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1.
Health Serv Res ; 59(4): e14308, 2024 Aug.
Article in English | MEDLINE | ID: mdl-38594081

ABSTRACT

OBJECTIVE: The objective was to measure specialty provider networks in Medicare Advantage (MA) and examine associations with market factors. DATA SOURCES AND STUDY SETTING: We relied on traditional Medicare (TM) and MA prescription drug event data from 2011 to 2017 for all Medicare beneficiaries in the United States as well as data from the Area Health Resources File. STUDY DESIGN: Relying on a recently developed and validated prediction model, we calculated the provider network restrictiveness of MA contracts for nine high-prescribing specialties. We characterized network restrictiveness through an observed-to-expected ratio, calculated as the number of unique providers seen by MA beneficiaries divided by the number expected based on the prediction model. We assessed the relationship between network restrictiveness and market factors across specialties with multivariable linear regression. DATA COLLECTION/EXTRACTION METHODS: Prescription drug event data for a 20% random sample of beneficiaries enrolled in prescription drug coverage from 2011 to 2017. PRINCIPAL FINDINGS: Provider networks in MA varied in restrictiveness. OB-Gynecology was the most restrictive with enrollees seeing 34.5% (95% CI: 34.3%-34.7%) as many providers as they would absent network restrictions; cardiology was the least restrictive with enrollees seeing 58.6% (95% CI: 58.4%-58.8%) as many providers as they otherwise would. Factors associated with less restrictive networks included the county-level TM average hierarchical condition category score (0.06; 95% CI: 0.04-0.07), the county-level number of doctors per 1000 population (0.04; 95% CI: 0.02-0.05), the natural log of local median household income (0.03; 95% CI: 0.007-0.05), and the parent company's market share in the county (0.16; 95% CI: 0.13-0.18). Rurality was a major predictor of more restrictive networks (-0.28; 95% CI: -0.32 to -0.24). CONCLUSIONS: Our findings suggest that rural beneficiaries may face disproportionately reduced access in these networks and that efforts to improve access should vary by specialty.


Subject(s)
Medicare Part C , United States , Humans , Medicare Part C/statistics & numerical data , Male , Medicine/statistics & numerical data , Female , Aged , Specialization/statistics & numerical data , Physicians/statistics & numerical data
3.
J Clin Oncol ; 41(6): 1239-1249, 2023 02 20.
Article in English | MEDLINE | ID: mdl-36356283

ABSTRACT

PURPOSE: Nearly half of all Medicare beneficiaries are enrolled in privatized Medicare insurance plans (Medicare Advantage [MA]). Little comparative information is available about access, outcomes, and cost of inpatient cancer surgery between MA and Traditional Medicare (TM) beneficiaries. We set out to assess and compare access, postoperative outcomes, and estimated cost of inpatient cancer surgery among MA and TM beneficiaries. METHODS: Retrospective cohort analysis of MA or TM beneficiaries undergoing elective inpatient cancer surgery (for cancers located in lung, esophagus, stomach, pancreas, liver, colon, or rectum) was performed using the Office of Statewide Health Planning Inpatient Database linked to California Cancer Registry from 2000 to 2020. For each cancer site, risk-standardized access to high-volume hospitals, postoperative 30-day mortality, complications, failure to rescue, and surgery-specific estimated costs were compared between MA and TM beneficiaries. RESULTS: This analysis of 76,655 Medicare beneficiaries (median age 74 years, 51% female, 39% MA) included 31,913 colectomies, 10,358 proctectomies, 4,604 hepatectomies, 2,895 pancreatectomies, 3,639 gastrectomies, 1,555 esophagectomies, and 21,691 lung resections. Except for colon surgery, MA beneficiaries were less likely to receive care at a high-volume hospital. Mortality was significantly higher among MA beneficiaries (v TM) for gastrectomy (adjusted risk difference [ARD], 1.5%; 95% CI, 0.01 to 2.9; P = .036), pancreatectomy (ARD, 2.0%; CI, 0.80 to 3.3; P = .002), and hepatectomy (ARD, 1.4%; 95% CI, 0.1 to 2.9; P = .04). By contrast, compared with TM, MA beneficiaries incurred lower estimated hospital costs. CONCLUSION: Enrollment in MA plan is associated with lower estimated hospital costs. However, compared with TM, MA beneficiaries had lower access to high-volume hospitals and increased 30-day mortality for stomach, pancreas, or liver surgery.


