Primary Care Physicians In Medicare Advantage Were Less Costly, Provided Similar Quality Versus Regional Average.

The use of many services is lower in Medicare Advantage (MA) compared with traditional Medicare, generating cost savings for insurers, whereas the quality of ambulatory services is higher. This study examined the role of selective contracting with providers in achieving these outcomes, focusing on primary care physicians. Assessing primary care physician costliness based on the gap between observed and predicted costs for their traditional Medicare patients, we found that the average primary care physician in MA networks was $433 less costly per patient (2.9 percent of baseline) compared with the regional mean, with less costly primary care physicians included in more networks than more costly ones. Favorable selection of patients by MA primary care physicians contributed partially to this result. The quality measures of MA primary care physicians were similar to the regional mean. In contrast, primary care physicians excluded from all MA networks were $1,617 (13.8 percent) costlier than the regional mean, with lower quality. Primary care physicians in narrow networks were $212 (1.4 percent) less costly than those in wide networks, but their quality was slightly lower. These findings highlight the potential role of selective contracting in reducing costs in the MA program.

Tiered Physician Network Plans and Patient Choices of Specialist Physicians.

Importance: Tiered physician network (TPN) health plans sort physicians into tiers based on their cost and quality, and patients pay lower copays for visits with physicians in the lower-cost and better-quality tiers. When the plans are first introduced, they lead patients to seek care from higher-value physicians. Objectives: To examine whether TPNs are associated with patient choice of physician when the plans have been in place for 8 to 12 years and whether there are inequities in patient out-of-pocket costs associated with inequities in access to physicians in lower-copay tiers. Design, Setting, and Participants: This cross-sectional study comprising 46 645 physicians and 585 399 patients in TPNs, including 54 683 patients who had a new patient visit with a physician in a TPN, used health insurance claims data from a large employer purchaser from July 1, 2014, to June 30, 2019. Statistical analysis was performed from November 2020 to August 2023. Exposure: Evaluation and management visit with a physician in a TPN. Main Outcomes and Measures: Main outcomes were new patient market share per physician-carrier-zip code-year, distance from centroid of patient zip code to centroid of zip code of nearest low- or medium-copay physician, and mean TPN physician office visit copay per patient. A regression discontinuity design was used to estimate the association of a physician's tier ranking, and a difference-in-differences analysis was used to estimate the association of copayment differences across tiers with market share among new patients. Equity in access was measured by comparing travel distance to the nearest physician in a low-copay or medium-copay tier and mean copayments across patient incomes. Results: The main analysis sample included 46 645 physician-carrier-zip code-year observations, 9506 (20.4%) of which were in the low-copay tier, 31 798 (68.2%) in the medium-copay tier, and 5341 (11.5%) in the high-copay tier. The 54 683 new patients in the sample had a mean (SD) age of 46.4 (16.7) years and included 33 542 women (61.3%). There was no association of having a worse tier ranking (0.045 percentage points [95% CI, -0.058 to 0.148 percentage points]) or of copayment differences between tiers (0.001 percentage points [95% CI, -0.002 to 0.004 percentage points]) with physician market share among new patients. The patients with the lowest income paid slightly lower mean (SD) copayments for office visits to a TPN physician than the patients with high income ($48.08 [$16.42] vs $51.59 [$16.79], a 6.8% difference). Conclusions and Relevance: In this cross-sectional study of TPN health plans, there was no association between physician tier ranking and physician market share among any group of patients. These findings suggest there are limitations in TPNs' steering of patients toward high-value physicians. These plans were not associated with exacerbated health inequity in this setting.

Variation in tiered network health plan penetration and local provider market characteristics.

