Changes in Prescription Drug and Health Care Use Over 9 Years After the Large Drug Price Increase for Colchicine.

Importance: Prescription drug prices are a leading concern among patients and policy makers. There have been large and sharp price increases for some drugs, but the long-term implications of large drug price increases remain poorly understood. Objective: To examine the association of the large 2010 price increase in colchicine, a common treatment for gout, with long-term changes in colchicine use, substitution with other drugs, and health care use. Design, Setting, and Participants: This retrospective cohort study examined MarketScan data from a longitudinal cohort of patients with gout with employer-sponsored insurance from 2007 through 2019. Exposures: The US Food and Drug Administration's discontinuation of lower-priced versions of colchicine from the market in 2010. Main Outcomes and Measures: Mean price of colchicine; use of colchicine, allopurinol, and oral corticosteroids; and emergency department (ED) and rheumatology visits for gout in year 1 and over the first decade of the policy (through 2019) were calculated. Data were analyzed between November 16, 2021, and January 17, 2023. Results: A total of 2 723 327 patient-year observations were examined from 2007 through 2019 (mean [SD] age of patients, 57.0 [13.8] years; 20.9% documented as female; 79.1% documented as male). The mean price per prescription of colchicine increased sharply from $11.25 (95% CI, $11.23-$11.28) in 2009 to $190.49 (95% CI, $190.07-$190.91) in 2011, a 15.9-fold increase, with the mean out-of-pocket price increasing 4.4-fold from $7.37 (95% CI, $7.37-$7.38) to $39.49 (95% CI, $39.42-$39.56). At the same time, colchicine use declined from 35.0 (95% CI, 34.6-35.5) to 27.3 (95% CI, 26.9-27.6) pills per patient in year 1 and to 22.6 (95% CI, 22.2-23.0) pills per patient in 2019. Adjusted analyses showed a 16.7% reduction in year 1 and a 27.0% reduction over the decade (P < .001). Meanwhile, adjusted allopurinol use rose by 7.8 (95% CI, 6.9-8.7) pills per patient in year 1, a 7.6% increase from baseline, and by 33.1 (95% CI, 32.6-33.7) pills per patient through 2019, a 32.0% increase from baseline over the decade (P < .001). Moreover, adjusted oral corticosteroid use exhibited no significant change in the first year, then increased by 1.5 (95% CI, 1.3-1.7) pills per patient through 2019, an 8.3% increase from baseline over the decade. Adjusted ED visits for gout rose by 0.02 (95% CI, 0.02-0.03) per patient in year 1, a 21.5% increase, and by 0.05 (95% CI, 0.04-0.05) per patient through 2019, a 39.8% increase over the decade (P < .001). Adjusted rheumatology visits for gout increased by 0.02 (95% CI, 0.02-0.03) per patient through 2019, a 10.5% increase over the decade (P < .001). Conclusions and Relevance: In this cohort study among individuals with gout, the large increase in colchicine prices in 2010 was associated with an immediate decrease in colchicine use that persisted over approximately a decade. Substitution with allopurinol and oral corticosteroids was also evident. Increased ED and rheumatology visits for gout over the same period suggest poorer disease control.

Inequities in surgical outcomes by race and sex in the United States: retrospective cohort study.

