Unbiased Analysis of Today's Healthcare Issues
How does formulary restrictions impact health outcomes for patients with multiple sclerosis (MS)? To answer this question, Blaylock, Van Nuys and Joyce (2025) use data 100% Medicare claims data from 2018-2022 covering patients with both prescription drug plans (PDPs) and Medicare Advantage Prescription Drug plans (MA-PDs). Individuals were categorized as above vs. below average formulary…
According to a recent Health Affairs Perspective from Michael Chernew, the answer is ‘no’. In fact, physician and hospital prices may be too low. Although much has been made of high prices contributing to high spending in the US, 5 spending growth in Medicare is not driven by price growth. In fact, inflation-adjusted Medicare physician…
How does a hospital’s participation in a health plan’s Medicare Advantage (MA) provider network impact their commercial rates? Since many insurers offer both MA plans and commercial plans, there could be spillovers with respect to negotiating. How would MA network participation impact commercial rates? Marr et al. (2025) offers some hypotheses: On the one hand,…
The answer is ‘yes’ according to a paper by Borrelli et al. (2025). The authors use annual Medicare Star Rating health plan performance for Medicare Advantage-Part D (MAPD) plans over the past decade (2015 to 2024). They find that: For plans achieving at least 4 stars on the medication adherence measures, 70%-74% of them also…
My FTI colleagues Mark Van Ert and Krunal Patel summarize some of the new quality measures that will be incorporated into the 2025 CMS Star Ratings that are used to evaluate Medicare Advantage (MA) plans. The CMS Star Ratings are very important as CMS payments to MA plans is expected to increase by 3.7% or…
Recently, the Inflation Reduction Act (IRA) is getting a lot of attention, particularly for its provision that allows CMS to start drug price negotiation for selected drugs 9 (small molecules) or 13 (biologics) years after drug launch. However, the Centers for Medicare and Medicaid Innovation (CMMI) has proposed a number of a number of payment…
To account for differences in disease burden across a Medicare Advantage (MA) plans patient population, uses risk adjustment based on patient disease burden. Specifically, MedPAC notes that: Medicare uses beneficiaries’ characteristics, such as age and prior health conditions, and a risk-adjustment model—the CMS hierarchical condition categories (CMS– HCCs)—to develop a measure of their expected relative…
How does Medicare Advantage market share impact skilled nursing facility (SNF) profitability? That is the question asked by Marr and Shen (2024). Using data from Medicare SNF cost reports, LTCFocus.org data, and county MA penetration rates, the authors use an ordinary least squares regression with SNF and year fixed effects examining how MA penetration impacts…
Medicare Advantage (MA) plans have a number of advantages and drawbacks over traditional Medicare (TM) (i.e., fee-for-service). One advantage of MA plans is that cost sharing is often lower. Another benefit is that enrollees may receive additional coverage benefits. One drawback is that enrollee provider choice may be restricted. Fewer provider options may be bad…
Now that 51% of Medicare beneficiaries are enrolled in Medicare Advantage (MA), one key question is how restrictive are MA narrow networks? While beneficiaries enrolled in Medicare fee-for-service can choose any provider, MA plans can impose restrictions on enrollee’s provider choices. Measuring how restrictive an MA plan is, however, is difficult because “restrictiveness” is a…