At least half of new Medicare advantage enrollees had switched from traditional Medicare during 2006-11.

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.

Dx for a careful approach to moving dual-eligible beneficiaries into managed care plans.

Policy makers are moving rapidly to develop and test reforms aimed at doing a better job of managing the costs and care for people dually eligible for Medicare and Medicaid. This commentary underscores the importance of pursuing new initiatives to address care coordination and spending concerns. It then focuses on key issues raised by proposals that would shift dual-eligible beneficiaries into managed care plans. The paper describes the heterogeneity and complexity of this population, emphasizing the need for approaches closely tied to the needs of particular subgroups of dual-eligible beneficiaries. It warns against moving too quickly, noting the time and resources required to build capacity to serve patients, secure provider networks, and develop an infrastructure for integrating and managing both Medicare and Medicaid services. The commentary cautions that optimistic savings assumptions might not materialize, raises questions about how savings will be allocated, and highlights the need for accountability as new models are being developed and tested to improve care for a population with complex needs.

Medicare doesn't work as well for younger, disabled beneficiaries as it does for older enrollees.

Medicare is not working as well for its eight million disabled beneficiaries under age sixty-five as it is for its older beneficiaries. We report on a 2008 survey that found significant differences between the two Medicare populations, with the younger group experiencing more problems of cost and access. Even with the Medicare Part D prescription drug program, the nonelderly disabled reported greater difficulty in affording medications, and more adverse health consequences as a result. One potential remedy is the Patient Protection and Affordable Care Act. The law includes reforms that could improve access to care and limit out-of-pocket expenses for the nonelderly disabled in Medicare-as well as those who are waiting to become eligible for the program.

Prescription coverage, use and spending before and after Part D implementation: a national longitudinal panel study.

BACKGROUND: In January 2006, 43 million Medicare beneficiaries became eligible for subsidized prescription coverage (Part D) through Medicare. To date, no longitudinal study has afforded information on beneficiaries' prescription coverage transitions and corresponding changes in prescription use and spending. OBJECTIVE: To evaluate changes in Medicare beneficiaries' prescription coverage, use and spending before and after Part D implementation, including comparison of those who enrolled in Part D with those who did not. DESIGN, SETTING AND PARTICIPANTS: Longitudinal observational study of non-institutionalized Medicare beneficiaries aged 65 and older (n = 9,573) employing administrative data from the Centers for Medicare and Medicaid Services (CMS) and survey-based data from beneficiaries (2003, 2006). Sampling drew from a 1% national probability sample (2003), oversampling low-income beneficiaries including those dually-enrolled in Medicare and Medicaid. MEASUREMENTS & MAIN RESULTS: Number and type of prescriptions, monthly out-of-pocket prescription spending, and cost-related non-adherence to prescription regimens. Most respondents who lacked prescription coverage in 2003 had acquired it by 2006 (82.6%)-primarily through Part D (63.1%). Part D enrollees who previously lacked coverage or had Medigap coverage appear particularly advantaged by Part D, as evidenced by significantly increased prescription use, lower out-of-pocket spending and lower non-adherence. Those with employer-based coverage experienced significantly increased spending. Among those still lacking coverage in 2006, high rates of cost-related non-adherence (31.8%) were reported by the low-income, chronically ill subgroup. CONCLUSIONS: In its first year, Part D coverage appears to have moderated prescription spending and cost-related burden for those who previously had meager benefits or none. Increased spending among those with employer-based coverage may reflect a narrowing of those benefits over this period. Evidence of foregone care among low-income, chronically ill seniors who still lack prescription coverage highlights the importance of targeted outreach to this group for Part D's low-income subsidy program.

How much 'skin in the game' do medicare beneficiaries have? The increasing financial burden of health care spending, 1997-2003.

Rising health costs and an aging population present critical policy challenges. This paper examines the financial burden of out-of-pocket health spending among Medicare beneficiaries between 1997 and 2003. Over this period, median out-of-pocket spending as a share of income increased from 11.9 percent to 15.5 percent. In 2003, the 25 percent of beneficiaries with the largest burden spent at least 29.9 percent of their income on health care, while 39.9 percent spent more than a fifth of their income on health care. Results suggest that sustained increases in out-of-pocket spending could make health care less affordable for all but the highest-income beneficiaries.

Medicare prescription drug benefit progress report: findings from a 2006 national survey of seniors.

A national survey in 2006 found that Part D secured drug coverage for most seniors who were without it in 2005, prior to the Medicare drug benefit. Seniors without drug coverage in 2006 generally fell into two groups: those in relatively good health and those potentially difficult to reach. Compared with seniors covered through employer plans or the Department of Veterans Affairs, Part D enrollees had higher out-of-pocket spending and greater cost-related nonadherence. Low-income subsidies offered protection against high out-of-pocket spending; without them, one-third of Part D enrollees at or below 150 percent of poverty paid more than $100 a month for their medications.

Physician-patient communication about prescription medication nonadherence: a 50-state study of America's seniors.

