Diagnoses and Treatment of Behavioral and Psychological Symptoms of Dementia Among Racially and Ethnically Diverse Persons Living with Dementia

Background

Behavioral and psychological symptoms of dementia (BPSD) and prescribed central nervous system (CNS) active drugs to treat them are prevalent among persons living with Alzheimer's disease and related dementias (PLWD) and lead to negative outcomes for PLWD and their caregivers. Yet, little is known about racial/ethnic disparities in diagnosis and use of drugs to treat BPSD.

Objective

Quantify racial/ethnic disparities in BPSD diagnoses and CNS-active drug use among community-dwelling PLWD.

Methods

We used a retrospective cohort of community-dwelling Medicare Fee-for-Service beneficiaries with dementia, continuously enrolled in Parts A, B and D, 2017-2019. Multivariate logistic models estimated rates of BPSD diagnosis and, conditional on diagnosis, CNS-active drug use.

Results

Among PLWD, 67.1% had diagnoses of an affective, psychosis or hyperactivity symptom. White (68.3%) and Hispanic (63.9%) PLWD were most likely, Blacks (56.6%) and Asians (52.7%) least likely, to have diagnoses. Among PLWD with BPSD diagnoses, 78.6% took a CNS-active drug. Use was highest among whites (79.3%) and Hispanics (76.2%) and lowest among Blacks (70.8%) and Asians (69.3%). Racial/ethnic differences in affective disorders were pronounced, 56.8% of white PLWD diagnosed; Asians had the lowest rates (37.8%). Similar differences were found in use of antidepressants.

Conclusions

BPSD diagnoses and CNS-active drug use were common in our study. Lower rates of BPSD diagnoses in non-white compared to white populations may indicate underdiagnosis in clinical settings of treatable conditions. Clinicians' review of prescriptions in this population to reduce poor outcomes is important as is informing care partners on the risks/benefits of using CNS-active drugs.

Trends in Incident Dementia Diagnosis Before and After Medicare Risk Adjustment

This cohort study examines rates of new diagnosis of Alzheimer disease and related dementias among beneficiaries of Medicare Advantage plans vs traditional Medicare from 2016 through 2020.

Did Medicare Part D reduce disparities?

OBJECTIVES

We assessed whether Medicare Part D reduced disparities in access to medication.

STUDY DESIGN

Secondary data analysis of a 20% sample of Medicare beneficiaries, using Parts A and B medical claims from 2002 to 2008 and Part D drug claims from 2006 to 2008.

METHODS

We analyzed the medication use of Hispanic, black, and white beneficiaries with diabetes before and after reaching the Part D coverage gap, and compared their use with that of race-specific reference groups not exposed to the loss in coverage. Unadjusted difference-in-difference results were validated with multivariate regression models adjusted for demographics, comorbidities, and zip code-level household income used as a proxy for socioeconomic status.

RESULTS

The rate at which Hispanics reduced use of diabetes-related medications in the coverage gap was twice as high as whites, while blacks decreased their use of diabetes-related medications by 33% more than whites. The reduction in medication use was correlated with drug price. Hispanics and blacks were more likely than whites to discontinue a therapy after reaching the coverage gap but more likely to resume once coverage restarted. Hispanics without subsidies and living in low-income areas reduced medication use more than similar blacks and whites in the coverage gap.

CONCLUSIONS

We found that the Part D coverage gap is particularly disruptive to minorities and those living in low-income areas. The implications of this work suggest that protecting the health of vulnerable groups requires more than premium subsidies. Patient education may be a first step, but more substantive improvements in adherence may require changes in healthcare delivery.

Digesting the doughnut hole

Despite its success, Medicare Part D has been widely criticized for the gap in coverage, the so-called "doughnut hole". We compare the use of prescription drugs among beneficiaries subject to the coverage gap with usage among beneficiaries who are not exposed to it. We find that the coverage gap does, indeed, disrupt the use of prescription drugs among seniors with diabetes. But the declines in usage are modest and concentrated among higher cost, brand-name medications. Demand for high cost medications such as antipsychotics, antiasthmatics, and drugs of the central nervous system decline by 8-18% in the coverage gap, while use of lower cost medications with high generic penetration such as beta blockers, ACE inhibitors and antidepressants decline by 3-5% after reaching the gap. More importantly, lower adherence to medications is not associated with increases in medical service use.

Coverage and use of cancer therapies in the treatment of chronic myeloid leukemia

OBJECTIVES

This study was designed to assess the effect of tyrosine kinase inhibitor (TKI) use on nonpharmaceutical medical spending for patients with chronic myeloid leukemia (CML), and estimate the association between cost-sharing and the TKI medication possession ratio (MPR).

STUDY DESIGN

The retrospective study covered the 13 years from 1997 to 2009.

METHODS

Analyses were conducted using a large administrative health insurance claims database covering 45 large employers. From this database, 995 unique patients with CML were identified, with 3,765 patient-years; of these patients, 415 (or 1,689 patientyears) were TKI users. We estimated the association of TKI use with total pharmaceutical spending and total non-pharmaceutical medical spending. In addition, we characterized plan-level cost-sharing rules for TKIs and assessed whether these were associated with the MPR for TKI therapy among CML patients.

RESULTS

TKI users averaged $26,406 in annual non-pharmaceutical medical spending, compared with $38,194 for non-users; this was a difference of approximately 30%, which was statistically significant at the 5% level. The median patient out-ofpocket payment was $25, which increased to $63 at the 75th percentile and to $122 at the 95th percentile. MPRs were 94.8 at the median cost-sharing level and 100.0 at the 75th percentile and higher. There was no statistically significant association between cost-sharing and MPR.

CONCLUSIONS

Use of TKIs was associated with a 30% reduction in non-pharmaceutical medical spending for CML patients. This difference is approximately equal to 40% of the incremental pharmaceutical cost associated with using TKI therapy. The net annual cost of TKI therapy is roughly $15,000. An informal calculation suggests that this is well within the range of conventional cost-effectiveness thresholds. On balance, coverage of TKIs is relatively generous, with the vast majority of patients exhibiting high levels of adherence to therapy.

Out-of-pocket medication costs and use of medications and health care services among children with asthma

CONTEXT

Health plans have implemented policies to restrain prescription medication spending by shifting costs toward patients. It is unknown how these policies have affected children with chronic illness.

OBJECTIVE

To analyze the association of medication cost sharing with medication and hospital services utilization among children with asthma, the most prevalent chronic disease of childhood.

DESIGN, SETTING, AND PATIENTS

Retrospective study of insurance claims for 8834 US children with asthma who initiated asthma control therapy between 1997 and 2007. Using variation in out-of-pocket costs for a fixed "basket" of asthma medications across 37 employers, we estimated multivariate models of asthma medication use, asthma-related hospitalization, and emergency department (ED) visits with respect to out-of-pocket costs and child and family characteristics.

MAIN OUTCOME MEASURES

Asthma medication use, asthma-related hospitalizations, and ED visits during 1-year follow-up.

