The effects of patient out-of-pocket costs on insulin use among people with type 1 and type 2 diabetes with Medicare Advantage insurance-2014-2018.

OBJECTIVE: To identify the association between insulin out-of-pocket costs (OOPC) and adherence to insulin in Medicare Advantage (MA) patients. DATA SOURCES AND STUDY SETTING: The study is based on Optum Labs Data Warehouse, a longitudinal, real-world data asset with de-identified administrative claims and electronic health record data. STUDY DESIGN: Using descriptive and multivariable logistic regression analyses, we identified the likelihood of patients with diabetes having ≥60 consecutive days between an expected insulin fill date and the actual fill date (refill lapse) by OOPC, categorized by $0, >$0-$20 (reference), >$20-$35, >$35-$50, and > $50 per 30-day supply. DATA COLLECTION/EXTRACTION METHODS: The study included MA enrollees with type 1 or type 2 diabetes and prescription claims for insulin between 2014 and 2018. PRINCIPAL FINDINGS: Those with average insulin OOPC per 30-day supply >$35 or $0 were more likely to have an insulin refill lapse versus OOPC of >$0 to $20, with odds ratios ranging 1.18 (95% CI 1.13-1.22) to 1.74 (95% CI 1.66-1.83) depending on OOPC group and diabetes type. CONCLUSIONS: Capping average insulin OOPC at $35 per 30-day supply may help avoid cost-related insulin non-adherence in MA patients; efforts to address non-cost barriers to medication adherence remain important.

The effects of patient out-of-pocket costs for insulin on medication adherence and health care utilization in patients with commercial insurance; 2007-2018.

BACKGROUND: High out-of-pocket costs (OOPCs) for insulin can lead to cost-related nonadherence and poor outcomes, prompting payers to limit insulin OOPCs. However, data are scarce on whether insulin OOPCs at policy-relevant levels is associated with improved adherence and outcomes. OBJECTIVE: To identify associations between insulin OOPCs and insulin adherence, noninsulin antihyperglycemic (AHG) medication adherence, and diabetes-related emergency department (ED) visits and hospitalizations. METHODS: This retrospective cohort study was conducted using OptumLabs Data Warehouse, a longitudinal, real-world data asset with deidentified administrative claims and electronic health record data. Individuals with type 1 diabetes (T1D) or type 2 diabetes (T2D), insulin use on January 1 of a study year (index date: 2007-2018), continuous commercial health plan eligibility 12 months pre-index and post-index date, and at least 1 insulin claim during the 12-month follow-up period were included. Average insulin OOPCs per 30-day supply in the follow-up period was identified and categorized ($0, > $0-$20 [referent group], > $20-$35, > $35-$50, and > $50). The proportion of patients with a gap in insulin supply of 60 or more continuous days, AHG nonadherence per modified proportion of days covered less than 0.80, and a diabetes-related ED visit or hospitalization were identified and compared by insulin OOPC category vs more than $0 to $20 using pairwise chi-square tests and multivariable logistic regression. RESULTS: The study included 21,085 individuals with T1D and 72,512 with T2D. Patients with average OOPCs more than $50 were more likely to have a gap in insulin supply vs those with OOPCs more than $0 to $20, with an odds ratio (OR) of 1.14 (95% CI =1.05-1.24) and 1.38 (95% CI = 1.32-1.45) for T1D and T2D, respectively. Those with T2D and OOPCs more than $35 were also more likely to have a 60-day gap in insulin supply (OR 1.17; 95% CI = 1.11-1.23). Odds of having a diabetes-related hospitalization or ED visit did not increase with higher OOPCs; rather, associations tended to be inverse. Nonadherence to AHG medications in the T2D cohort was higher with insulin OOPCs more than $20 vs those more than $0-$20 (P < 0.05 for all). CONCLUSIONS: Individuals with T2D were more likely to have a 60-day gap in insulin supply when the OOPC was more than $35 per 30-day supply and with the OOPC more than $50 in those with T1D. These findings suggest that health plans can facilitate adherence to insulin therapy and possibly to noninsulin AHG medications by protecting patients with diabetes from experiencing high insulin OOPC. A study with a longer follow-up period is warranted to fully assess ED and hospitalization outcomes. DISCLOSURES: This study was funded by the Robert Wood Johnson Foundation, Health Data for Action Research Program. The study sponsor played no role in the design or conduct of this study. The views expressed here do not necessarily reflect the views of the Foundation.

Medication Adherence, Health Care Utilization, and Spending Among Privately Insured Adults With Chronic Conditions in the United States, 2010-2016.

BACKGROUND: Chronic conditions are common and costly for older Americans and for the health system. Adherence to daily maintenance medications may improve patient health and lead to lower health care spending. METHODS: To identify predictors of adherence and to quantify associations with health care utilization and spending among older adults with chronic conditions, we conducted a longitudinal retrospective analysis using the OptumLabs Data Warehouse. This database of deidentified administrative claims includes medical and eligibility information for more than 200 million commercial and Medicare Advantage enrollees. We identified adults age 50+ years initiating treatment for atrial fibrillation (N = 33,472), chronic obstructive pulmonary disease (COPD; N = 44,130), diabetes (N =76,726), and hyperlipidemia (N= 249,391) between January 2010 and December 2014. We assessed adherence, health care utilization, and spending during the first 2 years of treatment. RESULTS: During the first year of treatment, 13%-53% of each condition cohort was adherent (proportion of days covered ≥0.80). White race, Midwest residence, and having fewer comorbidities consistently and independently predicted adherence among enrollees initiating treatment for chronic obstructive pulmonary disease, diabetes, and hyperlipidemia. Male sex and higher net worth were also independently associated with adherence among commercial enrollees with these conditions. Patients in most condition cohorts who were adherent to treatment had significantly lower odds of hospitalization or emergency department use compared to patients who were not adherent. Additional spending on pharmacy claims by patients who were adherent was not consistently offset by lower spending on medical claims over a 2-year horizon. CONCLUSIONS: Although many patient factors are strongly associated with medication adherence, the problem of non-adherence is common across all groups and may increase risk of adverse health outcomes.