1
|
Layton TJ, Maestas N, Prinz D, Vabson B. Healthcare Rationing in Public Insurance Programs: Evidence from Medicaid. AMERICAN ECONOMIC JOURNAL. ECONOMIC POLICY 2022; 14:397-431. [PMID: 36824998 PMCID: PMC9945909 DOI: 10.1257/pol.20190628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
We study two mechanisms used by public health insurance programs for rationing health care: outsourcing to private managed care plans and quantity limits for prescription drugs. Leveraging a natural experiment in Texas’s Medicaid program, we find that the shift to managed care and the relaxation of a strict drug cap increased access to high-value drugs and outpatient services and reduced avoidable hospitalizations. Program costs increased significantly, indicating a trade-off between cost and quality. We provide suggestive evidence attributing the reduction in hospitalizations to the relaxation of the drug cap and much of the spending increase to the shift to managed care. (JEL G22, H75, I13, I18, I38)
Collapse
|
2
|
Sharma B, Mehta A, Farooqui HH, Negandhi H, Selvaraj S. Impact of the Drug Prices Control Order (2013) on the Utilization of Anticancer Medicines in India: An Interrupted Time-Series Analysis. Cureus 2022; 14:e26367. [PMID: 35911346 PMCID: PMC9329597 DOI: 10.7759/cureus.26367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2022] [Indexed: 11/05/2022] Open
Abstract
Objectives The National Pharmaceutical Pricing Authority introduced a series of Drug Prices Control Orders since 1970 to regulate the prices of essential medicines in India. This study evaluated the impact of the Drug Prices Control Order of 2013 on the utilization of anticancer medicines in the Indian private sector. Methods We used monthly sales audit data for a period of 2012-15, provided by Intercontinental Medical Statistics (IMS) Health. Through interrupted time series design and segmented regression models, we estimated the change in utilization of anticancer medicines following the drug pricing policy implementation. Results Of 1556 anticancer drug packs, 22.3% (n= 347) were price-controlled. The policy led to an immediate monthly reduction of 27.3% (95% CI -38.6%, -13.9%; p=0.001) and a long-term monthly reduction of 0.7% (95% CI -1.6%, 0.3%; p=0.16) in price-controlled formulation’s utilization. In the final study month, the price-controlled formulation’s utilization was 5.03 thousand standard units lower than what would have been expected without the policy. Melphalan showed the highest immediate reduction, and alpha-interferon showed the highest long-term reduction in utilization. Conclusion Drug prices control order 2013 caused an immediate and long-term decline in the utilization of anticancer medicines in the Indian private sector. However, study data was limited to a specific part of the Indian anticancer drug market, which must be considered when interpreting findings.
Collapse
|
3
|
Bloom CI, Montonen J, Jöns O, Garry EM, Bhatt SP. First Maintenance Therapy for Chronic Obstructive Pulmonary Disease: Retrospective Analyses of US and UK Healthcare Databases. Pulm Ther 2022; 8:57-74. [PMID: 35015270 PMCID: PMC8861230 DOI: 10.1007/s41030-021-00179-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/22/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Inhaled corticosteroids (ICS) are often prescribed inappropriately alongside long-acting bronchodilators for chronic obstructive pulmonary disease (COPD). We aimed to investigate if prescribing habits in the US and UK differ from recommendations for initiation of COPD maintenance therapy. METHODS We used healthcare data from the US IBM® MarketScan® and UK Clinical Practice Research Datalink databases to assess exacerbations and comorbidities in patients with COPD initiating first maintenance therapy (1MT) between 2015 and 2018. Patients with a recorded asthma diagnosis prior to initiation of 1MT were excluded. We evaluated time from recorded diagnosis of COPD until initiation of 1MT, and treatment regimen at 1MT (long-acting muscarinic antagonist [LAMA], long-acting β2-agonist [LABA], ICS, as monotherapy or in combination). RESULTS In the US and UK, median (IQR) time between recorded COPD diagnosis and 1MT was 158 (12; 839) and 29 (1; 521) days, respectively. Among the 53,473 US patients and 8786 UK patients who initiated 1MT, 50.9% and 32.4% had ≥ 1 exacerbation in the previous year. In the US, 20% of patients initiated LAMA, 1% LABA, 13% LAMA/LABA, and 66% an ICS-containing regimen (49% LABA/ICS, 13% ICS, and 4% LAMA/LABA/ICS). In the UK, 53% of patients initiated LAMA, 4% LABA, 16% LAMA/LABA, and 27% an ICS-containing regimen (14% LABA/ICS, 9% ICS, and 4% LAMA/LABA/ICS). CONCLUSIONS At 1MT, two-thirds of patients in the US received ICS-containing therapies, with almost half on LABA/ICS. In contrast, less than one-third received ICS-containing therapy in the UK and more than half of patients received LAMA. In both countries, more patients received ICS-containing therapies at initiation of 1MT than would be expected based on their exacerbation history, suggesting overprescribing.
