April 2023Original Research: Dissatisfaction of Out-of-Pocket Costs and Problems Paying Medical Bills Among

Dissatisfaction of Out-of-Pocket Costs and Problems Paying Medical Bills Among Medicare Beneficiaries With Type 2 Diabetes
Boon Peng Ng, PhD

, Morgan P. Stewart, PharmD, BCACP, BC-ADM, Seoyon Kwon, MPH, Georgianne Tiu Hawkins, DrPH, MPH, and Chanhyun Park, PhD, MPharm, MEdThe Science of Diabetes Self-Management and Care
2023, Vol. 49(2) 126 –135
© The Author(s) 2023
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DOI: 10.1177/26350106231163516
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Abstract
Purpose: The purpose of the study was to examine the relationship between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills among Medicare beneficiaries with type 2 diabetes.Methods: The 2019 Medicare Current Beneficiary Survey Public Use File, a nationally representative sample of Medicare beneficiaries aged ≥65 years with type 2 diabetes, was analyzed (n = 2178). A survey-weighted multivariable logit regression model was conducted to examine the association between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills, adjusted for sociodemographics and comorbidities.Results: Among study beneficiaries, 12.6% reported problems paying medical bills. Among those with and without problems paying medical bills, 59.5% and 12.8%, respectively, were dissatisfied with out-of-pocket costs. In the multivariable analysis, beneficiaries who were dissatisfied with out-of-pocket costs were more likely to report problems paying medical bills than those who were satisfied. Younger beneficiaries, beneficiaries with lower incomes, those with functional limitations, and those with multiple comorbidities were more likely to report problems paying medical bills.Conclusions: Despite having health care coverage, more than one-tenth of Medicare beneficiaries with type 2 diabetes reported problems paying medical bills, which raises concerns about delaying or forgoing needed medical care due to unaffordability. Screenings and targeted interventions that identify and reduce financial hardships associated with out-of-pocket costs should be prioritized.Medicare plays a vital role in the continuum of care for older adults. In 2019, approximately 53 million older adults relied on Medicare for their primary health care coverage,¹ and around 72% had at least two chronic conditions.² One of the most common chronic conditions is diabetes,³ which imposes substantial health and economic burdens on the health care system as well as the Medicare beneficiaries themselves. In 2015, the prevalence of diabetes was approximately 32% among Medicare beneficiaries,⁴ a percentage that is anticipated to increase substantially over the coming years due to the aging US population.^5,6In 2016, Medicare spent approximately $42 billion on diabetes-related health care services.⁷ The Centers for Disease Control and Prevention (CDC) reported that Medicare beneficiaries with diabetes paid around $4600 annual out-of-pocket costs in 2017, and approximately 60% and 30% of beneficiaries had annual out-of-pocket costs that exceeded 10% and 20% of their income, respectively.⁸ With many beneficiaries living on fixed incomes,⁹ this high financial burden from diabetes-related out-of-pocket costs can result in difficulty paying medical bills or incurred medical debt. Subsequently, these financial hardships have been linked to delayed or forgone medical treatment, which can be especially deleterious in the treatment and care for diabetes and diabetes-related complications.^10,11Information related to characteristics and factors associated with problems paying medical bills among Medicare beneficiaries with type 2 diabetes is limited. Empirically, factors such as comorbidities, income level, insurance status, and belonging to racial or ethnic minority groups have been previously associated with problems paying medical bills; however, these studies mainly focused on general adult populations or nonelderly adults with diabetes.^10,12–15Many Medicare beneficiaries have diabetes and are at risk for facing high out-of-pocket costs. Because of the chronic nature and high financial burden diabetes can impose,⁸ understanding factors associated with problems paying medical bills, such as beneficiaries’ dissatisfaction of out-of-pocket costs, is needed. Gaining a better understanding of these factors can inform decision makers about the severity of the problems paying medical bills, disparities across groups, and potential interventions that may be effective and feasible to mitigate the issue for this at-risk population.Conceptually, there are several frameworks that have been developed to understand the determinants of financial well-being of individuals.