Published Articles

Fostering Flexibility: How Medicare Advantage Potentially Accelerated Telehealth Benefits

with Lisa M. Grabert, Erin Trish and Kathryn L. Wagner

Inquiry

In 2018, the US Congress enacted a policy permitting Medicare Advantage (MA) plans to cover telehealth services in a beneficiary’s home and through audio-only means as part of the basic benefit package of services, where prior to the policy change such benefits were only allowed to be covered as a supplemental benefit. MA plans were afforded 2 years of lead time for strategizing, negotiating, and capital investment prior to the start date (January 1, 2020) of the new coverage option. Our data analysis found basic benefit telehealth was offered by plans comprising 71% of enrollment in 2020 and increased to 95% in 2021. At the same time, remote access telehealth was offered as a supplemental benefit for 69% of enrollees in 2020, a decrease of 23% compared to 2019. These efforts by MA plans may have enabled traditional Medicare (TM) to leverage an existing telehealth infrastructure as a solution to the access issues created by public health policies requiring sheltering in place and social distancing during the COVID-19 pandemic. The success of this MA policy prompts consideration of additional flexibility beyond the standard basic benefit package, and whether such benefits reduce costs while improving access and/or outcomes in the context of a managed care environment like MA. Subject to oversight, such flexibility could potentially improve value in MA, and facilitate future changes in TM, as appropriate.

Physician Responses to Medicare Reimbursement Rates

with Aileen Devlin 

Journal of Health Economics, Forthcoming

This paper investigates how office-based physicians respond to Medicare reimbursement changes. Using variation from an Affordable Care Act policy that increased reimbursements for office-based care in four states, we use a triple difference analysis, comparing physicians with higher and lower reimbursement changes in treated states to similar physicians in untreated states. We find two mechanisms through which physicians respond. First, the reimbursement change affected integration—physicians with larger increases in office-based reimbursement were less likely to vertically integrate with hospitals and more likely to continue providing office-based care than physicians with smaller reimbursement increases. Second, we find some evidence that physicians who continued practicing in an office setting increased the volume of services provided.

Trends in the Level and Composition of Supplemental Benefits in Medicare Advantage

with Erin Trish 

Health Affairs Scholar

Medicare Advantage (MA) plans that bid below benchmarks (or bidding targets) receive a portion of that difference as rebates, which they then must return to beneficiaries through supplemental benefits or reduced premiums or cost-sharing. Using Centers for Medicare & Medicaid Services data, we evaluate the growth in rebates and concomitant changes in supplemental benefit composition among health maintenance organizations (HMOs) and local preferred provider organizations (PPOs) from 2011 through 2022. Average rebates grew considerably, particularly after 2015 and among PPOs. Alongside this rebate growth, the share of enrollees in plans offering dental, vision, and hearing benefits also increased, with nearly universal coverage of these benefits among both HMOs and PPOs by 2022. Medicare Advantage plans also increasingly reduced beneficiary Part D premium obligations, while increasing beneficiary financial exposure in the form of higher Part D deductibles, medical out-of-pocket maximums, and cost-sharing for inpatient stays. These findings are particularly relevant as policymakers debate the merits of various reforms to MA payment policy. 

Association of ACA Medicaid Expansion with Medicaid Receipt and Health Care Use in Low-Income Older Adults with Chronic Conditions

with Melissa McInerney, Jan Mellor, and Lindsay Sabik

JAMA Health Forum 

Was the expansion of Medicaid to working-age adults under the Patient Protection and Affordable Care Act (ACA) associated with changes in Medicaid enrollment and health care use among older adults with low income and chronic condition limitations? In this cross-sectional study of 7153 US adults 65 years or older with low income, ACA Medicaid expansion was associated with significant increases in the likelihood of Medicaid enrollment and outpatient health care use among those with chronic condition limitations. No associations were found between ACA Medicaid expansion and Medicaid enrollment and health care use among those without such limitations. In this study, expansion of Medicaid to working-age adults was associated with increased Medicaid enrollment and outpatient health care use among older adults with low income and chronic condition limitations who were enrolled in Medicare.

The Two Margin Problem in Insurance Markets  

with Mike Geruso, Tim Layton, Mark Shepard 

RESTAT 

Insurance markets often feature consumer sorting along both an extensive margin (whether to buy) and an intensive margin (which plan to buy). We present a new graphical theoretical frame-work that extends a workhorse model to incorporate both selection margins simultaneously. A key insight from our framework is that policies aimed at addressing one margin of selection often involve an economically meaningful trade-of on the other margin in terms of prices, enrollment, and welfare. Using data from Massachusetts, we illustrate these trade-offs in an empirical sufficient statistics approach that is tightly linked to the graphical framework we develop.

Immigrant Essential Workers Likely Avoided Medicaid And SNAP Because Of A Change To The Public Charge Rule 

with Sharon Touw, David U. Himmelstein, Steffie Woolhandler, and Leah Zallman

Health Affairs Article

During the COVID-19 pandemic in the US, essential workers have provided health care, food, and other necessities, often incurring considerable risk. At the pandemic’s start, the federal government was in the process of tightening the “public charge” rule by adding nutrition and health benefits to the cash benefits that, if drawn, could subject immigrants to sanctions (for example, green card denial). Census Bureau data indicate that immigrants accounted for 13.6 percent of the population but 17.8 percent of essential workers in 2019. About 20.0 million immigrants held essential jobs, and more than one-third of these immigrants resided in US states bordering Mexico. Nationwide, 12.3 million essential workers and 18.9 million of their household members were at risk because of the new sanctions. The rule change (which was subsequently revoked) likely caused 2.1 million essential workers and household members to forgo Medicaid and 1.3 million to forgo Supplemental Nutrition Assistance Program assistance on the eve of the pandemic, highlighting the potential of immigration policy changes to exacerbate health risks. 

Economic Vulnerability of Households with Essential Workers

with Christopher Avery, Ariella Kahn-Lang Spitzer, Amitabh Chandra

JAMA Letter

The label of “essential worker” reflects society’s needs but does not mean that society has compensated those workers for additional risks incurred on the job during the current pandemic. When an essential worker contracts severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), they pose a risk to the other members of their household. These members may be elderly or lack health insurance, and the household may have limited resources to care for a sick family member. We assessed the proportion of essential workers in the US population and described the economic vulnerability of their households. 

Published Commentary

Medicare’s Mental Health Care Problem

with Mark Meiselbach and Josephine Rohrer

Health Affairs Forefront 

Health Care Spending, Use, and Financial Hardship Among Traditional Medicare and Medicare Advantage Enrollees With Mental Health Symptoms, Commentary

American Journal of Geriatric Psychiatry