Effectiveness of Medicare cost-sharing elimination for Cancer screening on utilization.

BACKGROUND: The Patient Protection and Affordable Care Act (ACA) eliminated the cost-sharing requirement for several preventive cancer screenings. This study examined the cancer screening utilization of mammogram, Pap smear and colonoscopy in Medicare fee-for-service (FFS) under the ACA. METHODS: The primary data were the 2007-2013 Medicare Current Beneficiary Survey linked to FFS claims. The effect of the cost-sharing removal on the probability of receiving a preventive cancer screening test was estimated using a logistic regression, separately for each screening test, adjusting for the complex survey design. The model was also separately estimated for different socioeconomic and race/ethnic groups. The study sample included beneficiaries with Part B coverage for the entire calendar year, excluding beneficiaries in Medicaid or Medicare Advantage plans. Beneficiaries with a claims-documented or self-reported history of targeted cancers, who were likely to have diagnostic tests or have surveillance screenings were excluded. The screening measures were constructed separately following Medicare coverage and U.S. Preventive Services Task Force (USPSTF) recommendations. We measured the screening utilization outcome drawing from claims data, as well as using the self-reported survey data. RESULTS: After the cost-sharing removal policy, we found no statistically significant difference in a beneficiary's probability of receiving a colonoscopy (transition period: OR = 1.08, 95% CI = 0.90-1.29; post-policy period: OR = 1.08, 95% CI = 0.83-1.42), a mammogram (transition period: OR = 1.03, 95% CI = 0.91-1.17; post-policy period: OR = 1.07, 95% CI = 0.88-1.30), or a biennial Pap smear (transition period: OR = 0.87, 95% CI = 0.69-1.09; post-policy period: OR = 0.72, 95% CI = 0.51-1.03) in claims-based measures following Medicare coverage. Similarly, we found null effects of the policy change on utilization of colonoscopy among enrollees 50-75 years old, biennial mammograms by women 50-74, and triennial Pap smear tests among women 21-65 in claims-based measures according to USPSTF. The findings from survey-based measures were consistent with the estimates from claims-based measures, except that the use of Pap smear declined since 2011. Further, the policy change did not increase utilization in patients with disadvantaged socioeconomic characteristics. Yet the disparate patterns in adjusted screening rates by socioeconomic status and race/ethnicity persisted over time. CONCLUSIONS: Removing out-of-pocket costs for screenings did not provide enough incentives to increase the screening rates among Medicare beneficiaries.

Socioeconomic Differences in Use of Low-Value Cancer Screenings and Distributional Effects in Medicare.

OBJECTIVE: Consuming low-value health care not only highlights inefficient resource use but also brings an important concern regarding the economics of disparities. We identify the relation of socioeconomic characteristics to the use of low-value cancer screenings in Medicare fee-for-service (FFS) settings, and quantify the amount subsidized from nonusers and taxpayers to users of these screenings. DATA SOURCES: 2007-2013 Medicare Current Beneficiary Survey, Medicare FFS claims, and the Area Health Resource Files. STUDY DESIGN: Our sample included enrollees in FFS Part B for the entire calendar year. We excluded beneficiaries with a claims-documented or self-reported history of targeted cancers, or those enrolled in Medicaid or Medicare Advantage plans. We identified use of low-value Pap smears, mammograms, and prostate-specific antigen tests based on established algorithms, and estimated a logistic model with year dummies separately for each test. DATA COLLECTION/EXTRACTION METHODS: Secondary data analyses. PRINCIPAL FINDINGS: We found a statistically significant positive association between privileged socioeconomic characteristics and use of low-value screenings. Having higher income and supplemental private insurance strongly predicted more net subsidies from Medicare. CONCLUSIONS: FFS enrollees who are better off in terms of sociodemographic characteristics receive greater subsidies from taxpayers for using low-value cancer screenings.

The Price Elasticity of Specialty Drug Use: Evidence from Cancer Patients in Medicare Part D.