Collapse
Affiliation(s)
| | - Jukka Montonen
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Olaf Jöns
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | - Surya P Bhatt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
4
|
Affiliation(s)
- Jeanne M. Madden
- Department of Pharmacy and Health Systems Sciences, School of Pharmacy and Pharmaceutical Sciences, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| |
Collapse
|
5
|
Geiger CK, Cohen JL, Sommers BD. Association Between Medicaid Prescription Drug Limits and Access to Medications and Health Care Use Among Young Adults With Disabilities. JAMA HEALTH FORUM 2021; 2:e211048. [PMID: 35977173 PMCID: PMC8796920 DOI: 10.1001/jamahealthforum.2021.1048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/17/2021] [Indexed: 11/22/2022] Open
Abstract
Question Are policies that cap monthly prescriptions in Medicaid associated with access to medication and health care use among young adults with disabilities in Arkansas and Texas? Findings In this cohort study using difference-in-differences analysis of 28 046 young adults with disabilities, including 8214 in states with a 3-drug limit at age 21 years, the 3-drug limit was associated with lower monthly prescriptions for medications used to treat mental health conditions and higher inpatient admissions among all individuals with disabilities in states with the drug cap policy compared with those in states without this policy. Meaning In this study, state drug cap policies in Medicaid were associated with lower access to medications and higher use of inpatient care. Importance Prescription drugs are necessary for managing complex physical and mental health conditions for more than 10 million Medicaid beneficiaries with disabilities. However, some state Medicaid programs limit the number of prescription drugs that beneficiaries can obtain monthly, which may decrease access to essential medications. Objective To examine the association between exposure to the 3-drug limit at age 21 years in Arkansas and Texas and prescription drug and health care use among beneficiaries with disabilities enrolled in Medicaid. Design, Setting, and Participants In this cohort study of 28 046 young adults with disabilities, difference-in-differences analysis was performed using Medicaid Analytic eXtract claims data from January 1, 2007, to December 31, 2012. Analyses were completed December 1, 2020. The analyses included Medicaid beneficiaries with disabilities in Arkansas and Texas (ie, drug cap states) or 15 comparison states without drug cap policies who became age 21 years during the study period and were continuously enrolled in fee-for-service Medicaid in the year before and after that point. Exposures Exposure to the 3-drug prescription limit at age 21 years in 2 drug cap states. Main Outcomes and Measures Monthly total prescriptions and prescriptions for drugs to treat mental health conditions, total prescription drug spending, and inpatient and emergency department visits and spending in the 12 months before and after becoming age 21 years. Results Among 28 046 young adults with disabilities, 8214 (29.3%) resided in drug cap states and were subject to the 3-drug limit at age 21 years. Most individuals were male (drug cap states: 61.4%, comparison states: 60.6%), and the minority were White individuals (drug cap states: 36.7%, comparison states: 49.4%). More than one-half of individuals with disabilities were diagnosed with a mental health condition before age 21 years (drug cap states: 57.0%, comparison states: 60.0%). In the year before the analyzed individuals became aged 21 years, the mean (SD) number of prescriptions per beneficiary per month was 1.58 (2.16) in drug cap states vs 1.82 (1.91) in comparison states. The drug cap policy was associated with 19.6% (95% CI, −21.3% to −17.8%; P < .001) fewer monthly prescriptions and 16.5% (95% CI, −21.9% to −10.8%; P < .001) fewer prescriptions for drugs for mental health conditions but was not associated with total prescription drug spending. The drug cap policy was associated with 13.6% (95% CI, 1.9% to 26.6%; P = .02) more inpatient admissions. Conclusions and Relevance In this cohort study of young adults with disabilities, drug cap policies were associated with lower rates of access to important medications and higher rates of hospitalization among individuals in states with drug cap policies vs those without these policies.
