Insurance disruption due to spousal Medicare transitions: implications for access to care and health care utilization for women approaching age 65

Breast cancer patients' insurance status and residence zip code correlate with early discontinuation of endocrine therapy: An analysis of the ECOG-ACRIN TAILORx trial

BACKGROUND

Early discontinuation is a substantial barrier to the delivery of endocrine therapies (ETs) and may influence recurrence and survival. The authors investigated the association between early discontinuation of ET and social determinants of health, including insurance coverage and the neighborhood deprivation index (NDI), which was measured on the basis of patients' zip codes, in breast cancer.

METHODS

In this retrospective analysis of a prospective randomized clinical trial (Trial Assigning Individualized Options for Treatment), women with hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer who started ET within a year of study entry were included. Early discontinuation was calculated as stopping ET within 4 years of its start for reasons other than distant recurrence or death via Kaplan-Meier estimates. A Cox proportional hazards joint model was used to analyze the association between early discontinuation of ET and factors such as the study-entry insurance and NDI, with adjustments made for other variables.

RESULTS

Of the included 9475 women (mean age, 55.6 years; White race, 84%), 58.0% had private insurance, whereas 11.7% had Medicare, 5.8% had Medicaid, 3.8% were self-pay, and 19.1% were treated at international sites. The early discontinuation rate was 12.3%. Compared with those with private insurance, patients with Medicaid (hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.23-1.92) and self-pay patients (HR, 1.65; 95% CI, 1.25-2.17) had higher early discontinuation. Participants with a first-quartile NDI (highest deprivation) had a higher probability of discontinuation than those with a fourth-quartile NDI (lowest deprivation; HR, 1.34; 95% CI, 1.11-1.62).

CONCLUSIONS

Patients' insurance and zip code at study entry play roles in adherence to ET, with uninsured and underinsured patients having a high rate of treatment nonadherence. Early identification of patients at risk may improve adherence to therapy.

LAY SUMMARY

In this retrospective analysis of 9475 women with breast cancer participating in a clinical trial (Trial Assigning Individualized Options for Treatment), Medicaid and self-pay patients (compared with those with private insurance) and those in the highest quartile of neighborhood deprivation scores (compared with those in the lowest quartile) had a higher probability of early discontinuation of endocrine therapy. These social determinants of health assume larger importance with the expected increase in unemployment rates and loss of insurance coverage in the aftermath of the coronavirus disease 2019 pandemic. Early identification of patients at risk and enrollment in insurance optimization programs may improve the persistence of therapy.

Effect of new Medicare enrollment on health, healthcare utilization, and cost: A scoping review

BACKGROUND

More than three million Americans turn 65 each year and newly enroll in Medicare, making this one of the most common insurance transitions. Non-Medicare insurance transitions are associated with changes in health, healthcare utilization and costs. In addition, older Americans have higher morbidity, mortality, healthcare utilization, and healthcare costs than the general population. However, the effect of new Medicare enrollment on these outcomes is unclear.

DESIGN

We conducted a scoping review to rigorously identify the scope of evidence on the association between new Medicare enrollment and health, healthcare utilization and costs.

SETTING

We included English-language, peer-reviewed, studies cataloged in Medline (PubMed) and EconLit from 1998 to 2018.

PARTICIPANTS

Individuals newly enrolling in Medicare.

MEASUREMENTS

We measured health (e.g., self-reported health), healthcare utilization (e.g., provider visits, preventive care, and hospitalizations) and costs (e.g., patient out-of-pocket and health plan spending).

RESULTS

We screened 5265 articles and included 20 articles. New Medicare enrollment was found to increase self-reported health and healthcare utilization overall, as well as reduce disparities across racial and socioeconomic strata. Provider visits, preventive care and hospitalizations all increased. However, patient out-of-pocket spending decreased, and health plan spending also decreased, when Medicare's lower prices were accounted for. Few studies compared outcomes among new Medicare Advantage enrollees with new Medicare fee-for-service enrollees. None of the studies specifically evaluated the effect of new Medicare enrollment on adults with multiple chronic conditions.

CONCLUSION

New Medicare enrollment improves access overall and reduces access disparities. However, the impact of new Medicare enrollment among subgroups defined by insurance coverage type and number of chronic conditions is less clear. Future work should also evaluate the mechanism for increases in hospitalizations.

Perceptions of generic drug discount programs among low-income women: a qualitative study

PURPOSE

Increasing the awareness and use of generic drug discount programs (GDDP) may improve access to essential prescription drugs. However, little is known about public perceptions of GDDPs. The purpose of this study is to understand the perceptions and utilization patterns of low-income women regarding GDDP.

METHODS

Using a purposive sampling strategy, we conducted seven focus groups with a total of 50 participants using a semistructured guide to assess awareness and utilization of GDDP. Transcripts of the focus groups were systematically analyzed across groups with a general inductive approach for qualitative data analysis.

RESULTS

Five major categorical themes emerged from the focus group content analysis: 1) Perceived differences between generic and brand-name prescription drugs, 2) barriers to utilizing GDDP, 3) lack of adequate communication between pharmacy, physician and patient about GDDP, 4) perceived health impact of utilizing GDDPs, and 5) perceived health care savings. Most participants indicated that they perceive no difference between generic and brand-name prescription drugs. Lack of awareness was indicated as a barrier to utilization. There was general agreement among participants that GDDP can help to maintain health while saving money.

CONCLUSION

Study participants demonstrated generally favorable perceptions regarding GDDPs. Our findings underscore the need for policies that encourage expansion of the GDDP formulary and increasing awareness and utilization of GDDP.

A window of vulnerability: health insurance coverage among women 55 to 64 years of age

INTRODUCTION

largely a consequence of historical gender differences in labor force attachment in the United States, many women rely on their spouse for health insurance coverage, particularly during late middle age. Prior research finds that this creates a window of vulnerability for women during late middle age who may lose their (older) spouse's employment-based coverage when he retires from the labor force and enrolls in Medicare. However, the few studies that have examined this window of vulnerability have been based primarily on white adults.

METHODS

we used the 2004 and 2006 Annual Social and Economic Supplements to the Current Population Survey to examine whether the window of vulnerability exists among non-Hispanic Black, Mexican-origin, and non-Hispanic White women 55 to 64 years of age, and whether similar factors contribute to the vulnerability across these race/ethnic groups.

RESULTS

women 55 to 64 years of age married to men 65 years or older had an elevated risk of lacking coverage at a time of life when health problems are common and expensive. Among non-Hispanic White women, their husband's exit from full-time employment accounted for the higher risk, whereas a more complex and systemic set of social factors contributed to the higher risk among non-Hispanic Black and Mexican-origin women.

CONCLUSION

ensuring adequate and affordable health insurance coverage among women during late middle age may require additional health care reforms such as extending Medicare eligibility to younger adults or basing Medicare age eligibility on the age of the older partner within a married couple.