Subject(s)
Medicare Part C , Neoplasms , Humans , Female , Aged , United States , Male , Retrospective Studies , Cohort Studies , Inpatients , Neoplasms/surgery
5.
Ann Surg ; 274(4): e315-e319, 2021 10 01.
Article in English | MEDLINE | ID: mdl-34506325

ABSTRACT

OBJECTIVE: To determine how Medicare Advantage (MA) health plan networks impact access to high-volume hospitals for cancer surgery. BACKGROUND: Cancer surgery at high-volume hospitals is associated with better short- and long-term outcomes. In the United States, health insurance is a major detriment to seeking care at high-volume hospitals. A third of older (>65 years) Americans are enrolled in privatized MA health plans. The impact of MA plan networks on access to high-volume surgery hospitals is unknown. METHODS: We analyzed in-network hospitals for MA plans offered in Los Angeles county during open enrollment of 2015. For the purposes of this analysis, MA network data from provider directories were linked to hospital volume data from California Office of Statewide Health Planning and Development. Volume thresholds were based on published literature. RESULTS: A total of 34 MA plans enrolled 554,754 beneficiaries in Los Angeles county during 2014 open enrollment for coverage starting in 2015 (MA penetration ∼43%). The proportion of MA plans that included high-volume cancer surgery hospital varied by the type of cancer surgery. While most plans (>71%) included at least one high-volume hospital for colon, rectum, lung, and stomach; 59% to 82% of MA plans did not include any high-volume hospitals for liver, esophagus, or pancreatic surgery. A significant proportion of beneficiaries in MA plans did not have access to high-volume hospitals for esophagus (93%), stomach (44%), liver (39%), or pancreas (70%) surgery. In contrast, nearly all MA beneficiaries had access to at least one high-volume hospital for lung (93%), colon (100%), or rectal (100%) surgery. Overall, Centers for Medicare & Medicaid Services plan rating or plan popularity were not correlated with access to high-volume hospital (P > 0.05). CONCLUSIONS: The study identifies lack of high-volume hospital coverage in MA health plans as a major detriment in regionalization of cancer surgery impacting at least a third of older Americans.


Subject(s)
Health Services Accessibility/organization & administration , Hospitals, High-Volume/statistics & numerical data , Medicare Part C/organization & administration , Neoplasms/surgery , Surgical Procedures, Operative/statistics & numerical data , Aged , Facilities and Services Utilization , Female , Humans , Male , Neoplasms/epidemiology , Neoplasms/pathology , Procedures and Techniques Utilization , Retrospective Studies , United States
7.
9.
Health Aff (Millwood) ; 34(1): 48-55, 2015 Jan.
Article in English | MEDLINE | ID: mdl-25561643

ABSTRACT

With ongoing interest in rising Medicare Advantage enrollment, we examined whether the growth in enrollment between 2006 and 2011 was mainly due to new beneficiaries choosing Medicare Advantage when they first become eligible for Medicare. We also examined the extent to which beneficiaries in traditional Medicare switched to Medicare Advantage, and vice versa. We found that 22 percent of new Medicare beneficiaries elected Medicare Advantage over traditional Medicare in 2011; they accounted for 48 percent of new Medicare Advantage enrollees that year. People ages 65-69 switched from traditional Medicare to Medicare Advantage at higher-than-average rates. Dual eligibles (people eligible for both Medicare and Medicaid) and beneficiaries younger than age sixty-five with disabilities disenrolled from Medicare Advantage at higher-than-average rates. On average, in each year of the study period we found that fewer than 5 percent of traditional Medicare beneficiaries switched to Medicare Advantage, and a similar percentage of Medicare Advantage enrollees switched to traditional Medicare. These results suggest that initial coverage decisions have long-lasting effects.


Subject(s)
Choice Behavior , Medicare Part C/statistics & numerical data , Medicare Part C/trends , Medicare/statistics & numerical data , Medicare/trends , Aged , Costs and Cost Analysis/economics , Costs and Cost Analysis/trends , Female , Forecasting , Health Surveys , Humans , Insurance Coverage/economics , Insurance Coverage/statistics & numerical data , Insurance Coverage/trends , Male , Medicare/economics , Medicare Part C/economics , Patient Protection and Affordable Care Act/economics , Patient Protection and Affordable Care Act/statistics & numerical data , Patient Protection and Affordable Care Act/trends , Population Dynamics/trends , United States , Utilization Review/trends
10.
Med Care Res Rev ; 71(6): 661-89, 2014 Dec.
Article in English | MEDLINE | ID: mdl-25371217

