Treatment Burdens in Traditional Medicare and Medicare Advantage

ABSTRACT

Objectives: To examine the treatment burdens from managing health care among Medicare beneficiaries in traditional Medicare (TM) and Medicare Advantage (MA).

Study Design: Cross-sectional analysis of the 2022 Health and Retirement Study Treatment Burden Questionnaire module.

Methods: We analyzed survey responses from 1024 Medicare beneficiaries 65 years and older, comprising 513 TM enrollees and 511 MA enrollees. We examined treatment burdens from doctor visits and appointments (frequency and time spent on these visits), administrative burden (paperwork and claims to obtain care or reimbursement), difficulty in relationships with providers (listening and responsiveness), and financial burden (out-of-pocket costs).

Results: Although most respondents reported no treatment burden, 8.6% of Medicare beneficiaries reported having high administrative burdens, and 6.9% reported high financial burdens. Treatment burden increased with the number of chronic diseases. Among those with 6 or more chronic diseases, 24.3% of MA enrollees and 15.0% of TM beneficiaries reported high administrative burdens, and similarly, 27.7% of MA enrollees and 15.0% of TM beneficiaries reported high financial burdens.

Conclusions: Although the overall treatment burden is low, for those with 6 or more chronic diseases, approximately 1 in 4 MA enrollees and 1 in 6 TM beneficiaries experienced high administrative and financial burdens. These findings suggest that managed care techniques, such as prior authorizations, may exacerbate burdens. Study findings also underscore the need for strengthened regulatory oversight to reduce administrative and cost complexities for vulnerable beneficiaries.

Am J Manag Care. 2025;31(12):In Press

Takeaway Points

Most Medicare beneficiaries reported manageable treatment burdens from health care.

• Among Medicare beneficiaries with heavier chronic condition burdens, 1 in 4 Medicare Advantage enrollees faced high administrative burdens, possibly due to managed care practices such as prior authorization requirements.
• Among Medicare beneficiaries with heavier chronic condition burdens, more than 1 in 4 Medicare Advantage enrollees also experienced high financial burdens.
• Strengthened regulatory oversight is needed to simplify administrative processes and reduce financial strain for vulnerable beneficiaries.

There were 43.8 million Medicare beneficiaries 65 years and older in 2024.1 In this population, 85% had at least 1 chronic condition, and 60% had 2 or more chronic conditions.2 As a result, the workload related to health care, such as managing doctor visits, navigating administrative tasks, maintaining effective relationships with providers, and handling financial burdens, can be highly burdensome for older individuals. High treatment burdens can decrease a patient’s well-being, reduce adherence to care plans,3 lower quality of life,4 and lead to worse health outcomes.5,6 Using data from a nationally representative survey,7 we found that overall treatment burden among Medicare beneficiaries is moderate, but it increases with the number of chronic diseases. Among those with 6 or more chronic diseases, 24.3% of Medicare Advantage (MA) enrollees and 15.0% of traditional Medicare (TM) beneficiaries reported high administrative burdens; similarly, 27.7% of MA enrollees and 15.0% of TM beneficiaries reported high financial burdens.

METHODS

Study Data and Sample

The primary data source was the 2022 Health and Retirement Study (HRS) Treatment Burden Questionnaire module.8 The HRS data are nationally representative for both TM and MA enrollees.8 The Treatment Burden experimental module was conducted in 2022, administered to a randomly selected 10% subsample of respondents in the core HRS. The national representativeness of TM and MA enrollees in the overall HRS sample extends to this subsample.9 For this module, the HRS adopted the Treatment Burden Questionnaire (TBQ) developed by Tran et al,10 a validated instrument to assess patients’ perceived burdens of managing their health.11 We focused on Medicare beneficiaries 65 years and older.

Treatment Burden Measures

The study examined 4 elements related to perceived burdens of medical treatment needs. Specifically, doctor visits and appointments measured the burden from the frequency and time spent on medical visits and the process of finding health care provider appointments. Administrative burden and paperwork related to health care included tasks required to obtain care or reimbursements, such as paperwork related to prior authorizations for services, filling out forms for hospital admissions, or filing a claim for Medicare reimbursement. Difficulty in relationships with providers measured difficulties one could have in their relationships with health care providers, including feeling not listened to enough or not taken seriously by providers. When these relationships are disrupted, patients may experience greater treatment burden, potentially leading to worse health outcomes and reduced engagement in care.12-14 Financial burden was related to perceived burdens from out-of-pocket (OOP) expenses for health care. Each element was measured by a 0-to-10 Likert scale, where 0 indicated “no problem” and 10 indicated “big problem.” We categorized scales into 4 levels: no burden (0), low burden (1-3), medium burden (4-7), and high burden (8-10).