OBJECTIVE: To understand variation in enrollment in tiered network health plans (TNPs) and the local provider market characteristics associated with TNP penetration. DATA SOURCES AND STUDY SETTING: We used 2013-2017 Massachusetts three-digit ZIP code level employer-sponsored health insurance enrollment data, data on physician horizontal and vertical affiliations from the Massachusetts Provider Database, state hospital reports in 2013, 2015, and 2017, and the 2013-2017 Massachusetts All-Payer Claims database. STUDY DESIGN: Linear regressions were used to estimate associations between TNP and local provider market characteristics. DATA EXTRACTION: We constructed measures of TNP penetration and local provider market characteristics and linked these data using three-digit ZIP code. PRINCIPAL FINDINGS: TNP penetration was at least 10% in all employer market sectors and highest among jumbo sized employers. All state employee health plan enrollees were in a tiered network health plan. Among enrollees not in the state employee health plan, TNP penetration varied from 6.0% to 19.6% across three-digit ZIP codes in Massachusetts. TNP penetration was higher in areas with less horizontal and vertical physician market concentration. CONCLUSIONS: Market competition, rather than the absolute quantity of physicians in an area, is associated with TNP penetration.

Utilization, Steering, and Spending in Vertical Relationships Between Physicians and Health Systems.

Importance: Vertical relationships (eg, ownership or affiliations, including joint contracting) between physicians and health systems are increasing in the US. Objective: To analyze how vertical relationships between primary care physicians (PCPs) and large health systems are associated with changes in ambulatory and acute care utilization, referral patterns, readmissions, and total medical spending for commercially insured individuals. Design, Setting, and Participants: This case-control study with a repeated cross-section, stacked event design analyzed outcomes of patients whose attributed PCP entered a vertical relationship with a large health care system in 2015 or 2017 compared with patients whose attributed PCP was either never or always in a vertical relationship with a large health system from 2013 to 2017 in the state of Massachusetts. The sample consisted of commercially insured patients who met enrollment criteria and who were attributed to PCPs who were included in the Massachusetts Provider Database in 2013, 2015, and 2017 and for whom vertical relationships were measured. Enrollee and claims data were obtained from the 2013 to 2017 Massachusetts All-Payer Claims Database. Statistical analyses were conducted between January 5, 2021, and June 5, 2023. Exposure: Evaluation-and-management visit with attributed PCP in 2015 to 2017. Main Outcomes and Measures: Outcomes (which were measured per patient-year [ie, per patient per year from January to December] in this sample) were utilization (count of specialist physician visits, emergency department [ED] visits, and hospitalizations overall and within attributed PCP's health system), spending (total medical expenditures and use of high-price hospitals), and readmissions (readmission rate and use of hospitals with a low readmission rate). Results: The sample of 4 030 224 observations included 2 147 303 females (53.3%) and 1 881 921 males (46.7%) with a mean (SD) age of 35.07 (19.95) years. Vertical relationships between PCPs and large health systems were associated with an increase of 0.69 (95% CI, 0.34-1.04; P < .001) in specialist visits per patient-year, a 22.64% increase vs the comparison group mean of 3.06 visits, and a $356.67 (95% CI, $77.16-$636.18; P = .01) increase in total medical expenditures per patient-year, a 6.26% increase vs the comparison group mean of $5700.07. Within the health care system of the attributed PCPs, the number of specialist visits changed by 0.80 (95% CI, 0.56-1.05) per patient year (P < .001), a 29.38% increase vs the comparison group mean of 2.73 specialist visits per patient-year. The number of ED visits changed by 0.02 (95% CI, 0.01-0.03) per patient year (P = .001), a 14.19% increase over the comparison group mean of 0.15 ED visits per patient-year. The number of hospitalizations changed by 0.01 (95% CI, 0.00-0.01) per patient-year (P < .001), a 22.36% increase over the comparison group mean of 0.03 hospitalizations per patient-year. There were no differences in readmission outcomes. Conclusions: Results of this case-control study suggest that vertical relationships between PCPs and large health systems were associated with steering of patients into health systems and increased spending on patient care, but no difference in readmissions was found.

Changes in the Use of Long-Term Medications Following Incident Dementia Diagnosis.

