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.

Reconciliation Payments in the Bundled Payments for Care Improvement Advanced Program and Reductions in Clinical Spending Needed for CMS to Avoid Financial Losses.

This study examines the magnitude of reconciliation payments and clinical spending reductions necessary for the Centers for Medicare & Medicaid Services to break even in the first 4 performance periods of the BPCI-A (Bundled Payments for Care Improvement Advanced) program.

Physician Group Practices Accrued Large Bonuses Under Medicare's Bundled Payment Model, 2018-20.

The Bundled Payments for Care Improvement Advanced Model (BPCI-A), a voluntary Alternative Payment Model for Medicare, incentivizes hospitals and physician group practices to reduce spending for patient care episodes below preset target prices. The experience of physician groups in BPCI-A is not well understood. We found that physician groups earned $421 million in incentive payments during BPCI-A's first four performance periods (2018-20). Target prices were positively associated with bonuses, with a mean reconciliation payment of $139 per episode in the lowest decile of target prices and $2,775 in the highest decile. In the first year of the COVID-19 pandemic, mean bonuses increased from $815 per episode to $2,736 per episode. These findings suggest that further policy changes, such as improving target price accuracy and refining participation rules, will be important as the Centers for Medicare and Medicaid Services continues to expand BPCI-A and develop other bundled payment models.

Equity And The Uneven Distribution Of Federal COVID-19 Relief Funds To US Hospitals.

People of color, immigrants, and those relying on the safety net have experienced a disproportionate share of the death and disease resulting from COVID-19 in the US. At the same time, Congress delegated great power to the Trump administration to distribute $178 billion in funding to health care providers. We studied the relationship between the relief received by 2,709 hospitals and community- and hospital-level characteristics. Funding through early February 2021 averaged $25.7 million per hospital. Our findings offer a mixed picture. Some correlates of real-world need, including serving a community with a very high share of Black residents or having a very high ratio of Medicaid revenue to beds, were associated with meaningfully increased funding. Other correlates of need-including serving a very high share of Hispanic residents or a Medically Underserved Area-were associated with decreased funding or no difference in funding. Our findings emphasize that funding formulas reflect consequential political judgments. In future allocations, the relationship between need and aid should be strengthened by de-emphasizing historical net patient revenue in favor of a broader set of community and hospital characteristics.

Contributions Of Public Health, Pharmaceuticals, And Other Medical Care To US Life Expectancy Changes, 1990-2015.

Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, and other/unknown factors contributed to the improvement. We found that twelve conditions most responsible for changing life expectancy explained 2.9 years of net improvement (85 percent of the total). Ischemic heart disease was the largest positive contributor to life expectancy, and accidental poisoning or drug overdose was the largest negative contributor. Forty-four percent of improved life expectancy was attributable to public health, 35 percent was attributable to pharmaceuticals, 13 percent was attributable to other medical care, and -7 percent was attributable to other/unknown factors. Our findings emphasize the crucial role of public health advances, as well as pharmaceutical innovation, in explaining improving life expectancy.

Precision medicines need precision patient assistance programs.

The competing strategies of patient assistance programs and co-pay accumulator adjustment programs create confusion and administrative burden for clinicians and patients, potentially reducing adherence to clinically indicated services and worsening patient outcomes.

Changes in coding of pneumonia and impact on the Hospital Readmission Reduction Program.

OBJECTIVE: To evaluate whether changes in diagnosis assignment explain reductions in 30-day readmission for patients with pneumonia following the Hospital Readmission Reduction Program (HRRP). DATA SOURCES: 100 percent MedPAR, 2008-2015. STUDY DESIGN: Retrospective cohort study of Medicare discharges in HRRP-eligible hospitals. Outcomes were 30-day readmission rates for pneumonia under a "narrow" definition (used for the HRRP until October 2015; n = 2 288 644) and a "broad" definition that included certain diagnoses of sepsis and aspiration pneumonia (used since October 2015; n = 3 618 215). We estimated changes in 30-day readmissions in the pre-HRRP period (January 2008-March 2010), the HRRP implementation period (April 2010-September 2012), and the HRRP penalty period (October 2012-June 2015). PRINCIPAL FINDINGS: Under the narrow definition, adjusted annual readmission rates changed by +0.07 percentage points (pp) during the pre-HRRP period (95% CI: -0.03 pp, +0.18 pp), -1.07 pp during HRRP implementation (95% CI: -1.15 pp, -0.99 pp), and -0.09 pp during the penalty period (95% CI: -0.18 pp, -0.00 pp). Under the broad definition, 30-day readmissions changed by +0.21 pp during the pre-HRRP period (95% CI: +0.12 pp, +0.30 pp), -1.28 pp during HRRP implementation (95% CI: -1.35 pp, -1.21 pp), and -0.09 pp during the penalty period (95% CI: -0.16 pp, -0.02 pp). CONCLUSIONS: Changes in the coding of inpatient pneumonia admissions do not explain readmission reduction following the HRRP.

Association Between Switching to a High-Deductible Health Plan and Discontinuation of Type 2 Diabetes Treatment.

