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In this episode, Matt & Lauren speak with Dr. Lianlian Lei, an Assistant Professor in the Department of Psychiatry at the University of Michigan. Dr. Lei discusses a recent study that looks at the impact of partner’s plan choice on the likelihood of Medicare Advantage disenrollment and how that may impact older adults living with dementia. Unlike traditional Medicare that's administered by the federal government, Medicare Advantage are healthcare plans that are administered by private health insurance companies. These plans can vary a lot and typically cover additional services not covered by traditional Medicare. Navigating the various plan options can be a challenge for older adults, and it's not uncommon for individuals to change plans depending on their current needs. 

More resources

Dr. Lianlian Lei Faculty Profile 

Article from Episode: Lei L, Levy H, Ankuda C, Hoffman GJ, Kim HM, Strominger J, Maust DT. Partner Plan Choices and Medicare Advantage Enrollment Decisions Among Older Adults. JAMA. 2024 Mar 20:e241773. doi: 10.1001/jama.2024.1773. Epub ahead of print. PMID: 38506841; PMCID: PMC10955388. 

Transcript

Matt Davis:

Today, approximately half of older adults are enrolled in Medicare Advantage Healthcare Plans. Unlike traditional Medicare that's administered by the federal government, Medicare Advantage, also sometimes referred to as Medicare Part C are healthcare plans that are administered by private health insurance companies. These plans can vary a lot and typically cover additional services not covered by traditional Medicare. Navigating the various plan options can be a challenge for older adults, and it's not uncommon for individuals to change plans depending on their current needs.

Today we're going to speak with the researcher who took a unique look at the impact of partner’s plan choice on the likelihood of Medicare Advantage disenrollment. We'll discuss the study and the implications for older adults living with dementia. I'm Matt Davis.

Lauren Gerlach:

I'm Lauren Gerlach.

Matt Davis:

And you're listening to Minding Memory. Today we're joined by Dr. Lianlian Lei. Dr. Lei is an Assistant Professor in the Department of Psychiatry at the University of Michigan Medical School. Her research focuses on aging, dementia care, and healthcare insurance. Dr. Lei is also an affiliate of the Center to Accelerate Population Research in Alzheimer's for which this podcast is affiliated. She's here today to speak with us about her recent study. Lianlian, welcome to the podcast.

Lianlian Lei:

Thank you. Thank you for this great opportunity.

Matt Davis:

Dr. Lei was the lead author of the study titled “Partner Plan Choice and Medicare Advantage Enrollment Decisions Among Older Adults” that was published in JAMA. A link to the article can be found attached to this episode. So to start things off, some of our listeners may not know all the details of Medicare. I was wondering if you could just give us a brief, high-level overview of the major parts of Medicare. In other words, what should our listeners know?

Lianlian Lei:

Medicare is the insurance, federal insurance for individuals aged 65 years or older adults, and also for this individuals younger than 65 years, but they have disabilities or end stage renal disease. So right now Medicare has four parts. Part A is the hospital insurance that covers services such as care in the hospital, skilled nursing facility care, hospice care. Part B is the medical insurance and it covers all patient care and physician services. Part D is the prescription drug benefits and it covers prescription medications. And then here also there is Part C that's also called Medicare Advantage. It is managed care, so it is not paid by Medicare directly, but Medicare will pay the private health insurance company, fix a certain amount of money each beneficiary, each month. So these private health companies will help take care of this, older adults of these beneficiaries. So right now there are growing popularity of Medicare Advantage. As you have just mentioned, it has been now covers more than half of Medicare beneficiaries.

Matt Davis:

And what do people mean when they talk about fee-for-service?

Lianlian Lei:

Yeah, fee-for-service, it's basically like how Medicare pays. Part A and Part B, it’s like when they get some kind of service, then Medicare will pay directly to their providers. So that's called fee-for-service. But so correct me if it's... But for Medicare Advantage, so that “managed care”, is not paid by fee-for-service. Medicare pays this private insurance companies a fixed amount for each beneficiary each month. So that's a capitated payment. So that's the difference among the fee-for-service and also the Medicare Advantage.

