Spending on Dual Over-the-Counter and Prescription Drugs in the Medicare Part D Program

This study compares Medicare and patient spending for dual over-the-counter and prescription drugs with their over-the-counter cash prices.

Reimbursement to Pharmacies for Generic Drugs by Medicare Part D Sponsors

This study evaluates whether organizations that offer Medicare Part D plans (referred to as Part D sponsors) overpay pharmacies for generic drugs.

Insulin Fills by Medicare Enrollees and Out-of-Pocket Caps Under the Inflation Reduction Act

This study uses data from IQVIA’s National Prescription Audit to assess the association of the Inflation Reduction Act’s cap on cost sharing with insulin fills by Medicare beneficiaries.

Added Therapeutic Benefit of Top-Selling Brand-name Drugs in Medicare

Importance

The Inflation Reduction Act of 2022 authorizes Medicare to negotiate prices of top-selling drugs based on several factors, including therapeutic benefit compared with existing treatment options.

Objective

To determine the added therapeutic benefit of the 50 top-selling brand-name drugs in Medicare in 2020, as assessed by health technology assessment (HTA) organizations in Canada, France, and Germany.

Design, Setting, and Participants

In this cross-sectional study, publicly available therapeutic benefit ratings, US Food and Drug Administration documents, and the Medicare Part B and Part D prescription drug spending dashboards were used to determine the 50 top-selling single-source drugs used in Medicare in 2020 and to assess their added therapeutic benefit ratings through 2021.

Main Outcomes and Measures

Ratings from HTA bodies in Canada, France, and Germany were categorized as high (moderate or greater) or low (minor or no) added benefit. Each drug was rated based on its most favorable rating across countries, indications, subpopulations, and dosage forms. We compared the use and prerebate and postrebate (ie, net) Medicare spending between drugs with high vs low added benefit.

Results

Forty-nine drugs (98%) received an HTA rating by at least 1 country; 22 of 36 drugs (61%) received a low added benefit rating in Canada, 34 of 47 in France (72%), and 17 of 29 in Germany (59%). Across countries, 27 drugs (55%) had a low added therapeutic rating, accounting for $19.3 billion in annual estimated net spending, or 35% of Medicare net spending on the 50 top-selling single-source drugs and 11% of total Medicare net prescription drug spending in 2020. Compared with those with high added benefit, drugs with a low added therapeutic rating were used by more Medicare beneficiaries (median 387 149 vs 44 869) and had lower net spending per beneficiary (median $992 vs $32 287).

Conclusions and Relevance

Many top-selling Medicare drugs received low added benefit ratings by the national HTA organizations of Canada, France, and Germany. When negotiating prices for these drugs, Medicare should ensure they are not priced higher than reasonable therapeutic alternatives.

Prescription Drug Spending in Fee-for-Service Medicare, 2008-2019

IMPORTANCE

Prescription drug spending is a topic of increased interest to the public and policymakers. However, prior assessments have been limited by focusing on retail spending (Part D-covered drugs), omitting clinician-administered (Part B-covered) drug spending, or focusing on all fee-for-service Medicare beneficiaries, regardless of their enrollment into prescription drug coverage.

OBJECTIVE

To estimate the proportion of health care spending contributed by prescription drugs and to assess spending for retail and clinician-administered prescriptions.

DESIGN, SETTING, AND PARTICIPANTS

Descriptive, serial, cross-sectional analysis of a 20% random sample of fee-for-service Medicare beneficiaries in the United States from 2008 to 2019 who were continuously enrolled in Parts A (hospital), B (medical), and D (prescription drug) benefits, and not in Medicare Advantage.

EXPOSURE

Calendar year.

MAIN OUTCOMES AND MEASURES

Net spending on retail (Part D-covered) and clinician-administered (Part B-covered) prescription drugs; prescription drug spending (spending on Part B-covered and Part D-covered drugs) as a percentage of total per-capita health care spending. Measures were adjusted for inflation and for postsale rebates (for Part D-covered drugs).

RESULTS

There were 3 201 284 beneficiaries enrolled in Parts A, B, and D in 2008 and 4 502 718 in 2019. In 2019, beneficiaries had a mean (SD) age of 71.7 (12.0) years, documented sex was female for 57.7%, and 69.5% had no low-income subsidies. Total per-capita spending was $16 345 in 2008 and $20 117 in 2019. Comparing 2008 with 2019, per-capita Part A spending was $7106 (95% CI, $7084-$7128) vs $7120 (95% CI, $7098-$7141), Part B drug spending was $720 (95% CI, $713-$728) vs $1641 (95% CI, $1629-$1653), Part B nondrug spending was $5113 (95% CI, $5105-$5122) vs $6702 (95% CI, $6692-$6712), and Part D net spending was $3122 (95% CI, $3117-$3127) vs $3477 (95% CI, $3466-$3489). The proportion of total annual spending attributed to prescription drugs increased from 24.0% in 2008 to 27.2% in 2019, net of estimated rebates and discounts.

CONCLUSIONS AND RELEVANCE

In 2019, spending on prescription drugs represented approximately 27% of total spending among fee-for-service Medicare beneficiaries enrolled in Part D, even after accounting for postsale rebates.

Association Between Payments by Pharmaceutical Manufacturers and Prescribing Behavior in Rheumatology

OBJECTIVE

To evaluate the association between pharmaceutical industry payments to rheumatologists and their prescribing behaviors.

METHODS

A cross-sectional analysis was conducted of Medicare Part B Public Use File, Medicare Part D Public Use File, and Open Payments data for 2013 to 2015. Prescription drugs responsible for 80% of the total Medicare pharmaceutical expenditures in rheumatology were analyzed. We calculated the mean annual drug cost per beneficiary per year, the percentage of rheumatologists who received payments, and the median annual payment per physician per drug per year. Industry payments were categorized as food/beverage and consulting/compensation. Multivariable regression models were used to assess associations between industry payments and both prescribing patterns and prescription drug expenditures.

RESULTS

Of 4822 rheumatologists in the Medicare prescribing databases, 3729 received any payment from a pharmaceutical company during this time frame. Food/beverage payments were associated with an increased proportion of prescriptions for the related drugs (range, 1.5% to 4.5%) and an increased proportion of annual Medicare spending for the related drugs (range, 3% to 23%). For every $100 in food/beverage payments, the probability of prescribing increased (range, 1.5% to 14% for most drugs) and Medicare reimbursements increased (range, 6% to 44% for most drugs). Consulting/compensation payments were associated with an increased proportion of prescriptions (range, 1.2% to 1.6%) and an increased proportion of annual Medicare spending (range, 1% to 2%). For every $1000 in consulting/compensation payments, both the probability of prescribing increased (5% or less for most drugs) and Medicare reimbursements increased (less than 10% for most drugs).

CONCLUSION

Payments to rheumatologists by pharmaceutical companies are associated with increased probability of prescribing and Medicare spending.

Availability of Cost-effectiveness Studies for Drugs With High Medicare Part D Expenditures

IMPORTANCE

Prescription drug spending in the US requires policy intervention to control costs and improve the value obtained from pharmaceutical spending. One such intervention is to apply cost-effectiveness evidence to decisions regarding drug coverage and pricing, but this intervention depends on the existence of such evidence to guide decisions.

OBJECTIVE

To characterize the availability and quality of cost-effectiveness studies for prescription drugs with the greatest Medicare Part D spending.

DESIGN, SETTING, AND PARTICIPANTS

In this national cross-sectional analysis, publicly available 2016 Medicare drug spending records were merged with 2016 US Food & Drug Administration Orange Book data and the Tufts Medical Center Cost-Effectiveness Analysis (CEA) Registry. All studies published through 2015 that evaluated the cost-effectiveness of the 250 drugs for which Medicare Part D spending was the greatest in US-based adult patient populations were included. Data were analyzed from September 2018 to June 2020.

