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Fitness Memberships and Favorable Selection in Medicare Advantage Plans
Abstract
Because Medicare Advantage plans must pay for covered services, they may design insurance benefits to appeal to healthier beneficiaries.
We identified 11 Medicare Advantage plans that offered new fitness-membership benefits in 2004 or 2005 and matched these plans to 11 Medicare Advantage control plans that did not offer coverage for fitness memberships. Using a difference-in-differences approach, we compared the self-reported health status of persons who enrolled after the fitness benefit was added to the plan with the self-reported health status of persons entering the same plan before the fitness benefit was offered.
The proportion of enrollees reporting excellent or very good health was 6.1 percentage points higher (95% confidence interval [CI], 2.6 to 9.7) among the 755 new enrollees in plans that added fitness benefits than among the 4097 earlier enrollees. The proportion of new enrollees reporting activity limitation was 10.4 percentage points lower (95% CI, 6.6 to 14.3) and the proportion reporting difficulty walking was 8.1 percentage points lower (95% CI, 4.4 to 11.7), as compared with earlier enrollees. Within control plans, the differences between the 1154 new enrollees and the 3910 earlier enrollees were 1.5 percentage points or less for each measure. The adjusted differences between the fitness-benefit plans and the control plans were 4.7 percentage points higher for general health (95% CI, 0.2 to 9.2), 9.2 percentage points lower for activity limitation (95% CI, 5.1 to 13.3), and 7.4 percentage points lower for difficulty walking (95% CI, 4.5 to 10.4). These differences persisted at 2 years for activity limitation and difficulty walking.
Medicare Advantage plans offering coverage for fitness memberships may attract and retain a healthier subgroup of the Medicare population. (Funded by the National Institute on Aging.).
... While risk adjustment has had some success in pricing heterogeneity across Medicare Advantage plans (McWilliams et al., 2012), MCOs have responded by redirecting selection efforts toward unadjusted characteristics (Brown et al., 2014). This is accomplished in a variety of ways, including targeted advertising (Aizawa and Kim, 2018), offering supplementary benefits attractive to healthy individuals and unappealing to the disabled (Cooper and Trivedi, 2012), and increased spending on services used by high-profit patients (Ellis et al., 2013). Such behavior is difficult to verify as intentionally selective, and is thus difficult for administrators to ban or regulate. ...
... Conditions Categories (HCC) adjustment model employed in Medicare Advantage reduces it by 11% (Cooper and Trivedi, 2012). Some private risk adjustment systems can reduce the variance by over 50% in certain circumstances (Thomas et al., 2004). ...
Many developed countries rely, to varying degrees, on competition among private health plans to obtain affordable and high-quality health insurance for their residents. Incorporating beneficiary-level competitive bidding into these healthcare systems can better align the incentives of these health plans, increase their willingness to enroll, and serve the sickest and most vulnerable patients while keeping costs manageable. We identify two digitally enabled program designs that allow private insurance plans to competitively bid to enroll individual beneficiaries. Compared with those used in existing entitlement programs, these designs always make a larger share of the beneficiary population profitable to enroll, thereby increasing willingness of the plans to enroll the most costly beneficiaries and improving access to care. On simulating the conditions of existing real-word healthcare entitlement programs, we found that these new designs actually tend to lower the tax burden in up to 83% of simulations. The research findings suggest that these new designs hold great promise in achieving the dual aim of improved access and lower costs. We believe that findings from this research can guide policymakers implement policies that will enroll more beneficiaries and cost the taxpayers less.
... While risk adjustment has had some success in pricing heterogeneity across Medicare Advantage plans , MCOs have responded by redirecting selection efforts toward unadjusted characteristics (Brown et al., 2014). This is accomplished in a variety of ways, including targeted advertising (Aizawa and Kim, 2018), offering supplementary benefits attractive to healthy individuals and unappealing to the disabled (Cooper and Trivedi, 2012), and increased spending on services used by high-profit patients (Ellis et al., 2013). Such behavior is difficult to verify as intentionally selective, and is thus difficult for administrators to ban or regulate. ...
... These bounds approximate the degree to which real-world risk adjustment mechanisms reduce the unexplained variance in patient costs. The Hierarchical Conditions Categories (HCC) adjustment model employed in Medicare Advantage reduces it by 11% (Cooper and Trivedi, 2012;Newhouse et al., 2012). Some private risk adjustment systems can reduce the variance by over 50% in certain circumstances (Thomas et al., 2004). ...
Health care entitlement programs in the U.S. represent a large and growing financial outlay for taxpayers. In the pursuit of operational efficiencies, program administrators often contract with private managed care organizations (MCOs) to procure insurance for beneficiaries. This, however, encourages MCOs to attract the healthiest beneficiaries and avoid the sickest; a phenomenon known as risk selection. Risk selection leaves the sickest patients to potentially seek care in safety net facilities or emergency rooms. A mechanism that improves beneficiaries' access to care without increasing costs would be invaluable to managers and poli-cymakers. This paper investigates whether risk selection can be mitigated with a mechanism where MCOs bid to enroll individual beneficiaries. Although procurement auctions have been studied extensively in the literature, extant research has rarely discussed individual-level bidding. Using game theory, we model an entitlement program under three payment mechanisms: risk-adjustment, bidding, and a mix of prospective payment and bidding. Analytical results show that traditional risk-adjustment cannot optimally be used to eliminate risk selection, while either bidding mechanism eliminates it entirely. Mixed bidding eliminates risk selection at a strictly lower cost than pure bidding. The proposed mixed bidding approach is a new type of mechanism with pre-auction offers that strictly dominates the second-price auction without requiring additional assumptions. Numerical analysis shows bidding dominates risk adjustment in 73.1 percent of simulated parameter sets. Compared to risk adjustment, bidding enrolls 12.1 percent more beneficiaries at 12.7 percent lower cost. Sensitivity analysis reveals that the proposed bidding mechanism dominates in scenarios that more closely resemble real-world health care entitlement environments. More remarkably, bidding would likely generate more cost savings in jurisdictions with a large population of higher risk beneficiaries. These results show that individual-level auctions are a promising mechanism for achieving the dual aim of financial sustainability and expanded access to care for the most vulnerable.
... [7][8][9] Others have worried that these gains may reflect plans using benefit design to attract healthier patients with fewer, less complex, and less costly health care needs. [10][11][12] Although the increased popularity of MA could result in a more representative beneficiary population, favorable selection could be exacerbated if the growth of MA plans reflects enrollment of people with fewer health care needs. 13,14 Despite significant research on the MA program, relatively few studies have assessed MA/FFS differences in utilization. ...
... Similarly, many studies have found healthier populations seem to enroll in MA plans. 10,12 However, one study 17 found that favorable selection of healthier enrollees accounts for between one quarter and one third of MA/FFS utilization differences. Our study suggests that more fully accounting for health status can eliminate the unadjusted differences between groups. ...
Background:
Previous studies found lower hospitalization rates for enrollees in Medicare Advantage (MA) plans than for beneficiaries with Fee-For-Service (FFS) coverage. MA enrollment is increasing, especially for those newly eligible for Medicare, but little is known about how service use in FFS or MA differs for new beneficiaries.
Objective:
To compare differences in rates of hospitalization between MA and FFS.
Research design:
A retrospective study of hospitalization among FFS and MA respondents to the Medicare Consumer Assessment of Healthcare Providers and Systems (MCAHPS) survey. Differences in hospitalization rates were assessed using multivariable logistic regression models that controlled for patient sociodemographic and health characteristics. Models included an interaction between age and coverage type to determine whether patterns of care were distinct for enrollees recently eligible for Medicare.
Study population:
In total, 259,335 respondents to the 2013 MCAHPS survey.
Results:
In total, 14% of FFS and 12% of MA enrollees had ≥1 hospitalization in the 6 months before survey administration. Models adjusted for enrollee demographics found that MA enrollees had 0.81 the odds of being hospitalized relative to those with FFS coverage (95% confidence interval, 0.78-0.84). Differences between groups were substantially reduced and no longer statistically significant when they were fully adjusted (adjusted odds ratio 1.01, 95% confidence interval, 0.97-1.08). Models with interactions indicated no significant age differences in the MA/FFS hospitalization gap.
Conclusion:
Differences in hospital admissions between those with MA and FFS coverage appear to be primarily related to differences in health status.
... The original proposal included power and sample size analyses for both clinically relevant outcomes and the original sample size left the study overpowered to detect a difference in FF/ SFRI, with power estimates ranging from 94-99% under a range of assumptions of the rate of FF/SFRI and treatment effect. This change was consistent with the overall aim of the study, to test the impact of an exercise program on a clinical outcome which, if positive, may provide a rationale for an exercise program to be included as a standard Medicare benefit for older adults at risk of a fall-related injury [12,13]. The study had a racial/ethnic minority enrollment goal of 18%, slightly lower than the statewide rate of 21%, based on 2012 Census data, given the lower incidence of osteoporosis in Black, compared to White, women [14]. ...
Background
The aim of this paper is to describe the utility of various recruitment modalities utilized in the Working to Increase Stability through Exercise (WISE) study. WISE is a pragmatic randomized trial that is testing the impact of a 3-year, multicomponent (strength, balance, aerobic) physical activity program led by trained volunteers or delivered via DVD on the rate of serious fall-related injuries among adults 65 and older with a past history of fragility fractures (e.g., vertebral, fall-related). The modified goal was to recruit 1130 participants over 2 years in three regions of Pennsylvania.
Methods
The at-risk population was identified primarily using letters mailed to patients of three health systems and those over 65 in each region, as well as using provider alerts in the health record, proactive recruitment phone calls, radio advertisements, and presentations at community meetings.
Results
Over 24 months of recruitment, 209,301 recruitment letters were mailed, resulting in 6818 telephone interviews. The two most productive recruitment methods were letters (72% of randomized participants) and the research registries at the University of Pittsburgh (11%). An average of 211 letters were required to be mailed for each participant enrolled. Of those interviewed, 2854 were ineligible, 2,825 declined to enroll and 1139 were enrolled and randomized. Most participants were female (84.4%), under age 75 (64.2%), and 50% took an osteoporosis medication. Not having a prior fragility fracture was the most common reason for not being eligible (87.5%). The most common reason provided for declining enrollment was not feeling healthy enough to participate (12.6%).
Conclusions
The WISE study achieved its overall recruitment goal. Bulk mailing was the most productive method for recruiting community-dwelling older adults at risk of serious fall-related injury into this long-term physical activity intervention trial, and electronic registries are important sources and should be considered.
... 2 Research shows that individuals with MA tend to be healthier with lower healthcare utilization, and upon becoming HN, they tend to switch to FFS Medicare. [31][32][33][34] To operationalize the HN definitions in the NHATS survey data, we mapped the most similar components to prior datasets. However, this is imperfect given the set of variables available across datasets does not perfectly align. ...
Background:
Multiple algorithms have been developed to identify and characterize the high-need (HN) Medicare population. However, they vary in components and yield different populations, and were developed for varying purposes. We compared the performance of existing survey and claims-based definitions in identifying HN beneficiaries and predicting poor outcomes among a community-dwelling population.
