Association between Medicare Program Type and Health Care Access, Acute Care Utilization, and Affordability Among Adults with Cardiovascular Disease

Abstract

Background:

Medicare Advantage plans now provide health insurance coverage to more than 24 million older adults in the US, and enrollment is increasing among individuals with cardiovascular disease (CVD). Whether Medicare Advantage enrollment is associated with similar health care access, acute care utilization, and financial strain for adults with CVD compared with traditional Medicare is unknown.

Methods:

We performed a cross-sectional study of Medicare beneficiaries 65 years or older with CVD using the 2019 National Health Interview Survey. We fit multivariable logistic regression models to examine the association of Medicare program type (Medicare Advantage vs traditional Medicare) with measures of health care access, acute care utilization, and affordability.

Results:

The weighted population included 11,013,437 Medicare beneficiaries, of whom 3,922,104 (35.6%) were enrolled in Medicare Advantage and 7,091,334 (64.4%) were enrolled in traditional Medicare. Medicare Advantage and traditional Medicare enrollees were similar with respect to age, gender, racial/ethnic distribution, and household income; however, Medicare Advantage beneficiaries were more likely to live in an urban setting (82.7% vs 76.0%, p=0.01) and to be college educated (24.2% vs 19.0%, p=0.01). Medicare Advantage beneficiaries were more likely to have a usual source of care (93.5% vs 88.9%; OR 1.99, 95% CI 1.33–2.98); however, there were no other differences in health care access or utilization. Medicare Advantage beneficiaries were more likely to have problems paying medical bills (16.5% vs 11.6%; OR 1.68, 1.17–2.40) and to worry about paying medical bills (40.1% vs 33.8%; OR 1.37, 1.07–1.76) compared to those enrolled in traditional Medicare.

Conclusions:

Adults with CVD in Medicare Advantage were more likely to experience financial strain related to their medical bills compared to those in traditional Medicare. As enrollment in Medicare Advantage grows, policy efforts should focus on ensuring care is affordable for patients with cardiovascular disease.

INTRODUCTION

In the United States, the burden of cardiovascular disease (CVD) remains high among older adults ¹. Individuals with CVD face barriers in access to care ², which is associated with excess morbidity and mortality ³, and disproportionately suffer from financial strain associated with their medical conditions ^4,5. Therefore, finding ways to increase health care access and reduce the financial burden of care is critical to improving outcomes for adults with CVD ⁶.

One potential way to improve access and affordability of care is through health insurance design. While many adults age 65 years or older are insured by traditional fee-for-service Medicare, the Medicare Advantage program gives beneficiaries the option of receiving health benefits through private insurance plans ⁷. Medicare Advantage plans frequently employ measures to control costs such as restricted provider networks and prior authorization strategies. However, they also commonly provide additional benefits (e.g., prescription drug coverage, hearing, vision, and dental) and services (e.g., care coordination, disease management coaching), and also limit out-of-pocket spending for Medicare covered services in order to attract beneficiaries ⁸. These specific features of Medicare Advantage plans may impact health care access and affordability for adults with CVD in a positive, or potentially negative, manner. However, little is known about how this high-risk population – who are at greater risk for adverse health outcomes – fare under Medicare Advantage plans compared with those in traditional Medicare. Understanding these patterns is especially important as enrollment in Medicare Advantage plans has doubled over the past decade and beneficiaries have become increasingly medically complex, with over 60% suffering from at least four chronic conditions ^7,9.

Therefore, in this study we aimed to answer 3 questions. First, what are the clinical and sociodemographic characteristics of adults age 65 years and older with CVD who are enrolled in Medicare Advantage compared to those enrolled in traditional Medicare? Second, do measures of health care access and acute care utilization differ between adults age 65 years or older with CVD who are enrolled in Medicare Advantage plans vs. traditional Medicare? Third, how do measures of health care affordability, including financial strain due to medical bills and cost-related barriers to prescription medication use, compare between these groups?

METHODS

Study Population

We used the 2019 National Health Interview Survey (NHIS) from the National Center for Health Statistics at the Centers for Disease Control and Prevention. The NHIS is a cross-sectional, nationally representative, household survey that includes approximately 30,000 non-institutionalized adults (≥18 years) per year ¹⁰. The survey questionnaire includes data on respondent demographics, health insurance, presence of specific health conditions, health care access and utilization, and health care affordability. The data that support the findings of this study are publicly available, and additional materials can be made available for the purposes of reproducing the results upon reasonable request.

