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Medicare Part B is one of the federal health insurance programs available to senior citizens in the United States. Unlike Medicare Part A, Part B enrollment is not automatic, and those missing their initial enrollment period are assessed a 10% or more penalty in addition to their monthly premium rate for the rest of their lives. This problematic enrollment policy has impacted senior citizens who have missed Part B enrollment windows, creating for them an added financial burden when many are transitioning to fixed incomes. Guided by social construction theory and using a nonprobability, convenience sampling approach, the likelihood coefficient values associated with Medicare Part B enrollee awareness, stress, and income of 112 residents of a suburban city in a northeastern state who were 65 years and older were examined. Sequential Forward: LR methodology yielded a significant, negative (b = -1.21, Wald X2(1) = 7.56, OR = .298, p = .006, CI [.126, .707]) and a significant, positive (b = 2.16, Wald X2(1) = 6.29, OR = 8.678, p = .012, CI [1.60, 46.99]) likelihood of predicting Medicare Part B late enrollment penalties for awareness and stress; income was not a significant model predictor. Participants who reported higher stress levels were 8.7 times more likely to be classified in the Medicare Part B late enrollment penalty than those reporting lower stress. Participants who were aware of enrollment needs were 3.4 times more likely to have no late enrollment penalties than those who were unaware. Positive social change centers on increasing Medicare Part B consumer awareness, reducing stress of enrollment deadlines, and providing information to federal policy makers to simplify enrollment policies to reduce or end late enrollment penalties.

This dissertation is composed of two essays that examine the role of public and private health insurance on healthcare access, use, and cost containment. In Chapter 1, Dugan, Virani, and Ho examine the impact of Medicare eligibility on healthcare utilization and access. Although Medicare eligibility has been shown to generally increase health care utilization, few studies have examined these relationships among the chronically ill. We use a regression-discontinuity framework to compare physician utilization and financial access to care among people before and after the Medicare eligibility threshold at age 65. Specifically, we focus on coronary heart disease and stroke (CHDS) patients. We find that Medicare eligibility improves health care access and physician utilization for many adults with CHDS, but it may not promote appropriate levels of physician use among blacks with CHDS. My second chapter examines the extent to which the managed care backlash affected managed care's ability to contain hospital costs among short-term, non-federal hospitals between 1998 and 2008. My analysis focuses on health maintenance organizations (HMOs), the most aggressive managed care model. Unlike previous studies that use cross-sectional or fixed effects estimators to address the endogeneity of HMO penetration with respect to hospital costs, this study uses a fixed effects instrumental variable approach. The results suggest two conclusions. First, I find the impact of increased HMO penetration on costs declined over the study period, suggesting regulation adversely impacted managed care's ability to contain hospital costs. Second, when costs are decomposed into unit costs by hospital service, I find the impact of increased HMO penetration on inpatient costs reversed over the study period, but HMOs were still effective at containing outpatient costs.

Thesis (M.A. (Population and Reproductive Health Research))--Mahidol University, 2007. / LICL has E-Thesis 0029 ; please contact computer services.

We consider the effect of disability status on Medicare expenditures. Disabled elderly historically have accounted for a significant portion of Medicare expenditures. Recent demographic trends exhibit a decline in the size of this population, causing some observers to predict declines in Medicare expenditures. There are, however, reasons to be suspicious of this rosy forecast. To better understand the effect of disability on Medicare expenditures, we develop and estimate a model using the generalized method of moments technique. We find that newly disabled elderly generally spend more than those who have been disabled for longer periods of time. Also, we find that increases in expenditures have risen much more quickly for those disabled Medicare beneficiaries who were at the higher ends of the expenditure distribution before the increases.

BACKGROUND:The Affordable Care Act of 2010 proposed maximum penalty equal to 1% of regular Medicare reimbursements which prompted change in how hospitals regard 30-day readmissions. While several hospital to home transitional care models demonstrated a reduction in readmissions and cost savings, programs adapted to population needs and existing resources was essential.METHODS:Focusing on process and outcomes evaluation, a retrospective analysis of a modified community based care transitions program was conducted.RESULTS:In addition to high levels of patient satisfaction with the care transitions program, participants' confidence with self care was significantly improved. Further, the program evaluation demonstrated a 73% reduction in readmissions and an actual Medicare cost savings during the 9-month study period of $214,192, excluding the cost to administer the program.CONCLUSIONS:While there are several transitional care programs in existence, a customized approach is desirable and often required as the most cost effective way to manage care transitions and employ evidence based policy making. This study established some of the pitfalls when implementing a community-based transitional care program and demonstrated encouraging outcomes.