Collapse
Affiliation(s)
- Caroline K. Geiger
- Harvard University, Interfaculty Initiative in Health Policy, Cambridge, Massachusetts
- Genentech, Inc, South San Francisco, California
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School/Brigham & Women’s Hospital, Boston, Massachusetts
| |
Collapse
|
6
|
Salciccioli KB, Salemi JL, Broda CR, Lopez KN. Disparities in insurance coverage among hospitalized adult congenital heart disease patients before and after the Affordable Care Act. Birth Defects Res 2021; 113:644-659. [PMID: 33590705 DOI: 10.1002/bdr2.1878] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/27/2020] [Accepted: 01/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Data are lacking regarding the insurance status of adults with congenital heart disease (ACHD). We investigated whether the Affordable Care Act (ACA) impacted insurance status among hospitalized ACHD, identified associated sociodemographic factors, and compared coverage to adults with other chronic childhood conditions. METHODS Serial cross-sectional analysis of National Inpatient Sample hospitalizations from 2007 to 2016 was performed for patients 18-64 years old. ACHD were identified using ICD-9/10-CM codes and compared to patients with sickle cell disease (SCD), cystic fibrosis (CF), and the general population. Age was dichotomized as 18-25 years (transition aged) or 26-64 years. Groups were compared by era (pre-ACA [January 2007-June 2010]; early-ACA [July 2010-December 2013], which eliminated pre-existing condition exclusions; and full-ACA [January 2014-December 2016]) using interrupted time series and multivariable Poisson regression analyses. RESULTS Overall, uninsured hospitalizations decreased from pre-ACA (12.0%) to full-ACA (8.5%). After full ACA implementation, ACHD had lower uninsured rates than the general hospitalized population (6.0 vs. 8.6%, p < .01), but higher rates than those with other chronic childhood diseases (SCD [4.5%]; CF [1.6%]). Across ACA eras, transition aged ACHD had higher uninsured rates than older patients (8.9 vs. 7.6%, p < .01), and Hispanic patients remained less insured than other groups. CONCLUSIONS Hospitalized ACHD were better insured than the general population but less insured than those with SCD or CF. Full ACA implementation was associated with improved insurance coverage for all groups, but disparities persisted for transition aged and Hispanic patients. Ongoing evaluation of the effects of insurance and health policy on ACHD remains critical to diminish health disparities.
Collapse
Affiliation(s)
- Katherine B Salciccioli
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jason L Salemi
- College of Public Health, University of South Florida, Tampa, Florida, USA.,Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Christopher R Broda
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Keila N Lopez
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| |
Collapse
|
7
|
Holbrook AM, Wang M, Lee M, Chen Z, Garcia M, Nguyen L, Ford A, Manji S, Law MR. Cost-related medication nonadherence in Canada: a systematic review of prevalence, predictors, and clinical impact. Syst Rev 2021; 10:11. [PMID: 33407875 PMCID: PMC7788798 DOI: 10.1186/s13643-020-01558-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 12/15/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Cost-related nonadherence to medications (CRNA) is common in many countries and thought to be associated with adverse outcomes. The characteristics of CRNA in Canada, with its patchwork coverage of increasingly expensive medications, are unclear. OBJECTIVES Our objective in this systematic review was to summarize the literature evaluating CRNA in Canada in three domains: prevalence, predictors, and effect on clinical outcomes. METHODS We searched MEDLINE, Embase, Google Scholar, and the Cochrane Library from 1992 to December 2019 using search terms covering medication adherence, costs, and Canada. Eligible studies, without restriction on design, had to have original data on at least one of the three domains specifically for Canadian participants. Articles were identified and reviewed in duplicate. Risk of bias was assessed using design-specific tools. RESULTS Twenty-six studies of varying quality (n = 483,065 Canadians) were eligible for inclusion. Sixteen studies reported on the overall prevalence of CRNA, with population-based estimates ranging from 5.1 to 10.2%. Factors predicting CRNA included high out-of-pocket spending, low income or financial flexibility, lack of drug insurance, younger age, and poorer health. A single randomized trial of free essential medications with free delivery in Ontario improved adherence but did not find any change in clinical outcomes at 1 year. CONCLUSION CRNA affects many Canadians. The estimated percentage depends on the sampling frame, the main predictors tend to be financial, and its association with clinical outcomes in Canada remains unproven.
