Research
Published Articles
With Erin Duffy, Josephine Rohrer, Adam Biener
Health Services Research
Objective: To test whether enrolling in traditional Medicare (TM) or Medicare Advantage (MA) at age 65 reduces mental healthcare utilization among individuals with mental health symptoms and low or moderate family incomes.
Study Setting and Design: We employ a fuzzy regression discontinuity design, comparing the likelihood of having an outpatient mental health visit or a psychotropic drug fill among individuals younger than or older than the age 65 Medicare eligibility threshold.
Data Sources and Analytic Sample: We analyze 2014–2021 Medical Expenditure Panel Survey data. Our primary sample is restricted to individuals with probable mental health symptoms as indicated by their score on the Kessler K6 psychological distress scale (K6) and Patient Health Questionnaire-2 instrument (PHQ-2) and who have incomes less than 400% of the federal poverty level.
Principal Findings: Among individuals with probable mental health symptoms and low or moderate incomes, enrolling in Medicare (combining the effect of MA and TM) is associated with a 24.9 percentage point reduction (95% CI −49.1 to −0.8; p = 0.043) in the likelihood of having any type of outpatient mental health visit and a 31.3 percentage point reduction (95% CI −54.2 to −8.4; p = 0.008) in the likelihood of having a prescription drug fill for a psychotropic drug. Effects of MA and TM on mental healthcare utilization are not statistically different from each other. We observe no impact of enrolling in Medicare on the likelihood of having a visit to a primary care provider, having a visit to a non-mental healthcare specialist, or having a fill for a prescribed non-psychotropic drug.
Conclusions: Enrolling in Medicare is associated with a reduction in the use of mental healthcare among individuals with probable mental health symptoms and low or moderate family incomes. Our findings suggest that the program poses access barriers specific to mental healthcare.
Out-Of-Network Utilization and Plan Selection Among Medicare Advantage Cost Plan Enrollees
With Erin Trish
Health Services Research
Objective: To understand how Medicare Advantage (MA) networks impact utilization patterns and plan choices, using the 2019 discontinuation of MA 1876 Cost plans as a natural experiment.
Study Setting and Design: We study 1876 Cost plans, MA plans for which out-of-network care is covered through traditional Medicare (TM) and many of which CMS discontinued in 2019. We characterize the proportion of Cost plan enrollees who utilized out-of-network care in 2018 from different types of medical specialties. We then study how enrollees in discontinued plans selected into new plans in 2019. We use regression analysis to characterize whether higher risk enrollees selected into TM at higher rates.
Data Sources and Analytic Sample: We identify discontinued plans using public MA plan data. We employ administrative Medicare enrollment and TM claims data to identify 2018 enrollees of discontinued plans, their 2018 out-of-network utilization, and their subsequent 2019 enrollment decisions.
Principal Findings: Among Cost plan enrollees, 69% utilized non-emergency room related care out of network in 2018. Out-of-network utilization was distributed across several types of specialties: 43% of Cost plan enrollees had at least one out-of-network claim with a primary care physician and over 20% had a claim with a medical specialist, surgical specialist, or nurse practitioner. We find evidence of adverse selection among enrollees of discontinued Cost plans in 2019. Conditional on one's 2018 Cost plan and county of residence, a standard deviation increase in risk score was on average associated with a 26.35% (95% CI, 25.57%–27.12%) increased likelihood of enrolling in TM.
Conclusion: The high rate of out-of-network utilization suggests that MA enrollees value access to care outside of standard MA networks. Subsequent selection patterns indicate that preferences for broader networks and subsequent enrollment in TM is highest among higher risk enrollees, suggesting limited networks may induce extensive margin selection.
How Specialized Are Special Needs Plans? Evidence From Provider Networks
with Rachel Wu and Mark Meiselbach
Journal of Medical Care Research and Review
Enrollment in Medicare Advantage (MA) Dual-Eligible Special Needs Plans (D-SNPs) among individuals dually eligible for Medicare and Medicaid has more than tripled over the past decade. Little is known about whether D-SNP plan design differs from standard MA plan design nor whether this design reflects the needs of dual-eligible enrollees. We characterize the degree to which D-SNPs specialize in an important plan design dimension—provider networks. We find that in 2022, 46% of D-SNPs offer networks that are distinct from the insurer’s standard MA plan networks. Compared with D-SNP networks that are shared with standard MA plans, specialized D-SNP networks include more psychiatrists, Ob/Gyn’s, and neurologists, providers that specialize in treating conditions more common among dually eligible enrollees. Network specialization is more common among insurers participating in the local Medicaid market and less common in provider shortage areas, suggesting investment in Medicaid and reduced provider negotiation costs may facilitate specialization.
