Seniors don’t use Medicare.Gov: how do eligible beneficiaries obtain information about Medicare Advantage Plans in the United States?

Background Managed care programs in the US are becoming a preferred alternative among low-income individuals in the US. Every year during open enrollment, seniors can enroll in Medicare Advantage (MA) or switch MA plans. However, there is very limited information about how seniors obtain information to help them make their choices. While the Centers for Medicaid and Medicare offer online resources that are designed to enable potential beneficiaries to make informed coverage decisions, there is no information as to whether seniors use these resources, and therefore whether these resources are effective compared to other information retrieval methods. Methods The purpose of the present study was to qualitatively explore how seniors obtain information about insurance plans in MA. We conducted semi-structured interviews with 26 MA beneficiaries from Rhode Island. Results We found that most seniors have strong preferences for obtaining information in-person regarding benefits, cost and other plan information. Some seniors relied heavily on insurance brokers or representatives, and considered the information provided to them without questioning the potential for bias. Others consulted with family and/or friends for guidance, or to compare costs and benefits. Only a few of these seniors used the available internet resources, and in fact most of them mentioned that they did not have a computer/smart device with internet capabilities. However, among those who used and appeared to be comfortable with navigating the internet, www.medicare.gov was not discussed as a useful resource for making decisions regarding health insurance. Conclusions This study suggests that existing online medical resource usage and effects among senior citizens in the United States may need supplementing with in-person communication among influential agents.

An Economic Analysis of Intensive Multidisciplinary Interventions for Treating Medicaid-Insured Children with Pediatric Feeding Disorders

Background. Intensive multidisciplinary intervention (IMI) represents a well-established treatment for pediatric feeding disorders (PFDs), but program availability represents an access care barrier. We develop an economic analysis of IMI for weaning from gastronomy tube (G-tube) treatment for children diagnosed with PFDs from the Medicaid programs’ perspective, where Medicaid programs refer to both fee-for-service and managed care programs. Methods. The 2010–2012 Medicaid Analytic eXtract claims provided health care data for children aged 13 to 72 months. An IMI program provided data on average admission costs. We employed a finite-horizon Markov model to simulate PFD treatment progression assuming 2 treatment arms: G-tube only v. IMI targeting G-tube weaning. We compared the expenditure differential between the 2 arms under varying time horizons and treatment effectiveness. Results. Overall Medicaid expenditure per member per month was $6814, $2846, and $1550 for the study population of children with PFDs and G-tube treatment, the control population with PFDs without G-tube treatment, and the no-PFD control population, respectively. The PFD-diagnosed children with G-tube treatment only had the highest overall expenditures across all health care settings except psychological services. The expenditure at the end of the 8-year time horizon was $405,525 and $208,218 per child for the G-tube treatment only and IMI arms, respectively. Median Medicaid expenditure was between 1.7 and 2.2 times higher for the G-tube treatment arm than for the IMI treatment arm. Limitations. Data quality issues could cause overestimates or underestimates of Medicaid expenditure. Conclusions. This study demonstrated the economic benefits of IMI to treat complex PFDs from the perspective of Medicaid programs, indicating this model of care not only holds benefit in terms of improving overall quality of life but also brings significant expenditure savings in the short and long term.

Medicaid Managed Care's Effects on Costs, Access, and Quality: An Update

Medicaid is integral to public health because it insures one in five Americans and half of the nation's births. Nearly two-thirds of all Medicaid recipients are currently enrolled in a health maintenance organization (HMO). Proponents of HMOs argue that they can lower costs while maintaining access and quality. We critically reviewed 32 studies on Medicaid managed care (2011–2019). Authors reported state-specific cost savings and instances of increased access or quality with implementation or redesign of Medicaid managed-care programs. Studies on high-risk populations (e.g., disabled) found improvements in quality specific to a state or a high-risk population. A unique model of managed care (i.e., the Oregon Health Plan) was associated with reduced costs and improved access and quality, but results varied by comparison state. New trends in the literature focused on analysis of auto-assignment algorithms, provider networks, and plan quality. More analysis of costs jointly with access/quality is needed, as is research on managing long-term care among elderly and disabled Medicaid recipients.

Parity is Not Enough!

This commentary describes limitations of mental health parity requirements in ensuring access to insurance coverage for mental health treatment and surveys regulatory options employed by states in Medicaid managed care programs as supplements to parity that can further reduce the risk of inappropriate denials of coverage.

Analysis of reimbursement (R) for next generation sequencing (NGS) on patients' tumors in the context of a personalized medicine program.

6506 Background: R policies for NGS testing vary widely among private and public insurers. While drug costs are the greatest challenge in personalized or precision medicine, cost and R are substantial barriers to genomic profiling with NGS. We examined variation in coverage and R for a cohort of cancer patients (pts) treated at a tertiary oncology center. Methods: An Institutional Review Board approved prospective registration protocol was activated with the objective of establishing a centralized longitudinal clinical, molecular phenotypic, and research data repository for pts diagnosed with cancer. Based on provider assessment of medical necessity, mutations in 68 cancer associated genes were analyzed. Evaluation of R for NGS was performed from Sept, 2014 through Jan, 2017, with use of CPT code 81455. R was analyzed based on: payer type; pt age; localized vs. metastatic disease; and actionability of data. Results: 588 pts with evaluable analytic cases, and NGS testing, with R results shown in the table below. For groups with >= 10 pts: R frequency was highest in managed care programs, either private or Medicare, and least frequent in non-HMO Medicare (p<.001). In pts receiving R, payments by private HMOs were highest (p<.02). NGS results with labelled drug indications were associated with less frequent R (26% vs. 35%; p<.05), and lower payments (mean of $358 vs. $567; p<.02) compared to other NGS results. Younger age was associated with more frequent R (38% in pts <60 years, 24% in pts >= 60 years; p<.005). Neither cancer diagnosis nor stage were significantly associated with R. Conclusions: One third of pts received some R for NGS testing. R was more frequent and higher in managed care programs, both private and Medicare. R was more likely for younger age pts, while actionable NGS results were associated with lower R. These data demonstrate the need for rational, transparent, and consistent R policies, along with a value-based R model for NGS across all payer groups. [Table: see text]

What are key determinants of hospital admissions, readmission rate and day case rate within the South African medical schemes population?

BACKGROUND: In South Africa, private hospitals absorb a high proportion of the total health expenditure on private health care. Between 2008-2010 private hospital expenditure which includes ward fees, theatre fees, consumables, medicines and per diem arrangements consumed between 40.5% and 40.9% of the total benefits paid by medical schemes from the risk pool, whilst in-hospital managed care fees ranged between 1.8% and 2.8% for the equivalent years.OBJECTIVE: The aim of this paper is to highlight key factors contributing to utilisation of hospital services within the medical schemes population and to recommend “appropriate” and cost effective strategies on hospital utilisation management.METHODS: A cross sectional survey informed by retrospective analysis of quantitative data was used. Researchers also triangulated quantitative data with systematic review of literature.RESULTS: The results show that demographic indicators such as age profile, dependency ratio, pensioner ratio and prevalence of chronic conditions are not the only key factors influencing hospital admissions, but rather the effectiveness of each medical scheme in containing hospital admissions is also influenced by available technical capacity on utilisation review and audit as well as the managed care methodology including the philosophy underpinning benefit option design.CONCLUSION: This study highlights the importance of “value based” managed care programs linked to benefit option design in health care utilisation management. The choice of one managed care program over the other often leads to tradeoffs whereby unintended consequences emanate. Medical schemes are therefore encouraged to continuously review their managed care programs to ensure value for money as well as better access and health outcomes.