Examining patient-provider relationship (PPR) quality and patient activation in the Medicare population.

BACKGROUND: Patient activation describes an individual's willingness and ability to take actions to independently manage health. Additional qualities of the relationship between a patient and provider may play a role in patient decision-making and motivation. AIMS: (1) To describe patient characteristics for groups who perceive different quality levels of PPR. (2) To examine the association and determine the effect of PPR on patient activation. METHODS: The Medicare Current Beneficiary Surveys was used to gather information on patient confidence, information seeking behaviors, and PPR. Scores for each variable set were categorized and described. Odds ratios were calculated using multinomial logistic regression models adjusting for sociodemographic variables. RESULTS: The study included 15,185 beneficiaries, 4198 (27.6 %) were categorized as low PPR, 6752 (44.5 %) were moderate PPR, and 4235 (27.9 %) high PPR. Adjusting for covariates, patients with moderate PPR and high PPR were more likely to have higher confidence when making healthcare decisions and exhibit information seeking behaviors compared to low PPR beneficiaries. DISCUSSION: This study supports the notion that patients with stronger relationships with their providers are also more active in healthcare decisions. After adjusting for gender, race, age, education, and income, high-quality PPR was still found to be associated with increased levels of activation in the Medicare population. CONCLUSIONS: High-quality patient-provider relationships are associated with improved patient confidence and information seeking behaviors. Provider-centered strategies to improve patients' connections to their physicians may motivate patients to engage in the healthcare process.

The Impact of Coverage Restrictions on Antipsychotic Utilization Among Low-Income Medicare Part D Enrollees.

Prior research demonstrates substantial access problems associated with utilization management and formulary exclusions for antipsychotics in Medicaid, but the use and impact of coverage restrictions for these medications in Medicare Part D remains unknown. We assess the effect of coverage restrictions on antipsychotic utilization in Part D by exploiting a unique natural experiment in which low-income beneficiaries are randomly assigned to prescription drug plans with varying levels of formulary generosity. Despite considerable variation in use of coverage restrictions across Part D plans, we find no evidence that these restrictions significantly deter utilization or reduce access to antipsychotics for low-income beneficiaries.

Do Restrictions on Antipsychotic Use Differ Between Medicare Part D Stand-Alone Versus Medicare Advantage Plans?

OBJECTIVE: The objective of this study was to describe the type of restrictions and differences among antipsychotic users enrolled in Medicare Part D Stand-Alone (PDPs) and Advantage (MAPDs) prescription drug plans. METHODS: This retrospective study used data from Chronic Condition Data Warehouse, comprising a random 5% sample of the Medicare population in 2008. This study used bivariate analyses and multivariate logistical regression models to study differences in formulary restrictions on antipsychotic use between PDP and MAPD enrollees, adjusting for enrollee characteristics. Dependent variables included type of restriction and antipsychotic therapeutic class. The study sample was restricted to continuous Part D enrollees (N = 1,346,978) stratified by plan type, MAPDs (N = 435,591), and PDPs (N = 911,387). RESULTS: According to the bivariate analysis, antipsychotic users enrolled in PDPs were more likely to encounter restrictions (39.8%), compared with those in MAPDs (30.3%). In the multivariate analyses, antipsychotic users in MAPDs were less likely to face any restriction (odds ratio [OR] = 0.75, 95% confidence interval [CI] 0.72-0.78). Furthermore, atypical antipsychotic users in MAPDs were less likely to face any restriction (OR = 0.76, 95% CI 0.73-0.79), while first-generation antipsychotic users in MAPDs were more likely to face any restriction (OR = 1.87, 95% CI 1.32-2.65). Low-income subsidy (LIS) beneficiaries using any antipsychotic were much more likely to face restrictions compared with non-LIS beneficiaries. CONCLUSION: PDP enrollees prescribed antipsychotics were more likely to face formulary restrictions, as opposed to those in MAPDs. LIS beneficiaries enrolled in PDPs faced much higher risk of restricted access to this "protected" drug class.

Type 2 diabetes detection and management among insured adults.

