Projected environmental and public health benefits of extended-interval dosing: an analysis of pembrolizumab use in a US national health system.

BACKGROUND: Health care is a major source of greenhouse gas emissions, leading to climate change and public health harms. Changes are needed to improve the environmental sustainability of health-care practices, but such changes should not sacrifice patient outcomes or financial sustainability. Alternative dosing strategies that reduce the frequency with which specialty drugs are administered, without sacrificing patient outcomes, are an attractive possibility for improving environmental sustainability. We sought to inform environmentally sustainable cancer care by estimating and comparing the environmental and financial effects of alternative, clinically equivalent strategies for pembrolizumab administration. METHODS: We conducted a retrospective analysis using a cohort of patients from the Veterans Health Administration (VHA) in the USA who received one or more pembrolizumab doses between May 1, 2020, and Sept 30, 2022. Using baseline, real-world administration of pembrolizumab, we generated simulated pembrolizumab use data under three near-equivalent counterfactual pembrolizumab administration strategies defined by combinations of weight-based dosing, pharmacy-level vial sharing and dose rounding, and extended-interval dosing (ie, every 6 weeks). For each counterfactual dosing strategy, we estimated greenhouse gas emissions related to pembrolizumab use across the VHA cohort using a deterministic environmental impact model that estimated greenhouse gas emissions due to patient travel, drug manufacture, and medical waste as the primary outcome measure. FINDINGS: We identified 7813 veterans who received at least one dose of pembrolizumab-containing therapy in the VHA during the study period. 59 140 pembrolizumab administrations occurred in the study period, of which 46 255 (78·2%) were dosed at 200 mg every 3 weeks, 12 885 (21·8%) at 400 mg every 6 weeks, and 14 955 (25·3%) were coadministered with infusional chemotherapies. Adoption of weight-based, extended-interval pembrolizumab dosing (4 mg/kg every 6 weeks) and pharmacy-level stewardship strategies (ie, dose rounding and vial sharing) for all pembrolizumab infusions would have resulted in 24·7% fewer administration events than baseline dosing (44 533 events vs 59 140 events) and an estimated 200 metric tons less CO2 emitted per year as a result of pembrolizumab use within the VHA (650 tons vs 850 tons of CO2, a relative reduction of 24%), largely due to reductions in distance travelled by patients to receive treatment. Similar results were observed when weight-based and extended-interval dosing were applied only to pembrolizumab monotherapy and pembrolizumab in combination with oral therapies. INTERPRETATION: Alternative pembrolizumab administration strategies might have environmental advantages over the current dosing and compounding paradigms. Specialty medication dosing can be optimised for health-care spending and environmental sustainability without sacrificing clinical outcomes. FUNDING: None.

High Deductibles are Associated With Severe Disease, Catastrophic Out-of-Pocket Payments for Emergency Surgical Conditions.

BACKGROUND: Out-of-pocket spending has risen for individuals with private health insurance, yet little is known about the unintended consequences that high levels of cost-sharing may have on delayed clinical presentation and financial outcomes for common emergency surgical conditions. METHODS: In this retrospective analysis of claims data from a large commercial insurer (2016-2019), we identified adult inpatient admissions following emergency department presentation for common emergency surgical conditions (eg, appendicitis, cholecystitis, diverticulitis, and intestinal obstruction). Primary exposure of interest was enrollment in a high-deductible health insurance plan (HDHP). Our primary outcome was disease severity at presentation-determined using ICD-10-CM diagnoses codes and based on validated measures of anatomic severity (eg, perforation, abscess, diffuse peritonitis). Our secondary outcome was catastrophic out-of-pocket spending, defined by the World Health Organization as out-of-pocket spending >10% of annual income. RESULTS: Among 43,516 patients [mean age 48.4 (SD: 11.9) years; 51% female], 41% were enrolled HDHPs. Despite being younger, healthier, wealthier, and more educated, HDHP enrollees were more likely to present with more severe disease (28.5% vs 21.3%, P <0.001; odds ratio (OR): 1.34, 95% CI: 1.28-1.42]); even after adjusting for relevant demographics (adjusted OR: 1.23, 95% CI: 1.18-1.31). HDHP enrollees were also more likely to incur 30-day out-of-pocket spending that exceeded 10% of annual income (20.8% vs 6.4%, adjusted OR: 3.93, 95% CI: 3.65-4.24). Lower-income patients, Black patients, and Hispanic patients were at highest risk of financial strain. CONCLUSIONS: For privately insured patients presenting with common surgical emergencies, high-deductible health plans are associated with increased disease severity at admission and a greater financial burden after discharge-especially for vulnerable populations. Strategies are needed to improve financial risk protection for common surgical emergencies.