ABSTRACT

This article presents, critiques, and analyzes the influence of prices on insurance choices made by Medicare beneficiaries in the Medicare Advantage, Part D, and Medigap markets. We define price as health insurance premiums for the Medicare Advantage and Medigap markets, and total out-of-pocket costs (including premiums and cost sharing) for the Part D market. In Medicare Advantage and Part D, prices only partly explain insurance choices. Enrollment decisions also may be influenced by other factors such as the perceived quality of the higher-premium plans, better provider networks, lower cost-sharing for services, more generous benefits, and a preference for certain brand-name products. In contrast, the one study available on the Medigap market concludes that price appears to be associated with plan selection. This may be because Medigap benefits are fully standardized, making it easier for beneficiaries to compare alternative policies. The article concludes by discussing policy options available to Medicare.


Subject(s)
Choice Behavior , Health Care Costs/statistics & numerical data , Insurance, Health/economics , Insurance, Medigap/statistics & numerical data , Medicare Part D/statistics & numerical data , Financing, Personal/economics , Financing, Personal/statistics & numerical data , Humans , United States
11.
Health Aff (Millwood) ; 31(6): 1176-85, 2012 Jun.
Article in English | MEDLINE | ID: mdl-22665829

ABSTRACT

Coordinating care for the nine million elderly or disabled and low-income people who are dually eligible for Medicare and Medicaid is a pressing policy issue. To support the debate over this issue, we synthesized public data on how services are provided to dual eligibles receiving covered benefits in both programs. Our analysis confirmed that most dual-eligible beneficiaries receive benefits separately for each program through fee-for-service arrangements. Their enrollment in Medicare and Medicaid managed care is growing but still low, with highly uneven experiences across states. Few states or health plans have experience with coordinating care for dual eligibles within an integrated plan. These findings reinforce the need for caution in considering policies that would rapidly give states the responsibility for coordinating dual eligibles' care and coverage. We also found data gaps that warrant prompt attention in order to provide national-level oversight and improve the evidence base for debating and tracking policy changes.


Subject(s)
Delivery of Health Care, Integrated , Eligibility Determination , Medicaid/statistics & numerical data , Medicare/statistics & numerical data , Policy Making , Databases, Factual , Humans , State Government , United States
12.
Annu Rev Med ; 61: 469-76, 2010.
Article in English | MEDLINE | ID: mdl-20059349

ABSTRACT

The Medicare Modernization Act was intended to improve access to prescription drugs for millions of seniors, by providing a range of benefit packages with different prices and different formularies for beneficiaries to choose from. The major challenge for physicians has been to recognize when a Medicare beneficiary has coverage versus when that patient is in the "doughnut hole" where Medicare beneficiaries do not have coverage and therefore have to pay the full cost of the drugs out-of-pocket. A second challenge is that different Medicare beneficiaries are enrolled in different drug plans, and drugs that are covered in some plans are not covered in other plans.


Subject(s)
Insurance Benefits , Insurance Coverage/organization & administration , Medicare Part D/organization & administration , Humans , United States
14.
Am J Trop Med Hyg ; 69(5 Suppl): 1-10, 2003 Nov.
Article in English | MEDLINE | ID: mdl-14692674

ABSTRACT

Interest in the economics of trachoma is high because of the refinement of a strategy to control trachomatous blindness, an ongoing global effort to eliminate incident blindness from trachoma by 2020, and an azithromycin donation program that is a component of trachoma control programs in several countries. This report comments on the economic distribution of blindness from trachoma and adds insight to published data on the burden of trachoma and the comparative costs and effects of trachoma control. Results suggest that 1) trichiasis without visual impairment may result in an economic burden comparable to trachomatous low vision and blindness so that 2) the monetary burden of trachoma may be 50% higher than conservative, published figures; 3) within some regions more productive economies are associated with less national blindness from trachoma; and 4) the ability to achieve a positive net benefit of trachoma control depends importantly on the cost per dose of antibiotic.


Subject(s)
Blindness/prevention & control , Trachoma/economics , Anti-Bacterial Agents/economics , Blindness/economics , Blindness/etiology , Cost-Benefit Analysis , Disability Evaluation , Global Health , Health Behavior , Humans , Poverty/economics , Poverty/statistics & numerical data , Trachoma/complications , Trachoma/prevention & control
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