BACKGROUND: The Centers for Disease Control and Prevention estimates that 28.9 million adults had diabetes in 2012 in the US, though many patients are undiagnosed or not managing their condition. This study provides US national and state estimates of insured adults with type 2 diabetes who are diagnosed, receiving exams and medication, managing glycemic levels, with diabetes complications, and their health expenditures. Such information can be used for benchmarking and to identify gaps in diabetes detection and management. METHODS: The study combines analysis of survey data with medical claims analysis for the commercially insured, Medicare, and Medicaid populations to estimate the number of adults with diagnosed type 2 diabetes and undiagnosed diabetes by insurance type, age, and sex. Medical claims analysis used the 2012 de-identified Normative Health Information database covering a nationally representative commercially insured population, the 2011 Medicare 5% Sample, and the 2008 Medicaid Mini-Max. RESULTS: Among insured adults in 2012, approximately 16.9 million had diagnosed type 2 diabetes, 1.45 million had diagnosed type 1 diabetes, and 6.9 million had undiagnosed diabetes. Of those with diagnosed type 2, approximately 13.0 million (77%) received diabetes medication-ranging from 70% in New Jersey to 82% in Utah. Suboptimal percentages had claims indicating recommended exams were performed. Of those receiving diabetes medication, 43% (5.6 million) had medical claims indicating poorly controlled diabetes-ranging from 29% with poor control in Minnesota and Iowa to 53% in Texas. Poor control was correlated with higher prevalence of neurological complications (+14%), renal complications (+14%), and peripheral vascular disease (+11%). Patients with poor control averaged $4,860 higher average annual health care expenditures-ranging from $6,680 for commercially insured patients to $4,360 for Medicaid and $3,430 for Medicare patients. CONCLUSIONS: This study highlights the large number of insured adults with undiagnosed type 2 diabetes by insurance type and state. Furthermore, this study sheds light on other gaps in diabetes care quality among patients with diagnosed diabetes and corresponding poorly controlled diabetes. These findings underscore the need for improvements in data collection and diabetes screening and management, along with policies that support these improvements.

Does good medication adherence really save payers money?

BACKGROUND: Despite a growing consensus that better adherence with evidence-based medications can save payers money, assertions of cost offsets may be incomplete if they fail to consider additional drug costs and/or are biased by healthy adherer behaviors unobserved in typical medical claims-based analyses. OBJECTIVES: The objective of this study was to determine whether controlling for healthy adherer bias (HAB) materially affected estimated medical cost offsets and additional drug spending associated with higher adherence. SUBJECTS: A total of 1273 Medicare beneficiaries with diabetes enrolled in Part D plans between 2006 and 2009. RESEARCH DESIGN: Using survey and claims data from the Medicare Current Beneficiary Survey, we measured medical and drug costs associated with good and poor adherence (proportion of days covered ≥ 80% and <80%, respectively) to oral antidiabetic drugs, ACE inhibitors/ARBs, and statins over 2 years. To test for HAB, we estimated pairs of regression models, one set containing variables typically controlled for in conventional claims analysis and a second set with survey-based variables selected to capture HAB effects. RESULTS: We found consistent evidence that controlling for HAB reduces estimated savings in medical costs from better adherence, and likewise, reduces estimates of additional adherence-related drug spending. For ACE inhibitors/ARBs we estimate that controlling for HAB reduced adherence-related medical cost offsets from $6389 to $4920 per person (P<0.05). Estimates of additional adherence-related drug costs were 26% and 14% lower in HAB-controlled models (P < 0.05). CONCLUSIONS: These results buttress the economic case for action by health care payers to improve medication adherence among insured persons with chronic disease. However, given the limitations of our research design, further research on larger samples with other disease states is clearly warranted.

Physician specialty cost differences of treating nonmelanoma skin cancer.

