Medicare beneficiaries less likely to experience cost- and access-related problems than adults with private coverage

The experiences of people covered by Medicare and those with private employer insurance can help inform policy debates over the federal budget deficit, Medicare's affordability, and the expansion of private health insurance under the Affordable Care Act. This article provides evidence that people with employer-sponsored coverage were more likely than Medicare beneficiaries to forgo needed care, experience access problems due to cost, encounter medical bill problems, and be less satisfied with their coverage. Within the subset of beneficiaries who are age sixty-five or older, those enrolled in the private Medicare Advantage program were less likely than those in traditional Medicare to have premiums and out-of-pocket costs exceed 10?percent of their income. But they were also more likely than those in traditional Medicare to rate their insurance poorly and to report cost-related access problems. These results suggest that policy options to shift Medicare beneficiaries into private insurance would need to be attentive to potentially negative insurance experiences, problems obtaining needed care, and difficulties paying medical bills.     

Medicare beneficiary information needs: 1994

The Medicare Current Beneficiary Survey (MCBS) is a powerful tool for analyzing enrollees' access to medical care (Adler, 1994). Based on a stratified random sample, we can derive information about the health care use, expenditure, and financing of Medicare's 36 million enrollees. We can also learn about those enrollees' health status, living arrangements, and access to and satisfaction with care. In the charts that follow, we have presented some findings on enrollee information needs in 1994, number of beneficiaries with information needs met, and sources of information used by beneficiaries. These charts attempt to answer the following questions: What types of needs do our beneficiaries have? How well do our beneficiaries understand Medicare?     

Access and satisfaction within the disabled Medicare population

Little is known about variations in the levels of access and satisfaction within the disabled Medicare population. Based on the Medicare Current Beneficiary Survey (MCBS), beneficiaries under 65 years of age were classified by original reason for disability (mental versus physical). Those with a mental disability were less likely to have a private physician as a usual source; were less satisfied with the overall quality of care, availability of after-hours care, followup care, and coordination of care; and were more likely to report unmet need, owing in large part to supply barriers. Implications for the current delivery system and for design of managed care programs are discussed.     

Financial vulnerability among Medicare managed care enrollees

Consumer Assessment of Health Plans Survey (CAHPS) data show that Medicare managed care plans often receive low satisfaction scores from certain vulnerable populations. This article describes findings from a qualitative study with beneficiaries about their Medicare managed care experiences. Focus groups were stratified by participant race/ethnicity and self-described health status. Yet participants did not describe their concerns in terms of their race, ethnicity, or health condition, but rather their access to financial resources. Our findings suggest that researchers consider how socioeconomics creates health care vulnerability for racial and ethnic minorities, females, people with disabilities, and other economically marginalized persons.     

Access to care and satisfaction with care among fee-for-service Medicare beneficiaries by level of care need

BackgroundVariation among fee-for-service (FFS) Medicare beneficiaries by level of care need for access to care and satisfaction with care is unknown.ObjectiveWe examined access to care and satisfaction with care among FFS Medicare beneficiaries by level of care need.MethodsWe employed a cross-sectional study design. Using the Medicare Current Beneficiary Survey, we categorized 17,967 FFS Medicare beneficiaries into six groups based on level of care need: the relatively healthy (11.0%), those with simple chronic conditions (26.1%), those with minor complex chronic conditions (28.6%), those with major complex chronic conditions (14.2%), the frail (6.2%), and the non-elderly disabled or end-stage renal disease (ESRD) (13.9%). Outcome measures included multiple indicators for access to care and satisfaction with care. For each outcome, we conducted a linear probability model while adjusting for individual-level and county-level characteristics and estimated the adjusted value of the outcome by level of care need.ResultsThe non-elderly disabled or ESRD were more likely to experience limited access to care and poor satisfaction with care than other five care need groups. Particularly, the rates of reporting trouble accessing needed medical care were the highest among the non-elderly disabled or ESRD (12.4% [95% CI: 9.6–15.3] vs. 2.1 [95% CI: 1.5–2.8] to 2.5 [95% CI: 1.6–3.5]). The leading reason for trouble accessing needed care among the non-elderly disabled or ESRD was attributable to affordability (59.6%).ConclusionsPolicymakers need to develop targeted approaches to improve access to care and satisfaction with care for the non-elderly with a disability or ESRD.     