Methods:
A retrospective cohort study using Round 5 (2015) of the National Health and Aging Trends Study (NHATS) linked with Medicare claims. We applied HN definitions from previous studies to our cohort of community-dwelling, fee-for-service beneficiaries (n = 4201) using sampling weights to obtain nationally representative estimates. The Bélanger et al. (2019) definition defines HN as individuals with complex conditions, multi-morbidity, acute and post-acute healthcare utilization, dependency in activities of daily living, and frailty. The Hayes et al. (2016) definition defines HN as individuals with 3+ chronic conditions and a functional limitation. We applied each definition to survey and claims data. Outcomes were hospitalization or mortality in the subsequent year.
Results:
The proportion of NHATS respondents classified as HN varied greatly across definitions, ranging from 3.1% using the claims-based Hayes definition to 32.9% using the survey-based Bélanger definition. HN respondents had significantly higher mortality and hospitalization rates in 2016. Although all definitions had good specificity, none were able to predict outcomes in the following year with good accuracy.
Conclusions:
While mortality and hospitalization rates were significantly higher among respondents classified as HN, existing claims and survey-based HN definitions were not able to accurately predict future outcomes in a community-dwelling, nationally representative sample measured by the area under the curve.
... We found that step test modifications to a shorter or even flat self-paced step enabled individuals of higher BMI to complete a cardiovascular fitness evaluation in office, thus enabling appropriate cardiovascular exercise prescription. We also found that a significant proportion (25%) of survivors of cancer completing the step test at pace had a BMI in the obesity range (> 30, observed range [30][31][32][33][34][35][36][37][38][39][40][41][42][43][44]. Taken together, these results illustrate the importance of having an approach that encompasses accessibility, safety, comfort and engagement while not pre-judging ability to complete a specific step test format simply based on BMI. ...
Although exercise is widely recommended for survivors of cancer, readily implementable approaches for evaluating exercise tolerance enabling exercise prescriptions at appropriate levels of cardiovascular exertion are not always available. We evaluated the utility of modified Harvard Step tests within the context of a standard physical examination for fitness evaluation and exercise prescription for survivors of cancer across a range of age, BMI and exercise history. While 52% of presenting individuals with a past cancer diagnosis were able to complete a 3-min test at pace with a reduced 9-in. step, adoption of self-determined pacing, test duration and completion on a flat surface enabled relative fitness rating and appropriate exercise prescription for the remaining survivors. Younger age and more vigorous exercise histories correlated with completion of the standard 3-min test at pace, but all 9-in. formats led to exercise prescriptions more vigorous than current activity. The physical examination setting expedited inclusion of core and specific muscle group strength testing. The approach is adaptable to a range of health care settings, providers, and patients, providing a shared opportunity for providers and patients to evaluate exercise tolerance. It can be used to further expand incorporation of exercise testing and prescription into routine care.
... We did find that coverage with Medicare FFS or Medicaid was associated with markedly less adherence compared with coverage by Medicare Advantage or commercial insurance. Medicare Advantage is offered by private insurance companies, and there is selection of healthier patients into this program [43]. In addition, Medicaid insurance is likely a surrogate for lower socioeconomic status. ...
Objective
Lung cancer screening (LCS) efficacy is highly dependent on adherence to annual screening, but little is known about real-world adherence determinants. We used insurance claims data to examine associations between LCS annual adherence and demographic, comorbidity, health care usage, and geographic factors.
Materials and Methods
Insurance claims data for all individuals with an LCS low-dose CT scan were obtained from the Colorado All Payer Claims Dataset. Adherence was defined as a second claim for a screening CT 10 to 18 months after the index claim. Cox proportional hazards regression was used to define the relationship between annual adherence and age, gender, insurance type, residence location, outpatient health care usage, and comorbidity burden.
Results
After exclusions, the final data set consisted of 9,056 records with 3,072 adherent, 3,570 nonadherent, and 2,414 censored (unclassifiable) individuals. Less adherence was associated with ages 55 to 59 (hazard ratio [HR] = 0.80, 99% confidence interval [CI] = 0.67-0.94), 60 to 64 (HR = 0.83, 99% CI = 0.71-0.97), and 75 to 79 (HR = 0.79, 99% CI = 0.65-0.97); rural residence (HR = 0.56, 99% CI = 0.43-0.73); Medicare fee-for-service (HR = 0.45, 99% CI = 0.39-0.51), and Medicaid (HR = 0.50, 99% CI = 0.40-0.62). A significant interaction between outpatient health care usage and comorbidity was also observed. Increased outpatient usage was associated with increased adherence and was most pronounced for individuals without comorbidities.
Conclusions
This population-based description of LCS adherence determinants provides insight into populations that might benefit from specific interventions targeted toward improving adherence and maximizing LCS benefit. Quantifying population-based adherence rates and understanding factors associated with annual adherence are critical to improving screening adherence and reducing lung cancer death.
... We found that step test modifications to a shorter or even flat self-paced step enabled individuals of higher BMI to complete a cardiovascular fitness evaluation in office, thus enabling appropriate cardiovascular exercise prescription. We also found that a significant proportion (25%) of survivors of cancer completing the step test at pace had a BMI in the obesity range (> 30, observed range [30][31][32][33][34][35][36][37][38][39][40][41][42][43][44]. Taken together, these results illustrate the importance of having an approach that encompasses accessibility, safety, comfort and engagement while not pre-judging ability to complete a specific step test format simply based on BMI. ...
Purpose
To evaluate the utility of modified Harvard Step tests within the context of a comprehensive physical examination for fitness evaluation and exercise prescription for cancer survivors.
Methods
A retrospective chart review of initial cancer survivor clinic visits over a ten-year period (n=169) was conducted to evaluate correlations between demographic factors, clinical characteristics, step and strength test performance, and exercise prescriptions.
Results
Clinic population was 94% female, aged 27-79 years, predominantly breast cancer (87%), presenting within two years of cancer diagnosis with current exercise history significantly less vigorous than past exercise (p=0.00; 34% sedentary). Fifty-two percent completed a 3-minute-9-inch step test at pace (96 steps per minute). Fourteen percent required slower self-pacing, 12% both a slower pace and shortened time, and 5% a flat test. Younger age (p=0.04) and more vigorous exercise histories (p<0.04) correlated with ability to complete the at pace test but all
formats led to exercise prescriptions more vigorous than current activity (p<0.0002). Stratified fitness ratings using YMCA normative data yielded associations between higher fitness levels and lower BMI (F(1,86)=4.149, p<0.05), office pulse (F(1,87)=7.677, p<0.05), and systolic blood pressure (F(1,18)=6.58, p<0.05).
Conclusions
Office-based fitness evaluation with a panel of modified step test options accommodating different baseline fitness levels enabled personalized exercise prescriptions more vigorous than current activity.
Implications for Cancer Survivors
Cancer patients frequently engage in less vigorous activity as they enter into survivorship. Modified step tests are a means for office-based evaluation of cardiovascular fitness within the context of a comprehensive physical examination.
... MA plans may put several restrictions on access to care for enrollees (such as narrow networks and prior authorization), but they may also provide additional benefits not available in traditional Medicare (such as gym memberships and dental care). 3 A beneficiary may not enroll in both Medigap and MA at the same time because coverage would be duplicative. However, Medigap enrollees may enroll in a standalone Part D drug plan without losing Medigap coverage. ...
In all but eight states, Medicare supplemental coverage (or Medigap) plans may deny coverage or charge higher premiums on the basis of preexisting health conditions. This may particularly affect chronically ill or high-need Medicare Advantage enrollees who switch to traditional Medicare and subsequently discover that they are unable to purchase affordable Medigap coverage. We found that in states with no Medigap consumer protections, high-need Medicare Advantage enrollees had a 16.9-percentage-point higher reenrollment rate in Medicare Advantage in the year after switching to traditional Medicare, compared to high-need enrollees in states with strong Medigap consumer protections-namely, guaranteed issue and community rating (charging all enrollees the same premium regardless of health condition). Expanding protections in the Medigap market may increase consumers' access to this type of supplemental coverage.
... However, the large sample size may partially mitigate this potential bias. 28,29 We used AUROC to descriptively compare these scoring systems, yet the AUROC has limitations. The AUROC is based on ranks, does not account for the goodness-of-fit of model predictions, and does not adequately represent the ability of the model to discriminate those with and without the outcome for categorical variables (e.g., GTRI) and ordinal variables (e.g., the CCI and MFI). ...
Objectives
Early identification of geriatric patients at high risk for mortality is important to guide clinical care, medical decision‐making, palliative discussions, quality assurance, and research. We sought to identify injured older adults at highest risk for 30‐day mortality using an empirically derived scoring system from available data, and to compare it with current prognostic scoring systems.
Methods
This was a retrospective cohort study of injured adults ≥ 65 years transported by 44 emergency medical services (EMS) agencies to 49 emergency departments in Oregon and Washington from 1/1/2011 through 12/31/2011, with follow‐up through 12/31/2012. We matched data from EMS, to Medicare, inpatient, trauma registries, and vital statistics. Using a primary outcome of 30‐day mortality, we empirically derived a new risk score using binary recursive partitioning and compared it to the Charlson comorbidity index (CCI); modified frailty index (MFI); geriatric trauma outcome score (GTOS); GTOS II; and injury severity score (ISS).
Results
There were 4,849 patients, of whom 234 (4.8%) died within 30 days and 1,040 (21.5%) died within 1 year. The derived score, the Geriatric Trauma Risk Indicator (GTRI) (emergent airway or CCI ≥2), had 87.2% sensitivity (95% CI 83.0‐91.5%) and 30.6%% specificity (95% CI 29.3‐31.9%) for 30‐day mortality (AUROC 0.589, 95% CI: 0.566‐0.611). AUROC values for other scoring systems ranged from 0.592 to 0.678. When the sensitivity for each existing score was held at 90%, specificity values ranged from 7.5% (ISS) to 30.6% (GTRI).
Conclusions
Older, injured, adults transported by EMS to a large variety of trauma and non‐trauma hospitals were more likely to die within 30 days if they required emergent airway management or have a higher comorbidity burden. When compared to other risk measures and holding sensitivity constant near 90%, the GTRI had higher specificity, despite a lower AUROC. Using GTOS II or the GTRI may better identify high‐risk older adults than traditional scores, such as ISS, but identification of an ideal prognostic tool remains elusive.
This article is protected by copyright. All rights reserved.
... Second, our study findings may not be generalizable to beneficiaries in traditional Medicare. Although there are differences between these 2 populations, 16,17 we found that the duration of home health care was similar among traditional Medicare and MA enrollees in case plans. Third, we do not have claims data from MA plans to directly measure the number of home health visits per MA member. ...
Importance:
Several policy proposals advocate introducing copayments for home health care in the Medicare program. To our knowledge, no prior studies have assessed this cost-containment strategy.
Objective:
To determine the association of home health copayments with use of home health services.
Design, setting, and participants:
A difference-in-differences case-control study of 18 Medicare Advantage (MA) plans that introduced copayments for home health care between 2007 and 2011 and 18 concurrent control MA plans. The study included 135 302 enrollees in plans that introduced copayment and 155 892 enrollees in matched control plans.
Exposures:
Introduction of copayments for home health care between 2007 and 2011.
Main outcomes and measures:
Proportion of enrollees receiving home health care, annual numbers of home health episodes, and days receiving home health care.