Specialty-related cost differences for the treatment of nonmelanoma skin cancer (NMSC) have been previously reported but without taking into account confounding factors. Using a previously validated model for NMSC episode of care, episodes were identified in the Medicare Current Beneficiary Survey claims 2005 to 2007. A γ regression with log link model estimated the effect of physician exposure on total episode costs controlling for sociodemographics, health status and comorbidities, treatment and repair procedures, as well as tumor size and location. Treatment-related NMSC episodes (1285) were identified. In the unadjusted model, episodes managed by generalists were associated with 36% lower costs, those by otolaryngologists/plastic surgeons with 82% higher costs, and those by multiple specialists with 111% higher costs, compared to dermatologists. Cost differences were substantially reduced in the adjusted regression analysis; compared to dermatologists, episodes managed by generalists were associated with 20% lower costs (P < 0.0001), whereas otolaryngologists/plastic surgeons and multiple specialists were associated with 20% (P < 0.01) and 11% (P = 0.02) higher costs, respectively. Overall, comparison between unadjusted and adjusted estimates suggests that controlling for severity and treatment modalities explains most of the specialty cost differences. Our estimates could be subject to residual confounding due to selection bias and the limitations to using claims data to characterize an NMSC episode of care. Adjusting for the severity of the disease and other confounders, our study found much smaller specialty-related cost differences for the management of NMSC than previously reported unadjusted estimates.

Antiparkinson drug adherence and its association with health care utilization and economic outcomes in a Medicare Part D population.

OBJECTIVES: We examine the associations of adherence to antiparkinson drugs (APDs) with health care utilization and economic outcomes among patients with Parkinson's disease (PD). METHODS: By using 2006-2007 Medicare administrative data, we examined 7583 beneficiaries with PD who filled two or more APD prescriptions during 19 months (June 1, 2006, to December 31, 2007) in the Part D program. Two adherence measures--duration of therapy (DOT) and medication possession ratio (MPR)--were assessed. Negative binomial and gamma generalized linear models were used to estimate the rate ratios (RRs) of all-cause health care utilization and expenditures, respectively, conditional upon adherence, adjusting for survival risk, sample selection, and health-seeking behavior. RESULTS: Approximately one-fourth of patients with PD had low adherence (MPR < 0.80, 28.7%) or had a short DOT (≤ 400 days, 23.9%). Increasing adherence to APD therapy was associated with decreased health care utilization and expenditures. For example, compared with patients with low adherence, those with high adherence (MPR = 0.90-1.00) had significantly lower rates of hospitalization (RR = 0.86), emergency room visits (RR = 0.91), skilled nursing facility episodes (RR = 0.67), home health agency episodes (RR = 0.83), physician visits (RR = 0.93), as well as lower total health care expenditures (-$2242), measured over 19 months. Similarly, lower total expenditure (-$6308) was observed in patients with a long DOT versus those with a short DOT. CONCLUSIONS: In this nationally representative sample, higher adherence to APDs and longer duration of use of APDs were associated with lower all-cause health care utilization and total health care expenditures. Our findings suggest the need for improving medication-taking behaviors among patients with PD to reduce the use of and expenditures for medical resources.

The effect of supplemental medical and prescription drug coverage on health care spending for Medicare beneficiaries with cancer.

OBJECTIVES: To examine whether patients with newly diagnosed cancer respond differently to supplemental coverage than the general Medicare population. METHODS: A cohort of newly diagnosed cancer patients (n = 1,799) from the 1997-2007 Medicare Current Beneficiary Survey and a noncancer cohort (n = 9,726) were identified and matched by panel year. Two-year total medical care spending was estimated by using generalized linear models with gamma distribution and log link-including endogeneity-corrected models. Interactions between cancer and type of insurance allowed testing for differential effects of a cancer diagnosis. RESULTS: The cancer cohort spent an adjusted $15,605 more over 2 years than did the noncancer comparison group. Relative to those without supplemental coverage, beneficiaries with employer-sponsored insurance, other private with prescription drug coverage, and public coverage had significantly higher total spending ($3,510, $2,823, and $4,065, respectively, for main models). For beneficiaries with cancer, supplemental insurance effects were similar in magnitude yet negative, suggesting little net effect of supplemental insurance for cancer patients. The endogeneity-corrected models produced implausibly large main effects of supplemental insurance, but the Cancer × Insurance interactions were similar in both models. CONCLUSIONS: Medicare beneficiaries with cancer are less responsive to the presence and type of supplemental insurance than are beneficiaries without cancer. Proposed restrictions on the availability of supplemental insurance intended to reduce Medicare spending would be unlikely to limit expenditures by beneficiaries with cancer, but would shift the financial burden to those beneficiaries. Policymakers should consider welfare effects associated with coverage restrictions.

