Is there an advantage? Considerations for researchers studying the effects of the type of Medicare coverage.

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.

Using Address Data to Track Household Financial Burden of Disease.

The financial burden of illness cannot be correctly characterized without accounting for the impacts across healthy and sick members of a household. Currently, we have very few large, nationally representative data resources to facilitate such work. This paper describes ways to move the field forward through a novel application of address data.

The impact of Covid-19 on older workers' employment and Social Security spillovers.

The COVID-19 pandemic represents a major threat to health and economic well-being in the USA, especially for older and disabled workers, and may spill over onto Social Security. We use individual-level from the Current Population Survey, state-level monthly Social Security administrative data on disability benefit applications, and national-level monthly data on Social Security retirement benefit applications to assess the impact of the pandemic on older adults' employment and benefit claiming. State-level monthly Google Trends data are used as a leading indicator of future claiming in the population. We find that employment for older workers dropped substantially more than would have been predicted prior to the pandemic: employment for 50-61-year-olds was 5.7 pp (8.3 percent) lower, while employment for 62-70-year-olds was 3.9 pp (10.7 percent) lower. We find declines in labor force exit due to disability (4-5 percent), applications for disability insurance (15 percent), the average age of disability program applicants, and Google searches for disability (7 percent). We contrast with prior periods of economic downturn and explore potential mechanisms, finding evidence for both supply- and demand-side explanations. Supplementary information: The online version contains supplementary material available at 10.1007/s00148-022-00915-z.

Cancer Survivorship and Supportive Care Economics Research: Current Challenges and Next Steps.

BACKGROUND: Rapid growth in the number of cancer survivors raises numerous questions about health and economic outcomes among survivors along with their families, caregivers, and employers. Health economics theory and methods can contribute to many open questions to improve survivorship. METHODS: In this paper, we review key areas where more research is needed and describe strategies for improving data infrastructure, research funding, and capacity building to strengthen survivorship health economics research. CONCLUSIONS: Health economics has broadened an understanding of key supply- and demand-side factors that promote cancer survivorship. To ensure necessary research in survivorship health economics moving forward, we recommend dedicated funding, inclusion of health economics outcomes in primary data collection, and investments in secondary data sets.

Cancer's Lasting Financial Burden: Evidence From a Longitudinal Assessment.

BACKGROUND: The purpose of this study was to conduct a longitudinal analysis of out-of-pocket expenditure (OOPE) trajectories for the assessment of cancer's lasting financial impact. METHODS: We identified newly diagnosed cancer patients and constructed matched control group of noncancer participants from the 2002-2018 Health and Retirement Study. Outcomes included monthly OOPE for prescription drugs (RX-OOPE_MONTHLY) and OOPE for medical services other than drugs in the past 2 years (non-RX-OOPE_2YR), consumer debt, and new individual retirement account (IRA) withdrawals. Generalized linear models were used to compare OOPEs between cancer and matched control groups. Logistic regressions were used to compare household-level consumer debt or early IRA withdrawal. Subgroup analysis stratified patients by age, health status, and household income, with the low-income group stratified by Medicaid coverage. All statistical tests were 2-sided. RESULTS: The study cohort included 2022 cancer patients and 10 110 participants in the matched noncancer control group. Mean non-RX-OOPE_2YR of cancer patients was similar to that of participants in the matched control group before diagnosis but statistically significantly higher at diagnosis ($1157, P < .001), 2 ($511, P < .001) years, 4 ($360, P = .006) years, and 6 ($430, P = .01) years after diagnosis. A similar pattern was observed in RX-OOPE_MONTHLY. A statistically significantly higher proportion of cancer patients incurred consumer debt at diagnosis (34.5% vs 29.9%; P < .001) and 2 years after (32.5% vs 28.2%; P = .002). There was no statistically significant difference in new IRA withdrawals. Patients experienced lasting financial consequences following cancer diagnosis that were most pronounced among patients aged 65 years and older, in good-to-excellent health at baseline, and with low income, but without Medicaid coverage. CONCLUSIONS: Policies to reduce costs and expand insurance coverage options while reducing cost-sharing are needed.