MAIN OUTCOMES AND MEASURES

The presence and quality of published cost-effectiveness analyses for the 250 drugs for which Medicare Part D spending was greatest in 2016 were assessed based on the inclusion of key cost-effectiveness analysis elements and global ratings by independent reviewers for the Tufts CEA Registry.

RESULTS

Medicare Part D spending on the 250 drugs in the sample totaled $122.8 billion in 2016 (84.1% of total spending). Of these 250 drugs, 91 (36.4%) had a generic equivalent and 159 (63.6%) retained some patent exclusivity. There were 280 unique cost-effectiveness analyses for these drugs, representing data on 135 (54.0%) of the 250 drugs included and 67.0% of Part D spending on the top 250 drugs. The 115 drugs (46.0%) without cost-effectiveness studies accounted for 33.0% of Part D spending on the top 250 drugs. Of the 280 available studies, 128 (45.7%) were industry sponsored. A large proportion of the studies (250 [89.3%]) did not meet the minimum quality requirements.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, a substantial proportion of 2016 Medicare Part D spending was for drugs with absent or low-quality cost-effectiveness analyses. The lack of quality analyses may present a challenge in efforts to develop policies addressing drug spending in terms of value.

Addressing Insulin Access and Affordability: An Endocrine Society Position Statement

Rising costs have made access to affordable insulin far more difficult for people with diabetes, especially low-income individuals, those on high deductible health plans, beneficiaries using Medicare Part B to cover insulin delivered via pump, Medicare beneficiaries in the Part D donut hole, and those who turn 26 and must transition from their parents' insurance, to manage their diabetes and avoid unnecessary complications and hospitalizations. For many patients with diabetes, insulin is a life-saving medication. Policymakers should immediately address drivers of rising insulin prices and implement solutions that would reduce high out-of-pocket expenditures for patients. The Endocrine Society recommends policy options to expand access to lower cost insulin in this paper.

Factors Associated With Prescriptions for Branded Medications in the Medicare Part D Program

IMPORTANCE

Branded products of multisource drugs are frequently dispensed in the Medicare Part D program, increasing costs for the program and patients.

OBJECTIVE

To examine the reasons for dispensing branded multisource drugs in Medicare Part D.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study examined claims for multisource drugs with more than 1000 branded claims dispensed in Medicare Part D using Medicare Prescription Drug Event data from a 2017 nationwide random sample of 20% of Medicare beneficiaries. Data were analyzed between January and October 2020.

EXPOSURES

Justification for branded dispensing as indicated by each claim's dispense-as-written code.

MAIN OUTCOMES AND MEASURES

Mean Medicare Part D program spending and patient out-of-pocket spending for branded and generic products, and generic vs branded spending discounts in program and patient out-of-pocket spending for each multisource drug.

RESULTS

Among 169 million claims for 224 multisource drugs, 8.3 million claims (4.9%) were dispensed with a branded product. Among these claims, 4.9 million claims (59.2%) did not have a recorded reason for branded dispensing; 1.4 million claims (16.9%) occurred because of prescriber requests; and 1.1 million claims (13.5%) occurred because of patient requests. If all branded dispensing requested by prescribers had been substituted by the corresponding generics, the projected savings to the Medicare Part D program and Medicare patients were $997 million (56.0%) and $161 million (64.4%), respectively. If all branded dispensing requested by patients had been substituted by generics, the projected savings to the Medicare Part D program and Medicare patient were $673 million (53.4%) and $109 million (55.1%), respectively. Drugs with the highest proportion of branded dispensing by physician or patient request were typically high cost (eg, drugs with above-median frequencies of branded dispensing: mean [SD] discount on generic vs branded, 73.9% [26.9%] for prescriber requests).

CONCLUSIONS AND RELEVANCE

Prescribers and patients motivated 30.4% of all branded dispensing of multisource drugs in the Medicare Part D program. Branded dispensing requested by prescribers or patients incurred an incremental annual cost of $1.67 billion to the Medicare program and $270 million to patients when compared with switching to generics. Policy makers should consider ways to discourage prescribers and patients from requesting branded dispensing of multisource drugs because of the higher cost.

Why France Spends Less Than the United States on Drugs: A Comparative Study of Drug Pricing and Pricing Regulation

Policy Points  Spending on prescription drugs is much higher per capita in the United States than in most other industrialized nations, including France.  Lower prescription drug spending in France is due to different approaches to managing drug prices, volume of prescribing, and global health budgets.  Linking a drug's price to value both at the launch of the drug and over its lifetime is key to controlling spending. Regulations on prescription volume and global spending complement the interventions on prices.  If the United States adopted the French approach to regulating drug pricing, Medicare could potentially save billions of dollars annually on prescription drug spending.

CONTEXT

Prescription drug spending per capita in the United States is higher than in most other industrialized countries. Policymakers seeking to lower drug spending often suggest benchmarking prices against other countries, including France, which spends half as much as the United States per capita on prescription drugs. Because differences in drug prices may result from how markets are organized in each nation, we sought to directly compare drug prices and pricing regulations between the United States and France.

METHODS

For the six brand-name drugs with the highest gross expenditures in Medicare Part D in 2017, we compared the price dynamics in France and the United States between 2010 and 2018 and analyzed associations between price changes in each country and key regulatory events. We also comprehensively reviewed US and French laws and regulations related to drug pricing.

FINDINGS

Prices for the six drugs studied were higher in the United States than in France. In 2018, if Medicare had paid French prices for the brand-name drugs in our cohort, the agency would have saved $5.1 billion. We identified 12 factors that explain why the United States spends more than France on drugs, including variations in unit prices and the volume of prescriptions, driven by use of health technology assessment and value-based pricing in France.

CONCLUSIONS

Key drivers of lower drug spending in France compared to the United States are that the French government regulates drug prices when products are launched and prohibits substantial price increases after launch. The regulation of prescription drugs in France is governed by rules that can inform discussions of US prescription drug policy and potential Medicare price negotiations.

Assessing the Added Therapeutic Benefit of Ultra-Expensive Drugs

OBJECTIVES

While the United States does not have a method for assessing the added therapeutic benefit of drugs, France, Canada, and Germany do. We examined the added therapeutic benefit of the most expensive drugs prescribed to Medicare Part D beneficiaries in the United States.

METHODS

We identified ultra-expensive drugs with annual Medicare spending that exceeded $62 794 (United States GDP per capita in 2018) using Medicare Part D Prescription Drug Spending and Utilization Data. We used added therapeutic benefit ratings assessed by health technology assessment agencies in France, Canada, and Germany.

RESULTS

We identified 122 ultra-expensive drugs in 2018. Sixty-five percent of these drugs (n = 79) were assessed by at least one of the countries. Based on these assessments, approximately 75% received a low added therapeutic benefit rating.

CONCLUSIONS

Most ultra-expensive drugs prescribed in the United States and assessed by France, Canada, and Germany provide low added therapeutic benefit. Policy reforms in the United States could use added therapeutic benefit to inform coverage and pricing decisions for ultra-expensive drugs. Similar to Germany, one approach would be to allow the company to set a market price for a limited period of time before requiring a price reduction if the added therapeutic benefit is below a certain threshold. Another approach would be to identify when drug prices are substantially more expensive in the United States and conduct an added therapeutic benefit assessment and price review on these drugs.