Results:
Copayments for home health visits ranged from 20 per visit, which were estimated to be associated with 45-660 (IQR, 720) in out-of-pocket spending for the average user of home health care. The increased copayment for home health care was not associated with the proportion of enrollees receiving home health care (adjusted difference-in-differences, -0.15 percentage points; 95% CI, -0.38 to 0.09), the number of home health episodes per user (adjusted difference-in-differences, 0.01; 95% CI, -0.01 to 0.03), and home health days per user (adjusted difference-in-differences, -0.19; 95% CI, -3.02 to 2.64). In both intervention and control plans and across all levels of copayments, we observed higher disenrollment rates among enrollees with greater baseline use of home health care.
Conclusions and relevance:
We found no evidence that imposing copayments reduced the use of home health services among older adults. More intensive use of home health services was associated with increased rates of disenrollment in MA plans. The findings raise questions about the potential effectiveness of this cost-containment strategy.
... Additionally, relatively younger beneficiaries aged 65 to 69 years switched from TM to MA at higher-than-average rates (Jacobson, Neuman, & Damico, 2015). MA plans can enroll relatively healthier beneficiaries in their plans by using several strategies: restricting the physician network to physicians to better contain costs, specifying drug formularies and benefits, making strategic marketing choices, as well as focusing on geographic locations that incur less costs (Cooper & Trivedi, 2012;Newhouse, Price, McWilliams, Hsu, & McGuire, 2015). ...
The 2003 Medicare Modernization Act (MMA) increased payments to Medicare Advantage plans and instituted a new risk-adjustment payment model to reduce plans’ incentives to enroll healthier Medicare beneficiaries and avoid those with higher costs. Whether the MMA reduced risk selection remains debatable. This study uses mortality differences, nursing home utilization, and switch rates to assess whether the MMA successfully decreased risk selection from 2000 to 2012. We found no decrease in the mortality difference or adjusted difference in nursing home use between plan beneficiaries pre- and post the MMA. Among beneficiaries with nursing home use, disenrollment from Medicare Advantage plans declined from 20% to 12%, but it remained 6 times higher than the switch rate from traditional Medicare to Medicare Advantage. These findings suggest that the MMA was not associated with reductions in favorable risk selection, as measured by mortality, nursing home use, and switch rates.
... 1,2 Cost-sharing requirements for inpatient and SNF care can also influence whether MA plans appeal to beneficiaries with a range of health needs. [1][2][3][4][5] To attract beneficiaries, MA plans often offer coverage for services that are not covered in traditional Medicare, including dental care, fitness memberships, and eyeglasses. If cost sharing is low for these optional benefits but high for critical services such as inpatient care, healthy beneficiaries may be more satisfied with MA plans than beneficiaries with serious health conditions are. ...
Inpatient and skilled nursing facility (SNF) cost sharing in Medicare Advantage (MA) plans may reduce unnecessary use of these services. However, large out-of-pocket expenses potentially limit access to care and encourage beneficiaries at high risk of needing inpatient and postacute care to avoid or leave MA plans. In 2011 new federal regulations restricted inpatient and skilled nursing facility cost sharing and mandated limits on out-of-pocket spending in MA plans. After these regulations, MA members in plans with low premiums averaged 293 increase in average cost sharing for an inpatient and skilled nursing facility episode, possibly to offset plans' expenses in financing out-of-pocket limits. Some MA beneficiaries may still have difficulty affording acute and postacute care despite greater regulation of cost sharing.
Project HOPE—The People-to-People Health Foundation, Inc.
... Conversely, MA plans receive capitated, prospective payments to cover all subsequent care required by their enrollees, providing a strong financial incentive for plans to reduce enrollees' use of health services and potentially shift the costs of care to another government payer. Unlike the traditional Medicare program, MA plans can restrict the networks of available providers and alter their insurance benefits for Medicarecovered services (Cooper and Trivedi 2012). Therefore, the reliance on VA care and the potential health consequences for dually enrolled veterans in MA plans may differ from what has been reported in the fee-for-service population. ...
The concurrent use of multiple health care systems may duplicate or fragment care. We assessed the characteristics of veterans who were dually enrolled in both the Veterans Affairs (VA) health care system and a Medicare Advantage (MA) plan, and compared intermediate quality outcomes among those exclusively receiving care in the VA with those receiving care in both systems.
VA and MA quality and administrative data from 2008 to 2009.
We used propensity score methods to test the association between dual use and five intermediate outcome quality measures. Outcomes included control of cholesterol, blood pressure, and glycosylated hemoglobin among persons with coronary heart disease (CHD), hypertension, and diabetes.
VA and MA data were merged to identify VA-only users (n = 1,637) and dual-system users (n = 5,006).
We found no significant differences in intermediate outcomes between VA-only and dual-user populations. Differences ranged from a 3.2 percentage point (95 percent CI: -1.8 to 8.2) greater rate of controlled cholesterol among VA-only users with CHD to a 2.2 percentage point (95 percent CI: -2.4 to 6.6) greater rate of controlled blood pressure among dual users with diabetes.
For the five measures studied, we did not find evidence that veterans with dual use of VA and MA care experienced improved or worsened outcomes as compared with veterans who exclusively used VA care.
© Health Research and Educational Trust.
... With these patients, insurance companies receive a higher risk-adjusted premium but do not spend as much on medical care as they would with a diabetic whose condition is uncontrolled or a CHF patient who is not motivated or able to make behavior modifications or follow treatment plans. Adding a gym membership and health education classes to the benefit package is a good way to attract these more motivated individuals (Cooper and Trivedi 2012). ...
The financial exuberance that eventually culminated in the recent world economic crisis also ushered in dramatic shifts in how health care is financed, administered, and imagined. Drawing on research conducted in the mid-2000s at a health insurance company in Puerto Rico, this article shows how health care has been financialized in many ways that include: (1) privatizing public services; (2) engineering new insurance products like high deductible plans and health savings accounts; (3) applying financial techniques to premium payments to yield maximum profitability; (4) a managerial focus on shareholder value; and (5) prioritizing mergers and financial speculation. The article argues that financial techniques obfuscate how much health care costs[,] foster widespread gaming of reimbursement systems that drives up prices and “unpool” risk by devolving financial and moral responsibility for health care onto individual consumers.This article is protected by copyright. All rights reserved.
... One explanation for the differences in rates seen in this report could be that MA beneficiaries are healthier and require fewer CV procedures than MFFS beneficiaries. 19 We partially address this by showing that disease and demographically adjusted rates are highly correlated with the demographically adjusted rates. Future research should explore if the differences in procedure rates between MA and MFFS patients are associated with differences in appropriateness and in clinical outcomes. ...
Importance
Little is known about how different financial incentives between Medicare Advantage and Medicare fee-for-service (FFS) reimbursement structures influence use of cardiovascular procedures.Objective
To compare regional cardiovascular procedure rates between Medicare Advantage and Medicare FFS beneficiaries.Design, Setting, and Participants
Cross-sectional study of Medicare beneficiaries older than 65 years between 2003-2007 comparing rates of coronary angiography, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery across 32 hospital referral regions in 12 states.Main Outcomes and Measures
Rates of coronary angiography, PCI, and CABG surgery.Results
We evaluated a total of 878 339 Medicare Advantage patients and 5 013 650 Medicare FFS patients. Compared with Medicare FFS patients, Medicare Advantage patients had lower age-, sex-, race-, and income-adjusted procedure rates per 1000 person-years for angiography (16.5 [95% CI, 14.8-18.2] vs 25.9 [95% CI, 24.0-27.9]; P < .001) and PCI (6.8 [95% CI, 6.0-7.6] vs 9.8 [95% CI, 9.0-10.6]; P < .001) but similar rates for CABG surgery (3.1 [95% CI, 2.8-3.5] vs 3.4 [95% CI, 3.1-3.7]; P = .33). There were no significant differences between Medicare Advantage and Medicare FFS patients in the rates per 1000 person-years of urgent angiography (3.9 [95% CI, 3.6-4.2] vs 4.3 [95% CI, 4.0-4.6]; P = .24) or PCI (2.4 [95% CI, 2.2-2.7] vs 2.7 [95% CI, 2.5-2.9]; P = .16). Procedure rates varied widely across hospital referral regions among Medicare Advantage and Medicare FFS patients. For angiography, the rates per 1000 person-years ranged from 9.8 to 40.6 for Medicare Advantage beneficiaries and from 15.7 to 44.3 for Medicare FFS beneficiaries. For PCI, the rates ranged from 3.5 to 16.8 for Medicare Advantage and from 4.7 to 16.1 for Medicare FFS. The rates for CABG surgery ranged from 1.5 to 6.1 for Medicare Advantage and from 2.5 to 6.0 for Medicare FFS. Across regions, we found no statistically significant correlation between Medicare Advantage and Medicare FFS beneficiary utilization for angiography (Spearman r = 0.19, P = .29) and modest correlations for PCI (Spearman r = 0.33, P = .06) and CABG surgery (Spearman r = 0.35, P = .05). Among Medicare Advantage beneficiaries, adjustment for additional cardiac risk factors had little influence on procedure rates.Conclusions and Relevance
Although Medicare beneficiaries enrolled in capitated Medicare Advantage programs had lower angiography and PCI procedure rates than those enrolled in Medicare FFS, the degree of geographic variation in procedure rates was substantial among Medicare Advantage beneficiaries and was similar in magnitude to that observed among Medicare FFS beneficiaries.
Importance
As more than 50% of Medicare beneficiaries are enrolled in Medicare Advantage (MA), understanding whether the treatment covered by MA vs traditional Medicare (TM) is comparable can aid in providing high-value care. As the majority of patients with cancer undergo radiotherapy, it is important to quantify TM and MA utilization in oncology.
Objective
To analyze the primary type of radiotherapy technology used, treatment length, and estimated spending for MA patients with cancer undergoing radiotherapy compared with TM patients with cancer.
Design, Setting, and Participants
This retrospective cross-sectional study used 2018 Medicare claims data for TM and MA patients aged 65 years or older who received radiotherapy for 1 of 15 cancer types. Analyses were performed between May 1 and December 28, 2024.
Exposures
Insurance type (MA vs TM), cancer type, age, dual-eligibility status, medical comorbidities, county, and radiotherapy center type.
Main Outcomes and Measures
Primary type of radiotherapy technology used, treatment length, and estimated spending for 90-day radiotherapy episodes. Adjusted rates and odds ratios (ORs) were calculated to compare technology types and rate ratios (RRs) to compare treatment length and estimated spending between TM and MA episodes.
Results
Of 31 563 treatment episodes among 30 941 patients, 22 594 (71.58%) were covered by TM (mean [SD] age, 74.76 [6.57] years; 50.76% among males) and 8969 (28.42%) were covered by MA (mean [SD] age, 74.51 [6.24] years; 51.78% among males). For radiotherapy episodes in patients with MA, adjusted analyses revealed lower odds of proton therapy use (52 [0.58% (95% CI, 0.34%-0.82%)] vs 373 [1.65% (95% CI, 1.50%-1.80%)]; OR, 0.36 [95% CI, 0.27-0.48]) and stereotactic radiotherapy use (1235 [13.77% (95% CI, 13.13%-14.41%)] vs 3391 [15.01% (95% CI, 14.61%-15.41%)]; OR, 0.87 [95% CI, 0.81-0.95]), higher odds of 2- or 3-dimensional radiotherapy use (3962 [44.17% (95% CI, 43.39%-44.96%)] vs 9584 [42.43% (95% CI, 41.93%-42.92%)]; OR, 1.13 [95% CI, 1.06-1.21]), greater mean treatment length (21.38 [95% CI, 21.14-21.61] vs 19.48 [95% CI, 19.33-19.62] treatments; RR, 1.10 [95% CI, 1.08-1.11]), and higher estimated radiotherapy spending (8566.58-8393.20 [95% CI, 8463.05]; RR, 1.04 [95% CI, 1.02-1.06]) compared with episodes in patients with TM.