^16–18 Adapting the conceptual framework developed by Fan and Henager,¹⁸ this study evaluated the relationship between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills. The hypothesis for this study was that Medicare beneficiaries with type 2 diabetes who were dissatisfied with out-of-pocket costs would be more likely to report problems paying medical bills. Therefore, the objective of this study was to evaluate the association between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills among Medicare beneficiaries with type 2 diabetes, adjusted for sociodemographics and comorbidities, using nationally representative data.MethodsResearch DesignThis is a retrospective study using secondary data for a cross-sectional analysis.DataThe Medicare Current Beneficiary Survey Public Use File (MCBS PUF) of 2019 was analyzed for this study.¹⁹ The data are a nationally representative survey of community-dwelling Medicare beneficiaries. Data such as sociodemographic characteristics, health conditions, and satisfaction of health-care-delivery-related variables were collected by the Centers for Medicare & Medicaid Services (CMS) Office of Enterprise Data and Analytics through a contract with NORC at the University of Chicago.¹⁹ More information about the MCBS PUF is available at the CMS MCBS website.¹⁹ This study was considered non-human subjects research because the data are deidentified and publicly available.¹⁹Study PopulationThe study population included Medicare beneficiaries aged ≥65 years with reported type 2 diabetes (n = 2178). The identification of type 2 diabetes was based on the following 2 survey questions: “Has a doctor or other health professional ever told [you/sample person (SP)] that [you/he/she] had any type of diabetes, including: sugar diabetes, high blood sugar, [borderline diabetes, pre-diabetes, or pregnancy-related diabetes/borderline diabetes, or pre-diabetes]?” and “Please tell me which type of diabetes the doctor or other health professional said that [you have/(SP) has]?”²⁰MeasuresDependent variable. A binary dependent variable of problems paying medical bills was created based on the survey question of “Since (LAST MONTH YEAR) [have you/has (SP)] had problems paying or were unable to pay any medical bills?” with a binary response option (yes vs no).²⁰Key independent variable. Beneficiaries’ satisfaction with the out-of-pocket costs paid for health care was measured by the following question, “[Please tell me how satisfied or dissatisfied you have been with . . . ] the out-of-pocket costs [you/(SP)] paid for health care.”²⁰ To ensure sufficient sample sizes for reliable estimates, this survey question was recoded, and a binary variable was created with Likert scale responses of very satisfied/satisfied = 0 and very dissatisfied/dissatisfied = 1.Covariates. The sociodemographic characteristics included age (65-74 years, ≥75 years), sex (male, female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and other), marital status (married, widowed, divorced/separated, and never married), education level (<high school, high school/vocational, and >high school), annual income (<$25 000 ≥$25 000), and residing area (metropolitan area, nonmetropolitan area). For insurance coverages, Part D (yes, no) and type of Medicare coverage (only fee-for-service [FFS] for the year, only managed care for the year, part FFS or part managed care for the year) were included. The health-related characteristics included functional limitations (no functional limitations, limitations with instrumental activities of daily living only [IADLs], limitations with 1 to 2 activities of daily living [ADLs)], and limitations with 3 or more ADLs), and the number of chronic conditions (0-1, 2-3, and ≥4). The number of chronic conditions was based on Medicare beneficiaries’ reported chronic conditions, which included high blood pressure, high cholesterol, myocardial infarction, angina, congestive heart failure, other heart conditions, stroke, arthritis, osteoporosis, depression, emphysema/asthma/chronic obstructive pulmonary disease, Alzheimer’s disease, and cancer.Statistical AnalysesThe bivariate analysis and Wald χ² tests were first conducted to examine characteristics of beneficiaries with type 2 diabetes by problems paying medical bills status. A multivariable logit model with sociodemographic and comorbidity variables was used to estimate predictive margins and marginal effects for comparing prevalence of problems paying medical bills across groups. Due to the complex survey design of the MCBS, survey procedures in SAS and STATA and survey weight variables were used for all the analyses.