Medicare beneficiary satisfaction with durable medical equipment suppliers

CMS has recently launched a series of initiatives to control Medicare spending on durable medical equipment (DME) and prosthetics, orthotics, and supplies (DMEPOS). An important question is how these initiatives will affect beneficiary satisfaction. Using survey data, we analyze Medicare beneficiary satisfaction with DMEPOS suppliers in two Florida counties. Our results show that beneficiaries are currently highly satisfied with their DMEPOS suppliers. Beneficiary satisfaction is positively related to rapid delivery, training, dependability, and frequency of service. Results of our analysis can be used as baseline estimates in evaluating CMS initiatives to reduce Medicare payments for DMEPOS.     

Access to Care for Rural Medicare Beneficiaries

This paper examines variations between urban and rural Medicare beneficiaries in three measures of access to care: self-reported access to care, satisfaction with care received and use of services. The assessment focuses on these measures and their relationship to adjacency to metropolitan areas. Comparisons are also provided for the relative effects of adjacency versus broader access barriers such as income. Data from the 1993 Medicare Current Beneficiary Survey are used. The analyses offer several new perspectives on access in rural areas. First, as perceived by respondents, rural residence does not indicate access problems; instead, Medicare beneficiaries in rural counties that are adjacent to urban areas and that have their own city of at least 10,000 people report higher levels of satisfaction and fewer self-reported access problems than do residents of urban counties. These results may stem either from differences in rural residents' expectations regarding access or willingness to accept appropriate substitutions. Preventive vaccination rates in rural areas are on par with or better than rates by beneficiaries in urban areas. The only services where utilization in rural areas was limited relative to urban areas were preventive cancer screening for women and dental care. Development of policies to address these specific service gaps may be warranted. Low income has a more pervasive and problematic relationship to self-reported access, satisfaction and utilization than does rural residence per se.     

Differences between generalists and mental health specialists in the psychiatric treatment of Medicare beneficiaries.

OBJECTIVE: To examine differences between the general medical and mental health specialty sectors in the expenditure and treatment patterns of aged and disabled Medicare beneficiaries with a physician diagnosis of psychiatric disorder. DATA SOURCES: Based on 1991-1993 Medicare Current Beneficiary Survey data, linked to the beneficiary's claims and area-level data on provider supply from the Area Resources File and the American Psychological Association. STUDY DESIGN: Outcomes examined included the number of psychiatric services received, psychiatric and total Medicare expenditures, the type of services received, whether or not the patient was hospitalized for a psychiatric disorder, the length of the psychiatric care episode, the intensity of service use, and satisfaction with care. We compared these outcomes for beneficiaries who did and did not receive mental health specialty services during the episode, using multiple regression analyses to adjust for observable population differences. We also performed sensitivity analyses using instrumental variables techniques to reduce the potential bias arising from unmeasured differences in patient case mix across sectors. PRINCIPAL FINDINGS: Relative to beneficiaries treated only in the general medical sector, those seen by a mental health specialist had longer episodes of care, were more likely to receive services specific to psychiatry, and had greater psychiatric and total expenditures. Among the elderly persons, the higher costs were due to a combination of longer episodes and greater intensity; among the persons who were disabled, they were due primarily to longer episodes. Some evidence was also found of higher satisfaction with care among the disabled individuals treated in the specialty sector. However, evidence of differences in psychiatric hospitalization rates was weaker. CONCLUSIONS: Mental health care provided to Medicare beneficiaries in the general medical sector does not appear to substitute perfectly for care provided in the specialty sector. Our study suggests that the treatment patterns in the specialty sector may be preferred by some patients; further, earlier findings indicate geographic barriers to obtaining specialty care. Thus, the matching of service use to clinical need among this vulnerable population may be inappropriate. The need for further research on outcomes is indicated.     

Impact of Medicare managed care market withdrawal on beneficiaries

The 2001 Survey of Involuntary Disenrollees was conducted to investigate the impact of Medicare+Choice (M+C) plan withdrawals on Medicare beneficiaries. Eighty-four percent of a total of 4,732 beneficiaries whose Medicare managed care (MMC) plan stopped serving them at the end of 2000 responded to the survey. Their responses indicated that the withdrawal of plans from Medicare affected beneficiaries in terms of concerns about getting and paying for care, increased payments for premiums and out-of-pocket costs, and changes in health care arrangements. Of particular concern were the impacts on those in vulnerable subgroups such as the disabled, less educated, and minorities.     

