cost-sharing reduction significantly improved self-reported health only among lower-income individuals, but drawing clear conclusions about health outcomes is difficult because of a lack of strong graphical evidence to support health improvement. Our results suggest that varying cost-sharing by income for older people (i.e., smaller cost-sharing for lower-income individuals and larger cost-sharing for higher-income individuals) may reduce health expenditure without compromising health.
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Affiliation(s)
- Hirotaka Kato
- Graduate School of Business Administration, Keio University, 4-1-1 Hiyoshi, Yokohama, Kanagawa 223-8521 Japan
- Graduate School of Health Management, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582 Japan
| | - Rei Goto
- Graduate School of Business Administration, Keio University, 4-1-1 Hiyoshi, Yokohama, Kanagawa 223-8521 Japan
| | - Taishi Tsuji
- Center for Preventive Medical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670 Japan
- Faculty of Health and Sport Sciences, University of Tsukuba, 3-29-1 Otsuka, Bunkyo-ku, Tokyo, 112-0012 Japan
| | - Katsunori Kondo
- Center for Preventive Medical Sciences, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670 Japan
- Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, 7-430 Morioka-cho, Obu-shi, Aichi, 474-8511 Japan
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12
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McInerney M, McCormack G, Mellor JM, Sabik LM. Association of Medicaid Expansion With Medicaid Enrollment and Health Care Use Among Older Adults With Low Income and Chronic Condition Limitations. JAMA HEALTH FORUM 2022; 3:e221373. [PMID: 35977244 PMCID: PMC9166222 DOI: 10.1001/jamahealthforum.2022.1373] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/14/2022] [Indexed: 12/02/2022] Open
Abstract
Question Was the expansion of Medicaid to working-age adults under the Patient Protection and Affordable Care Act (ACA) associated with changes in Medicaid enrollment and health care use among older adults with low income and chronic condition limitations? Findings In this cross-sectional study of 7153 US adults 65 years or older with low income, ACA Medicaid expansion was associated with significant increases in the likelihood of Medicaid enrollment and outpatient health care use among those with chronic condition limitations. No associations were found between ACA Medicaid expansion and Medicaid enrollment and health care use among those without such limitations. Meaning In this study, expansion of Medicaid to working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were enrolled in Medicare. Importance Medicaid is an important source of supplemental coverage for older Medicare beneficiaries with low income. Research has shown that Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with increased Medicaid coverage for previously eligible older adults with low income, but there has been little research on whether their health care use increased or whether such changes differed by beneficiaries’ health status. Objective To assess whether the ACA Medicaid expansion to working-age adults was associated with increased Medicaid enrollment and health care use among older adults with low income with and without chronic condition limitations. Design, Setting, and Participants This cross-sectional study used data from the National Health Interview Survey from 2010 to 2017 for adults 65 years or older with low income (≤100% of the federal poverty level). Data were analyzed from November 2020 to March 2022. Exposure Residence in a state with Medicaid expansion for working-age adults. Main Outcomes and Measures The main outcomes were Medicaid coverage and health care use, measured by physician office visits and inpatient hospital care. Survey weights were used in calculating descriptive statistics and regression estimates. In multivariate analysis, difference-in-differences models were used to compare changes in outcomes over time between respondents in Medicaid expansion states and respondents in nonexpansion states. Results Of 21 859 adults included in the study, 7153 had chronic condition limitations (4983 [70.1%] female; mean [SD] age, 76.0 [0.1] years) and 14 706 did not have chronic condition limitations (9609 [66.3%] female; mean [SD] age, 74.85 [0.08] years). Of those with chronic condition limitations, 2707 (36.7%) were enrolled in Medicaid, 2816 (39.4%) had an office visit in the past 2 weeks, and 2152 (30.7%) used inpatient hospital care in the past year. Medicaid expansion was associated with differential increases in the likelihood of having Medicaid (4.92 percentage points; 95% CI, 0.25-9.60 percentage points; P = .04) and having an office visit in the past 2 weeks (5.31 percentage points; 95% CI, 0.10-10.51 percentage points; P = .046) compared with nonexpansion. There were no differential changes between expansion and nonexpansion states in receipt of inpatient hospital care (−0.62 percentage points; 95% CI, −5.39 to 4.14 percentage points; P = .79). Among adults without chronic condition limitations, 3159 (19.8%) were enrolled in Medicaid, and no differential changes between expansion and nonexpansion states in Medicaid enrollment (−0.24 percentage points; 95% CI, −3.06 to 2.57 percentage points; P = .86) or health care use were found. Conclusions and Relevance In this cross-sectional study, ACA Medicaid expansion for working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were dually eligible for Medicare and Medicaid.
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Affiliation(s)
- Melissa McInerney
- Department of Economics, Tufts University, Medford, Massachusetts
- National Bureau of Economic Research, Cambridge, Massachusetts
| | - Grace McCormack
- Harvard Kennedy School, Harvard University, Cambridge, Massachusetts
| | - Jennifer M. Mellor
- Department of Economics, William & Mary, Williamsburg, Virginia
- Schroeder Center for Health Policy, William & Mary, Williamsburg, Virginia
| | - Lindsay M. Sabik
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
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Buttorff C, Girosi F, Lai J, Taylor EA, Lewis SE, Ma S, Eibner C. Do Financial Incentives Affect Utilization for Chronically Ill Medicare Beneficiaries? Med Care 2022; 60:302-310. [PMID: 35213426 DOI: 10.1097/mlr.0000000000001695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to examine the price sensitivity for provider visits among Medicare Advantage beneficiaries. DATA SOURCES We used Medicare Advantage encounter data from 2014 to 2017 accessed as part of an evaluation for the Center for Medicare & Medicaid Innovation. STUDY DESIGN We analyzed the effect of cost-sharing on the utilization of 2 outcome categories: number of visits (specialist and primary care) and the probability of any visit (specialist and primary care). Our main independent variable was the size of the copayment for the visit, which we regressed on the outcomes with several beneficiary-level and plan-level control variables. DATA COLLECTION/EXTRACTION METHODS We included beneficiaries with at least 1 of 4 specific chronic conditions and matched comparison beneficiaries. We did not require beneficiaries to be continuously enrolled from 2014 to 2017, but we required a full year of data for each year they were observed. This resulted in 371,140 beneficiary-year observations. PRINCIPAL FINDINGS Copay reductions were associated with increases in utilization, although the changes were small, with elasticities <-0.2. We also found evidence of substitution effects between primary care provider (PCP) and specialist visits, particularly cardiology and endocrinology. When PCP copays declined, visits to these specialists also declined. CONCLUSIONS We find that individuals with chronic conditions respond to changes in copays, although these responses are small. Reductions in PCP copays lead to reduced use of some specialists, suggesting that lowering PCP copays could be an effective way to reduce the use of specialist care, a desirable outcome if specialists are overused.
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Affiliation(s)
| | | | | | | | - Sarah E Lewis
- Center for Medicare & Medicaid Innovation, Baltimore, MD
| | - Sai Ma
- Clinical Transformation, Humana, Washington, DC
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14
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Fang Q, Ma G, Wang Y, Wei J, Zhang Q, Xu X, Wang X. Current curative expenditure of non-communicable diseases changed in Dalian, China from 2017 to 2019: a study based on 'System of Health Accounts 2011'. BMJ Open 2022; 12:e056900. [PMID: 35365532 PMCID: PMC8977744 DOI: 10.1136/bmjopen-2021-056900] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 03/08/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To analyse the current curative expenditure (CCE) of NCDs in China from 2017 to 2019. DESIGN A cross-sectional study. Medical institutions were collected by multistage stratified random sampling from 2017 to 2019. SETTING Dalian, China PARTICIPANTS: 408 institutions and 8 104 233 valid items were included in the study. NCDs patients were selected according to International Classification of Diseases-10. PRIMARY AND SECONDARY OUTCOME MEASURES CCE for NCDs was measured based on the System of Health Accounts 2011. Influenced factors were analysed by linear regression. All analyses and calculations were performed by STATA V.15.0. RESULTS The CCE of NCDs was ¥14.929 billion in 2017, ¥16.377 billion in 2018 and ¥18.055 billion in 2019, which accounted for more than 65% of total expenditure spent each year. More than 60% came from public financing. The proportion of family health financing continued to decline, reaching 31.16% in 2019. The expenditures were mainly in general hospitals, above 70%. Elderly patients account for the majority. Diseases of the circulatory system, diseases of the digestive system and neoplasms were the main NCDs. Year, age, gender, length of stay, surgery, insurance and institution level affected hospitalisation expenses. CONCLUSIONS NCDs are the main CCE of diseases in China, and their resources are not allocated reasonably. To reduce the CCE of NCDs, the government needs to optimise resource allocation and rationalise institutional flows and functions.
