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The Affordable Care Act (ACA) includes provisions to reduce Medicare beneficiaries' out-of-pocket spending for prescription drugs by gradually closing the coverage gap between the initial coverage limit and the catastrophic coverage threshold (known as the doughnut hole) beginning in 2011. However, Medicare beneficiaries who take specialty pharmaceuticals could still face a large out-of-pocket burden because of uncapped cost sharing in the catastrophic coverage phase. Using 2008-12 pharmacy claims data from a 20 percent sample of Medicare beneficiaries, we analyzed trends in total and out-of-pocket spending among Medicare beneficiaries who take at least one high-cost specialty drug from the top eight specialty drug classes in terms of spending. Annual total drug spending per specialty drug user studied increased considerably during the study period, from $18,335 to $33,301, and the proportion of expenditures incurred while in the catastrophic coverage phase increased from 70 percent to 80 percent. We observed a 26 percent decrease in mean annual out-of-pocket expenditures incurred below the catastrophic coverage threshold, likely attributable to the ACA's doughnut hole cost-sharing reductions, but increases in mean annual out-of-pocket expenditures incurred while in the catastrophic coverage phase offset these reductions almost entirely. Policy makers should consider implementing limits on patients' out-of-pocket burden., (Project HOPE—The People-to-People Health Foundation, Inc.)

Objective: To examine whether certain Medicare Advantage (MA) plan characteristics are associated with driving beneficiaries to providers that generate fewer avoidable hospital stays. Data Sources: This paper primarily used 2018–2019 MA encounter data and traditional Medicare (TM) claims data for a nationally representative 20% sample of Medicare beneficiaries. Study Design: For each plan design aspect—plan type, carrier, star rating, and network breadth—we estimated two adjusted Poisson regressions of avoidable hospital stays: one without clinician fixed effects and the other with. We calculated the difference between the coefficients to evaluate the extent to which patient sorting affected avoidable hospital stays relative to TM. Data Extraction Methods: Our sample included Medicare beneficiaries 65 years and older who were continuously enrolled in either MA or TM during 2018–2019. Beneficiaries in our sample had one or more chronic, ambulatory care‐sensitive conditions. Principal Findings: Patient sorting can be attributed to certain characteristics of plan design aspects. For plan type, HMOs account for 86%, with PPOs accounting for only 14%. For carriers, Humana and smaller carriers account for 89%. For star ratings, high‐star contracts account for 94%, with other stars only accounting for 6%. By network design, narrow network plan‐counties explained 20% of the patient sorting effect. Conclusions: While MA plans were found to be associated with driving beneficiaries to providers that generate fewer avoidable hospital stays, the effect is not homogeneous across the characteristics of MA plans. HMOs and high‐star contracts are drivers of this MA phenomenon. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Simple Summary: This research study aims to understand whether the Medicare Advantage program, which provides healthcare to a significant portion of Medicare beneficiaries, including cancer survivors, is effectively improving access to care, healthcare outcomes, and affordability. The study highlights the need for the ongoing evaluation and re-evaluation of the role of Medicare Advantage in promoting equity among beneficiaries with cancer. It provides valuable insights for policymakers and healthcare professionals involved in decision-making processes related to Medicare Advantage and its impact on healthcare access, affordability, and financial well-being for cancer survivors. This research informs discussions on potential improvements in the Medicare program to ensure that the needs of cancer survivors are adequately addressed. Background: The Medicare Advantage program provides care to nearly half of Medicare beneficiaries, including a rapidly growing population of cancer survivors. Despite its increased adoption, it is still unknown whether or not the program improves healthcare access, outcomes, and affordability for cancer survivors. Methods: We performed a cross-sectional study of Medicare beneficiaries aged ≥ 65 years with a self-reported history of cancer from the 2019 National Health Interview Survey. We used multivariable logistic