Matt Davis:

People have been talking a lot about how more and more people are enrolling in Medicare Advantage plans. Has that leveled off or are we still seeing kind of increases in more and more people moving from fee-for-service to Medicare part C or Medicare Advantage?

Lianlian Lei:

So I miss from now, so it is kept every year. It kept the number of older adults enrolling in Medicare Advantage compared to fee-for-service Medicare. It's kept increasing and also the predictions also says in the next 20 or 30 years it will still keep increasing. So it's like growing popularity of this Medicare Advantage population. So there is a lot of policy focus on this group now. Yeah.

Lauren Gerlach:

We know that Medicare Advantage plans can really vary a lot in terms of the type of services that they provide. Can you briefly tell our listeners some of the additional services that can be covered by Medicare Advantage plans that are not covered by traditional Medicare?

Lianlian Lei:

So yeah, there are some medical services that traditional Medicare, they don't cover. For example, like vision, hearing, dental. So we usually will get, the older adults usually will get to other insurance to cover this services even if they were in traditional fee-for-service Medicare. But many Medicare plans will cover this services, the vision, dental, hearing, and also they will cover some non-medical services. That's definitely not covered by traditional fee-for-service service Medicare such as the caregiver support, meals, transportation, and in-home support. These services might be particularly attractive to older adults with dementia and their caregivers.

Matt Davis:

I mean it seems like today there are a lot of different available options. I was just curious, what do you think goes into making decisions around what type of Medicare plan to enroll in?

Lianlian Lei:

That's a very, very important and also a very complex and challenging task for older adults. So there are just so many reasons that will impact whether they choose fee-for-service Medicare also that's called traditional Medicare or they choose Medicare Advantage. If they choose Medicare Advantage so right now, on average, each beneficiary will have more than 40 plans to choose from in their local market. So there are many things to consider. For example, what's the provider networks of their plan and also what's premium cost sharing benefits package? Because each plan might provide slightly different benefits, not slightly, but some very different benefits.

So also the star rating, the quality of the plan. So there are just so many factors they should consider and they should be which factors they want to place more weight on when they make their decisions. Also on the supply side, there are many factors. For example, like the marketing of the health plans and also the brokers which information will give their beneficiaries. And also they make their friends or their families in their social network what people choose. So all these factors will impact their decisions. So it's a very complex and very complex process.

Matt Davis:

Is it safe to assume that people that select to participate in Medicare Advantage, are they from higher income backgrounds or are there differences in health status compared to traditional fee-for-service enrollees?

Lianlian Lei:

Yeah, typically there will be certain patterns. For example, the research shows people are more likely to transfer from fee-for-service Medicare to traditional fee-for-service Medicare to Medicare Advantage. And also the Medicare Advantage, they will have much faster growth among those socioeconomic disadvantaged populations such as the minorities. So yeah, there will definitely be some patterns, but all kind of people will choose Medicare Advantage plans.

Matt Davis:

So you hinted at this a little bit, I guess, what are your thoughts on the specific services when it comes to older adults living with dementia that are most relevant to selecting Medicare Advantage? Some of the... I mean, do they cover some informal caregiving type services?

Lianlian Lei:

Yeah, so right now some plans will cover this supplemental benefits. Then it'll be like this caregiver support or in-home support or sometimes meals and transportation. So this will be, if you think that oh, they're with dementia and their caregivers, that will be a really effective benefits for them. Yeah.

Lauren Gerlach:

I was wondering, how common is it to change plans and can this be done at any time during the year or there're set enrollment times?

Lianlian Lei:

Yeah, so actually the enrollment into Medicare Advantage or disenrollment from Medicare Advantage to traditional Medicare is both directions is very frequent. So currently the Medicare, they will have the open enrollment period, that's usually is late October or to early December each year. So every Medicare beneficiary, they can change plans during this time period for the next year's coverage. And also, but there are some other time people can change plans. For Medicare Advantage beneficiaries, they can also change their plan from January to March of each year if they don't like that plan, they can make the change during that time.

