Disagreement between a public insurer’s recommendation and beneficiary’s choice of long-term care services in Korea

This study examined the disagreement between an insurer’s recommendation for long-term care (LTC) services and beneficiaries’ choices and analyzed the factors associated with the disagreement. Data from the National Long-Term Care Insurance (LTCI) and the Standard Care Plan were merged to create a dataset of 43,319 LTCI beneficiaries. The dependent variable was the disagreement between beneficiaries and insurers. Predisposing, enabling, and needs factors were independent variables based on the Andersen’s Model. Disagreement between the insurer’s recommendation of home care services and the beneficiaries’ choice of institution service was 6.7% (n = 2357). The opposite disagreement occurred in 23.0% (n = 1820) of cases. A multivariate analysis showed that the OR for disagreement between insurer-recommended home care services and beneficiary-selected institution services increased with age, living with someone, having Medical Aid, living in a facility, and having high care needs, dementia, and poor subjective hearing. The OR for disagreement between insurer-recommended institution service and beneficiary-selected home care service increased for men and decreased for those 90 years or older, living with someone, having Medicaid etc, and living at institution. Korean beneficiaries of LTCI have a high preference for aging in their home, and changes in LTCI contents must be made to address the needs of this population.     

Impact of COVID-19 on Long-Term Care Service Utilization of Older Home-Dwelling Adults in Japan

ObjectivesThe COVID-19 outbreak severely affected long-term care (LTC) service provision. This study aimed to quantitatively evaluate its impact on the utilization of LTC services by older home-dwelling adults and identify its associated factors.DesignA retrospective repeated cross-sectional study.Setting and ParticipantsData from a nationwide LTC Insurance Comprehensive Database comprising monthly claims from January 2019 to September 2020.MethodsInterrupted time series analyses and segmented negative binomial regression were employed to examine changes in use for each of the 15 LTC services. Results of the analyses were synthesized using random effects meta-analysis in 3 service types (home visit, commuting, and short-stay services).ResultsLTC service use declined in April 2020 when the state of emergency (SOE) was declared, followed by a gradual recovery in June after the SOE was lifted. There was a significant association between decline in LTC service use and SOE, whereas the association between LTC service use and the status of the infection spread was limited. Service type was associated with changes in service utilization, with a more precipitous decline in commuting and short-stay services than in home visiting services during the SOE. Service use by those with dementia was higher than that by those without dementia, particularly in commuting and short-stay services, partially canceling out the decline in service use that occurred during the SOE.Conclusions and ImplicationsThere was a significant decline in LTC service utilization during the SOE. The decline varied depending on service types and the dementia severity of service users. These findings would help LTC professionals identify vulnerable groups and guide future plans geared toward effective infection prevention while alleviating unfavorable impacts by infection prevention measures. Future studies are required to examine the effects of the LTC service decline on older adults.     

长期护理保险受益人的满意度及影响因素研究——基于江西省上饶市调查数据的分析

目的：分析江西省上饶市长期护理保险（以下简称长护险）受益人的满意度现状及其影响因素,为完善长护险提供建议。方法：利用项目组在上饶市通过质性访谈和问卷调查收集的一手数据,以描述性统计和定序Logistic回归分析受益人的满意度及影响因素。结果：上饶市长护险受益人对长护险表示比较满意的占43.85%、非常满意的占53.37%。具有农业户口、受教育程度低、月收入低的受益人对长护险的满意度更高。享受居家上门护理待遇、认为长护险对缓解长护费用负担的作用大、对护理人员表示非常满意的受益人对长护险的满意度更高。结论：上饶市长护险受益人的满意度普遍较高。同时,在保障长护险财务可持续性的基础上适当提高待遇水平、加强居家上门护理待遇给付以及促进长护服务品质等举措对提升长护险满意度具有重要意义。     

Bridging health technology assessment (HTA) with multicriteria decision analyses (MCDA): field testing of the EVIDEM framework for coverage decisions by a public payer in Canada

Background

In Japan, as the number of elderly covered by the Long-term Care Insurance (LTCI) system has increased, demand for long-term care services has increased substantially and consequently growing expenditures are threatening the sustainability of the system. Understanding the predictive factors associated with long-term care expenditures among the elderly would be useful in developing future strategies to ensure the sustainability of the system. We report a set of predictors of the highest long-term care expenditures in a cohort of elderly persons who received consecutive long-term care services during a year in a Japanese city.