Our study population included adults age 65 years and older with CVD whose primary insurance was either Medicare Advantage or traditional Medicare (both parts A and B). We defined CVD based on a self-reported history of either coronary heart disease, angina, myocardial infarction, or cerebral vascular accident. Patient demographics, including age, sex, race and ethnicity (non-Hispanic [NH] White, NH Black, NH Asian, Hispanic, Other), as well as other socioeconomic (education, household income) and geographic characteristics (urban versus rural, US region) were included, as reported at the time of survey.

Study Outcomes

We examined outcomes across three domains: (1) health care access, (2) acute care utilization, and (3) affordability of health care.

Health care access was evaluated based on whether an individual had (1) a usual source of care, (2) a physician visit within the last year, and (3) received routine cardiovascular monitoring including yearly blood pressure, cholesterol, and blood sugar checks. Measures of acute care utilization included whether an individual had (1) ≥ 2 urgent care visits, (2) at least one emergency room visit, and (3) at least one overnight hospitalization within the past year.

Affordability of health care was evaluated based on financial strain due to medical bills and cost-related barriers to prescription medications. Financial strain was determined based on whether individuals reported (1) problems paying medical bills within the last year, (2) inability to pay current medical bills (among those with problems paying bills), (3) worry about paying medical bills if person were to get sick, (4) delaying care due to cost within the last year, and (5) not seeking care due to cost within the last year. Cost-related barriers to prescription medication use (among those taking medications) included (1) skipping prescription medication doses to save money, (2) taking less medication to save money, (3) delaying filling prescription medication to save money, as well as (4) not obtaining a needed prescription due to cost (among all respondents). All outcomes were self-reported and adults were asked regarding their experiences within the last one year.

Statistical Analysis

We first compared the baseline characteristics of adults with CVD in Medicare Advantage vs. traditional Medicare using the second-order Rao-Scott chi-squared test¹¹.

Next, we calculated observed rates of each outcome by Medicare program type and fit a logistic regression model to examine the association of enrollment in Medicare Advantage (vs. traditional Medicare) with each outcome. Multivariable logistic regression models were then estimated adjusting for demographics (age, gender, race/ethnicity), socioeconomic characteristics (educational attainment, household income), and geographic variables (urban-rural status and US region [Northeast, Midwest, South, West]).

For all analyses, nationally representative estimates were generated using NHIS survey weights. NHIS weights account for the complex two-level sampling design (stratification and clustering) as well as non-response ^12,13. The target patient sample was treated as an unconditional subgroup (i.e., the subgroups were unevenly or sparsely distributed across different strata and clusters) of the full NHIS 2019 adult sample. The variance and confidence intervals were estimated using the Taylor series estimator taking into consideration the complex survey design¹¹. Confidence intervals were estimated using the Taylor series linearization method.

A p-value threshold of <0.05 was used to determine statistical significance. All statistical analyses were two-sided and were conducted using SAS version 9.4 (SAS Institute, Cary, NC), procedures SURVEYFREQ and SURVEYLOGISTIC ^11,14. Institutional review board approval was not required by Beth Israel Deaconess Medical Center because the National Bureau of Economic Research has deemed research involving NHIS does not require IRB review.

RESULTS

Baseline characteristics

The study population included 1,956 respondents corresponding to a weighted national total of 11,013,437 adults, of which 3,922,104 (35.6%) were enrolled in Medicare Advantage and 7,091,334 (64.4%) in traditional Medicare. The baseline characteristics of adults enrolled in Medicare Advantage vs. traditional Medicare were similar, including age, gender, racial/ethnic distribution, household income, and US region, as shown in Table 1. However, Medicare Advantage beneficiaries were more likely to live in an urban setting (82.7% vs 76.0%, p=0.01) and to be at least college educated (24.2% vs 19.0%, p=0.01).

Table 1.

Baseline Characteristics of Medicare Beneficiaries Age ≥65 Years with Cardiovascular Disease by Medicare Program Type, 2019