Conclusions and Relevance
In this cross-sectional study, MA patients with cancer undergoing radiotherapy had higher estimated spending and greater mean treatment length than those covered by TM. Despite lower utilization of more expensive advanced treatment modalities, MA was not associated with cost savings. Whether MA meets the value proposition for radiation oncology requires further investigation.
Importance
Recently, there has been an emergence of veteran Medicare Advantage affinity plans (VMAPs) marketing to veterans, including those dually covered by the Veterans Health Administration (VHA). To date, limited evidence exists characterizing what benefits VMAPs offer and their veteran enrollees.
Objective
To examine plan-level differences between VMAPs and other Medicare Advantage (MA) plans and characteristics of their veteran enrollees.
Design, Setting, and Participants
This cross-sectional study compared the plan benefit design, supplemental benefit offerings, and veteran enrollee characteristics of all VMAP and other MA plan enrollees in 2022 using standardized mean differences (SMDs). VMAPs were identified based on military-associated words in their plan name and further validated through a web-based search. Data were analyzed from April 2023 to August 2024.
Exposure
VMAP designation.
Main Outcomes and Measures
Plan-level characteristics, supplemental benefits, and veteran enrollee characteristics.
Results
The sample included 188 VMAPs with 179 449 veteran enrollees and 3442 other MA plans with 954 581 veteran enrollees. A total of 1 088 938 (96.0%) were male, 3558 (0.3%) were American Indian or Alaska Native, 8845 (0.8%) were Asian or Pacific Islander, 162 934 (14.4%) were Black, 61 264 (5.4%) were Hispanic, and 876 234 (77.3%) were White; the mean (SD) age was 75.9 (8.6) years. Most VMAPs were administered by for-profit insurers (173 [92.0%]; SMD, 0.42), including Aetna (46 [24.9%]), Humana (36 [19.5%]), and United HealthCare (49 [26.5%]). Compared with veterans in other MA plans, veterans in VMAPs were slightly younger (mean [SD] age, 73.7 [8.0] years vs 76.3 [8.7] years; SMD, 0.31), more likely to be Black (34 837 [19.4%] vs 128 097 [13.4%]; SMD, 0.18), and more likely to have zero cost sharing for VHA services (ie, priority group 1) (62 056 [34.6%] vs 195 688 [20.5%]; SMD, 0.40). VMAPs were more likely than other MA plans to offer 33 more in cash back benefits. Only 1 VMAP offered Medicare Part D coverage compared with most other MA plans (1 [0.5%] vs 3293 [95.7%]; SMD, 6.23). VMAPs were more likely than other MA plans to provide comprehensive dental coverage (179 [95.2%] vs 3006 [87.3%]; SMD, 0.28), hearing aids (184 [97.9%] vs 3012 [87.5%]; SMD, 0.40), eyewear (188 [100%] vs 3620 [94.7%]; SMD, 0.33), over-the-counter drug coverage (179 [95.2%] vs 2831 [82.2%]; SMD, 0.42), and meal benefits (151 [80.3%] vs 2348 [68.2%]; SMD, 0.28).
Conclusions and Relevance
This study found that MA insurers—specifically VMAPs—engaged in targeted marketing to veterans, offering $0 premiums, cash back benefits, and supplemental benefits. However, nearly all VMAPs excluded Medicare Part D, likely designed to attract veteran enrollees who use VHA care, making them low-cost enrollees to the plan. Since the VHA cannot bill plans for Medicare-covered services, VMAPs may be increasing wasteful federal spending.
Objective
To evaluate the association between Medicare Advantage (MA) supplemental benefit adoption and plan disenrollment among plans that adopted either the 2019 nonmedical primarily health‐related benefits (PHRB) or the 2020 social needs Special Supplemental Benefits for the Chronically Ill (SSBCIs).
Study Setting and Design
We linked individual‐level Medicare administrative data to publicly available, plan‐level MA benefit, enrollment, crosswalk, and penetration files from 2017 to 2021. The PHRB benefits included benefits such as caregiver support, adult day care, in‐home support services, and so forth. The SSBCI benefits included benefits such as food and produce, nonmedical transportation, pest control, and so forth. We used a difference‐in‐differences design studying MA enrollees stratified by Medicare‐Medicaid dual eligibility status.
Data Sources and Analytic Sample
We included individuals from across the 50 United States and DC enrolled in MA plans that adopted a PHRB in 2019 or SSBCI in 2020 and matched comparator plans from the same counties that did not adopt either benefit. Individuals were excluded if they moved, died, or lacked county‐level information during the year.
Principal Findings
Our sample includes 8,947,810 unique MA enrollees (27.4% in plans that adopted a PHRB and 1.0% in plans that adopted an SSBCI). For dual‐eligible enrollees, neither PHRB adoption (0.2%, 95% CI, −2.7%, 2.8%) nor SSBCI adoption (−1.7%, 95% CI, −6.0%, 2.5%) was significantly associated with the rate of plan disenrollment. For Medicare‐only enrollees, neither PHRB adoption (−2.6%, 95% CI, −5.9%, 0.7%) nor SSBCI adoption (−5.4%, 95% CI, −15.8%, 5.1%) was significantly associated with the disenrollment rate.
Conclusion
The promise of these benefits was that MA plans could more directly address enrollees' nonmedical and social needs, leading to better social and health outcomes and reducing costs. We find that adoption did not decrease plan disenrollment, which suggests it may not drive enrollment decisions.
Problem definition: This study identifies a resource misallocation problem in Medicare Advantage (MA), the United States’ largest healthcare capitation program, which may result in discrepancies between patients’ health status and the healthcare resources allocated to them. Methodology/results: Utilizing a large commercial insurance database with claims from more than 2 million MA enrollees, this research investigates the allocation of MA capitation payments. By exploiting an exogenous policy shock on MA capitation payments through a difference-in-difference design, we find empirical evidence of an illegal practice known as “cross-subsidization.” This practice involves MA health plans strategically reallocating portions of the capitation payments intended for one group of patients to spend on another group of patients. Additionally, we show that this cross-subsidization practice is associated with the risk selection problem in MA, where low-risk patients are more likely to enroll in MA compared with high-risk patients. Managerial implications: This research unveils a previously undocumented healthcare resource misallocation problem, that is, strategic cross-subsidization. This practice is explicitly prohibited by law in the United States due to its heightened effect on the undesired risk selection within capitation programs, where health plans cherry-pick profitable enrollees through strategic benefit designs. Our study has direct practical implications as it underscores the need for greater transparency in MA claims data to enable the Centers for Medicare & Medicaid Services to more effectively administer the MA program.
Supplemental Material: The online appendices are available at https://doi.org/10.1287/msom.2023.0637 .
Importance
A growing proportion of the population is enrolling in Medicare Advantage (MA), which typically offers additional benefits compared with traditional Medicare (TM).
Objective
To determine whether frailty and frailty trajectories differ between MA enrollees and TM enrollees.
Design, Setting, and Participants
This retrospective cohort study used data from the National Health and Aging Trends Study (2015-2016). Analyses were conducted from August 2023 to March 2024. Participants were community-dwelling Medicare beneficiaries aged 65 years and older.
Exposure
Enrollment in MA vs TM.
Main Outcomes and Measures
Frailty was calculated by a frailty index (FI) (range, 0-1, with higher values indicating greater frailty) and the Fried Frailty Phenotype (FFP) score (range, 0-5, with higher values indicating greater frailty). Physical performance, including Short Physical Performance Battery (SPPB) score (range, 0-12, with higher values indicating better performance), and gait speed (meters per second) were measured. The primary outcome was the difference in FI and FFP scores from the 2015 baseline assessment to the 2016 follow-up assessment. Secondary outcomes include the 1-year changes in SPPB and gait speed.
Results
The final cohort consisted of 7063 participants (2775 [23.1%] aged >80 years; 4040 [54.7%] female), representing a sample of the 38.8 million beneficiaries. There were 2583 (35.0%) MA enrollees (13.6 million) and 4480 (65.0%) TM enrollees (25.2 million). At baseline, the FI score was similar between MA and TM enrollees (mean [SD], 0.22 [0.15] vs 0.21 [0.14]), although MA enrollees had worse phenotypic frailty (496 participants [15.2%] vs 811 participants [13.7%] considered frail by FFP score), SPPB scores (mean [SD], 6.91 [3.34] vs 7.21 [3.27]), and gait speed (0.79 [0.24] m/s vs 0.82 [0.23] m/s) than TM enrollees. One year later, there were no differences between MA and TM enrollees in the 1-year change in FI score (mean [SD], 0.016 [0.071] vs 0.014 [0.066]; adjusted mean difference, 0.001 [95% CI, −0.004 to 0.005]), FFP score (mean [SD], 0.017 [1.004] vs 0.007 [0.958]; adjusted mean difference, −0.009 [95% CI, −0.067 to 0.049]), SPPB score (mean [SD], −0.144 [2.064] vs −0.211 [1.968]; adjusted mean difference, 0.068 [95% CI, −0.076 to 0.212]), and gait speed (mean [SD], −0.0160 [0.148] m/s vs −0.007 [0.148] m/s; adjusted mean difference, −0.010 m/s [95% CI, −0.067 to 0.049 m/s]).
Conclusions and Relevance
In this cohort study of Medicare beneficiaries from 2015, MA enrollees experienced similar declines in frailty over 1 year compared with TM enrollees. Future work should examine whether the specific types of services covered by health insurance can impact frailty and health trajectories for older adults.
Importance
In 2018, the US Congress gave Medicare Advantage (MA) historic flexibility to address members’ social needs with a set of Special Supplemental Benefits for the Chronically Ill (SSBCIs). In response, the Centers for Medicare & Medicaid Services expanded the definition of primarily health-related benefits (PHRBs) to include nonmedical services in 2019. Uptake has been modest; MA plans cited a lack of evidence as a limiting factor.
Objective
To evaluate the association between adopting the expanded supplemental benefits designed to address MA enrollees’ nonmedical and social needs and enrollees’ plan ratings.
Design, Setting, and Participants
This cohort study compared the plan ratings of MA enrollees in plans that adopted an expanded PHRB, SSBCI, or both using difference-in-differences estimators with MA Consumer Assessment of Health Care Providers and Systems survey data from March to June 2017, 2018, 2019, and 2021 linked to Medicare administrative claims and publicly available benefits and enrollment data. Data analysis was performed between April 2023 and March 2024.
Exposure
Enrollees in MA plans that adopted a PHRB and/or SSBCI in 2021.
Main Outcomes and Measures
Enrollee plan rating on a 0- to 10-point scale, with 0 indicating the worst health plan possible and 10 indicating the best health plan possible.
