1 One Program, Two Populations: A Comparison of Disabled Workers and Retirees in Medicare Jae Kennedy, PhD Darren Liu, DrPH Josh Engle, MHPA Liz Blodgett, MHPA (cand) WSU Dept. of Health Policy and Administration
2 Research Support Funding National Institute of Disability and Rehabilitation Research Field Initiated Research Project Project Title Assessing the Impact of Medicare-D on SSDI Beneficiaries (H133G070055) Study Sites Spokane WA & San Diego CA Three year project FY 07 $199,955; FY 08 $199,706; FY 09 $199,830 Methodology study uses a multimethod, repeated-measures approach
3 Program and Policy Overview SSDI and Medicare
4 Medicare program Established in 1965 (benefits extended to SSDI beneficiaries in 1972). Insures ~43 million elderly and disabled Americans at an annual cost of over $375 billion. Part A - inpatient hospital care. Part B - physician services, preventive services, and outpatient care. Part C - established in 1997, allows private HMOs to offer Medicare Advantage (MA) plans. Part D - introduced in 2006, creates private prescription drug plans (PDPs).
5 Medicare Part D The most significant change in Medicare coverage since the program s inception Beneficiaries receive drug benefits by enrolling in private PDPs or MAPs There is considerable variability in premiums, costsharing requirements, and coverage The most notorious limit is the doughnut hole: beneficiaries receive partial coverage for prescription drugs up to an annual cap of $2,250, but are fully responsible for the next $2,850 in drug costs. If they exceed $5,100 in total drug costs in a given year, beneficiaries become eligible for catastrophic coverage.
6 SSDI program Established in 1956, SSDI now provides cash benefits to over 6.8 million American workers and 1.8 million dependents, at a total annual cost of about $92 billion. Applicant must go through a multi-stage evaluation to demonstrate the inability to engage in any substantial gainful activity because of a medically determinable impairment. Preliminary SSA review of applications takes about four months more than half of the applications are denied. Appeals, which can take a year or longer, push the allowance rate for applicants to about 62% Average monthly benefits in 2006 were $978 for disabled workers and $1,044 for retired workers.
7 SSDI and Medicare eligibility SSDI beneficiaries become eligible for Medicare 24 months after they are deemed eligible for Social Security benefits. Roughly 19% of SSDI beneficiaries are currently in this waiting period, and 32% of those beneficiaries have no health insurance at all. About one out of six SSDI beneficiaries have incomes low enough to qualify for Supplemental Security Income (SSI), and are consequently eligible for Medicaid benefits.
8 Policy relevance of disabled workers in Medicare Younger adults (age 18-65) currently comprise about 17% of the total Medicare population. Growth in Medicare enrollment for disabled workers has consistently outpaced overall program growth. Younger beneficiaries often have higher needs, and higher service costs, than retirees. Younger beneficiaries are more likely to encounter problems with access to needed care.
9 Disabled workers have proportionally higher annual enrollments than older beneficiaries driving up Medicare costs 10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% Aged Disabled
10 Study Methodology The Medicare Current Beneficiary Surveys
11 The Medicare Current Beneficiary Survey (MCBS) An ongoing national panel survey conducted by the Centers for Medicare and Medicaid Services (CMS) participants are interviewed multiple times over a three year period. Data divided into two annual files Access to Care (A2C) and Cost and Utilization (CU)
12 MCBS Sampling Strategy Sample included both community- and facilitydwelling beneficiaries. Stratified multistage sampling strategy, drawn from 107 primary sampling units (PSUs). Oversampling of younger beneficiaries (aged 18-64) and older beneficiaries (age 85 or older). Total sample includes 2,907 beneficiaries aged and 12,862 beneficiaries age 65 or older
13 Statistical analysis The data set includes sample weights derived from the 2000 Decennial Census. Weighted population estimates are calculated using Professional Software for SUrvey DAta ANalysis for Multi-stage Sample Designs (SUDAAN). Estimates with high relative standard errors (>30%) are collapsed or flagged. Group comparisons are tested with the Wald X 2
14 Study limitations Self report (possible recall bias, social desirability, etc.) Policy analyses often contain a disclaimer like: This analysis is a snapshot of a rapidly changing system, but it s literally true in this case enrollment in part D was occurring while the survey was being conducted.