The aggregate value of cancer screenings in the United States: full potential value and value considering adherence.

BACKGROUND: Although cancer mortality has been decreasing since 1991, many cancers are still not detected until later stages with poorer outcomes. Screening for early-stage cancer can save lives because treatments are generally more effective at earlier than later stages of disease. Evidence of the aggregate benefits of guideline-recommended single-site cancer screenings has been limited. This article assesses the benefits in terms of life-years gained and associated value from major cancer screening technologies in the United States. METHODS: A mathematical model was built to estimate the aggregate benefits of screenings for breast, colorectal, cervical, and lung cancer over time since the start of US Preventive Services Task Force (USPSTF) recommendations. For each type, the full potential benefits under perfect adherence and the benefits considering reported adherence rates were estimated. The effectiveness of each screening technology was abstracted from published literature on the life-years gained per screened individual. The number of individuals eligible for screening per year was estimated using US Census data matched to the USPSTF recommendations, which changed over time. Adherence rates to screening protocols were based on the National Health Interview Survey results with extrapolation. RESULTS: Since initial USPSTF recommendations, up to 417 million people were eligible for cancer screening. Assuming perfect adherence to screening recommendations, the life-years gained from screenings are estimated to be 15.5-21.3 million (2.2-4.9, 1.4-3.6, 11.4-12.3, and 0.5 million for breast, colorectal, cervical, and lung cancer, respectively). At reported adherence rates, combined screening has saved 12.2-16.2 million life-years since the introduction of USPSTF recommendations, ~ 75% of potential with perfect adherence. These benefits translate into a value of $8.2-$11.3 trillion at full potential and $6.5-$8.6 trillion considering current adherence. Therefore, single-site screening could have saved an additional 3.2-5.1 million life-years, equating to $1.7-$2.7 trillion, with perfect adherence. CONCLUSIONS: Although gaps persist between the full potential benefit and benefits considering adherence, existing cancer screening technologies have offered significant value to the US population. Technologies and policy interventions that can improve adherence and/or expand the number of cancer types tested will provide significantly more value and save significantly more patient lives.

Evaluating the accessibility and value of U.S. ambulatory care among Medicaid expansion states and non-expansion states, 2012-2015.

BACKGROUND: While the Affordable Care Act's Medicaid expansion improved healthcare coverage and access for millions of uninsured Americans, less is known about its effects on the overall accessibility and quality of care across all payers. Rapid volume increases of newly enrolled Medicaid patients might have unintentionally strained accessibility or quality of care. We assessed changes in physician office visits and high- and low-value care associated with Medicaid expansion across all payers. METHODS: Prespecified, quasi-experimental, difference-in-differences analysis pre and post Medicaid expansion (2012-2015) in 8 states that did and 5 that did not choose to expand Medicaid. Physician office visits sampled from the National Ambulatory Medical Care Survey, standardized with U.S. Census population estimates. Outcomes included visit rates per state population and rates of high or low-value service composites of 10 high-value measures and 7 low-value care measures respectively, stratified by year and insurance. RESULTS: We identified approximately 143 million adults utilizing 1.9 billion visits (mean age 56; 60% female) during 2012-2015. Medicaid visits increased in expansion states post-expansion compared to non-expansion states by 16.2 per 100 adults (p = 0.031 95% CI 1.5-31.0). New Medicaid visits increased by 3.1 per 100 adults (95% CI 0.9-5.3, p = 0.007). No changes were observed in Medicare or commercially-insured visit rates. High or low-value care did not change for any insurance type, except high-value care during new Medicaid visits, which increased by 4.3 services per 100 adults (95% CI 1.1-7.5, p = 0.009). CONCLUSIONS: Following Medicaid expansion, the U.S. healthcare system increased access to care and use of high-value services for millions of Medicaid enrollees, without observable reductions in access or quality for those enrolled in other insurance types. Provision of low-value care continued at similar rates post-expansion, informing future federal policies designed to improve the value of care.