²⁰ SAS Enterprise Guide version 7.1 (SAS Institute Inc) and Stata/MP version 16.1 (StataCorp LLC) were used to perform the analysis.ResultsAmong study Medicare beneficiaries aged ≥65 years with type 2 diabetes, 12.6% reported problems paying medical bills (Table 1 and Figure 1). Of those who were dissatisfied with out-of-pocket costs, there were more beneficiaries who reported problems paying medical bills than those who were able to pay (59.5% vs 12.8%, P < .001). Compared to beneficiaries who were able to pay medical bills, those who reported problems paying were younger (65-74 years, 69.6% vs 59.1%, P = .012), had lower incomes (income <$25 000, 44.8% vs 30.3%, P < .001), more non-Hispanic Black (eg, 23.3% vs 12.4%, P = .024), had more comorbidities (eg, ≥4 chronic conditions, 59.6% vs 44.5%, P < .001), had more limitations in IADLs/ADLs (eg, 3-6 ADLs, 22.5% vs 10.8%, P < .001), and were enrolled partly in FFS or managed care plans for the year (11.0% vs 4.8%, P = .003).In the multivariable model, beneficiaries who reported feeling very dissatisfied/dissatisfied with out-of-pocket costs were 28.3% (marginal effect [ME] = 28.3%; 95% confidence interval [CI], 21.8%-34.7%) more likely to report problems paying medical bills than those who were very satisfied/satisfied with out-of-pocket costs (Table 2 and Figure 2). This result supports the hypothesis stated in the Methods section. Beneficiaries with lower incomes (<$25 000) were 4.8% (95% CI, 0.9%-8.6%) more likely to report problems paying medical bills than beneficiaries with higher incomes (≥$25 000). Younger Medicare beneficiaries (aged 65-74 years) were 5.2% (95% CI, 1.9%-8.4%) more likely to report problems paying medical bills than older beneficiaries (aged ≥ 75 years). Beneficiaries who reported limitations with IADLs/ADLs were more likely to report problems paying medical bills than those without limitations in IADLs/ADLs (eg, ≥3 ADLs limited, ME = 12.2%; 95% CI, 5.5%-18.9%). Those who reported having multiple comorbidities were more likely to report problems paying medical bills compared to those with only 0 to 1 other chronic conditions (eg, chronic conditions ≥4, ME = 8.3%; 95% CI, 2.6%-14.0%).DiscussionIn this study of Medicare beneficiaries with reported type 2 diabetes, approximately one-tenth of respondents (representing 1.2 million Medicare beneficiaries) reported problems paying medical bills. Younger beneficiaries and those with lower incomes were more likely to experience this financial hardship. Functional limitations, such as limited IADLs and ADLs, and a higher number of comorbidities were also associated with problems paying medical bills. Beneficiaries who reported dissatisfaction with out-of-pocket medical costs were also more likely to report this financial hardship. Diabetes management can be costly because the condition requires frequent utilization of medical services and daily self-management. Even with insurance coverage for Medicare beneficiaries, problems paying medical bills among this at-risk population raises serious concerns. Many may delay or forgo needed diabetes care due to the unaffordability of medical services. This barrier to care may increase the risk of diabetes-related complications, which can generate increased health care utilization and cost. Screenings for financial hardship among Medicare beneficiaries with diabetes, collaborative programs among clinicians and financial planners, and copayment reduction programs should be considered to mitigate this problem. However, a longterm and more sustainable strategy should focus on diabetes prevention efforts, such as a lifestyle change program, which has been proven to be cost-effective.²¹Tab1Tab1aTable 1. Characteristics of Medicare Beneficiaries Aged ≥65 Years With Type 2 Diabetes by Problems Paying Medical Bills StatusFig1Figure 1. Selected characteristics of Medicare beneficiaries aged ≥65 years with type 2 diabetes by problems paying medical bills status based on the bivariate analysis.