Methods

Data were obtained from databases of the LTC insurer of City A in Japan. Binary logistic regression was used to examine the predictors of the highest long-term care expenditures. We used a simplified model that focused on the effects of disability status and type of services used, while controlling for several relevant factors. Goodness of fit, a multicollinearity test, and logistic regression diagnostics were carried out for the final model.

Results

The study cohort consisted of 862 current users of LTCI system in city A. After controlling for gender and income, age, increased utilization rate of benefits, decline in functional status, higher care needs level and institutional care were found to be associated with the highest LTCI expenditures. An increased utilization rate of benefits (OR = 24.2) was a strong main effect predictors of the high LTC expenditures. However, a significant interaction between institutional care and high care need level was found, providing evidence of the combined effect of the two covariates.

Conclusions

Beyond to confirm that disability status of elderly persons is the main factor driving the demand of LTC services and consequently the expenditures, we showed that changes in utilization rate of benefits -a specific insurance factor- and the use of institutional care conditional on the high care level, were strongest predictors of the highest LTC expenditures. These findings could become crucial for tracking policies aimed at ensuring financial sustainability of LTCI from a public insurer perspective in Japan.     

Driving immunization through the Medicare Annual Wellness Visit: A growing opportunity

IntroductionThe Annual Wellness Visit (AWV) is a Medicare benefit designed to help prevent disease and disability based on individualized health and risk factors.MethodsThis study analyzes Medicare Part B fee-for-service claims from 2011 to 2016 to assess AWV and seasonal influenza and pneumococcal conjugate vaccinations utilization over time.ResultsUtilization of the AWV has increased from 8% of Medicare beneficiaries in 2011 to 19% in 2015. In each year, influenza and PCV13 vaccination rates are higher among those who utilize the benefit. More than one-third (33%) of patients who had an AWV in 2015 received a PCV13 vaccination in that same year, compared to 14% of those who did not. Similarly, the seasonal influenza vaccination rate was 64% among those with an AWV and 44% among those without.ConclusionThe AWV demonstrates promise for improving immunization rates among Medicare beneficiaries particularly at the point of care.     

Effects of Copayment in Long-Term Care Insurance on Long-Term Care and Medical Care Expenditure

ObjectiveThis study aimed to clarify the difference in (1) long-term care (LTC) usage and expenditure and (2) medical care service usage and expenditure before and after the change in the copayment limit for qualifying individuals from 10% to 20%.Setting and ParticipantsThis quasi-experimental longitudinal design used the database from 1 prefecture of Japan that included 570,434 person-month records of 23,879 insured individuals (in August 2014) who used LTC services between August 2014 and July 2015 and were aged 65 years and older on August 1, 2014.MethodsWe conducted difference-in-difference estimations to compare “before” and “after” outcome differences between insured individuals whose LTC copayment increased to 20% and those whose copayment remained at 10%. Sex, age, Care Needs Level, subsidy, and public assistance were adjusted in the models, along with robustness checks.ResultsDifferences in both insurer's payment and insured's copayment indicated statistical significance between those whose copayment increased and those whose copayment did not increase. We found no significant difference in the number of minutes of home care service use, days of facility care service use, and LTC expenditures among those with copayment increases as well as those with no increase in copayment following the insured's copayment increase policy implementation. In contrast, the policy implementation caused significant differences in the number of days of hospitalization, medical care expenditures, and total expenditures.Conclusions and ImplicationsThe increase in insured individuals' copayment decreased LTC insurer's payment. However, total LTC expenditure increased over time although the increase trend slowed down in the treatment group after the copayment increase policy implemented. Besides, medical care expenditure increased consistently among insured individuals whose copayment increased. As there appears to be a “balloon effect” between LTC and medical care services, it is important to discuss the medical care system while considering the LTC insurance system comprehensively.     

