Medicare Advantage Is Associated with Lower Utilization of Total Joint Arthroplasty.

BACKGROUND: Medicare Advantage (MA) insurers use managed care techniques to review the utilization of medical services and control costs. It is unclear if MA enrollees have a lower utilization of elective surgical procedures such as inpatient hip and knee total joint arthroplasty (TJA), which have traditionally been covered by traditional Medicare (TM) without restrictions. METHODS: We conducted a cross-sectional study using a 20% sample of 2018 TM claims and MA encounter records for 5,300,188 TM enrollees and 1,970,032 MA enrollees who were 65 to 85 years of age. We calculated unadjusted and adjusted differences (controlling for beneficiary and market characteristics) in the incidence of TJA for MA compared with TM, and by MA plan type. Finally, we calculated differences in the time to contact with an orthopaedic surgeon and time to the surgical procedure among enrollees with an osteoarthritis diagnosis. RESULTS: After controlling for observable characteristics, there was a 15.6% lower incidence of TJA in MA enrollees compared with TM enrollees (p < 0.001). Compared with TM enrollees, health maintenance organization (HMO) enrollees were 28.1% less likely to undergo TJA, controlling for observable characteristics (p < 0.001). From the initial diagnosis, the time to contact with an orthopaedic surgeon and the time to the surgical procedure were also lower among TM enrollees compared with MA enrollees. At 2 years after an osteoarthritis diagnosis, 10.4% of TM enrollees, 7.9% of preferred provider organization (PPO) enrollees, and 5.7% of HMO enrollees had undergone inpatient TJA. CONCLUSIONS: MA coverage was associated with a lower utilization of elective, inpatient hip and knee TJA. MA was also associated with a longer time to orthopaedic surgeon evaluation and surgical procedure. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Psychiatrist and Nonpsychiatrist Physician Network Breadth in Dual Eligible Special Needs Plans.

OBJECTIVE: Dual Eligible Special Needs Plans (D-SNPs) are a type of Medicare Advantage (MA) plan for individuals who have both Medicare and Medicaid coverage. The authors compared the breadths of psychiatrist and nonpsychiatrist provider networks in D-SNPs and other MA plans. METHODS: MA plan provider network data were merged with plan service areas and a nationwide provider database to form a data set with 843 observations on networks subclassified by state and network type (D-SNP or other MA) covering 42 U.S. states and Washington, D.C. Network breadth measured the in-network fraction of clinically active Medicare-accepting psychiatrists and other physician providers in the plans' service areas in each state. Regression analyses were used to compare psychiatrist and nonpsychiatrist network breadth and psychiatrist-nonpsychiatrist breadth differences between D-SNPs and other MA plans, after adjustment for state-level differences. RESULTS: Mean psychiatrist network breadth was 0.319 in D-SNPs and 0.299 in other MA plans, and nonpsychiatrist network breadth was 0.346 in D-SNPs and 0.358 in other MA plans. Psychiatrist networks were narrower than nonpsychiatrist networks (0.303 vs. 0.355, p<0.001), but mean psychiatrist network breadth did not differ between D-SNPs and other MA plans. In regression analyses, the psychiatrist-nonpsychiatrist breadth difference was smaller in D-SNPs (-0.031) than in other MA plans (-0.060) (p=0.002). CONCLUSIONS: Psychiatrist provider networks in a nationwide sample of D-SNPs had similar breadth as psychiatrist networks used in other MA plans. Special provider network adequacy requirements for psychiatrists in D-SNP networks may be worthy of further consideration given D-SNPs' disproportionate enrollment of adults with serious mental illness who have dual Medicare-Medicaid insurance coverage.

Do Local Tobacco-21 Laws Reduce Smoking Among 18 to 20 Year-Olds?

INTRODUCTION: States and municipalities are increasingly restricting tobacco sales to those under age 21, in an effort to reduce youth and young adult smoking. However, the effectiveness of such policies remains unclear, particularly when implemented locally. METHODS: Analyses use 2011-2016 data from the Behavioral Risk Factor Surveillance System's Selected Metropolitan/Micropolitan Area Risk Trends dataset. Difference-in-differences and triple-difference regressions estimate the relationship between local tobacco-21 policies and smoking among 18- to 20-year-olds living in MMSAs (metropolitan/micropolitan statistical areas and metropolitan divisions). RESULTS: Current smoking rates fell from 16.5% in 2011 to 8.9% in 2016 among 18- 20-year-olds in these data. Regressions indicate that a tobacco-21 policy covering one's entire MMSA yields an approximately 3.1 percentage point reduction in 18- to 20-year-olds' likelihoods of smoking (confidence interval [CI] = -0.0548 to -0.0063). Accounting for partial policy exposure-tobacco-21 laws implemented in some but not all jurisdictions within an MMSA-this estimate implies that the average exposed 18- to 20-year-old experienced a 1.2 percentage point drop in their likelihood of being a smoker at interview relative to unexposed respondents of the same age, all else equal. CONCLUSIONS: Local tobacco-21 policies yield a substantive reduction in smoking among 18- to 20-year-olds living in MMSAs. This finding provides empirical support for efforts to raise the tobacco purchasing age to 21 as a means to reduce young adult smoking. Moreover, it suggests that state laws preempting local tobacco-21 policies may impede public health. IMPLICATIONS: Although states and municipalities are increasingly restricting tobacco sales to under 21-year-olds, such policies' effectiveness remains unclear, particularly when implemented locally. Using quasi-experimental methods, this article provides what may be the first evidence that sub-state tobacco-21 laws reduce smoking among 18- to 20-year-olds. Specifically, considering metropolitan and micropolitan areas from 2011 to 2016, the average 18- to 20-year-old who was exposed to these policies exhibited a 1.2 percentage point drop in their likelihood of being a current established smoker, relative to those who were unexposed. These findings validate local tobacco-21 laws as a means to reduce young adult smoking.