15 Key Findings Differences between disabled workers and retirees on Medicare
16 Sociodemographic attributes According to estimates derived from the 2006 MCBS, about 6.6 million adults under age 65 receive Medicare. Within this group, less than half (47.2%) are near retirement age (55-64). Compared to retirees, beneficiaries under age 65 are more likely to be male (51.9% vs. 42.6%), black or African American (17.8% vs. 7.8%), and Hispanic or Latino (10.3% vs. 7.1%). Younger beneficiaries are less likely to be married than retirees (41.5% vs. 56.2%), limiting social and economic support.
17 Sociodemographic attributes age or older est. N % est. N % TOTAL 6, % 33, % age , % <.001 age , % - age , % - age , % age 75 or older - 15, % Male 3, % 14, % 43.1 <.001 Female 3, % 19, % White or Caucasian 4, % 28, % 15.5 <.001 Black or African-American 1, % 2, % Asian % % Native American or Alaska Native % % Native Hawaiian or Pacific Isla nder % % Other race % % More than one race % % Hispanic or Latino origin % 2, % Married 2, % 16, % <.001 Never married 1, % % Divorced/seperated 1, % 2, % Widowed % 9, % Source: 2006 Medicare Current Beneficiary Survey, Fall (2006) Supplement, Access to Care; RSE> 30% X 2 p
18 Socioeconomic status and health insurance coverage Beneficiaries under age 65 are less likely to have a college degree than retirees (14.4% vs. 21.4%). They are also much more likely to be poor than retirees (67.5% have annual incomes of less than $20,000, compared to 38.4% of older Medicare beneficiaries). Because of their lower incomes, younger beneficiaries are much more likely than retirees to be eligible for Medicaid as well as Medicare insurance coverage (42.6% vs. 11.5%).
19 Socioeconomic status age or older est. N % est. N % TOTAL 6, % 33, % Income <.001 $10,000 or less 2, % 4, % $10,001 to $20,000 1, % 7, % $20,001 to $30, % 6, % $30,001 or more 1, % 12, % Education 12.9 <.001 not HS graduate 1, % 7, % HS graduate 1, % 8, % some college 1, % 6, % college graduate % 6, % Currently working % 4, % Source: 2006 Medicare Current Beneficiary Survey, Fall (2006) Supplement, Access to Care; RSE> 30% X 2 p
20 Health insurance coverage e st. N % est. N % Total 5, % 29, % Medicare health insurance coverage A only % 1, % 49.2 <.001 A and B 5, % 28, % Supple menta l health insurance covera ge age or older Private supplemental 1, % 18, % <.001 Medicare HMO % 6, % 36.8 <.001 Medicaid 2, % 3, % <.001 Source: 2006 Medicare Current Beneficiary Survey, Fall (2006) Supplement, Health Insurance X 2 p
21 Health and disability status Beneficiaries under age 65 are much more likely to describe their health as fair or poor (57.5% vs. 20.9%) and report limitations in one or more basic activities of daily living (29.8% vs. 15.0%). Nearly 90% of both age groups reported being diagnosed with one or more chronic conditions, but the specific conditions varied by age group. Of particular note is the relatively high rate of psychiatric conditions in the younger population (45.9% vs. 11.8%).
22 Health and disability status age or older est. N % est. N % Hype rtension/ High blood pre ssure 3, % 20, % 54.0 <.001 Arthritis 3, % 18, % Cardiovascular disease 2, % 13, % 28.3 <.001 Cancer 1, % 10, % <.001 Diabetes 1, % 7, % 20.4 <.001 Psychiatric conditions 3, % 3, % <.001 Emphysema, asthma or COPD 1, % 4, % 64.9 <.001 Neurological disease % 2, % 42.0 <.001 Number of limits in activities of daily living (ADLs) 61.0 <.001 none 4, % 28, % one % 1, % 2 or more 1, % 3, % Gene ral health (compared to others same age) <.001 Excellent % 5, % Very good % 9, % Good 1, % 10, % Fair 2, % 4, % Poor 1, % 1, % Source: 2006 Medicare Current Beneficiary Survey, Fall (2006) Supplement, Health Status and Functioning (community) X 2 p
23 Prescription drug coverage Disabled workers have similar rates of prescription drug insurance coverage (73.4%) to retirees (72.6%). Disabled workers were more likely to receive Medicare part D (38.3% vs. 11.0%). Because of their high rates of Medicaid coverage, disabled workers were much more likely to be auto-enrolled in Medicare Part D (29.4% vs. 8.7%). Disabled workers were more likely to apply for and receive a Low Income Subsidy (LIS) for their Part D benefits
24 Prescription drug coverage age or older est. N % est. N % Total 5, % 29, % Prescription drug coverage (any) 4, % 21, % Private supplemental 1, % 10, % <.001 Medicare HMO % 5, % 36.0 <.001 Part D 2, % 3, % <.001 Auto-enrolled in Part D 1, % 2, % <.001 Source: 2006 Medicare Current Beneficiary Survey, Fall (2006) Supplement, Health Insurance Note: Prescription insurance status collected during implimentation phase of Medicare D X 2 p
25 Part D Low Income Subsidy (LIS) age or older (1000s) % (1000s) % Did you apply for supplemental coverage (low income)? 43.0 <.001 yes % % no 2, % 14, % If yes, what is the status of the application? accepted % % denied % % pending % % Source: 2006 Medicare Current Beneficiary Survey, Winter (2007) Supplement, Prescription Drug Plans Note: Counts do not include autoenrolled beneficiaries X 2 p
26 Prescription drug access Younger beneficiaries are much more likely to deviate from their prescription drug regimen than retirees (36.5% vs. 13.6%), due primarily to cost. Younger beneficiaries also more likely to engage in other strategies to reduce drug costs. Prescription medication nonadherence has declined with the advent of Medicare D for younger and older beneficiaries.