OBJECTIVE: To assess inequities in mortality by race and sex for eight common surgical procedures (elective and non-elective) across specialties in the United States. DESIGN: Retrospective cohort study. SETTING: US, 2016-18. PARTICIPANTS: 1 868 036 Black and White Medicare beneficiaries aged 65-99 years undergoing one of eight common surgeries: repair of abdominal aortic aneurysm, appendectomy, cholecystectomy, colectomy, coronary artery bypass surgery, hip replacement, knee replacement, and lung resection. MAIN OUTCOME MEASURE: The main outcome measure was 30 day mortality, defined as death during hospital admission or within 30 days of the surgical procedure. RESULTS: Postoperative mortality overall was higher in Black men (1698 deaths, adjusted mortality rate 3.05%, 95% confidence interval 2.85% to 3.24%) compared with White men (21 833 deaths, 2.69%, 2.65% to 2.73%), White women (21 847 deaths, 2.38%, 2.35% to 2.41%), and Black women (1631 deaths, 2.18%, 2.04% to 2.31%), after adjusting for potential confounders. A similar pattern was found for elective surgeries, with Black men showing a higher adjusted mortality (393 deaths, 1.30%, 1.14% to 1.46%) compared with White men (5650 deaths, 0.85%, 0.83% to 0.88%), White women (4615 deaths, 0.82%, 0.80% to 0.84%), and Black women (359 deaths, 0.79%, 0.70% to 0.88%). This 0.45 percentage point difference implies that mortality after elective procedures was 50% higher in Black men compared with White men. For non-elective surgeries, however, mortality did not differ between Black men and White men (1305 deaths, 6.69%, 6.26% to 7.11%; and 16 183 deaths, 7.03%, 6.92% to 7.14%, respectively), although mortality was lower for White women and Black women (17 232 deaths, 6.12%, 6.02% to 6.21%; and 1272 deaths, 5.29%, 4.93% to 5.64%, respectively). These differences in mortality appeared within seven days after surgery and persisted for up to 60 days after surgery. CONCLUSIONS: Postoperative mortality overall was higher among Black men compared with White men, White women, and Black women. These findings highlight the need to understand better the unique challenges Black men who require surgery face.

Association of Patient Race and Ethnicity With Differences in Opioid Prescribing by Primary Care Physicians for Older Adults With New Low Back Pain.

Importance: Substantial patient racial and ethnic differences in opioid prescribing have been documented, but how much of these differences were attributable to physicians prescribing opioids differently to patients of racial and ethnic minority groups is unknown, particularly during the first wave of the opioid epidemic when the dangers of opioid prescribing and use were not as well known. Objective: To examine associations of patient race and ethnicity with differences in opioid prescribing by the same primary care physician (PCP) for new low back pain episodes among older adults from 2007 to 2014. Design Setting and Participants: This cross-sectional study used Medicare data of PCP office visits by Medicare beneficiaries who were 66 years or older with new low back pain. Main Outcomes and Measures: Prescribing of any opioid in the first year of a new low back pain episode (days 1-365) and subsequent long-term use of an opioid (prescribed for ≥180 days in days 366-730). Results: Among the study population of 274 771 patients (mean [SD] age, 77.1 [7.2] years; 192 105 [69.9%] women) with new low back pain, 15 285 (6%) were Asian or Pacific Islander, 16 079 (6%) were Black, 21 289 (8%) were Hispanic, and 222 118 (81%) were White, cared for by 63 494 physicians. In adjusted analysis, on average, 11.5% of the White patients (95% CI, 11.4 to 11.6) received an opioid prescription in the first year of new low back pain. The same prescribing physician was 1.5 percentage points (PP; 95% CI, -2.2 PP to -0.8 PP) less likely to prescribe an opioid if the patient was Black, 2.7 PP (95% CI, -3.5 PP to -1.8 PP) less likely if the patient was Asian or Pacific Islander, and 1.0 PP (95% CI, -1.7 PP to -0.3 PP) less likely if the patient was Hispanic. The same physician was more likely to prescribe a prescription nonsteroidal anti-inflammatory drug to a patient of a racial or ethnic minority group. White patients with new low back pain were more likely to develop subsequent long-term opioid use than patients of racial and ethnic minority groups (eg, 1.8% for White patients vs 0.5% for Hispanic patients). Conclusions and Relevance: This cross-sectional study found that from 2007 to 2014, primary care physicians prescribed opioids for new low back pain more often to White patients than to patients of racial and ethnic minority groups. These results suggest that there may have been unequal treatment of pain by physicians when less was known about the morbidity associated with opioid use.

Evaluation and Treatment Patterns of New Low Back Pain Episodes for Elderly Adults in the United States, 2011-2014.