A Descriptive Study of HIV Patients Highly Adherent to Antiretroviral

HIV medication adherence is a topic of major public health concern in the United States. Adherent patients may be less likely to experience treatment failure, AIDS presentations and extreme medical costs. We evaluate a cohort of highly adherent Medicare beneficiaries to establish if the out of pocket costs of HIV medications are an inherent barrier to adherence. We analyzed a 100% sample of Medicare Part-D prescription medications. The drug and out ofpocket costs for HIV and non-HIV medications of highly adherent cohort were extracted and analyzed. The average gross drug cost per beneficiary was $34,029for HIV medications and $11,439for non-HIV medications. Average out of pocket costs per beneficiary was $454for HIV medications and $129 for non-HIV medications. Out of pocket costs do not reasonably appear to be a barrier to adherence for Part-D beneficiaries.

Association of Out-of-Pocket Spending With Insulin Adherence in Medicare Part D

This cross-sectional study examines whether efforts to limit out-of-pocket spending for enrollees in nonsubsidized Medicare Part D plans are associated with insulin adherence rates among these patients.

Associations of Intensive Lifestyle Intervention in Type 2 Diabetes With Health Care Use, Spending, and Disability: An Ancillary Study of the Look AHEAD Study

IMPORTANCE

Intensive lifestyle interventions focused on diet and exercise can reduce weight and improve diabetes management. However, the long-term effects on health care use and spending are unclear, especially for public payers.

OBJECTIVE

To estimate the association of effective intensive lifestyle intervention for weight loss with long-term health care use and Medicare spending.

DESIGN, SETTING, AND PARTICIPANTS

This ancillary study used data from the Look AHEAD randomized clinical trial, which randomized participants with type 2 diabetes to an intensive lifestyle intervention or control group (ie, diabetes support and education), provided ongoing intervention from 2001 to 2012, and demonstrated improved diabetes management and reduced health care costs during the intervention. This study compared Medicare data between study arms from 2012 to 2015 to determine whether the intervention was associated with persistent reductions in health care spending.

EXPOSURE

Starting in 2001, Look AHEAD's intervention group participated in sessions with lifestyle counselors, dieticians, exercise specialists, and behavioral therapists with the goal of reducing weight 7% in the first year. Sessions occurred weekly in the first 6 months of the intervention and decreased over the intervention period. The controls participated in periodic group education sessions that occurred 3 times per year in the first year and decreased to 1 time per year later in the trial.

MAIN OUTCOMES AND MEASURES

Outcomes included total Medicare spending, Part D prescription drug costs, Part A and Part B Medicare spending, hospital admissions, emergency department visits, and disability-related Medicare eligibility.

RESULTS

This study matched Medicare administrative records for 2796 Look AHEAD study participants (54% of 5145 participants initially randomized and 86% of 3246 participants consenting to linkages). Linked intervention and control participants were of a similar age (mean [SD] age, 59.6 [5.4] years vs 59.6 [5.5] years at randomization) and sex (818 [58.1%] women vs 822 [59.3%] women). There was no statistically significant difference in total Medicare spending between groups (difference, -$133 [95% CI, -$1946 to $1681]; P = .89). In the intervention group, compared with the control group, there was statistically significantly higher Part B spending (difference, $513 [95% CI, $70 to $955]; P = .02) but lower prescription drug costs (difference, -$803 [95% CI, -$1522 to -$83]; P = .03).

CONCLUSIONS AND RELEVANCE

This ancillary study of a randomized clinical trial found that reductions in health care use and spending associated with an intensive lifestyle intervention for type 2 diabetes diminished as participants aged. Intensive lifestyle interventions may need to be sustained to reduce long-term health care spending.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03952728.

Understanding the Socioeconomic and Geographical Characteristics of Beneficiaries Receiving a Comprehensive Medication Review

BACKGROUND

Medicare Part D sponsors are required to offer medication therapy management (MTM) programs to eligible beneficiaries. Recent studies have demonstrated that there have been racial/ethnic disparities in MTM eligibility criteria. For example, compared with non-Hispanic White beneficiaries, Hispanic and non-Hispanic Black beneficiaries are less likely to be eligible for MTM. However, there is limited evidence for socioeconomic and geographical characteristics of those who are eligible and receive MTM services.

OBJECTIVE

To describe the demographic, socioeconomic, and geographic characteristics of Medicare beneficiaries who received MTM services.

METHODS

As part of a previous study, a national survey evaluated a convenience sample of perspectives of Medicare beneficiaries on the MTM standardized format. The survey was distributed through Medicare Part D plans to beneficiaries receiving MTM services from 2017-2018. As part of the survey, respondents could provide their ZIP codes. Geographical variables, such as the National Center for Health Statistics (NCHS) urban-rural classification scheme and economic research service (ERS) county typology codes, were then applied to respondents' ZIP codes, allowing for the classification of counties or census tracts by urbanization and economic dependence measures. Descriptive statistics are reported for demographic, geographical, and socioeconomic information.

RESULTS

Of the 300 (of 434) respondents who provided their ZIP codes, 51.3% were aged 65-74 years; 50% were male; and 66.7% had at least a college education. There were 82.7% who self-identified as White, while only 8% self-identified as Hispanic or Black/African American. The majority of respondents (58.4%) lived in large metropolitan areas as defined by the NCHS urban-rural classification scheme. Respondents' counties were characterized by economic dependence with 14.0% of respondents living in federal/state government-dependent counties and 12.7% living in recreation-dependent counties.

CONCLUSIONS

The majority of respondents who provided their ZIP codes identified themselves as White and lived in large metropolitan areas. Respondents who identified themselves as Hispanic or Black/African American were not well represented. This study provides geographical and socioeconomic characteristics of Medicare beneficiaries who received MTM services and highlights racial/ethnic differences. Further work is needed to confirm geographical and socioeconomic disparities among beneficiaries who received MTM services.

DISCLOSURES

No outside funding supported this study. Pellegrin is a member of the AMCP MTM Advisory Group. The other authors have nothing to disclose.

Association Between the Percentage of US Drug Sales Subject to Inflation Penalties and the Extent of Drug Price Increases

IMPORTANCE

Policy makers have proposed levying penalties for drug price increases that are higher than the rate of inflation for drugs covered in the US Medicare program, but research is lacking regarding the ways in which manufacturers might respond to those penalties. An understanding of manufacturers' responses to existing inflation penalties could inform such policy discussions.

OBJECTIVE

To estimate the association of existing inflation penalties in the US 340B Drug Pricing Program with manufacturer pricing behavior in the Medicare Part D program and associated changes in Medicare pharmacy expenditures.

DESIGN, SETTING, AND PARTICIPANTS

This study included a pooled cross-sectional time-series analysis of price changes for Medicare Part D drugs used annually by more than 5000 beneficiaries between January 1, 2013, and December 31, 2017. The percentage of Medicare Part D sales subject to inflation penalties in the 340B program was used to perform a regression analysis to estimate the association of inflation penalties with annual drug price changes. The 340B program requires manufacturers to sell their drugs at a lower price to safety-net health care organizations; this lower price includes a base discount and an additional discount equal to the amount of any price increase that is higher than the rate of inflation. Sales to these 340B-eligible health care organizations represent the market share of a drug subject to inflation penalties. Health care organization-level claims data were obtained from the Medicare Provider Utilization and Payment Data-Part D Prescriber database, and organizations were matched to the Office of Pharmacy Affairs Information System of the Health Resources and Services Administration to identify those organizations that were eligible for the 340B program. Price change and drug use data were obtained from the Medicare Part D Drug Spending Dashboard. Name-brand drugs were included in the analysis if they did not have generic competition and were used by more than 5000 individuals with Medicare Part D in 1 calendar year. Data analysis was conducted from January 1 to February 28, 2020.

MAIN OUTCOMES AND MEASURE

Annual price change was the primary outcome measure; spending changes associated with lower price increases were also estimated. Sales percentage subject to inflation penalties was the primary independent variable, and formulary classification was a control variable.

