• Supplemental Insurance and Health Care Utilization and Spending among Elderly Cancer Survivors

      Ke, Xuehua; Davidoff, Amy J., 1957-; Stuart, Bruce C. (2014)
      Little is known about the impact of complex interactions of financial resources, health status, and attitudes towards health care seeking upon access to and utilization of health care beyond the acute cancer diagnosis and treatment phases. The study examined the relationship between supplemental medical and prescription insurance and use and spending on selected health care services for elderly Medicare cancer survivors compared to non-cancer controls. Data were pooled from the 1997-2007 Medicare Current Beneficiary Survey (MCBS) including linked historical and concurrent claims. A cancer survivorship year was randomly selected from one of the MCBS years that met the following criteria: (1) being post cancer-diagnosis year 2 or later, (2) no active treatment, and (3) no enrollment in hospice, or death, and with complete Cost and Use survey data available. The observation year for non-cancer controls was randomly selected from one of the MCBS years meeting the selection criteria (3). Spending was adjusted to 2007 dollars. Univariate and bivariate analyses were used to describe sample baseline characteristics. Naive generalized linear models and two-stage residual inclusion methods were conducted to examine whether there is a differential effect of supplemental insurance on health care utilization and spending for cancer survivors vs. non-cancer controls. The study included 3,958 cancer survivors and 7,056 non-cancer controls. Breast (21%), prostate (21%), and colorectal (16%) were the three most common cancer sites among cancer survivors. The study showed that cancer survivors had generally higher socioeconomic status, were more likely to have supplemental insurance, had more comorbidities, and had stronger preferences for medical care than non-cancer controls. Cancer survivors tended to use more selected preventive services and had higher total healthcare and prescription drugs spending, while use less recommended medications for diabetes than non-cancer controls. In the main multivariate analyses, supplemental insurance had an effect on use and spending on selected health care services, but had no differential effect for cancer survivors vs. non-cancer controls. The results help fill a gap in understanding the relationship of supplemental insurance to health care utilization and spending for elderly Medicare cancer survivors.
    • Topics in Medicare Part D: Eligibility, Participation, and Impacts

      Shoemaker, Julia Samantha; Davidoff, Amy J., 1957- (2012)
      Part D expanded Medicare in 2006 by creating a prescription drug benefit offered through private insurance plans. Key features of this benefit include the Low Income Subsidy (LIS), which provides discounts for plan premium and cost sharing for qualifying beneficiaries, and enrollment regulations, which provide economic incentives to encourage enrollment regardless of health status. Enrollment is voluntary among non-Medicaid duals; consequently, enrollment decisions are critical to program efficiency. This study addresses fundamental aspects of participation in Part D to inform policy design related to insurance access and impacts. Low LIS participation is a major policy concern; however, published estimates of eligibility and take-up are unreliable due to the lack of unified data capturing both dimensions. The objective of Aim 1 was to develop better estimates of whom, among likely eligible beneficiaries, enrolled, and to identify characteristics of non-enrollees. I used an unpublished supplement to the Medicare Current Beneficiary Survey in conjunction with an income imputation procedure, to determine eligibility. Findings suggest that published literature may misrepresent the population unreached by the LIS. In particular, this study brings attention to the high rate of likely LIS eligible beneficiaries obtaining unsubsidized Part D. Aim 2 expanded upon this to estimate the impact of the LIS on drug spending among eligible Part D enrollees using generalized linear regression models. Results indicated that LIS was associated with $534 greater Part D spending compared to non-LIS enrollees. Greater spending was associated with more drug fills and use of higher cost fills. Aim 3 assessed the efficiency of Part D design in offering incentives for timely enrollment by examining the role of health shocks on late enrollment among non-duals. The study focused on beneficiaries who did not obtain Part D or have other creditable coverage following their initial enrollment opportunity using a 5% sample of the Medicare population. Results indicated that a health shock was associated with a greater likelihood of late Part D enrollment suggesting that policy mechanisms alone were not effective in inducing participation. Most beneficiaries remained without coverage, thus penalizing the initial decision to decline Part D may deter later enrollment.