Retrospective Use of Patients' Characteristics to Assess Variation in Prenatal Care Utilization.

OBJECTIVE: We used patients' medical and psychosocial risk factors to explore prenatal care utilization and health outcomes to inform prenatal care tailoring. STUDY DESIGN: This retrospective cohort study assessed patients who gave birth at an academic institution from January 1 to December 31, 2018, using electronic health record (EHR) data. Patients were categorized into four phenotypes based on medical/psychosocial risk factors available in the EHR: Completely low risk; High psychosocial risk only; High medical risk only; and Completely high risk. We examined patient characteristics, visit utilization, nonvisit utilization (e.g., phone calls), and outcomes (e.g., preterm birth, preeclampsia) across groups. RESULTS: Of 4,681 patients, the majority were age 18 to 35 (3,697, 79.0%), White (3,326, 70.9%), multiparous (3,263, 69.7%), and Completely high risk (2,752, 58.8%). More Black and Hispanic patients had psychosocial risk factors than White patients. Patients with psychosocial risk factors had fewer prenatal visits (10, interquartile range [IQR]: 8-12) than those without (11, IQR: 9-12). Patients with psychosocial risk factors experienced less time in prenatal care, more phone calls, and fewer EHR messages across the same medical risk group. Rates of preterm birth and gestational hypertension were incrementally higher with additional medical/psychosocial risk factors. CONCLUSION: Data readily available in the EHR can assess the compounding influence of medical/psychosocial risk factor on patients' care utilization and outcomes. KEY POINTS: · Medical and psychosocial needs in pregnancy can inform patient phenotypes and are associated with prenatal care use and outcomes.. · Patient phenotypes are associated with prenatal care use and outcomes.. · Patients with high psychosocial risk spent less time in prenatal care and had more phone calls in pregnancy.. · Tailored prenatal care models may proactively address differences in patient's needs..

Value-Based Insurance Design: Clinically Nuanced Consumer Cost-Sharing for Mental Health Services.

BACKGROUND: While consumer cost-sharing is a widely used strategy to mitigate health care spending, numerous studies have demonstrated that even modest levels of out-of-pocket cost are associated with lower use of medical care, including clinically necessary, high-value services. Within mental health care, increases in cost-sharing are associated with reductions in use of mental health care and psychotropic medication use. Further, these reductions in mental health services and treatments can lead to downstream consequences including worsening of psychiatric illness and increased need for acute care and psychiatric hospitalization. Thus, there is a need for clinically informed solutions that explicitly balance the need for appropriate access to essential mental health services and treatments with growing fiscal pressures faced by public and private payers. Value-Based Insurance Design (VBID) describes a model where consumer cost-sharing is based on the potential clinical benefit rather than the price of a specific health care service or treatment. AIMS OF THE STUDY: Describe value-based insurance design and applications in mental health care. RESULTS, DISCUSSION AND IMPLICATIONS FOR HEALTH POLICIES: For over two decades, clinically nuanced VBID programs have been implemented in an effort to optimize the use of high-value health services and enhance equity through reduced consumer cost-sharing. Overall, the evidence suggests that VBID has demonstrated success in reducing consumer out-of-pocket costs associated with specific, high value services. By reducing financial barriers to essential clinical services and medications, VBID has potential to enhance equity. However, the impact of VBID on overall mental health care spending and clinical outcomes remains uncertain.

A Care Coordination Intervention Improves Symptoms But Not Charges in High-Risk Patients With Inflammatory Bowel Disease.