Variables presented are those that were significantly associated with problems paying medical bills based on the multivariable analysis.Tab2Tab2aTable 2. Factors Associated With Problems Paying Medical Bills Among Medicare Beneficiaries Aged ≥65 Years With Reported Type 2 Diabetes.Fig2Figure 2. Probability/prevalence of problems paying medical bills across groups based on the multivariable regression model. Only variables that were significantly associated with problems paying medical bills were presented.This study illustrated that dissatisfaction with out-of-pocket medical costs was positively associated with problems paying medical bills. Because many Medicare beneficiaries live on retirement and/or fixed incomes⁹ and incur a high diabetes-related out-of-pocket cost burden,⁸ having a high proportion of beneficiaries dissatisfied with outof-pocket costs and its association with problems paying medical bills was consistent with the hypothesis (as a proxy for measuring financial burden of out-of-pocket cost from a beneficiary’s perspective).Past research has attributed the high out-of-pocket costs to prescription drugs and high insulin prices.^22,23 Therefore, cost-saving strategies related to prescription drugs should be considered by all members of the health care system to minimize out-of-pocket costs for beneficiaries with diabetes. Copayment reduction programs²⁴ can reduce individuals’ financial burden, and many of the programs have been shown to also encourage positive diabetes care and medication management behaviors (eg, improved medication adherence).²⁵ Additionally, previous research has shown that generic and therapeutic substitutions can reduce annual out-of-pocket costs among Medicare Part D beneficiaries.²⁶ However, many low-cost, generic medication options (eg, sulfonylureas and thiazolidinediones) used in the treatment of type 2 diabetes are considered potentially inappropriate for older adults.²⁷ Emerging trends in diabetes management focus on utilizing medications associated with cardiovascular, renal, and/or weight loss benefits, such as glucagon-like peptide-1 receptor agonists (GLP-1 RA) and sodiumglucose cotransporter-2 inhibitors (SGLT2i), both of which have been shown to reduce micro- and macro-vascular complications and overall long-term medical costs.^28,29 Furthermore, medications with lower hypoglycemia risk profiles (eg, metformin and oral dipeptidyl peptidase-4 inhibitors [DPP-IVi]) are particularly preferred in older adults because this population has a greater risk of hypoglycemia.⁵ Unfortunately, most of these clinically preferred medications for older adults (eg, GLP-1 RA, SGLT2i, DPP-IVi) are cost prohibitive because they are new to the market and are brand name only. While some Medicare Part D plans do include these newer agents on their formulary, many beneficiaries reach their Part D initial coverage period annual spending limit (and enter into a coverage gap) within a few months due to the high medication costs.⁶ This can lead to interruptions in drug therapy, medication sparing, poor medication adherence, and/or disease progression.However, there are ongoing efforts to address the financial burden of drug costs during the coverage gap (also known as the “donut hole”) for Medicare beneficiaries. The Affordable Care Act, which was passed in 2010, included provision to close the donut hole by gradually reducing the share of total out-of-pocket costs (coinsurance) paid by Medicare Part D beneficiaries, from 100% in 2010 to 25% in 2020.³⁰ Although the donut hole has been closed as of 2020, those with diabetes still can experience financial burden due to their medication needs and variation in Part D plan formulary coverage and tier placement.³¹ In 2021, CMS launched a voluntary program, called “Part D Senior Savings Model.” The program offers insulin coverage for a flat monthly payment of $35 instead of paying coinsurance in the deductible, initial coverage, and coverage gap phases; this model is estimated to save annual out-of-pocket cost for beneficiaries by about 66%, relative to their current cost-sharing.³² Thus, addressing the costs of medications for Medicare beneficiaries with diabetes is an area of significance, and more research is needed.Evidence-based prevention and management strategies for diabetes should be prioritized as well. Programs such as CDC National Diabetes Prevention Program (National DPP)²¹ and Diabetes Self-management Education and Support (DSMES)³³ have been shown to be effective in preventing or delaying type 2 diabetes and diabetes-related complications, respectively, thereby, reducing the financial burden imposed on Medicare beneficiaries. Since 2000 for the Diabetic Self-Management Training (DSMT) and since 2018 for the Medicare Diabetes Prevention Program (MDPP), both programs have been part of the Medicare coverage benefits for Medicare beneficiaries. However, the uptake of the programs has been reported low by Medicare beneficiaries, especially for DSMT.³⁴ Previous research has shown that provider referral has positive influence on the enrollment in these programs.