INTRODUCTION: New low back pain (LBP) is a common outpatient complaint. Little is known about how care is delivered over the course of a year to patients who develop new LBP and whether such care patterns are guideline-concordant. METHODS: This retrospective analysis included Medicare claims of 162,238 opioid-naïve beneficiaries with new LBP from January 1, 2011, through December 31, 2014. Simple rates of modality use [computed tomography and magnetic resonance imaging (advanced imaging), physical therapy (PT), opioid and nonopioid medications] and percentiles (5th percentile, 25th percentile, median, 75th percentile, and 95th percentile) were reported. RESULTS: Within the first year, 29.4% [95% confidence interval (CI), 29.1-29.8] of patients with ≥2 visits for new LBP received advanced imaging, and 48.4% (95% CI, 47.7-49.0) of these patients received advanced imaging within 6 weeks of the first visit; 17.3% (95% CI, 17.1-17.6) of patients with ≥2 visits received PT; 42.2% (95% CI, 41.8-42.5) of patients with ≥2 visits received non-steroidal anti-inflammatory drugs (NSAIDs), 16.9% (95% CI, 16.6-17.1) received a muscle relaxant, and 26.2% (95% CI, 25.9-26.6) received tramadol; 32.3% (95% CI, 31.9-32.6) of patients with ≥2 visits received opioids; 52.4% (95% CI, 51.7-53.0) of these patients had not received a prescription NSAID, and 82.2% (95% CI, 81.7-82.7) of these patients had not received PT. CONCLUSIONS: Many patients who develop new LBP receive guideline nonconcordant care such as early advanced imaging and opioids before other modalities like PT and prescription NSAIDs.

Racial and Ethnic Disparities in the Evaluation and Management of Pain in the Outpatient Setting, 2006-2015.

OBJECTIVE: Much is known about racial and ethnic disparities in receipt of opioids for pain in emergency departments. Less is known about such disparities in the evaluation and management of pain in the outpatient setting. METHODS: Using the nationally representative National Ambulatory Medical Care Survey (NAMCS), we estimated disparities in visit time with physicians and opioid receipt in the outpatient setting. We focused on patients whose reason for visiting was abdominal pain or back pain. Our sample included 4,764 white patients, 692 black patients, and 682 Hispanic patients. RESULTS: Back pain visits of Hispanic patients lasted 1.6 fewer minutes than those of white non-Hispanic patients (P = 0.04 for the difference). Black patients were 6.0% less likely than white patients to receive opioids for abdominal pain (P = 0.04 for the difference) and 7.1% less likely than white patients to receive opioids for back pain (P = 0.046 for the difference). Hispanic patients were 6.3% less likely than white patients to receive opioids for abdominal pain (P = 0.003 for the difference) and 14.8% less likely than white patients to receive opioids for back pain (P < 0.001 for the difference). Hispanic patients were more likely than white patients to receive nonopioids instead of opioids for both abdominal pain and back pain. Differences in opioid receipt did not narrow during the examined time period. CONCLUSIONS: Identifying causes of racial and ethnic disparities in the evaluation and treatment of pain in the outpatient setting is important to improving the health and function of patients.

Factors of U.S. Hospitals Associated with Improved Profit Margins: An Observational Study.

BACKGROUND: Hospitals face financial pressure from decreased margins from Medicare and Medicaid and lower reimbursement from consolidating insurers. OBJECTIVES: The objectives of this study are to determine whether hospitals that became more profitable increased revenues or decreased costs more and to examine characteristics associated with improved financial performance over time. DESIGN: The design of this study is retrospective analyses of U.S. non-federal acute care hospitals between 2003 and 2013. SUBJECTS: There are 2824 hospitals as subjects of this study. MAIN MEASURES: The main measures of this study are the change in clinical operating margin, change in revenues per bed, and change in expenses per bed between 2003 and 2013. KEY RESULTS: Hospitals that became more profitable had a larger magnitude of increases in revenue per bed (about $113,000 per year [95% confidence interval: $93,132 to $133,401]) than of decreases in costs per bed (about - $10,000 per year [95% confidence interval: - $28,956 to $9617]), largely driven by higher non-Medicare reimbursement. Hospitals that improved their margins were larger or joined a hospital system. Not-for-profit status was associated with increases in operating margin, while rural status and having a larger share of Medicare patients were associated with decreases in operating margin. There was no association between improved hospital profitability and changes in diagnosis related group weight, in number of profitable services, or in payer mix. Hospitals that became more profitable were more likely to increase their admissions per bed per year. CONCLUSIONS: Differential price increases have led to improved margins for some hospitals over time. Where significant price increases are not possible, hospitals will have to become more efficient to maintain profitability.

Differences in incomes of physicians in the United States by race and sex: observational study.