BACKGROUND: Inflammatory bowel disease (IBD) is associated with substantial symptom burden, variability in clinical outcomes, and high direct costs. We sought to determine if a care coordination-based strategy was effective at improving patient symptom burden and reducing healthcare costs for patients with IBD in the top quintile of predicted healthcare utilization and costs. METHODS: We performed a randomized controlled trial to evaluate the efficacy of a patient-tailored multicomponent care coordination intervention composed of proactive symptom monitoring and care coordinator-triggered algorithms. Enrolled patients with IBD were randomized to usual care or to our care coordination intervention over a 9-month period (April 2019 to January 2020). Primary outcomes included change in patient symptom scores throughout the intervention and IBD-related charges at 12 months. RESULTS: Eligible IBD patients in the top quintile for predicted healthcare utilization and expenditures were identified. A total of 205 patients were enrolled and randomized to our intervention (n = 100) or to usual care (n = 105). Patients in the care coordinator arm demonstrated an improvement in symptoms scores compared with usual care (coefficient, -0.68, 95% confidence interval, -1.18 to -0.18; P = .008) without a significant difference in median annual IBD-related healthcare charges ($10,094 vs $9080; P = .322). CONCLUSIONS: In this first randomized controlled trial of a patient-tailored care coordination intervention, composed of proactive symptom monitoring and care coordinator-triggered algorithms, we observed an improvement in patient symptom scores but not in healthcare charges. Care coordination programs may represent an effective value-based approach to improve symptoms scores without added direct costs in a subgroup of high-risk patients with IBD. (ClinicalTrials.gov, Number: NCT04796571).

Out-of-pocket payments for part d covered medications by medicare fee-for-service beneficiaries with heart failure with reduced ejection fraction.

BACKGROUND: Out-of-pocket (OOP) drug costs for Medicare Fee-for-Service (FFS) beneficiaries with heart failure with reduced ejection fraction (HFrEF) are not well characterized. This study evaluated Part D OOP spending by Medicare beneficiaries with chronic HFrEF, stratified by those with and without a worsening HF event (WHFE). METHODS: Medicare FFS 100% Part D claims were used to identify HFrEF patients with 12 months of continuous Part D enrollment in 2018. HFrEF was defined as 1 inpatient or 2 outpatient claims of systolic HF or 1 systolic HF plus 1 HF outpatient claim. WHFE was defined as having a HF hospitalization or intravenous diuretic use within 12 months of HFrEF index date. OOP costs by Medicare Part D coverage phase for all covered drugs were calculated for HFrEF patients, and those with and without WHFE. RESULTS: Of 305,373 Medicare patients with HFrEF, 26% had a WHFE. Total mean (SD) OOP drug costs among all HFrEF patients was $1,166 (1,205)/year. Patients with WHFE and patients without WHFE had respectively a mean (SD) annual OOP costs of $1,302 (1,273) and $1,117 (1,176). Over 39% of HFrEF patients entered the "donut hole" (44% and 37% of patients with WHFE and without WHFE, respectively), while 11% of HFrEF patients entered the catastrophic phase (13% and 10% of patients with and without WHFE, respectively). CONCLUSIONS: More than 1 in 10 patients with heart failure entered the catastrophic phase within Medicare-Fee-For-Service, whereas in 2018 only 10% of costs were attributable to heart failure medication and 90% to comorbidities.

Value-Based Insurance Design: Clinically Nuanced Consumer Cost Sharing to Increase the Use of High-Value Medications.

Consumer cost sharing is widely employed by payers in the United States in an effort to control spending. Most cost-sharing strategies set patient contributions on the basis of costs incurred by payers and often do not consider medical necessity as a coverage criterion. Available evidence suggests that increases in cost sharing worsen health disparities and adversely affect patient-centered outcomes, particularly among economically vulnerable individuals, people of color, and those with chronic conditions. A key question has been how to better engage consumers while balancing appropriate access to essential services with increasing fiscal pressures. Value-based insurance design (VBID) is a promising approach designed to improve desired clinical and financial outcomes, in which out-of-pocket costs are based on the potential for clinical benefit, taking into consideration the patient's clinical condition. For more than two decades, broad multistakeholder support and multiple federal policy initiatives have led to the implementation of VBID programs that enhance access to vital preventive and chronic disease medications for millions of Americans. A robust evidence base shows that when financial barriers to essential medications are reduced, increased adherence results, leading to improved patient-centered outcomes, reduced health care disparities, and in some (but not most) instances, lower total medical expenditures.

The Utilization and Costs of Grade D USPSTF Services in Medicare, 2007-2016.