RESULTS

Of 2148 brand-name drugs included in the database, 606 drugs were used by more than 5000 beneficiaries annually, with a mean sales percentage subject to inflation penalties of 12.1%. A higher sales percentage subject to inflation penalties was associated with lower annual price increases (between-effects coefficient, -0.114; 95% CI, -0.205 to -0.023; P = .01; fixed-effects coefficient, -0.380; 95% CI, -0.466 to -0.294; P < .001). Lower price increases owing to inflation penalties were estimated to be associated with a reduction in Medicare Part D pharmacy expenditures of $7.1 billion between 2013 and 2017.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, increases in the percentage of drug sales subject to inflation penalties were associated with lower annual price increases. Broader application of inflation penalties may help to reduce drug price increases and decrease overall drug spending.

Real-world cost of treatment for multiple sclerosis patients initiating and receiving infused disease-modifying therapies per recommended label in the United States

Aims: The study evaluated the real-world cost of treatment in multiple sclerosis (MS) patients initiating infused disease-modifying-therapies (DMT) in the United States.Materials and Methods: This retrospective cohort study using administrative claims data included adult patients with MS initiating index infusion DMT (ocrelizumab (OCR), natalizumab (NTZ) or alemtuzumab (ATZ)) from April 2017-September 2018 with 6-months pre/12-months post-index continuous enrollment. The primary cohort included patients who had prescribed annual dosing visits indicated by the approved product label (PL): 3 OCR, 5 ATZ, and 12-13 NTZ infusion visits within the first year of initiation. Annual treatment cost was the sum of all costs on index DMT infusion visit dates. Costs were summarized for a primary and secondary cohort of patients receiving additional doses than prescribed in PL (>3 OCR, >5 ATZ, and >13 NTZ infusion visits); and an overall cohort of patients who met minimum required annual dose (≥3 OCR, ≥5 ATZ, and ≥12 NTZ), further stratified by insurance type.Results: For patients in the primary cohort (123 OCR, 18 ATZ, and 48 NTZ), mean (standard-deviation) annual cost of treatment with OCR, ATZ, and NTZ cohorts was $72,066 ($34,480), $121,053 ($51,097) and $93,777 ($38,815), respectively. Among patients initiating OCR and NTZ, 15 and 6% respectively, had additional infusion visits leading to greater costs. Mean annual costs of index infusion DMT treatment in the overall cohort (162 patients treated with OCR, 18 with ATZ, 56 with NTZ) were $80,582, $121,053, and $93,807, respectively. The mean costs for commercial enrollees were higher than those for MAPD enrollees.Limitations: Small sample size, limited population generalizability, and cost-reduction for ATZ beyond the second year need to be accounted for.Conclusions: Real-world infusion DMT treatment costs for commercially insured patients were higher than perceived expenditures based on wholesale acquisition cost and administration costs via a physician-fee schedule. Consideration of real-world costs in cost-effectiveness and treatment/coverage decisions is needed.

Economic impact of cardiac implantable electronic device infections: cost analysis at one year in a large U.S. health insurer

Aims: Cardiac device infections (CDIs) are serious adverse events associated with morbidity and mortality, significant costs and increased healthcare utilization. The objective of the current study was to characterize the CDI rate by device type, risk factors for infection and healthcare costs from a large U.S. health insurer perspective.Materials and Methods: A retrospective analysis of a large U.S. health insurer database identified commercial and Medicare Advantage with Part D (MAPD) members ≥18 years with ≥1 claim for a cardiac implantable electronic device (CIED) procedure between 01 October 2011 and 31 October 2015. CIEDs included pacemakers (IPG), implantable cardioverter defibrillators (ICDs), and cardiac resynchronization therapy - pacemakers without (CRT-P) and with defibrillation (CRT-D). Probabilities of CDI through one-year post implant were estimated using the Kaplan-Meier method. A regression model with stepwise variable selection was used to select risk factors associated with CDIs.Results: A total of 63,406 patients were included with an overall CDI rate of 1.28% (1.0% de novo and 1.74% replacement devices), varying by device type: IPG = 0.91%; ICD = 1.63%; CRT-p = 1.50%; CRT-D = 2.22%. The average adjusted annual medical costs were 2.4 times greater [95% confidence interval (CI) = 2.1-2.7] for those with an infection compared to those without, and the incremental cost difference was estimated to be $57,322 [95% CI $46,572-$70,484]. Observed risk factors of CDIs included prior device infection [Odds ratio (OR) = 11.356; 95% CI = 7.923-16.276], undergoing a CIED replacement procedure (OR = 1.644; 95% CI = 1.361-1.987), implantation of a high-power device (OR = 1.354; 95% CI = 1.115-1.643), and younger age (age < 65) (OR = 1.607; 95% CI = 1.307-1.976).Conclusions: The CDI rate at one year ranged from 0.91%-2.22% depending on device type. Management of CDIs among commercial and MAPD members is associated with high healthcare expenditures.

Medicare Part D and Cost-Sharing for Antiretroviral Therapy and Preexposure Prophylaxis

IMPORTANCE

The 2019 federal Ending the HIV Epidemic initiative requires a vast expansion of access to antiretroviral therapy (ART) and preexposure prophylaxis (PrEP) for HIV treatment and prevention. However, high prices for ART and PrEP can reduce their affordability and use. Medicare covers 1 in 4 persons living with HIV, and the Medicare Part D drug benefit imposes complicated cost-sharing between patients and other stakeholders.

OBJECTIVE

To determine how the Medicare Part D design distributes the cost burden for ART and PrEP between patients, insurance plans, manufacturers, and Medicare.

DESIGN AND SETTING

Nationwide cross-sectional analyses of first quarter 2019 Medicare formulary and pricing files for 3326 Part D plans were performed. These files contain drug benefit data, including prices and cost-sharing requirements.

MAIN OUTCOMES AND MEASURES

For 18 ART and 2 PrEP regimens, the out-of-pocket costs for patients and the cost borne by plans, manufacturers, and Medicare were projected for 1 year of treatment or prevention under a 2019 standard Medicare Part D insurance plan. Analyses assumed that patients used the ART or PrEP regimen and no other medications.

RESULTS

In 2019, ART prices ranged from $24 010 to $46 770 annually (median price, $35 780), with patients projected to pay 9% to 14% of the cost ($3270-$4350), insurance plans 18% to 24% ($5340-$8450), manufacturers 6% to 11% ($2370-$2750), and Medicare 53% to 67% ($12 770-$31 270). The price of PrEP was $20 570 annually, with patients contributing 15% ($2990), insurance plans 22% ($4570), manufacturers 13% ($2750), and Medicare 50% ($10 260). For beneficiaries with low-income subsidies that cover all patient cost-sharing, Medicare would assume 67% to 76% of ART costs and 65% of PrEP costs.

CONCLUSIONS AND RELEVANCE

Medicare Part D mandates universal ART and PrEP coverage, but high prices (>$35 000 annually for ART and>$20 000 annually for PrEP) and the design of Part D can jeopardize affordability for patients and place most of the cost burden on taxpayers. Under a standard Medicare Part D benefit, patients pay $3000 to $4000 out-of-pocket yearly, unless they qualify for low-income subsidies, and half to two-thirds of the cost of ART and PrEP is borne by Medicare rather than insurance plans or manufacturers. To end the HIV epidemic by 2030, it appears that policies must address both high drug prices and revamp Medicare Part D cost-sharing.