OBJECTIVES:  To estimate differences in annual income of physicians in the United States by race and sex adjusted for characteristics of physicians and practices. DESIGN:  Cross sectional survey study. SETTING:  Nationally representative samples of US physicians. PARTICIPANTS:  The 2000-13 American Community Survey (ACS) included 43 213 white male, 1698 black male, 15 164 white female, and 1252 black female physicians. The 2000-08 Center for Studying Health System Change (HSC) physician surveys included 12 843 white male, 518 black male, 3880 white female, and 342 black female physicians. MAIN OUTCOME MEASURES:  Annual income adjusted for age, hours worked, time period, and state of residence (from ACS data). Income was adjusted for age, specialty, hours worked, time period, years in practice, practice type, and percentage of revenue from Medicare/Medicaid (from HSC physician surveys). RESULTS:  White male physicians had a higher median annual income than black male physicians, whereas race was not consistently associated with median income among female physicians. For example, in 2010-13 in the ACS, white male physicians had an adjusted median annual income of $253 042 (95% confidence interval $248 670 to $257 413) compared with $188 230 ($170 844 to $205 616) for black male physicians (difference $64 812; P<0.001). White female physicians had an adjusted median annual income of $163 234 ($159 912 to 166 557) compared with $152 784 ($137 927 to $167 641) for black female physicians (difference $10 450; P=0.17). $100 000 is currently equivalent to about £69 000 (€89 000). Patterns were unaffected by adjustment for specialty and characteristics of practice in the HSC physician surveys. CONCLUSIONS:  White male physicians earn substantially more than black male physicians, after adjustment for characteristics of physicians and practices, while white and black female physicians earn similar incomes to each other, but significantly less than their male counterparts. Whether these differences reflect disparities in job opportunities is important to determine.

The impact of managed care contracting on physicians.

BACKGROUND: Prior literature suggests that the fragmented U.S. health care system places a large administrative burden on physicians. Less is known about how this burden varies with physician contracting practices. OBJECTIVE: To assess the extent to which physician practice outcomes vary with the number of managed care contracts held or the availability of such contracts. DESIGN, PARTICIPANTS, AND MAIN MEASURES: We perform secondary data analyses of the first four rounds of the nationally representative Community Tracking Study Physician Survey (1996-2005), which includes 36,340 physicians (21,567 PCPs [primary care physicians] and 14,773 specialists) across the four survey periods. Our measures include reported hours in patient care, share of hours outside patient care, adequacy of time with patients, career satisfaction, and income. RESULTS: Doctors who contract with more plans report spending more time in patient care (per 11 additional contracts, about 30 min per week for PCPs and 20 min per week for specialists), report spending a modestly larger share of their time outside patient care (per 11 additional contracts, about 10 min per week for PCPs and specialists), are slightly more likely to report inadequate time with patients (odds ratio 1.005 per additional contract for PCPs), and earn higher incomes (per 11 additional contracts, about 3 % more per year for specialists). CONCLUSIONS: Contracting opportunities confer significant benefits on physicians, although they do add modest costs in terms of time spent outside patient care and lower adequacy of time with patients. Simplifications that reduce the administrative burden of contracting may improve care by optimizing allocation of physician effort.

The association between hospital margins, quality of care, and closure or other change in operating status.

BACKGROUND: Hospitals face increased pressure to improve their quality of care in an environment of dwindling hospital payments. It is unclear whether lower hospital margins are associated with worse quality of care or closure. OBJECTIVE: To determine the association of hospital margins with quality of care and changes in operating status. DESIGN, SUBJECTS, AND MAIN MEASURES: We conducted an observational cross-sectional study analyzing hospitals' margin, quality of care (process quality, risk-adjusted readmission rates, and risk-adjusted mortality rates), and changes in operating status (rates of closure, merger and acquisition, and conversion to a critical access hospital) for 3,262 non-public U.S. hospitals with data from the Hospital Quality Alliance and Medicare Cost Reports. KEY RESULTS: Compared to those in the bottom 10% of operating margin, those in the top 10% had higher process quality (e.g. 95.3 vs. 93.7, p = 0.002 for acute myocardial infarction [AMI]) and lower readmission rates (e.g. 19.7% vs. 22.4%, p < 0.001 for AMI). We found no association between margins and mortality rates. Hospitals in the bottom 10% were more likely than those in the top 10% to close (5.7% vs. 2.0%), merge or become acquired (4.0% vs. 0.3%), or convert to a Critical Access Hospital (5.4% vs. 0.6%). Over 15% of hospitals in the lowest decile of hospital margin changed operating status in the subsequent year. CONCLUSIONS: Low hospital margins are associated with worse processes of care and readmission rates and with changes in operating status. We should monitor low-margin hospitals closely for declining quality of care.