Recent Cohorts Aging Into Medicare Use More Counseling and Psychotherapy Than Past Cohorts
with Erin Duffy and Adam Biener
American Journal of Managed Care
Despite recent policy interest in improving access to mental health care in Medicare, little is known about how demand for care will change among the Medicare population as newer cohorts age into the program. We documented the growing rate of counseling and psychotherapy use in the decade prior to turning age 65 years among subsequent cohorts aging into Medicare. We characterized how this growth varied across demographic groups, income levels, and mental and physical health status. We present trends using data from the 2002-2017 Medical Expenditure Panel Survey Household Component. We categorized individuals into 5-year Medicare entry cohorts based on the year they turned age 65 years. Our outcome was an indicator for having a visit for counseling or psychotherapy in a given year. Employing a probit regression, we characterized visit rates across 5-year cohorts, presenting both unadjusted and covariate-adjusted results. We ran stratified regressions by subpopulations. Our sample included 54,666 individuals aged 55 to 64 years, weighted to be nationally representative. The cohort aging into Medicare between 2021 and 2025 was 88% (95% CI, 57%-119%) more likely to have a counseling or psychotherapy visit between the ages of 55 and 64 years compared with the cohort that gained eligibility for Medicare between 2006 and 2010 at the same age. Growth in utilization was pervasive across many subpopulations. Our findings suggest that more recent cohorts aging into Medicare seek significantly more counseling and psychotherapy than prior cohorts. This increased utilization is pervasive across subpopulations, suggesting that plans must prepare to accommodate the needs of new Medicare entrants.
Growing divergence between Medicare Advantage plan bids and payments to plans
with Erin Trish
Health Affairs Scholar
As the Medicare Advantage (MA) program grows in enrollment and costs, there has been increasing concern that federal payments to MA plans exceed necessary levels. Estimates suggest that, in 2023, MA plans were paid up to 6% more per enrollee than would have been spent had that beneficiary instead enrolled in traditional Medicare (TM). We evaluated the factors driving this overpayment, characterizing trends in MA benchmarks, bids, and total payments from pre-Affordable Care Act (pre-ACA) levels through 2023. We found that, despite an overall decrease in risk-adjusted bids relative to average risk-adjusted TM enrollee costs, total payments to plans have modestly increased since 2015. Decomposing these trends into various factors in the MA payment formula, we found that divergent trends in benchmarks and bids are, in part, due to the increasing influence of payment adjustments, such as quartile spending adjustments, quality bonus payments, and risk adjustment. Our results suggest that current payment rules have contributed to overpayments and policy reform may be necessary.
Fostering Flexibility: How Medicare Advantage Potentially Accelerated Telehealth Benefits
with Lisa M. Grabert, Erin Trish and Kathryn L. Wagner
Inquiry
In 2018, the US Congress enacted a policy permitting Medicare Advantage (MA) plans to cover telehealth services in a beneficiary’s home and through audio-only means as part of the basic benefit package of services, where prior to the policy change such benefits were only allowed to be covered as a supplemental benefit. MA plans were afforded 2 years of lead time for strategizing, negotiating, and capital investment prior to the start date (January 1, 2020) of the new coverage option. Our data analysis found basic benefit telehealth was offered by plans comprising 71% of enrollment in 2020 and increased to 95% in 2021. At the same time, remote access telehealth was offered as a supplemental benefit for 69% of enrollees in 2020, a decrease of 23% compared to 2019. These efforts by MA plans may have enabled traditional Medicare (TM) to leverage an existing telehealth infrastructure as a solution to the access issues created by public health policies requiring sheltering in place and social distancing during the COVID-19 pandemic. The success of this MA policy prompts consideration of additional flexibility beyond the standard basic benefit package, and whether such benefits reduce costs while improving access and/or outcomes in the context of a managed care environment like MA. Subject to oversight, such flexibility could potentially improve value in MA, and facilitate future changes in TM, as appropriate.
Physician Responses to Medicare Reimbursement Rates
with Aileen Devlin
Journal of Health Economics
This paper investigates how office-based physicians respond to Medicare reimbursement changes. Using variation from an Affordable Care Act policy that increased reimbursements for office-based care in four states, we use a triple difference analysis, comparing physicians with higher and lower reimbursement changes in treated states to similar physicians in untreated states. We find two mechanisms through which physicians respond. First, the reimbursement change affected integration—physicians with larger increases in office-based reimbursement were less likely to vertically integrate with hospitals and more likely to continue providing office-based care than physicians with smaller reimbursement increases. Second, we find some evidence that physicians who continued practicing in an office setting increased the volume of services provided.