Disability profile and health care costs of Medicare beneficiaries under age sixty-five

Medicare has more than five million beneficiaries with disabilities who are under age sixty-five, and enrollment is rising rapidly. This paper presents a profile of nonelderly beneficiaries in fee-for-service Medicare by major disability category, excluding those with end-stage renal disease. The profile is based on Medicare Current Beneficiary Survey (MCBS) Cost and Use data for 1994-1996. We estimate Medicare costs by service type and health care costs by payer type, and we discuss implications for Medicare reform and related federal disability policy issues.     

Health insurance and health at age 65: implications for medical care spending on new Medicare beneficiaries

OBJECTIVES: To investigate the consequences of endogeneity bias on the estimated effect of having health insurance on health at age 63 or 64, just before most people qualify for Medicare, and to simulate the implications for total and public insurance (Medicare and Medicaid) spending on newly enrolled beneficiaries in their first years of Medicare coverage. DATA: The longitudinal Health and Retirement Survey of people who were 55-61 years old in 1992, followed through biannual surveys to age 63-64 or until 2000 (whichever came first), and those who were 66-70 years olds from the Medicare Current Beneficiary Surveys, 1992-1998. STUDY DESIGN: Instrumental variable (IV) estimation of a simultaneous equation model of insurance choice and health at age 63-64 as a function of baseline health and sociodemographic characteristics in 1992 and endogenous insurance coverage over the observation period. FINDINGS: Continuous insurance coverage is associated with significantly fewer deaths prior to age 65 and, among those who survive, a significant upward shift in the distribution of health states from fair and poor health with disabilities to good to excellent health. Treating insurance coverage as endogenous increases the magnitude of the estimated effect of having insurance on improved health prior to age 65. The medical spending simulations suggest that if the near-elderly had continuous insurance coverage, average annual medical spending per capita for new Medicare beneficiaries in their first few years of coverage would be slightly lower because of the improvement in health status. In addition, total Medicare and Medicaid spending for new beneficiaries over their first few years of coverage would be about the same or slightly lower, even though more people survive to age 65. CONCLUSIONS: Extending insurance coverage to all Americans between the ages of 55 and 64 would improve health (increase survival and shift people from good-fair-poor health to excellent-very good health) at age 65, and possibly reduce total short-term spending by Medicare and Medicaid for newly eligible Medicare beneficiaries, even though more people would enter the program because of increased survival.     

Hospital Choice of Rural Medicare Beneficiaries: Patient, Hospital Attributes, and the Patient–Physician Relationship

Objective. To examine how patient and hospital attributes and the patient–physician relationship influence hospital choice of rural Medicare beneficiaries.
Data Sources. Medicare Current Beneficiary Survey (MCBS), Health Care Financing Administration (HCFA) Provider of Services (POS) file, American Hospital Association (AHA) Annual Survey, and Medicare Hospital Service Area (HSA) files for 1994 and 1995.
Study Design. The study sample consisted of 1,702 hospitalizations of rural Medicare beneficiaries. McFadden's conditional logit model was used to analyze hospital choices of rural Medicare beneficiaries. The model included independent variables to control for patients' and hospitals' attributes and the distance to hospital alternatives.
Principal Findings. The empirical results show strong preferences of aged patients for closer hospitals and those of greater scale and service capacity. Patients with complex acute medical conditions and those with more resources were more likely to bypass their closest rural hospitals. Beneficiaries were more likely to bypass their closest rural hospital if they had no regular physician, had a shorter patient–physician tie, were dissatisfied with the availability of health care, and had a longer travel time to their physician's office.
Conclusions. The significant influences of patients' socioeconomic, health, and functional status, their satisfaction with and access to primary care, and their strong preferences for certain hospital attributes should inform federal program initiatives about the likely impacts of policy changes on hospital bypassing behavior.     

Longitudinal analysis of patient satisfaction among Medicare beneficiaries in different models of health maintenance organizations and fee-for-service care.

Based on a randomly selected nationwide sample of Medicare beneficiaries, this study analyzes changes in patient satisfaction over a one year period for beneficiaries receiving care in a variety of delivery settings: fee for service, group model HMO, staff model HMO, and Independent Practice Association model HMO. The findings reveal the patient satisfaction changes significantly over a one year period, from lower levels of satisfaction to higher levels of satisfaction. The primary explanation for this change in satisfaction is a decline in health status over the same one year period. Additional differences in satisfaction with care were observed for Medicare beneficiaries served by different types of delivery settings with varying degrees of utilization controls.     