Association between depression and maintenance medication adherence among Medicare beneficiaries with chronic obstructive pulmonary disease.

OBJECTIVE: Depression is a significant comorbidity in patients with chronic obstructive pulmonary disease (COPD). Although comorbid depression is associated with low use and poor adherence to medications treating other chronic conditions, evidence of the relationship between depression and COPD management is limited. This study estimated the association between depression and COPD maintenance medication (MM) adherence among patients with COPD. METHODS: This cross-sectional study used a 5% random sample of 2006-2007 Chronic Condition Warehouse data. Medicare beneficiaries enrolled in Parts A, B, and D plans with diagnosed COPD who survived through 2006 were included (n = 74,863). COPD MM adherence was measured as medication discontinuation and proportion of days covered (PDC). Depression was identified through the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Multivariable models with modified generalized estimating equations were used to estimate adjusted association between depression diagnosis and medication adherence, controlling for sociodemographics, comorbidities, and disease severity. RESULTS: Among the sample, about one third (33.6%) had diagnosed depression. More than half (61.8%) of beneficiaries with COPD filled at least one COPD MM prescription. Depressed beneficiaries had a higher likelihood of using COPD MM than non-depressed beneficiaries (adjusted prevalence ratios [PR] = 1.02; 95% confidence intervals [CI] = 1.01, 1.03). Among COPD MM users, depressed beneficiaries were more likely to discontinue medications (PR = 1.09; 95% CI = 1.04, 1.14) and less likely to exhibit PDC ≥ 0.80 (PR = 0.89; 95% CI = 0.86, 0.92) than non-depressed beneficiaries. CONCLUSIONS: Depression is prevalent in Medicare beneficiaries with COPD and independently associated with lower COPD MM adherence. Interventions to improve medication adherence for COPD patients may consider management of comorbidities such as depression.

Use of and spending on supportive care medications among Medicare beneficiaries with cancer.

PURPOSE: The study objective was to provide population-based estimates of supportive care medication (SCM) use among Medicare beneficiaries with cancer and determine factors related to SCM receipt. METHODS: This retrospective cohort study of community-based Medicare beneficiaries used the Medicare Current Beneficiary Survey (1997­2007). Dependent variables comprised use and spending on SCMs for three medication classes: opioids, antidepressants/sedative/hypnotics (ASH), and antiemetics. Independent variables of interest were supplemental insurance coverage, cancer site, and treatment. Multivariate models determined factors affecting receipt of, and spending on, SCMs. We also compared SCM use and spending among beneficiaries with and without cancer in order to understand what portion of SCM use and spending could be attributed to cancer as opposed to other comorbid conditions. RESULTS: A total of 1,836 Medicare beneficiaries with cancer and 9,898 beneficiaries without cancer were eligible for the study. Beneficiaries with cancer were more likely to receive opioids, ASH, and antiemetics compared to non-cancer beneficiaries. Adjusted annual payments for antiemetics were on average $637 higher in with cancer versus without cancer (p<0.01), while ASH payments were $184 lower (p<0.01). Opioid spending was similar among cancer and non-cancer users. Relative to colon cancer, beneficiaries with prostate cancer were least likely to receive any of the three SCM classes. Receipt of antineoplastic treatment increased the probability of use of all three classes of SCMs. Insurance coverage did not influence the use of or spending on opioids or antiemetics, but was associated with both outcomes for ASH. The use of all three SCM classes was significantly lower during years before Part D implementation of the new Medicare Part D prescription drug benefit and was higher after implementation of Part D. CONCLUSION: This study provides population-based information on SCM use among Medicare beneficiaries with cancer. Cancer site and treatment modality were important predictors of SCM use.

Affordability and adherence gains for Medicare Part D low-income subsidy recipients when low-income subsidy benefits expanded in 2024.

