Methodology Article
Medicare Utilization and Payment Analysis
Nwaoko Ada*,
Linda Fynn Prah,
Ekow Bediako,
Number Iredia
Issue:
Volume 14, Issue 1, February 2026
Pages:
1-20
Received:
1 November 2025
Accepted:
22 November 2025
Published:
16 January 2026
DOI:
10.11648/j.ijefm.20261401.11
Downloads:
Views:
Abstract: This analysis investigates the key factors driving total program payments in healthcare, focusing on the impact of coinsurance payments and visit frequency per enrollee. Using a combination of linear regression modeling and scenario analysis, we explored how changes in these factors affect overall program costs. The goal was to provide actionable insights for effective cost management in the healthcare program. The analysis proves that Coinsurance payments are a significant driver of total program costs. With each dollar increase in coinsurance payments correlate with an increase in total program payments. In Scenario 1, where coinsurance payments increased by 10% with no change in utilization, total program payments rose significantly to $1.22 billion. This finding underscores the cost sensitivity of the program to changes in out-of-pocket coinsurance amounts. Visit frequency per enrollee also plays a critical role in cost dynamics, though it has a complex relationship with total payments. In Scenario 2, a 5% reduction in coinsurance payments accompanied by a 10% increase in visit frequency led to a decrease in total program payments to $1.01 billion. This result suggests that higher utilization may help in reducing overall costs if it aligns with efficient or preventive care. Conversely, in Scenario 3, a 5% increase in coinsurance payments with a 10% decrease in visits led to a moderate increase in total program payments to $1.17 billion, indicating that lower utilization can reduce costs but may depend on the care's effectiveness. Based on our findings we recommend the following prescriptive analysis. Managing visit frequency per enrollee through preventive care programs or other efficient measures can significantly impact on total program costs, potentially reducing the need for frequent high-cost interventions. Adjusting coinsurance rates offers a lever for managing program costs. Lowering coinsurance might encourage utilization but could increase total program expenses. Conversely, increasing coinsurance payments could offset costs but may raise financial burdens for enrollees. A balanced approach is recommended. Leveraging scenario analysis as shown in this study can support proactive policymaking. This analysis could be relevant to policy makers to evaluate the financial implication of proposed changes to cost sharing mechanisms or programs affecting public health and utilization management.
Abstract: This analysis investigates the key factors driving total program payments in healthcare, focusing on the impact of coinsurance payments and visit frequency per enrollee. Using a combination of linear regression modeling and scenario analysis, we explored how changes in these factors affect overall program costs. The goal was to provide actionable i...
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