Barrier to Access or Cost Share? Coinsurance and Dental-Care Utilization in Colombia

Background

Copayments, deductibles, and coinsurance, are elements of health-care systems to make prices salient for the insured. Individuals may respond differently to cost sharing, according to the type of care they seek; dental care, as a combination of both acute and elective care, is an ideal setting to study the effects of cost-sharing mechanisms on utilization.

Objective

To test how coinsurance affects dental-care utilization in a middle-income country context.

Methods

This study uses policy variations in the Colombian health-care system to analyze changes in dental-care utilization due to different levels of coinsurance. We used matching procedures to balance observed differences in pre-treatment variables between those who face coinsurance (non-policy holders, or beneficiaries) and those who don’t (policyholders). We use zero-inflated negative binomial models for the count of visits and two-part models for total expenditures, and test for unobservable confounders with random-effect models and instrumental variables.

Results

Individuals who face coinsurance are less likely to have any dental-care utilization, at a relatively small scale. Facing coinsurance does not correlate with changes in total expenditures. Falsification tests with dental-care visits exempt from coinsurance show no statistically distinguishable changes in utilization. Random-effect models and instrumental variable models show results similar to the main specification.

Conclusions

Cost-sharing policies in Colombia seem to be well designed because they don’t represent an important barrier to dental-care access.

     

Carve-out plan financial requirements associated with national behavioral health parity

ObjectivesTo examine changes in carve‐out financial requirements (copayments, coinsurance, use of deductibles, and out‐of‐pocket maxima) following the Mental Health Parity and Addiction Equity Act (MHPAEA).Data Source/Study SettingSpecialty mental health benefit design information for employer‐sponsored carve‐out plans from a national managed behavioral health organization''s claims processing engine (2008‐2013).Study DesignThis pre‐post study reports linear and logistic regression as the main analysis.Data Collection/Extraction MethodsNA.Principal FindingsCopayments for in‐network emergency room (−$44.9, 95% CI: −78.3, −11.5; preparity mean: $56.2), outpatient services (eg, individual psychotherapy: −$7.4, 95% CI: −10.5, −4.2; preparity mean: $17.8), and out‐of‐network coinsurance for emergency room (−11 percentage points, 95% CI: −16.7, −5.4; preparity mean: 38.8 percent) and outpatient (eg, individual psychotherapy: −5.8 percentage points, 95% CI: −10.0, −1.6; preparity mean 41.0 percent) decreased. Probability of family OOP maxima use (29 percentage points, 95% CI: 19.3, 38.6; preparity mean: 36 percent) increased. In‐network outpatient coinsurance increased (eg, individual psychotherapy: 4.5 percentage points, 95% CI: 1.1, 7.9; preparity mean: 2.7 percent), as did probability of use of family deductibles (15 percentage points, 95% CI: 6.1, 23.3; preparity mean: 38 percent).ConclusionsMHPAEA was associated with increased generosity in most financial requirements observed here. However, increased use of deductibles may have reduced generosity for some patients.     