RESULTS

The mean annual out-of-pocket asthma medication cost was $154 (95% CI, $152-$156) among children aged 5 to 18 years and $151 (95% CI, $148-$153) among those younger than 5 years. Among 5913 children aged 5 to 18 years, filled asthma prescriptions covered a mean of 40.9% of days (95% CI, 40.2%-41.5%). During 1-year follow-up, 121 children (2.1%) had an asthma-related hospitalization and 220 (3.7%) had an ED visit. Among 2921 children younger than 5 years, mean medication use was 46.2% of days (95% CI, 45.2%-47.1%); 136 children (4.7%) had an asthma-related hospitalization and 231 (7.9%) had an ED visit. An increase in out-of-pocket medication costs from the 25th to the 75th percentile was associated with a reduction in adjusted medication use among children aged 5 to 18 years (41.7% [95% CI, 40.7%-42.7%] vs 40.3% [95% CI, 39.4%-41.3%] of days; P = .02) but no change among younger children. Adjusted rates of asthma-related hospitalization were higher for children aged 5 to 18 years in the top quartile of out-of-pocket costs (2.4 [95% CI, 1.9-2.8] hospitalizations per 100 children vs 1.7 [95% CI, 1.3-2.1] per 100 in bottom quartile; P = .004) but not for younger children. Annual adjusted rates of ED use did not vary across out-of-pocket quartiles for either age group.

CONCLUSION

Greater cost sharing for asthma medications was associated with a slight reduction in medication use and higher rates of asthma hospitalization among children aged 5 years or older.

Physician prescribing behavior and its impact on patient-level outcomes

OBJECTIVES

Concerns over rising drug costs, pharmaceutical advertising, and potential conflicts of interest have focused attention on physician prescribing behavior. We examine how broadly physicians prescribe within the 10 most prevalent therapeutic classes, the factors affecting their choices, and the impact of their prescribing behavior on patient-level outcomes.

STUDY DESIGN

Retrospective study from 2005 to 2007 examining prescribers with at least 5 initial prescriptions within a class from 2005 to 2007. Medical and pharmacy claims are linked to prescriber information from 146 different health plans, reflecting 1975 to 8923 unique providers per drug class.

METHODS

Primary outcomes are the number of distinct drugs in a class initially prescribed by a physician over 1- and 3-year periods, medication possession ratio, and out-of-pocket costs.

RESULTS

In 8 of 10 therapeutic classes, the median physician prescribes at least 3 different drugs and fewer than 1 in 6 physicians prescribe only brand drugs. Physicians prescribing only 1 or 2 drugs in a class are more likely to prescribe the most advertised drug. Physicians who prescribe fewer drugs are less likely to see patients with other comorbid conditions and varied formulary designs. Prescribing fewer drugs is associated with lower rates of medication adherence and higher out-ofpocket costs for drugs, but the effects are small and inconsistent across classes.

CONCLUSIONS

Physicians prescribe more broadly than commonly perceived. Though narrow prescribers are more likely to prescribe highly advertised drugs, few physicians prescribe these drugs exclusively. Narrow prescribing has modest effects on medication adherence and out-of-pocket costs in some classes.

Part D Formulary and Benefit Design as a Risk-Steering Mechanism

Medicare Part D relies upon drug plan competition. Plans have enormous scope to design benefits and to set premiums, but they may not charge differential premiums based on risk. We use the formulary and benefit design of all Medicare prescription drug plans and pharmacy claims data to construct a simulation model of out-of-pocket drug spending. We use this simulation model to examine individual incentives in Medicare Part D for adverse selection. We find that high drug users have much stronger incentives to enroll in generous plans than do low users, thus there is significant scope for adverse selection.

Coverage and preventive screening

CONTEXT

Preventive care has been shown as a high-value health care service. Many employers now offer expanded coverage of preventive care to encourage utilization.

OBJECTIVE

To determine whether expanding coverage is an effective means to encourage utilization.

DESIGN

Comparison of screening rates before and after introduction of deductible-free coverage.

SETTING

People insured through large corporations between 2002 and 2006.

PATIENTS OR OTHER PARTICIPANTS

Preferred Provider Organization (PPO) enrollees from an employer introducing deductible-free coverage, and a control group enrolled in a PPO from a second employer with no policy change.

MAIN OUTCOME MEASURES

Adjusted probability of endoscopy, fecal occult blood test (FOBT), lipid screens, mammography, and Papanicolaou (pap) smears.

INTERVENTION

Introduction of first-dollar coverage (FDC) of preventive services in 2003.

RESULTS

After adjusting for demographics and secular trends, there were between 23 and 78 additional uses per 1,000 eligible patients of covered preventive screens (lipid screens, pap smears, mammograms, and FOBT), with no significant changes in the control group or in a service without FDC (endoscopy).

CONCLUSIONS

FDC improves utilization modestly among healthy individuals, particularly those in lower deductible plans. Compliance with guidelines can be encouraged by lowering out-of-pocket costs, but patients' predisposing characteristics merit attention.

Cost sharing, family health care burden, and the use of specialty drugs for rheumatoid arthritis

OBJECTIVES

To examine the impact of benefit generosity and household health care financial burden on the demand for specialty drugs in the treatment of rheumatoid arthritis (RA).

DATA SOURCES/STUDY SETTING

Enrollment, claims, and benefit design information for 35 large private employers during 2000-2005.

STUDY DESIGN

We estimated multivariate models of the effects of benefit generosity and household financial burden on initiation and continuation of biologic therapies.

DATA EXTRACTION METHODS

We defined initiation of biologic therapy as first-time use of etanercept, adalimumab, or infliximab, and we constructed an index of plan generosity based on coverage of biologic therapies in each plan. We estimated the household's burden by summing up the annual out-of-pocket (OOP) expenses of other family members.

PRINCIPAL FINDINGS

Benefit generosity affected both the likelihood of initiating a biologic and continuing drug therapy, although the effects were stronger for initiation. Initiation of a biologic was lower in households where other family members incurred high OOP expenses.

CONCLUSIONS

The use of biologic therapy for RA is sensitive to benefit generosity and household financial burden. The increasing use of coinsurance rates for specialty drugs (as under Medicare Part D) raises concern about adverse health consequences.

Evolution in an RNA world

A long-standing research goal has been to develop a self-sustained chemical system that is capable of undergoing Darwinian evolution. The notion of primitive RNA-based life suggests that this goal might be achieved by constructing an RNA enzyme that catalyzes the replication of RNA molecules, including the RNA enzyme itself. This reaction was demonstrated recently in a cross-catalytic system involving two RNA enzymes that catalyze each other's synthesis from a total of four component substrates. The cross-replicating RNA enzymes undergo self-sustained exponential amplification at a constant temperature in the absence of proteins or other biological materials. Amplification occurs with a doubling time of approximately 1 hour and can be continued indefinitely. Small populations of cross-replicating RNA enzymes can be made to compete for limited resources within a common environment. The molecules reproduce with high fidelity but occasionally give rise to recombinants that also can replicate. Over the course of many "generations" of selective amplification, novel variants arise and grow to dominate the population based on their relative fitness under the chosen reaction conditions. This is the first example, outside of biology, of evolutionary adaptation in a molecular genetic system.