Importance: Dementia is a life-altering diagnosis that may affect medication safety and goals for chronic disease management. Objective: To examine changes in medication use following an incident dementia diagnosis among community-dwelling older adults. Design, Setting, and Participants: In this cohort study of adults aged 67 years or older enrolled in traditional Medicare and Medicare Part D, patients with incident dementia diagnosed between January 2012 and December 2018 were matched to control patients based on demographics, geographic location, and baseline medication count. The index date was defined as the date of first dementia diagnosis or, for controls, the date of the closest office visit. Data were analyzed from August 2021 to June 2023. Exposure: Incident dementia diagnosis. Main Outcomes and Measures: The main outcomes were overall medication counts and use of cardiometabolic, central nervous system (CNS)-active, and anticholinergic medications. A comparative time-series analysis was conducted to examine quarterly changes in medication use in the year before through the year following the index date. Results: The study included 266 675 adults with incident dementia and 266 675 control adults; in both groups, 65.1% were aged 80 years or older (mean [SD] age, 82.2 [7.1] years) and 67.8% were female. At baseline, patients with incident dementia were more likely than controls to use CNS-active medications (54.32% vs 48.39%) and anticholinergic medications (17.79% vs 15.96%) and less likely to use most cardiometabolic medications (eg, diabetes medications, 31.19% vs 36.45%). Immediately following the index date, the cohort with dementia had a greater increase in mean number of medications used (0.41 vs -0.06; difference, 0.46 [95% CI, 0.27-0.66]) and in the proportion of patients using CNS-active medications (absolute change, 3.44% vs 0.79%; difference, 2.65% [95% CI, 0.85%-4.45%]) owing to an increased use of antipsychotics, antidepressants, and antiepileptics. The cohort with dementia also had a modestly greater decline in use of anticholinergic medications (quarterly change in use, -0.53% vs -0.21%; difference, -0.32% [95% CI, -0.55% to -0.08%]) and most cardiometabolic medications (eg, quarterly change in antihypertensive use: -0.84% vs -0.40%; difference, -0.44% [95% CI, -0.64% to -0.25%]). One year after diagnosis, 75.2% of the cohort with dementia were using 5 or more medications (2.8% increase). Conclusions and Relevance: In this cohort study of Medicare Part D beneficiaries, following an incident dementia diagnosis, patients were more likely to initiate CNS-active medications and modestly more likely to discontinue cardiometabolic and anticholinergic medications compared with the control group. These findings suggest missed opportunities to reduce burdensome polypharmacy by deprescribing long-term medications with high safety risks or limited likelihood of benefit or that may be associated with impaired cognition.

Pricing regulations in individual health insurance: Evidence from Medigap.

I compare two pricing regulations that protect those with health conditions-"community rating," which requires insurers to charge uniform premiums, and "guaranteed renewal," which requires insurers to increase future premiums uniformly. Using individual-level Medigap data from 2006-2010, I compare individuals within 25 miles of borders between 3 community rating and 6 guaranteed renewal states. Relative to guaranteed renewal, community rating (with guaranteed issue) leads to a decrease in Medigap enrollment of 9.70 pp (29.7%), or 26.8-33.7% for low-spending conditions (diabetes, heart disease) and 21.9-29.9% for high-spending conditions (cancer, kidney disease); an increase in annual Medigap premiums of $276 (10.1%); a decrease in the likelihood of an earlier purchase of 7.99 pp (50.3%); and an increase in purchase delay of 1.08 years (17.0%).

Differences In Use Of Services And Quality Of Care In Medicare Advantage And Traditional Medicare, 2010 And 2017.

Medicare Advantage (MA) enrollment growth could make it difficult for MA plans to maintain their track record of limiting discretionary utilization while delivering higher-quality care than traditional Medicare. We compared quality and utilization measures in Medicare Advantage and traditional Medicare in 2010 and 2017. Clinical quality performance was higher in MA health maintenance organizations (HMOs) and preferred provider organizations (PPOs) than in traditional Medicare for almost all measures in both years. MA HMOs outperformed traditional Medicare on all measures in 2017. MA HMOs' performance on nearly all seven patient-reported quality measures improved, and MA HMOs outperformed traditional Medicare on five of those measures in 2017. MA PPOs performed the same as or better than traditional Medicare on all but one patient-reported quality measure in 2010 and 2017. The number of emergency department visits was 30 percent lower, the number of elective hip and knee replacements was approximately 10 percent lower, and the number of back surgeries was almost 30 percent lower in MA HMOs than in traditional Medicare in 2017. Utilization trends were similar in MA PPOs, but differences from traditional Medicare were narrower. Despite increased enrollment, overall utilization remains lower in Medicare Advantage than in traditional Medicare, whereas quality performance is the same or higher.