Importance: High-deductible health plans (HDHPs) are a common cost-savings option for employers but may lead to underuse of necessary treatments because beneficiaries bear the full cost of health care, including medications, until a deductible is met. Objectives: To evaluate the association between switching from a non-HDHP to an HDHP and discontinuation of antihyperglycemic medication and to assess whether the association differs in patients using branded vs generic antihyperglycemic medications. Design, Setting, and Participants: This retrospective matched cohort study used administrative claims from MarketScan databases to identify commercially insured adult patients with type 2 diabetes who used at least 1 antihyperglycemic medication in 2013. Patients in the HDHP cohort (n = 1490) were matched by propensity scores to a non-HDPH control cohort (n = 1490). Data were collected and analyzed from January 1, 2013, through December 31, 2014. Exposures: Switching from a non-HDHP in 2013 to a full replacement HDHP in 2014 (no non-HDHP option offered) vs staying on a non-HDHP. Main Outcomes and Measures: Difference-in-differences models estimated discontinuation of branded and generic antihyperglycemic medications. Results: Among the 2980 patients included in the analysis (1932 men [64.8%]; mean [SD] age, HDHP cohort: 52.6 [6.9] years; non-HDHP cohort: 52.7 [7.3] years), no difference between the HDHP and non-HDHP cohorts was found in unadjusted follow-up discontinuation rates for all antihyperglycemic medications (255 [22.7%] vs 255 [23.3%]; P = .72); however, among patients using branded medication, a significantly greater proportion of patients in the HDHP group did not refill branded medications (81 of 396 [20.5%] vs 61 of 437 [14.0%]; P = .009). Difference-in-differences models were not statistically significant. Conclusions and Relevance: These findings suggest switching to an HDHP is associated with discontinuation specifically of branded medications. Unintended health consequences may result and should be considered by employers making health care benefit decisions.

Cost sharing and branded antidepressant initiation among patients treated with generics.

OBJECTIVES: To determine the relationship between consumer cost sharing for branded antidepressants and the initiation of branded therapy among patients with major depressive disorder (MDD) filling a prescription for generic MDD medication. STUDY DESIGN: Retrospective cross-sectional analyses. METHODS: Patients aged 18 to 64 years with MDD who filled a generic antidepressant were identified in commercial claims data for 2012 to 2014. For each year-specific analysis, an average cost-sharing index for branded antidepressants at the level of the plan was computed. Multivariable models were used to estimate the relationship between plan-level cost sharing for branded antidepressant medications and the filling of branded prescriptions, with demographic and clinical variables as covariates. RESULTS: For patients with MDD filling a generic prescription, increases in branded cost sharing were associated with significant decreases in the likelihood of filling a branded antidepressant in each year (P <.001). Results in 2012 imply that a shift from the 0th to 90th percentile in the branded cost-sharing index corresponded with a 9.5% decrease in the relative likelihood of a branded fill among patients receiving a generic antidepressant. The corresponding figures for 2013 and 2014 were 9.3% and 3.5%, respectively. CONCLUSIONS: In MDD, patients and clinicians who dutifully adhere to guidelines requiring a trial of first-line medication may ultimately require therapy with alternate agents to achieve adequate disease control. A "reward the good soldier" benefit design would lower cost sharing for higher-tier evidence-based therapies when clinically indicated. Results suggest that narrowing the gap in cost sharing between branded and generic medications following a trial of a generic agent might improve access to second-line treatment in MDD.

"Doubling Up" on Produce at Detroit Farmers Markets: Patterns and Correlates of Use of a Healthy Food Incentive.

INTRODUCTION: Federal food assistance programs such as the Supplemental Nutrition Assistance Program (SNAP) help address food insecurity, yet many participants still struggle to afford nutritionally adequate foods. The U.S. Department of Agriculture has committed $100 million to the expansion and evaluation of SNAP healthy food incentives, which match SNAP funds spent on produce. However, little is known about who uses SNAP incentives or how often they are used. This study examines patterns and correlates of use of the SNAP incentive Double Up Food Bucks at all eight participating Detroit farmers markets during 2012-2013. METHODS: SNAP/Double Up Food Bucks transactions from handwritten farmers market logs (n=21,541) were linked with state administrative SNAP enrollment data. Frequency of incentive use and characteristics of Double Up Food Bucks users relative to the overall Detroit SNAP-enrolled population were examined, as were market-level characteristics associated with program use. Negative binomial regression was used to estimate predictors of repeat transactions (analyses conducted 2015-2017). RESULTS: Although demographic characteristics of Double Up Food Bucks users reflected those of the overall Detroit SNAP-enrolled population, Double Up Food Bucks users were poorer and disproportionately female. One third of Double Up Food Bucks users had more than one transaction during the 2-year period. Repeat transactions were directly correlated with identifying as white (incidence rate ratio=2.34, 95% CI=2.11, 2.59, p<0.001), and inversely correlated with driving distance from market of first transaction (incidence rate ratio=0.98 per mile, 95% CI=0.98, 0.99, p<0.001). Rates of repeat transactions also varied significantly by market. CONCLUSIONS: Addressing barriers to initial use and return visits can help maximize the impact and reach of SNAP incentives among Americans at highest risk of diet-related disease.