CONTEXT: Understanding and improving the quality of medication management is particularly important in the context of the Medicare prescription drug benefit that took effect last January 2006. OBJECTIVE: To determine the prevalence of physician-patient dialogue about medication cost and medication adherence among elderly adults nationwide. DESIGN: Cross-sectional survey. PARTICIPANTS: National stratified random sample of community-dwelling Medicare beneficiaries aged 65 and older. MAIN OUTCOME MEASURES: Rates of physician-patient dialogue about nonadherence and cost-related medication switching. RESULTS: Forty-one percent of seniors reported taking five or more prescription medications, and more than half has 2 or more prescribing physicians. Thirty-two percent overall and 24% of those with 3 or more chronic conditions reported not having talked with their doctor about all their different medicines in the last 12 months. Of seniors reporting skipping doses or stopping a medication because of side effects or perceived nonefficacy, 27% had not talked with a physician about it. Of those reporting cost-related nonadherence, 39% had not talked with a physician about it. Thirty-eight percent of those with cost-related nonadherence reported switching to a lower priced drug, and in a multivariable model, having had a discussion about drug cost was significantly associated with this switch (odds ratio [OR] 5.04, 95% confidence interval [CI] 4.28-5.93, P < .001). CONCLUSIONS: We show that there is a communication gap between seniors and their physicians around prescription medications. This communication problem is an important quality and safety issue, and takes on added salience as physicians and patients confront new challenges associated with coverage under new Medicare prescription drug plans. Meeting these challenges will require that more attention be devoted to medication management during all clinical encounters.

Status report on Medicare Part D enrollment in 2006: analysis of plan-specific market share and coverage.

The centerpiece of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 was the Part D drug benefit, provided through new stand-alone prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans. We examine 2006 Part D enrollment data to analyze organization- and plan-level market share and enrollment by plan type, benefit design, and gap coverage. Ten organizations captured 72 percent of Part D enrollment, primarily in low-premium plans and those with name recognition. More than twelve million Part D enrollees without low-income subsidies enrolled in plans with limited or no gap coverage in 2006, but the number with actual spending in the gap remains to be seen.

Prescription drug coverage and seniors: findings from a 2003 national survey.

Beginning in 2006 the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) will offer pharmacy benefits to forty-two million Medicare beneficiaries nationwide. In a 2003 national survey of Medicare beneficiaries age sixty-five and older, more than one-quarter reported no prescription coverage, and nearly half of low-income seniors in some states lacked coverage. Wide coverage differences among states highlight implementation challenges and the need for tailored enrollment strategies. Evidence of Medicaid's highly effective coverage delineates the importance of assuring this group's continued protection under Part D plans. Reports of complex drug regimens, multiple prescribing physicians and pharmacies, nonadherence, and reimportation demonstrate the challenges of integrating seniors' prescription care. We discuss MMA's potential to improve quality and the need to monitor performance.

Large firms' retiree health benefits before Medicare reform: 2003 survey results.

This survey of large, private-sector employers offering retiree health benefits in 2003 provides a detailed baseline of private retiree health plans on the eve of the most sweeping changes to Medicare since its enactment. Total retiree health costs rose 13.7 percent in 2003, and average retiree contributions to premiums for employees age sixty-five and older retiring in 2003 rose 18 percent. Nearly half of surveyed employers have capped their contributions to health coverage for retirees over age sixty-five. Before passage of the new Medicare legislation, 20 percent said that they are likely to eliminate benefits for future retirees within three years.

Uncovering the health challenges facing people with disabilities: the role of health insurance.

Americans with disabilities have wide-ranging health care needs and face serious challenges in the health care system. This 2003 survey of 1,505 nonelderly adults with disabilities finds relatively large shares of people with disabilities reporting cost-related barriers to care. The study also reveals marked differences in cost-related experiences both between those with and without health insurance and across sources of coverage. These findings suggest the need for additional research, along with policies to provide health insurance to people with disabilities who lack coverage, to fill gaps in coverage among those with Medicare and private insurance, and to maintain coverage for Medicaid enrollees amid rising costs and state budget shortfalls.

Trends in Medicare supplemental insurance and prescription drug coverage, 1996-1999.

Medicare Current Beneficiary Survey (MCBS) Access to Care data indicate a five-percentage-point decline in the share of Medicare beneficiaries having Medigap coverage between 1996 and 1999; this was matched by a commensurate rise in the share enrolled in Medicare HMOs, contributing to an increase in the percentage with drug coverage. During this period, high-income beneficiaries, and to a lesser extent healthier and rural beneficiaries, experienced greater net declines in supplemental coverage and smaller relative gains in drug coverage, compared with others. By fall 1999, 38 percent of beneficiaries lacked drug coverage, based on point-in-time estimates. This is much higher than previous estimates that measured beneficiaries' drug coverage at any time during the calendar year. Many of Medicare's most vulnerable beneficiaries--rural (50 percent), near-poor (44 percent), and oldest old (45 percent)--were most likely to lack drug coverage in the fall of 1999.

Prescription drug coverage and seniors: how well are states closing the gap?

As policymakers debate adding a drug benefit to Medicare, many states are attempting to provide drug coverage for low-income seniors through Medicaid and state-funded pharmacy assistance programs. This 2001 survey of seniors in eight states finds marked differences among states in the percentage of seniors with coverage and in the sources providing coverage. Among low-income seniors, a range of 20 percent (New York and California) to 38 percent (Michigan and Texas) lacked drug coverage. In all states Medicaid was an important source of coverage for the poor, but the depth of Medicaid drug coverage varied widely across states. Even states with pharmacy assistance programs fell far short of closing the prescription coverage gap for low-income seniors. Finally, the study finds that classifying beneficiaries as either having coverage or not misses major differences in depth of coverage, with some sources of coverage appearing only marginally better than no coverage at all. With erosion of state and private sources of prescription benefits expected, the findings speak to the need for a national policy solution.