Characteristic	Medicare Advantage*	Traditional Medicare	P-value
Population size, n (%) †	922,104 (35.6%)	7,091,334 (64.4%)
Age, years (%)			0.27
65–69	19.6	19.3
70–74	27.3	22.5
75–79	18.2	21.6
80–84	16.1	16.7
>85	18.8	19.8
Female (%)	48.3	44.9	0.22
Race (%)			0.91
Non-Hispanic White	77.1	79.4
Non-Hispanic Black	9.8	9.1
Non-Hispanic Asian	2.2	1.8
Hispanic	7.8	7.3
Other	3.0	2.4
Urban (%)	82.7	76.0	0.01
US Region (%) ‡			0.12
Northeast	15.6	19.7
Midwest	23.3	22.0
South	39.4	41.0
West	21.7	17.3
College educated (%) §	24.2	19.0	0.01
Household Income (%)			0.15
0–34,999	44.7	41.5
35,000–49,999	13.5	18.3
50,000–74,999	18.0	16.8
75,000–99,999	9.4	10.8
100,000 or greater	14.4	12.6
Cardiovascular Conditions (%) ∥
Coronary heart disease	61.3	60.0	0.62
Angina	20.0	18.6	0.51
Myocardial Infarction	39.5	39.1	0.90
Cerebral vascular accident	33.8	36.7	0.29
Other Chronic Conditions (%)
Hypertension	78.0%	79.6%	0.48
Hyperlipidemia	67.1%	65.5%	0.54
Prediabetes	32.2%	35.0%	0.28
Diabetes	31.3%	30.5%	0.78
Asthma	14.8%	13.8%	0.66
Cancer	30.3%	30.9%	0.81
Chronic obstructive pulmonary disease	20.6%	17.5%	0.16
Dementia	8.6%	7.4%	0.48

^*Medicare Advantage enrollment was defined as answering “yes” to the question “Are you enrolled in a Medicare Advantage plan?”

^†National estimates based on survey weights for the 2019 National Health Interview Survey

^‡US Census Bureau regions

^§Missing rates for college educated status were 0.4%. All other covariates had complete information

^∥Presence of cardiovascular conditions was self-reported based on an answer of “yes” to one of four questions (e.g., “have you ever been told by a doctor or other health professional that you have coronary heart disease?”)

Health Care Access

Medicare Advantage beneficiaries were more likely to have access to a usual source of care compared to those enrolled in traditional Medicare (93.5% vs 88.9%, adjusted OR 1.99, 95% CI 1.33–2.98). Despite this, there were no differences in access to routine outpatient care as determined by the percentage of patients with a recent physician visit (98.6% vs 98.7%, adjusted OR 0.98, 95% CI 0.44–2.20) (Table 2). There were also no differences in routine cardiovascular monitoring as both groups had high rates of blood pressure (99.0% vs 99.3%, adjusted OR 0.66, 95% CI 0.25–1.76), cholesterol (94.8% vs 96.2%, adjusted OR 0.71, 95% CI 0.44–1.13), and blood sugar (94.5% vs 94.9%, adjusted OR 0.81, 95% CI 0.53–1.23) checks within the last year.

Table 2.

Association of Medicare Program Type with Health Care Access and Utilization Among Adults Age ≥65 Years with Cardiovascular Disease^{* †}

	Medicare Advantage (%)	Traditional Medicare (%)	Unadjusted OR (95% CI)	Adjusted OR (95% CI) §
Health Care Access
Is there a place that you usually go if you are sick and need health care? ‡	93.5	88.9	1.79 (1.22, 2.63)	1.99 (1.33, 2.98)
Have you had a doctor visit within the last year?	98.6	98.7	0.90 (0.39, 2.05)	0.98 (0.44, 2.20)
Have you had your blood pressure checked within the last year?	99.0	99.3	0.59 (0.22, 1.60)	0.66 (0.25, 1.76)
Have you had your cholesterol checked within the last year?	94.8	96.2	0.73 (0.45, 1.19)	0.71 (0.44, 1.13)
Have you had your blood sugar checked within the last year?	94.5	94.9	0.92 (0.59, 1.45)	0.81 (0.53, 1.23)
Acute Care Utilization
Have you visited an urgent care clinic ≥ 2 times in the last year?	3.1	4.1	0.74 (0.39, 1.40)	0.69 (0.37, 1.28)
Have you visited an emergency department in the last year?	39.2	38.1	1.05 (0.84, 1.30)	1.03 (0.82, 1.29)
Have you had an overnight hospital stay in the last year?	29.7	29.0	1.03 (0.81, 1.32)	1.01 (0.79, 1.30)

^*Percentages represent proportion of respondents answering ‘yes’

^†For each outcome, responses of “Refused”, “Not ascertained”, or “Don’t know” were set to missing; adults with a missing response were excluded from the analysis of the respective outcome (<1% across all outcomes except for cholesterol [2.1%], blood sugar check [3.4%])

^‡Individuals were identified as not having a usual source of care if they reported that they did not have a usual place to go when they are sick or if they identified an urgent care center or hospital emergency room as their usual source of care

^§Models were adjusted for age, gender, race/ethnicity, educational attainment, household income, urban-rural status, and US region

Acute Care Utilization

In terms of acute care utilization, the percentage of adults in Medicare Advantage vs. traditional Medicare with 2 or more urgent care visits in the past year did not significantly differ (3.1% vs 4.1%, adjust OR 0.69, 95% CI 0.37, 1.28). In addition, the percentage of adults with at least one emergency department visit (39.2% vs 38.1%, adjusted OR 1.03, 95% CI 0.82, 1.29), or overnight hospitalization (29.7% vs 29.0%, adjusted OR 1.01, 95% CI 0.79–1.30) did not differ between groups.