Medicare part D after 2 years

OBJECTIVE

To assess the broad impacts of Medicare Part D and the extent to which prior concerns have been realized.

METHODS

We used administrative data to summarize beneficiary enrollment and plan participation in Part D, and compared pharmaceutical use and out-of-pocket spending before and after the introduction of Part D. We characterized the benefit designs of the 10 largest Part D plans in 2006 and compared them with the benefit designs of 7 non-Part D plans often cited as examples of low-cost or comprehensive drug benefits.

RESULTS

By 2008, nearly 90% of seniors had drug coverage at least as generous as the standard Part D benefit. Excluding premiums, annual out-of-pocket spending in the 10 largest Part D plans was comparable to that of other private and public drug benefits, with the most prominent differences attributable to out-of-pocket spending on drugs not covered in the plan. Poorer beneficiaries have gained the most from Part D in terms of increased access to medications and reduced out-of-pocket spending.

CONCLUSIONS

Coverage under Part D is comparable to that under non-Part D plans with respect to key features that are likely to be important to Medicare beneficiaries--access to medications and out-of-pocket costs. Nonetheless, concerns remain over drug pricing and gaps in coverage. The government should continue to monitor the competitiveness of the Part D market to ensure it meets the diverse needs of Medicare beneficiaries.

Cost sharing and the initiation of drug therapy for the chronically ill

BACKGROUND

Increased cost sharing reduces utilization of prescription drugs, but little evidence demonstrates how this reduction occurs or the factors associated with price sensitivity.

METHODS

We conducted a retrospective cohort study of older adults with employer-provided drug coverage from 1997 to 2002 from 31 different health plans. We measured the time until initiation of medical therapy for 17 183 patients with newly diagnosed hypertension, diabetes, or hypercholesterolemia.

RESULTS

For all study conditions, higher copayments were associated with delayed initiation of therapy. In survival models, doubling copayments resulted in large reductions in the predicted proportion of patients initiating pharmacotherapy at 1 and 5 years after diagnosis: for hypertension, 54.8% vs 39.9% at 1 year and 81.6% vs 66.2% at 5 years (P < .001); for hypercholesterolemia, 40.2% vs 31.1% at 1 year and 64.3% vs 53.8% at 5 years (P < .002); and for diabetes, 45.8% vs 40.0% at 1 year and 69.3% vs 62.9% at 5 years (P < .04). However, patients' rate of initiation and sensitivity to copayments strongly depended on their prior experience with prescription drugs. Those without prior drug use (26.1%, 10.4%, and 12.9%) initiated later (833, >1170, and >1402 days later in median time until initiation) and were far more price sensitive (increase of 34.5%, 20.1%, and 27.2% remaining untreated after 5 years when copayments doubled) than those with a history of drug use among patients with newly diagnosed hypertension, hypercholesterolemia, and diabetes, respectively. These results were robust to a wide range of sensitivity analyses.

CONCLUSIONS

High cost sharing delays the initiation of drug therapy for patients newly diagnosed with chronic disease. This effect is greater among patients who lack experience with prescription drugs. Policy makers and physicians should consider the effects of benefits design on patient behavior to encourage the adoption of necessary care.

Impact of specialty drugs on the use of other medical services

OBJECTIVE

To examine whether initiation of a biologic agent to treat 2 autoimmune disorders -- rheumatoid arthritis (RA) and multiple sclerosis (MS) -- affects use of other medical services.

STUDY DESIGN

Longitudinal analysis from 1997 to 2005 examining linked pharmacy and medical claims from large, private employers.

METHODS

The study sample included 30,761 individuals newly diagnosed with RA (92,660 person-years) and 8961 unique individuals with MS (25,100 person-years). Negative binomial models were used to estimate changes in inpatient, outpatient, and procedure use before and after initiating a biologic drug for each condition.

RESULTS

Starting a biologic response modifier was associated with a reduction in physician visits and use of expensive procedures for patients with RA within 2 to 3 years of initiation. Use of immunomodulatory therapy for MS was associated with a reduced number of hospitalizations and expensive procedures within 2 years of initiation. Although biologics may reduce other types of service use, the savings do not come close to offsetting the full cost of these drugs.

CONCLUSIONS

Given the high cost of many specialty drugs, health plans may rightly focus on making sure only patients who will most benefit receive them. But once such patients are identified, it makes little sense to limit coverage.

The effectiveness of covering smoking cessation services for medicare beneficiaries

OBJECTIVE

To examine whether reimbursement for Provider Counseling, Pharmacotherapies, and a telephone Quitline increase smoking cessation relative to Usual Care.

STUDY DESIGN

Randomized comparison trial testing the effectiveness of four smoking cessation benefits.

SETTING

Seven states that best represented the national population in terms of the proportion of those > or = 65 years of age and smoking rate.

PARTICIPANTS

There were 7,354 seniors voluntarily enrolled in the Medicare Stop Smoking Program and they were followed-up for 12 months.

INTERVENTION(S)

(1) Usual Care, (2) reimbursement for Provider Counseling, (3) reimbursement for Provider Counseling with Pharmacotherapy, and (4) telephone counseling Quitline with nicotine patch.

MAIN OUTCOME MEASURE

Seven-day self-reported cessation at 6- and 12-month follow-ups.

PRINCIPAL FINDINGS

Unadjusted quit rates assuming missing data=smoking were 10.2 percent (9.0-11.5), 14.1 percent (11.7-16.5), 15.8 percent (14.4-17.2), and 19.3 percent (17.4-21.2) at 12 months for the Usual Care, Provider Counseling, Provider Counseling + Pharmacotherapy, and Quitline arms, respectively. Results were robust to sociodemographics, smoking history, motivation, health status, and survey nonresponse. The additional cost per quitter (relative to Usual Care) ranged from several hundred dollars to $6,450.

CONCLUSIONS

A telephone Quitline in conjunction with low-cost Pharmacotherapy was the most effective means of reducing smoking in the elderly.

Pharmacy benefit caps and the chronically ill

In this paper we examine medication use among retirees with employer-sponsored drug coverage both with and without annual benefit limits. We find that pharmacy benefit caps are associated with higher rates of medication discontinuation across the most common therapeutic classes and that only a minority of those who discontinue use reinitiate therapy once coverage resumes. Plan members who reach their cap are more likely than others to switch plans and increase their rate of generic use; however, in most cases, the shift is temporary. Given the similarities between these plans and Part D, we make some inferences about reforms for Medicare.

Kidney cancer

PURPOSE

We quantified the burden of kidney cancer in the United States by identifying trends in the use of health care resources and estimating the economic impact of the disease.

MATERIALS AND METHODS

The analytical methods used to generate these results were described previously.