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Affiliation(s)
- Quan Fang
- College of Health Management, China Medical University, Shenyang, Liaoning, China
| | - Guoliang Ma
- College of Health Management, China Medical University, Shenyang, Liaoning, China
- Executive Office, Nanjing Municipal Center for Disease Control and Prevention, Nanjing, Jiangsu, China
| | - Yuhang Wang
- Finance Section, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jingjing Wei
- School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Qin Zhang
- College of Health Management, China Medical University, Shenyang, Liaoning, China
- Finance Section, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xinzhou Xu
- College of Health Management, China Medical University, Shenyang, Liaoning, China
- Medical Department, Nanjing Medical University Affiliated Wuxi No.2 People's Hospital, Wuxi, Jiangsu, China
| | - Xin Wang
- College of Health Management, China Medical University, Shenyang, Liaoning, China
- Research Center for Health Development - Liaoning New Type Think Tank for University, China Medical University, Shenyang, Liaoning, China
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15
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He W. Effects of establishing a financing scheme for outpatient care on inpatient services: empirical evidence from a quasi-experiment in China. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:7-22. [PMID: 34224059 DOI: 10.1007/s10198-021-01340-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 06/22/2021] [Indexed: 06/13/2023]
Abstract
The relationship between outpatient and inpatient care is central to the current healthcare reform debate especially in developing countries. Despite the importance of this relationship to health policy makers, empirical evidence, particularly evidence that can be interpreted as causal is limited and inconclusive. This paper examines the effects of establishing a financing scheme for outpatient care on inpatient utilization and expenditure in China's Urban Employee Basic Medical Insurance scheme. Under a quasi-experimental design, we use a unique administrative insurance claim dataset and conduct a difference-in-differences analysis. Our results indicate that after the policy change, total number of admissions and total inpatient expenditure of the enrollees decreased by 0.47% and 6.05% respectively, which imply outpatient and inpatient care are substitutes, and the reduction in cost-sharing can release the underuse of the outpatient care, so as to reduce those excessive demands for inpatient care. Moreover, we present evidence that the effects on the admissions of Ambulatory Care Sensitive Conditions which should be sensitive to outpatient care intervention are relatively limited because of the lower reimbursement cap, inadequate capacity of the local primary care providers and stickiness in patients' healthcare-seeking behaviors. While the enrollees aged over 55 and retirees are more vulnerable to the medical prices, and the enrollees living in the central districts are more responsive because of the better and more accessible primary care.
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Affiliation(s)
- Wen He
- School of Public Administration, Hunan University, Lushan Road (S), Yuelu District, Changsha, 410082, China.
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16
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Neiman PU, Mouli VH, Taylor KK, Ayanian JZ, Dimick JB, Scott JW. The Impact of Medicare Coverage on Downstream Financial Outcomes for Adults Who Undergo Surgery. Ann Surg 2022; 275:99-105. [PMID: 34914661 PMCID: PMC10088463 DOI: 10.1097/sla.0000000000005272] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate the effects of gaining access to Medicare on key financial outcomes for surgical patients. SUMMARY BACKGROUND DATA Surgical care poses a significant financial burden, especially among patients with insufficient financial risk protection. Medicare may mitigate the risk of these adverse circumstances, but the impact of Medicare eligibility on surgical patients remains poorly understood. METHODS Regression discontinuity analysis of national, cross-sectional survey and cost data from the 2008 to 2018 National Health Interview Survey and Medical Expenditure Panel Survey. Patients were between the ages of 57 to 72 with surgery in the past 12 months. The primary outcomes were the presence of medical debt, delay/deferment of care due to cost, total annual out-of-pocket costs, and experiencing catastrophic health expenditures. RESULTS Among 45,982,243 National Health Interview Survey patients, Medicare eligibility was associated with a 6.6 percentage-point decrease (95% confidence interval [CI]: -9.0% to -4.3) in being uninsured (>99% relative reduction), 7.6 percentage-point decrease (24% relative reduction) in having medical debt (95%CI: -14.1% to -1.1%), and 4.9 percentage-point decrease (95%CI: -9.4% to -0.4%) in deferrals/delays in medical care due to cost (28% relative reduction). Among 33,084,967 Medical Expenditure Panel Survey patients, annual out-of-pocket spending decreased by $1199 per patient (95%CI: -$1633 to -$765), a 33% relative reduction, and catastrophic health expenditures decreased by 7.3 percentage points (95%CI: -13.6% to -0.1%), a 55% relative reduction. CONCLUSIONS Medicare may reduce the economic burden of healthcare spending and delays in care for older adult surgical patients. These findings have important implications for policy discussions regarding changing insurance eligibility thresholds for the older adult population.
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Affiliation(s)
- Pooja U Neiman
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, Brigham and Women's Hospital, Boston, MA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Vibav H Mouli
- University of Michigan Medical School, Ann Arbor, MI
| | - Kathryn K Taylor
- National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, Stanford University, Stanford, CA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - John Z Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Justin B Dimick
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - John W Scott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
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17
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Roberts ET. The Unintended Cost of High Cost Sharing in Medicare-Assessing Consequences for Patients and Options for Policy. JAMA HEALTH FORUM 2021; 2:e213624. [PMID: 35024690 PMCID: PMC8751488 DOI: 10.1001/jamahealthforum.2021.3624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Affiliation(s)
- Eric T Roberts
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
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18
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Madden JM, Bayapureddy S, Briesacher BA, Zhang F, Ross-Degnan D, Soumerai SB, Gurwitz JH, Galbraith AA. Affordability of Medical Care Among Medicare Enrollees. JAMA HEALTH FORUM 2021; 2:e214104. [PMID: 35977305 PMCID: PMC8796945 DOI: 10.1001/jamahealthforum.2021.4104] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/18/2021] [Indexed: 11/17/2022] Open
Abstract
Importance Cost-sharing requirements can discourage patients from seeking care and impose financial hardship. The Medicare program serves many older and disabled individuals with multimorbidity and limited resources, but little has been known about the affordability of care in this population. Objective To examine the affordability of medical care among Medicare enrollees, in terms of the prevalence of delaying medical care because of costs and having problems paying medical bills, and risk factors for these outcomes. Design Setting and Participants Cross-sectional analyses conducted from November 1, 2019, to October 15, 2021, used logistic regression to compare the probability of outcomes by demographic and health characteristics. Data were obtained from the 2017 nationally representative Medicare Current Beneficiary Survey (response rate, 61.7%), with respondents representing 53 million community-dwelling Medicare enrollees. Main Outcomes and Measures New questions about medical care affordability were included in the 2017 Medicare Current Beneficiary Survey: difficulty paying medical bills, ongoing medical debt, and contact by collection agencies. A companion survey question asked whether individuals had delayed seeking medical care because of worries about costs. Results Respondents included 10 974 adults aged 65 years or older and 2197 aged 18 to 64 years; 54.2% of all respondents were women. The weighted proportions of Medicare enrollees with annual incomes below $25 000K were 30.7% in the older population and 67.4% in the younger group. Self-reported prevalence of delaying care because of cost was 8.3% (95% CI, 7.4%-9.1%) among enrollees aged 65 years or older, 25.2% (95% CI, 21.8%-28.6%) among enrollees younger than 65 years, and 10.9% (95% CI, 9.9%-11.9%) overall. Similarly, 7.4% (95% CI, 6.6%-8.2%) of older enrollees had problems paying medical bills, compared with 29.8% (95% CI, 25.6%-34.1%) among those younger than 65 years and 10.8% (95% CI, 9.8%-11.9%) overall. Regarding specific payment problems, 7.9% (95% CI, 7.0%-8.9%) of enrollees overall experienced ongoing medical debt, contact by a collection agency, or both. In adjusted analyses, older adults with incomes $15 000 to $25 000 per year had odds of delaying care more than twice as high as those with incomes greater than $50 000 (odds ratio, 2.47; 95% CI, 1.82-3.39), and their odds of problems paying medical bills were more than 3 times as high (odds ratio, 3.37; 95% CI, 2.81-5.21). Older adults with 4 to 10 chronic conditions were more than twice as likely to have problems paying medical bills as those with 0 or 1 condition. Conclusions and Relevance The findings of this study suggest that unaffordability of medical care is common among Medicare enrollees, especially those with lower incomes, or worse health, or who qualify for Medicare based on disability. Policy reforms, such as caps on patient spending, are needed to reduce Medical cost burdens on the most vulnerable enrollees.
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Affiliation(s)
- Jeanne M. Madden
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy and Pharmaceutical Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care, Boston, Massachusetts
| | - Susmitha Bayapureddy
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy and Pharmaceutical Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Becky A. Briesacher
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy and Pharmaceutical Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
| | - Fang Zhang
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care, Boston, Massachusetts
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care, Boston, Massachusetts
| | - Stephen B. Soumerai
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care, Boston, Massachusetts
| | - Jerry H. Gurwitz
- Meyers Primary Care Institute, Worcester, Massachusetts
- Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester
| | - Alison A. Galbraith
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care, Boston, Massachusetts
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19
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Wiltshire J, Liu E, Dean CA, Colato EG, Elder K. Health Insurance Literacy and Medical Debt in Middle-Age Americans. Health Lit Res Pract 2021; 5:e319-e332. [PMID: 34905430 PMCID: PMC8668166 DOI: 10.3928/24748307-20211102-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Health insurance literacy (HIL) may influence medical financial burden among people who are sick and the most vulnerable. OBJECTIVE This study examined the relationships between HIL, health insurance factors, and medical debt among middle-age Americans, a population with an increasing prevalence of illnesses. METHODS Linear and generalized linear regression analyses were conducted on data drawn from the 2015-2016 waves of the Health Reform Monitoring Survey, a national, internet-based sample of Americans age 18 to 64 years. The analytical sample included 8,042 people age 50 to 64 years. KEY RESULTS Adjusted mean HIL scores did not differ by private versus public insurance or by out-of-pocket costs. Mean HIL scores were lower with higher deductibles; however, differences in mean scores were small. Higher HIL was associated with lower medical debt (odds ratio = 0.97; 95% confidence interval [0.96, 0.98]), but at the highest HIL score, the risk of having medical debt was still 13.8%. Public coverage, higher annual deductibles, and out-of-pocket costs were associated with higher risks of having medical debt. CONCLUSIONS The findings suggest that HIL plays an important role in medical debt burden. However, with the shift toward high cost-sharing insurance plans, addressing health care affordability issues along with HIL are critical to eliminate medical debt problems. [HLRP: Health Literacy Research and Practice. 2021;5(4):e319-e332.] Plain Language Summary: Understanding and using health insurance (also defined as health insurance literacy) may influence the ability to pay medical bills among people who are sick and vulnerable. This study examined the relationships among health insurance literacy, health insurance factors, and difficulty paying medical bills (i.e., medical debt) in Americans age 50 to 64 years using data from the Health Reform Monitoring Survey. People with higher health insurance literacy reported lower medical debt. Type of insurance coverage did not influence medical debt. Those with annual deductibles and out-of-pocket health care costs were more likely to report having medical debt.