Collapse
Affiliation(s)
- Anne M Holbrook
- Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Mei Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Munil Lee
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Zhiyuan Chen
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael Garcia
- Bachelor of Health Studies Program, University of Waterloo, Waterloo, ON, Canada
| | - Laura Nguyen
- Bachelor of Health Sciences Program, McMaster University, Hamilton, ON, Canada
| | - Angela Ford
- School of Medicine, Queen's University, Kingston, ON, Canada
| | - Selina Manji
- Global Health Program, McMaster University, Hamilton, ON, Canada
| | - Michael R Law
- The Centre for Health Services and Policy Research, School of Population and Public Health, The University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
8
|
Roberts AW, Look KA, Trull G, Carpenter DM. Medicaid prescription limits and their implications for naloxone accessibility. Drug Alcohol Depend 2021; 218:108355. [PMID: 33309522 PMCID: PMC7568500 DOI: 10.1016/j.drugalcdep.2020.108355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/07/2020] [Accepted: 10/08/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Expanding access to and utilization of naloxone is a vitally important harm reduction strategy for preventing opioid overdose deaths, particularly in vulnerable populations like Medicaid beneficiaries. The objective of this study was to characterize the landscape of monthly prescription fill limit policies in Medicaid programs and their potential implications for expanding naloxone use for opioid overdose harm reduction. METHODS A cross-sectional, multi-modal online and telephonic data collection strategy was used to identify and describe the presence and characteristics of monthly prescription fill limit policies across state Medicaid programs. Contextual characteristics were described regarding each state's Medicaid enrollment, opioid prescribing rates, and overdose death rates. Data collection and analysis occurred between February and May 2020. RESULTS Medicaid-covered naloxone fills are currently subject to monthly prescription fill limit policies in 10 state Medicaid programs, which cover 20 % of the Medicaid population nationwide. Seven of these programs are located in states ranking in the top 10 highest per-capita opioid prescribing rates in the country. However, 8 of these programs are located in states with opioid overdose death rates below the national average. CONCLUSIONS Medicaid beneficiaries at high risk of opioid overdose living in states with monthly prescription fill limits may experience significant barriers to obtaining naloxone. Exempting naloxone from Medicaid prescription limit restrictions may help spur broader adoption of naloxone for opioid overdose mortality prevention, especially in states with high opioid prescribing rates. Achieving unfettered naloxone coverage in Medicaid is critical as opioid overdoses and Medicaid enrollment increase amid the COVID-19 pandemic.
Collapse
Affiliation(s)
- Andrew W. Roberts
- Department of Population Health, Department of Anesthesiology, 3901 Rainbow Blvd, Mailstop 1008, Kansas City, KS 66160, USA,Corresponding author
| | - Kevin A. Look
- Social and Administrative Sciences Division, University of Wisconsin-Madison School of Pharmacy, 777 Highland Avenue, Madison, WI 53705, USA
| | - Grace Trull
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, One University Heights, CB# 2125, Asheville, NC 28804, USA.
| | - Delesha M. Carpenter
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, One University Heights, CB# 2125, Asheville, NC 28804, USA
| |
Collapse
|
9
|
Seringa J, Marques AP, Moita B, Gaspar C, Raposo JF, Santana R. The impact of diabetes on multiple avoidable admissions: a cross-sectional study. BMC Health Serv Res 2019; 19:1002. [PMID: 31881962 PMCID: PMC6935195 DOI: 10.1186/s12913-019-4840-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/16/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Multiple admissions for ambulatory care sensitive conditions (ACSC) are responsible for an important proportion of health care expenditures. Diabetes is one of the conditions consensually classified as an ACSC being considered a major public health concern. The aim of this study was to analyse the impact of diabetes on the occurrence of multiple admissions for ACSC. METHODS We analysed inpatient data of all public Portuguese NHS hospitals from 2013 to 2015 on multiple admissions for ACSC among adults aged 18 or older. Multiple ACSC users were identified if they had two or more admissions for any ACSC during the period of analysis. Two logistic regression models were computed. A baseline model where a logistic regression was performed to assess the association between multiple admissions and the presence of diabetes, adjusting for age and sex. A full model to test if diabetes had no constant association with multiple admissions by any ACSC across age groups. RESULTS Among 301,334 ACSC admissions, 144,209 (47.9%) were classified as multiple admissions and from those, 59,436 had diabetes diagnosis, which corresponded to 23,692 patients. Patients with diabetes were 1.49 times (p < 0,001) more likely to be admitted multiple times for any ACSC than patients without diabetes. Younger adults with diabetes (18-39 years old) were more likely to become multiple users. CONCLUSION Diabetes increases the risk of multiple admissions for ACSC, especially in younger adults. Diabetes presence is associated with a higher resource utilization, which highlights the need for the implementation of adequate management of chronic diseases policies.