Results
The study sample included 388 356 responses representing 467 MA contracts and 2558 plans in 2021. Within the weighted population of responders, the mean (SD) age was 74.6 (8.7) years, 57.2% were female, 8.9% were fully Medicare-Medicaid dual eligible, 74.6% had at least 1 chronic medical condition, 13.7% had not graduated high school, 9.7% were helped by a proxy, 45.1% reported fair or poor physical health, and 15.6% were entitled to Medicare due to disability. Adopting both a new PHRB and SSBCI benefit in 2021 was associated with an increase of 0.22 out of 10 points (95% CI, 0.4-4.0 points) in mean enrollee plan ratings. There was no association between adoption of only a PHRB (adjusted difference, −0.12 points; 95% CI, −0.26 to 0.02 points) or SSBCI (adjusted difference, 0.09 points; 95% CI, −0.03 to 0.21 points) and plan rating.
Conclusions and Relevance
Medicare Advantage plans that adopted both benefits saw modest increases in mean enrollee plan ratings. This evidence suggests that more investments in supplemental benefits were associated with improved plan experiences, which could contribute to improved plan quality ratings.
Background and Aim: Currently students in China are paying more attention to exercise. With the rising cost of living and increasingly hectic lifestyle in China, there are still relatively few universities with fitness centers and is not yet widespread. In addition, there is a lack of clear management in the fitness center and this does not cover this causes university students to lack support in exercising. The purpose of this study was to construct guidelines for management strategies to develop fitness centers at the university. Materials and Methods: This study is a survey type and it is qualitative research. The sample group is divided into two groups: the first group was 10 people with stakeholders to be used in interviews to find problems in the current management of fitness centers. Using questions created by the researcher that are based on the 4M and POLC theories; the second group was 15 experts with specialized knowledge including Fitness center managers, University administrators, Fitness center coaches, and Fitness center customers. The researcher will bring the draft strategy to the second group of experts to screen and evaluate to obtain a final strategy that is of high quality and can be used. The researcher took the problems obtained from interviews with stakeholders and analyzed them on a side-by-side basis which includes Policy, Economic, Social, Technology, Environment, and Legal. Results: The result of this research shows: It was found that 48 draft strategies were consulted and opinions were sought for evaluation and screening from experts. Obtained 31 strategies that have quality and efficiency in actual use which include: 5 Policy strategies, 5 Economic strategies, 6 Social strategies, 5 Technology strategies, 5 Environment strategies, and 5 Legal strategies, and all strategies were accepted by a total of 15 experts. Conclusion: (1) Fitness management has problems in every aspect and the collected problems are similar. It can be seen that there is a problem of insufficient staff and insufficient equipment in the fitness center to meet the demand. In the matter of budget allocation, there is still no clarity. (2) Management strategies are designed according to problems encountered, such as increasing the number of employees. Using technology helps alleviate responsibility. Including recording the use of the budget. Operating under the policies and laws of China.
Objective
To describe common methodological problems that arise in comparisons of Medicare Advantage (MA) and Traditional Medicare (TM) and within‐MA studies and provide suggestions of how researchers can address these issues.
Study Setting
Published research evaluating Medicare coverage options in the United States.
Study Design
We considered key conceptual challenges and promising solutions that have been used thus far and suggest additional directions.
Data Collection
Not available.
Principal Findings
Many existing studies of MA versus TM include significant limitations, such as failing to account for unobserved confounders driving both beneficiary coverage choice and health outcomes once enrolled, not accounting for variation in benefit generosity, provider networks, or plan design across MA plans, and/or having been conducted at a time when MA enrollment was less than a third of all Medicare beneficiaries. We provide a review of methods that can help researchers to overcome these weaknesses and suggest additional methods and data sources that may aid future research.
Conclusions
The MA program is becoming an essential part of the US healthcare system. By accounting for non‐random movement into and out of MA and studying the heterogeneity of beneficiary experience across plan and market characteristics, researchers can provide the high‐quality evidence necessary for policymakers to design the program and reform TM in ways that maximize beneficiary outcomes.
Importance:
Pure Barre is a form of physical exercise using low-impact, high-intensity, pulsatile isometric movements that may serve as a treatment option for urinary incontinence.
Objective:
The objective of this study was to measure the effects of the Pure Barre workout on urinary incontinence symptoms and sexual function.
Study design:
This was a prospective observational study of new, female Pure Barre clients with urinary incontinence. Eligible participants completed 3 validated questionnaires at baseline and at follow-up after 10 Pure Barre classes within 2 months. Questionnaires included the Michigan Incontinence Symptoms Index (M-ISI), the Pelvic Floor Distress Inventory-20, and the Female Sexual Function Index-6. Matched differences in domain questionnaire scores between baseline and follow-up were analyzed.
Results:
All questionnaire domains significantly improved for all 25 participants after 10 Pure Barre classes. Median M-ISI severity domain scores decreased from 13 (interquartile range, 9-19) at baseline to 7 at follow-up (interquartile range, 3-10; P < 0.0001). Mean ± SD M-ISI urgency urinary incontinence domain scores decreased from 6.40 ± 3.06 to 2.96 ± 2.13 (P < 0.0001). Mean ± SD M-ISI stress urinary incontinence scores decreased from 5.24 ± 2.71 to 2.48 ± 1.58 (P < 0.0001). Mean ± SD Urinary Distress Inventory domain scores decreased from 42.17 ± 17.15 to 29.67 ± 13.73 (P < 0.0001). Matched rank sum analysis indicated increasing Female Sexual Function Index-6 scores from baseline to follow-up (P = 0.0022).
Conclusion:
The Pure Barre workout may be an enjoyable, conservative management option that improves symptoms of urinary incontinence and sexual function.
Problem definition: This paper analyzes a market design problem in Medicare Advantage (MA), the largest risk-adjusted capitation payment program in the U.S. healthcare market. Evidence exists that the current MA capitation payment program unintentionally incentivizes health plans to cherry pick profitable patient types, which is referred to as “risk selection”. However, the root causes of the risk selection are not comprehensively understood, which we study in this paper. Academic / Practical Relevance: The existing literature primarily attributes the observed risk selection in MA market to data limitations and low explanatory power (e.g. low R ² ) of the current risk adjustment design. As a result, the current understanding and expectation are that risk selection would gradually disappear over time with increased availability of big data. However, if informationally imperfect risk adjustment is not the only cause of risk selection, big data would provide false assurance to key stakeholders, which we investigate in this paper. Given that risk-adjusted capitation payment models have been increasingly adopted by payers in the U.S., our study would be of primary interest to payers, providers and policy makers in the healthcare market. Results: This paper shows that big data alone cannot cure risk selection in the MA capitation program. In particular, we show that even if the current MA risk adjustment design became informationally perfect (e.g. R ² = 1), health plans would still have incentives to conduct risk selection, as imperfect risk adjustment is not the only cause of risk selection in the MA market. More specifically, we show that incentives would continue to persist for risk selection in the age of big data through strategically subsidizing some subgroups of patients using capitation payments collected from other subgroups, which we call “risk selection induced by cross subsidization.” We further propose a simple mechanism to address this risk selection problem induced by cross subsidization in MA. Methodology: We construct a game-theoretical model to derive the MA capitation rates under informationally perfect risk adjustment, and show that these capitation rates cannot eliminate risk selection in MA. Managerial Implications: To eliminate risk selection, payers should modify their current capitation mechanisms to take into account the cross subsidization incentives, as proposed in this paper.
Supplemental Material: The online appendix is available at https://doi.org/10.1287/msom.2022.1127 .
Introduction
Untreated dental caries (UC), although preventable, is the most prevalent disease in the United States. UC diminishes quality of life and lowers productivity for millions of Americans and is notably higher among lower-income compared to higher-income persons.
Objective
This study examines changes in disparities by income in past-year dental use (DU) and UC in 4 life stages (2−5, 6−19, 20−64, and ≥65 y) between 1999−2004 and 2011−2016. We also examined changes in dental safety net policies during this time.
Methods
We obtained data on dependent variables, UC and DU, from cross-sectional, nationally representative surveys for 1999−2004 and 2011−2016. We used multivariable regression models with 3 main-effect explanatory variables: income (<200% or ≥200% federal poverty level), life stage, and survey period (1999−2004 or 2011−2016) and sociodemographic variables. We included 2-way interaction terms among main-effect variables to test whether disparities had changed over time in each life stage and a 3-way term to test changes in disparities differed across life stages.
Results
Model-adjusted disparities in DU decreased for both preschool-age and school-age children, and disparities in UC decreased for school-age children. Changes in DU and UC disparities were not detectable for working-age adults and increased for retirement-age adults. Changes in DU and UC among preschool and school-age children were not significantly different from one another and were significantly different from changes among retirement-age adults. Compared to working-age adults, changes in disparities for DU and UC were significantly different for school-age children, and changes in DU were significantly different for preschool-age children. Between surveys, the dental safety net was expanded for youth but remained largely unchanged for adults.
Conclusions
Expanding the dental safety net for youth could have contributed to increased access to dental care among children relative to adults and contributed to the decrease in disparities in DU and UC among youth. Knowledge Transfer Statement: Between 1999−2004 and 2011−2016, the dental safety net was expanded for youth but remained largely unchanged for adults. Using national survey data to compare changes in disparities in past-year dental use and untreated dental caries by income between adults and youth sheds light on the potential impact of expanding the dental safety net.
Does hospital advertising influence patient choice and health outcomes? We examine more than 220,000 individual patient-level visits over 24 months in Massachusetts to answer this question. We find that patients are positively influenced by hospital advertising; seeing a television advertisement for a given hospital makes a patient more likely to select that hospital. We also observe significant heterogeneity in patient response depending on insurance status, medical conditions, and demographic factors, like age, gender, and race. For example, patients with more restrictive forms of insurance are less sensitive to advertisements. Our demand model allows us to study the impact of a ban on hospital advertising, which has been recently considered by policy makers. We find that banning hospital advertising can hurt patient health outcomes through increased hospital readmissions. This is because hospital advertisements drive patients to higher-quality hospitals, which tend to advertise more and have lower readmission rates. However, we do not find a significant change in the overall mortality rate.
Democratic candidates for president in 2020 will likely include some type of public plan in their health care reform platforms. Existing public plans take many forms and often incorporate private elements, as do most proposals to extend such plans. We review the types of public plans in the current system. We describe and assess the range of proposals to extend these plans or elements of them to additional populations. We suggest questions that candidates could use to guide their decisions about the scope and content of their health policy proposals. Developmental work during campaigns will contribute to success in turning candidates' promises into accomplishments.
The effects of television advertising in the market for health insurance are of distinct interest to both firms and regulators. Regulators are concerned about firms potentially using ads to “cream skim,” or attract an advantageous risk pool, as well as the potential for firms to use misinformation to take advantage of the elderly. Firms are interested in using advertising to acquire potentially highly profitable seniors. Meanwhile, health insurance is a useful setting to study the mechanisms through which advertising could work. Using the discontinuity in advertising exposure created by the borders of television markets, this study estimates the effects of advertising on consumer choice in health insurance. Television advertising has a small effect on brand enrollments, making advertising a relatively expensive means of acquiring customers. Heterogeneous effects point to advertising being more effective in less healthy counties, which runs opposite to the concern of cream skimming. Leveraging the unilateral cessation of advertising by United-Healthcare, evidence is provided that the small advertising effect is not explained by a prisoner’s dilemma equilibrium. An analysis of longer-run effects of advertising shows that advertising effects are short lived, further decreasing the potential of advertising to create long-run value to the firm.