RESULTS

The incidence of all stages of kidney cancer is increasing in America, particularly T1 disease. Rates are increasing more rapidly in the black than in the white population and survival is worse for black individuals at all stages of diagnosis. Total expenditures for kidney cancer were $401 million in 2000, representing a 46% increase from 1994. Approximately 85% of health care dollars spent on kidney cancer were for inpatient care with steady increases through the 1990s. Regarding treatment, more partial nephrectomies were performed in Medicare patients as the 1990s progressed. Health Care Cost and Utilization Project data showed an increase in the number of inpatient hospitalizations but this trend was not seen in the Centers for Medicare and Medicaid Services data set. Length of stay decreased from 1994 to 2000 in the Health Care Cost and Utilization Project database. The adoption of laparoscopic techniques began to appear in the Veterans Affairs data set in 2001 and it increased thereafter.

CONCLUSIONS

Increasing trends in the incidence of and costs associated with kidney cancer have been apparent for more than 10 years. As the population ages and the prevalence of risk factors such as obesity and hypertension increases, the burden of disease will increase significantly. Consideration should be given to expanding tumor registries such as Surveillance, Epidemiology and End Results. Treatment databases could better characterize the cost and effectiveness of treatment for metastatic disease and of trends in the adoption of laparoscopy.

Interstitial cystitis and painful bladder syndrome

PURPOSE

We quantified the burden of interstitial cystitis/painful bladder syndrome on the health care system in the United States.

MATERIALS AND METHODS

The analytical methods used to generate these results were described previously. Interstitial cystitis was defined based on International Classification of Diseases, 9th revision code 595.1 (interstitial cystitis). For painful bladder syndrome we used the definition International Classification of Diseases, 9th revision code 788.41 (urinary frequency) with code 625.8 (other specified symptoms associated with female genital organs) or 625.9 (unspecified symptoms associated with female genital organs).

RESULTS

Between 1992 and 2001 there was a 2-fold increase in the rate of hospital outpatient visits and a 3-fold increase in the rate of physician office visits related to interstitial cystitis. The annualized rate was 102 office visits per 100,000 population. Ambulatory surgery for interstitial cystitis decreased. A diagnosis of interstitial cystitis was associated with a 2-fold increase in direct medical costs. Between 1994 and 2000 annual national expenditures for interstitial cystitis were stable at $37 million but annual costs for painful bladder syndrome increased from $481 million to $750 million.

CONCLUSIONS

Although interstitial cystitis accounts for a small percent of health care visits, its economic burden is substantial. Because of misdiagnosis, the true burden of interstitial cystitis/painful bladder syndrome on the health care system in the United States is probably underestimated in administrative data that rely only on physician coding to identify the disorder. The greatest part of the disease burden is likely not captured in this economic analysis.

Testis cancer

PURPOSE

We quantified the burden of testis cancer in the United States by identifying trends in its incidence, its treatment and the use of health care resources to estimate the economic impact of the disease.

MATERIALS AND METHODS

The analytical methods used to generate these results were described previously.

RESULTS

The overall incidence of testis cancer in the United States increased 46% between 1975 and 2001. During the same period the ratio of seminoma to nonseminoma increased and there were fewer men presenting with stage II and III tumors. Survival rates increased successively, attaining the current level of 95.9%. Treatment patterns changed and active surveillance increased as a primary treatment modality. Overall hospitalization rates for men with testis cancer decreased from 1.8/100,000 in 1994 and 1.4/100,000 in 2000. Care for white men shifted to the outpatient setting, which did not occur for black men. The estimated annual expenditure for testis cancer for privately insured individuals between ages 18 and 54 years was $6,236. National estimates of annual medical expenditures placed the total cost of treatment at $21.8 million in 2000, representing an increase of 10% over the total in 1994. Of men with testis cancer 16% missed work for treatment of the disease with an average of 8.4 total hours of work missed.

CONCLUSIONS

The cost of testis cancer is estimated at almost $21.8 million annually. It appears to be increasing with time despite a shift to active surveillance treatments and less hospitalization.

Prostatitis

PURPOSE

We quantified the burden of prostatitis in the United States by identifying trends in the use of health care resources and estimating the economic impact of the disease.

MATERIALS AND METHODS

The analytical methods used to generate these results were described previously.

RESULTS

The rate of national inpatient hospitalizations for a diagnosis of prostatitis decreased by 21% between 1994 and 2000. Hospitalization rates were 2 to 2.5 times higher for Medicare beneficiaries with a 42% decrease between 1992 and 2001. Combined physician outpatient and hospital outpatient visits revealed an age adjusted, annualized visit rate for prostatitis of 1,798/100,000 population. More than 6% of visits with a primary diagnosis of prostatitis had a concomitant diagnosis of benign prostatic hyperplasia. The most common medications associated with any visits for prostatitis were quinolones (annualized rate 319/100,000 population) and the rate remained about the same even after visits for infectious prostatitis were removed from the data. The cost of prostatitis was about $84 million annually, exclusive of pharmaceutical spending. Of 897 privately insured men with a medical claim for prostatitis in 2002, 14% missed some work because of the condition.

CONCLUSIONS

Overall spending in the United States for the diagnosis and management of prostatitis, exclusive of pharmaceutical spending, totaled $84 million in 2000 and it appears to be increasing with time. Given the extensive gaps in our understanding of the diagnosis of and treatment for prostatitis, many of these expenditures may represent a waste of resources.

Prescription drug cost sharing: associations with medication and medical utilization and spending and health

CONTEXT

Prescription drugs are instrumental to managing and preventing chronic disease. Recent changes in US prescription drug cost sharing could affect access to them.

OBJECTIVE

To synthesize published evidence on the associations among cost-sharing features of prescription drug benefits and use of prescription drugs, use of nonpharmaceutical services, and health outcomes.

DATA SOURCES

We searched PubMed for studies published in English between 1985 and 2006.

STUDY SELECTION AND DATA EXTRACTION

Among 923 articles found in the search, we identified 132 articles examining the associations between prescription drug plan cost-containment measures, including co-payments, tiering, or coinsurance (n = 65), pharmacy benefit caps or monthly prescription limits (n = 11), formulary restrictions (n = 41), and reference pricing (n = 16), and salient outcomes, including pharmacy utilization and spending, medical care utilization and spending, and health outcomes.

RESULTS

Increased cost sharing is associated with lower rates of drug treatment, worse adherence among existing users, and more frequent discontinuation of therapy. For each 10% increase in cost sharing, prescription drug spending decreases by 2% to 6%, depending on class of drug and condition of the patient. The reduction in use associated with a benefit cap, which limits either the coverage amount or the number of covered prescriptions, is consistent with other cost-sharing features. For some chronic conditions, higher cost sharing is associated with increased use of medical services, at least for patients with congestive heart failure, lipid disorders, diabetes, and schizophrenia. While low-income groups may be more sensitive to increased cost sharing, there is little evidence to support this contention.

CONCLUSIONS

Pharmacy benefit design represents an important public health tool for improving patient treatment and adherence. While increased cost sharing is highly correlated with reductions in pharmacy use, the long-term consequences of benefit changes on health are still uncertain.