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Affiliation(s)
- Jacqueline Wiltshire
- Address correspondence to Jacqueline Wiltshire, PD, MPH, College of Public Health, University of South Florida, 13201 Bruce B. Downs Boulevard, MDC 56, Tampa, FL 33612;
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20
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Roberts ET, Glynn A, Cornelio N, Donohue JM, Gellad WF, McWilliams JM, Sabik LM. Medicaid Coverage 'Cliff' Increases Expenses And Decreases Care For Near-Poor Medicare Beneficiaries. Health Aff (Millwood) 2021; 40:552-561. [PMID: 33819086 DOI: 10.1377/hlthaff.2020.02272] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cost sharing in traditional Medicare can consume a substantial portion of the income of beneficiaries who do not have supplemental insurance from Medicaid, an employer, or a Medigap plan. Near-poor Medicare beneficiaries (with incomes more than 100 percent but less than 200 percent of the federal poverty level) are ineligible for Medicaid but frequently lack alternative supplemental coverage, resulting in a supplemental coverage "cliff" of 25.8 percentage points just above the eligibility threshold for Medicaid (100 percent of poverty). We estimated that beneficiaries affected by this supplemental coverage cliff incurred an additional $2,288 in out-of-pocket spending over the course of two years, used 55 percent fewer outpatient evaluation and management services per year, and filled fewer prescriptions. Lower prescription drug use was partly driven by low take-up of Part D subsidies, which Medicare beneficiaries automatically receive if they have Medicaid. Expanding eligibility for Medicaid supplemental coverage and increasing take-up of Part D subsidies would lessen cost-related barriers to health care among near-poor Medicare beneficiaries.
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Affiliation(s)
- Eric T Roberts
- Eric T. Roberts is an assistant professor in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, in Pittsburgh, Pennsylvania
| | - Alexandra Glynn
- Alexandra Glynn is a doctoral student in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
| | - Noelle Cornelio
- Noelle Cornelio is a doctoral student in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
| | - Julie M Donohue
- Julie M. Donohue is a professor and chair in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
| | - Walid F Gellad
- Walid F. Gellad is a core investigator at the Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, and a professor of medicine in the Division of General Internal Medicine, University of Pittsburgh School of Medicine
| | - J Michael McWilliams
- J. Michael McWilliams is the Warren Alpert Foundation Professor of Health Care Policy in the Department of Health Care Policy at Harvard Medical School and a professor of medicine and general internist at Brigham and Women's Hospital, in Boston, Massachusetts
| | - Lindsay M Sabik
- Lindsay M. Sabik is an associate professor in the Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health
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21
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High-Deductible Health Plans and Healthcare Access, Use, and Financial Strain in Those with Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2021; 17:49-56. [PMID: 31599647 DOI: 10.1513/annalsats.201905-400oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Rationale: Medical treatment can improve quality of life and avert exacerbations for those with chronic obstructive pulmonary disease (COPD). High-deductible health plans (HDHPs) can increase exposure to medical costs, and might compromise healthcare access and financial well-being for patients with COPD.Objectives: To examine the association of HDHPs with healthcare access, utilization, and financial strain among individuals with COPD.Methods: We analyzed privately insured adults aged 40-64 years with COPD in the 2011-2017 National Health Interview Survey, which uses Internal Revenue Service-specified thresholds to classify health plans as "high" or "traditional" deductible coverage. We assessed the association between enrollment in an HDHP and indicators of cost-related impediments to care, financial strain, and healthcare utilization, adjusting for potential confounders.Results: Our sample included 803 individuals with an HDHP and 1,334 with a traditional plan. The two groups' demographic and health characteristics were similar. Individuals enrolled in an HDHP more frequently reported delayed or foregone care, cost-related medication nonadherence, medical bill problems, and financial strain. They also more frequently reported out-of-pocket healthcare spending in excess of $5,000 a year. Although the two groups' office visit rates were similar, those enrolled in an HDHP were more likely to report a hospitalization or emergency room visit in the past year.Conclusions: For patients with COPD, enrollment in an HDHP was associated with cost-related barriers to care, financial strain, and more frequent emergency room visits and hospitalizations.
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22
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Gruber J, Maclean JC, Wright B, Wilkinson E, Volpp KG. The effect of increased cost-sharing on low-value service use. HEALTH ECONOMICS 2020; 29:1180-1201. [PMID: 32686138 DOI: 10.1002/hec.4127] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/06/2020] [Accepted: 06/04/2020] [Indexed: 06/11/2023]
Abstract
We examine the effect of a value-based insurance design (VBID) program implemented at a large public employer in the state of Oregon. The program substantially increased cost-sharing for several healthcare services likely to be of low value for most patients: diagnostic services (e.g., imaging services) and surgeries (e.g., spinal surgeries for pain). Using a difference-in-differences design coupled with granular, administrative health insurance claims data over the period 2008-2012, we estimate the change in low-value service use among beneficiaries before and after program implementation relative to a comparison group not exposed to the VBID. Our findings suggest that the VBID significantly reduced the use of targeted services, with an implied elasticity of demand of -0.22. We find no evidence that the VBID led to substitution to non-targeted services or increased overall healthcare costs. However, we also observe no evidence that the program led to cost-savings.
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Affiliation(s)
- Jonathan Gruber
- Department of Economics, National Bureau of Economic Research, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Johanna Catherine Maclean
- Department of Economics, National Bureau of Economic Research, Institute of Labor Economics, Temple University, Philadelphia, Pennsylvania, USA
| | - Bill Wright
- Providence Health and Services, Center for Outcomes Research and Education, Portland, Oregon, USA
| | - Eric Wilkinson
- Department of Economics, Temple University, Philadelphia, Pennsylvania, USA
| | - Kevin G Volpp
- Director, Penn Center for Health Incentives and Behavioral Economics (CHIBE), Founders Presidential Distinguished Professor, Perelman School of Medicine and the Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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McInerney M, Mellor JM, Sabik LM. Welcome Mats and On-Ramps for Older Adults: The Impact of the Affordable Care Act's Medicaid Expansions on Dual Enrollment in Medicare and Medicaid. JOURNAL OF POLICY ANALYSIS AND MANAGEMENT : [THE JOURNAL OF THE ASSOCIATION FOR PUBLIC POLICY ANALYSIS AND MANAGEMENT] 2020; 40:12-41. [PMID: 34194129 PMCID: PMC8238124 DOI: 10.1002/pam.22259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
For many low-income Medicare beneficiaries, Medicaid provides important supplemental insurance that covers out-of-pocket costs and additional benefits. We examine whether Medicaid participation by low-income adults age 65 and up increased as a result of Medicaid expansions to working-age adults under the Affordable Care Act (ACA). Previous literature documents so-called "welcome mat" effects in other populations but has not explicitly studied older persons dually eligible for Medicare and Medicaid. We extend this literature by estimating models of Medicaid participation among persons age 65 and up using American Community Survey data from 2010 to 2017 and state variation in ACA Medicaid expansions. We find that Medicaid expansions to working-age adults increased Medicaid participation among low-income older adults by 1.8 percentage points (4.4 percent). We also find evidence of an "on-ramp" effect; that is, low-income Medicare beneficiaries residing in expansion states who were young enough to gain coverage under the 2014 ACA Medicaid expansions before aging into Medicare were 4 percentage points (9.5 percent) more likely to have dual Medicaid coverage relative to similar individuals who either turned 65 before the 2014 expansions or resided in non-expansion states. This on-ramp effect is an important mechanism behind welcome mat effects among some older adults.
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Affiliation(s)
| | - Jennifer M Mellor
- Department of Economics and Schroeder Center for Health Policy, William and Mary, Williamsburg, VA
| | - Lindsay M Sabik
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
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Call KT, Conmy A, Alarcón G, Hagge SL, Simon AB. Health insurance literacy: How best to measure and does it matter to health care access and affordability? Res Social Adm Pharm 2020; 17:1166-1173. [PMID: 32952089 DOI: 10.1016/j.sapharm.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 09/01/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Health insurance is complex, cost are continuously rising, and people are assuming more of these costs. Health insurance literacy (HIL) is related to healthcare access, yet there is no agreement about how best to measure HIL. OBJECTIVES Contrast two HIL measures. First, evaluating their association with demographic characteristics, insurance type, and health status. Second, comparing how these distinct measures relate to access, forgone care, and financial burden of health care. METHODS Data are from a 2017 telephone survey focused on health insurance coverage and access. Participants were randomly assigned either the 4-item likelihood of proactive use scale or a 4-item measure of confidence in use of insurance. Logistic regressions assess correlates of each HIL measure and their association with a range of access measures. RESULTS For both measures, 25% of insured adults report high HIL. Few demographic and health status measures are associated with high HIL and they are different for each measure. For both measures, high HIL translates into reports of having a usual source of care and confidence in getting care when needed. The HIL measures behave in opposite ways for forgone care due to costs and problems paying medical bills. Adults scoring high on the likelihood measure are more likely to forgo care and report financial burden. By contrast, adults scoring high on the confidence measure are less likely to forgo care and report burdensome medical bills. CONCLUSIONS The two measures capture different concepts and raise the question of whether reporting a likely behavior or being confident of that behavior are predictive when it is time to use health insurance. Because HIL is measured at the same time as the outcomes, we reason that the likelihood measure is capturing peoples' past experience using insurance and may result in more proactive use of insurance in the future.