Association of Medicare Advantage vs Traditional Medicare With 30-Day Mortality Among Patients With Acute Myocardial Infarction.

Importance: Medicare Advantage health plans covered 37% of beneficiaries in 2018, and coverage increased to 48% in 2022. Whether Medicare Advantage plans provide similar care for patients presenting with specific clinical conditions is unknown. Objective: To compare 30-day mortality and treatment for Medicare Advantage and traditional Medicare patients presenting with acute myocardial infarction (MI) from 2009 to 2018. Design, Setting, and Participants: Retrospective cohort study that included 557 309 participants with ST-segment elevation [acute] MI (STEMI) and 1 670 193 with non-ST-segment elevation [acute] MI (NSTEMI) presenting to US hospitals from 2009-2018 (date of final follow up, December 31, 2019). Exposures: Enrollment in Medicare Advantage vs traditional Medicare. Main Outcomes and Measures: The primary outcome was adjusted 30-day mortality. Secondary outcomes included age- and sex-adjusted rates of procedure use (catheterization, revascularization), postdischarge medication prescriptions and adherence, and measures of health system performance (intensive care unit [ICU] admission and 30-day readmissions). Results: The study included a total of 2 227 502 participants, and the mean age in 2018 ranged from 76.9 years (Medicare Advantage STEMI) to 79.3 years (traditional Medicare NSTEMI), with similar proportions of female patients in Medicare Advantage and traditional Medicare (41.4% vs 41.9% for STEMI in 2018). Enrollment in Medicare Advantage vs traditional Medicare was associated with significantly lower adjusted 30-day mortality rates in 2009 (19.1% vs 20.6% for STEMI; difference, -1.5 percentage points [95% CI, -2.2 to -0.7] and 12.0% vs 12.5% for NSTEMI; difference, -0.5 percentage points [95% CI, -0.9% to -0.1%]). By 2018, mortality had declined in all groups, and there were no longer statically significant differences between Medicare Advantage (17.7%) and traditional Medicare (17.8%) for STEMI (difference, 0.0 percentage points [95% CI, -0.7 to 0.6]) or between Medicare Advantage (10.9%) and traditional Medicare (11.1%) for NSTEMI (difference, -0.2 percentage points [95% CI, -0.4 to 0.1]). By 2018, there was no statistically significant difference in standardized 90-day revascularization rates between Medicare Advantage and traditional Medicare. Rates of guideline-recommended medication prescriptions were significantly higher in Medicare Advantage (91.7%) vs traditional Medicare patients (89.0%) who received a statin prescription (difference, 2.7 percentage points [95% CI, 1.2 to 4.2] for 2018 STEMI). Medicare Advantage patients were significantly less likely to be admitted to an ICU than traditional Medicare patients (for 2018 STEMI, 50.3% vs 51.2%; difference, -0.9 percentage points [95% CI, -1.8 to 0.0]) and significantly more likely to be discharged to home rather than to a postacute facility (for 2018 STEMI, 71.5% vs 70.2%; difference, 1.3 percentage points [95% CI, 0.5 to 2.1]). Adjusted 30-day readmission rates were consistently lower in Medicare Advantage than in traditional Medicare (for 2009 STEMI, 13.8% vs 15.2%; difference, -1.3 percentage points [95% CI, -2.0 to -0.6]; and for 2018 STEMI, 11.2% vs 11.9%; difference, 0.6 percentage points [95% CI, -1.5 to 0.0]). Conclusions and Relevance: Among Medicare beneficiaries with acute MI, enrollment in Medicare Advantage, compared with traditional Medicare, was significantly associated with modestly lower rates of 30-day mortality in 2009, and the difference was no longer statistically significant by 2018. These findings, considered with other outcomes, may provide insight into differences in treatment and outcomes by Medicare insurance type.