Male Infertility

PURPOSE

We assessed male infertility and its treatment in the United States by identifying trends in the use of health care resources and estimating the economic impact of such care.

MATERIALS AND METHODS

The analytical methods used to generate these results were previously described.

RESULTS

Inpatient hospitalizations for male infertility were relatively few with an overall rate of 0.9/100,000 population. Of these stays 55% were associated with inpatient management of varicocele and 749 of 797 occurred in a rural setting. Between 1994 and 1996 there were 55,411 ambulatory surgery visits with men 25 to 34 years old having the highest use rate of 61/100,000. Men living in the West had the lowest rate of ambulatory surgical visits, which was significantly lower than that for men living in the Northeast and Midwest (29/100,000 vs 104/100,000 and 72/100,000, respectively). The Veterans Affairs health system showed no geographic trend in infertility diagnosis and Hispanic men had the highest frequency of treatment for male infertility, followed by black and then white men. The National Survey for Ambulatory Surgery estimated that 67% of patients undergoing ambulatory surgery for male infertility had a diagnosis of varicocele. In 2000 total expenditures for treating primary male infertility were approximately $17 million. However, adding the cost for assisted reproduction technology cycles placed total cost at about $18 billion.

CONCLUSIONS

Infertile males generally seek infertility care outside of traditional reimbursement patterns. For this reason obtaining accurate data regarding the costs associated with male fertility care has proved to be challenging. Given the expense of in vitro fertilization and its attendant technologies, emphasis should be placed on addressing the underlying causes of male infertility. Further systematic examination of the demographics and management of male reproductive dysfunction is warranted.

Cryptorchidism and hypospadias

PURPOSE

We quantified the burden of cryptorchidism and hypospadias in the United States by identifying trends in the use of health care resources and estimating the economic impact of the disease.

MATERIALS AND METHODS

The analytical methods used to generate these results were described previously.

RESULTS

Cryptorchidism is managed almost exclusively in the outpatient setting and insufficient data were available on inpatient health care use. Annual inpatient hospitalizations for hypospadias decreased by 75% between 1994 and 2000 from 2,669 (2.2/100,000 children) to 849 (0.6/100,000). Between 1992 and 2000 there were 611,647 physician office visits (96/100,000 per year) with undescended testis listed as the primary diagnosis. The rate of physician office visits for hypospadias by commercially insured boys younger than 3 years increased significantly from 429/100,000 in 1994 to 655/100,000 in 2002. The annualized rate of 18/100,000 in 1994 to 1996 remained relatively constant during these 3 years. Orchiopexy rates were highest in 0 to 2-year-old children, as generally recommended, but a substantial minority of these procedures was done in 3 to 10-year-old children. Geographic variation was noted with higher ambulatory surgery rates in the Northeast and Midwest than in the South and West. Data on commercially insured boys younger than 3 years revealed a 1.5-fold overall increase in the rate of hypospadias surgery from 321/100,000 in 1994 to 468/100,000 in 2002, reflecting the known increase in hypospadias incidence in the United States during the late 1990 s.

CONCLUSIONS

Average cost per hospitalization for hypospadias exceeded $5,389 with costs per case higher in children 3 years or older, although there were more cases in children younger than 3 years. The cost per case of hypospadias was higher in the Northeast and South than in the other regions. Data on cryptorchidism are too sparse to provide insights into its downstream economic costs.

Male urethral stricture disease

PURPOSE

The incidence of urethral stricture disease in the United States is unknown. We estimated the impact of urethral stricture disease by determining its prevalence, costs and other measures of burden, including side effects and the need for surgical intervention.

MATERIALS AND METHODS

Analyses of services for urethral stricture disease were performed in 10 public and private data sets by epidemiological, biostatistical and clinical experts.

RESULTS

Male urethral stricture disease occurred at a rate as high as 0.6% in some susceptible populations and resulted in more than 5,000 inpatient visits yearly. Yearly office visits for urethral stricture numbered almost 1.5 million between 1992 and 2000. The total cost of urethral stricture diseases in 2000 was almost $200 million, not including medication costs. A diagnosis of urethral stricture increased health care expenditures by more than $6,000 per individual yearly in insured populations after controlling for comorbidities. Urethral stricture disease appeared to be more common in the elderly population and in black patients, as measured by health care use. In most data sets services provided for urethral stricture disease decreased with time. Patients with urethral stricture disease appeared to have a high rate of urinary tract infection (41%) and incontinence (11%).

CONCLUSIONS

Despite decreasing rates of urethral strictures with time the burden of urethral stricture disease is still significant, resulting in hundreds of millions of dollars spent and hundreds of thousands of caregiver visits yearly.

Vesicoureteral reflux and ureteroceles

PURPOSE

We quantified the burden of vesicoureteral reflux and ureteroceles in the United States by identifying trends in the use of health care resources and estimating the economic impact of the diseases.

MATERIALS AND METHODS

The analytical methods used to generate these results were described previously.

RESULTS

Annual inpatient hospitalizations for vesicoureteral reflux increased slightly between 1994 and 2000 from 6.4/100,000 to 7.0/100,000 children, although this trend did not attain statistical significance. Inpatient hospitalization for ureteroceles remained relatively stable between 1994 and 2000 at an average of approximately 2,818 cases annually (1.0/100,000 to 1.1/100,000 children). The rates of visits to physician offices doubled during the 1990 s for commercially insured children (12/100,000 in 1994 and 26/100,000 in 2002) and children covered by Medicaid (43/100,000 in 1996 and 85/100,000 in 2000). Overall the rate of ambulatory surgery visits by commercially insured children increased from 3.4/100,000 in 1998 to 4.8/100,000 in 2002. Similar estimates were not available for children covered by Medicaid. Emergency room use by children with a primary diagnosis of vesicoureteral reflux was rare, reflecting the trend toward delivery of care at physician offices, ambulatory surgery centers and inpatient hospitals. No reliable data could be obtained on outpatient visits or ambulatory surgery for ureteroceles. In 2000 total expenditures for inpatient pediatric vesicoureteral reflux were $47 million, an increase of more than $10 million since 1997. Based on data from 2000 the yearly national inpatient expenditures from ureterocele treatment were an estimated $4 million.

CONCLUSIONS

The economic impact of inpatient treatment for pediatric vesicoureteral reflux is considerable. If other service types such as pharmaceuticals, and outpatient and ambulatory services were considered, the observed impact of this condition would certainly be greater. Importantly the costs of prophylactic medical therapy and emerging therapies such as Deflux are not accounted for in this estimate. Furthermore, indirect economic costs, such as work loss to parents of children with pediatric vesicoureteral reflux, were not considered, causing an even greater underestimation of the true costs associated with the condition. Although the National Association of Children's Hospitals and Related Institutions, and the Health Care Cost and Utilization Project Kids' Inpatient Database include data on ureteroceles, the data were limited and, thus, they could not be used to determine reliable cost trends. Available data indicate that the mean cost per ureterocele case was almost $8,000 with little variation observed across ages, regions or sexes.