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Affiliation(s)
- Kathleen Thiede Call
- University of Minnesota, School of Public Health, State Health Access Data Assistance Center 2221 University Avenue, Suite 345, Minneapolis, MN, 55414, United States.
| | - Ann Conmy
- Office of Health Policy, Office of the Assistant Secretary for Planning and Evaluation, Room 447D--Hubert H. Humphrey Building 200 Independence Avenue SW, Washington, DC, 20201, United States
| | - Giovann Alarcón
- University of Minnesota, School of Public Health, State Health Access Data Assistance Center 2221 University Avenue, Suite 345, Minneapolis, MN, 55414, United States
| | - Sarah L Hagge
- Minnesota Department of Health, Health Economics Program, Golden Rule Building 85 7th Place E, St Paul, MN, 55101, United States
| | - Alisha Baines Simon
- Minnesota Department of Health, Health Economics Program, Golden Rule Building 85 7th Place E, St Paul, MN, 55101, United States
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Would the United States Have Had Too Few Beds for Universal Emergency Care in the Event of a More Widespread Covid-19 Epidemic? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17145210. [PMID: 32707674 PMCID: PMC7399859 DOI: 10.3390/ijerph17145210] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/17/2022]
Abstract
(1) Background: To evaluate the level of hospital bed numbers in U.S. states relative to other countries using a new method for evaluating bed numbers, and to determine if this is sufficient for universal health care during a major Covid-19 epidemic in all states (2) Methods: Hospital bed numbers in each state were compared using a new international comparison methodology. Covid-19 deaths per 100 hospital beds were used as a proxy for bed capacity pressures. (3) Results: Hospital bed numbers show large variation between U.S. states and half of the states have equivalent beds to those in developing countries. Relatively low population density in over half of US states appeared to have limited the spread of Covid-19 thus averting a potential major hospital capacity crisis. (4) Conclusions: Many U.S. states had too few beds to cope with a major Covid-19 epidemic, but this was averted by low population density in many states, which seemed to limit the spread of the virus.
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Reducing high-risk medication use through pharmacist-led interventions in an outpatient setting. J Am Pharm Assoc (2003) 2020; 60:e86-e92. [DOI: 10.1016/j.japh.2020.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/09/2020] [Accepted: 01/20/2020] [Indexed: 11/23/2022]
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Mooney MA, Yoon S, Cole T, Sheehy JP, Bohl MA, Barranco FD, Nakaji P, Little AS, Lawton MT. Cost Transparency in Neurosurgery: A Single-Institution Analysis of Patient Out-of-Pocket Spending in 13 673 Consecutive Neurosurgery Cases. Neurosurgery 2020; 84:1280-1289. [PMID: 29767766 DOI: 10.1093/neuros/nyy185] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/10/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Patient out-of-pocket (OOP) spending is an increasingly discussed topic; however, there is minimal data available on the patient financial burden of surgical procedures. OBJECTIVE To analyze hospital and surgeon expected payment data and patient OOP spending in neurosurgery. METHODS This is a retrospective cohort study of neurosurgical patients at a tertiary-referral center from 2013 to 2016. Expected payments, reflecting negotiated costs-of-care, as well as actual patient OOP payments for hospital care and surgeon professional fees were analyzed. A 4-tiered model of patient OOP cost sharing and a multivariate model of patient expected payments were created. RESULTS A total of 13 673 consecutive neurosurgical cases were analyzed. Patient age, insurance type, case category, severity of illness, length of stay (LOS), and elective case status were significant predictors of increased expected payments (P < .05). Craniotomy ($53 397 ± 811) and posterior spinal fusion ($48 329 ± 864) were associated with the highest expected payments. In a model of patient OOP cost sharing, nearly all neurosurgical procedures exceeded yearly OOP maximums for Healthcare Marketplace plans. Mean patient payments for hospital care and surgeon professional fees were the highest for anterior/lateral spinal fusion cases for commercially insured patients ($1662 ± 165). Mean expected payments and mean patient payments for commercially insured patients increased significantly from 2013 to 2016 (P < .05). CONCLUSION Expected payments and patient OOP spending for commercially insured patients significantly increased from 2013 to 2016, representing increased healthcare costs and patient cost sharing in an evolving healthcare environment. Patients and providers can consider this information prior to surgery to better anticipate the individual financial burden for neurosurgical care.
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Affiliation(s)
- Michael A Mooney
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Seungwon Yoon
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tyler Cole
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - John P Sheehy
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael A Bohl
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - F David Barranco
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Peter Nakaji
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Andrew S Little
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Michael T Lawton
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
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Fanaroff AC, Peterson ED, Kaltenbach LA, Anstrom KJ, Fonarow GC, Henry TD, Cannon CP, Choudhry NK, Cohen DJ, Atreja N, Bhalla N, Eudicone JM, Wang TY. Copayment Reduction Voucher Utilization and Associations With Medication Persistence and Clinical Outcomes. Circ Cardiovasc Qual Outcomes 2020; 13:e006182. [DOI: 10.1161/circoutcomes.119.006182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Cost is frequently cited as a barrier to optimal medication use, but the extent to which copayment assistance interventions are used when available, and their impact on evidence-based medication persistence and major adverse cardiovascular events is unknown.
Methods and Results:
The ARTEMIS trial (Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study) randomized 301 hospitals to usual care versus the ability to provide patients with vouchers that offset copayment costs when filling P2Y
12
inhibitors in the 1 year post-myocardial infarction. In the intervention group, we used multivariable logistic regression to identify patient and medication cost characteristics associated with voucher use. We then used this model to stratify both intervention and usual care patients by likelihood of voucher use, and examined the impact of the voucher intervention on 1-year P2Y
12
inhibitor persistence (no gap in pharmacy supply >30 days) and major adverse cardiovascular events (all-cause death, myocardial infarction, or stroke). Among 10 102 enrolled patients, 6135 patients were treated at hospitals randomized to the copayment intervention. Of these, 1742 (28.4%) never used the voucher, although 1729 (99.2%) voucher never-users filled at least one P2Y
12
inhibitor prescription in the 1 year post-myocardial infarction. Characteristics most associated with voucher use included: discharge on ticagrelor, planned 1-year course of P2Y
12
inhibitor treatment, white race, commercial insurance, and higher out-of-pocket medication costs (c-statistic 0.74). Applying this propensity model to stratify all enrolled patients by likelihood of voucher use, the intervention improved medication persistence the most in patients with high likelihood of voucher use (adjusted interaction
P
=0.03, odds ratio, 1.86 [95% CI, 1.48–2.33]). The intervention did not significantly reduce major adverse cardiovascular events in any voucher use likelihood group, although the odds ratio was lowest (0.86 [95% CI, 0.56–1.16]) among patients with high likelihood of voucher use (adjusted interaction
P
=0.04).
Conclusions:
Among patients discharged after myocardial infarction, those with higher copayments and greater out-of-pocket medication costs were more likely to use a copayment assistance voucher, but some classes of patients were less likely to use a copayment assistance voucher. Patients at low likelihood of voucher use benefitted least from copayment assistance, and other interventions may be needed to improve medication-taking behaviors and clinical outcomes in these patients.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT02406677.
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Affiliation(s)
- Alexander C. Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute of Health Economics, Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia (A.C.F.)
| | - Eric D. Peterson
- Division of Cardiology (E.D.P., T.Y.W.), Duke University, Durham, NC
- the Duke Clinical Research Institute (E.D.P., L.A.K., K.J.A., T.Y.W.), Duke University, Durham, NC
| | - Lisa A. Kaltenbach
- the Duke Clinical Research Institute (E.D.P., L.A.K., K.J.A., T.Y.W.), Duke University, Durham, NC
| | - Kevin J. Anstrom
- the Duke Clinical Research Institute (E.D.P., L.A.K., K.J.A., T.Y.W.), Duke University, Durham, NC
| | - Gregg C. Fonarow
- Division of Cardiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Timothy D. Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH (T.D.H.)
| | - Christopher P. Cannon
- Division of Cardiology (C.P.P.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Niteesh K. Choudhry
- Center for Healthcare Delivery Sciences, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (N.K.C.), Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - David J. Cohen
- University of Missouri-Kansas City School of Medicine, Kansas City, MO (D.J.C.)
| | - Nipun Atreja
- AstraZeneca, Wilmington, DE (N.A., N.B., J.M.E.)
| | | | | | - Tracy Y. Wang
- Division of Cardiology (E.D.P., T.Y.W.), Duke University, Durham, NC
- the Duke Clinical Research Institute (E.D.P., L.A.K., K.J.A., T.Y.W.), Duke University, Durham, NC
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Trescher AL, Listl S, van der Galien O, Gabel F, Kalmus O. Once bitten, twice shy? Lessons learned from an experiment to liberalize price regulations for dental care. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:425-436. [PMID: 31893330 PMCID: PMC7188704 DOI: 10.1007/s10198-019-01145-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 10/24/2019] [Indexed: 06/10/2023]
Abstract
In 2012, The Netherlands established the so-called "free market experiment", which allowed providers of dental care to set the prices for their dental services themselves. The introduction of market mechanisms is intended to improve the quality of care and to contribute to cost containment, but increasing health expenditures for citizens have been observed in this context. Using large-volume health insurance claims data and exploiting the 2012 experiment in Dutch dental care, we identified the effects of a liberalization of service prices. Using pooled regression with individual fixed effects, we analyzed changes in utilization patterns of prevention-oriented dental services in response to the experiment as well as the elasticities in demand in response to variations in out-of-pocket (OOP) prices. We found substantial increases in prices and patients' OOP contributions for dental services following the liberalization with differences in increases between types of services. In response to the experiment, the proportion of treatment sessions containing preventive-oriented services decreased significantly by 3.4% among adults and by 5.3% for children and adolescents. Estimates of short-run price elasticities of demand for different services point towards differences in price sensitivity. One potential explanation for the observed variations in prices and utilization could be different extents of asymmetric information for first-stage and follow-on services. Price liberalization seems to have affected the composition of treatment sessions towards a decreasing use of preventive services, suggesting a shift in the reason for seeing a dental care provider from a regular-preventive perspective to a symptom-based restorative approach.
