Person:

Fung, Vicki

Objective: Standard Medicare Part D prescription drug benefits include substantial and complex cost-sharing. Many beneficiaries also have functional limitations that could affect self-care capabilities, including managing medications, but also have varying levels of social support to help with these activities. We examined the associations between drug cost responses, functional limitations, and social support. Data Sources and Study Setting We conducted telephone interviews in a stratified random sample of community-dwelling Medicare Advantage beneficiaries (N = 1,201, response rate = 70.0%). Participants reported their functional status (i.e., difficulty with activities of daily living) and social support (i.e., receiving help with medications). Drug cost responses included cost-reducing behaviors, cost-related non-adherence, and financial stress. Study Design We used multivariate logistic regression to assess associations among functional status, help with medications, and drug cost responses, adjusting for patient characteristics. Principal Findings Respondents with multiple limitations who did not receive help with their medications were more likely to report cost-related non-adherence (OR = 3.2, 95% CI: 1.2–8.5) and financial stress (OR = 2.4, 95% CI: 1.3–4.5) compared to subjects with fewer limitations and no help; however, those with multiple limitations and with medication help had similar odds of unfavorable cost responses as those with fewer limitations. Conclusion: The majority of beneficiaries with functional limitations did not receive help with medications. Support with medication management for beneficiaries who have functional limitations could improve adherence and outcomes.

Importance: Dual-eligible Medicare-Medicaid beneficiaries represent 1-in-5 Medicare beneficiaries, but providers receive less than 100% of the Medicare fee for them because of reimbursement caps in many states.

Objective: To examine how this payment differential impacts the availability of primary care physicians (PCPs) for dual vs. non-dual Traditional Medicare (TM) beneficiaries, we leverage the Affordable Care Act (ACA) primary care fee bump that temporarily eliminated this differential in 2013-2014.

Design: We used the Medicare Physician and Other Supplier Public Use File (2012-2017) to enumerate TM beneficiaries each provider billed for annually by dual status and calculate dual caseloads as a percentage of a physicians’ TM patients. We examined differences in PCPs’ Medicare dual caseloads in states with and without dual reimbursement differentials using multivariate regression models, adjusted for provider and area-level traits. We also used a triple difference approach to examine the effects of temporary and extended fee bumps vs. no bump on PCP’s dual caseloads compared with caseloads of selected specialists unexposed to the fee bump.

Setting: Traditional Medicare

Participants: PCPs and a comparison specialty group of cardiologists, orthopedic surgeons, and general surgeons

Exposure: State dual reimbursement policies and changes over time due to the ACA fee bump

Main outcome measures: Medicare dual caseloads of at least 20% (the national average) or 10% (81% of PCP’s).

Results: In 2012, prior to the fee bump, PCPs in states with lower reimbursement for duals vs. minimal differences were less likely to have a dual caseload of at least 10% (e.g., difference=-4.83 percentage points (pp) (95% CI: -7.22 to -2.44) for states with temporary fee bumps). Despite the constant proportion of dual beneficiaries, the proportion of PCPs with dual caseloads of at least 10% or 20% decreased between 2012-2017, and the fee increase was not consistently associated with increases in the likelihood of PCPs exceeding these thresholds.

Conclusions: Pre-ACA, state reimbursement caps for dual-eligibles were associated with a lower proportion of duals on PCPs’ Medicare panels. Despite the ACA’s fee bump, the proportion of physicians treating duals declined over time, raising concerns of worsening access for duals.

IMPORTANCE The Patient Protection and Affordable Care Act (ACA) temporarily increased primary care practitioners’ (PCP) Medicaid fees to that of Medicare for 2013 to 2014 (fee bump) to help accommodate potential increases in demand for care with ACA coverage expansion. This also increased fees for PCPs treating dual-eligible Medicare and Medicaid beneficiaries in many states and eliminated payment differentials for dual-eligible vs non–dual-eligible Medicare beneficiaries that could limit access to care. OBJECTIVE To examine the association between the ACA fee bump and primary care visits for dual eligible Medicare and Medicaid beneficiaries. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a difference-in-difference design and Medicare claims data from 2012 to 2016 to compare changes in visit rates for full-subsidy dual eligible Medicare and Medicaid beneficiaries vs non–dual-eligible Medicare beneficiaries with low income whose fees did not change. Changes were examined overall and separately in states with temporary, extended, or minimal fee increases for dual-eligible vs non–dual-eligible beneficiaries in 2013 to 2014 (mandatory bump) and 2015 to 2016 (postbump or bump extension) vs 2012 (prebump). The study used linear regression models with beneficiary fixed effects, adjusting for time-changing area and beneficiary characteristics. Statistical analysis was performed from February 2018 to November 2019. EXPOSURE ACA-mandated Medicaid fee bump. MAIN OUTCOMES AND MEASURES Primary care visits per 100 beneficiaries overall and visits billed by physicians vs nurse practitioners and physician assistants. RESULTS The study included 3 052 044 dual-eligible and non–dual-eligible beneficiaries in 2012; 1 516 534 (49.7%) were aged 65 years or younger, 1 797 556 (58.9%) were women, and 1 754 626 (57.5%) had non-Hispanic White race/ethnicity. Overall primary care visit rates for dual-eligible beneficiaries were unchanged or decreased slightly relative to non–dual-eligible beneficiaries during the fee bump (2013-2014) and the postbump or bump extension period (2015-2016) vs baseline. Compared with non–dual-eligible beneficiaries, visit rates with primary care physicians declined more uniformly for dual-eligible beneficiaries across state groups and time periods (difference-in-difference: −0.37 [95%CI, −0.43 to −0.32] visits per 100 beneficiaries in 2013-2014 vs 2012; P < .001; and difference-in-difference: −0.62 [95%CI, −0.68 to −0.56] visits per 100 beneficiaries in 2015-2016 vs 2012; P < .001), whereas visits with nurse practitioners and physician assistants increased over time (difference-in-difference: 0.11 [95%CI, 0.08 to 0.14] visits per 100 beneficiaries in 2013-2014 vs 2012; P < .001; and difference-in-difference: 0.46 [95%CI, 0.43 to 0.50] visits per 100 beneficiaries in 2015-2016 vs 2012; P < .001). These changes, however, were not associated with the timing of the payment changes. CONCLUSIONS AND RELEVANCE The ACA fee bump was not associated with increases in primary care visits for dual-eligible Medicare and Medicaid beneficiaries. Visits for dual-eligible beneficiaries with primary care physicians decreased after the ACA, a decrease that was partially offset by increases in visits with nonphysician clinicians.

The federal government eliminated the tax penalty for non-compliance with the Affordable Care Act’s individual mandate starting with the 2019 enrollment year. Using interviews with individual market enrollees in California in 2017, we found that 19 percent reported that they would not have purchased insurance had there been no penalty. We estimate premiums would have increased by four to seven percent if these enrollees were not in the risk pool. Moreover, the effects of eliminating the penalty were more concentrated in vulnerable subgroups, including those with lower income or educational attainment, Hispanic enrollees, and those who were uninsured in the prior year. Younger enrollees and those without chronic conditions were also more likely to say they would not have purchased insurance if there was no penalty. Eliminating the mandate penalty alone is unlikely to destabilize the individual market in California, but could erode coverage gains, especially among groups who have historically been less likely to be insured.