Audio Interview
Interview with Dr. Amber Willink on a new law that increases the flexibility of benefit offerings in Medicare Advantage plans. (11:32)Download
The CHRONIC Care Act boosts efforts to provide more integrated care for Medicare beneficiaries to better address needs that are not strictly medical, but it may also substantially affect risk selection in Medicare Advantage plans, which would be counterproductive.
Although measuring outcomes is an integral part of medical quality improvement, large-scale outcome reporting efforts face several challenges. Among these are difficulties in establishing consensus definitions for outcome measurement; classifying gray outcomes, such as postoperative respiratory failure; and adequately adjusting for patient comorbidities and severity of illness. Unintended consequences of outcome reporting can also distort care in undesirable ways, and clinician reluctance to care for high-risk patients may occur with reporting programs. Ultimately, clinicians need not compare outcomes to improve and should recognize that even outcomes that cannot be precisely quantitated can still be improved.
Previous research has found differences in characteristics of beneficiaries enrolled in Medicare fee-for-service versus Medicare Advantage (MA), but there has been limited research using more recent MA enrollment data. We used 1997-2005 National Health Interview Survey data linked to 2000-2009 Medicare enrollment data to compare characteristics of Medicare beneficiaries before their initial enrollment into Medicare fee-for-service or MA at age 65 and whether the characteristics of beneficiaries changed from 2006 to 2009 compared with 2000 to 2005. During this period of MA growth, the greatest increase in enrollment appears to have come from those with no chronic conditions and men.
Personal responsibility matters for both rationing and resource allocation. If people were healthier, there would be less competition for absolutely scarce resources such as organs or limited ICU beds. If fewer people were overweight, obese, or smokers, dilemmas arising from relative scarcity could be attenuated, as there would be reduced need for providing (and funding) interventions for conditions such as diabetes, heart disease, stroke, some cancers, or hip or knee-replacements. Yet, how to implement reasonable personal responsibility policies is far from straightforward. In the best case, the stars are aligned and programs empower people’s health literacy and agency, reduce overall healthcare spending, alleviate rationing and resource allocation dilemmas, and lead to healthier and more productive workforces. But the devil is often in the detail: a focus on controlling or reducing cost can also lead to an inequitable distribution of benefits from incentive programs, and penalize people for health risk factors that are beyond their control. This article reviews the different motivations that can underlie and drive personal responsibility policies; sets out a proposal for how to decide on the reasonableness of personal responsibility policies given the constraints of the realpolitik of health policy and the normative issues that are at stake; and provides an overview of central ethical issues raised by incentive programs, the dominant policy tool to promote personal responsibility.
In 2014, Medicare Advantage (MA) enrollment surpassed 30 percent of eligible beneficiaries. Twenty-five years earlier, enrollment hovered at just 3 percent. The expansion of private Medicare plans presents a puzzling instance of policy change within Medicare-a program long held to be a quintessential case of policy stasis. This article investigates the policy features that made Medicare susceptible to this dramatic policy shift, as well as the processes by which the initial policy change remade the politics of Medicare and solidified the MA program. The first enrollment surge occurred in the absence of a proximate legislative or administrative change. Instead, increased spending and expanded benefits were the result of the interaction of new market dynamics with an existing legislative framework-demonstrating an expansionary form of policy drift. The 1982 Tax Equity and Fiscal Responsibility Act created a policy space that gave the new and lightly controlled managed care industry considerable operational discretion. As the interests of the government's private partners changed in response to new market dynamics, a change occurred in the output and performance of the Medicare managed care program. As enrollment and spending increased, Medicare's politics were re-made by the political empowerment of the managed care industry and the creation of a new sub-constituency of beneficiaries.
Evidence suggests that the share of Medicare managed care enrollees in a region affects the costs of treating traditional fee-for-service (FFS) Medicare beneficiaries; however, little is known about the mechanisms through which these 'spillover effects' operate. This paper examines the relationship between Medicare managed care penetration and treatment intensity for FFS enrollees hospitalized with a primary diagnosis of AMI. I find that increased Medicare managed care penetration is associated with a reduction in both the costs and the treatment intensity of FFS AMI patients. Specifically, as Medicare managed care penetration increases, FFS AMI patients are less likely to receive surgical reperfusion and mechanical ventilation and to experience an overall reduction in the number of inpatient procedures. Copyright © 2015 John Wiley & Sons, Ltd.
Copyright © 2015 John Wiley & Sons, Ltd.
Objectives:
To assess the relationship between Medicare Advantage (MA) plan rebates and enrollment and simulate the effects of Affordable Care Act (ACA) payment reforms.
Study design and methods:
First difference regressions of county-level MA payment and enrollment data from CMS from 2006 to 2010.
Results:
A 10 decrease in monthly rebates was associated with a 0.64 percentage point decline in MA penetration and a 10% decrease in risk score. ACA reforms are predicted to reduce the level of rebates in lower-spending counties, leading to enrollment decreases of 1.7 to 1.9 percentage points in the lowest-spending counties. The simulation predicts that the disenrollment would come from MA enrollees with higher risk scores.
Conclusions:
MA enrollment responds to availability of supplemental benefits supported by rebates. ACA provisions designed to lower MA spending will predominantly affect Medicare beneficiaries living in counties where MA plans may be unable to offer a comparable product at a price similar to that of traditional Medicare.
Incentives are controversial, but increasingly widespread. Their basic rationales are not always clear, nor is the complexity
of design options fully appreciated. Four common goals are outlined, and ten key dimensions of incentive programmes are described. Possible goal conflicts should be addressed through transparent communication and through monitoring the extent to which goals
are in fact accomplished. Particular emphasis should be given to identifying the distribution of benefit among users. Regulators should specify broad categories in which data should be reported to help identify and promote appropriate programmes, and prevent or phase out inappropriate ones.
The Massachusetts 2006 health care reform has been called a model for the Affordable Care Act. The law attained near-universal insurance coverage and increased access to care. Its effect on population health is less clear.
To determine whether the Massachusetts reform was associated with changes in all-cause mortality and mortality from causes amenable to health care.
Comparison of mortality rates before and after reform in Massachusetts versus a control group with similar demographics and economic conditions.
Changes in mortality rates for adults in Massachusetts counties from 2001 to 2005 (prereform) and 2007 to 2010 (postreform) were compared with changes in a propensity score-defined control group of counties in other states.
Adults aged 20 to 64 years in Massachusetts and control group counties.
Annual county-level all-cause mortality in age-, sex-, and race-specific cells (n = 146 825) from the Centers for Disease Control and Prevention's Compressed Mortality File. Secondary outcomes were deaths from causes amenable to health care, insurance coverage, access to care, and self-reported health.
Reform in Massachusetts was associated with a significant decrease in all-cause mortality compared with the control group (-2.9%; P = 0.003, or an absolute decrease of 8.2 deaths per 100 000 adults). Deaths from causes amenable to health care also significantly decreased (-4.5%; P < 0.001). Changes were larger in counties with lower household incomes and higher prereform uninsured rates. Secondary analyses showed significant gains in coverage, access to care, and self-reported health. The number needed to treat was approximately 830 adults gaining health insurance to prevent 1 death per year.
Nonrandomized design subject to unmeasured confounders. Massachusetts results may not generalize to other states.
Health reform in Massachusetts was associated with significant reductions in all-cause mortality and deaths from causes amenable to health care.
None.
Background and purpose:
After stroke, many individuals have reduced physical activity. Pedometer use is reported to enhance physical activity in patients with other health conditions. The purpose of this study was to investigate the feasibility of a community-based, pedometer-monitored walking program and determine its effects on gait speed and distance, quality of life, and balance self-efficacy post stroke.
Methods:
A single-group, pretest-posttest follow-up design was used. Eleven individuals with chronic stroke (mean age, 60.4 years; mean time since stroke, 12.2 years) completed a pedometer-monitored, community-based intervention. Primary outcomes were the 6-minute walk test (6MWT) and 10-meter walk test. Secondary outcomes were the Activities-Specific Balance Confidence Scale, Stroke Impact Scale-16 (SIS-16), and a pedometer satisfaction survey. Subjects used pedometers daily for 6 weeks and recorded step counts, adverse symptoms, and exertion levels in exercise diaries. Weekly phone coaching was used to set walking goals.
Results:
No adverse events occurred. All subjects were able to don pedometers, 91% could read step counts, and 80% expressed satisfaction. There were no significant group changes across outcome measures. There were moderate effect sizes for changes in SIS-16 (0.312) and 6MWT (0.293). Increasing steps correlated with increased perception of physical function.
Discussion:
The results support the feasibility of and participant satisfaction with a community-based, pedometer-monitored walking program post stroke. Limitations include small sample size and lack of a comparison group.
Conclusions:
This study represents a preliminary step in determining the effectiveness of pedometer-based interventions for enhancing physical activity in persons with chronic stroke. Further study is warranted.
Why do legislators sometimes engage in behavior that deviates from the expressed policy preferences of constituents who participate in politics at high rates? We examine this puzzle in the context of Democratic legislators' representation of their senior citizen constituents on the Patient Protection and Affordable Care Act of 2010 (ACA). We find that legislators' roll-call votes on the ACA did not reflect the stated preferences of their respective senior constituents; by contrast, these roll-call votes did reflect the preferences of nonsenior adults. We draw upon a theoretical framework developed by Mansbridge to explain this apparent nonresponsiveness to seniors on the ACA. This framework distinguishes between promissory representation, whereby legislators merely respond to constituents' preferences, and anticipatory representation, whereby legislators respond to constituents' underlying policy interests, even when such interests conflict with expressed preferences. By considering the Medicare provisions in the ACA and analyzing Democratic legislators' floor speeches on health reform, we provide preliminary evidence that members of Congress engaged in anticipatory representation of their senior constituents by attempting to educate seniors about how the ACA serves their policy interests.
Two meanings of personal responsibility are distinguished, and different policy options for promoting health and responsibility are presented. Key insights from research seeking to promote personal responsibility through health information and incentives are outlined and discussed with regard to their potential to improve health and reduce cost. Data is presented on the socioeconomic characteristics of incentive programme users. It is concluded that due to different factors the availability of data regarding the effectiveness of incentive programmes is unsatisfactory. Evaluation requirements set out in the German Social Security Code (SGB V) should focus not only on cost, but should also extend to changes in health status and the socioeconomic status of users: provisions should be revised accordingly.
(As supplied by publisher)
In this article, we examine the relationship between self-assessed health status, defined as ex-ante health risk, and the demand for private health insurance using data from the Korean Longitudinal Study of Aging. Contrary to theoretical predictions, insurance purchases increase with better health. We present an evidence that this phenomenon may be due to the screening on the part of insurers in the Korean private health insurance market.
In this study the authors use 3 years of the Medicare Current Beneficiary Survey (MCBS) to evaluate alternative demographic, survey, and claims-based risk adjusters for Medicare capitation payment. The survey health-status models have three to four times the predictive power of the demographic models. The risk-adjustment model derived from claims diagnoses has 75-percent greater predictive power than a comprehensive survey model. No single model predicts average expenditures well for all beneficiary subgroups of interest, suggesting a combined model may be appropriate. More data are needed to obtain stable estimates of model parameters. Advantages and disadvantages of alternative risk adjusters are discussed.
