Cancer Drug Trastuzumab And Its Biosimilars Compete On Price For Market Share.

Using Medicare claims, we documented US prescribing patterns for originator biologic trastuzumab (Herceptin), a targeted cancer therapy, and five biosimilar entrants since 2019. The first biosimilar captured a dominant share, but over time, average sales prices of all products declined, and later entrants became dominant in some states. Despite strong brand loyalty to the first biosimilar, competitive pressure increased with subsequent entrants.

Patient Frailty and Functional Use of Hemodialysis Vascular Access: A Retrospective Study of the US Renal Data System.

RATIONALE & OBJECTIVE: Despite the high prevalence of frailty among dialysis patients, it is unknown whether frailty is associated with dialysis vascular access failure. This study examined the association between frailty and functional use of vascular access. STUDY DESIGN: Retrospective observational study. SETTING & PARTICIPANTS: Patients who initiated hemodialysis through a tunneled catheter in the US Renal Data System database from 2012 through 2017 and underwent subsequent creation of an arteriovenous fistula or graft. PREDICTORS: The "claims-based frailty indicator" (CFI) was calculated using a validated claims-based disability status model anchored to a well-described frailty phenotype. OUTCOMES: Time to functional use for fistulas and grafts defined as the time from initiation of hemodialysis to treatments using the index vascular access with 2 needles. ANALYTICAL APPROACH: Fine and Gray competing risk models separately examining fistula and graft outcomes. Patient survival was modeled for the entire cohort using Cox proportional hazards regression. RESULTS: A total of 41,471 patients met inclusion criteria, including 33,212 who underwent fistula creation and 8,259 who underwent graft placement. Higher CFI quartiles were associated with a greater rate of mortality. Patients in the highest CFI quartile had more than 2 times the rate of mortality compared with patients in the lowest CFI quartile (hazard ratio [HR], 2.49 [95% CI, 2.41-2.58]). In multivariable analyses, the highest CFI quartile was significantly associated with longer time to functional use of fistulas (HR, 0.65 [95% CI, 0.62-0.69]) and grafts (HR, 0.88 [95% CI, 0.79-0.98]). LIMITATIONS: Generalizability may be limited by the requirement of 12 months of Medicare claims availability before initiation of dialysis. There were no data on patient anatomic characteristics or surgeon characteristics and limited patient-specific sociodemographic data. CONCLUSIONS: Higher degrees of frailty are associated with longer times to vascular access functional use. Frailty may be useful for informing clinical decision-making regarding choice of vascular access.

Higher Surgeon Procedure Volume Is Associated with Improved Hemodialysis Vascular Access Outcomes.

The objective of this study was to examine the association between surgeon characteristics, procedural volume, and short-term outcomes of hemodialysis vascular access. A retrospective cohort study was performed using Medicare Part A and B data from 2007 through 2014 merged with American Medical Association Physician Masterfile surgeon data. A total of 29,034 procedures met the inclusion criteria: 22,541 (78%) arteriovenous fistula (AVF) and 6,493 (22%) arteriovenous graft (AVG). Of these, 13,110 (45.2%) were performed by vascular surgeons, 9,398 (32.3%) by general surgeons, 2,313 (8%) by thoracic surgeons, 1,517 (5.2%) by other specialties, and 2,696 (9.3%) were unknown. Every 10-year increase in years in practice was associated with a 6.9 per cent decrease in the odds of creating AVF versus AVG (P = 0.02). Surgeon characteristics were not associated with the likelihood of vascular access failure. Every 10-procedure increase in cumulative procedure volume was associated with a 5 per cent decrease in the odds of vascular access failure (P = 0.007). There was no association of provider characteristics or procedure volume with survival free of repeat AVF/AVG or TC placement at 12 months. A significant portion of the variability in likelihood of creating AVF versus AVG is attributable to the provider-level variation. Increase in procedure volume is associated with decreased odds of vascular access failure.

Generic Drug Price Hikes And Out-Of-Pocket Spending For Medicare Beneficiaries.

Recent increases in prices of longtime generic drugs have focused attention on competition in generic markets. We used Medicare Part D data for the period 2006-15 to examine sudden large price increases in generic drugs in the context of their base prices, duration, and accompanying changes in patients' out-of-pocket spending. The fraction of drugs that at least doubled in price increased from 1.00 percent of generic products in 2007 to 4.39 percent in 2013. Almost all were initially low- or medium-price medications and not among the most widely used generics. Changes in out-of-pocket spending for these drugs were modest. However, the elevated prices persisted for two to five years. Data for 2011-15 showed similar trends. Potential steps to ensure that generic markets remain strong include fast-tracking new generic drug applications when competition is limited, allowing temporary importation of off-patent drugs, and implementing greater oversight of drug company mergers and takeovers.

Physician Reimbursement in Medicare Advantage Compared With Traditional Medicare and Commercial Health Insurance.