BACKGROUND: The lowest-income beneficiaries enrolled in the Medicare Part D prescription drug program receive "full subsidies" that waive the premium and deductible and impose minimal copayments. Those with slightly higher incomes and assets may be eligible for "partial subsidies." Prior to 2024, individuals receiving partial subsidies faced reduced Part D premiums and deductibles and paid 15% coinsurance. Under provisions of the Inflation Reduction Act, recipients of partial subsidies were upgraded to full subsidies beginning in 2024. The objective of this pilot study was to assess whether the new policy is likely to reduce cost-related nonadherence to prescribed medications- a common problem faced by older adults even among those receiving subsidies. OBJECTIVE: To compare cost-related nonadherence among partial- vs full-subsidy recipients with similar characteristics. METHODS: We used 2019 Medicare Current Beneficiary Survey data for the study. The Medicare Current Beneficiary Survey is uniquely suited for this work because it contains administrative data on low-income subsidy enrollment plus extensive survey-based information on financial resources necessary to establish program eligibility and rates of cost-related nonadherence. Explanatory variables included sociodemographic characteristics, economic resources, work status, and health variables. RESULTS: We found that the partial-subsidy group reported significantly more cost-related nonadherence (39% vs 22%; P = 0.01) arising both from a lower propensity to fill some prescriptions (23% vs 12%; P = 0.03) and to more delays in filling others (29% vs 8%; P = 0.03). The differences were more pronounced for women and racial and ethnic minority groups in contrast to men and majority populations, respectively. Because the study samples were small, we could not conduct a detailed regression analysis. CONCLUSIONS: The magnitude of cost-related nonadherence effects associated with partial-subsidy cost sharing suggests that the Inflation Reduction Act policy to expand low-income subsidies may boost medication adherence, most notably among women and racial and ethnic minority groups.

Medicare Part D low-income subsidies expanded in January 2024, but more needs to be done to ensure that eligible beneficiaries enroll.

BACKGROUND: The Inflation Reduction Act of 2022 extended full low-income subsidies (LIS) to a small group of Medicare Part D recipients with limited assets and incomes between 135% and 150% of the Federal Poverty Level beginning in January 2024. This policy may result in small enrollment gains among beneficiaries eligible for the new benefits, but the biggest problem with the current LIS program is underenrollment across all eligibility groups. Prior research has shown that underenrollment has been a persistent problem since the LIS program began in 2006, yet little has been done to correct the situation. OBJECTIVE: To identify individual-level factors associated with failure to enroll among low-income beneficiaries eligible for both full subsidies and partial subsidies under the LIS program. METHODS: We used 2019 Medicare Current Beneficiary Survey data for the study. The Medicare Current Beneficiary Survey is uniquely suited for this work because it contains administrative data on LIS enrollment plus extensive survey information on financial resources necessary to establish program eligibility. We conducted descriptive and multivariate analyses to identify factors associated with failure to enroll when eligible for either full or partial subsidies. Explanatory variables included sociodemographic characteristics, economic resources, work status, health variables, and source of prescription coverage (for nonsubsidized beneficiaries). RESULTS: In 2019, 73% of beneficiaries eligible for full subsidies under pre-Inflation Reduction Act LIS provisions were enrolled, compared with only 25% eligible for partial subsidies. The number of those estimated to be eligible for full subsidies but not enrolled (N = 3.9 million) was more than double that of those eligible but not enrolled for partial subsidies (N = 1.5 million). Factors associated with failure to enroll (older age, male sex, White race, married, higher education, higher income and assets, and excellent/very good health status) were similar for both groups. In multivariate analyses, the single strongest predictor of failure to enroll was receipt of income from work (odds ratio = 5.50; P < 0.001). Among the nonenrolled, 64% eligible for full subsidies and 75% eligible for partial subsidies maintained unsubsidized Part D coverage. CONCLUSIONS: Significant numbers of low-income Medicare beneficiaries are eligible for Part D subsidies but fail to enroll. Common characteristics distinguishing nonenrollees from enrollees include older age with higher proportions of White individuals, married individuals, higher income and assets, and better overall health. Two promising targets for increasing LIS enrollment are evidence of work income and unsubsidized Part D coverage.

Out-of-pocket health care expenditure burden for Medicare beneficiaries with cancer.