Individual choice among health insurance policies may result in risk-based sorting across plans. Such adverse selection induces three types of losses: efficiency losses from individuals' being allocated to the wrong plans; risk-sharing losses, because premium variability is increased; and losses from insurers' distorting their policies to improve their mix of insureds. We discuss the potential for these losses and present empirical evidence on adverse selection in two groups of employees: Harvard University and the Group Insurance Commission of Massachusetts (serving state and local employees). In both groups, adverse selection is a signiacant concern. Harvard’s decision to contribute an equal amount to all insurance plans led to the disappearance of the most generous policy within three years. The Group Insurance Commission has contained adverse selection by subsidizing premiums proportionally and managing the most generous policy very tightly. A combination of prospective or retrospective risk adjustment, coupled with reinsurance for high-cost cases, seems promising as a way to provide appropriate incentives for enrollees and to reduce losses from adverse selection.
Chronic obstructive pulmonary disease (COPD) is a leading cause of death and 70% of the cost of COPD is due to hospitalizations. Self-reported daily physical activity and health status have been reported as predictors of a hospitalization in COPD but are not routinely assessed.
We tested the hypothesis that self-reported daily physical activity and health status assessed by a simple question were predictors of a hospitalization in a well-characterized cohort of patients with severe emphysema.
Investigators gathered daily physical activity and health status data assessed by a simple question in 597 patients with severe emphysema and tested the association of those patient-reported outcomes to the occurrence of a hospitalization in the following year. Multiple logistic regression analyses were used to determine predictors of hospitalization during the first 12 months after randomization.
The two variables tested in the hypothesis were significant predictors of a hospitalization after adjusting for all univariable significant predictors: >2 h of physical activity per week had a protective effect [odds ratio (OR) 0.60; 95% confidence interval (95% CI) 0.41-0.88] and self-reported health status as fair or poor had a deleterious effect (OR 1.57; 95% CI 1.10-2.23). In addition, two other variables became significant in the multivariate model: total lung capacity (every 10% increase) had a protective effect (OR 0.88; 95% CI 0.78-0.99) and self-reported anxiety had a deleterious effect (OR 1.75; 95% CI 1.13-2.70).
Self-reported daily physical activity and health status are independently associated with COPD hospitalizations. Our findings, assessed by simple questions, suggest the value of patient-reported outcomes in developing risk assessment tools that are easy to use.
Medical care in the United States has become more competitive in many areas. Providers are increasingly competing for patients; third-party payers are negotiating with providers for better rates; and competition among third-party payers has increased markedly. This article will explore some of the issues associated with increased competition among these third parties in how they deal with each other and their clients. In particular, while third-party payers may compete by designing more efficient methods of delivering medical care, it is far easier to attempt to attract enrollees whose need for medical care is less than average, while quoting a premium only slightly below average. This type of competition through biased selection has two deleterious consequences: it diverts energy away from the design of more efficient systems, and it undercuts support for a diversity among plans. The first section of the article will outline some of the changes in the market for third-party coverage that give rise to more concern about problems of biased selection and the setting of premiums. The second section briefly reviews empirical studies on the presence of biased selection. The third section outlines a series of methods to deal with selection bias problems. The final section outlines some of the policy considerations associated with the various options.
To estimate the effect of Medicare+Choice (M+C) plan premiums and benefits and individual beneficiary characteristics on the probability of enrollment in a Medicare+Choice plan.
Individual data from the Medicare Current Beneficiary Survey were combined with plan-level data from Medicare Compare.
Health plan choices, including the Medicare+Choice/Fee-for-Service decision and the choice of plan within the M+C sector, were modeled using limited information maximum likelihood nested logit.
Premiums have a significant effect on plan selection, with an estimated out-of-pocket premium elasticity of -0.134 and an insurer-perspective elasticity of -4.57. Beneficiaries are responsive to plan characteristics, with prescription drug benefits having the largest marginal effect. Sicker beneficiaries were more likely to choose plans with drug benefits and diabetics were more likely to pick plans with vision coverage.
Plan characteristics significantly impact beneficiaries' decisions to enroll in Medicare M+C plans and individuals sort themselves systematically into plans based on individual characteristics.
This article describes the CMS hierarchical condition categories (HCC) model implemented in 2004 to adjust Medicare capitation payments to private health care plans for the health expenditure risk of their enrollees. We explain the model's principles, elements, organization, calibration, and performance. Modifications to reduce plan data reporting burden and adaptations for disabled, institutionalized, newly enrolled, and secondary payer subpopulations are discussed.
To investigate separately for men and women whether moderate or high leisure time physical activity, occupational physical activity, and commuting activity are associated with a reduced cardiovascular disease (CVD) and all-cause mortality, independent of CVD risk factors and other forms of physical activity.
Prospective follow-up of 15,853 men and 16,824 women aged 30-59 years living in eastern and south-western Finland (median follow-up time 20 years). CVD and all-cause mortality were lower (9-21%) in men and women (2-17%) who were moderately or highly physically active during leisure time. Moderate and high levels of occupational physical activity decreased CVD and all-cause mortality by 21-27% in both sexes. Women spending daily 15 min or more in walking or cycling to and from work had a reduced CVD and all-cause mortality before adjustment for occupational and leisure time physical activity. Commuting activity was not associated with CVD or all-cause mortality in men.
Moderate and high levels of leisure time and occupational physical activity are associated with a reduced CVD and all-cause mortality among both sexes. Promoting already moderate levels of leisure time and occupational physical activity are essential to prevent premature CVD and all-cause mortality.
The Medicare Modernization Act of 2003 created several new types of private insurance plans within Medicare, starting in 2006. Some of these plan types previously did not exist in the commercial market and there was great uncertainty about their prospects. In this paper, we show that statistical models and historical data from the Medicare Current Beneficiary Survey can be used to predict the experience of new plan types with reasonable accuracy. This lays the foundation for the analysis of program modifications currently under consideration. We predict market share, risk selection, and stability for the most prominent new plan type, the stand-alone Medicare prescription drug plan (PDP). First, we estimate a model of consumer choice across Medicare insurance plans available in the data. Next, we modify the data to include PDPs and use the model to predict the probability of enrollment for each beneficiary in each plan type. Finally, we calculate mean-adjusted actual spending by plan type. We predict that adverse selection into PDPs will be substantial, but that enrollment and premiums will be stable. Our predictions correspond well to actual experience in 2006.
Our study was undertaken to determine the association between use of a health plan-sponsored health club benefit by older adults and total health care costs over 2 years.
This retrospective cohort study used administrative and claims data from a Medicare Advantage plan. Participants (n = 4766) were enrolled in the plan for at least 1 year before participating in the plan-sponsored health club benefit (Silver Sneakers). Controls (n = 9035) were matched to participants by age and sex according to the index date of Silver Sneakers enrollment. Multivariate regression models were used to estimate health care use and costs and to make subgroup comparisons according to frequency of health club visits.
Compared with controls, Silver Sneakers participants were older and more likely to be male, used more preventive services, and had higher total health care costs at baseline. Adjusted total health care costs for Silver Sneakers participants and controls did not differ significantly in year 1. By year 2, compared with controls, Silver Sneakers participants had significantly fewer inpatient admissions (-2.3%, 95% confidence interval, -3.3% to -1.2%; P < .001) and lower total health care costs (-892 to -1252 (95% confidence interval, -567; P < .001) less in health care costs in year 2 than did those who visited on average less than once per week.
Regular use of a health club benefit was associated with slower growth in total health care costs in the long term but not in the short term. These findings warrant additional prospective investigations to determine whether policies to offer health club benefits and promote physical activity among older adults can reduce increases in health care costs.
The Medicare Advantage (MA) program offers beneficiaries a choice of private health plans as alternatives to the traditional fee-for-service Medicare program. MA plans potentially provide additional value, but as plan choices have proliferated, consumers contemplating their options have had difficulty understanding how they differ. Through "standardization" more consistent types of information and a limited number of dimensions along which plans vary--MA plans could reduce complexity and improve beneficiaries' ability to make informed choices. Such standardization steps would offer more meaningful variation in the health coverage options available to beneficiaries, Medicare officials and their community partners would find it far easier to educate beneficiaries about their health plan choices, and beneficiaries would better understand what they were buying. Standardization might also strengthen the ability of the market-based Medicare Advantage program to incorporate beneficiary preferences.
The purpose of this study was to determine whether elective use of a health plan-sponsored health club membership had an impact on health care use and costs among older adults with diabetes.
Administrative claims for 2,031 older adults with diabetes enrolled in a Medicare Advantage plan were obtained for this retrospective cohort study. Participants (n = 618) in the plan-sponsored health club benefit (Silver Sneakers [SS]) and control subjects (n = 1,413) matched on SS enrollment index date were enrolled in the plan for at least 1 year before the index date. Two-year health care use and costs of SS participants and control subjects were estimated in regressions adjusting for baseline differences.
SS participants were more likely to be male, had a lower chronic disease burden, used more preventive services, and had a lower prevalence of arthritis (P <or= 05). SS participants had lower adjusted total health care costs than control subjects in the first year after enrollment (-2,620 to -1,230 [-33], P = 0.06). Participants who made on average >or=2 SS visits/week in year 1 had lower total costs in year 2 (3,877 to -$405], P = 0.02) than participants who made <2 visits/week.
Use of a health club benefit by older adults with diabetes was associated with slower growth in total health care costs over 2 years; greater use of the benefit was actually associated with declines in total costs.
This paper provides a survey on studies that analyze the macroeconomic effects of intellectual property rights (IPR). The first part of this paper introduces different patent policy instruments and reviews their effects on R&D and economic growth. This part also discusses the distortionary effects and distributional consequences of IPR protection as well as empirical evidence on the effects of patent rights. Then, the second part considers the international aspects of IPR protection. In summary, this paper draws the following conclusions from the literature. Firstly, different patent policy instruments have different effects on R&D and growth. Secondly, there is empirical evidence supporting a positive relationship between IPR protection and innovation, but the evidence is stronger for developed countries than for developing countries. Thirdly, the optimal level of IPR protection should tradeoff the social benefits of enhanced innovation against the social costs of multiple distortions and income inequality. Finally, in an open economy, achieving the globally optimal level of protection requires an international coordination (rather than the harmonization) of IPR protection.
Regular exercise lowers the risk of disease progression for many chronic illnesses, but older adults experience relatively low rates of exercise. Although multiple intervention studies indicate that community-based programs can facilitate exercise participation, whether this research has resulted in widespread targeted exercise programs within communities is unknown. This study seeks to understand the ecological context of exercise for older adults through a cross-sectional survey of community exercise facilities within a mid-Atlantic city. The findings highlight the limited nature of the existing exercise infrastructure and reveal gaps in the community translation of research evidence regarding exercise adherence. An expansion in the availability of community exercise programs for older adults and more uniform policies to support older adult exercise are needed.
Prediction models that identify populations at risk for high health expenditures can guide the management and allocation of financial resources.
To compare the ability for identifying individuals at risk for high health expenditures between the single-item assessment of general self-rated health (GSRH), "In general, would you say your health is Excellent, Very Good, Good, Fair, or Poor?," and 3 more complex measures.
We used data from a prospective cohort, representative of the US civilian noninstitutionalized population, to compare the predictive ability of GSRH to: (1) the Short Form-12, (2) the Seattle Index of Comorbidity, and (3) the Diagnostic Cost-Related Groups/Hierarchal Condition Categories Relative-Risk Score. The outcomes were total, pharmacy, and office-based annualized expenditures in the top quintile, decile, and fifth percentile and any inpatient expenditures.