Erectile Dysfunction

PURPOSE

Male sexual health has taken on increased importance as the United States population ages, develops coexisting medical conditions and undergoes interventions that can affect sexual function. We characterized the burden and severity of disease, treatment patterns and economic consequences of erectile dysfunction.

MATERIALS AND METHODS

The analytical methods used to generate these results were described previously.

RESULTS

Erectile dysfunction was self-reported by almost 1 of 5 men and it increased with age. Erectile dysfunction may have been more commonly reported in Hispanic men and in those with a history of diabetes, obesity, smoking and hypertension. In most databases black American men had rates of use for office visits and inpatient hospital care that were twice those of other racial groups, although these rates were not controlled for comorbid conditions or other regional and socioeconomic factors. The use of diagnostic tests markedly decreased, while pharmacological therapy, especially with oral phosphodiesterase-5 inhibitors, markedly increased. Penile implant surgery continued to be performed with most patients electing inflatable devices. Extrapolating from the population based estimates of erectile dysfunction prevalence and current use trends showed that the cost of treatment nationwide could reach $15 billion if all men sought treatment.

CONCLUSIONS

The burden of disease due to erectile dysfunction in the United States will increase with the aging of the male population, increasing prevalence of comorbid conditions, expanded treatment seeking behavior and costs of pharmaceutical therapy. Accurate estimates of economic cost will require better understanding of pathogenesis, treatment seeking behavior, patient preference for therapies, success of treatments and relative satisfaction with oral pharmacotherapy and penile implants.

Bladder and Upper Tract Urothelial Cancer

PURPOSE

While there are data available indicating the incidence and prevalence of bladder and upper tract urothelial cancer, population level data on resource use, costs and patterns of care for these cancers are limited. We quantified the economic impact of caring for patients with bladder and upper tract urothelial cancer, and determined the primary drivers for such costs in the population in the United States.

MATERIALS AND METHODS

The analytical methods used to generate these results have been described previously.

RESULTS

An increasing proportion of patients with bladder and upper tract urothelial cancer were being treated in the outpatient setting. Most care was provided by urologists and visit frequency was directly related to disease stage. Only a small proportion of patients potentially eligible for chemotherapy, ie those with advanced disease, sought specialized care from oncologists. Office based diagnostic tests such as cytology were not commonly done, although a substantial number of patients with bladder cancer underwent cystoscopy. The use of excretory urography in these patients was decreasing, while the use of computerized tomography was increasing. Ileal conduits were the most frequently performed type of urinary diversion following cystectomy. The cystectomy rate remained unchanged for a decade. Intravesical therapy was done infrequently in patients with bladder cancer. Annual costs for treating bladder and upper urinary tract cancers were $1 billion and $64 million, respectively, in 2000. These costs represented a $164 million increase over 1994 levels, which outpaced inflation.

CONCLUSIONS

The costs of treating bladder cancer increased steadily during a 6-year period despite a decrease in inpatient care. Coupled with a lack of substantial change in transurethral resection and cystectomy rates, this suggests that the primary cost drivers are increased outpatient testing, eg computerized tomography and cystoscopy, and an increase in the number of diagnosed cases. Greater focus on selective use of testing modalities, preventive care such as smoking cessation and earlier identification of patients at risk may help curtail further expenditure with regard to managing bladder and upper urinary tract cancers.

Benefit design and specialty drug use

In this paper we examine spending by privately insured patients with four conditions often treated with specialty drugs: cancer, kidney disease, rheumatoid arthritis, and multiple sclerosis. Despite having employer-sponsored health insurance, these patients face substantial risk for high out-of-pocket spending. In contrast to traditional pharmaceuticals, we find that specialty drug use is largely insensitive to cost sharing, with price elasticities ranging from 0.01 to 0.21. Given the expense of many specialty drugs, care management should focus on making sure that patients who will most benefit receive them. Once such patients are identified, it makes little economic sense to limit coverage.

The lifetime burden of chronic disease among the elderly

The high costs of treating chronic diseases suggest that reducing their prevalence would improve Medicare's financial stability. In this paper we examine the impact of selected chronic diseases on the distribution of health spending and its variation over the course of disease. We also use a microsimulation model to estimate these conditions' impact on life expectancy and health spending from age sixty-five to death. A sixty-five-year-old with a serious chronic illness spends 1000-2000 dollars more per year on health care than a similar adult without the condition. However, cumulative Medicare payments are only modestly higher for the chronically ill because of their shorter life expectancy.

Consequences of health trends and medical innovation for the future elderly

Recent innovations in biomedicine seem poised to revolutionize medical practice. At the same time, disease and disability are increasing among younger populations. This paper considers how these confluent trends will affect the elderly's health status and health care spending over the next thirty years. Because healthier people live longer, cumulative Medicare spending varies little with a beneficiary's disease and disability status upon entering Medicare. On the other hand, ten of the most promising medical technologies are forecast to increase spending greatly. It is unlikely that a "silver bullet" will emerge to both improve health and dramatically reduce medical spending.

Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy

OBJECTIVE

To determine whether a pharmacy benefit that varies copayments for cholesterol-lowering (CL) therapy according to expected therapeutic benefit would improve compliance and reduce use of other services.

METHODS

Using claims data from 88 health plans, we studied 62 274 patients aged 20 years and older who initiated CL therapy between 1997 and 2001. We examined the association between copayments and compliance in the year after initiation of therapy, and the association between compliance and subsequent hospital and emergency department (ED) use for up to 4 years after initiation.

RESULTS

The fraction of fully compliant patients fell by 6 to 10 percentage points when copayments increased from 10 dollars to 20 dollars, depending on patient risk (P < .05). Full compliance was associated with 357 fewer hospitalizations annually per 1000 high-risk patients (P < .01) and 168 fewer ED visits (P < .01) compared with patients not in full compliance. For patients at low risk, full compliance was associated with 42 fewer hospitalizations (P = .02) and 21 fewer ED visits (P = .22). Using these results, we simulated a policy that eliminated copayments for high- and medium-risk patients but raised them (from 10 dollars to 22 dollars) for low-risk patients. Based on a national sample of 6.3 million adults on CL therapy, this policy would avert 79,837 hospitalizations and 31,411 ED admissions annually.

CONCLUSION

Although many obstacles exist, varying copayments for CL therapy by therapeutic need would reduce hospitalizations and ED use--with total savings of more than 1 billion dollars annually.

Mental Health Status and Use of General Medical Services for Persons With Human Immunodeficiency Virus

BACKGROUND

Serious medical illness often is accompanied by psychological distress. Individuals experiencing mental disorders or symptoms have higher rates of morbidity and mortality, worse social functioning, and use of general medical services.

OBJECTIVES

We sought to examine the association between mental health and use of general medical services for persons in care for HIV.

DESIGN AND PARTICIPANTS

We used longitudinal data from the HIV Cost and Services Utilization Study (HCSUS), a nationally representative sample of 2267 HIV+ adults receiving care and who completed all 3 interviews during an 18-month period.

MAIN OUTCOME MEASURES

Probability of use and general medical expenditures, by type of service.