BACKGROUND: Low-value care, or patient care that offers no net benefit in specific clinical scenarios, is costly and often associated with patient harm. The US Preventive Services Task Force (USPSTF) Grade D recommendations represent one of the most scientifically sound and frequently delivered groups of low-value services, but a more contemporary measurement of the utilization and spending for Grade D services beyond the small number of previously studied measures is needed. OBJECTIVE: To estimate utilization and costs of seven USPSTF Grade D services among US Medicare beneficiaries. DESIGN: We conducted a cross-sectional study of data from the National Ambulatory Medical Care Survey (NAMCS) from 2007 to 2016 to identify instances of Grade D services. SETTING/PARTICIPANTS: NAMCS is a nationally representative survey of US ambulatory visits at non-federal and non-hospital-based offices that uses a multistage probability sampling design. We included all visits by Medicare enrollees, which included traditional fee-for-service, Medicare Advantage, supplemental coverage, and dual-eligible Medicare-Medicaid enrollees. MAIN MEASURES: We measured annual utilization of seven Grade D services among adult Medicare patients, using inclusion and exclusion criteria from prior studies and the USPSTF recommendations. We calculated annual costs by multiplying annual utilization counts by mean per-unit costs of services using publicly available sources. KEY RESULTS: During the study period, we identified 95,121 unweighted Medicare patient visits, representing approximately 2.4 billion visits. Each year, these seven Grade D services were utilized 31.1 million times for Medicare beneficiaries and cost $477,891,886. Three services-screening for asymptomatic bacteriuria, vitamin D supplements for fracture prevention, and colorectal cancer screening for adults over 85 years-comprised $322,382,772, or two-thirds of the annual costs of the Grade D services measured in this study. CONCLUSIONS: US Medicare beneficiaries frequently received a group of rigorously defined and costly low-value preventive services. Spending on low-value preventive care concentrated among a small subset of measures, representing important opportunities to safely lower US health care spending while improving the quality of care.

Cost sharing, postpartum contraceptive use, and short interpregnancy interval rates among commercially insured women.

BACKGROUND: Increasing access to effective birth control after childbirth may meet many women's preferences and reduce short interpregnancy interval rates. Eliminating out-of-pocket costs for contraception has been reported to increase the use of the most effective methods among women with employer-based insurance, but the prevalence and effects of patient cost sharing for contraception have not been studied during the postpartum period. OBJECTIVE: This study aimed to examine the association between cost sharing for long-acting reversible contraception and postpartum contraception use patterns and pregnancies in the 12 months after delivery. STUDY DESIGN: We conducted a retrospective cohort analysis of commercially insured women undergoing childbirth from 2014 to 2018 using Optum's (Eden Prairie, MN) de-identified Clinformatics Data Mart database. This large national database includes nonretired employees and their dependents who are enrolled in health insurance plans sponsored by large- or medium-sized US-based employers. Women with 12 months of continuous enrollment postpartum were included. Childbirth, pregnancy, and contraceptive method (female sterilization, long-acting reversible contraceptives, other hormonal methods, and no prescription method observed) were identified using claims data. Contraceptive use patterns were observed at 3, 6, and 12 months postpartum and adjusted for individual and plan characteristics. Median out-of-pocket costs were $0 for sterilization and other hormonal methods but nonzero for long-acting reversible contraception. We therefore used simple and multivariable logistic regressions to examine the association between plan-level cost sharing (no cost sharing, $0; low cost sharing, >$0-<$200; and high cost sharing, ≥$200 out-of-pocket cost) for any long-acting reversible contraceptive insertion and contraceptive use patterns and short interpregnancy interval rates, controlling for age, household income, race and ethnicity, region, and insurance plan type. RESULTS: Among 25,298 plans with cost sharing data, we identified 172,941 women with continuous enrollment for 12 months postpartum, including 82,500 (47.7%) in no cost sharing, 22,595 (13.1%) in low cost sharing, and 67,846 (39.2%) in high cost sharing plans. The percentage of postpartum women in the study sample using any prescription contraceptive method was 39.5% by 3 months, 43.8% by 6 months, and 46.0% by 12 months. At all time points, postpartum women in no cost sharing plans had a higher predicted probability of long-acting reversible contraceptive use (eg, at 12 months: no cost sharing, 22.0%; low cost-sharing, 17.5%; high cost sharing, 18.3%; P<.001) and a lower predicted probability of no prescription method use (eg, at 12 months: no cost sharing, 51.8%; low cost sharing, 55.0%; high cost sharing, 54.9%; P<.001) than those in low or high cost sharing plans. Predicted probabilities of female sterilization and other hormonal method use did not differ substantively by plan cost sharing for long-acting reversible contraception at any time point. The proportion of women experiencing a short interpregnancy interval was low (1.9% by 3 months, 1.9% by 6 months, 2.0% by 12 months) and did not differ by plan cost sharing for long-acting reversible contraception at any time point. CONCLUSION: Out-of-pocket costs for long-acting reversible contraception influence the method of contraception used by postpartum women with employer-based insurance. Eliminating financial barriers to long-acting reversible contraception access after childbirth may help women initiate their preferred method and increase the use of long-acting reversible contraceptives among interested women who otherwise might utilize less effective methods.

