Blog | Payment Reimbursement and Managed Care

Survey data highlights shortcomings in private insurance coverage compared with Medicare

Blog | Payment Reimbursement and Managed Care

Survey data highlights shortcomings in private insurance coverage compared with Medicare

Indicators of coverage gaps were more likely to be seen among individuals with private insurance.

Commercial insurance coverage is better for a healthcare provider’s payer mix, but a new study indicates Medicare has advantages for consumers.

Examining survey data from a representative sample of more than 149,000 individuals residing in 17 states and Washington, D.C., researchers found that those with private insurance were more likely than those with government-sponsored coverage to report poor access to care, higher care costs and less satisfaction with care.

Disparities especially were seen when comparing Medicare coverage with private insurance (both individually purchased and employer-sponsored), according to data from the study, which was published in JAMA Network Open. Individuals in the latter category were less likely to report having a personal physician and more likely to report:

  • Instability in insurance coverage
  • Difficulty seeing a physician because of costs
  • Not taking medication because of costs
  • Having medical debt

Differences were less notable when comparing private insurance coverage to Medicaid. Those with employer-sponsored insurance were more likely to report having medical debt but less likely to report difficulty seeing a physician or not taking medication because of cost-related issues.

Individuals with employer-sponsored coverage reported lower satisfaction with their care compared with Medicare beneficiaries, while there was no difference when compared with Medicaid enrollees.

The concern for providers

The study findings indicate that “efforts to increase the number of individuals covered by public insurance programs or improve protections for individuals covered by private insurance against increasing costs are needed," according to the authors.

Hospital advocates oppose initiatives to expand public insurance programs, such as through a single-payer system or via a federally run public option that would be added to individual-insurance markets.

That’s because private insurers pay significantly more for services, offering a vital recenue source. According to a 2020 literature review by the Kaiser Family Foundation (KFF), private insurers pay 199% of Medicare rates for all services, including 264% for outpatient services. When discounting supplemental payments, Medicaid rates are lower than those for Medicare and generally don’t cover the cost of care.

Combined, hospitals experience an annual shortfall of $57.8 billion from providing care for Medicare and Medicaid beneficiaries, according to a 2017 brief by the American Hospital Association.

“If provider payments were phased down closer to Medicare levels, providers would have stronger incentives to become more efficient, which could help make health coverage and care more affordable for patients and employers,” the KFF authors wrote.

“However, even some relatively efficient providers appear to have been losing money on Medicare patients over the past few years, prompting some leading public option and Medicare for all proposals to set hospital payments somewhat above current Medicare rates.”

About the Author

Nick Hut

is a senior editor with HFMA, Westchester, Ill. (nhut@hfma.org).

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