A Causal Estimate of Long-Term Health Care Spending Attributable to Body Mass Index Among Adults.

While high body mass index (BMI) is believed to be a major driver of poor health, there is little evidence about whether it leads to higher health care spending. Understanding the causal contribution of BMI to health care spending is necessary to estimate the returns to investment in weight loss efforts. We exploit genetic variation in BMI across siblings as a natural experiment to estimate the impact of BMI on cumulative third party and out-of-pocket health care spending among adults using the Panel Study of Income Dynamics data from 1999 through 2011. We estimate a two-stage residual inclusion model with a generalized linear model. We find a $611.60 increase in cumulative insurer spending for each one-unit increase in BMI. This amounts to $130.49 in mean annual spending, and is two times higher than the non-causal estimate. We find no difference in out-of-pocket spending by BMI. These findings suggest that having a higher BMI in young/middle adulthood leads to significantly higher insurer health expenditures over the life course, which can help to inform public and private insurer policies on BMI reduction and control.

Are Transplant Centers That Meet Insurer Minimum Volume Requirements Better Quality?

A pervasive viewpoint in health care is that higher patient volume leads to better outcomes, implying that facility volume can be used to identify high-quality providers. Hundreds of studies documenting a positive correlation between hospital volume and patient survival have motivated payers to use arbitrary minimum volume standards for elective surgical procedures, though it is unknown whether these policies actually improve patient outcomes. Using an instrumental variables approach, we show that minimum volume requirements in kidney transplantation do not reduce posttransplant mortality. These results suggest minimum volume requirements are not a useful proxy measure for quality and that restricting the number of hospitals from which patients can receive care could reduce access to necessary health care services.

Financial Presentation of Alzheimer Disease and Related Dementias.

Importance: Alzheimer disease and related dementias (ADRD), currently incurable neurodegenerative diseases, can threaten patients' financial status owing to memory deficits and changes in risk perception. Deteriorating financial capabilities are among the earliest signs of cognitive decline, but the frequency and extent of adverse financial events before and after diagnosis have not been characterized. Objectives: To describe the financial presentation of ADRD using administrative credit data. Design, Setting, and Participants: This retrospective secondary data analysis of consumer credit report outcomes from 1999 to 2018 linked to Medicare claims data included 81 364 Medicare beneficiaries living in single-person households. Exposures: Occurrence of adverse financial events in those with vs without ADRD diagnosis and time of adverse financial event from ADRD diagnosis. Main Outcomes and Measures: Missed payments on credit accounts (30 or more days late) and subprime credit scores. Results: Overall, 54 062 (17 890 [33.1%] men; mean [SD] age, 74 [7.3] years) were never diagnosed with ADRD during the sample period and 27 302 had ADRD for at least 1 quarter of observation (8573 [31.4%] men; mean [SD] age, 79.4 [7.5] years). Single Medicare beneficiaries diagnosed with ADRD were more likely to miss payments on credit accounts as early as 6 years prior to diagnosis compared with demographically similar beneficiaries without ADRD (7.7% vs 7.3%; absolute difference, 0.4 percentage points [pp]; 95% CI, 0.07-0.70:) and to develop subprime credit scores 2.5 years prior to diagnosis (8.5% vs 8.1%; absolute difference, 0.38 pp; 95% CI, 0.04-0.72). By the quarter after diagnosis, patients with ADRD remained more likely to miss payments than similar beneficiaries who did not develop ADRD (7.9% vs 6.9%; absolute difference, 1.0 pp; 95% CI, 0.67-1.40) and more likely to have subprime credit scores than those without ADRD (8.2% vs 7.5%; absolute difference, 0.70 pp; 95% CI, 0.34-1.1). Adverse financial events were more common among patients with ADRD in lower-education census tracts. The patterns of adverse events associated with ADRD were unique compared with other medical conditions (eg, glaucoma, hip fracture). Conclusions and Relevance: Alzheimer disease and related dementias were associated with adverse financial events years prior to clinical diagnosis that become more prevalent after diagnosis and were most common in lower-education census tracts.

Marijuana legalization and disability claiming.