27 Prescription drug access age or older (1000s) % (1000s) % Total 5, % 29, % Did not adhere to prescription regimen 2, % 4, % <.001 dela yed getting Rx because of cost 1, % 1, % <.001 took smaller doses to make Rx last longer 1, % 1, % <.001 decided not to fill Rx because of cost 1, % 1, % <.001 skipped doses to make Rx last longer 1, % 1, % <.001 Other Rx cost containme nt stra tegies asked for generic form of Rx 2, % 13, % 26.5 <.001 asked for Rx samples 2, % 13, % purchased Rx via mail/internet % 8, % <.001 shopped for best price s 1, % 4, % 29.5 <.001 spent less $ on other household ne eds 1, % 1, % <.001 purchased Rx from outside the US % % Source: 2006 Medicare Current Beneficiary Survey, Fall (2006) Supplement, Access to Care X 2 p
28 Prescription medication nonadherence: Percent of Beneficiaries reporting PMNA 30.0% 25.0% 20.0% % 10.0% 5.0% MCBS Survey Year
29 2005 Prescription Medicine Cost & Use (Pre-D) Working-age Medicare beneficiaries report higher annual total prescription costs ($3,206 vs. $2,048) and overall utilization (43 PMEs vs. 31), compared to the elderly Medicare population. Based on the standard benefit structure for Part D prescription drug plans, roughly 47% of working-age beneficiaries report total costs that would exceed the doughnut hole threshold, versus only 34% of the elderly. A greater proportion of younger beneficiaries also would qualify for catastrophic coverage (21.1% vs. 8.8%).
30 Conclusions Differences between disabled workers and retirees on Medicare
31 Disabled workers are a distinct beneficiary population They tend to be poorer, less educated, than retirees On average, disabled workers are less healthy, and more limited Psychiatric conditions are common in this population Despite these problems, many disabled workers say they would like to return to work
32 Disabled workers are more reliant on supplemental programs Dual eligibility receipt of Medicaid and Medicare is much more common among disabled workers Low income subsidy disabled workers are more likely to seek out and receive a Part D LIS
33 Disabled workers have more difficulty getting medical care Along with prescription drugs, disabled workers are more likely to postpone other forms of medical care due to cost Although satisfaction in both groups is quite high, disabled workers report more problems and less satisfaction with their drug plans, HMOs, and health care providers
34 Further research Differences between disabled workers and retirees on Medicare
35 The Medicare waiting period The waiting period is a shocking limitation to SSDI Applicants have undergone clinical and vocational evaluation and have been deemed unable to engage in substantial gainful employment due to a clinically verifiable health condition Clearly in need of health insurance coverage, as well as benefit checks The wait period is at the top of many advocates agenda for Medicare reform
36 Decoupling health insurance and disability insurance TWWIIA and other RTW programs don t fully address the perceived risks to health insurance and financial stability Medicare for all could be pricey, but Medicare for all workers with disabilities could eliminate a major barrier to workforce participation and reduce one big incentive for enrolling in SSDI
37 Disabled workers are an obvious target for disease management Integration of primary care, specialty care, and rehabilitation could slow the progression of chronic conditions and associated costs Given the lengthy period of participation, disabled workers in DM programs are more likely to show a return on investment
38 For more information Jae Kennedy, Ph.D., Associate Professor Department of Health Policy and Administration School of Pharmacy, Washington State University Academic Center, Suite 411, PO Box 1495 Spokane, WA Telephone: (509) Fax: (509)
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