Date of Award

2018

Document Type

Open Access Dissertation

Department

Health Services and Policy Management

Sub-Department

The Norman J. Arnold School of Public Health

First Advisor

Janice C. Probst

Abstract

Medicare beneficiaries diagnosed with diabetes are likely to have health complications or episodes associated with diabetes, resulting in higher health care utilization and costs. Andersen’s Health Care Utilization Behavior Model (HCBM) includes predisposing, enabling, and need factors, but it excludes perception. Ajzen’s Theory of Planned Behavior (TPB) shows that perception influences health service use. This study was performed using a real-world model integrating Andersen’s HCBM and Ajzen’s TPB to determine whether there was an association between insurance type (Medicare Part D versus non-Part D) and perceived ease of access or cost among Medicare beneficiaries with diabetes. The second objective was to determine whether the receipt of care from primary care physicians was associated with greater perceived ease of access or better perceived cost when compared to non-primary care physicians.

This cross-sectional study examined Medicare beneficiaries diagnosed with diabetes using data from the Medicare Current Beneficiary Survey (MCBS) 2013 Access to Care (ATC) Public Use File (PUF). Perceived ease of access and perceived cost were identified as the dependent variables using factor analysis and explored as a sum of survey responses. Insurance type and provider type were the two independent variables. Covariates were age, sex, race, marital status, education, income, metro status, and health compared to past year. Multivariable linear regression models were used for analyzing the relationship between independent and dependent variables. This relationship was examined in the unadjusted model, and the relationship was further examined in adjusted models which included the covariates or characteristics of Medicare beneficiaries. Study results showed a significant relationship between insurance type and perceived cost. There was a significant association between insurance type and perceived cost, and the significance of this relationship did not change when including characteristics of Medicare beneficiaries with diabetes. The unadjusted effect between insurance type (i.e., Part D vs. non-Part D) and perceived ease of access was significant. The significance of the association between insurance type and perceived ease of access did change when accounting for characteristics of diabetic beneficiaries. The relationship between provider type and perception of cost and the relationship between provider type and perceived ease of access were not significant when running the bivariate and multivariate analyses.

The results from this study showed Medicare beneficiaries diagnosed with diabetes overall do not perceive well the cost of self-administered prescriptions needed for regulation of blood sugar levels. Diabetic beneficiaries have evaluation and management visits with their health care providers, but often feel incapable of getting the antidiabetic drugs (OADs) and/or insulin they need to self-manage diabetes due to perceptions of costs and ease of access afforded by insurance, specifically Part D coverage. Often, these perceptions result in preventable emergency department (ED) visits and hospitalizations as well as more unaffordable health care costs. This becomes important for policymakers, health care providers, and public health professionals to assist this population with getting timely appropriate care by developing policies that improve perception of access and cost.

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