Specialty drugs can bring substantial benefits to patients with debilitating conditions, such as cancer, but their costs are very high. Insurers/payers have increased patient cost-sharing for specialty drugs to manage specialty drug spending. We utilized Medicare Part D plan formulary data to create the initial price (cost-sharing in the initial coverage phase in Part D), and estimated the total demand (both on- and off-label uses) for specialty cancer drugs among elderly Medicare Part D enrollees with no low-income subsidies (non-LIS) as a function of the initial price. We corrected for potential endogeneity associated with plan choice by instrumenting the initial price of specialty cancer drugs with the initial prices of specialty drugs in unrelated classes. We report three findings. First, we found that elderly non-LIS beneficiaries with cancer were less likely to use a Part D specialty cancer drug when the initial price was high: the overall price elasticity of specialty cancer drug spending ranged between -0.72 and -0.75. Second, the price effect in Part D specialty cancer drug use was not significant among newly diagnosed patients. Finally, we found that use of Part B-covered cancer drugs was not responsive to the Part D specialty cancer drug price. As the demand for costly specialty drugs grows, it will be important to identify clinical circumstances where specialty drugs can be valuable and ensure access to high-value treatments.

The Effect of Publicized Quality Information on Home Health Agency Choice.

We examine consumers' use of publicized quality information in Medicare home health care markets, where consumer cost sharing and travel costs are absent. We report two findings. First, agencies with high quality scores are more likely to be preferred by consumers after the introduction of a public reporting program than before. Second, consumers' use of publicized quality information differs by patient group. Community-based patients have slightly larger responses to public reporting than hospital-discharged patients. Patients with functional limitations at the start of their care, at least among hospital-discharged patients, have a larger response to the reported functional outcome measure than those without functional limitations. In all cases of significant marginal effects, magnitudes are small. We conclude that the current public reporting approach is unlikely to have critical impacts on home health agency choice. Identifying and releasing quality information that is meaningful to consumers may help increase consumers' use of public reports.

Coverage for hepatitis C drugs in Medicare Part D.

OBJECTIVES: The recent arrival of new hepatitis C virus (HCV) drugs has brought fiscal pressures onto Medicare Part D; spending on HCV drugs in Part D jumped from $283 million in 2013 to $4.5 billion in 2014. We examined the current benefit designs for HCV drugs in Part D plans and analyzed patients' financial burden for those drugs. STUDY DESIGN: A cross-sectional analysis of CMS' July 2015 Part D Plan Formulary File and the Wolters Kluwer Health Medi-Span Electronic Drug File v.2. METHODS: We analyzed the type and amount of cost sharing for HCV drugs and the extent to which plans apply utilization management tools. We then estimated total out-of-pocket spending for beneficiaries to complete a course of treatment. RESULTS: All Part D plans covered at least 1 recently introduced HCV drug, as of July 2015. Nearly all plans charged relatively high coinsurance and required prior authorization for new HCV drugs. For enrollees with no subsidy, the mean out-of-pocket spending needed to complete a course of treatment is substantial, ranging from $6297 to $10,889. For enrollees with a low-income subsidy, out-of-pocket spending varies between $10.80 and $1191. CONCLUSIONS: Under the current Part D benefits, HCV drug users with no subsidy face sizable financial burdens, even with catastrophic coverage and the recent in-gap discount for brand name drugs. As baby boomers-the group most likely to have HCV-join Medicare, efforts should be made to ensure patient access to these needed drugs.

New entrants' practice patterns in Medicare home health care after the prospective payment system revision in 2008.

BACKGROUND: Medicare home health care spending increased under the prospective payment system (PPS) that was introduced specifically to control the rising spending. To explain this unexpected spending rise, we focused on new home health agencies that entered the market under the PPS. The high profit margins under the PPS attracted many new agencies to the market partially due to home health care's unique feature of low entry costs. We examined whether new entrants were more likely to adopt the practice patterns leading to higher profit margins than incumbent agencies that had been operating in the market before the PPS. METHODS: Using 2008 to 2010 Medicare Home Health Claims and Provider of Services File, we estimated regressions of agencies' practice patterns controlling for agency and patient characteristics. RESULTS: We found that new entrants were more likely than incumbents to adopt practice patterns leading to high profit margins. They were more likely to target the 14th and 20th therapy visit where marginal revenue is relatively greater than that of other number of visits. Under the payment system that compensates extra therapy visits but not for other types of visits, entrants were also more likely to provide therapy visits, but less likely to provide medical social service visits. CONCLUSIONS: Given the high entry rates of agencies under the PPS, distinct practice patterns among entrants explain the drastic home health spending increase under the PPS. Heterogeneity in agencies' practice patterns also suggests an opportunity to improve efficiency in the Medicare home health care market.