Price Effects Of Vertical Integration And Joint Contracting Between Physicians And Hospitals In Massachusetts.

Vertical integration in health care has recently garnered scrutiny by antitrust authorities and state regulators. We examined trends, geographic variation, and price effects of vertical integration and joint contracting between physicians and hospitals, using physician affiliations and all-payer claims data from Massachusetts from the period 2013-17. Vertical integration and joint contracting with small and medium health systems rose from 19.5 percent in 2013 to 32.8 percent in 2017 for primary care physicians and from 26.1 percent to 37.8 percent for specialists. Vertical integration and joint contracting with large health systems slightly declined, whereas geographic variation in these physician affiliations rose. We found that vertical integration and joint contracting led to price increases from 2013 to 2017, from 2.1 percent to 12.0 percent for primary care physicians and from 0.7 percent to 6.0 percent for specialists, with the greatest increases seen in large health systems. These findings can inform policy makers seeking to limit growth in health care prices.

Impacts of early ACA Medicaid expansions on physician participation.

OBJECTIVE: To quantify impacts of early Affordable Care Act (ACA) Medicaid expansions on Medicaid participation for primary care physicians. DATA SOURCES: The study uses secondary Medicaid Analytic eXtract (MAX) data from the United States for 2009-2012, as well as secondary National Plan and Provider Enumeration System (NPPES) data from the United States for 2015. STUDY DESIGN: The study uses a quasi-experimental difference-in-differences study design where the policy change is Medicaid expansion in six states that adopted early ACA Medicaid expansions during 2010 and 2011: California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington. The key outcome variables are five monthly measures of physician participation: the number of Medicaid visits, the number of Medicaid patients, seeing at least 1 Medicaid patient, seeing at least 25 Medicaid patients, and seeing at least 50 Medicaid patients. DATA COLLECTION/EXTRACTION METHODS: The sample consists of all physicians who were active between 2005 and 2015, according to the NPPES. PRINCIPAL FINDINGS: For primary care physicians, Medicaid expansion led to a 29% increase in Medicaid visits (5.88 per month; 95% CI: 2.49-9.27), a 29% increase in Medicaid patients (4.59 per month; 95% CI: 2.16-7.02), and did not affect the probability of any Medicaid participation. Medicaid expansion also led to a 22% increase in the probability of seeing at least 25 Medicaid patients per month (4.58 percentage points; 95% CI: 1.27-7.89) and a 31% increase in the probability of seeing at least 50 Medicaid patients per month (2.99 percentage points; 95% CI: 0.99-4.99). CONCLUSIONS: Early ACA Medicaid expansions led to increased Medicaid visits for primary care physicians but did not affect the probability of any Medicaid participation. Primary care physicians who had previously served Medicaid patients responded to early ACA Medicaid expansions by serving substantially more Medicaid patients.

Health Care Spending and Utilization in Public and Private Medicare.

We compare healthcare spending in public and private Medicare using newly available claims data from Medicare Advantage (MA) insurers. MA insurer revenues are 30 percent higher than their healthcare spending. Adjusting for enrollee mix, healthcare spending per enrollee in MA is 9 to 30 percent lower than in traditional Medicare (TM), depending on the way we define "comparable" enrollees. Spending differences primarily reflect differences in healthcare utilization, with similar reductions for "high value" and "low value" care, rather than healthcare prices. We present evidence consistent with MA plans encouraging substitution to less expensive care and engaging in utilization management. (JEL H11, H42, H51, I11, I13).

Financial Literacy and Financial Sophistication in the Older Population.

Using a special-purpose module implemented in the Health and Retirement Study, we evaluate financial sophistication in the American population over the age of 50. We combine several financial literacy questions into an overall index to highlight which questions best capture financial sophistication and examine the sensitivity of financial literacy responses to framing effects. Results show that many older respondents are not financially sophisticated: they fail to grasp essential aspects of risk diversification, asset valuation, portfolio choice, and investment fees. Subgroups with notable deficits include women, the least educated, non-Whites, and those over age 75. In view of the fact that retirees increasingly must take on responsibility for their own retirement security, such meager levels of knowledge have potentially serious and negative implications.