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Affiliation(s)
- Anna-Lena Trescher
- Department of Conservative Dentistry - Section for Translational Health Economics, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Stefan Listl
- Department of Conservative Dentistry - Section for Translational Health Economics, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- Department of Dentistry - Quality and Safety of Oral Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Philips van Leydenlaan 25, 6525 EX, Nijmegen, The Netherlands.
| | | | - Frank Gabel
- Department of Conservative Dentistry - Section for Translational Health Economics, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Olivier Kalmus
- Department of Conservative Dentistry - Section for Translational Health Economics, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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Ray KN, Shi Z, Ganguli I, Rao A, Orav EJ, Mehrotra A. Trends in Pediatric Primary Care Visits Among Commercially Insured US Children, 2008-2016. JAMA Pediatr 2020; 174:350-357. [PMID: 31961428 PMCID: PMC6990970 DOI: 10.1001/jamapediatrics.2019.5509] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Primary care is the foundation of pediatric care. While policy interventions have focused on improving access and quality of primary care, trends in overall use of primary care among children have not been described. OBJECTIVE To assess trends in primary care visit rates and out-of-pocket costs, to examine variation in these trends by patient and visit characteristics, and to assess shifts to alternative care options (eg, retail clinics, urgent care, and telemedicine). DESIGN, SETTING, AND PARTICIPANTS Observational cohort study of claims data from 2008 to 2016 for children 17 years and younger covered by a large national commercial health plan. Visit rate per 100 child-years was determined for each year overall, by child and geographic characteristics, and by visit type (eg, primary diagnosis), and trends were assessed with a series of child-year Poisson models. Data were analyzed from November 2017 to September 2019. MAIN OUTCOMES AND MEASURES Visits to primary care and other settings. RESULTS This cohort study included more than 71 million pediatric primary care visits over 29 million pediatric child-years (51% male in 2008 and 2016; 37% between 12-17 years in 2008 and 38% between 12-17 years in 2016). Unadjusted results for primary care visit rates per 100 child-years decreased from 259.6 in 2008 to 227.2 in 2016, yielding a regression-estimated change in primary care visits across the 9 years of -14.4% (95% CI, -15.0% to -13.9%; absolute change: -32.4 visits per 100 child-years). After controlling for shifts in demographics, the relative decrease was -12.8% (95% CI, -13.3% to -12.2%). Preventive care visits per 100 child-years increased from 74.9 in 2008 to 83.2 visits in 2016 (9.9% change in visit rate; 95% CI, 9.0%-10.9%; absolute change: 8.3 visits per 100 child-years), while problem-based visits per 100 child-years decreased from 184.7 in 2008 to 144.1 in 2016 (-24.1%; 95% CI, -24.6% to -23.5%; absolute change: -40.6 visits per 100 child-years). Visit rates decreased for all diagnostic groups except for the behavioral and psychiatric category. Out-of-pocket costs for problem-based primary care visits increased by 42% during the same period. Per 100 child-years, visits to other acute care venues increased from 21.3 to 27.6 (30.3%; 95% CI, 28.5% to 32.1%; absolute change: 6.3 visits per 100 child-years) and visits to specialists from 45.2 to 53.5 (16.4%; 95% CI, 14.8% to 18.0%, absolute change: 8.3 visits per 100 child-years). CONCLUSIONS AND RELEVANCE Primary care visit rates among commercially insured children decreased over the last decade. Increases in out-of-pocket costs and shifts to other venues appear to explain some of this decrease.
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Affiliation(s)
- Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Zhuo Shi
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ishani Ganguli
- Department of Medicine, Harvard Medical School, Boston, Massachusetts,Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Aarti Rao
- Icahn School of Medicine at Mt Sinai, New York City, New York
| | - E. John Orav
- Department of Medicine, Harvard Medical School, Boston, Massachusetts,Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts,Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Ganguli I, Shi Z, Orav EJ, Rao A, Ray KN, Mehrotra A. Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016. Ann Intern Med 2020; 172:240-247. [PMID: 32016285 DOI: 10.7326/m19-1834] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline. OBJECTIVE To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits. DESIGN Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008-2016. A 5% claims sample was used for Poisson regression models to quantify visit trends. SETTING National, population-based. PARTICIPANTS Adult health plan members aged 18 to 64 years. MEASUREMENTS PCP visit rates per 100 member-years. RESULTS In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, -48.1% to -47.3%). The decline was largest among the youngest adults (-27.6% [CI, -28.2% to -27.1%]), those without chronic conditions (-26.4% [CI, -26.7% to -26.1%]), and those living in the lowest-income areas (-31.4% [CI, -31.8% to -30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (-0.08% [CI, -0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%). LIMITATION Data were limited to a single commercial insurer and did not capture nonbilled clinician-patient interactions. CONCLUSION Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
| | - Zhuo Shi
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
| | - E John Orav
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
| | - Aarti Rao
- Icahn School of Medicine at Mount Sinai, New York City, New York (A.R.)
| | - Kristin N Ray
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (K.N.R.)
| | - Ateev Mehrotra
- Harvard Medical School, Boston, Massachusetts (I.G., Z.S., E.J.O., A.M.)
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Warner JJ, Benjamin IJ, Churchwell K, Firestone G, Gardner TJ, Johnson JC, Ng-Osorio J, Rodriguez CJ, Todman L, Yaffe K, Yancy CW, Harrington RA. Advancing Healthcare Reform: The American Heart Association's 2020 Statement of Principles for Adequate, Accessible, and Affordable Health Care: A Presidential Advisory From the American Heart Association. Circulation 2020; 141:e601-e614. [PMID: 32008369 DOI: 10.1161/cir.0000000000000759] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The mission of the American Heart Association is to be a relentless force for a world of longer, healthier lives. The American Heart Association has consistently prioritized the needs and perspective of the patient in taking positions on healthcare reform while recognizing the importance of biomedical research, providers, and healthcare delivery systems in advancing the care of patients and the prevention of disease. The American Heart Association's vision for healthcare reform describes the foundational changes needed for the health system to serve the best interests of patients and to achieve health care and coverage that are adequate, accessible, and affordable for everyone living in the United States. The American Heart Association is committed to advancing the dialogue around healthcare reform and has prepared this updated statement of our principles, placed in the context of the advances in coverage and care that have occurred after the passage of the Affordable Care Act, the rapidly changing landscape of healthcare delivery systems, and our evolving recognition that efforts to prevent cardiovascular disease can have synergistic benefit in preventing other diseases and improving overall well-being. These updated principles focus on expanding access to affordable health care and coverage; enhancing the availability of evidence-based preventive services; eliminating disparities that limit the availability and equitable delivery of health care; strengthening the public health infrastructure to respond to social determinants of health; prioritizing and accelerating investments in biomedical research; and growing a diverse, culturally competent health and healthcare workforce prepared to meet the challenges of delivering high-value health care.
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McHugh JP, Keohane L, Grebla R, Lee Y, Trivedi AN. Association of daily copayments with use of hospital care among medicare advantage enrollees. BMC Health Serv Res 2019; 19:961. [PMID: 31830987 PMCID: PMC6909444 DOI: 10.1186/s12913-019-4770-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/22/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND While the traditional Medicare program imposes a deductible for hospital admissions, many Medicare Advantage plans have instituted per-diem copayments for hospital care. Little evidence exists about the effects of changes in cost-sharing for hospital care among the elderly. Changing inpatient benefits from a deductible to a per diem may benefit enrollees with shorter lengths of stay, but adversely affect the out-of-pocket burden for hospitalized enrollees with longer lengths of stay. METHODS We used a quasi-experimental difference-in-differences study to compare longitudinal changes in proportion hospitalized, inpatient admissions and days per 100 enrollees, and hospital length of stay between enrollees in MA plans that changed inpatient benefit from deductible at admission to per diem, intervention plans, and enrollees in matched control plans - similar plans that maintained inpatient deductibles. The study population included 423,634 unique beneficiaries enrolled in 23 intervention plans and 36 matched control plans in the 2007-2010 period. RESULTS The imposition of per-diem copayments were associated with adjusted declines of 1.3 admissions/100 enrollees (95% CI - 1.8 to - 0.9), 6.9 inpatient days/100 enrollees (95% CI - 10.1 to - 3.8) and 0.7 percentage points in the probability of hospital admission (95% CI - 1.0 to - 0.4), with no significant change in adjusted length of stay in intervention plans relative to control plans. For persons with 2 or more hospitalizations in the year prior to the cost-sharing change, adjusted declines were 3.5 admissions/100 (95% CI - 8.4 to 1.4), 31.1 days/100 (95% CI - 75.2 to 13.0) and 2.2 percentage points in the probability of hospitalization (95% CI - 3.8 to - 0.6) in intervention plans relative to control plans. CONCLUSIONS Instituting per-diem copayments was associated with reductions in number of admissions and hospital stays, but not length of stay once admitted. Effects of inpatient cost-sharing changes were magnified for persons with greater baseline use of hospital care.
