Changes in Out-of-Pocket Spending and Catastrophic Health Care Expenditures Associated With Medicare Eligibility

Scott, John W.; Neiman, Pooja U.; Tipirneni, Renuka; Fan, Zhaohui; Ayanian, John Z.

doi:10.1001/jamahealthforum.2021.2531

Cited by 13 publications

(25 citation statements)

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“…5 Like many areas of health care, spending by private insurers may be even higher. 6 , 7 In 2007, for example, total monthly health care spending was approximately twice as high for privately insured patients just after they started dialysis compared with those insured by Medicare; the same was true of per-person per-year net cost in 2011, a statistic that we updated in this study using contemporary data. 1 , 2 Previous research has reported that the median price paid by employer-sponsored plans for a single hemodialysis session is more than 6 times the base rate paid by Medicare for the same service.…”

Section: Introductionmentioning

confidence: 76%

“…As treatment for a chronic condition, dialysis care is expensive: annual Medicare spending per patient receiving hemodialysis was $93 200 in 2018 . Like many areas of health care, spending by private insurers may be even higher . In 2007, for example, total monthly health care spending was approximately twice as high for privately insured patients just after they started dialysis compared with those insured by Medicare; the same was true of per-person per-year net cost in 2011, a statistic that we updated in this study using contemporary data .…”

Section: Introductionmentioning

confidence: 81%

“…Previous research has shown that dialysis care imposes large costs on payers and patients. Trish et al, 7 for example, reported that the mean monthly spending for patients with kidney failure was $13 964 higher than for other patients. Although this finding is similar to our estimated difference of $14 685 (95% CI, $14 413-$14 957), our level of spending was notably higher, at $19 654 (95% CI, $19 544-$19 763) per month after starting dialysis.…”

Section: Discussionmentioning

confidence: 99%

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Assessment of Spending for Patients Initiating Dialysis Care

et al. 2022

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ImportanceDespite a widespread belief that private insurers spend large amounts on health care for enrollees receiving dialysis, data limitations over the past decade have precluded a comprehensive analysis of the topic.ObjectiveTo examine the amount and types of increases in health care spending for privately insured patients associated with initiating dialysis care.Design, Setting, and ParticipantsA cohort study covering calendar years 2012 to 2019 included patients with kidney failure who had employer-sponsored insurance for 12 months following dialysis initiation. Data analysis was performed from August 27, 2021, to August 18, 2022. The data cover the entirety of the US and were obtained from the Health Care Cost Institute. The data include all medical claims for enrollees in employer-sponsored health insurance plans offered by multiple major health care insurers within the US. Participants included patients younger than 65 years who were continuously enrolled in these plans in the 12 months before and after their first claim for dialysis care. Patients also had to have nonmissing documented key characteristics, such as sex, race and ethnicity, and health characteristics.ExposuresA claim for dialysis care.Main Outcomes and MeasuresOut-of-pocket, inpatient, outpatient, physician services, prescription medication, and total health care spending. The hypothesis tested was formulated before data collection.ResultsThe sample included 309 800 enrollee-months, which was a balanced panel of 25 months for 12 392 enrollees. At baseline, 7534 patients (61%) were male, 5415 (44%) were aged 55 to 64 years, and patients had been enrolled with their insurer for a mean of 30 months (95% CI, 29.9-30.1 months). In the 12 months before initiating dialysis care, total monthly health care spending was $5025 per patient per month (95% CI, $4945-$5106). Dialysis care initiation was associated with an increase in total monthly spending of $14 685 (95% CI, $14 413-$14 957). This increase occurred across all spending categories (dialysis, nondialysis outpatient, inpatient, physician services, and prescription drugs). Monthly patient out-of-pocket spending increased by $170 (95% CI, $162-$178). These spending increases occurred abruptly, beginning about 2 months before dialysis initiation, and remained increased for the subsequent 12 months.Conclusions and RelevanceIn this cohort study, evidence that private insurers experience significant, sustained increases in spending when patients initiated dialysis was noted. The findings suggest that proposed policies aimed at limiting the amount dialysis facilities charge private insurers and the enrollees has the potential to reduce health care spending in this high-cost population.

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Section: Introductionmentioning

confidence: 76%

Section: Introductionmentioning

confidence: 81%

Section: Discussionmentioning

confidence: 99%

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Assessment of Spending for Patients Initiating Dialysis Care

et al. 2022

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“…These age ranges were chosen to evaluate for trends in outcomes of interest before and after age 65 years, consistent with prior research which utilized a similar study design. 8,9 These datasets are uniquely suited for this analysis as they are the only sources of nationally-representative data that enable the identification of patients who have undergone surgery. These also include detailed information on financial outcomes of interest and detailed demographic data that are highly associated with financial outcomes.…”