And also there are some special enrollment periods. This is for beneficiaries that usually they have a change in their status or they have encountered some events, for example, beneficiaries if they went to a nursing home or they move to another country so they can change their plan at this time and any time of the year when the event happened. So that's called the “special enrollment period”.

Matt Davis:

Are these different plans during that enrollment period? And I don't know that much about Medicare. I'm not an older adult yet, but is it a competitive thing? I mean are the companies advertising to potential beneficiaries, trying to get them to select their plan or what?

Lianlian Lei:

Yeah, that's a very, very important topic. So the insurance companies actually for Medicare Advantage plans, the insurance companies spend a lot of money on the advertising. So sometimes they will advertise for specific populations such as those for [inaudible 00:12:20] because they cover some services that are good for them or medications specifically for them. So yeah, the advertising of health plans is very, very heavy, especially among for Medicare Advantage plans.

Matt Davis:

It makes you wonder if, I mean I have to imagine that they're probably targeting certain populations that, they are cost-effective for them. Right. I mean, yeah, interesting. So somewhat related, and I hear this a lot, people talk about this, and I see grants and papers talking about it. So with this kind of situation with Medicare Advantage, I was wondering if you could talk a little bit about the star ratings and whether you think they play any kind of role and what plans individuals select?

Lianlian Lei:

So the star rating system is the key feature of the Medicare Advantage Quality Finance program. So the Medicare Advantage plans might get extra pay because they have a better star rating. So that's like the reverting program for health plans they provide better healthcare. There are stories that choose that better star ratings is associated with improved quality of care and Medicare beneficiaries, they are more likely to enroll in plans if their plans have a better star rating.

Lauren Gerlach:

This is a little bit in the weeds, but it's my understanding that CMS publishes the star ratings at the level of the Medicare Advantage contract and that each contract could have multiple plans. And so, that they kind of sum up the star rating based on all those plans. So an enrollee may go into a specific plan that may or may not reflect the overall star rating. I was hoping you could speak a little bit to that.

Lianlian Lei:

Yeah, that's correct. So the star rating is at the contract level and each contract they might have very different health plans. So right now that might be some fires. So yeah, because each plan is different, what services they cover, what networks they have and what care access would be. So yeah, that's part of the... Right now we cannot measure star ratings for each plan. It's only at the contract level.

Matt Davis:

I feel like we could do an entire episode on the star ratings and I have a dozen more questions that I'm going to kind of spare you from, but it raises so many questions. I mean, whenever you have a system like that that's designed to help people, but then facilities are dependent on their ratings, it makes me wonder about the distribution and the relevance of what goes into these things. But I know that we don't necessarily have the time to talk about star ratings for the rest of the time, but super fascinating to me as a scientist.

Lauren Gerlach:

One other thing I just wanted to mention maybe specific to dementia is you mentioned that switching plans is pretty common. For older adults living with dementia, is it common to switch plans either between Medicare Advantage and fee-for-service or does that happen any more frequently for patients living with dementia than the general older adult population? Do we know anything about that?

Lianlian Lei:

Yeah, definitely. I think there are several papers, many papers that says, "Oh, healthy patients are more likely to switch from fee-for-service Medicare to Medicare Advantage." And also the sicker patients, they are more likely to switch from Medicare Advantage back to traditional Medicare. So that make you wonder, oh, this Medicare Advantage plans, they might not serve these sicker patients very well. So for older adults with dementia, they're much, much more likely to disenroll from Medicare Advantage to traditional Medicare. So probably will be higher than any other chronic conditions. So this would just make you wonder what happens to this patients in this Medicare Advantage plans and whether their healthcare are met and what makes them to leave. Yeah, there are just so many interesting questions on this.

