Benefit Design And Biosimilar Coverage In Medicare Part D: Evidence And Implications From Recent Reforms.

There is substantial disparity between Medicare Part D and employer-sponsored health insurance plans in the coverage of biosimilars and their reference biologics. These disparities may be due to design elements of Part D plans that encourage the adoption of more expensive biologic drugs. We undertook several analyses to illustrate the dynamics of benefit design incentives over time, compare formulary coverage in Part D plans with that of employer-sponsored plans, and study how the Bipartisan Budget Act of 2018 affected Part D formulary coverage. Using these analyses of Part D reforms enacted through the Bipartisan Budget Act, we discuss the implications of elements of the Inflation Reduction Act of 2022 that will be implemented in 2025. Biosimilar coverage increased by 23 percentage points five quarters after the Bipartisan Budget Act was implemented. We predict that the Inflation Reduction Act will also have a positive effect on biosimilar coverage. Given ample evidence of a relationship between drug coverage and utilization, our results suggest that Medicare patients and the federal government could realize substantial savings if Part D formularies resembled those of employer-sponsored plans.

Out-of-pocket costs for diabetes medications in employer-sponsored health insurance plans.

Out-of-pocket costs of diabetes medications other than insulin can be quite high for individuals with employer-sponsored health insurance.

Specialty drug use for autoimmune conditions varies by race and wage among employees with employer-sponsored health insurance.

BACKGROUND: The relationship between race and ethnicity, wage status, and specialty medication (SpRx) use among employees with autoimmune conditions (AICs) is poorly understood. Insight into sociodemographic variations in use of these medications can inform health equity improvement efforts. OBJECTIVE: To assess the association of race and ethnicity and wage status on SpRx use and adherence patterns among employees with AICs enrolled in employer-sponsored health insurance. METHODS: In this observational, retrospective cohort analysis, data were obtained from the IBM Watson MarketScan database for calendar year 2018. Employees were separated into race and ethnicity subgroups based on employer-provided data. Midyear employee wage data were used to allocate employees into the following annual income quartiles: $47,000 or less, $47,001-$71,000, $71,001-$106,000, and $106,001 or more. The lowest quartile was further divided into 2 groups ($35,000 or less and $35,001-$47,000) to better evaluate subgroup differences. Outcomes included monthly days SpRx-AIC supply, proportion of days covered (PDC), and medication discontinuation rates. Generalized linear regressions were used to assess differences while adjusting for patient and other characteristics. RESULTS: From a sample of more than 2,000,000 enrollees, race and ethnicity data were available for 617,117 (29.8%). Of those, 47,839 (7.8%) were identified as having an AIC of interest, with prevalence rates of AICs differing by race within wage categories. Among those with AICs, 5,358 (11.2%) had filled at least 1 SpRx-AIC prescription. Following adjustment, except for the highest wage category, prevalence of SpRx-AIC use was significantly less among Black and Hispanic subpopulations. Black patients had significantly lower SpRx-AIC use rates than White patients (≤$35,000: 4.9 vs 9.4%, >$35,000-$47,000: 5.5 vs 10.6%, >$47,000-$71,000: 8.5 vs 11.1%, and >$71,000-$106,000: 9.1 vs 12.7%; P <0.001 for all). For Hispanic patients, prevalence rates were significantly lower than White patients in 3 different wage categories (≤$35,000: 4.5 vs 9.4%, >$35,000-$47,000: 6.1 vs 10.6%, and >$71,000-$106,000: 8.6 vs 12.7%; P < 0.001). PDC and 90-day discontinuation rates did not differ among race and ethnicity groups within the respective wage bands. CONCLUSIONS: Race and ethnicity and wage-related disparities exist in SpRx use, but not PDC or discontinuation rates for treatment of AICs among non-White and low-income populations with employer-sponsored insurance, and may adversely impact clinical outcomes.

Who Provides Outpatient Clinical Care for Adults With ADHD? Analysis of Healthcare Claims by Types of Providers Among Private Insurance and Medicaid Enrollees, 2021.

OBJECTIVE: To characterize provider types delivering outpatient care overall and through telehealth to U.S. adults with ADHD. METHOD: Using employer-sponsored insurance (ESI) and Medicaid claims, we identified enrollees aged 18 to 64 years who received outpatient care for ADHD in 2021. Billing provider codes were used to tabulate the percentage of enrollees receiving ADHD care from 10 provider types overall and through telehealth. RESULTS: Family practice physicians, psychiatrists, and nurse practitioners/psychiatric nurses were the most common providers for adults with ESI, although the distribution of provider types varied across states. Lower percentages of adults with Medicaid received ADHD care from physicians. Approximately half of adults receiving outpatient ADHD care received ADHD care by telehealth. CONCLUSION: Results may inform the development of clinical guidelines for adult ADHD and identify audiences for guideline dissemination and education planning.