Medical Expenditure Panel Survey panels 8 (2003-2004, n = 7948) and 9 (2004-2005, n = 7921).
The GSRH model predicted the top quintile of expenditures, as well as the SF-12, Seattle Index of Comorbidity, though not as well as the Diagnostic Cost-Related Groups/Hierarchal Condition Categories Relative-Risk Score: total expenditures [area under the curve (AUC): 0.79, 0.80, 0.74, and 0.84, respectively], pharmacy expenditures (AUC: 0.83, 0.83, 0.76, and 0.87, respectively), and office-based expenditures (AUC: 0.73, 0.74, 0.68, and 0.78, respectively), as well as any hospital inpatient expenditures (AUC: 0.74, 0.76, 0.72, and 0.78, respectively). Results were similar for the decile and fifth percentile expenditure cut-points.
A simple model of GSRH and age robustly stratifies populations and predicts future health expenditures generally as well as more complex models.
The validity of various self-reported health assessments in predicting physician contracts and all-cause mortality was investigated in a prospective study in Finland. The follow-up periods were one year for the use of physician services and ten years ten months for the mortality. The study cohort comprised 1340 men and 1500 women, 35-63 years of age at the beginning of the study. The initial health assessments were derived from postal questionnaires in 1980 (response rate 77.5%). The survey was repeated one year later to verify the stability of the respondents' perceived health status. The data on the physician contacts and mortality were registered independently. The stability of perceived health status was relatively good and the perceived health was inversely associated with the number of physician contacts per year. A consistent inverse association, standardized by age, sex and social status, was observed between perceived health status and perceived physical fitness and mortality, while the predictive value of self-reported chronic diseases was low. The results suggest that the subjective health assessments are valid health status indicator in middle-aged populations, and they can be used in cohort studies and population health monitoring.
The 1997 Balanced Budget Act (Public Law 105-33) not only balanced the federal budget for the first time in decades but also mandated major changes in Medicare. One important goal of these changes was to expand the choice of health plans for Medicare beneficiaries, both to encourage the provision of high-quality care and to control aggregate program costs through competition and risk sharing. Under the new provisions, health-plan options include traditional fee-for-service care, high-deductible medical savings accounts, provider-sponsored organizations, and capitated plans, such as health maintenance organizations. However, questions arose about whether all beneficiaries would have these choices. In particular, . . .
The rapidly expanding proportion of the US population 65 years and older is anticipated to have a profound effect on health care expenditures. Whether the changing health status of older Americans will modulate this effect is not well understood. This study sought to determine the relationship between functional status and government-reimbursed health care services in older persons.
Longitudinal cohort study of a representative sample of community-dwelling persons 72 years or older. Clinical data were linked with data on 2-year expenditures for Medicare-reimbursed hospital, outpatient, and home care services and Medicare- and Medicaid-reimbursed nursing home services. Per capita expenditures associated with different functional status transitions were calculated, as were excess expenditures associated with functional disability adjusted for demographic, health, and psychosocial variables.
The 19.6% of older persons who had stable functional dependence or who declined to dependence accounted for almost half (46.3%) of total expenditures. Persons in these groups had an excess of approximately $10 000 in expenditures in 2 years compared with those who remained independent. The 9.6% of patients who were dependent at baseline accounted for more than 40.0% of home health and nursing home expenditures; the 10.0% who declined accounted for more than 20.0% of hospital, outpatient, and nursing home expenditures.
Functional dependence places a large burden on government-funded health care services. Whereas functional decline places this burden on short- and long-term care services, stable functional dependence places the burden predominantly on long-term care services. Declining rates of functional disability and interventions to prevent disability hold promise for ameliorating this burden.
The goal of the Veterans Health Study (VHS) was to extend the work of the Medical Outcomes Study (MOS) into the VA, by developing methodology for monitoring patient-based outcomes of care for use in ambulatory outpatient care. The principal objective of the VHS was developing valid and reliable measures to assess general health-related quality of life (HRQoL) and identifying the presence of selected health conditions, their severity, and their impact on HRQoL. In this article, we provide an overview of the historical context, framework, objectives, and applications of the VHS for the purpose of assessing the health outcomes of veteran patients. The VHS is a prospective observational study that has followed 2425 VA patients for up to 2 years. The patients were sampled from users of the Veterans Affairs (VA) ambulatory care system in the Boston area. The health conditions selected were hypertension, diabetes, chronic lung disease, osteoarthritis of the knee, chronic low-back pain, and alcohol-related problems. These conditions were chosen because they are both prevalent in the VA and have measurable impacts on HRQoL. One of the cornerstones of the VHS was the development of the Veterans SF-36, modified from the MOS SF-36 for use in veteran ambulatory populations. Other key accomplishments included the development of patient-based disease-specific measures of health and the establishment of methods and logistics for comprehensive health outcomes research in large health care systems such as the VA, using these patient-based measures. Selected measures developed in the VHS, eg, the Veterans SF-36, have been integrated into the VA outcomes measurement system. The scope of the VHS is unique; it resulted in the development of a broad range of patient-focused process and outcome measures, as well as methodologies for assessing large numbers of patients, that have been widely used in the VA outpatient health care system for monitoring health outcomes across the nation.
We estimate the relation between enhanced benefits offered by the Medicare+Choice (M+C) plan in 1999 and a measure of risk selection based on inpatient encounter data. Higher risks are attracted to plans that offer outpatient drug coverage. The risk score increases by 2.2 percent for drug coverage with an annual limit less than 800. However, some benefits such as dental coverage were related to favorable risk selection. If M+C plans competed on the basis of benefits and premiums, as they would if they could give untaxed premium rebates, benefits that attract high risks would be underprovided.
The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) raised payment levels for established Medicare Advantage (private) local plans and would-be regional preferred provider organizations (PPOs). Even though plans on average receive about 108 percent of what would have been spent for the same beneficiaries in traditional Medicare, the Centers for Medicare and Medicaid Services (CMS) added another 2.3 percent in 2004 and 4.0 percent in 2005 in its implementation of risk-adjusted payments. Although MMA gives a clear preference to private plans to start a fundamental restructuring of Medicare, the question remains whether Congress will maintain overpayments to private plans when faced with the pressure to reduce budget deficits.
Health planners and policy makers are increasingly asking for a feasible method to identify vulnerable persons with the greatest health needs. We conducted a systematic review of the association between a single item assessing general self-rated health (GSRH) and mortality.
Systematic MEDLINE and EMBASE database searches for studies published from January 1966 to September 2003.
Two investigators independently searched English language prospective, community-based cohort studies that reported (1) all-cause mortality, (2) a question assessing GSRH; and (3) an adjusted relative risk or equivalent. The investigators searched the citations to determine inclusion eligibility and abstracted data by following a standardized protocol. Of the 163 relevant studies identified, 22 cohorts met the inclusion criteria. Using a random effects model, compared with persons reporting "excellent" health status, the relative risk (95% confidence interval) for all-cause mortality was 1.23 [1.09, 1.39], 1.44 [1.21, 1.71], and 1.92 [1.64, 2.25] for those reporting "good,"fair," and "poor" health status, respectively. This relationship was robust in sensitivity analyses, limited to studies that adjusted for co-morbid illness, functional status, cognitive status, and depression, and across subgroups defined by gender and country of origin.
Persons with "poor" self-rated health had a 2-fold higher mortality risk compared with persons with "excellent" self-rated health. Subjects' responses to a simple, single-item GSRH question maintained a strong association with mortality even after adjustment for key covariates such as functional status, depression, and co-morbidity.
The Veterans Health Study (VHS) had as its overarching goal the development, testing, and application of patient-centered assessments for monitoring patient outcomes in ambulatory care in large integrated care systems such as the Department of Veterans Affairs (VA). Unlike other previous studies, the VHS has capitalized on rich administrative databases restricted to the VA and linked to patient-centered outcomes. The VHS has developed a comprehensive set of general and disease-specific measures for use by systems of care for ambulatory patients. Chief among these assessments is the Veterans SF-36 Health Survey for measuring health-related quality of life in veteran ambulatory populations. The Veterans SF-36 Health Survey provides the cornerstone for this study and historically has been extensively disseminated and used in the VA with close to 2 million administrations nationally as part of its quality management system. National surveys administered by the VA since 1996 using the Veterans SF-36 Health Survey indicate important regional differences with implications for varying resource needs. Based upon the rich foundation provided by the VHS methodology, the VA has implemented some of these approaches as part of its quality monitoring system and can serve as a model for other large integrated systems of care.
The Veterans Health Study (VHS) followed a cohort of patients receiving ambulatory care in the Veterans Affairs healthcare system for up to 5 years. One of the principal aims of this study was to develop a library of methodologies including general and disease-specific health outcome questionnaires for use in monitoring the quality of healthcare and for research purposes. The cornerstone for this work is the Veterans RAND 36 and 12 Item Health Surveys (VR-36 and VR-12), a general measure developed in the VHS for measuring the physical and psychologic well-being of the patient. A comprehensive set of disease-specific assessments has also been developed as part of this study for the purposes of monitoring specific chronic conditions more commonly seen in routine ambulatory care settings. Since 1996, more than 2 million questionnaires have been administered in the VA for quality monitoring purposes, using the VR-36 and VR-12. Research studies that have used these batteries span randomized clinical trials in the VA cooperative studies program and clinical effectiveness research. Health assessments using VHS batteries are being disseminated for widespread use outside the VA. Chief among the assessments used is the VR-12, which has recently been included in the 2006 Health Plan Employer Data and Information Set (HEDIS) as part of the Medicare Health Outcomes Survey for monitoring the Medicare Advantage Program. The methods and batteries developed in the VHS are in the public domain and provide a framework for future patient monitoring using standard measures of health.
Prior research on selection bias in Medicare plans has demonstrated favorable enrollment of healthier beneficiaries, resulting in plan overpayment. However, total selection bias depends not only on who enrolls, but also on who disenrolls. Few studies examine selectivity in disenrollment; it is unclear how those who leave plans differ from those who remain.
The examination of health status and plan characteristics as potential predictors of voluntary disenrollment from Medicare managed care.
Baseline data on health of Medicare managed care enrollees are from the 1998 Medicare Health Outcomes Survey, merged with data on enrollment status and plan characteristics. Beneficiary voluntary disenrollment, versus continuous enrollment, 24 months after completing the survey was modeled as a function of perceived health in 1998 and plan characteristics. The sample included 109,882 community-dwelling elderly.
Between 1998 and 2000, 24% of Medicare managed care enrollees voluntarily disenrolled from plans. Poor perceived physical and mental health significantly increased the odds of voluntary disenrollment. Odds of disenrollment were higher for members of plans that increased premiums and had low market share between 1998 and 2000. Conversely, gaining drug coverage in a plan between 1998 and 2000 lowered the odds of disenrollment (relative to no coverage).
Medicare plans experience favorable selection bias partly because sicker members are likelier to disenroll. Plan-level policies that influence market share and benefits, particularly pharmaceutical coverage, also have important effects on disenrollment, regardless of health effects. Understanding both individual and plan influences on disenrollment is critical to benefit coverage and disenrollment restriction ("lock in") policies.
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