Impact of an Episode-Based Payment Initiative by Commercial Payers in Arkansas on Procedure Volume: an Observational Study.

BACKGROUND: Episode-based payment (EBP) is gaining traction among payers as an alternative to fee-for-service reimbursement. However, there is concern that EBP could influence the number of episodes. OBJECTIVE: To examine how procedure volume changed after the introduction of EBP in 2013 and 2014 under the Arkansas Health Care Payment Improvement Initiative. DESIGN: Using 2011-2016 commercial claims data, we estimate a difference-in-differences model to assess the impact of EBP on the probability of a beneficiary having an episode for four procedures that were reimbursed under EBP in Arkansas: total joint replacement, cholecystectomy, colonoscopy, and tonsillectomy. PARTICIPANTS: Commercially insured beneficiaries in Arkansas serve as our treatment group, while commercially insured beneficiaries in neighboring states serve as our comparison group. INTERVENTIONS: Statewide implementation of EBP for various clinical conditions by two of Arkansas' largest commercial insurers. MAIN MEASURES: For a given procedure type, the primary outcomes are the annual rate of procedures (number of procedures per 1000 beneficiaries) and the probability of a beneficiary undergoing that procedure in a given quarter. KEY RESULTS: The relationship between EBP and procedure volume varies across procedures. After EBP was implemented, the probability of undergoing colonoscopy increased by 17.2% (point estimate, 2.63; 95% CI, 1.18 to 4.08; p < 0.001; Arkansas pre-period mean, 15.29). The probability of undergoing total joint replacement increased by 9.9% (point estimate, 0.091; 95% CI, - 0.011 to 0.19; p = 0.08; Arkansas pre-period mean, 0.91), though this effect is not significant. There is no discernable impact on cholecystectomy or tonsillectomy volume. CONCLUSIONS: We do not find clear evidence of deleterious volume expansion. However, because the impact of EBP on procedure volume may vary by procedure, payers planning to implement EBP models should be aware of this possibility.

How Would Low-Income Communities Prioritize Medicaid Spending?

CONTEXT: Medicaid plays a critical role in low-income, minority, and medically underserved communities, particularly in states that have expanded Medicaid under the Affordable Care Act. Yet, the voices of underresourced communities are often unheard in decisions about how to allocate Medicaid's scarce resources, and traditional methods of public engagement are poorly suited to gathering such input. We argue that deliberative public engagement can be a useful tool for involving communities in setting Medicaid priorities. METHOD: We engaged 209 residents of low-income, medically underserved Michigan communities in discussions about Medicaid spending priorities using an exercise in informed deliberation: CHAT (CHoosing All Together). Participants learned about Medicaid, deliberated in small groups, and set priorities both individually and collectively. FINDINGS: Participants prioritized broad eligibility consistent with the ACA expansion, accepted some cost sharing, and prioritized spending in areas-including mental health-that are historically underfunded. Participants allocated less funding beyond benefit coverage, such as spending on healthy communities. Participants perceived the deliberative process as fair and informative, and they supported using it in the policy-making process. CONCLUSION: The choices of participants from low-income, medically underserved communities reflect a unique set of priorities and suggest that engaging low-income communities more deeply in Medicaid policy making might result in different prioritization decisions.

Attitudes About Consumer Strategies Among Americans in High-deductible Health Plans.