Trends in the Level and Composition of Supplemental Benefits in Medicare Advantage
with Erin Trish
Health Affairs Scholar
Medicare Advantage (MA) plans that bid below benchmarks (or bidding targets) receive a portion of that difference as rebates, which they then must return to beneficiaries through supplemental benefits or reduced premiums or cost-sharing. Using Centers for Medicare & Medicaid Services data, we evaluate the growth in rebates and concomitant changes in supplemental benefit composition among health maintenance organizations (HMOs) and local preferred provider organizations (PPOs) from 2011 through 2022. Average rebates grew considerably, particularly after 2015 and among PPOs. Alongside this rebate growth, the share of enrollees in plans offering dental, vision, and hearing benefits also increased, with nearly universal coverage of these benefits among both HMOs and PPOs by 2022. Medicare Advantage plans also increasingly reduced beneficiary Part D premium obligations, while increasing beneficiary financial exposure in the form of higher Part D deductibles, medical out-of-pocket maximums, and cost-sharing for inpatient stays. These findings are particularly relevant as policymakers debate the merits of various reforms to MA payment policy.
with Melissa McInerney, Jan Mellor, and Lindsay Sabik
JAMA Health Forum
Was the expansion of Medicaid to working-age adults under the Patient Protection and Affordable Care Act (ACA) associated with changes in Medicaid enrollment and health care use among older adults with low income and chronic condition limitations? In this cross-sectional study of 7153 US adults 65 years or older with low income, ACA Medicaid expansion was associated with significant increases in the likelihood of Medicaid enrollment and outpatient health care use among those with chronic condition limitations. No associations were found between ACA Medicaid expansion and Medicaid enrollment and health care use among those without such limitations. In this study, expansion of Medicaid to working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were enrolled in Medicare.
The Two Margin Problem in Insurance Markets
with Mike Geruso, Tim Layton, Mark Shepard
RESTAT
Insurance markets often feature consumer sorting along both an extensive margin (whether to buy) and an intensive margin (which plan to buy). We present a new graphical theoretical frame-work that extends a workhorse model to incorporate both selection margins simultaneously. A key insight from our framework is that policies aimed at addressing one margin of selection often involve an economically meaningful trade-of on the other margin in terms of prices, enrollment, and welfare. Using data from Massachusetts, we illustrate these trade-offs in an empirical sufficient statistics approach that is tightly linked to the graphical framework we develop.
with Sharon Touw, David U. Himmelstein, Steffie Woolhandler, and Leah Zallman
Health Affairs Article
During the COVID-19 pandemic in the US, essential workers have provided health care, food, and other necessities, often incurring considerable risk. At the pandemic’s start, the federal government was in the process of tightening the “public charge” rule by adding nutrition and health benefits to the cash benefits that, if drawn, could subject immigrants to sanctions (for example, green card denial). Census Bureau data indicate that immigrants accounted for 13.6 percent of the population but 17.8 percent of essential workers in 2019. About 20.0 million immigrants held essential jobs, and more than one-third of these immigrants resided in US states bordering Mexico. Nationwide, 12.3 million essential workers and 18.9 million of their household members were at risk because of the new sanctions. The rule change (which was subsequently revoked) likely caused 2.1 million essential workers and household members to forgo Medicaid and 1.3 million to forgo Supplemental Nutrition Assistance Program assistance on the eve of the pandemic, highlighting the potential of immigration policy changes to exacerbate health risks.
Economic Vulnerability of Households with Essential Workers
with Christopher Avery, Ariella Kahn-Lang Spitzer, Amitabh Chandra
JAMA Letter
The label of “essential worker” reflects society’s needs but does not mean that society has compensated those workers for additional risks incurred on the job during the current pandemic. When an essential worker contracts severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), they pose a risk to the other members of their household. These members may be elderly or lack health insurance, and the household may have limited resources to care for a sick family member. We assessed the proportion of essential workers in the US population and described the economic vulnerability of their households.
Published Commentary
with Melissa Garrido
The Conversation
Medicare’s Mental Health Care Problem
with Mark Meiselbach and Josephine Rohrer
Health Affairs Forefront
American Journal of Geriatric Psychiatry