Association of Medicare Part D Benzodiazepine Coverage Expansion With Changes in Fall-Related Injuries and Overdoses Among Medicare Advantage Beneficiaries

IMPORTANCE

Benzodiazepines, which are associated with safety-related harms for older adults, were not covered when the US Medicare Part D prescription drug benefit began. Coverage was extended to benzodiazepines in 2013.

OBJECTIVE

To examine whether the expansion of benzodiazepine coverage among Medicare Advantage (MA) beneficiaries was associated with increases in fall-related injuries or overdoses among older adults.

DESIGN, SETTING, AND PARTICIPANTS

This ecological study used interrupted time-series with comparison-series analyses of MA claims data from 4 635 312 age-eligible MA beneficiaries and 940 629 commercially insured individuals (comparison group) stratified by age (65-69, 70-74, 75-79, and ≥80 years) to separately compare trends in fall-related injury and overdose before (January 1, 2010, to December 31, 2012) and after (January 1, 2013, to December 31, 2015) coverage expansion for benzodiazepines. Data analysis was performed from September 1, 2018, to August 31, 2019.

EXPOSURES

Expansion of benzodiazepine coverage in Medicare Part D in 2013.

MAIN OUTCOMES AND MEASURES

Monthly rate of fall-related injury and overdose.

RESULTS

In 2012 (the year before the policy change), women constituted 57.5% of the MA group and 47.4% of the comparison group. A total of 25.8% of individuals in the MA group were aged 65 to 69 years, and 29.3% were 80 years or older (mean [SD], 75.1 [6.4] years); 56.7% of individuals in the comparison group were aged 65 to 69 years, and 15.1% were 80 years or older (mean [SD] age, 70.9 [6.5] years). In the MA group, 4 635 312 individuals contributed 156 754 749 person-months from 2010 through 2015; in the comparison group, 940 629 individuals contributed 25 104 534 person-months. After coverage of benzodiazepines began, the rate (ie, slope) of fall-related injury among MA beneficiaries increased from before to after coverage among all age groups. Compared with the comparison group, the increase in rate was statistically significant for those 80 years or older (rate changes for the MA vs comparison groups: 0.12 [95% CI, 0.07 to 0.17] vs -0.01 [95% CI, -0.11 to 0.10]; P = .04 for interaction). The overdose trend changed from decreasing to increasing among MA beneficiaries after coverage for all age groups, with a statistically significant increase compared with the comparison group among those aged 65 to 69 years (rate changes for the MA vs comparison groups: 0.23 [95% CI, 0.17 to 0.30] vs 0.02 [95% CI, -0.06 to 0.11]; P < .001 for interaction) and among those 80 years or older (rate changes for the MA vs comparison groups: 0.07 [95% CI, 0.00 to 0.14] vs -0.20 [95% CI, -0.35 to -0.05]; P = .002 for interaction). Results among MA beneficiaries were consistent when stratified by sex and when limited to those prescribed opioids.

CONCLUSIONS AND RELEVANCE

Medicare's expansion of benzodiazepine coverage may have been associated with increases in the rates of overdose among adults ages 65 to 69 years and in the rates of overdose and fall-related injury among those 80 years or older.

Assessment of Expected Out-of-Pocket Spending for Rheumatoid Arthritis Biologics Among Patients Enrolled in Medicare Part D, 2010-2019

IMPORTANCE

The closure of the Medicare Part D coverage gap from 2010 to 2019 was intended to help decrease out-of-pocket costs for beneficiaries, especially those taking high-cost drugs. However, yearly increases in list prices and the introduction of newer and more expensive drugs may have limited savings for beneficiaries.

OBJECTIVE

To assess the association of closure in the Medicare Part D coverage gap with projected annual out-of-pocket costs from 2010 through 2019 for rheumatoid arthritis (RA) biologics.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional analysis used data from the Medicare Formulary and Pricing Files for the first quarter (January 1 to March 31) in each calendar year from 2010 to 2019 for 17 RA biologic drug and strength combinations.

EXPOSURES

Medicare Part D plan design and drug price by year.

MAIN OUTCOMES AND MEASURES

Expected annual out-of-pocket costs for 1 year of treatment.

RESULTS

Among the 17 drug and strength combinations assessed, list prices increased each year for every product, with a mean increase of 160% for the 6 drugs available during the entire study period. For the 6 products available during the entire study period, projected mean (SD) annual out-of-pocket costs were 34% (2%) lower in 2011 than in 2010 ($6108 in 2010 to $4026 in 2011) but only 21% (8%) lower in 2019 ($4801) because of yearly increases in list price. All 4 products with higher out-of-pocket costs in 2019 than in the first year available entered the market between 2011 and 2015. For all products studied, the percentage of money spent in the catastrophic phase increased each year and was a mean (SD) of 22% (14%) higher in 2019 than in 2010 or the year first available.

CONCLUSIONS AND RELEVANCE

Although beneficiaries experienced large reductions in out-of-pocket spending from 2010 to 2011, more than half of those savings were lost by 2019 because of annual increases in list prices, even as the coverage gap continued to close in subsequent years.

Maximizing the impact of, and sustaining standing orders protocols for adult immunization in outpatient clinics

BACKGROUND

Low adult immunization rates leave adults at risk from infectious disease, and the resulting complications of vaccine-preventable diseases. Standing orders protocols (SOPs) for adult immunization have not been implemented widely in clinics serving adult patients. Our purpose was to evaluate the impact of SOPs on adult immunization rates and identify challenges to sustaining adult immunization coverage rates after implementation of SOPs.

METHODS

Baseline adult vaccination rates were calculated for the year prior to SOPs implementation in 5 diverse clinics. Vaccines included in the implemented standing orders included Tdap, influenza, pneumococcal, human papillomavirus, herpes zoster, and hepatitis B. Adult vaccination rates were tracked for 1 year after SOPs implementation.

RESULTS

Sites generally sustained modest gains in coverage rates (4%-8% increase) after SOP implementation, but greater success was found in practices that used SOPs as a foundation on which additional interventions were built. Challenges to increasing coverage rates included prioritization of acute and chronic conditions over adult vaccination, Medicare Part D reimbursement policies, electronic medical record issues related to data reporting and programming for patient alerts, and the lack of interoperability between the state immunization information system (missing patient vaccination history) and electronic medical record.

CONCLUSIONS

SOPs may provide a good starting point for increasing adult immunization coverage rates. Using additional interventions, quality-based metrics, or incentives could lead to sustained adult immunization prioritization.

The relationship between the number of available therapeutic options and government payer (medicare part D) spending on topical drug products

The cost of prescription drugs has increased at rates far exceeding general inflation in recent history, with topical drugs increasing at a disproportionate rate compared to other routes of administration. We assessed the relationship between net changes in the number of therapeutic options, defined as any approved drug or therapeutic equivalent on the market, and prescription topical drug spending. Drugs were divided based on the category of use through pairing of Medicare Part D Prescriber Public Use and Food and Drug Administration (FDA) approved drug products databases. Across drug classes, we modeled the log of the ratio of total spending per unit in 2015 to total spending per unit in 2011 as a linear function of net number of topical therapeutic options over this time period. Primary outcomes include total Medicaid Part D spending on topical drugs and net change in the number of available therapeutic options within each category of use. Total spending on topical drugs increased by 61%, while the number of units dispensed increased by only 18% from 2011-2015. The greatest total spending increases were in categories with few new therapeutic options, such as topical corticosteroid and antifungal medications. Each net additional therapeutic option during 2011-2015 was associated with an reduction in how much relative spending per unit increased (95% CI 2.5%-14.4%, p = 0.013). Stimulating greater competition through increasing the net number of therapeutic options within each major topical category of use may place downward pressure on topical prescription drug spending under medicare Part D.