RESULTS

HIV+ individuals who screened positive for depression or had 5 or more mental health symptoms at baseline spent 20% to 25% more for general medical services in the following 12 months than HIV+ adults without mental health symptoms, after adjusting for disease severity and patient characteristics. Higher spending was largely the result of greater use of inpatient and emergency services.

CONCLUSIONS

Psychological distress remains an independent predictor of general medical service use, although the magnitude of effect diminishes with better controls for physical well-being and previous service use. Identifying HIV patients with symptoms of affective or anxiety disorders may reduce overall treatment costs modestly.

A socioeconomic profile of older adults with HIV

The objective of this study was to assess the socioeconomic circumstances of older patients with HIV and acquired immunodeficiency syndrome (AIDS). The investigators compared subjects from a national probability sample of 2,864 respondents from the HIV Cost and Services Utilization Study (HCSUS, 1996) with 9,810 subjects from Wave 1 (1992) of the Health and Retirement Survey (HRS). Bivariate analyses compare demographic characteristics, financial resources, and health insurance status between older and younger adults and between older adults with HIV and the general population. It was found that nearly 10% of the HIV-positive population is between the ages of 50 and 61 years. Older whites with HIV are mostly homosexual men who are more well educated, more often privately insured, and more financially stable than the HIV population as a whole. In contrast, older minorities with HIV possess few economic resources in either absolute or relative terms. The success of new drug therapies and the changing demographics of the HIV population necessitate innovative policies that promote labor force participation and continuous access to antiretroviral therapies.

Urologic diseases in America Project: analytical methods and principal findings

PURPOSE

The burden of urological diseases on the American public is immense in human and financial terms but it has been under studied. We undertook a project, Urologic Diseases in America, to quantify the burden of urological diseases on the American public.

MATERIALS AND METHODS

We identified public and private data sources that contain population based data on resource utilization by patients with benign and malignant urological conditions. Sources included the Centers for Medicare and Medicaid Services, National Center for Health Statistics, Medical Expenditure Panel Survey, National Health and Nutrition Examination Survey, Department of Veterans Affairs, National Association of Children's Hospitals and Related Institutions, and private data sets maintained by MarketScan Health and Productivity Management (MarketScan, Chichester, United Kingdom), Ingenix (Ingenix, Salt Lake City, Utah) and Center for Health Care Policy and Evaluation. Using diagnosis and procedure codes we described trends in the utilization of urological services.

RESULTS

In 2000 urinary tract infections accounted for more than 6.8 million office visits and 1.3 million emergency room visits, and 245,000 hospitalizations in women with an annual cost of more than 2.4 billion dollars. Urinary tract infections accounted for more than 1.4 million office visits, 424,000 emergency room visits and 121,000 hospitalizations in men with an annual cost of more than 1 billion dollars. Benign prostatic hyperplasia was the primary diagnosis in more than 4.4 million office visits, 117,000 emergency room visits and 105,000 hospitalizations, accounting for 1.1 billion dollars in expenditures that year. Urolithiasis was the primary diagnosis for almost 2 million office visits, more than 600,000 emergency room visits, and more than 177,000 hospitalizations, totaling more than 2 billion dollars in annual expenditures. Urinary incontinence in women was the primary cause for more than 1.1 million office visits in 2000 and 452 million dollars in aggregate primary cause for more than 1.1 million office visits in 2000 and 452 million dollars in aggregate annual expenditures. Other manuscripts in this series present further detail for specific urologic conditions.

CONCLUSIONS

Recent trends in epidemiology, practice patterns, resource utilization and costs for urological diseases have broad implications for quality of health care, access to care and the equitable allocation of scarce resources for clinical care and research.

Disability forecasts and future Medicare costs

The traditional focus of disability research has been on the elderly, with good reason. Chronic disability is much more prevalent among the elderly, and it has a more direct impact on the demand for medical care. It is also important to understand trends in disability among the young, however, particularly if these trends diverge from those among the elderly. These trends could have serious implications for future health care spending because more disability at younger ages almost certainly translates into more disability among tomorrow's elderly, and disability is a key predictor of health care spending. Using data from the Medicare Current Beneficiary Survey (MCBS) and the National Health Interview Study (NHIS), we forecast that per-capita Medicare costs will decline for the next fifteen to twenty years, in accordance with recent projections of declining disability among the elderly. By 2020, however, the trend reverses. Per-capita costs begin to rise due to growth in disability among the younger elderly. Total costs may well remain relatively flat until 2010 and then begin to rise because per-capita costs will cease to decline rapidly enough to offset the influx of new elderly people. Overall, cost forecasts for the elderly that incorporate information about disability among today's younger generations yield more pessimistic scenarios than those based solely on elderly data sets, and this information should be incorporated into official Medicare forecasts.

Pharmacy benefits and the use of drugs by the chronically ill

CONTEXT

Many health plans have instituted more cost sharing to discourage use of more expensive pharmaceuticals and to reduce drug spending.

OBJECTIVE

To determine how changes in cost sharing affect use of the most commonly used drug classes among the privately insured and the chronically ill.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective US study conducted from 1997 to 2000, examining linked pharmacy claims data with health plan benefit designs from 30 employers and 52 health plans. Participants were 528,969 privately insured beneficiaries aged 18 to 64 years and enrolled from 1 to 4 years (960,791 person-years).

MAIN OUTCOME MEASURE

Relative change in drug days supplied (per member, per year) when co-payments doubled in a prototypical drug benefit plan.

RESULTS

Doubling co-payments was associated with reductions in use of 8 therapeutic classes. The largest decreases occurred for nonsteroidal anti-inflammatory drugs (NSAIDs) (45%) and antihistamines (44%). Reductions in overall days supplied of antihyperlipidemics (34%), antiulcerants (33%), antiasthmatics (32%), antihypertensives (26%), antidepressants (26%), and antidiabetics (25%) were also observed. Among patients diagnosed as having a chronic illness and receiving ongoing care, use was less responsive to co-payment changes. Use of antidepressants by depressed patients declined by 8%; use of antihypertensives by hypertensive patients decreased by 10%. Larger reductions were observed for arthritis patients taking NSAIDs (27%) and allergy patients taking antihistamines (31%). Patients with diabetes reduced their use of antidiabetes drugs by 23%.

CONCLUSIONS

The use of medications such as antihistamines and NSAIDs, which are taken intermittently to treat symptoms, was sensitive to co-payment changes. Other medications--antihypertensive, antiasthmatic, antidepressant, antihyperlipidemic, antiulcerant, and antidiabetic agents--also demonstrated significant price responsiveness. The reduction in use of medications for individuals in ongoing care was more modest. Still, significant increases in co-payments raise concern about adverse health consequences because of the large price effects, especially among diabetic patients.

The Changing Face Of Pharmacy Benefit Design

Employers, health plans, and pharmacy benefit managers-seeking to reduce rapid growth in pharmacy spending-have embraced multi-tier pharmacy benefit packages that use differential copayments to steer beneficiaries toward low-cost drugs. The consensus of fifteen pharmacy benefit design experts whom we interviewed is that such plans will become more prevalent and that the techniques these plans use to promote low-cost drugs will intensify. The effect on health outcomes depends on whether the high-cost drugs whose use is being discouraged have close, low-cost substitutes.