Importance: Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services. Medicare Advantage insurers typically also sell commercial plans, and the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear. Objective: To compare prices paid for physician and other health care services in MA, traditional Medicare, and commercial plans. Design, Setting, and Participants: Retrospective analysis of claims data evaluating MA prices paid to physicians and for laboratory services and durable medical equipment between 2007 and 2012 in 348 US core-based statistical areas. The study population included all MA and commercial enrollees with a large national health insurer operating in both markets, as well as a 20% sample of TM beneficiaries. Exposures: Enrollment in an MA plan. Main Outcomes and Measures: Mean reimbursement paid to physicians, laboratories, and durable medical equipment suppliers for MA and commercial enrollees relative to TM rates for 11 Healthcare Common Procedure Coding Systems (HCPCS) codes spanning 7 sites of care. Results: The sample consisted of 144 million claims. Physician reimbursement in MA was more strongly tied to TM rates than commercial prices, although MA plans tended to pay physicians less than TM. For a mid-level office visit with an established patient (Current Procedural Terminology [CPT] code 99213), the mean MA price was 96.9% (95% CI, 96.7%-97.2%) of TM. Across the common physician services we evaluated, mean MA reimbursement ranged from 91.3% of TM for cataract removal in an ambulatory surgery center (CPT 66984; 95% CI, 90.7%-91.9%) to 102.3% of TM for complex evaluation and management of a patient in the emergency department (CPT 99285; 95% CI, 102.1%-102.6%). However, for laboratory services and durable medical equipment, where commercial prices are lower than TM rates, MA plans take advantage of these lower commercial prices, ranging from 67.4% for a walker (HCPCS code E0143; 95% CI, 66.3%-68.5%) to 75.8% for a complete blood cell count (CPT 85025; 95% CI, 75.0%-76.6%). Conclusions and Relevance: Traditional Medicare's administratively set rates act as a strong anchor for physician reimbursement in the MA market, although MA plans succeed in negotiating lower prices for other health care services for which TM overpays. Reforms that transition the Medicare program toward some premium support models could substantially affect how physicians and other clinicians are paid.

Variations in outcomes of hemodialysis vascular access by race/ethnicity in the elderly.

OBJECTIVE: Prevalence of end-stage renal disease, modality of treatment, and type of hemodialysis vascular access used varies widely by race/ethnicity in the United States, but outcomes of hemodialysis vascular access by race/ethnicity are poorly described. The objective of this study is to evaluate variations in outcomes of hemodialysis vascular access in the elderly by race/ethnicity. METHODS: Medicare outpatient, inpatient, and carrier files were queried from 2006 to 2011 for beneficiaries that were age ≥66 years and dialysis-dependent at time of index fistula/graft creation, qualified for Medicare by age only, and were continuously enrolled in Medicare 12 months before and after index fistula/graft creation. Primary outcome measures were early vascular access failure and 12-month failure-free survival, specifically, the variation in the difference between fistula and graft in non-White vs White race/ethnicity groups. RESULTS: Fistulas comprised a smaller proportion of index procedures performed in Blacks (65.9%; P < .001) and Asians (71.4%; P < .001), compared with Whites (78.0%) with no difference in Hispanics (78.7%; P = .59). Incidence of early failure after graft vs fistula was Whites, 34.9% vs 43.5% (P < .001), Blacks, 32.9% vs 49.1% (P < .001), Asians, 30.8% vs 40.5% (P = .014), and Hispanics 35.2% vs 43.2% (P = .005). The difference in early failure after fistula vs graft in Blacks was significantly larger than the difference in Whites (P < .001). The 12-month failure-free survival after index graft vs fistula was Whites 41.9% vs 38.9% (P = .008), Blacks 48.5% vs 37.3% (P < .001), Asians 51.6% vs 45.2% (P = .98), and Hispanics 51.9% vs 42.2% (P < .001). The difference in 12-month failure-free survival after graft vs fistula in Blacks and in Hispanics was larger than the difference in Whites (P < .001 and P = .02, respectively). CONCLUSIONS: Outcomes of fistulas vs grafts in the elderly vary significantly by race/ethnicity. The decreased risk of early failure after graft vs fistula creation is larger in Blacks compared with Whites. The higher failure-free survival at 12 months after graft vs fistula creation is larger in Blacks compared with Whites and trends toward being larger in Hispanics compared with Whites.

Patients Who Choose Primary Care Physicians Based On Low Office Visit Price Can Realize Broader Savings.

Price transparency initiatives encourage patients to save money by choosing physicians with a relatively low price per office visit. Given that the price of such visits represents a small fraction of total spending, the extent of the savings from choosing such physicians has not been clear. Using a national sample of commercial claims data, we compared the care received by patients of high- and low-price primary care physicians. The median price for an established patient's office visit was $60 among low-price physicians and $86 among high-price physicians (price was calculated as reimbursement plus out-of-pocket spending). Patients of low-price physicians also received, on average, relatively low-price lab tests, imaging, and other procedures. Total spending per year among patients cared for by low-price physicians was $690 less than spending among patients cared for by high-price physicians. There were no consistent differences in patients' use of services between high- and low-price physicians. Despite modest differences in physicians' office visit prices, patients of low-price physicians had substantively lower overall spending, compared to patients of high-price physicians.