Economic Burden Associated With Extended-Release vs Immediate-Release Drug Formulations Among Medicare Part D and Medicaid Beneficiaries

IMPORTANCE

The United States spends more money on medications than any other country. Most extended-release drugs have not consistently shown therapeutic or adherence superiority, and switching these medications to less expensive, generic, immediate-release formulations may offer an opportunity to reduce health care spending.

OBJECTIVE

To evaluate Medicare Part D and Medicaid spending on extended-release drug formulations and the potential savings associated with switching to generic immediate-release formulations.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used the 2012 to 2017 Medicare Part D Drug Event and Medicaid Spending and Utilization data sets to analyze 20 extended-release drugs with 37 Medicare formulations and 36 Medicaid formulations. Only cardiovascular, diabetes, neurologic, and psychiatric extended-release drugs saving at most 1 additional daily dose compared with their immediate-release counterparts were included. Extended-release drugs with therapeutic superiority were excluded. Analyses were conducted from January to December 2019.

MAIN OUTCOMES AND MEASURES

Estimated Medicare Part D and Medicaid savings from switching extended-release to immediate-release drug formulations between 2012 and 2017.

RESULTS

Of the 6252 drugs screened for eligibility from the 2017 Medicaid Drug Utilization database and the 2017 Medicare Part D database, 67 drugs with extended-release formulations that were identified in the Medicare data set (20 distinct drugs with 37 formulations [19 brand, 18 generic]) were included in the analysis. In 2017, Medicare Part D spent $2.2 billion and Medicaid spent $952 million (a combined $3.1 billion) on 20 extended-release drugs. Between 2012 and 2017, Medicare Part D and Medicaid spent $12 billion and $5.9 billion, respectively, on extended-release formulations. Switching from brand-name to generic extended-release formulations was estimated to be associated with a $247 million reduction in Medicare spending and $299 million reduction in Medicaid spending in 2017, whereas switching all brand-name and generic extended-release formulations to immediate-release formulations in both Medicare and Medicaid was estimated to reduce spending by $2.6 billion ($1.8 billion for Medicare and $836 million for Medicaid) in 2017. During the study period, the estimated spending reduction associated with switching all patients receiving extended-release formulations (brand name extended-release and generic extended-release) to generic immediate-release formulations was $13.7 billion ($8.5 billion from Medicare and $5.2 billion from Medicaid).

CONCLUSIONS AND RELEVANCE

The findings suggest that switching from extended-release drug formulations to therapeutically equivalent immediate-release formulations when available represents a potential option to reduce Medicare and Medicaid spending.

Impact of Star Rating Medication Adherence Measures on Adherence for Targeted and Nontargeted Medications

BACKGROUND

In 2012, Medicare incorporated medication adherence targeting oral antidiabetic medications, renin-angiotensin system (RAS) antagonists, and statins as highly weighted components in its Star Ratings Program. In the same year, health plans began receiving quality bonus payments for higher star ratings.

OBJECTIVE

We aimed to assess how these policy changes affected adherence to targeted and other chronic disease medications in the United States.

METHODS

We performed interrupted time series analyses to assess monthly changes in medication adherence from 2010 to 2016 using health plans' Medicare claims submitted to a large pharmacy benefits manager. We conducted 2 sets of analyses. The first examined whether policy changes affected adherence to the 3 targeted therapy classes, and the second assessed the association between policy changes and adherence to 5 chronic disease classes not targeted by star ratings. For the second analysis, we further compared adherence between members who concomitantly used and did not use targeted medications.

RESULTS

For star-ratings analyses, we studied 240 811 members on oral antidiabetic medications, 500 958 on RAS antagonists, and 471 135 on statins. Adherence for all star rating-targeted and nontargeted medications increased after 2012 (P < .001). Oral antidiabetic, statin, and RAS antagonist adherence was, respectively, 11.2%, 3.7%, and 8.1% higher than adherence without policy changes (P < .001). Nontargeted antihypertensive and antihyperlipidemic adherence trends were higher among those concomitantly on star rating-targeted medications compared with those who were not (P < .001).

CONCLUSIONS

As policy makers strive to identify optimal quality measures for improving healthcare delivery, it is important to consider that incentives can promote improved performance in both targeted measures and related outcomes.

Online Provision of Part D Medication Therapy Management Program Information

BACKGROUND

Low rates of beneficiary participation in medication therapy management (MTM) programs may be partly due to lack of awareness and understanding of the MTM program. To address this, the Centers for Medicare & Medicaid Services (CMS) requires Medicare Part D sponsors to provide online information about their MTM programs. An early study conducted in 2014 found low compliance rates, with only 59.5% of a small convenience sample of Part D plan contract websites compliant with CMS requirements. The current study provides a more recent evaluation of compliance with website requirements using a random sample of Part D plan contracts.

OBJECTIVES

To (a) evaluate Part D sponsors' compliance with MTM program website elements that are required and suggested by CMS and (b) investigate the use of elements recommended by the National Institute on Aging (NIA) for websites for older adults.

METHODS

A random sample of 184 Part D plan contract MTM program websites was selected from a list of 624 approved Part D plan contracts for 2016. Duplicate and inaccessible websites were excluded. The remaining websites were reviewed to determine compliance with CMS-required, CMS-suggested, and NIA-recommended elements. Descriptive statistics were reported at the Part D contract level for compliance with individual elements, category elements (CMS-required, CMS-suggested, and NIA-recommended), and overall compliance. Overall compliance by category was also reported by Part D plan type.

RESULTS

Of the 184 MTM websites that were reviewed, 106 remained after excluding duplicate (n = 67) and inaccessible (n = 11) websites: 81 from Medicare Advantage prescription drug (MAPD) plans, 16 from prescription drug plans (PDPs), and 9 from Medicare-Medicaid plans (MMPs). Overall, 51% of Part D plan contract MTM websites were compliant with all of the 14 CMS-required elements. The only element in the CMS-suggested elements category, "accessibility by clicking through a maximum of two links," had a compliance rate of 79%. For the NIA-recommended elements category, 46% of the Part D plan contract MTM websites were compliant with the 4 elements.

CONCLUSIONS

Medicare Part D plan sponsors are providing information about their MTM programs on plan websites. However, only 51% of Part D plan websites are fully compliant with CMS guidance, providing all required elements.

DISCLOSURES

No outside funding supported this study. The authors have no financial or other relationships to disclose. The original research on a small and nonrandom sample of Part D plan contracts was presented during AMCP Nexus 2014; October 7-10, 2014; in Boston, MA. The results presented here are a larger and random sample of Part D plan contracts.

Spending on World Health Organization essential medicines in Medicare Part D, 2011-15: retrospective cost analysis

OBJECTIVES

To characterize the trends, drivers, and potential modifiers of increased spending by US Medicare beneficiaries on medicines deemed essential by the World Health Organization.

DESIGN

Retrospective cost analysis of Medicare Part D Prescriber Public Use File, detailing annual generic and brand name drug prescribing and spending from 2011 through 2015 by Medicare Part D participants who filled prescriptions for WHO essential medicines.

SETTING

US Medicare System.

MAIN OUTCOME MEASURES

Total and per beneficiary Medicare spending, total and per beneficiary out-of-pocket patient spending, cumulative beneficiary count, claim count, and per unit drug cost. All spending measures were adjusted for inflation and reported in 2015 US dollars.

RESULTS

Medicare Part D expenditures on 265 WHO essential medicines between 2011 and 2015 was $87.2bn (£68.4bn; €76.5bn), with annual spending increasing from $11.9bn in 2011 to $25.8bn in 2015 (116%). Patients' out-of-pocket spending for essential medicines over the same period was $12.1bn. Total annual out-of-pocket spending increased from $2.0bn to $2.9bn (47%), and annual per beneficiary out-of-pocket spending on these drugs increased from $20.42 to $21.17 (4%). Total prescription count increased from 376.1m to 498.9m (33%), and cumulative beneficiary count grew from 95.9m to 135.8m (42%). Of the essential medicines included in the study, the per unit cost of 133 (50%) agents increased faster than the average inflation rate during this period. Overall, approximately 58% of the increase in total spending during this period can be attributed to the introduction of novel agents.