Insurance status of HIV-infected adults in the post-HAART era: evidence from the United States

In the United States, universal public insurance is only available for the elderly. But unlike most other major diseases, HIV/AIDS predominantly affects the nonelderly. The result is that insurance availability and public programme participation are linked to disease progression in a complicated way. This paper uses data from a unique, nationally representative sample of HIV-infected adults receiving medical care, to describe the relationship between disease progression and insurance coverage in the United States. We find that public insurance is the predominant source of coverage for those in care for HIV, and that coverage increases as disease progresses. Those with public coverage have substantial work experience and earnings capacity, but do not work. This suggests that reforms allowing HIV positive (+) patients to maintain public coverage while returning to work could increase employment and earnings significantly. More speculatively, it suggests that the United States system for financing health care is not well-equipped to deal with epidemics that afflict a population in its prime work years.

Forecasting the nursing home population

OBJECTIVE

To forecast growth in the US nursing home population, as a function of trends in disability and marriage.

METHODS

Nursing home residence is modeled as a function of disability status, marital status, and other demographic covariates. Our predictions for nursing home residence are built upon joint forecasts of marriage and disability. We use data from the 1992 to 1996 Medicare Current Beneficiary Surveys, which are individual-level data sets designed to be representative of the US population older than the age of 65.

RESULTS

Today's young cohorts will have higher rates and levels of institutionalization than their older counterparts. This will reverse several decades of decline in rates of disability and institutionalization. The nursing home population is likely to be 10-25% higher than would be suggested by a simple extrapolation of past declines in disability.

CONCLUSIONS

In recent years, the rate of institutionalization among the elderly has been falling. It is predicted that this trend will reverse itself within the next decade, and that we will see substantial increases in the incidence of institutionalization among the elderly. This result is generated by our prediction of rising disability among the younger cohorts that are beginning to approach old age.

Employer drug benefit plans and spending on prescription drugs

CONTEXT

With drug spending rising rapidly for working-aged adults, many employers and health insurance providers have changed benefits packages to encourage use of fewer or less expensive drugs. It is unknown how these initiatives affect drug costs.

OBJECTIVE

To examine how innovations in benefits packages, such as those that include multitier formularies and mandatory generic substitution, affect total cost to insurance providers for generic and brand drugs and out-of-pocket payments to beneficiaries.

DESIGN AND PARTICIPANTS

Retrospective study from 1997 to 1999 linking claims data of 420,786 primary beneficiaries aged 18 through 64 years who worked at large firms (n = 25) with health insurance benefits that included outpatient drugs.

MAIN OUTCOME MEASURES

Overall drug costs; generic, single-source brand, and multisource brand costs; and drug expenditures by health insurance providers and out-of-pocket costs for beneficiaries.

RESULTS

For a 1-tier plan with a 5 US dollars co-payment for all drugs, the average annual spending was 725 US dollars per member. Doubling co-payments to 10 US dollars for all drugs reduced the annual average drug cost from 725 US dollars to 563 US dollars per member (22.3%, P<.001). Doubling co-payments in a 2-tier plan from 5 US dollars for generics and $10 for brand drugs to 10 US dollars for generics and 20 US dollars for brand drugs reduced costs from 678 US dollars to 455 US dollars (32.9%, P<.001). Adding an additional co-payment of 30 US dollars for nonpreferred brand drugs to a 2-tier plan (10 US dollars generics; 20 US dollars brand) lowered overall drug spending by 4% (P<.001). Requiring mandatory generic substitution in a 2-tier plan reduced drug spending by 8% (P<.001). Doubling co-payments in a 2-tier plan increased the fraction beneficiaries' paid out-of-pocket from 17.6% to 25.6%.

CONCLUSIONS

Adding an additional level of co-payment, increasing existing co-payments or coinsurance rates, and requiring mandatory generic substitution all reduced plan payments and overall drug spending among working-age enrollees with employer-provided drug coverage. The reduction in drug spending largely benefited health insurance plans because the percentage of drug expenses beneficiaries paid out-of-pocket rose significantly.

Medical care expenditures under gatekeeper and point-of-service arrangements

OBJECTIVE

To compare expenditures for medical care in a closed-panel gatekeeper HMO and an open-panel point-of-service (POS) plan that share the same provider network.

DATA SOURCE/STUDY SETTING

The two study HMOs are distinct product lines of a single managed care organization; both plans are commercial products. We used administrative data files from the study plans for 1994-95 to assess differences in total medical care expenditures and spending for five categories of services: physician services, inpatient hospital services, outpatient hospital services, prescription drugs, and other services.

STUDY DESIGN

Multivariate analyses were based on the two-part model of the demand for medical care. The dependent variables in these models were expenditures in each of the five categories of services, and the independent variables were indicator variables for plan type and visit copayments, prescription drug copayment, distance to the nearest primary care physician (PCP), demographic characteristics, chronic conditions, area characteristics, and entry/exit indicator variables.

PRINCIPAL FINDINGS

Total expenditures for medical care ranged from equal in both plans to 7 percent higher in the gatekeeper HMO (p < .10), depending on the copayments for physician visits. Expenditures were not higher in the POS plan for any of the five categories of services. These findings were robust to a wide range of sensitivity analyses.

CONCLUSIONS

Direct patient access to specialists in POS plans does not necessarily result in higher medical care expenditures. When POS enrollees are required to choose PCPs, patient cost sharing, physician financial incentives, and utilization review may control expenditures without constraining direct patient access to providers.

Evolution in vitro: analysis of a lineage of ribozymes

BACKGROUND

Catalytic RNAs, or ribozymes, possessing both a genotype and a phenotype, are ideal molecules for evolution experiments in vitro. A large, heterogeneous pool of RNAs can be subjected to multiple rounds of selection, amplification and mutation, leading to the development of variants that have some desired phenotype. Such experiments allow the investigator to correlate specific genetic changes with quantifiable alterations of the catalytic properties of the RNA. In addition, patterns of evolutionary change can be discerned through a detailed examination of the genotypic composition of the evolving RNA population.

RESULTS

Beginning with a pool of 10(13) variants of the Tetrahymena ribozyme, we carried out in vitro evolution experiments that led to the generation of ribozymes with the ability to cleave an RNA substrate in the presence of Ca2+ ions, an activity that does not exist for the wild-type molecule. Over the course of 12 generations, a seven-error variant emerged that has substantial Ca(2+)-dependent RNA-cleavage activity. Advantageous mutations increased in frequency in the population according to three distinct dynamics--logarithmic, linear and transient. Through a comparative analysis of 31 individual variants, we infer how certain mutations influence the catalytic properties of the ribozyme.

CONCLUSIONS

In vitro evolution experiments make it possible to elucidate important aspects of both evolutionary biology and structural biochemistry on a reasonable short time scale.