Affordability of Health Care

Medicare Advantage beneficiaries were more likely to have problems paying medical bills within the last year (16.5% vs 11.6%, adjusted OR 1.68, 95% CI 1.17–2.40) and to worry about paying medical bills if they were to get sick (40.1% vs 33.8%, adjust OR 1.37, 95% CI 1.07–1.76) (figure 1). In addition, those in Medicare Advantage were more likely to not seek medical care due to costs (5.6% vs 3.2%, adjusted OR 1.70, 95% CI 0.97–2.98), although this difference was not statistically significant. With respect to financial barriers to prescription medications, Medicare Advantage beneficiaries were more likely to delay filling a prescription to save money (6.9% vs 4.3%, adjust OR 1.65, 95% CI 0.98–2.79) and not obtain a needed prescription due to cost (7.7% vs 5.4%, adjusted OR 1.41, 95% CI 0.91–2.19), although these differences were not statistically significant (table 3).

Figure 1. Comparison of financial strain among patients with CVD enrolled in Medicare Advantage vs Traditional Medicare.

Caption: Self-reported measures of health care affordability among patients with CVD, including measures of (A) financial strain due to medical bills and (B) cost-related barriers to prescription medication. After adjustment for demographic, socioeconomic, and geographic variables Medicare Advantage beneficiaries were significantly more likely to have problems paying medical bills within the last year and to worry about paying medical bills if they were to get sick. Rx = prescription medication.

Table 3.

Association of Medicare Program Type with Affordability of Health Care Among Adults Age ≥65 Years with Cardiovascular Disease^{* †}

	Medicare Advantage (%)	Traditional Medicare (%)	Unadjusted OR (95% CI)	Adjusted OR (95% CI) ∥
Financial strain due to medical bills
Have you had problems paying or were you unable to pay any medical bills within the last year?	16.5	11.6	1.51 (1.07, 2.13)	1.68 (1.17, 2.40)
Do you currently have any medical bills you are unable to pay? ‡	9.9	7.4	1.38 (0.88, 2.19)	1.46 (0.91, 2.35)
If you get sick, are you worried you will not be able to pay your medical bills?	40.1	33.8	1.31 (1.02, 1.67)	1.37 (1.07, 1.76)
Have you delayed care due to cost within last year?	4.9	3.0	1.67 (0.94, 2.99)	1.48 (0.79, 2.75)
Have you avoided medical care due to cost within last year?	5.6	3.2	1.79 (1.04, 3.07)	1.70 (0.97, 2.98)
Cost-related barriers to prescription medication
Have you skipped medication to save money within the last year? §	4.4	4.0	1.12 (0.66, 1.90)	1.10 (0.62, 1.96)
Have you taken less of your medication to save money within the last year? §	5.0	4.8	1.05 (0.60, 1.83)	1.03 (0.58, 1.82)
Have you delayed filling a prescription medication to save money within the last year? §	6.9	4.3	1.65 (1.00, 2.7)	1.65 (0.98, 2.79)
Have you avoided filling a prescription medication due to cost within the last year?	7.7	5.4	1.45 (0.97, 2.17)	1.41 (0.91, 2.19)

^*Percentages represent proportion of respondents answering ‘yes’

^†For each outcome, responses of “Refused”, “Not ascertained”, or “Don’t know” were set to missing; adults with a missing response were excluded from the analysis of the respective outcome (<1% across all outcomes except for cholesterol [2.1%], blood sugar check [3.4%])

^‡Among individuals who reported having problems paying or being unable to pay any medical bills within the last year

^§Among individuals taking prescription medications

^∥Models were adjusted for age, gender, race/ethnicity, educational attainment, household income, urban-rural status, and US region

DISCUSSION

In this nationally representative study, Medicare Advantage beneficiaries with CVD were more likely to have a usual source of care compared to traditional Medicare beneficiaries. However this did not translate into significant differences in physician visits, routine cardiovascular monitoring, or utilization of acute care services. In addition, Medicare Advantage beneficiaries were also more likely to experience financial strain due to medical bills.