Designing a Value-Based Formulary for a Commercial Health Plan: A Simulated Case Study of Diabetes Medications

ObjectivesThe healthcare expenditure for managing diabetes with glucose-lowering medications has been substantial in the United States. We simulated a novel, value-based formulary (VBF) design for a commercial health plan and modeled possible changes in spending and utilization of antidiabetic agents.MethodsWe designed a 4-tier VBF with exclusions in consultation with health plan stakeholders. The formulary information included covered drugs, tiers, thresholds, and cost sharing amounts. The value of 22 diabetes mellitus drugs was determined primarily in terms of incremental cost-effectiveness ratios. Using pharmacy claims database (2019-2020), we identified 40 150 beneficiaries who were on the included diabetes mellitus medicines. We simulated future health plan spending and out-of-pocket costs with 3 VBF designs, using published own price elasticity estimates.ResultsThe average age of the cohort is 55 years (51% female). Compared with the current formulary, the proposed VBF design with exclusions is estimated to reduce total annual health plan spending by 33.2% (current: $33 956 211; VBF: $22 682 576), saving $281 in annual spending per member (current: $846; VBF: $565) and $100 in annual out-of-pocket spending per member (current: $119; VBF: $19). Implementing the full VBF with new cost shares, along with exclusions, has the potential to achieve the greatest savings, compared with the 2 intermediate VBF designs (ie, VBF with prior cost sharing and VBF without exclusions). Sensitivity analyses using various price elasticity values showed declines in all spending outcomes.ConclusionDesigning a VBF with exclusions in a US employer–based health plan has the potential to reduce health plan and patient spending.     

Cost Sharing and Utilization of Postpartum Intrauterine Devices and Contraceptive Implants Among Commercially Insured Women

BackgroundCost sharing may impede postpartum contraceptive use. We evaluated the association between out-of-pocket costs and long-acting reversible contraceptive (LARC) insertion among commercially insured postpartum women.MethodsUsing the Clinformatics Data Mart, we examined out-of-pocket costs for LARC insertions at 0 to 3 and 4–60 days postpartum among women in employer-sponsored health plans from 2013 to 2016. Patient costs were estimated by summing copayment, coinsurance, and deductible payments for LARC services (device + placement). Multivariable logistic regression evaluated the association between plan cost sharing for LARC services (at least one beneficiary with >$200 cost share) and LARC insertion by 60 days postpartum (yes/no).ResultsWe identified 396,073 deliveries among women in 51,797 employer-based plans. Overall, LARC placement by 60 days postpartum was observed after 5.2% (n = 20,604) of deliveries. Inpatient LARC insertion (n = 233; 0.06% of deliveries) was less common than outpatient LARC insertion (n = 20,375; 5.14% of deliveries). Cost sharing was observed in 23.4% of LARC insertions (inpatient IUD: median, $50.00; range, $0.93–5,055.91; inpatient implant: median, $11.91; range, $2.49–650.14; outpatient IUD: median, $25.00; range, $0.01–3,354.80; outpatient implant: median, $27.20; range, $0.18–2,444.01). Among 5,895 plans with at least one LARC insertion and after adjusting for patient age, poverty status, race/ethnicity, region, and plan type, women in plans with cost sharing of more than $200 demonstrated lower odds of LARC use by 60 days postpartum (odds ratio, 0.74; 95% confidence interval, 0.71–0.77).ConclusionsCost sharing for postpartum LARC is associated with use, suggesting that out-of-pocket costs may impede LARC access for some commercially insured postpartum women. Reducing out-of-pocket costs for the most effective forms of contraception may increase use.     

The effect of a subsidy policy on the utilization of community care services under a public long-term care insurance program in rural Japan

This cross-sectional study investigated the effect of an interim subsidy policy for low-income beneficiaries to buy home help services under Japanese long-term care insurance (LTCI) for the service utilization of home help and other community care services. Claims records during the period from October to December 2001 were reviewed to compare the monthly amounts for each service and out-of-pocket copayment for subsidized (n = 137) and non-subsidized (n = 124) beneficiaries. A multivariable linear regression analysis was conducted to control for age, gender, household size, length of care, and care eligibility level. Compared with the non-subsidized beneficiaries, the subsidized beneficiaries used 1.53 times as much home help service (p < 0.001), and spent 0.70 times as much on out-of-pocket copayments (p < 0.001), while they used fewer adult daycare services (0.71 times as much as the non-subsidized did, p = 0.063). The results strongly indicated that the interim subsidy for low-income beneficiaries alleviated the economic burden, but also resulted in service overuse and the substitution of home help services for other community care services. The policy implications of these findings were discussed.     