regression to evaluate the association between Medicare program type (Medicare Advantage vs. traditional Medicare) and measures of healthcare access, acute care utilization, and affordability. Results: We identified 4451 beneficiaries with a history of cancer, corresponding to 26.6 million weighted cancer survivors in 2019. Of the beneficiaries, 35.8% were enrolled in Medicare Advantage, whereas 64.2% were enrolled in traditional Medicare. The age, sex, racial and ethnic composition, household income, primary site of cancer, and comorbidity burden of Medicare Advantage and traditional Medicare beneficiaries were similar. In the adjusted analysis, there were no differences in healthcare access or acute care utilization between traditional Medicare and Medicare Advantage beneficiaries. However, cancer survivors enrolled in Medicare Advantage were more likely to worry about (34.3% vs. 29.4%; aOR, 1.3 (95% CI, 1.1–1.5)) or have problems paying (13.6% vs. 11.1%; aOR, 1.4 (95% CI, 1.1–1.8)) medical bills. Conclusions: We found no evidence that Medicare Advantage beneficiaries with cancer had better healthcare access, affordability, or acute care utilization than traditional Medicare beneficiaries did. Furthermore, Medicare Advantage beneficiaries were more likely to report financial strain and have difficulty paying for their medical bills than were those with traditional Medicare. Despite the generous benefits and attractive incentives, Medicare Advantage plans may not be more cost-effective than traditional Medicare is for cancer survivors. Our study informs ongoing congressional deliberations to re-evaluate the role of Medicare Advantage in promoting equity among beneficiaries with cancer. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The share of Medicare stand-alone prescription drug plans with a preferred pharmacy network has grown from less than 9% in 2011 to 98% in 2021. This article assesses the financial incentives that such networks created for unsubsidized and subsidized beneficiaries and their pharmacy switching. STUDY DESIGN: We analyzed prescription drug claims data for a nationally representative 20% sample of Medicare beneficiaries from 2010 through 2016. METHODS: We evaluated the financial incentives for using preferred pharmacies by simulating unsubsidized and subsidized beneficiaries' annual out-of-pocket spending differentials between using nonpreferred and preferred pharmacies for all their prescriptions. We then compared beneficiaries' use of pharmacies before and after their plans adopted preferred networks. We also examined the amount of money that beneficiaries left on the table under such networks, based on their pharmacy use. RESULTS: Unsubsidized beneficiaries faced substantial incentives--on average, $147 annually in out-of-pocket spending--and moderately switched toward preferred pharmacies, whereas subsidized beneficiaries were insulated from the incentives and demonstrated little switching. Among those who continued to mainly use nonpreferred pharmacies (half of the unsubsidized and about two-thirds of the subsidized), on average, the unsubsidized paid more out of pocket ($94) relative to if they had used preferred pharmacies, whereas Medicare bore the extra spending ($170) for the subsidized through cost-sharing subsidies. CONCLUSIONS: Preferred networks have important implications for beneficiaries' out-of-pocket spending and the low-income subsidy program. Further research is needed about the impact on the quality of beneficiaries' decision-making and cost savings to fully evaluate preferred networks. [ABSTRACT FROM AUTHOR]

Beginning with the 2018 benefit year, the Centers for Medicare and Medicaid Services started incorporating select prescription drug utilization information into the Marketplace risk adjustment model. There has been little evidence about the impact of this change on payment accuracy and the mechanisms through which it may occur. Using commercial claims in 2017 from a large national health insurer, we find that the policy change improves payment accuracy in our sample and would help mitigate insurers' selection incentives for some enrollees through two channels: imputing missing diagnoses and varying risk scores to better capture the heterogeneity in expenditures among patients with certain health conditions. However, while improving payment accuracy overall, there are potential perverse incentives that could distort treatment choice for marginal patients. Additionally, overcompensation and undercompensation persists for certain patient subgroups, suggesting an opportunity to further refine and improve the model. [ABSTRACT FROM AUTHOR]