Collapse
Affiliation(s)
- Joana Seringa
- NOVA National School of Public Health, Universidade NOVA de Lisboa, Lisbon, Portugal.
| | - Ana Patrícia Marques
- NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center (CHRC), Lisbon, Portugal
| | - Bruno Moita
- NOVA National School of Public Health, Universidade NOVA de Lisboa, Lisbon, Portugal
- Algarve University Hospital Center, Faro, Portugal
| | - Cátia Gaspar
- NOVA National School of Public Health, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - João Filipe Raposo
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
- Associação Protectora dos Diabéticos de Portugal, Lisbon, Portugal
| | - Rui Santana
- NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, Lisbon, Portugal
- Comprehensive Health Research Center (CHRC), Lisbon, Portugal
| |
Collapse
|
10
|
Abstract
IMPORTANCE The United States spends more on health care than any other country, with costs approaching 18% of the gross domestic product (GDP). Prior studies estimated that approximately 30% of health care spending may be considered waste. Despite efforts to reduce overtreatment, improve care, and address overpayment, it is likely that substantial waste in US health care spending remains. OBJECTIVES To estimate current levels of waste in the US health care system in 6 previously developed domains and to report estimates of potential savings for each domain. EVIDENCE A search of peer-reviewed and "gray" literature from January 2012 to May 2019 focused on the 6 waste domains previously identified by the Institute of Medicine and Berwick and Hackbarth: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. For each domain, available estimates of waste-related costs and data from interventions shown to reduce waste-related costs were recorded, converted to annual estimates in 2019 dollars for national populations when necessary, and combined into ranges or summed as appropriate. FINDINGS The review yielded 71 estimates from 54 unique peer-reviewed publications, government-based reports, and reports from the gray literature. Computations yielded the following estimated ranges of total annual cost of waste: failure of care delivery, $102.4 billion to $165.7 billion; failure of care coordination, $27.2 billion to $78.2 billion; overtreatment or low-value care, $75.7 billion to $101.2 billion; pricing failure, $230.7 billion to $240.5 billion; fraud and abuse, $58.5 billion to $83.9 billion; and administrative complexity, $265.6 billion. The estimated annual savings from measures to eliminate waste were as follows: failure of care delivery, $44.4 billion to $97.3 billion; failure of care coordination, $29.6 billion to $38.2 billion; overtreatment or low-value care, $12.8 billion to $28.6 billion; pricing failure, $81.4 billion to $91.2 billion; and fraud and abuse, $22.8 billion to $30.8 billion. No studies were identified that focused on interventions targeting administrative complexity. The estimated total annual costs of waste were $760 billion to $935 billion and savings from interventions that address waste were $191 billion to $286 billion. CONCLUSIONS AND RELEVANCE In this review based on 6 previously identified domains of health care waste, the estimated cost of waste in the US health care system ranged from $760 billion to $935 billion, accounting for approximately 25% of total health care spending, and the projected potential savings from interventions that reduce waste, excluding savings from administrative complexity, ranged from $191 billion to $286 billion, representing a potential 25% reduction in the total cost of waste. Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in US health care expenditures.
Collapse
Affiliation(s)
| | | | - Natasha Parekh
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
11
|
Morse E, Hanna J, Mehra S. The Association between Industry Payments and Brand-Name Prescriptions in Otolaryngologists. Otolaryngol Head Neck Surg 2019; 161:605-612. [PMID: 31547772 DOI: 10.1177/0194599819852321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To associate pharmaceutical industry payments to brand-name prescriptions by otolaryngologists. STUDY DESIGN Retrospective cross-sectional analysis. SETTING Open Payments Database and the Medicare Part D Participant User File 2013-2016. SUBJECTS AND METHODS We identified otolaryngologists receiving nonresearch industry payments and prescribing to Medicare Part D recipients. Records were linked by physician name and state. The value of industry payments and the percentage of brand-name drugs prescribed per hospital referral region (HRR) were characterized as medians. Industry payments were correlated to the rate of brand-name prescription by Kendall's τ correlation. This was repeated at the individual physician level and stratified by payment type. RESULTS In total, 8167 otolaryngologists received a median of $434 (interquartile range, $138-$1278) in industry compensation over 11 (3-26) payments. Brand-name drugs made up a median of 12.9% (8.6%-18-4%) of each physician's drug claims. The number (τ = 0.05, P < .001) and dollar amount (τ = 0.04, P < .001) of industry payments were correlated with the rate of brand-name drug prescription at the individual physician level. The number of industry payments was also associated with the rate of brand-name prescription by HRR (τ = 0.14, P < .001), but the dollar amount was not. By HRR, food and beverage payments received by physicians were associated with the rate of brand-name drug prescription (τ = 0.04, P < .001), but travel and lodging payments were not. CONCLUSIONS Industry financial transactions are associated with brand-name drug prescriptions in otolaryngologists, and these associations are stronger at the regional level than at the individual physician level. These correlations are of modest strength and should be interpreted cautiously by readers.