BACKGROUND: There is increasing concern regarding the financial burden of care on cancer patients and their families. Medicare beneficiaries often have extensive comorbidities and limited financial resources, and may face substantial cost sharing even with supplemental coverage. In the current study, the authors examined out-of-pocket (OOP) spending and burden relative to income for Medicare beneficiaries with cancer. METHODS: This retrospective, observational study pooled data for 1997 through 2007 from the Medicare Current Beneficiary Survey linked to Medicare claims. Medicare beneficiaries with newly diagnosed cancer were selected using claims-based diagnoses. Generalized linear models were used to estimate OOP spending. Logistic regression models identified factors associated with a high OOP burden, defined as spending > 20% of one's income during the cancer diagnosis and subsequent year. RESULTS: The cohort included 1868 beneficiaries with and 10,047 without cancer. Compared with the noncancer cohort, cancer patients were older, had more comorbidities, and were more likely to lack supplemental coverage. The mean OOP spending for cancer patients was $4727. Cancer patients faced an adjusted $976 (P < .01) incremental OOP spending. Greater than one-quarter (28%) of beneficiaries with cancer experienced a high OOP burden compared with 16% of beneficiaries without cancer (P < .001). Supplemental insurance and higher income were found to be protective against a high OOP burden, whereas assets, comorbidity, and receipt of cancer-directed radiation and antineoplastic therapy were associated with a higher OOP burden. CONCLUSIONS: Medicare beneficiaries with cancer face a higher OOP burden than their counterparts without cancer; some of the higher burden was explained by the higher comorbidity burden and lack of supplemental insurance noted among these patients. Financial pressures may discourage some elderly patients from pursuing treatment.

Use and spending on antineoplastic therapy for Medicare beneficiaries with cancer.

BACKGROUND: Oral antineoplastic drugs, not generally covered by Medicare Part B, have assumed an increasingly important role in cancer treatment. OBJECTIVE: We examined use and spending on infused/injected (Part B covered) and non-Part B antineoplastic agents in a Medicare beneficiary population with cancer, and the effect of supplemental insurance. RESEARCH DESIGN: This retrospective, observational study used pooled 1997-2007 data from the Medicare Current Beneficiary Survey, linked to Medicare claims. Logistic regression models identified factors associated with antineoplastic use. Generalized linear models were used to estimate spending among antineoplastic users. POPULATION STUDIED: A total of 1836 Medicare beneficiaries with newly diagnosed cancer were selected based on the presence of claims-based diagnoses after a 12-month washout period. RESULTS: Five hundred fifty-nine (31.0%) Medicare beneficiaries received antineoplastic therapy; 395 (21.3%) used Part B, 253 (14.6%) used non-Part B antineoplastics. Spending per user was $7841 (any), $10,364 (Part B), and $1535 for non-Part B antineoplastics. Supplemental insurance was associated with antineoplastic use. Primary cancer site and age were key predictors of spending among users. Spending on non-Part B antineoplastics increased during 2006-2007 relative to 2004-2005 but time trends were not significant in multivariate analysis. CONCLUSIONS: Antineoplastic therapy use by Medicare beneficiaries is sensitive to the presence but not type of supplemental insurance. Non-Part B therapy was used by a relatively large proportion of beneficiaries with cancer receiving therapy, although spending was less than for Part B therapy. Monitoring the role of supplemental insurance, and particularly the role of Medicare Part D is a critical area for ongoing research.

Impact of Part D low-income subsidies on medication patterns for Medicare beneficiaries with diabetes.