Over the past decade, enrollment in Medicare Advantage has rapidly increased, particularly among adults with chronic conditions, and more than 24 million adults in the US are now covered by these plans ^7,9,15. Therefore, our finding that older adults with CVD in Medicare Advantage are more likely to experience financial strain due to medical bills than those in traditional Medicare is concerning. In contrast to prior work that has examined total spending or episode of care costs for Medicare Advantage beneficiaries ^16,17, we evaluated self-reported measures of financial strain for a higher-risk population with CVD, which provides important insights on patients’ experience. The differences in measures of financial strain that we observe are noteworthy given that federal regulations limit total cost-sharing for Medicare Advantage beneficiaries and this finding may be a function of the high rates of supplemental insurance coverage observed among traditional Medicare beneficiaries ¹⁸. Additionally, because CVD patients have higher total cost of care and frequently require specialty and acute care services ¹, it is possible that they are disadvantaged by the cost-sharing structure of Medicare Advantage plans; for example by receiving more out-of-network care with resultant higher out-of-pocket costs.

While we found that one measure of health care access was better for Medicare Advantage patients (e.g., usual source of care), all other measures of access and acute care utilization did not differ between groups. Health care access and utilization patterns among Medicare Advantage beneficiaries have been studied for a large number of outcomes in diverse patient populations¹⁹. Prior work has generally shown that Medicare Advantage enrollees have more frequent outpatient visits and better CVD screening rates ^20,21, fewer emergency department visits ^22–24, and fewer hospital admissions ^16,24,25, compared to those enrolled in traditional Medicare. In our study, many of these patterns were not observed. The mechanisms underlying these findings require additional investigation, however, it is possible that the typical utilization management strategies employed by many Medicare Advantage plans are designed for a healthier patient cohort and may not be as effective for higher-risk patients with CVD.

Higher payments for Medicare Advantage enrollees (relative to traditional Medicare) create an additional $7 billion in costs annually for the federal government.²⁶ In order to justify this higher cost, Medicare Advantage plans are expected to demonstrate superior value by finding ways to improve the quality of care (e.g., health care access, utilization, and affordability) for their beneficiaries. For adult CVD patients, our findings suggest this may not be the case. While Medicare Advantage plans are already systematically evaluated by the Centers for Medicare and Medicaid Services through a Star Rating System, more targeted or disease-specific outcome measures may be needed to incentivize plans to develop tailored management strategies for key sub-populations. Policy interventions like these are especially important for high-cost and resource intensive populations like elderly adults with CVD.

Limitations

This study has several limitations. First, we examined self-reported measures of access, utilization, and affordability, which have been used in prior studies ^27–29. Although our study did not use electronic health record or administrative claims data, it provides important insights based on patients’ perspectives and our findings on differential affordability were consistent with studies evaluating the overall Medicare population ⁸. Second, Medicare Advantage penetration is variable across the country and often related to favorable market dynamics. In addition, market penetration has been shown to have spillover effects that could affect the care delivered to the general Medicare population ³⁰. While county-level information was not available in our data, we did account for geographic region and urban versus rural areas in our analysis. Third, the Medicare Advantage program is made up of many heterogenous plans that provide different benefits and have variable cost-sharing structures. Therefore, while these findings represent an overall assessment of access and affordability across all Medicare Advantage plans, it is possible that specific plans perform better on these measures than others. Identifying the potential drivers of plan-specific efficiencies is an important area for future research.

CONCLUSION

Medicare Advantage beneficiaries with CVD were more likely to have a usual source of care compared to those in traditional Medicare. However, Medicare Advantage enrollment was associated with increased financial strain across several measures. As Medicare Advantage grows in popularity, policy strategies may be needed to ensure that care is affordable for high-risk patients with cardiovascular disease.

CLINICAL PERSPECTIVES.

What is known?

• Older adults with cardiovascular disease frequently face barriers in access to care and disproportionately suffer from financial strain associated with their medical conditions, placing them at higher risk for poor health outcomes.

• Enrollment in the Medicare Advantage programs has rapidly increased over the past decade, particularly among individuals with chronic conditions like cardiovascular disease.

What the study adds?

• Among adults with cardiovascular disease, those enrolled in Medicare Advantage plans had better access to a usual source of care compared to those in traditional Medicare, but there were no differences in routine cardiovascular monitoring or acute care utilization.

• Adults with cardiovascular disease in Medicare Advantage were more likely to experience financial strain due to medical bills than those in traditional Medicare

Abbreviations and Acronyms

CVD

cardiovascular disease