Collapse
Affiliation(s)
- Elliot Morse
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jonathan Hanna
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saral Mehra
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, USA
- Yale Cancer Center, New Haven, Connecticut, USA
| |
Collapse
|
12
|
Direct medical cost of oropharyngeal cancer among patients insured by Medicaid in Texas. Oral Oncol 2019; 96:21-26. [PMID: 31422209 DOI: 10.1016/j.oraloncology.2019.06.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 05/17/2019] [Accepted: 06/28/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The aim of this study was to estimate the direct 2-year mean incremental medical care costs for incident oropharyngeal cancer (OPC) from the perspective of the Texas Medicaid program. METHODS OPC patients treated from 2008 to 2012 were selected in the Texas Medicaid database. Using a two-step 1:1 propensity score matching method, we selected controls to determine the differential cost associated with OPC. Monthly and yearly direct costs were estimated for 2 years after the cancer diagnosis. For patients without 2-year complete follow-up, a generalized linear model with gamma distribution and log link function was applied to predict costs for the censored months. RESULTS A total of 352 patients with OPC and the same number of controls were included in the study. Among OPC patients, 204 (58%) were covered by Medicaid and Medicare, and 148 patients (42%) were insured under Medicaid only. The adjusted first- and second-year mean differential costs were $45,102 and $11,684 for Medicaid-only enrollees and $5734 and $2162 for Medicaid-Medicare dual-eligible enrollees, respectively. Being male, Hispanic, Medicaid-only eligible, living in the Harlingen region, and having more comorbidities were positively associated with monthly cost. Lubbock residents experienced lower costs. CONCLUSIONS The direct incremental medical costs associated with OPCs among patients insured by Texas Medicaid were substantial in the first 2 years after cancer diagnosis and should be considered in assessing the economic consequences of increasing the investment in HPV vaccination in Texas.
Collapse
|
13
|
Impact of U.S. federal and state generic drug policies on drug use, spending, and patient outcomes: A systematic review. Res Social Adm Pharm 2019; 16:736-745. [PMID: 31445986 DOI: 10.1016/j.sapharm.2019.08.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Prescription drugs contribute to increased healthcare expenditures in the United States (U.S.). Use of generic drugs has been recognized as an effective tool to control rising prescription drug costs. This study aimed to evaluate the impact of U.S. federal and state generic drug policies on drug use, spending, and patient outcomes. METHODS A systematic search was performed in June 2017, using PubMed, Web of Science, PsycINFO, and Business Source Premier. Search was limited to published articles in English language, including human subjects in the U.S., and with at least one outcome measure related to health service utilization, spending, or patient outcomes. RESULTS Thirty-four studies constituting seven key policy domains were included. Medicaid/Medicare Prior Authorization (PA) policies (n = 4) led to increased generic use, reduced patient and payer's spending on prescriptions without causing deterioration in patient's health-related quality of life. Medicare prescription plan's generic drug benefits (n = 4) had impact on increased generic use and generated savings, but the limited access to branded drugs may increase medication use gaps and risks of hospitalizations. State generic substitution laws (n = 3) caused increased generic use and cost savings for both consumers and states. Medicare/Medicaid coverage cap policies (n = 3) were associated with increased patient's out-of-pocket spending (OOP) and reduced prescription spending for payers. Policies lowering cost-sharing (n = 7) were associated with increased patient's medication use and adherence, but the impact varied by therapeutic classes. Existing evidence evaluating Medicare Part D (n = 12) suggested decreased prescription spending for beneficiaries and Medicare. Generic gap coverage reduced patient's OOP and Medicare spending. Finally, early evidence showed reduced consumers' OOP prescription spending after the ACA (n = 2). CONCLUSIONS Federal and state policies regarding generic drugs have resulted in reduced spending for consumers and payers. However, the overall impact on patient outcomes remains unclear.