Section: Methods Data Source and Study Cohortmentioning

confidence: 99%

The Impact of Medicare Coverage on Downstream Financial Outcomes for Adults Who Undergo Surgery

et al. 2021

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Objective: To evaluate the effects of gaining access to Medicare on key financial outcomes for surgical patients. Summary Background Data: Surgical care poses a significant financial burden, especially among patients with insufficient financial risk protection. Medicare may mitigate the risk of these adverse circumstances, but the impact of Medicare eligibility on surgical patients remains poorly understood. Methods: Regression discontinuity analysis of national, cross-sectional survey and cost data from the 2008 to 2018 National Health Interview Survey and Medical Expenditure Panel Survey. Patients were between the ages of 57 to 72 with surgery in the past 12 months. The primary outcomes were the presence of medical debt, delay/deferment of care due to cost, total annual out-of-pocket costs, and experiencing catastrophic health expenditures. Results: Among 45,982,243 National Health Interview Survey patients, Medicare eligibility was associated with a 6.6 percentage-point decrease (95% confidence interval [CI]: -9.0% to -4.3) in being uninsured (>99% relative reduction), 7.6 percentage-point decrease (24% relative reduction) in having medical debt (95%CI: -14.1% to -1.1%), and 4.9 percentage-point decrease (95%CI: -9.4% to -0.4%) in deferrals/delays in medical care due to cost (28% relative reduction).

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“…Another analysis, in 2004, reported that universal healthcare at age 65 years was associated with reductions in disparities for lowerincome adults [42]. More recent work has shown that Medicare eligibility improves access and affordability [12], reduces medical debt [43], decreases out-of-pocket spending [44], reduces catastrophic expenditures for patients hospitalized with surgical conditions [45], and also reduces racial disparities in insurance coverage, access to care, and self-reported health [46]. Our work extends upon this evidence by examining the effects of Medicare eligibility specifically by income status (low-versus higher-income), while also estimating the effects of Medicare enrollmentAU : PleasenotethatasperPLOSstyle; italicsshouldnotbeusedforemphasis:Hence; theitali , in a contemporary, post-ACA population of US adults.…”

Section: Plos Medicinementioning

confidence: 99%

Medicare eligibility and healthcare access, affordability, and financial strain for low- and higher-income adults in the United States: A regression discontinuity analysis

et al. 2022

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Background US policymakers are debating whether to expand the Medicare program by lowering the age of eligibility. The goal of this study was to determine the association of Medicare eligibility and enrollment with healthcare access, affordability, and financial strain from medical bills in a contemporary population of low- and higher-income adults in the US. Methods and findings We used cross-sectional data from the National Health Interview Survey (2019) to examine the association of Medicare eligibility and enrollment with outcomes by income status using a local randomization-based regression discontinuity approach. After weighting to account for survey sampling, the low-income group consisted of 1,660,188 adults age 64 years and 1,488,875 adults age 66 years, with similar baseline characteristics, including distribution of sex (59.2% versus 59.7% female) and education (10.8% versus 12.5% with bachelor’s degree or higher). The higher-income group consisted of 2,110,995 adults age 64 years and 2,167,676 adults age 66 years, with similar distribution of baseline characteristics, including sex (40.0% versus 49.4% female) and education (41.0% versus 41.6%). The share of adults age 64 versus 66 years enrolled in Medicare differed within low-income (27.6% versus 87.8%, p < 0.001) and higher-income groups (8.0% versus 85.9%, p < 0.001). Medicare eligibility at 65 years was associated with a decreases in the percentage of low-income adults who delayed (14.7% to 6.2%; −8.5% [95% CI, −14.7%, −2.4%], P = 0.007) or avoided medical care (15.5% to 5.9%; −9.6% [−15.9%, −3.2%], P = 0.003) due to costs, and a larger decrease in the percentage who were worried about (66.5% to 51.1%; −15.4% [−25.4%, −5.4%], P = 0.003) or had problems (33.9% to 20.6%; −13.3% [−23.0%, −3.6%], P = 0.007) paying medical bills. In contrast, there were no significant associations between Medicare eligibility and measures of cost-related barriers to medication use. For higher-income adults, there was a large decrease in worrying about paying medical bills (40.5% to 27.5%; −13.0% [−21.4%, −4.5%], P = 0.003), a more modest decrease in avoiding medical care due to cost (3.5% to 0.6%; −2.9% [−5.3%, −0.5%], P = 0.02), and no significant association between eligibility and other measures of healthcare access and affordability. All estimates were stronger when examining the association of Medicare enrollment with outcomes for low and higher-income adults. Additional analyses that adjusted for clinical comorbidities and employment status were largely consistent with the main findings, as were analyses stratified by levels of educational attainment. Study limitations include the assumption adults age 64 and 66 would have similar outcomes if both groups were eligible for Medicare or if eligibility were withheld from both. Conclusions Medicare eligibility and enrollment at age 65 years were associated with improvements in healthcare access, affordability, and financial strain in low-income adults and, to a lesser extent, in higher-income adults. Our findings provide evidence that lowering the age of eligibility for Medicare may improve health inequities in the US.

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Changes in Out-of-Pocket Spending and Catastrophic Health Care Expenditures Associated With Medicare Eligibility

Cited by 13 publications

References 6 publications

Assessment of Spending for Patients Initiating Dialysis Care

Assessment of Spending for Patients Initiating Dialysis Care

The Impact of Medicare Coverage on Downstream Financial Outcomes for Adults Who Undergo Surgery

Medicare eligibility and healthcare access, affordability, and financial strain for low- and higher-income adults in the United States: A regression discontinuity analysis

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