The (paper) work of medicine: understanding international medical costs.

This paper draws on international evidence on medical spending to examine what the United States can learn about making its healthcare system more efficient. We focus primarily on understanding contemporaneous differences in the level of spending, generally from the 2000s. Medical spending differs across countries either because the price of services differs (for example, a coronary bypass surgery operation may cost more in the United States than in other countries) or because people receive more services in some countries than in others (for example, more bypass surgery operations). Within the price category, there are two further issues: whether factors earn different returns across countries and whether more clinical or administrative personnel are required to deliver the same care in different countries. We first present the results of a decomposition of healthcare spending along these lines in the United States and in Canada. We then delve into each component in more detail­administrative costs, factor prices, and the provision of care received­bringing in a broader range of international evidence when possible. Finally, we touch upon the organization of primary and chronic disease care and discuss possible gains in that area.

How do black-serving hospitals perform on patient safety indicators? Implications for national public reporting and pay-for-performance.

BACKGROUND: There is increasing policy interest in public reporting and tying financial incentives to metrics of patient safety. How black-serving hospitals fare on these measures will have important implications for disparities in care. OBJECTIVES: To determine how black-serving hospitals perform on patient safety indicators (PSIs). RESEARCH DESIGN: We used national Medicare data to calculate the performance of hospitals on 11 medical and surgical PSIs. We designated US hospitals in the top decile of proportion of hospitalized patients who are black as "black-serving." We calculated overall and race-specific rates and examined the relationship between being a black-serving hospital and PSI rates. SUBJECTS: Medicare fee-for-service enrollees discharged from 4488 acute-care US hospitals. RESULTS: Black-serving hospitals performed worse than other hospitals on 6 of 11 PSIs. For example, black-serving hospitals had nearly twice the rate of postoperative pulmonary embolism or deep venous thrombosis (19.4 vs. 11.5 per 1000 discharges, P < 0.001). Adjusting for hospital characteristics had moderate effects. In race-specific analyses, we found that both white and black patients generally had higher rates of potential safety events in black-serving hospitals than they did in non-black-serving hospitals. CONCLUSIONS: Hospitals that disproportionately care for black patients have higher rates of potential safety events among both black and white patients than other hospitals. Current efforts to penalize hospitals with high PSI rates will have a greater effect on hospitals that disproportionately care for black patients.

Disparities in service quality among insured adult patients seen in physicians' offices.

OBJECTIVE: To examine racial disparities in health care service quality. DESIGN: Secondary data analyses of visits by primary care service users in the Community Tracking Study household sample. SETTING: Sixty communities across the United States. PARTICIPANTS: A total of 41,537 insured adult patients making sick visits to primary care physicians in 1996-1997, 1998-1999, 2000-2001, and 2003. MEASUREMENTS: Lag between appointment and physician visit, waiting time in physician office, and satisfaction with care were analyzed. RESULTS: Blacks but not other minorities were more likely to have an appointment lag of more than 1 week (13% white vs. 21% black, p < 0.001). Blacks, Hispanics, and other minorities were more likely to wait more than 30 min before being seen by the physician (16% white vs. 26% black, p < 0.001; vs. 27% Hispanic and 22% other minority, p < 0.001 and p = 0.02, respectively) and were less likely to report that they were very satisfied with their care (65% white vs. 60% black, p = 0.02; vs. 57% Hispanic and 48% other minority, p = 0.004 and p < 0.001, respectively). The differences in appointment lag and wait time remain large and statistically significant after the inclusion of multiple covariates, including geographic controls for CTS site. For all groups, satisfaction with care was affected by objective measures of service quality. Differences in objective measures of service quality explained much of the black-white difference in satisfaction, though not differences for other minority groups. CONCLUSION: There are substantial racial/ethnic disparities in satisfaction with care, and these are related to objective quality measures that can be improved.