Lauren Gerlach:

I was hoping you could tell us a little bit about the data source that you used for your study. It seems like having the ability to identify partners is really a unique aspect.

Lianlian Lei:

Thank you. So in Medicare claims data, we could not identify partners for now. So that's why we use the health retirement study because of its unique design. Health retirement study interviews individuals over 51 years old as well as their household partners. So when we link the health and retirement study to the Medicare claims data, we could examine the insurance enrollment decisions for both partners. So that's a really cool and a unique design for health retirement study.

Matt Davis:

A lot of people listening in likely have experience with using administrative claims for traditional Medicare fee-for-service part B. I'm curious, how are Medicare Advantage claims any different from traditional part B claims?

Lianlian Lei:

So traditional part A and part B, fee-for-service Medicare, the claims, it's like the direct feel from Medicare had to the providers. But for Medicare Advantage, because Medicare pays Medicare Advantage health plans a certain amount of money each beneficiary, each month. So the information is the Medicare Advantage encounter data. So say, payment information or bill information in that is from the private health insurance company. So it is not direct pay from Medicare to the providers. So it will just be different. It's not the actual payment to these providers. Its information provided by this private health insurance company to Medicare.

Matt Davis:

I've heard people use the term encounter claims. Is that a term that's specific to Medicare Advantage?

Lianlian Lei:

Yeah, yeah, thank you. Yeah, it's different. We just call them encounter, it's not specific claims data.

Lauren Gerlach:

So turning to your study, what gave you the idea to look at the impact of partners’ decisions on plan enrollment?

Lianlian Lei:

So first of all, I would say CAPRA. So this is, it just begins with the CAPRA pilot study. I am very interested to examine what kind of Medicare Advantage plans older adults with dementia were enrolled in and what factors impact their enrollment decisions. Like leave Medicare Advantage among older adults with dementia. Because there are just so many different types of Medicare Advantage plans. So it's very little data what plans this older adults with dementia were enrolled in. So that's my first question.

And then I also want to examine what factors impact their decisions. When you’re using health and retirement study, you'll just have so many different factors. You can study their individual household. And then when we are doing this, we realize one piece, one very important factor was missing is what's their spouses’ choices. Because when you think about in your daily life, spouses just play such an important role in every aspect of your decision.

And also in the research, there are many studies examining like the health behaviors between spouses. So the sickness is all the concordance is very, very high, but there is very, very limited information about the Medicare insurance plan choices among partners or spouses. So then we just dive into this and then found it's a very, very important factor in the plan choice of older adults when you consider the partner's choice.

Matt Davis:

I find that aspect just so refreshing what you did and I'm starting to see that more and more. I mean, for an analyst we talk about unitive analysis and we're always trying to do studies of the personnel, but this idea of couples, it just makes so much sense to me just knowing how my parents operate and how they influence each other and things. This is, I don't know the answer to this because I never thought about analyzing dyads or couples in my own work, but I guess for both of you. So there really isn't a way in just traditional Medicare claims to identify people that are together?

Lianlian Lei:

I don't think you can identify partners in Medicare claims data. So that's why we don't see too many research on this to say how partners impact each other's decisions.

Matt Davis:

All right, so turning back to your study, I guess tell us what you found and we're curious if you found anything that surprised you.

Lianlian Lei:

So we found that partner’s enrollment choices is a much more important factor than any other factors. So when you think about what factors impact the decision making of whether you leave the Medicare Advantage plan, you think their socio-economic status, for example, whether they were enrolled in Medicaid, whether they were minorities and what's the income level. And also you think there are functional disability or their other healthcare needs will be very important.

Also, there are many other plan characteristics. For example, the sovereignty, you will think they're also very important and also there are many research papers examining that. But when it compares to partner's plan choice, these other factors are much less important than partner's choice in association with the Medicare Advantage enrollment decisions. At first I was so shocked, "Oh, why..." When I first look at the [inaudible 00:24:12] ratio, it's so big, I will say, "Oh, what is that my model wrong or anything?" So I go back, check and check it too, it's so strong. And then when you think about it is, when you think about your decisions in your everyday life. So their partners, it is playing a very important role in your decisions. For my insurance, sometimes I don't care about premiums or private networks. I would just say, "Oh, what's my partner's will think?" I would just stick to that. So we just go to the same doctors, it's easier. So yeah, I think it makes sense. Yeah. So you think it's so important.