Continuity of care and health care cost among community‐dwelling older adult veterans living with dementia

ObjectivesTo estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community‐dwelling older veterans with dementia.Data SourcesCombined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014‐2015.Study DesignFY 2014 COC was measured by the Bice‐Boxerman Continuity of Care (BBC) index on a 0‐1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long‐/short‐stay nursing home, and noninstitutional long‐term care (LTC) cost for medical (like skilled‐) and social (like unskilled‐) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders.Data CollectionCommunity‐dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073).Principal FindingsMean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute inpatient cost, $119 lower ED cost, $4368 lower long‐stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short‐stay nursing home cost.ConclusionsCOC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care.     

Beneficiary characteristics and vaccinations in the end-stage renal disease Medicare beneficiary population,an analysis of claims data 2006–2015

BackgroundThe Advisory Committee on Immunization Practices (ACIP) routinely recommends three vaccines – influenza, hepatitis B, and pneumococcal vaccines – for End-Stage Renal Disease (ESRD) dialysis patients.MethodsWe sought to assess vaccination coverage among fee-for-service (FFS) Medicare beneficiaries with ESRD who received Part B dialysis services at any point from January 1, 2006 through December 31, 2015 (through June 30, 2016 for influenza). To assess influenza vaccination rates in a given influenza season, we restricted the population to beneficiaries who were continuously enrolled in Medicare Parts A and B throughout all twelve months of that season. To assess hepatitis B and pneumococcal vaccine coverage following dialysis initiation, we developed a Kaplan-Meier curve for all patients who began dialysis between 2006 and 2015.ResultsFor influenza vaccination, we identified an average of approximately 325,000 ESRD dialysis beneficiaries enrolled through each influenza season from 2006–2015. Seasonal influenza vaccination rates steadily increased during the 10-year period, from 52% in 2006–2007 to 71% in 2015–2016. The greatest increases in influenza vaccination appear in non-white beneficiaries with overall utilization in non-whites higher than in whites (p < .001). For the hepatitis B and pneumococcal vaccinations, we identified over 350,000 ESRD dialysis beneficiaries who began dialysis over the 10-year study window. The probability of receiving a hepatitis B vaccine within the first three years of entering into the ESRD program was higher (77%) than the probability of receiving any pneumococcal vaccine (53%). 45% of ESRD patients completed at least one dose of the two hepatitis B series (three-dose or four-dose) at any time during the study period.ConclusionsOpportunities exist at regional and facility levels to improve vaccination coverage. Compliance to ACIP recommendations may directly affect risk for ESRD dialysis patients for complications from diseases that can be mitigated by vaccination.     

Public long-term care insurance and consumption of elderly households: Evidence from China

This study investigates the impact of long-term care insurance (LTCI) on the non-health consumption of elderly households. By exploiting a quasi-experiment on the public LTCI pilot program in China, we identify the effect of LTCI using a triple-difference approach. Using longitudinal data from the China Health and Retirement Longitudinal Study, we find that LTCI has led to an increase in the non-health consumption of elderly households by 15.7%, mostly observed in households having no older members with need for long-term care (LTC). Further evidence suggests that the effects are stronger for households with higher expected LTC risks, less wealth or family insurance, and covered by more generous schemes. Finally, LTCI increases the expectation of using formal LTC when disabled and subjective longevity expectations for older adults having no need for LTC. Overall, these findings offer empirical support for the role of LTCI in mitigating precautionary savings against LTC risks.     