Cost and outcomes of Medicare reimbursement for HMO preventive services

Medicare beneficiaries enrolled in a health maintenance organization (HMO) were randomized to a preventive services benefit package for 2 years or to usual care. At 24- and 48-month follow-ups, the treatment group had completed more advance directives, participated in more exercise, and consumed less dietary fat than the control group. Unexpectedly, more deaths occurred in the treatment group. Surviving treatment-group enrollees reported higher satisfaction with health, less decline in self-rated health status, and fewer depressive symptoms than surviving control participants. Despite these changes, the intervention did not yield lower cost per quality-adjusted life year in this historically prevention-oriented HMO.     

Pneumococcal pneumonia and influenza vaccination: access to and use by US Hispanic Medicare beneficiaries.

OBJECTIVES: This study examined differences between elderly Hispanic Medicare beneficiaries and other Medicare beneficiaries in the probability of being immunized for pneumococcal pneumonia and influenza. METHODS: We used the 1992 national Medicare Current Beneficiary Survey to evaluate influenza and pneumococcal pneumonia immunization rates. RESULTS: Elderly Hispanic Medicare beneficiaries were less likely than non-Hispanic White Medicare beneficiaries to have received an influenza vaccine in the past year or to have ever been immunized for pneumococcal pneumonia. Speaking Spanish was statistically significantly associated with influenza vaccination but not with pneumococcal pneumonia vaccination. Supplemental insurance status, HMO enrollment, having a usual source of care, and being satisfied with access to care were positively associated with immunization. CONCLUSIONS: Strategies that may improve immunization rates among elderly. Hispanics include reducing the inconvenience of being immunized, decreasing out-of-pocket costs, linking beneficiaries with providers, and educating Hispanic beneficiaries in Spanish about the benefits of vaccinations.     

Risk-adjustment system for the Medicare capitated ESRD program

Medicare is the principal payer for medical services for those in the U.S. population suffering from end-stage renal disease (ESRD). By law, beneficiaries diagnosed with ESRD may not subsequently enroll in Medicare Advantage (MA) plans, however, the potential benefits of managed care for this population have stimulated interest in changing the law and developing demonstration plans. We describe a new risk-adjustment system developed for Medicare to pay for ESRD beneficiaries in managed care plans. The model improves on current payment methodology by adjusting payments for treatment status and comorbidities.     

Risk differential between Medicare beneficiaries enrolled and not enrolled in an HMO.

Medicare provides incentive reimbursements to health maintenance organizations (HMOs) which enroll Medicare beneficiaries on a risk option and provide care at a lower cost than expected. The incentive reimbursements are tied to an actuarial calculation of Medicare Adjusted Average Per Capita Cost (AAPCC). The AAPCC adjusts for a number of variables which affect Medicare reimbursements and for which data are available: place of residence, age, sex, welfare status, and institutional status of beneficiaries. These factors account for much of the expected difference in health care reimbursements. They do not, however, account for differences in health status. Because of this, AAPCC calculations of expected costs may be too high if a selected group of beneficiaries is healthier than average, or too low if the selected group has a poorer health status than average. This case study examines the utilization behavior and reimbursement experience of a group of Medicare beneficiaries prior to their joining an HMO (during an open enrollment period) under a risk-sharing option. Their use was compared with a comparable Medicare population (the comparison group) to determine if their usage rates were greater, equal, or less than average. Results show that beneficiaries who joined during open enrollment had a rate of hospital inpatient use over 50 percent below the comparison group and a reimbursement rate for inpatient services 47 percent below the comparison group. These beneficiaries' use of Part B services also appears to be lower than the comparison group. These results must be interpreted with care. The information came from a single case study. Specific aspects of the open enrollment process, described in the paper, further limit the general liability of the findings. Also, while some studies of the same subject support the results, many others do not.     

Rural Medicare Beneficiaries'Use of Rural and Urban Hospitals

This report examines the use of rural and urban hospitals by rural Medicare beneficiaries. Many rural Medicare beneficiaries are treated in urban hospitals, primarily for specialized care that is not available locally. This study examines Medicare inpatient hospital discharge data for rural beneficiaries from fiscal year 1990 to fiscal year 1998. Utilization patterns by diagnosis-related group (DRG) are examined for fiscal year (FY) 1997. The percentage of rural beneficiaries treated in urban hospitals ranged from 30 percent to 36 percent during the study period. For the most frequently occurring DRGs among rural beneficiaries, which were those for routine conditions, treatment occurred predominantly in rural hospitals. The conditions most often responsible for rural beneficiaries' use of urban hospitals during this period reflected the need for coronary and other specialized surgical care. The stability of volume and case-mix throughout the study period underscores the viability of rural hospitals during a period of substantial change in the organization of health care provision.