Matt Davis:

Hearing you describe that sort of brings back memories when my group has sort of stumbled on something and if you see it and you're like, "Oh my gosh, this is strong." And then you keep cutting it, looking at different ways and it just keeps persisting and it's sort of an exciting moment to sort of feel like you stumbled onto something that maybe other people haven't quite shown before. That's cool.

Lauren Gerlach:

Has your team or others ever tried to look at the quality of Medicare enrollment? In other words, whether individuals or couples are making good decisions kind of considering their unique circumstances?

Lianlian Lei:

It's a very important question, but it's a very hard question. I think it's very hard to define quality of your decision, but it's more about your preferences. Some people might be like provider networks, they just want to go to some certain skilled nursing facility. So some people might care more about premiums, they just don't want to pay too much money at first, but it's more like preferences and also what factors you be more in your decisions.

And also sometimes it's a good choice, the plan is a good choice for some people, but it will not be a good choice for the other people. So it's very hard to define the quality of your decision.

Lauren Gerlach:

Sounds like it's very individualized.

Matt Davis:

So just kind of thinking about individuals living with dementia and your central finding about just how much a partner influences the other individual's decisions. I'm just curious, do you think things would be any different for a couple for which one of them is living with dementia?

Lianlian Lei:

So yeah, in this paper we didn't specifically look at older adults with dementia, but if you think older adults with dementia, they will have limited capacity to make decisions. And also, so it is more like a burden for the caregivers or their spouses to make the decision, make the Medicare option choice decisions for them. So it's a stressful option for caregivers.

Lauren Gerlach:

So regarding this line of work, what's next for you and your team?

Lianlian Lei:

Yeah, also the partners, like the partners though in the Medicare enrollment decisions of older adults is for this paper, it's a very, very high-level overview. So, let me just start over. So I think for this paper, it's just a very high-level overview of how partners’ decisions might be associated with the older adults Medicare enrollment decisions. So, we'll definitely dive into this to say more nuances, how this pattern will be different among different populations or different times. So yeah, that's definitely our next step.

Matt Davis:

So as we wrap things up, is there anything that we haven't covered that you'd want listeners to know?

Lianlian Lei:

Yeah, so just to highlight this, Medicare decision making is a very, very complex and very, very complex process. So definitely more support will be needed to help older adults as well as their caregivers to navigate this complex insurance market. So I've heard so many stories like in personal lives. So no matter how educated you are or even though you were working in the health industry or insurance industry, everyone gets so confused about these different Medicare options. So definitely it will be very important to have better support to help the older adults make their choices.

Matt Davis:

So, thanks so much for coming on. This is a wonderful overview of Medicare and Medicare Advantage. Even though it's not just specific to dementia, obviously something really important to this population that we talk about in this podcast. Lianlian, thanks so much for joining us today.

If you enjoyed our discussion today, please consider subscribing to our podcast. Other episodes can be found on Apple Podcasts, Spotify and SoundCloud, as well as directly from us at capra.med.umich.edu, where a full transcript of this episode is also available. On our website, you'll also find links to other resources we've created specifically for dementia research.

Music and engineering for this podcast was provided by Dan Langa. More information is available at www.danlanga.com. Minding Memory is part of the Michigan Medicine Podcast Network. Find more shows at michiganmedicine.org/podcasts. Support for this podcast comes from the National Institute on Aging at the National Institutes of Health, as well as the Institute for Healthcare Policy and Innovation at the University of Michigan. The views expressed in this podcast do not necessarily represent the views of the NIH or the University of Michigan. Thanks for joining us and we'll be back soon.