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Affiliation(s)
- John P. McHugh
- Columbia University, Mailman School of Public Health, 722 West 168th Street, 4th Floor, New York, NY 10032 USA
| | - Laura Keohane
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 1200, Nashville, TN 37203 USA
| | - Regina Grebla
- Center for Gerontology and Health care Research, Brown University, 121 South Main Street, Providence, RI 02903 USA
| | - Yoojin Lee
- Center for Gerontology and Health care Research, Brown University, 121 South Main Street, Providence, RI 02903 USA
| | - Amal N. Trivedi
- Department of Health Services Policy and Practice, Brown University, 121 South Main Street, Providence, RI 02903 USA
- Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI 02908 USA
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Goldstein JN. The Unintended Consequences of Medicare Observation Status. Dela J Public Health 2019; 5:26-28. [PMID: 34467067 PMCID: PMC8389145 DOI: 10.32481/djph.2019.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Observation status is a classification for Medicare beneficiaries that are billed as outpatients for a hospitalization. This has implications for out-of-pocket expenses for patients as well as their access to post-acute care. METHODS This is a review of 3 published studies performed by our research team to examine the potential unintended consequences of the current Medicare policies related to cost-sharing and post-acute care coverage for patients hospitalized under observation status. Our study questions were as follows: 1) Is there an unmet need for post-acute care among Medicare observation patients 2) Which patients are at highest risk for high out-of-pocket costs related to observation care 3) Is cost-sharing for observation care associated with health care -related financial strain and health care rationing? RESULTS Our studies demonstrated that Medicare observation policy could be associated with a number of unintended consequences including decreased access to necessary post-acute nursing care, increased out-of-pocket costs, particularly for low -income patients, increased concerns related to the cost of care, and inadequate patient understanding of observation policies. CONCLUSIONS Patients and providers should be aware of the current policies surrounding observation care. Patients should be informed of their observation status and should have access to case managers and social workers to help them navigate and understand the implications of their observation hospital stay.
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Farah M, Abdallah M, Szalai H, Berry R, Lagu T, Lindenauer PK, Pack QR. Association Between Patient Cost Sharing and Cardiac Rehabilitation Adherence. Mayo Clin Proc 2019; 94:2390-2398. [PMID: 31806097 PMCID: PMC6946372 DOI: 10.1016/j.mayocp.2019.07.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 07/31/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine the association between cost sharing and adherence to cardiac rehabilitation (CR). PATIENTS AND METHODS We collected detailed cost-sharing information for patients enrolled in CR at Baystate Medical Center in Springfield, Massachusetts, including the presence (or absence) and amounts of co-pays and deductibles. We evaluated the association between cost sharing and the total number of CR sessions attended as well as the influence of household income on CR attendance. RESULTS In 2015, 603 patients enrolled in CR had complete cost-sharing information. In total, 235 (39%) had some form of cost sharing. Of these, 192 (82%) had co-pays (median co-pay, $20; interquartile range [IQR], $10-$32) and 79 (34%) had an unmet deductible (median, $500; IQR, $250-$1800). The presence of any amount or form of cost sharing was associated with 6 fewer sessions of CR (16; IQR, 4-36 vs 10; IQR, 4-27; P<.001). Patients hospitalized in November or December with deductibles that renewed in January attended 4.5 fewer sessions of CR (8.5; IQR, 3.25-12.50 vs 13; IQR, 5.25-36.00; P=.049). After adjustment for differences in baseline characteristics, every $10 increase in co-pay was associated with 1.5 (95% CI, -2.3 to -0.7) fewer sessions of CR (P<.001). Household income did not moderate these relationships. CONCLUSION Cost sharing was associated with lower CR attendance and exhibited a dose-response relationship such that higher cost sharing was associated with lower CR attendance. Given that CR is cost-effective and underutilized, insurance companies and other payers should reevaluate their cost-sharing policies for CR.
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Affiliation(s)
- Michel Farah
- Department of Internal Medicine, University of Massachusetts Medical School - Baystate, Springfield
| | - Maya Abdallah
- Department of Internal Medicine, University of Massachusetts Medical School - Baystate, Springfield
| | - Heidi Szalai
- Division of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA
| | - Robert Berry
- Division of Preventive Cardiology, Henry Ford Hospital, Detroit, MI
| | - Tara Lagu
- Department of Internal Medicine, University of Massachusetts Medical School - Baystate, Springfield; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield
| | - Peter K Lindenauer
- Department of Internal Medicine, University of Massachusetts Medical School - Baystate, Springfield; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield
| | - Quinn R Pack
- Department of Internal Medicine, University of Massachusetts Medical School - Baystate, Springfield; Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield; Division of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA.
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Fendrick AM, Buxbaum JD, Tang Y, Vlahiotis A, McMorrow D, Rajpathak S, Chernew ME. Association Between Switching to a High-Deductible Health Plan and Discontinuation of Type 2 Diabetes Treatment. JAMA Netw Open 2019; 2:e1914372. [PMID: 31675081 PMCID: PMC6826641 DOI: 10.1001/jamanetworkopen.2019.14372] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE High-deductible health plans (HDHPs) are a common cost-savings option for employers but may lead to underuse of necessary treatments because beneficiaries bear the full cost of health care, including medications, until a deductible is met. OBJECTIVES To evaluate the association between switching from a non-HDHP to an HDHP and discontinuation of antihyperglycemic medication and to assess whether the association differs in patients using branded vs generic antihyperglycemic medications. DESIGN, SETTING, AND PARTICIPANTS This retrospective matched cohort study used administrative claims from MarketScan databases to identify commercially insured adult patients with type 2 diabetes who used at least 1 antihyperglycemic medication in 2013. Patients in the HDHP cohort (n = 1490) were matched by propensity scores to a non-HDPH control cohort (n = 1490). Data were collected and analyzed from January 1, 2013, through December 31, 2014. EXPOSURES Switching from a non-HDHP in 2013 to a full replacement HDHP in 2014 (no non-HDHP option offered) vs staying on a non-HDHP. MAIN OUTCOMES AND MEASURES Difference-in-differences models estimated discontinuation of branded and generic antihyperglycemic medications. RESULTS Among the 2980 patients included in the analysis (1932 men [64.8%]; mean [SD] age, HDHP cohort: 52.6 [6.9] years; non-HDHP cohort: 52.7 [7.3] years), no difference between the HDHP and non-HDHP cohorts was found in unadjusted follow-up discontinuation rates for all antihyperglycemic medications (255 [22.7%] vs 255 [23.3%]; P = .72); however, among patients using branded medication, a significantly greater proportion of patients in the HDHP group did not refill branded medications (81 of 396 [20.5%] vs 61 of 437 [14.0%]; P = .009). Difference-in-differences models were not statistically significant. CONCLUSIONS AND RELEVANCE These findings suggest switching to an HDHP is associated with discontinuation specifically of branded medications. Unintended health consequences may result and should be considered by employers making health care benefit decisions.
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Affiliation(s)
- A. Mark Fendrick
- Center for Value-Based Insurance Design, University of Michigan, Ann Arbor
| | - Jason D. Buxbaum
- Center for Value-Based Insurance Design, University of Michigan, Ann Arbor
| | - Yuexin Tang
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey
| | | | | | - Swapnil Rajpathak
- Merck Research Laboratories, Merck & Co, Inc, Kenilworth, New Jersey
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Goldstein JN, Schwartz JS, McGraw P, Hicks LS. "Implications of cost-sharing for observation care among Medicare beneficiaries: a pilot survey". BMC Health Serv Res 2019; 19:149. [PMID: 30845953 PMCID: PMC6407198 DOI: 10.1186/s12913-019-3982-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 03/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background Medicare beneficiaries hospitalized under observation status have significant cost-sharing responsibilities under Medicare Part B. Prior work has demonstrated an association between increased cost-sharing and health care rationing among low-income Medicare beneficiaries. The objective of this study was to explore the potential impact of observation cost-sharing on future medical decision making of Medicare beneficiaries. Methods Single-center pilot cohort study. A convenience sample of Medicare beneficiaries hospitalized under observation status care was surveyed. Results Out of 144 respondents, low-income beneficiaries were more likely to be concerned about the cost of their observation stay than higher-income respondents (70.7% vs29.3%, p = 0.015). If hospitalized under observation status again, there was a trend among low-income beneficiaries to request completion of their workup outside of the hospital (56.3% vs 43.8%), and to consider leaving against medical advice (AMA) (100% vs 0%), though these trends were not statistically significant (p = 0.30). Conclusion The results of this pilot study suggest that low-income Medicare beneficiaries hospitalized under observation status have greater concerns about their cost-sharing obligations than their higher income peers. Cost-sharing for observation care may have unintended consequences on utilization for low-income beneficiaries. Future studies should examine this potential relationship on a larger scale. Electronic supplementary material The online version of this article (10.1186/s12913-019-3982-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine & The Value Institute, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ammon Education Center Suite 2E70, Newark, DE, 19713, USA.