BACKGROUND: More than 70 million Americans are enrolled in a high-deductible health plan (HDHP), with high upfront cost-sharing to encourage strategies such as price shopping to mitigate out-of-pocket spending. Recent research suggests HDHP enrollees are reluctant to engage in these consumer strategies, but there is little information on why. OBJECTIVES: To describe associations between HDHP enrollees' attitudes about and intent to engage in consumer strategies. RESEARCH DESIGN: We conducted a nationally representative web survey of 1637 HDHP enrollees that included 2 hypothetical scenarios amenable to consumer strategies. For each scenario, we asked participants whether they would compare price or quality information, discuss cost with a provider, or try to negotiate a service price. We measured participants' ratings of the difficulty of each strategy, its effectiveness at reducing cost or increasing the likelihood of getting care, and how likely participants would be to actually engage in each strategy. RESULTS: Fewer than half of HDHP enrollees intended to engage in any of the surveyed strategies. Enrollees who viewed a consumer strategy as helpful were more likely to engage in that strategy; no associations were found with perceived difficulty of a strategy and intent to engage in it. CONCLUSIONS: HDHP enrollees may not pursue consumer strategies because they believe they are not helpful for getting care or lowering costs. Providers and payers should ensure these strategies are actually helpful to HDHP enrollees and that enrollees understand how they could use these strategies to reduce their out-of-pocket costs.

Shingles Vaccination in Medicare Part D After Inflation Reduction Act Elimination of Cost Sharing.

This cross-sectional study uses data from retail pharmacies to examine shingles vaccine uptake among Medicare Part D beneficiaries following an IRA policy to eliminate cost sharing.

The impact of cost sharing on women's use of annual examinations and effective contraception.

BACKGROUND: We sought to describe the relationship between the elimination of out-of-pocket costs and women's use of preventive care office visits and long-acting reversible contraception after accounting for baseline levels of cost sharing. OBJECTIVES: The objective of this analysis was to describe the relationship between the elimination of out-of-pocket costs and utilization of preventive care visits and long-acting reversible contraception insertion while taking baseline cost sharing levels under consideration. STUDY DESIGN: In 2017, we used administrative health plan data to examine changes in out-of-pocket costs and service utilization among 2,172,065 women enrolled in 15,118 employer-based health plans between 2008 and 2015. We used generalized estimating equations to examine utilization patterns. RESULTS: Women in this sample generally had low costs at baseline ($24 and $29 for preventive care visits and long-acting reversible contraception insertion, respectively). The elimination of baseline out-of-pocket costs were related to changes in the utilization of both services but more consistently for contraceptive device placement. Women whose low/moderate out-of-pocket costs were eliminated were more likely to use a preventive care office visit than women with persistent low/moderate costs (odds ratio, 1.05; 95% confidence interval, 1.04-1.05), but women with high out-of-pocket costs had lower utilization rates, even after their costs were eliminated. In contrast, the odds of having a contraceptive device placed was higher among all groups of women when out-of-pocket costs were zero, as compared with women with low/moderate costs. For instance, when compared with women with low/moderate costs, women were less likely to have a contraceptive device inserted (odds ratio, 0.92; 95% confidence interval, 0.86-0.97) when they had high costs but more likely after their costs were eliminated (odds ratio, 1.15; 95% confidence interval, 1.09-1.20). CONCLUSION: Out-of-pocket costs were low prior to the Affordable Care Act. Eliminating costs was associated with increases in preventive service use among those with high levels of cost, but effect sizes were low, suggesting that cost is only 1 barrier. Failing to recognize that cost sharing was already low could cause us to falsely conclude that the elimination of cost sharing was ineffective.

GLUCAGON PRESCRIPTIONS FOR DIABETES PATIENTS AFTER EMERGENCY DEPARTMENT VISITS FOR HYPOGLYCEMIA.

OBJECTIVE: To determine the proportion of prescription fills for glucagon within 90 days of an emergency department (ED) visit for hypoglycemia. METHODS: This was a retrospective research study of glucagon prescriptions filled after an ED visit for hypoglycemia (from January 2011 to June 2014) by people with type 1 diabetes (T1D) or type 2 diabetes (T2D) taking insulin who did not already have an unexpired glucagon prescription within the Truven Health MarketScan® Research Database. RESULTS: Less than 10% (T1D: 10.9%; T2D: 3.5%) filled a glucagon prescription after the ED visit. CONCLUSION: A substantial opportunity exists to improve care for at-risk patients with diabetes through a more consistent provision of glucagon, perhaps through the implementation of a quality metric. ABBREVIATIONS: DM = diabetes mellitus; ED = emergency department; IQR = interquartile range; T1D = type 1 diabetes; T2D = type 2 diabetes.