Analysis

The distribution of treatment burdens was exhibited across 4 dimensions. We estimated the proportion of enrollees with a high burden among Medicare beneficiaries in MA and TM, respectively, across chronic disease levels (0-1, 2-3, 4-5, and ≥ 6). We conducted sensitivity analyses to examine the proportion of high burden in MA and TM by education levels and racial/ethnic groups, respectively. In another sensitivity analysis, we repeated the main analysis using summed burden score from the entire TBQ. A summed score at or above 59, as defined by the TBQ developers, was used as the threshold of high treatment burden in this sensitivity analysis.15 In all analyses, we used the HRS survey weights to ensure national representation of both TM and MA beneficiaries.

RESULTS

The study analyzed survey responses from 1024 Medicare beneficiaries, comprising 513 TM enrollees and 511 MA enrollees. Descriptive characteristics for the study population are presented in eAppendix 1 (eAppendices available at ajmc.com).

Overall, most Medicare beneficiaries perceived low treatment burden (Figure 1). Half of Medicare beneficiaries reported no administrative burdens, 18.9% reported a medium burden, and 8.6% reported a high burden. A total of 59.2% of respondents reported no financial burdens, 13.9% reported a medium burden, and 6.9% reported a high burden. A large majority of Medicare beneficiaries—81% and 79%—felt no burden in provider relationship difficulty or in doctor visits and appointments, respectively.

The percentage of enrollees with high administrative burden increased with the number of chronic diseases (Figure 2). Among TM beneficiaries, 7.1% (95% CI, 2.7%-17.2%) of those with 0 or 1 chronic disease had high administrative burden, but 15.0% (95% CI, 5.2%-36.6%) of those with 6 or more chronic diseases did. MA enrollees experienced a steep increase as chronic diseases increased, from 5.4% (95% CI, 1.4%-18.5%) of those with 0 or 1 chronic disease to 24.3% (95% CI, 11.4%-44.6%) with 6 or more diseases.

We found similar patterns in high financial burden by chronic disease levels (Figure 2). For TM beneficiaries, high financial burden was perceived by 2.9% (95% CI, 1.0%-8.3%) of enrollees with 0 or 1 chronic disease and by 15.0% (95% CI, 5.2%-36.1%) of those with 6 or more chronic diseases. Among MA enrollees, the percentage of high financial burden did not vary much for those with fewer than 6 chronic diseases, at 3.0% (95% CI, 0.8%-11.0%) for 0 or 1 chronic disease, 4.8% (95% CI, 2.4%-9.5%) for 2 or 3 chronic diseases, and 3.5% (95% CI, 1.3%-9.5%) for 4 or 5 chronic diseases. However, the portion of enrollees perceiving high financial burdens surged to 27.7% (95% CI, 12.5%-50.7%) for those with 6 or more chronic diseases in MA.

The percentage of having high burden related to doctor visits and appointments among TM beneficiaries remained low (Figure 2), at 2.2% (95% CI, 0.4%-11.0%) for 0 or 1 chronic disease, 1.9% (95% CI, 0.8%-4.8%) for 2 or 3 chronic diseases, and 0.6% (95% CI, 0.1%-2.7%) for 4 or 5 chronic diseases. The rate of having high doctor visit burden rose to 10.0% (95% CI, 3.1%-27.7%) for those with 6 or more chronic diseases. Among MA enrollees, the percentage of high burden remained moderate for those with less than 6 chronic diseases, at 1.0% (95% CI, 0.3%-3.5%) for 0 or 1 chronic disease, 2.9% (95% CI, 1.2%-6.7%) for 2 or 3 chronic diseases, and 3.5% (95% CI, 1.1%-10.6%) for 4 or 5 chronic diseases, but rose to 9.0% (95% CI, 1.8%-35.2%) for those with 6 or more chronic diseases.

As shown in Figure 2, the percentages of having high burden related to relationship difficulty with providers among TM beneficiaries were low except for patients with 4 or 5 chronic diseases (3.6% [95% CI, 1.0%-12.1%] vs 1.2%-1.7% for other groups). For MA enrollees, the percentage of enrollees with high relationship burden was similarly low across chronic disease level: 0.8% (95% CI, 0.2%-3.6%) for 0 or 1 chronic disease, 2.7% (95% CI, 1.0%-7.3%) for 2 or 3 chronic diseases, 3.8% (95% CI, 1.3%-10.5%) for 4 or 5 chronic diseases, and 3.1% (95% CI, 0.4%-19.7%) for 6 or more chronic diseases. Overall, we found no statistically significant differences in any treatment burden element by enrollment type.