We study the effect of recent legalization of recreational marijuana use laws (RMLs) in the United States on new applications and allowances for Social Security Disability Insurance and Supplemental Security Income over the period 2001-2019. We combine administrative caseload data from the Social Security Administration with state policy changes using two-way fixed-effects methods. We find that RML adoption increases applications for both benefits. However, there is no change in allowances post-RML. We provide suggestive evidence that the observed changes in applications post-RML are driven by increases in marijuana misuse and selective migration, and decreases in unemployment.

Association Between Treatment by Fraud and Abuse Perpetrators and Health Outcomes Among Medicare Beneficiaries.

Importance: Fraud and abuse contribute to unnecessary spending in the Medicare program, and federal agencies have prioritized fund recovery and the exclusion of health care practitioners who violate policy. However, the human costs of fraud and abuse in terms of patient health are unknown. Objective: To assess whether Medicare beneficiaries' receipt of health care services from fraud and abuse perpetrators (FAPs) is associated with worse health outcomes. Design, Setting, and Participants: Retrospective cross-sectional study comparing mortality and emergency hospitalization rates of 8204 patients treated by an FAP with those among patients treated by a randomly selected non-FAP in 2013. Known FAPs were identified from the December 2018 List of Excluded Individuals/Entities (LEIE) published by the Office of the Inspector General in the Department of Health and Human Services. Patients were identified in a 5% sample of Medicare claims data and were enrolled in the Fee-for-Service program. Exposures: Treatment by a health care professional subsequently excluded from Medicare for fraud, patient harm, or a revoked license. Main Outcomes and Measures: All-cause mortality between 2013 and 2015 and 2013 emergency hospitalizations. Results: A total of 8204 Medicare beneficiaries in the study sample (mean [SD] age, 69.2 [14.2] years; 58.2% female, and 23.0% nonwhite) saw an FAP for the first time in 2013. Of these, 5054 (61.6%) were treated by fraud perpetrators, 1157 (14.1%) by patient harm perpetrators, and 1193 (24.3%) by revoked license perpetrators. Compared with 296 298 beneficiaries treated by non-FAPs (mean [SD] age, 71.1 [12.4] years; 58.6% female, and 16.5% nonwhite), beneficiaries exposed to an FAP were more likely to be eligible for both Medicare and Medicaid (34.7% [2845 of 8204] vs 21.9% [64 989 of 296 298]; P < .001) and more likely to be disabled at an age younger than 65 years (27.2% [2231 of 8204] vs 18.6% [55 168 of 296 298]; P < .001). All FAP exposures were associated with higher mortality and emergency hospitalization rates after risk adjustment and propensity score weighting: for mortality, exposures to fraud FAPs were associated with an increase of 4.58 percentage points (95% CI, 2.02-7.13; P < .001); to patient harm FAPs, with an increase of 3.34 percentage points (95% CI, 1.40-5.27; P = .001); and to revoked license FAPs, with an increase of 3.33 percentage points (95% CI, 1.58-5.09; P < .001). Increases were similar for emergency hospitalization rates: for fraud FAP exposures, 3.24 percentage points (95% CI, 0.01-6.46; P = .049); for patient harm FAP exposures, 9.34 percentage points (95% CI, 6.02-12.65; P < .001); and for revoked license FAP exposures, 9.28 percentage points (95% CI, 6.43-12.13; P < .001). Conclusions and Relevance: This study's findings suggest that receiving medical care from FAPs may be associated with significantly higher rates of all-cause mortality and emergency hospitalization after risk adjustment. Identifying and permanently removing FAPs from the Medicare program may be associated with improved beneficiary health in addition to financial savings.

Do Medicare Advantage Rebates Reduce Enrollees' Out-of-Pocket Spending?

The majority of Medicare Advantage (MA) plans receive payments that exceed their costs of providing basic Medicare benefits. There is controversy about whether these payments are passed on to the enrollees as supplemental benefits or are retained by plans. We used survey data on MA beneficiaries' actual out-of-pocket (OOP) spending linked to MA payment information to test whether higher plan payments and rebates lowered enrollee OOP spending. We used instrumental variables regression models to address concerns that plan payments and rebates may reflect anticipation of enrollees with particular health-spending profiles. We found that beneficiaries recovered only $0.65 of every $1.00 in payments exceeding fee-for-service spending through lower OOP spending but more than fully recovered the value of the rebates supporting supplemental benefits.