Collapse
|
14
|
Salemi JL, Tanner JP, Kirby RS, Cragan JD. The impact of the ICD-9-CM to ICD-10-CM transition on the prevalence of birth defects among infant hospitalizations in the United States. Birth Defects Res 2019; 111:1365-1379. [PMID: 31414582 DOI: 10.1002/bdr2.1578] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/23/2019] [Accepted: 07/31/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Many public health surveillance programs utilize hospital discharge data in their estimation of disease prevalence. These databases commonly use the International Classification of Diseases (ICD) coding scheme, which transitioned from the ICD-9 clinical modification (ICD-9-CM) to ICD-10-CM on October 1, 2015. This study examined this transition's impact on the prevalence of major birth defects among infant hospitalizations. METHODS Using data from the Agency for Health Care Research and Quality-sponsored National Inpatient Sample, hospitalizations during the first year of life with a discharge date between January 1, 2012 and December 31, 2016 were used to estimate the monthly national hospital prevalence of 46 birth defects for the ICD-9-CM and ICD-10-CM timeframes separately. Survey-weighted Poisson regression was used to estimate 95% confidence intervals for each hospital prevalence. Interrupted time series framework and corresponding segmented regression was used to estimate the immediate change in monthly hospital prevalence following the ICD-9-CM to ICD-10-CM transition. RESULTS Between 2012 and 2016, over 21 million inpatient hospitalizations occurred during the first year of life. Among the 46 defects studied, statistically significant decreases in the immediate hospital prevalence of five defects and significant increases in the immediate hospital prevalence of eight defects were observed after the ICD-10-CM transition. CONCLUSIONS Changes in prevalence were expected based on changes to ICD-10-CM. Observed changes for some conditions may result from variation in monthly hospital prevalence or initial unfamiliarity of coders with ICD-10-CM. These findings may help birth defects surveillance programs evaluate and interpret changes in their data related to the ICD-10-CM transition.
Collapse
Affiliation(s)
- Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas.,Birth Defects Surveillance Program, College of Public Health, University of South Florida, Tampa, Florida
| | - Jean Paul Tanner
- Birth Defects Surveillance Program, College of Public Health, University of South Florida, Tampa, Florida
| | - Russell S Kirby
- Birth Defects Surveillance Program, College of Public Health, University of South Florida, Tampa, Florida
| | - Janet D Cragan
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
15
|
Youn B, Shireman TI, Lee Y, Galárraga O, Wilson IB. Trends in medication adherence in HIV patients in the US, 2001 to 2012: an observational cohort study. J Int AIDS Soc 2019; 22:e25382. [PMID: 31441221 PMCID: PMC6706701 DOI: 10.1002/jia2.25382] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 07/31/2019] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Adherence to antiretroviral therapy (ART) is essential to reduce HIV-related morbidity and mortality as well as the risk of virological failure and HIV transmission. We determined the trends in ART adherence during the periods of therapeutic advances, wider use of ART and greater attention to ART adherence. To understand the general trends in medication adherence, we compared ART adherence with medications for other common chronic conditions. METHODS A retrospective cohort study using Medicaid claims between 2001 and 2012 from 14 US states with the highest HIV prevalence. Medicaid is the largest source of care for HIV patients in the US. We identified Medicaid beneficiaries with HIV who initiated ART between 2001 and 2010 (n=23,343). Comparison groups included (1) HIV- persons who initiated a statin, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEI/ARB), or metformin and (2) HIV+ persons who initiated these control medications while on and not on ART. We estimated adjusted odds of >90% medication implementation during the two years following initiation. RESULTS The proportion of HIV+ persons with >90% ART implementation increased from 33.5% in those who initiated in 2001 to 46.4% in 2005 and 52.4% in 2010. ART initiators in 2007 to 2010 had 53% increased odds of >90% implementation compared to those in 2001 to 2003 (adjusted OR 1.53, 99% CI: 1.34 to 1.75). Older age, male, White race, newer ART regimens and absence of substance use indicators were also associated with increased odds of >90% ART implementation. No or minimal improvements were found in the implementation of control medications in HIV- persons. For HIV- persons, the adjusted ORs comparing 2007-2010 to 2001-2003 were 1.06, 1.01 and 1.19 for statins, ACEI/ARB, metformin respectively. HIV+ persons who were on ART had, on average, 15.0 (SD: 4.2) and 16.1 (SD: 3.4) percentage points higher >90% implementation rates of concurrent statins, ACEI/ARB or metformin compared to HIV- persons and HIV+ persons who were not on ART respectively. CONCLUSIONS Adherence to ART substantially improved between 2001 and 2012. Nevertheless, the absolute rates of >90% implementation were low for all groups examined. Substantial disparities by age, sex and race were present, drawing attention to the need to continue to enhance medication adherence. Further studies are required to examine whether these trends and disparities persist in the most recent period.