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, 1203 Blockley Hall, 423 Guardian Drive University, Philadelphia, PA, 19104, USA
| | - Patricia McGraw
- Department of Medicine & The Value Institute, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ammon Education Center Suite 2E70, Newark, DE, 19713, USA
| | - LeRoi S Hicks
- Department of Medicine & The Value Institute, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ammon Education Center Suite 2C50, Newark, DE, 19713, USA
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Uhlig J, Sellers CM, Cha C, Khan SA, Lacy J, Stein SM, Kim HS. Intrahepatic Cholangiocarcinoma: Socioeconomic Discrepancies, Contemporary Treatment Approaches and Survival Trends from the National Cancer Database. Ann Surg Oncol 2019; 26:1993-2000. [PMID: 30693451 DOI: 10.1245/s10434-019-07175-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate socioeconomic discrepancies in current treatment approaches and survival trends among patients with intrahepatic cholangiocarcinoma (ICC). METHODS The 2004-2015 National Cancer Database was retrospectively analyzed for histopathologically proven ICC. Treatment predictors were evaluated using multinomial logistic regression and overall survival via multivariable Cox models. RESULTS Overall, 12,837 ICC patients were included. Multiple factors influenced treatment allocation, including age, education, comorbidities, cancer stage, grade, treatment center, and US state region (multivariable p < 0.05). The highest surgery rates were observed in the Middle Atlantic (28.7%) and lowest rates were observed in the Mountain States (18.4%). Decreased ICC treatment likelihood was observed for male African Americans with Medicaid insurance and those with low income (multivariable p < 0.05). Socioeconomic treatment discrepancies translated into decreased overall survival for patients of male sex (vs. female; hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.16-1.26, p < 0.001), with low income (< $37,999 vs. ≥ $63,000 annually; HR 1.07, 95% CI 1.01-1.14, p = 0.032), and with Medicaid insurance (vs. private insurance; HR 1.13, 95% CI 1.04-1.23, p = 0.006). Both surgical and non-surgical ICC management showed increased survival compared with no treatment, with the longest survival for surgery (5-year overall survival for surgery, 33.5%; interventional oncology, 11.8%; radiation oncology/chemotherapy, 4.4%; no treatment, 3.3%). Among non-surgically treated patients, interventional oncology yielded the longest survival versus radiation oncology/chemotherapy (HR 0.73, 95% CI 0.65-0.82, p < 0.001). CONCLUSIONS ICC treatment allocation and outcome demonstrated a marked variation depending on socioeconomic status, demography, cancer factors, and US geography. Healthcare providers should address these discrepancies by providing surgery and interventional oncology as first-line treatment to all eligible patients, with special attention to the vulnerable populations identified in this study.
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Affiliation(s)
- Johannes Uhlig
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA.,Department of Diagnostic and Interventional Radiology, University Medical Center Goettingen, Goettingen, Germany
| | - Cortlandt M Sellers
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Charles Cha
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Sajid A Khan
- Division of Surgical Oncology, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA
| | - Jill Lacy
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA.,Division of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stacey M Stein
- Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA.,Division of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Hyun S Kim
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA. .,Yale Cancer Center, Yale School of Medicine, New Haven, CT, USA. .,Division of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
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Mahlich J, Sruamsiri R. Co-insurance and health care utilization in Japanese patients with rheumatoid arthritis: a discontinuity regression approach. Int J Equity Health 2019; 18:22. [PMID: 30691462 PMCID: PMC6350300 DOI: 10.1186/s12939-019-0920-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 01/10/2019] [Indexed: 01/18/2023] Open
Abstract
Background Co-insurance rates in Japan decrease when patients turn 70 years of age. We aim to compare changes in medical demand for Japanese patients with rheumatoid arthritis (RA) at age 70 prior to 2014, when there was a reduction in co-insurance rates from 30 to 10%, with changes in medical demand at age 70 after 2014 when co-insurance rates decreased from 30% to only 20%. Methods We used administrative data from large Japanese hospitals. We employed a discontinuity regression (RD) approach to control for unobserved endogeneity in the data. Results We identified a total of 7343 patients with RA, 4905 (67%) turned age 70 before April, and found that a 20% decrease in co-insurance was associated with increased utilization of more expensive biologic RA drugs, more outpatient visits and higher total medical costs. However, a 10% decrease in co-insurance for patients who turned 70 after 2014 did not significantly change demand for medical services. Conclusions For the younger cohort, we did not observe any changes in medical demand after a price decrease. We therefore conclude that the economic goal of cost sharing, namely a behavioural change towards lower health-care utilization, is not achieved in this particular cohort of chronic patients. Electronic supplementary material The online version of this article (10.1186/s12939-019-0920-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jörg Mahlich
- Düsseldorf Institute for Competition Economics (DICE), University of Düsseldorf, Universitätsstr. 1, 40225, Düsseldorf, Germany. .,Health Economics and Outcomes Research, Janssen-Cilag, Neuss, Germany.
| | - Rosarin Sruamsiri
- Center of Pharmaceutical Outcomes Research, Naresuan University, Phitsanulok, Thailand
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Madureira-Lima J, Reeves A, Clair A, Stuckler D. The Great Recession and inequalities in access to health care: a study of unemployment and unmet medical need in Europe in the economic crisis. Int J Epidemiol 2019; 47:58-68. [PMID: 29024999 PMCID: PMC5837221 DOI: 10.1093/ije/dyx193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2017] [Indexed: 11/17/2022] Open
Abstract
Background Unmet medical need (UMN) had been declining steadily across Europe until the 2008 Recession, a period characterized by rising unemployment. We examined whether becoming unemployed increased the risk of UMN during the Great Recession and whether the extent of out-of-pocket payments (OOP) for health care and income replacement for the unemployed (IRU) moderated this relationship. Methods We used the European Survey on Income and Living Conditions (EU-SILC) to construct a pseudo-panel (n = 135 529) across 25 countries to estimate the relationship between unemployment and UMN. We estimated linear probability models, using a baseline of employed people with no UMN, to test whether this relationship is mediated by financial hardship and moderated by levels of OOP and IRU. Results Job loss increased the risk of UMN [β = 0.027, 95% confidence interval (CI) 0.022–0.033] and financial hardship exacerbated this effect. Fewer people experiencing job loss lost access to health care in countries where OOPs were low or in countries where IRU is high. The results are robust to different model specifications. Conclusions Unemployment does not necessarily compromise access to health care. Rather, access is jeopardized by diminishing financial resources that accompany job loss. Lower OOPs or higher IRU protect against loss of access, but they cannot guarantee it. Policy solutions should secure financial protection for the unemployed so that resources do not have to be diverted from health.
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Affiliation(s)
| | - Aaron Reeves
- International Inequalities Institute, London School of Economics and Political Science, London, UK
| | - Amy Clair
- Department of Sociology, University of Oxford, Oxford, UK
| | - David Stuckler
- Department of Sociology, University of Oxford, Oxford, UK
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Zhu Y, Liu J, Qu B, Yi Z. Quality of life, loneliness and health-related characteristics among older people in Liaoning province, China: a cross-sectional study. BMJ Open 2018; 8:e021822. [PMID: 30429143 PMCID: PMC6252650 DOI: 10.1136/bmjopen-2018-021822] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 08/09/2018] [Accepted: 10/02/2018] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The aim of the study was to examine the relations among quality of life (QOL), loneliness and health-related characteristics in a sample of Chinese older people. DESIGN Cross-sectional study. SETTING Communities in Dandong city, Liaoning province, China. PARTICIPANTS Sample of 732 older people aged 60 and older who were living in Dandong, Liaoning province, China. METHODS A questionnaire was administered to the participants face-to-face. The questionnaire contained four sections: demographic characteristics, health-related characteristics, the EQ-5D Scale and the UCLA Loneliness Scale. The t-test, F-test and multivariable linear regression analyses were performed to individually test associations between the demographic data, health-related characteristics, loneliness and QOL. RESULTS Chronic diseases, loneliness, age and smoking status were negatively associated with QOL (p<0.05). Satisfaction with health services, income and physical activity were positively associated with QOL (p<0.05). CONCLUSIONS Loneliness, chronic diseases and health service satisfaction were important factors related to low QOL among older people in China. The findings indicate that reducing loneliness, managing chronic diseases and improving the health service may help to improve the QOL for older people.
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Affiliation(s)
- Yaxin Zhu
- Department of Social Medicine, School of Public Health, China Medical University, Shenyang, People’s Republic of China
| | - Jie Liu
- Department of Health Statistics, School of Public Health, China Medical University, Shenyang, People’s Republic of China
| | - Bo Qu
- Department of Health Statistics, School of Public Health, China Medical University, Shenyang, People’s Republic of China
| | - Zhe Yi
- Department of Prothodontics, School of Stomatology, China Medical University, Shenyang, People’s Republic of China
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Diebold J. The Effects of Medicare Part D on Health Outcomes of Newly Covered Medicare Beneficiaries. J Gerontol B Psychol Sci Soc Sci 2018; 73:890-900. [PMID: 27154961 DOI: 10.1093/geronb/gbw030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 02/23/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives To estimate the impact of Medicare Part D on cost-related prescription nonadherence and health outcomes among the newly covered medicare beneficiaries. Method Difference-in-differences analyses of data from a balanced panel of Medicare beneficiaries observed in each wave of the Health and Retirement Study from 2000 to 2010 were carried out. The differences in the pre- and post-Part D changes in these outcomes are calculated for previously uncovered Part D enrollees and a comparison group of previously covered Medicare beneficiaries. Results The results from this analysis indicate that Part D reduced cost-related nonadherence rates among the newly covered by 7 percentage points and that this decline was sustained through 2010. Part D was also associated with a 5 percentage points increase in the likelihood that a newly covered enrollee reported to be in good or better health and a 4-percentage point decline in the likelihood of being diagnosed with high blood pressure. These improvements were also sustained through 2010 but were only evident among those newly covered beneficiaries who remained enrolled in a Part D plan through 2010. However, there is insufficient evidence to conclude that Part D improved the blood pressure of newly covered, hypertensive beneficiaries. Discussion Part D has had a sustained impact on cost-related nonadherence rates and the health status of newly covered beneficiaries. However, the change in health status is conditional on remaining enrolled in a Part D plan over time.