The purpose of this study was to investigate the impact of Medicare Part D coverage on medication adherence and health outcomes in dialysis patients. A retrospective analysis (2006-2010) using the United States Renal Data System was conducted for Medicare-eligible dialysis patients. Cardiovascular disease morbidity, healthcare utilization and expenditures, medication adherence, and mortality rates were compared, categorized based on patients’ Part D coverage in 2007 for those who: 1) did not reach the coverage gap (cohort 1); 2) reached the coverage gap but not catastrophic coverage (cohort 2); 3) reached catastrophic coverage (cohort 3); and 4) did not reach the coverage gap but received a low-income subsidy (cohort 4). Cox proportional hazards models, Kaplan-Meier methods, logistic regressions, generalized linear models, and generalized estimating equations were used. A total of 11,732 patients were included as meeting inclusion criteria: 1) cohort 1: 3,678 patients had out-of-pocket drug costs <$799; 2) cohort 2: 4,349 patients had out-of-pocket drug costs between $799 and $3,850; 3) cohort 3: 1,310 patients had out-of-pocket drug costs > $3,850; and 4) cohort 4: the remaining 2,395 patients had out-of-pocket drug costs <$799 but received a low-income subsidy. After adjusting for demographic and clinical factors, patients in cohort 2 and cohort 3 had 42 percent and 36 percent increased risk of cardiovascular disease (odds ratio (OR)=1.42, 95% confidence interval (CI):1.20-1.67; OR=1.38, 95% CI:1.10-1.72); and had 36 percent and 37 percent higher death rates compared to those in cohort 4, respectively (hazard ratio (HR)=1.36, 95% CI:1.27-1.44; HR=1.37, 95% CI:1.27-1.48). Patients in cohort 2 were more likely to be nonadherent to medications for diabetes (OR=1.72, 95% CI:1.48-1.99), hypertension (OR=1.69, 95% CI:1.54-1.85), hyperlipidemia (OR=2.01, 95% CI:1.76-2.29), hyperphosphatemia (OR=1.74, 95% CI:1.55-1.95), and hyperparathyroidism (OR=2.08, 95% CI:1.66-2.60) after reaching the coverage gap. These patients had total health care costs that were $2,644 higher due to increased rates of hospitalization and outpatient visits, despite $2,419 lower pharmacy costs compared to patients in cohort 4 after controlling for covariates (p<0.0001). Reaching the Part D coverage gap was associated with decreased medication adherence and unfavorable clinical and economic outcomes in dialysis patients. / text

The purpose of this study was to begin testing of a downward cross-level model for studying the ability of older adults to transition from a nursing home after a Medicare Part A reimbursed stay. Transitions are known to be a weak point in the provision of healthcare to older adults and thus far, research has not identified those factors that influence older adult's transitions i.e., from the nursing home after a post acute stay. The theoretical background for this study was supported by Resource Dependency Theory which is a theory that contends that organizations are externally controlled by activities outside the organization such as the "free-market" economic model that predominates the nursing home industry. It was thought that nursing homes may prioritize their need for resident census above the resident's need for discharge. The hypothesis was that both individual resident characteristics and organizational characteristics might influence the ability of older adults to transfer from the nursing home after a Medicare Part A stay. The method of analysis in this study was contextual regression. Individual and facility characteristics were the independent variables and length of stay was the dependent variable. For this project, emphasis was placed on the development of a methodology for using the MDS in this and future research studies. Selection of variables and methods for variable computation were highlighted. Individual and facility characteristics and discharge disposition (level of care) were reported descriptively. Although facility characteristics did not contribute significantly to the model, individual characteristics explained 28% of the variance in the length of stay. Fifteen percent of individuals in the sample died during their Medicare Part A stay and 18% were readmitted to the hospital. The most prevalent diagnoses of the sample were hypertension (35%), falls (34%) and arthritis (32%). Findings suggest that individual characteristics account for only a portion of the length of stay for post acute nursing home residents. Further model testing is needed and should include a larger facility sample size and market characteristics to determine if those factors significantly influence the ability of older adults to transfer after the Medicare Part A stay ends.

Purpose: The purpose of this research was to estimate the impact of Medicare Part D on prescription and medical utilization among Arizona's senior dual eligible population.Methods: Generalized estimating equations were used to analyze changes in utilization among dual eligibles (Arizona Health Care Cost Containment (AHCCCS) beneficiaries between the ages of 66 and 80 as of January 1, 2006) relative to a "comparison" group ineligible for Part D (AHCCCS beneficiaries between the ages of 50 and 62 as of January 1, 2006) for the first two years following the implementation of Part D. Medical and pharmacy claims from AHCCCS from January 1, 2005 to December 31, 2007 were used in this analysis.Results: The dual eligibles and Part D ineligible comparison group were similar in their level and trend of utilization of over-the-counter (OTC) medications and benzodiazepines in the pre-Part D period. Following implementation of Part D, there was an immediate decline in utilization of both OTC medications and benzodiazepines in the dual eligibles relative to the comparison group (p<0.001).Increasing trends for both the dual eligible and comparison group were observed during the pre-Part D period for total prescription utilization, generic medication utilization and antidepressant use. After the implementation of Medicare Part D, utilization of these drug classes was significantly lower among the dual eligibles relative to the comparison group.Trends in physician office visits were similar between the dual eligible group and comparison group for the entire study period. During the first month of Part D, the dual eligibles had a statistically significantly larger increase in physician visits over the previous month relative to the comparison group (p=0.001). The trend in hospitalizations between the two groups significantly differed during the pre-period, precluding meaningful comparisons between the groups for this particular outcome.Conclusion: This study supports the belief that medication use for dual eligible Medicare beneficiaries was disrupted by the transition of outpatient drug benefits from Medicaid to Medicare Part D.