BACKGROUND: It is not known whether low-income subsidies (LIS) under Medicare Part D help beneficiaries overcome impediments to medication use associated with poor socioeconomic status and high disease burden. OBJECTIVES: To compare Medicare beneficiaries with LIS and Medicaid (duals), LIS without dual eligibility, and non-LIS recipients on use of medications recommended in diabetes treatment. RESEARCH DESIGN: Fixed-effect comparisons among beneficiaries in the same Part D plans in 2006-2007. SUBJECTS: Nationally representative sample of enrollees in Part D prescription drug plans. A total of 109,292 beneficiaries were in 204 prescription drug plans; 47.5% non-LIS, 44.4% duals, and 8.1% nondual LIS recipients. MEASURES: Medications included antidiabetic agents, renin-angiotensin-aldosterone system inhibitors, and antihyperlipidemics. Drug use was measured by exposure, duration of therapy, and medication possession ratio. RESULTS: The LIS dual cohort had significantly higher comorbidity compared with non-LIS comparisons, LIS nonduals were significantly more likely to take medications in all 3 drug classes compared with non-LIS recipients, but differences were small (between 2% and 4%; P<0.05). Non-LIS recipients and duals had equivalent exposure to any antidiabetic drug and antihyperlipidemics, but duals were 3% less likely to receive renin-angiotensin-aldosterone system inhibitors compared with non-LIS recipients (P<0.05). Small differences in adjusted values for duration of therapy and medication possession ratio among the 3 cohorts were also observed, none of which were clinically meaningful. CONCLUSIONS: Similarities in medication utilization among Part D enrollees with and without LIS coverage supports the program objective of providing enhanced access to needed medications for diverse groups of Medicare beneficiaries.

Simulated value-based insurance design applied to statin use by Medicare beneficiaries with diabetes.

OBJECTIVE: To examine cost responsiveness and total costs associated with a simulated "value-based" insurance design for statin therapy in a Medicare population with diabetes. METHODS: Four-year panels were constructed from the 1997-2005 Medicare Current Beneficiary Survey selected by self-report or claims-based diagnoses of diabetes in year 1 and use of statins in year 2 (N = 899). We computed the number of 30-day statin prescription fills, out-of-pocket and third-party drug costs, and Medicare Part A and Part B spending. Multivariate ordinary least squares regression models predicted statin fills as a function of out-of-pocket costs, and a generalized linear model with log link predicted Medicare spending as a function of number of fills, controlling for baseline characteristics. Estimated coefficients were used to simulate changes in fills associated with co-payment caps from $25 to $1 and to compute changes in third-party payments and Medicare cost offsets associated with incremental fills. Analyses were stratified by patient cardiovascular event risk. RESULTS: A simulated out-of-pocket price of $25 [$1] increased plan drug spending by $340 [$794] and generated Medicare Part A/B savings of $262 [$531]; savings for high-risk patients were $558 [$1193], generating a net saving of $249 [$415]. CONCLUSIONS: Reducing statin co-payments for Medicare beneficiaries with diabetes resulted in modestly increased use and reduced medical spending. The value-based insurance design simulation strategy met financial feasibility criteria but only for higher-risk patients.

Eligibility and take-up of the Medicare Part D low-income subsidy.

There is concern about poor take-up of the Medicare Part D Low-Income Subsidy (LIS), but uncertainty in published estimates. The Medicare Current Beneficiary Survey (MCBS), which contains Medicare LIS enrollment records and extensive survey data on individual beneficiary characteristics, would appear an ideal resource for evaluating LIS take-up. However, use of the MCBS to identify eligible beneficiaries is limited due to underreporting of income and lack of asset information in the published MCBS releases. We evaluate LIS eligibility and participation by enhancing the reliability of MCBS financial information using unpublished survey data on income and assets together with an income imputation procedure.

Financial incentives tied to Medicare star ratings: impact on influenza vaccination uptake in Medicare beneficiaries.

OBJECTIVES: To evaluate the impact of the star rating bonus payment policy on annual influenza vaccination rates before and after the policy was adopted for Medicare Advantage (MA) plans in 2012. STUDY DESIGN: Observational study using data from the Medicare Current Beneficiary Survey from 2007 to 2015 to test whether the bonus payment policy led to higher flu vaccination rates in MA prescription drug (MAPD) plans vs fee-for-service prescription drug plans (PDPs), which were ineligible for bonus payments. METHODS: Mean preperiod (2007-2011) and postperiod (2012-2015) influenza vaccination rates were compared for enrollees in both types of plans using descriptive and multivariate difference-in-difference (DID) equations. The experimental effect of the MA bonus payment policy was estimated as the interaction between plan type (MAPD plan vs PDP) and period (pre- vs post period) controlling for the main effects of plan type (MAPD vs PDP), timing of the observation (pre- vs post period), and other potential confounders. RESULTS: The study sample included 40,369 person-years of data in the preperiod and 27,703 person-years of data in the post period. Vaccination rates increased by 3.8% in MAPD plans compared with 2.7% in PDPs, leading to a relative MAPD-favored difference that was nonsignificant (P = .31). However, the effect was statistically significant (odds ratio [OR], 1.12; P = .03) in the main multivariate DID model. A larger relative difference was observed among beneficiaries 75 years and older (OR, 1.18; P = .03). CONCLUSIONS: The Medicare bonus payment policy led to a small increase in beneficiaries' flu vaccination rates, suggesting that expanding the star measure set could be an effective way to increase uptake for other recommended adult vaccines.