Treatment burden is also affected by education level and race/ethnicity (eAppendix 2). Individuals with lower education levels experienced a greater treatment burden than those with higher education (eAppendix 3). Respondents who were Black or Hispanic generally faced a higher burden than White individuals, regardless of insurance type (eAppendix 4). The distribution of the total TBQ score (eAppendix 5) showed that most respondents reported no burden and only a small fraction reported high burden, a finding consistent with the data shown in Figure 1. Furthermore, the proportion of respondents having high total burden increased with the number of chronic conditions, and MA enrollees with 6 or more chronic conditions disproportionately reported high total burden (eAppendix 6), a similar pattern found in our main analysis (Figure 2).

DISCUSSION

In this study of treatment burdens by Medicare beneficiaries, we found that the majority experienced low burdens, but a notable portion of individuals reported high administrative and financial burdens. It is alarming that among those with 6 or more chronic diseases, approximately 1 in 4 MA enrollees and 1 in 6 TM beneficiaries reported high administrative burdens. Similarly, large portions of MA and TM enrollees reported high financial burdens. Beneficiaries with higher disease burdens also experienced slightly higher treatment burdens related to doctor visits and appointments, likely due to more frequent interactions with the health system. Burdens related to difficulties in provider relationships remained consistently low across insurance types and levels of chronic illness.

The high administrative burden seen in MA enrollees with multiple chronic conditions was not surprising. It may result from common managed care practices such as prior authorization and claim denials. All MA plans require prior authorizations, most commonly for costly services deemed necessary by health care providers, such as inpatient stays, skilled nursing care, and provider-administered Part B medications.16 Patients and providers must obtain approval from a health plan before a procedure can be covered. On average, each MA plan enrollee submitted 1.7 prior authorization requests in 2022,16 substantially adding to the administrative workload of patients with more health care needs.

Although MA plans typically charge lower premiums and cap annual OOP costs, we found that 27.7% of those with 6 or more chronic diseases in MA felt high financial burden from health care. It is possible that when patients require medical services from various specialists and hospital inpatient care, MA’s limited coverage for specific services through prior authorization denials and narrower provider networks may have resulted in a substantial share of care paid OOP. These treatment burdens may exacerbate one another: Administrative burdens can delay treatment, worsening health outcomes,17 and result in higher OOP because of insurance administrative hurdles (eg, prior authorization denials). Findings from our study help further explain the reason behind the patterns of disenrollment from MA when beneficiaries become sicker.18,19 Reducing treatment burdens for Medicare beneficiaries with multiple chronic conditions through strengthened regulatory oversight may warrant further policy considerations.

It is worth noting that treatment burdens from doctor visits, administrative workload, and costs are also substantial for sicker Medicare beneficiaries in TM. These burdens are likely a result of more intensive and frequent use of health care that increases with disease burden,20,21 but they also speak to the challenges the older population may face navigating care in a complex health system, scheduling appointments, and managing TM reimbursement paperwork.

The Inflation Reduction Act of 2022 has capped the yearly OOP cost for prescription drugs at $2000, starting in 2025.22 Although this measure is a step forward to reduce cost burdens, it addresses only a fraction of the broader health care financial challenges faced by Medicare beneficiaries. Prescription drug costs have consistently comprised only 10% to 12% of total personal health care expenditures since 2010.23 Therefore, despite the cap’s potential to alleviate a specific aspect of financial burden, Medicare beneficiaries still face substantial OOP spending for other essential health care services, such as hospitalizations and specialist visits. Broader policies to reduce the financial and administrative burdens of health care access for Medicare beneficiaries are critical to ensuring equitable and effective care, especially for those with complex medical needs.

Limitations

This study has several limitations. First, this study relied on self-reported data, which may be subject to recall bias.24 Patients’ perceptions of treatment burdens could be disproportionately influenced by recent or salient events. Second, we had only 1-year cross-sectional data with relatively small sample sizes. Future research is needed to causally compare treatment burden differences in MA and TM, with larger sample sizes and longitudinal data. Third, the items from TBQ were not individually validated, which may raise concerns about their individual psychometric properties. Lastly, this study lacked data on out-of-network provider visits, limiting our ability to assess more nuanced financial burdens in MA. Similarly, it was beyond the scope of this study to determine the portion of financial burdens mitigated by supplemental coverage.

CONCLUSIONS

Although most Medicare beneficiaries experienced low treatment burdens, MA enrollees with 6 or more chronic conditions frequently encountered high administrative and financial burdens. 

Author Affiliations: Division of Health Services Management and Policy, College of Public Health, The Ohio State University (KL, WYX), Columbus, OH.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (KL, WYX); acquisition of data (KL, WYX); analysis and interpretation of data (KL, WYX); drafting of the manuscript (KL, WYX); critical revision of the manuscript for important intellectual content (WYX); statistical analysis (KL); administrative, technical, or logistic support (WYX); and supervision (WYX).

Address Correspondence to: Kangyeon Lee, MPP, The Ohio State University, 1841 Neil Ave, Columbus, OH 43210. Email: lee.10881@buckeyemail.osu.edu.

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