When Medicare managed care plans raise outpatient co-payments, they experience fewer outpatient visits but also more hospitalizations and longer inpatient stays, especially among chronically ill beneficiaries and those living in areas of poverty, a study showed.
The study, “Increased Ambulatory Care Copayments and Hospitalizations Among the Elderly,” concluded that increasing cost sharing for ambulatory care among elderly patients may have adverse health consequences and could increase total spending on health care (N. Engl. J. Med. 2010;362:320-8).
“In response to increases in ambulatory co-payments, the elderly cut back on outpatient visits but are more likely to need expensive hospital care,” said lead author Dr. Amal Trivedi of Brown University, Providence, R.I. “Therefore, increasing such co-payments among the elderly may be an ill-advised cost-containment strategy,” he said in an interview.
Dr. Trivedi and his colleagues compared the use of outpatient and inpatient care between Medicare enrollees in plans that had increased co-payments for ambulatory care in a given year and enrollees in matched plans that had not. Nearly 900,000 Medicare beneficiaries were included in the study of 2001-2006 data.
The mean co-payment increases were from about $7 to $14 for outpatient primary and about $12 to $22 outpatient specialty care, while the control plans kept co-payments at about $8 for a primary care visit and $11 for specialty care.
In the year after a plan would increase co-payments, it would have almost 20 fewer outpatient visits per 100 enrollees but more than two additional inpatient hospital admissions per 100 enrollees, adding about 13 additional inpatient days—compared with plans not increasing co-payments.
The study noted that the effect of increased co-payments was significantly greater among enrollees in areas with lower average income and education. “We didn't explicitly measure health status, but the increased need for acute hospital care among these enrollees is concerning,” Dr. Trivedi said.
The effect of co-payment increases also was magnified among Medicare managed care enrollees diagnosed with hypertension or diabetes and those who had histories of acute myocardial infarction, the study said.
The authors reported no conflicts of interest.