CONCLUSIONS

Spending associated with essential medicines grew substantially from 2011 to 2015, driven largely by the increased use of two expensive novel drugs used in treating hepatitis C. Approximately 22% of increased total spending during this period can be attributed to increases in per unit cost of existing drugs. These trends may limit patients' access to essential drugs while also increasing healthcare system costs.

Price Increases of Protected-Class Drugs in Medicare Part D, Relative to Inflation, 2012-2017

This study characterizes price increases exceeding inflation between 2012 and 2017 for protected-class drugs (antineoplastics, antiretrovirals, antidepressants, antipsychotics, anticonvulsants, and immunosuppressants for transplant patients) that would lead to their exclusion from Medicare Part D coverage based on excessive cost under a 2018 CMS rule intended to facilitate more effective price negotiations.

Estimated Changes in Manufacturer and Health Care Organization Revenue Following List Price Reductions for Hepatitis C Treatments

IMPORTANCE

Pharmaceutical manufacturers rarely reduce drug list prices, but 3 expensive treatments for hepatitis C experienced significant list price reductions in 2018. Understanding the impetus for these price reductions could inform policies to reduce drug spending.

OBJECTIVE

To estimate the differences in manufacturer and health care organization revenue from the Medicare Part D program following list price reductions for hepatitis C treatments, accounting for manufacturer discounts to eligible health care organizations under the 340B drug discount program and manufacturer rebates to pharmacy benefit managers.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of Medicare Part D claims for hepatitis C treatments in 2016 was conducted. Data analysis was performed in February 2019. Using the observed price changes from 2018, manufacturer and 340B health care facility net revenues for each drug were estimated before and after the price change based on 2016 use, adjusting for estimated 340B health care organization discounts and pharmacy benefit manager rebates. The 340B health care organizations include hospitals, clinics, and other organizations that meet federal standards to participate in the 340B program and were actively enrolled in the 340B program from January 1 to December 31, 2016. Manufacturer discounts to 340B health care organizations are based on the price of a drug before rebates to pharmacy benefit managers, and a reduced list price would reduce discounts to 340B health care organizations. Health care organization-level claims data were obtained from the Medicare Part D Provider Utilization File, and health care organizations were matched to Health Resources and Services Administration Office of Pharmacy Affairs Information System to identify 340B-eligible health care organizations. Eligible claims included claims for ledipasvir with sofosbuvir (Harvoni; Gilead Sciences Inc), sofosbuvir with velpatasvir (Epclusa; Gilead Sciences Inc), and elbasvir with grazoprevir (Zepatier; Merck). Health care organizations were considered 340B eligible if their practice address was a registered 340B entity for the entirety of 2016.

MAIN OUTCOMES AND MEASURES

Discounts to 340B health care organizations and pharmacy benefit managers for each drug before and after the price change were the primary outcomes. Other outcomes included per-treatment and aggregate manufacturer and 340B health care organization net revenues for each drug before and after the price change and the share of claims prescribed by 340B health care organizations for each drug. Per-treatment manufacturer net revenues were estimated for 340B health care organizations, non-340B health care organizations, and a weighted average revenue across health care organization types.

RESULTS

The 3 hepatitis C treatments evaluated had 30% to 41% of claims prescribed by 340B-eligible health care organizations, greater than the 14% 340B prescribing rate for all Medicare Part D drugs. Based on use data from 2016, list price reductions for hepatitis C treatments in 2018 were estimated to have increased aggregate manufacturer net revenues for 3 treatments by $181.9 million-a 28% increase. Aggregate 340B health care organization net revenues were estimated to have been $181.9 million lower-a 74% decrease.

CONCLUSIONS AND RELEVANCE

List price reductions for hepatitis C treatments may have increased drug manufacturer net revenues, owing in part to lower discounts provided under the 340B program and the high share of sales subject to those discounts. Policymakers should consider the role of 340B discounts when evaluating policies to reduce drug spending.

Prescription Drug Spending and Medication Adherence Among Medicare Beneficiaries with Heart Failure

BACKGROUND

Evidence suggests that cost sharing adversely affects appropriate prescription drug use for chronic disorders. However, few studies have evaluated this effect in heart failure (HF), the most common cause of hospitalization in Medicare.

OBJECTIVE

To determine whether spending on HF pharmacotherapy by Medicare Part D enrollees was associated with prescription refill adherence.

METHODS

This correlational study used pooled data from the 2010-2012 Medicare Current Beneficiary Survey (MCBS). The analysis sample consisted of community-dwelling MCBS participants with self-reported HF and continuous Part D coverage during the year of participation. 3 drug classes were analyzed independently: beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs). 1,448 weighted participant-year records (derived from 964 individuals) met the inclusion criteria, of which 846 (58%) were included for beta-blockers, 633 (44%) for ACE inhibitors, and 229 (16%) for ARBs. Spending was measured by average out-of-pocket payment for the relevant prescription, standardized to a 30-day supply, as a percentage of average monthly income. Adherence was measured by the medication possession ratio (MPR): total days supplied for all but the last refill divided by number of days between the first and last fills of the year.

RESULTS

Accounting for sampling weights, the median (interquartile range) monthly income was $1,472 ($949-$2,466), and average percentage of monthly income spent on a 30-day medication supply was 0.22% for beta-blockers, 0.19% for ACE inhibitors, and 0.90% for ARBs. Mean MPR was 88.9% for beta-blockers, 88.5% for ACE inhibitors, and 90.4% for ARBs. Risk-adjusted models showed that percentage of income spent on a beta-blocker prescription was directly associated with odds of nonadherence (MPR < 80%), odds ratio = 1.38, 95% CI = 1.01-1.89, P = 0.045, and inversely associated with beta-blocker MPR, B = -4.17, SE = 1.23, P = 0.001. No such association was observed for ACE inhibitors or ARBs.

CONCLUSIONS

Price sensitivity was evident for beta-blockers but not for antiangiotensin drugs, despite very low out-of-pocket costs and high adherence. This study is relevant to value-based pricing of HF management drugs in Part D plans.

DISCLOSURES

No outside funding supported this study. Butler has served as a paid consultant or advisor on unrelated projects for Amgen, Array, Astra Zeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, CVRx, G3, Innolife, Janssen, Medtronic, Merck, Novartis, Relypsa, Stealth Peptide, SC Pharma, Vifor, and ZS Pharma. The other authors have no potential conflicts of interest to declare. An early version of this paper was presented as a poster at Sigma Theta Tau International's 28th Nursing Research Congress; July 27-31, 2017; Dublin, Ireland.

Exploring the Valley of Savings: Minimizing Part D Costs and Optimizing Drug Therapy Outcomes in Medicare Beneficiaries With Developmental Disability

Nonelderly disabled Medicare beneficiaries have a higher prevalence of chronic conditions, higher utilization of prescription medications, and increased demand for clinical services when compared to beneficiaries 65 years of age and older who are not disabled. Out-of-pocket costs and medication-related problems are major barriers to medication compliance and achievement of therapeutic goals. A school of pharmacy partnered with a nonprofit organization that provides care to individuals with developmental disabilities. The present study highlights outcomes resulting from (a) providing Medicare Part D plan optimization services to lower prescription drug costs and (b) Medication Therapy Management services to evaluate safe and effective medication use in this beneficiary population. Provided interventions were shown to reduce overall medication costs and identify significant medication-related problems.

