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 Pair of New Studies Point to Holes in Medicare Coverage

Two new studies said Medicare beneficiaries with a serious illness are finding it increasingly difficult to pay their medical bills even as they receive support from the government-funded program. This is mainly because of skyrocketing out-of-pocket costs and the fact some care is not covered by Medicare, the report said.

First off, a survey in Health Affairs said slightly more than half of Medicare beneficiaries with a chronic illness have experienced financial hardship when seeking care, with the most pressing concern their ability to pay for prescription drugs and hospital bills.

The study, “Financial Hardships Of Medicare Beneficiaries With Serious Illness,” said overall beneficiary satisfaction with Medicare is high, but that comes with a caveat that many respondents to the survey have supplemental insurance to fill in the gaps of traditional Medicare coverage. A second study published by the Kaiser Family Foundation examined Medicare beneficiaries’ out-of-pocket spending. The average for this area was $5,460 per year in 2016, which included premiums. Leading the way on expenses was long term care, with beneficiaries with diseases most likely to result in long term care, like Alzheimer’s or other types of dementia recording the highest spending.

For the Kaiser study, the medical and long term care services included in their analysis included dental services, inpatient hospital services, long term care facility services, skilled nursing care, medical providers and supplies, outpatient hospital services, and prescription drugs. In looking closer at the numbers, Kaiser said “not surprisingly,” beneficiaries living in long term care (LTC) facilities (5 percent of traditional Medicare beneficiaries overall) spent significantly more on LTC services than the average beneficiary in traditional Medicare in 2016 ($19,632 versus $1,014). “Out-of-pocket spending was much higher among LTC facility residents who did not have Medicaid ($41,782), which is the primary source of public support for long term care,” the report said. Out-of-pocket spending on LTC facility services was also higher among beneficiaries with certain chronic conditions. Specifically, the data show those with Alzheimer’s disease or other types of dementia had a $9,565 expense per year on average, with that number at $27,308 among LTC residents only.

For Parkinson’s disease, the average was $4,120, but $28,165 among LTC residents only.

“Notably, these estimates of out-of-pocket spending on long term care facility services are lower than the median estimated annual cost of a private room in a long term care facility, which was $92,000 in 2016,” Kaiser said. A possible reason for the discrepancy is that the average out-of-pocket spending estimates include Medicare beneficiaries who resided in a LTC facility for less than a full year, the report said. Kaiser said average spending on prescription drugs was higher for beneficiaries with multiple chronic conditions and those in relatively poor self-reported health status. “In 2016, traditional Medicare beneficiaries with five or more chronic conditions spent $1,065 on prescription drugs, on average, compared to $416 among those with one or two chronic conditions,” the report said. Those beneficiaries in poor self-reported health spent $1,018 on prescription drugs, compared to $410 for those categorized as in excellent self-reported health. On the question of which beneficiaries are impacted the most by high out-of-pocket expenses, Kaiser said its analysis shows that half of all beneficiaries in traditional Medicare spent at least 12 percent of their income on out-of-pocket health care costs in 2016. One-quarter of all beneficiaries spent at least 23 percent of their incomes on health-related services in 2016, while 10 percent spent nearly half of their income. “The financial burden of health care as a share of income falls disproportionately on lower-income Medicare beneficiaries,” the report said. “Half of traditional Medicare beneficiaries with incomes below $10,000 spent at least 18 percent of their total per capita income on health care costs in 2016, compared to 7 percent for those with incomes of $40,000 or more.”

But, the report said having Medicaid coverage sharply cuts the out-of-pocket spending burden among low-income Medicare beneficiaries. Those individuals with Medicaid spent just 5 percent of total income on out-of-pocket costs in 2016, the authors said.


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