Lifetime Job Demands and Later Life Disability.

Occupational characteristics may improve or harm health later in life. Previous research, largely based on limited exposure periods, reached mixed conclusions. We use Health and Retirement Study data linked to the Department of Labor's O*Net job classification system to examine the relationship between lifetime exposure to occupational demands and disability later in life. We consistently find an association between non-routine cognitive demands and lower rates of Social Security Disability Insurance (SSDI) receipt and work-limiting health conditions. Routine manual demands are associated with moderately worse health and increased SSDI receipt in most lifetime specifications. These results are robust to various specifications of occupational demand measures and controlling for transitions between jobs of different levels of occupational intensity. We show that failure to account for job characteristic exposure early in a worker's tenure obscures the relationship between physical job demands and disability later in life. While characteristics of jobs worked at ages 30 and 55 are both predictive of later-life health outcomes, early-life job characteristics frequently dominate in models containing early and late exposures.

Medicare Beneficiaries' Exposure To Fraud And Abuse Perpetrators.

In the period 2012-15, 1,364 fraud and abuse perpetrators (FAPs) treated over 1.2 million Medicare beneficiaries and received more than $630 million in Medicare payments. Compared to beneficiaries treated by non-FAPs, beneficiaries exposed to FAPs were more likely to be nonwhite, dually enrolled in Medicaid, and disabled and younger than age sixty-five.

"It still affects our economic situation": long-term economic burden of breast cancer and lymphedema.

PURPOSE: Financial toxicity after breast cancer may be exacerbated by adverse treatment effects, like breast cancer-related lymphedema. As the first study of long-term out-of-pocket costs for breast cancer survivors in the USA with lymphedema, this mixed methods study compares out-of-pocket costs for breast cancer survivors with and without lymphedema. METHODS: In 2015, 129 breast cancer survivors from Pennsylvania and New Jersey completed surveys on demographics, economically burdensome events since cancer diagnosis, cancer treatment factors, insurance, and comorbidities; and prospective monthly out-of-pocket cost diaries over 12 months. Forty participants completed in-person semi-structured interviews. GLM regression predicted annual dollar amount estimates. RESULTS: 46.5% of participants had lymphedema. Mean age was 63 years (SD = 8). Average time since cancer diagnosis was 12 years (SD = 5). Over 98% had insurance. Annual adjusted health-related out-of-pocket costs excluding productivity losses totaled $2306 compared to $1090 (p = 0.006) for those without lymphedema, or including productivity losses, $3325 compared to $2792 (p = 0.55). Interviews suggested that the cascading nature of economic burden on long-term savings and work opportunities, and insufficiency of insurance to cover lymphedema-related needs drove cost differences. Higher costs delayed retirement, reduced employment, and increased inability to access lymphedema care. CONCLUSIONS: Long-term cancer survivors with lymphedema may face up to 112% higher out-of-pocket costs than those without lymphedema, which influences lymphedema management, and has lasting impact on savings and productivity. Findings reinforce the need for actions at policy, provider, and individual patient levels, to reduce lymphedema costs. Future work should explore patient-driven recommendations to reduce economic burden after cancer.

Medicare Advantage and Traditional Medicare Hospitalization Intensity and Readmissions.

Medicare Advantage plans have incentives and tools to optimize patient care. Therefore, Medicare Advantage hospitalizations may have lower cost and higher quality than similar traditional Medicare hospitalizations. We applied a coarsened matching approach to 2013 Healthcare Cost and Utilization Project hospital discharge data from 22 states to compare hospital cost, length of stay, and readmissions for Traditional Medicare and Medicare Advantage. We found that Medicare Advantage hospitalizations were substantially less expensive and shorter for mental health stays but costlier and longer for injury and surgical stays. We found little difference in the cost and length of medical stays and in readmission rates. One explanation is that Medicare Advantage plans use outpatient settings for many patients with behavioral health conditions and for injury and surgical patients with less complex health needs. Alternatively, the observed differences in behavioral health cost and length of stay may represent skimping on appropriate care.