Collapse
Affiliation(s)
- Bora Youn
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRIUSA
| | - Theresa I Shireman
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRIUSA
| | - Yoojin Lee
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRIUSA
| | - Omar Galárraga
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRIUSA
| | - Ira B Wilson
- Department of Health Services, Policy & PracticeBrown University School of Public HealthProvidenceRIUSA
| |
Collapse
|
16
|
Prior Authorization Policies and Preferred Drug Lists in Medicaid Plans: Stakeholder Perspectives on the Implications for Youth with ADHD. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2019; 46:580-595. [PMID: 30993569 DOI: 10.1007/s10488-019-00937-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This qualitative study describes how Medicaid policies create challenges for the delivery and receipt of mental health treatment for low-income youth in Georgia. We conducted focus groups with caregivers of Medicaid-enrolled children with ADHD and semi-structured interviews with providers and administrators at four safety net clinics that provided mental health care to these youth. Stakeholders reported that prior authorization policies for psychosocial services, restrictiveness of preferred drug lists, and changes in preferred drug lists in Medicaid plans created barriers to treatment continuity and quality for youth with ADHD and led to more administrative burden for safety-net clinics serving these youth.
Collapse
|
17
|
Cliff EQ, Fendrick AM. "Clinically nuanced" Medicaid cost-sharing. J Med Econ 2018; 21:189-191. [PMID: 28975861 DOI: 10.1080/13696998.2017.1388807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Elizabeth Q Cliff
- a Center for Value-Based Insurance Design, School of Public Health , University of Michigan , Ann Arbor , MI , USA
- b Department of Health Management & Policy, School of Public Health , University of Michigan , Ann Arbor , MI , USA
| | - A Mark Fendrick
- a Center for Value-Based Insurance Design, School of Public Health , University of Michigan , Ann Arbor , MI , USA
- b Department of Health Management & Policy, School of Public Health , University of Michigan , Ann Arbor , MI , USA
| |
Collapse
|
18
|
Naghavi AO, Echevarria MI, Grass GD, Strom TJ, Abuodeh YA, Ahmed KA, Kim Y, Trotti AM, Harrison LB, Yamoah K, Caudell JJ. Having Medicaid insurance negatively impacts outcomes in patients with head and neck malignancies. Cancer 2016; 122:3529-3537. [PMID: 27479362 DOI: 10.1002/cncr.30212] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/21/2016] [Accepted: 06/22/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patients covered by Medicaid insurance appear to have poorer cancer outcomes. Herein, the authors sought to test whether Medicaid was associated with worse outcomes among patients with head and neck cancer (HNC). METHODS The records of 1698 patients with squamous cell HNC without distant metastatic disease were retrospectively reviewed from an institutional database between 1998 and 2011. At the time of diagnosis, insurance status was categorized as Medicaid, Medicare/other government insurance, or private insurance. Outcomes including locoregional control (LRC) and overall survival (OS) were estimated using the Kaplan-Meier method and Cox regression multivariate analysis (MVA). RESULTS The median follow-up for all patients was 35 months. Medicaid patients comprised 11% of the population; the remaining patients were privately insured (56%) or had Medicare/government insurance (34%). On MVA, Medicaid patients were younger, were current smokers, had higher tumor T and N classifications, and experienced a longer time from diagnosis to treatment initiation (all P<.005). Medicaid insurance status was associated with a deficit of 13% in LRC (69% vs 82%) and 26% in OS (46% vs 72%) at 3 years (all with P<.001). A time from diagnosis to treatment initiation of >45 days was found to be associated with worse 3-year LRC (77% vs 83%; P = .009) and OS (68% vs 71%; P = .008). On MVA, Medicaid remained associated with a deficit in LRC (P = .002) and OS (P<.001). CONCLUSIONS Patients with Medicaid insurance more often present with locally advanced HNC and experience a higher rate of treatment delays compared with non-Medicaid patients. Medicaid insurance status appears to be independently associated with deficits in LRC and OS. Improvements in the health care system, such as expediting treatment initiation, may improve the outcomes of patients with HNC. Cancer 2016;122:3529-3537. © 2016 American Cancer Society.
Collapse
Affiliation(s)
- Arash O Naghavi
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Michelle I Echevarria
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - G Daniel Grass
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Tobin J Strom
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Yazan A Abuodeh
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kamran A Ahmed
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Youngchul Kim
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Andy M Trotti
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Louis B Harrison
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Kosj Yamoah
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Jimmy J Caudell
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| |
Collapse
|