³⁵ Therefore, provider engagement and knowledge of the programs are vital to promote beneficiary utilization.^33,35Diabetes and its associated complications are linked to functional limitations, physical disability, and cardiometabolic comorbidities.³⁶ This study also found that those who reported limitations in IADLs/ADLs and those with multiple comorbidities were positively associated with problems paying medical bills. Those with limited IADLs/ADLs and comorbidities likely incurred higher medical and nonmedial expenditures associated with their needs, such as having helpers or caregivers to assist them. Moreover, it has been reported that moderate-intensity muscle strength exercise with task-oriented training and behavioral or social skills training can improve both performances of ADLs and IADLs, respectively.^37,38 Therefore, programs that promote healthy aging, such as eating healthy foods and participating in regular physical activity, should be encouraged.This study demonstrated that certain sociodemographic characteristics, such as age and income level, were associated with problems paying medical bills, in which younger beneficiaries and those with lower incomes were positively related to this financial hardship. Although older beneficiaries tend to spend higher out-of-pocket costs than younger beneficiaries due to greater use of health care,³⁹ younger beneficiaries have other financial obligations (eg, mortgage, transportation), and these expenses likely outweigh those of older beneficiaries. The finding about the association of lower incomes with problems paying medical bills is consistent with previous research where individuals with lower incomes reported higher problems paying medical bills.^10,40LimitationsThis study has several limitations. This study only included community-dwelling Medicare beneficiaries aged ≥65 years with type 2 diabetes; therefore, findings may not be generalizable to beneficiaries who live in long-term facilities or to non-Medicare populations. This is a cross-sectional study, and only associations, not causality, can be assumed between study variables. With the self-reported survey design, findings are subject to recall errors, biases, and individual interpretations of survey questions. With CMS predefining the broad categories of many variables, such as income (only 2 categories), higher granularity of categories might affect the findings of this study. Future research should focus on a qualitative study to better understand the reasons of problems paying medical bills and/or the coping mechanisms among this at-risk population.ConclusionIn conclusion, the health consequences of problems paying medical bills in terms of delaying or forgoing diabetes care can have serious health implications on Medicare beneficiaries with diabetes. Screenings and targeted interventions to be considered should involve identifying and reducing the financial hardship associated with out-ofpocket costs for this at-risk population. Prevention efforts, such as National DPP, to prevent or delay type 2 diabetes should be highlighted as well as DSMES for diabetes self-management and cost-saving strategies.Declaration of Conflicting InterestsNoneFundingNo financial disclosures were reported by the authors of this article.ORCID iDBoon Peng Ng

https://orcid.org/0000-0001-6070-661X
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From College of Nursing, University of Central Florida, Orlando, Florida (Dr Boon Peng Ng); Disability, Aging, and Technology Cluster, University of Central Florida, Orlando, Florida (Dr Boon Peng Ng); College of Pharmacy, The University of Texas at Austin, Austin, Texas (Dr Morgan P. Stewart, Dr Chanhyun Park); Department of Statistics and Data Science, University of Central Florida, Orlando, Florida (Ms Seoyon Kwon); and Department of Health Management and Policy, University of Kentucky, Lexington, Kentucky (Dr Georgianne Tiu Hawkins).Corresponding Author:
Boon Peng Ng, College of Nursing & Disability, Aging and Technology Cluster, University of Central Florida, 12201 Research Parkway, Suite 300, Orlando, FL 32826, USA.
Email: boonpeng.ng@ucf.eduJournal CoverOwen Munford AdEditorial BoardADCES23 AdADCES InfoIAC ListADCES Organization InfoADCES Workforce TrainingEditorial: Thank You and Welcome to New Editorial Advisory Board MembersOriginal Research: Gender Differences in Self-Efficacy for Diabetes Self-Management Among HispanicsOriginal Research: A Text-Mining Analysis to Examine Dominant Sources of Online InformationOriginal Research: Advancing Diabetes Quality Measurement in the Era of Continuous GlucoseOriginal Research: Dissatisfaction of Out-of-Pocket Costs and Problems Paying Medical Bills AmongOriginal Research: Diabetes-Related Quality of Life: Learning From Individuals Making LifestyleOriginal Research: The Diabetes Tune-Up Group: A Multidisciplinary Approach to Improve DiabetesMeta-analysis, Systematic Reviews and Integrative Reviews: Influence of Diabetes MellitusJournal InfoADCES BC-ADM AdSAGE Author ServicesSAGE JournalsSAGE VideoADCES DEAP AdCBDCE Ad