Out-of-Pocket Spending and Financial Burden Among Medicare Beneficiaries With Cancer.

IMPORTANCE: Medicare beneficiaries with cancer are at risk for financial hardship given increasingly expensive cancer care and significant cost sharing by beneficiaries. OBJECTIVES: To measure out-of-pocket (OOP) costs incurred by Medicare beneficiaries with cancer and identify which factors and services contribute to high OOP costs. DESIGN, SETTING, AND PARTICIPANTS: We prospectively collected survey data from 18 166 community-dwelling Medicare beneficiaries, including 1409 individuals who were diagnosed with cancer during the study period, who participated in the January 1, 2002, to December 31, 2012, waves of the Health and Retirement Study, a nationally representative panel study of US residents older than 50 years. Data analysis was performed from July 1, 2014, to June 30, 2015. MAIN OUTCOMES AND MEASURES: Out-of-pocket medical spending and financial burden (OOP expenditures divided by total household income). RESULTS: Among the 1409 participants (median age, 73 years [interquartile range, 69-79 years]; 46.4% female and 53.6% male) diagnosed with cancer during the study period, the type of supplementary insurance was significantly associated with mean annual OOP costs incurred after a cancer diagnosis ($2116 among those insured by Medicaid, $2367 among those insured by the Veterans Health Administration, $5976 among those insured by a Medicare health maintenance organization, $5492 among those with employer-sponsored insurance, $5670 among those with Medigap insurance coverage, and $8115 among those insured by traditional fee-for-service Medicare but without supplemental insurance coverage). A new diagnosis of cancer or common chronic noncancer condition was associated with increased odds of incurring costs in the highest decile of OOP expenditures (cancer: adjusted odds ratio, 1.86; 95% CI, 1.55-2.23; P < .001; chronic noncancer condition: adjusted odds ratio, 1.82; 95% CI, 1.69-1.97; P < .001). Beneficiaries with a new cancer diagnosis and Medicare alone incurred OOP expenditures that were a mean of 23.7% of their household income; 10% of these beneficiaries incurred OOP expenditures that were 63.1% of their household income. Among the 10% of beneficiaries with cancer who incurred the highest OOP costs, hospitalization contributed to 41.6% of total OOP costs. CONCLUSIONS AND RELEVANCE: Medicare beneficiaries without supplemental insurance incur significant OOP costs following a diagnosis of cancer. Costs associated with hospitalization may be a primary contributor to these high OOP costs. Medicare reform proposals that restructure the benefit design for hospital-based services and incorporate an OOP maximum may help alleviate financial burden, as can interventions that reduce hospitalization in this population.

The impact of changing economic conditions on overweight risk among children in California from 2008 to 2012.

BACKGROUND: The recent economic recession represents an opportunity to test whether decreases in economic resources may have deleterious consequences on childhood overweight/obesity risk. METHODS: We investigated the association between indicators of changing macroeconomic conditions from 2008 to 2012 and overweight/obesity risk among school-aged children in California (n=1 741 712) using longitudinal anthropometric measurements. Multivariate regression, with individual and county fixed effects, was used to examine the effects of annual county-level unemployment and foreclosure rates on risk of child overweight/obesity, overall and among subgroups (race/ethnicity, sex, county-level median household income and county-level urban/rural status). RESULTS: From 2008 to 2012, ∼38% of children were overweight/obese and unemployment and foreclosure rates averaged 11% and 6.9%, respectively. A 1-percentage point (pp) increase in unemployment was associated with a 1.4 pp (95% CI 1.3 to 1.5) increase in overweight/obesity risk. Therefore, a child of average weight could expect a 14% increase in their body mass index z-score in association with a 1 pp increase in unemployment during the study period. We found some differences in the magnitude of the effects for unemployment among demographic subgroups, with the largest effects observed for unemployment among American Indians and Pacific Islanders. CONCLUSIONS: Comparing children to themselves over time, we provide evidence that increases in county-level unemployment are associated with increased overweight/obesity risk. Given that overweight among children with lower economic resources remains a challenge for public health, these findings highlight the importance of policy-level approaches, which aim to mitigate the impact of decreased resources as economic conditions change.