TRICARE Extended Care Health Option Program: Prevalence of pediatric ECHO enrollees and healthcare service utilization in the Military Health System

BackgroundThe Extended Care Health Option (ECHO) Program is a TRICARE program aimed at reducing the disabling effects of chronic medical conditions for beneficiaries of the Department of Defense (DoD) healthcare program. However, little is known about military-connected children enrolled in the program.Objective/HypothesisThe aim of this study was to examine the demographic makeup of pediatric ECHO beneficiaries and their healthcare claims data. This is the first study to evaluate healthcare utilization of this subset of military dependents.MethodsA cross-sectional study was performed evaluating ECHO enrolled pediatric beneficiaries and their health service utilization during 2017–2019. TRICARE claims and military treatment facility (MTF) encounter data were utilized to evaluate health service utilization and identify the most frequently reported ICD-10-CM and CPT codes associated with care for this population.ResultsOf the 2,001,619 dependents aged 0–26 years who received medical care in the Military Health System (MHS) during 2017–2019, 21,588 individuals (1.1%) were enrolled in ECHO. The majority of encounters (65.4%) were provided in the MTFs. Inpatient visits, therapeutic services, and in-home nursing care were the top utilized private sector care services. Outpatient visits encompassed 94.8% of healthcare encounters, and neurodevelopmental disorders were the top principal diagnoses among ECHO beneficiaries.ConclusionsWith the increasing prevalence of children with medical complexity and developmental delay, the pediatric TRICARE beneficiaries eligible for ECHO will likely continue to rise. Improving services and supports for military children with special healthcare needs is needed to maximize their developmental trajectory.     

Access to Psychiatrist Services for Older Adults in Long-Term Care: A Population-Based Study

ObjectivesAlthough mental health disorders are common among older adults in long-term care (LTC), little is known about access to psychiatric services in LTC. We described the need for psychiatric services in LTC settings and identified variables associated with receipt of psychiatric services.DesignPopulation-based retrospective cohort study.Setting and participantsAll adults aged 66 years and older who resided in LTC homes in Ontario, Canada, between 2015 and 2016. Individuals were included in the study at the time of LTC admission or first annual reassessment.MeasuresWe determined the percentage of LTC residents who received any psychiatric service within 90 days. We then compared the characteristics of individuals who did and did not receive any psychiatric service to determine variables associated with receipt of psychiatric services. Multivariate logistic regression was used to determine independent variables associated with receipt of psychiatric services.ResultsA total of 67,165 unique participants were included in the study sample, 27,650 (41.2%) of whom had identified psychiatric need. Overall, 3175 (4.7%) individuals received any psychiatric service within 90 days following cohort entry. After adjustment for potential confounders, receipt of psychiatric services was positively associated with younger age, male gender, history of major mental disorders, previous receipt of psychiatric services, indicators of psychiatric need, residence in larger LTC homes, and health region of residence.Conclusions/ImplicationsReceiving psychiatric services in Ontario LTC homes is limited when compared to the high need for services. Several factors other than patient need symptoms are associated with receipt of services, which suggests inequities in access to care. Improving the distribution of psychiatric services may help address these inequities, and additional psychiatric resources are also likely required to meet these needs. Our results directly apply to a Canadian context and have implications for other comparable countries, including the United States.     

Long-Term Care Insurance in China: Public or Private?

China faces an overwhelming and urgent need for long-term care (LTC). We explored long-term care insurance (LTCI) plans in China and the factors associated with each plan’s contribution rate. A cross-sectional survey of 814 residents (18–59 years) was conducted to assess the expectations of elderly care, public and private LTCI features. Public LTCI may be more popular whether in terms of participation or contribution. The factors associated with public LTCI contribution rate were healthcare costs, household income, and number of daughters; for private LTCI, the factors were the proportion of living expenditures, worry about future care problems, and healthcare costs. Policymakers should develop public LTCI as a solid foundation and improve private LTCI as a substitute to meet the urgent LTC needs in China.