Impact of Updated Clinical Practice Guidelines on Outpatient Treatment for Clostridioides difficile Infection and Associated Clinical Outcomes.

Background: The 2017 Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) Clostridium (Clostridioides) difficile infection (CDI) guideline update recommended treatment with fidaxomicin or vancomycin for CDI. We aimed to examine outpatient CDI treatment utilization before and after the guideline update and compare clinical outcomes associated with fidaxomicin versus vancomycin use. Methods: A pre-post study design was employed using Medicare data. CDI treatment utilization and clinical outcomes (4- and 8-week sustained response, CDI recurrence) were compared between patients indexed from April-September 2017 (preguideline period) and those indexed from April-September 2018 (postguideline period). Clinical outcomes associated with fidaxomicin versus vancomycin were compared using propensity score-matched analyses. Results: From the pre- to postguideline period, metronidazole use decreased (initial CDI: 81.2% to 53.5%; recurrent CDI: 49.7% to 27.6%) while vancomycin (initial CDI: 17.9% to 44.9%; recurrent CDI: 48.1% to 66.4%) and fidaxomicin (initial CDI: 0.87% to 1.63%; recurrent CDI: 2.2% to 6.0%) use increased significantly (P < .001 for all). However, clinical outcomes did not improve. In propensity score-matched analyses, fidaxomicin versus vancomycin users had 4-week sustained response rates that were higher by 13.5% (95% confidence interval [CI], 4.0%-22.9%; P = .0058) and 30.0% (95% CI, 16.8%-44.3%; P = .0002) in initial and recurrent CDI cohorts, respectively. Recurrence rates were numerically lower for fidaxomicin in both cohorts. Conclusions: Vancomycin use increased and metronidazole use decreased after the 2017 guideline update. Fidaxomicin use increased but remained low. Improved outcomes associated with fidaxomicin relative to vancomycin suggest benefits from its greater use in Medicare patients.

Medication use and adherence among elderly Medicare beneficiaries with diabetes enrolled in Part D and retiree health plans.

BACKGROUND: Employer-based retiree drug benefits have long been viewed as the gold standard of drug coverage for elderly Medicare beneficiaries. The question for policy makers is whether beneficiaries enrolled in Part D plans exhibit drug utilization patterns comparable with those seen in retiree plans. OBJECTIVE: To compare utilization patterns for antidiabetic agents, renin-angiotensin-aldosterone system inhibitors, and antihyperlipidemics by elderly Medicare beneficiaries with diabetes enrolled in Medicare prescription drug plans (PDPs) and retiree health plans (RHPs). METHODS: A random 5% sample (N=45,613) of elderly diabetic patients with continuous 2006 PDP enrollment was selected from Medicare files and compared with a similar sample of elderly RHP enrollees from MarketScan (N=211,919) on any use, duration of therapy, and medication possession ratio for each drug class. Adjusted comparisons were made on samples (N=16,859 each) using propensity score matching. RESULTS: Drug utilization and adherence rates were high in both groups. In propensity score adjusted comparisons, prevalence rates for PDP enrollees were within 2.2% of the level of RHP enrollees for antidiabetic agents and renin-angiotensin-aldosterone system inhibitors, but differed sharply for antihyperlipidemics (61% vs. 69%; P<0.0001). There were no clinically meaningful differences between PDP and RHP enrollees in duration of therapy or medication possession ratio for any drug class. CONCLUSION: When otherwise similar Medicare beneficiaries with diabetes have drug coverage, the source of benefits has little effect on use and adherence with most (but not all) drugs recommended in diabetes guidelines.