Comparison of Medication Therapy Management Services and Their Effects on Health Care Utilization and Medication Adherence

BACKGROUND

Medication therapy management (MTM) programs are designed to improve clinical outcomes and enhance appropriate medication use. Comprehensive medication reviews (CMRs) and targeted medication reviews (TMRs) are 2 broad interventions defined within MTM services. While MTM services have been extensively researched, there are few comparisons of CMR versus non-CMR interventions. Given the variability in MTM interventions and lack of a consistent TMR definition in the literature, this study sought to compare CMRs and TMRs that were clearly defined based on Centers for Medicare & Medicaid Services (CMS) criteria.

OBJECTIVES

To (a) compare acute inpatient admissions and emergency department (ED) visits between patients participating in MTM services (CMR, TMR, or both) and eligible nonparticipating patients and (b) examine the effect of receiving TMR services on medication adherence.

METHODS

This was a retrospective cohort study of patients with Medicare Part D coverage who received MTM services and a 1:1 propensity score-matched control group. Participants had to be eligible for MTM services in 2014 or 2015 based on CMS requirements. CMRs were offered to all MTM-eligible patients, while TMRs were completed based on clinical rules that helped identify medication-related problems (MRPs). The date of MTM intervention, or eligibility for the control group, was considered the index date. Participants had to be continuously enrolled in a Medicare Advantage plan that included prescription drug coverage during the study period and have at least 6 months of data before and after the index date. Medical and pharmacy claims were assessed to examine trend-adjusted inpatient admissions and ED visits from pre-index to post-index date for participants and matched controls.

RESULTS

In 2014 and 2015, receipt of TMR interventions was associated with statistically significant reductions in acute inpatient admissions. In 2014, there were 55.2 fewer admits per 1,000 individuals (95% CI = 29-81) and 30.8 fewer admits per 1,000 individuals in 2015 (95% CI = 20-42). Receipt of CMR-only interventions was associated with fewer acute inpatient admissions only when coupled with preidentification of MRPs (36.8 [95% CI = 25-49] fewer admits per 1,000 individuals). In 2015, there were significant reductions in ED visits for participants receiving TMR-only interventions or TMR/CMR interventions (26.1 [95% CI = 11-41] and 12.0 [95% CI = 1-23] fewer ED visits per 1,000 individuals, respectively). In both years, a larger percentage (0.4% for oral diabetes medications; 7.7% for antihypertensives; 3.0% for statins) of MTM participants had greater improvements in medication adherence in the post-index period compared with controls.

CONCLUSIONS

Receiving MTM services targeted at resolution of MRPs (TMR or CMR/TMR) resulted in positive reductions in health care utilization and increases in medication adherence. Given the importance of optimal medication utilization, this study highlights the need for additional focus on resolution of MRPs through TMRs and CMRs that can support improved clinical outcomes.

DISCLOSURES

No outside funding supported this study. Researchers completed the work as part of their employment with Humana. All authors are or were employees of Humana at the time of the study. There are no other conflicts of interest to disclose. This study was previously presented at AMCP Nexus 2017 on October 16, 2017, in Dallas, TX.

Specialty Drug Pricing and Out-of-Pocket Spending on Orally Administered Anticancer Drugs in Medicare Part D, 2010 to 2019

This study describes point-of-sale prices for orally administered anticancer drugs offered through Medicare Part D and out-of-pocket changes in spending as a result of decreasing coinsurance and price changes between 2010 and 2019.

Associations Between Chronic Disease, Polypharmacy, and Medication-Related Problems Among Medicare Beneficiaries

BACKGROUND

Mismanaged polypharmacy among older adults costs the health care system approximately $2 billion each year. Medication therapy management (MTM), a service designed to optimize medication use, improve health outcomes, and reduce associated costs, is available to eligible Medicare beneficiaries. Yet, it remains unclear which beneficiaries benefit most from this service.

OBJECTIVE

To assess associations between patient characteristics, chronic disease, polypharmacy, and medication-related problems (MRPs) in a sample population of Medicare beneficiaries.

METHODS

This study was a retrospective cross-sectional analysis of 1 Medicare Part D plan provider for the year 2015. Medicare beneficiaries were included if they were eligible to receive MTM services and excluded if they were aged under 65 years or the dataset had no count of MRPs for the beneficiary. A negative binomial regression assessed the relationship between age, sex, and chronic health conditions with MRPs. Second and third negative binomial regressions assessed the relationship between age, sex, and polypharmacy with MRPs.

RESULTS

A sample of 27,765 Medicare beneficiaries had a mean (SD) age of 76 (±7) years, were predominantly female (59%), and used a mean (SD) of 11 (±4) chronic medications. Beneficiaries with certain conditions were more likely to incur an MRP than those without, including depression (OR = 1.58; 95% CI = 1.51-1.64), congestive heart failure (OR = 1.26; 95% CI = 1.20-1.31), diabetes (OR = 1.24; 95% CI = 1.18-1.29), end-stage renal disease (OR = 1.38; 95% CI = 1.25-1.52), respiratory conditions (OR = 1.25; 95% CI = 1.19-1.31), and hypertension (OR = 1.09; 95% CI = 1.01-1.18). Medicare beneficiaries with polypharmacy (11 or more medications) were 1.86 (95% CI = 1.80-1.93) times more likely to experience an MRP than those taking fewer medications. For every additional medication, the odds of incurring an MRP increased by 10% (OR = 1.11; 95% CI = 1.10-1.1.11).

CONCLUSIONS

The diagnosis of depression presented with the strongest association with MRPs. Diabetes, congestive heart failure, end-stage renal disease, respiratory conditions, and hypertension also presented with significant associations with MRPs. Beneficiaries with polypharmacy (11 or more medications) were almost 2 times more likely to experience an MRP than those taking fewer medications. Addition of a chronic medication resulted in a 10% increase in the odds of incurring an MRP. MTM programs may find a greater number of MRPs among those diagnosed with depression in their MTM-eligible patient populations.

DISCLOSURES

No outside funding supported this research. Silva Almodóvar reports fees from SinfoniaRx, outside the submitted work. Nahata has nothing to disclose.

Secular Trends in the Cost of Immunosuppressants after Solid Organ Transplantation in the United States

BACKGROUND AND OBJECTIVES

Immunosuppressive medications are critical for maintenance of graft function in transplant recipients but can represent a substantial financial burden to patients and their insurance carriers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

To determine whether availability of generic immunosuppressive medications starting in 2009 may have alleviated some of that burden, we used Medicare Part D prescription drug events between 2008 and 2013 to estimate the average annualized per-patient payments made by patients and Medicare in a large national sample of kidney, liver, and heart transplant recipients. Repeated measures linear regression was used to determine changes in payments over the study period.

RESULTS

Medicare Part D payments for two commonly used immunosuppressive medications, tacrolimus and mycophenolic acid (including mycophenolate mofetil and mycophenolate sodium), decreased overall by 48%-67% across organs and drugs from 2008 to 2013, reflecting decreasing payments for brand and generic tacrolimus (21%-54%), and generic mycophenolate (72%-74%). Low-income subsidy payments, which are additional payments made under Medicare Part D, also decreased during the study period. Out-of-pocket payments by patients who did not receive the low-income subsidy decreased by more than those who did receive the low-income subsidy (63%-79% versus 24%-44%).

CONCLUSIONS

The decline in payments by Medicare Part D and by transplant recipients for tacrolimus and mycophenolate between 2008 and 2013 suggests that the introduction of generic immunosuppressants during this period has resulted in substantial cost savings to Medicare and to patients, largely reflecting the transition from brand to generic products.