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Affiliation(s)
- Jeffrey Diebold
- Department of Public Administration, North Carolina State University, Raleigh
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Nilsson A, Paul A. Patient cost-sharing, socioeconomic status, and children's health care utilization. JOURNAL OF HEALTH ECONOMICS 2018; 59:109-124. [PMID: 29723695 DOI: 10.1016/j.jhealeco.2018.03.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 03/28/2018] [Accepted: 03/29/2018] [Indexed: 06/08/2023]
Abstract
This paper estimates the effect of cost-sharing on the demand for children's and adolescents' use of medical care. We use a large population-wide registry dataset including detailed information on contacts with the health care system as well as family income. Two different estimation strategies are used: regression discontinuity design exploiting age thresholds above which fees are charged, and difference-in-differences models exploiting policy changes. We also estimate combined regression discontinuity difference-in-differences models that take into account discontinuities around age thresholds caused by factors other than cost-sharing. We find that when care is free of charge, individuals increase their number of doctor visits by 5-10%. Effects are similar in middle childhood and adolescence, and are driven by those from low-income families. The differences across income groups cannot be explained by other factors that correlate with income, such as maternal education.
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Affiliation(s)
- Anton Nilsson
- Department of Economics and Business Economics, Aarhus University, DK-8210 Aarhus, Denmark; Centre for Economic Demography, Lund University, SE-22007 Lund, Sweden.
| | - Alexander Paul
- Department of Economics and Business Economics, Aarhus University, DK-8210 Aarhus, Denmark.
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Yoon S, Mooney MA, Bohl MA, Sheehy JP, Nakaji P, Little AS, Lawton MT. Patient out-of-pocket spending in cranial neurosurgery: single-institution analysis of 6569 consecutive cases and literature review. Neurosurg Focus 2018; 44:E6. [DOI: 10.3171/2018.1.focus17782] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEWith drastic changes to the health insurance market, patient cost sharing has significantly increased in recent years. However, the patient financial burden, or out-of-pocket (OOP) costs, for surgical procedures is poorly understood. The goal of this study was to analyze patient OOP spending in cranial neurosurgery and identify drivers of OOP spending growth.METHODSFor 6569 consecutive patients who underwent cranial neurosurgery from 2013 to 2016 at the authors’ institution, the authors created univariate and multivariate mixed-effects models to investigate the effect of patient demographic and clinical factors on patient OOP spending. The authors examined OOP payments stratified into 10 subsets of case categories and created a generalized linear model to study the growth of OOP spending over time.RESULTSIn the multivariate model, case categories (craniotomy for pain, tumor, and vascular lesions), commercial insurance, and out-of-network plans were significant predictors of higher OOP payments for patients (all p < 0.05). Patient spending varied substantially across procedure types, with patients undergoing craniotomy for pain ($1151 ± $209) having the highest mean OOP payments. On average, commercially insured patients spent nearly twice as much in OOP payments as the overall population. From 2013 to 2016, the mean patient OOP spending increased 17%, from $598 to $698 per patient encounter. Commercially insured patients experienced more significant growth in OOP spending, with a cumulative rate of growth of 42% ($991 in 2013 to $1403 in 2016).CONCLUSIONSEven after controlling for inflation, case-mix differences, and partial fiscal periods, OOP spending for cranial neurosurgery patients significantly increased from 2013 to 2016. The mean OOP spending for commercially insured neurosurgical patients exceeded $1400 in 2016, with an average annual growth rate of 13%. As patient cost sharing in health insurance plans becomes more prevalent, patients and providers must consider the potential financial burden for patients receiving specialized neurosurgical care.
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Abstract
OBJECTIVE To isolate the effect of greater inpatient cost-sharing on Medicaid entry among Medicare beneficiaries. DATA SOURCES Medicare administrative data (years 2007-2010) were linked to nursing home assessments and area-level socioeconomic indicators. STUDY DESIGN Medicare beneficiaries who are readmitted to a hospital must pay an additional deductible ($1,100 in 2010) if their readmission occurs more than 59 days following discharge. In a regression discontinuity analysis, we take advantage of this Medicare benefit feature to test whether beneficiaries with greater cost-sharing have higher rates of Medicaid enrollment. DATA EXTRACTION METHODS We identified 221,248 Medicare beneficiaries with an initial hospital stay and a readmission 53-59 days later (no deductible) or 60-66 days later (charged a deductible). PRINCIPAL FINDINGS Among beneficiaries in low-socioeconomic areas with two hospitalizations, those readmitted 60-66 days after discharge were 21 percent more likely to join Medicaid compared with those readmitted 53-59 days following their initial hospitalization (absolute difference in adjusted risk of Medicaid entry: 3.7 percent vs. 3.1 percent, p = .01). CONCLUSIONS Increasing Medicare cost-sharing requirements may promote Medicaid enrollment among low-income beneficiaries. Potential savings from an increased cost-sharing in the Medicare program may be offset by increased Medicaid participation.
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Affiliation(s)
- Laura M. Keohane
- Department of Health PolicyVanderbilt University School of MedicineNashvilleTN
| | - Amal N. Trivedi
- Department of Health Services, Policy and PracticeBrown UniversityProvidenceRI
- Center of Innovation in Long‐Term Services and Supports for Vulnerable VeteransProvidence VA Medical CenterProvidenceRI
| | - Vincent Mor
- Department of Health Services, Policy and PracticeBrown UniversityProvidenceRI
- Center of Innovation in Long‐Term Services and Supports for Vulnerable VeteransProvidence VA Medical CenterProvidenceRI
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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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48
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Goldstein JN, Zhang Z, Schwartz JS, Hicks LS. Observation Status, Poverty, and High Financial Liability Among Medicare Beneficiaries. Am J Med 2018; 131:101.e9-101.e15. [PMID: 28774801 PMCID: PMC5725232 DOI: 10.1016/j.amjmed.2017.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries. METHODS We performed a retrospective, observational analysis of Medicare Part B claims and US Census Bureau data from 2013. Medicare beneficiaries with Part A and B coverage for the full calendar year, with 1 or more observation stay(s), were included in the study. Beneficiaries were divided into quartiles representing poverty level. The associations between poverty quartile and high use of observation care and between poverty quartile and high financial liability for observation care were evaluated. RESULTS After multivariate adjustment, the risk of high use was higher for beneficiaries in the poor (Quartile 3) and poorest (Quartile 4) quartiles compared with those in the wealthiest quartile (Quartile 1) (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.13-1.31; AOR, 1.24; 95% CI, 1.16-1.33). The risk of high financial liability was higher in every poverty quartile compared with the wealthiest and peaked in Quartile 3, which represented the poor but not the poorest beneficiaries (AOR, 1.17; 95% CI, 1.10-1.24). CONCLUSIONS Poverty predicts high use of observation care. The poor or near poor may be at highest risk for high liability.
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Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine, Christiana Care Health System, Newark Del; The Value Institute, Christiana Care Health System, Newark, Del.
| | - Zugui Zhang
- The Value Institute, Christiana Care Health System, Newark, Del
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - LeRoi S Hicks
- Department of Medicine, Christiana Care Health System, Newark Del; The Value Institute, Christiana Care Health System, Newark, Del
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49
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Muthulingam D. Health Insurance and the Promise of Incrementalism. J Womens Health (Larchmt) 2017; 26:1263-1264. [DOI: 10.1089/jwh.2017.6696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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50
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Keohane LM, Grebla RC, Rahman M, Mukamel DB, Lee Y, Mor V, Trivedi A. First-dollar cost-sharing for skilled nursing facility care in medicare advantage plans. BMC Health Serv Res 2017; 17:611. [PMID: 28851435 PMCID: PMC5576284 DOI: 10.1186/s12913-017-2558-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 08/18/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The initial days of a Medicare-covered skilled nursing facility (SNF) stay may have no cost-sharing or daily copayments depending on beneficiaries' enrollment in traditional Medicare or Medicare Advantage. Some policymakers have advocated imposing first-dollar cost-sharing to reduce post-acute expenditures. We examined the relationship between first-dollar cost-sharing for a SNF stay and use of inpatient and SNF services. METHODS We identified seven Medicare Advantage plans that introduced daily SNF copayments of $25-$150 in 2009 or 2010. Copays began on the first day of a SNF admission. We matched these plans to seven matched control plans that did not introduce first-dollar cost-sharing. In a difference-in-differences analysis, we compared changes in SNF and inpatient utilization for the 172,958 members of intervention and control plans. RESULTS In intervention plans the mean annual number of SNF days per 100 continuously enrolled inpatients decreased from 768.3 to 750.6 days when cost-sharing changes took effect. Control plans experienced a concurrent increase: 721.7 to 808.1 SNF days per 100 inpatients (adjusted difference-in-differences: -87.0 days [95% CI (-112.1,-61.9)]). In intervention plans, we observed no significant changes in the probability of any SNF service use or the number of inpatient days per hospitalized member relative to concurrent trends among control plans. CONCLUSIONS Among several strategies Medicare Advantage plans can employ to moderate SNF use, first-dollar SNF cost-sharing may be one influential factor. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Laura M. Keohane
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Ave, Suite 1200, Nashville, TN 37203 USA
| | - Regina C. Grebla
- Department of Health Services, Policy and Practice, Brown University, 121 South Main Street, Providence, RI 02903 USA
| | - Momotazur Rahman
- Department of Health Services, Policy and Practice, Brown University, 121 South Main Street, Providence, RI 02903 USA
| | - Dana B. Mukamel
- Department of Medicine, Division of General Internal Medicine, University of California, Irvine, 100 Theory, Suite 120, Mail Code: 1835, Irvine, CA 92697 USA
| | - Yoojin Lee
- Department of Health Services, Policy and Practice, Brown University, 121 South Main Street, Providence, RI 02903 USA
| | - Vincent Mor
- Department of Health Services, Policy and Practice, Brown University, 121 South Main Street, Providence, RI 02903 USA
- Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence VA Medical Center, Providence, RI USA
| | - Amal Trivedi
- Department of Health Services, Policy and Practice, Brown University, 121 South Main Street, Providence, RI 02903 USA
- Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans, Providence VA Medical Center, Providence, RI USA
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