Affordable Health Insurance Options for Small Business and Low-Wage Workers Remains Elusive: Experience With New Health Reimbursement Arrangements in New Jersey.

Low-wage workers and those employed by small businesses are least likely to be offered health insurance coverage and they are over-represented among the uninsured. Two new forms of health reimbursement arrangements (HRAs) that allow employers to help fund individual market coverage for workers have been touted as breakthrough strategies to help fill this gap. Despite several years of experience and low adoption, little is known about employer understanding of or views about these HRA options. Consistent with other evidence, only 11.8% of New Jersey employers we surveyed offer or plan to offer either of the HRA options. Few respondents (18.5%) report familiarity with either option. Even among businesses that offer or plan to offer this form of HRA, under half (47.6%) say that they are familiar with them. Other reasons cited for not offering these options include broker advice and complexity. While more investigation is needed, these findings suggest that new strategies should be explored to fill the gap in health insurance for low-wage and small business employees.

Health Benefits In 2023: Premiums Increase With Inflation And Employer Coverage In The Wake Of Dobbs.

In 2023 the average annual premium for employer-sponsored family health insurance coverage was $23,968-an increase of $1,505 (7 percent) from 2022. Both single and family premiums increased faster in 2023 than in 2022, in a period of generally high inflation throughout the US economy. On average, covered workers contributed 17 percent ($1,401) of the cost of single coverage and 29 percent ($6,575) of the cost of family coverage. When compared to employers' perceptions of the number of primary care providers in their networks, a smaller share of employers believed that their provider networks had a sufficient number of mental health and substance abuse providers to provide timely access to services. One-quarter of employers indicated that their employees had a "high" level of concern with the level of cost sharing required by their plans. When asked about abortion coverage in the wake of the Supreme Court Dobbs decision, almost a third of large employers reported that their largest plan covered abortion in most or all circumstances.

Do minimum wage laws affect employer-sponsored insurance provision?

Employers may respond to minimum wage increases by adjusting their health benefits. We examine the impact of state minimum wage increases on employer health benefit offerings using the 2002-2020 Medical Expenditure Panel Survey - Insurance/Employer Component data. Our primary regression specifications are difference-in-differences models that estimate the relationship between within-state changes in employer-sponsored insurance and minimum wage laws over time. We find that a $1 increase in minimum wages is associated with a 0.92 percentage point (p.p.) decrease in the percentage of employers offering health insurance, largely driven by small employers and employers with a greater share of low-wage employees. A $1 increase is also associated with a 1.83 p.p. increase in the prevalence of plans with a deductible requirement, but we do not find consistent evidence that other benefit characteristics are affected. We find no consequent change in uninsurance, likely explained by an increase in Medicaid enrollment.

A Comprehensive Obesity Benefit as a Guide for Employers on the Core Components of Obesity Care: Guidance From the American College of Occupational and Environmental Medicine (ACOEM) Roundtable on Obesity.

OBJECTIVE: The need to confront the obesity epidemic and its impact on employers requires a serious look at how we address the treatment of obesity. This article focuses on the core components of obesity care and the need for employers to offer a comprehensive obesity benefit (COB) as part of employee insurance coverage. METHODS: In May 2022, the American College of Occupational and Environmental Medicine convened a roundtable meeting, which brought together five corporate medical directors and representatives from aerospace/defense and energy industries to learn about the disease of obesity and provide clinical insights regarding health and safety in their respective industries. The goals of the program were to provide awareness of benefits for the treatment of obesity and identify the feasibility for employers of implementing a COB for their employees. Participants learned how a comprehensive approach to covering obesity treatments is necessary, and what benefits should be offered to employees. RESULTS: Participants were invited to review the insurance benefits they currently offer to employees and compare them to the COB. Outcomes were limited by a lack of participation by the employers invited to participate. Participants identified actions that need to be addressed for employers to develop a more comprehensive approach to obesity care. CONCLUSION: Implementing a COB can help employers increase access and utilization of comprehensive obesity care by employees.

Choice of high-deductible health plans among enrollees with a substance use disorder.

INTRODUCTION: High-deductible health plans (HDHPs) expose enrollees to increased out-of-pocket costs for their medical care, which can exacerbate the undertreatment of substance use disorders (SUDs). However, the factors that influence whether an enrollee with SUD chooses an HDHP are not well understood. In this study, we examine the factors associated with an individual with an SUD's decision to enroll in an HDHP. METHODS: Using de-identified administrative commercial claims and enrollment data from OptumLabs (2007-2017), we identified individuals at employers offering at least one HDHP and one non-HDHP plan. We modeled whether an enrollee chose an HDHP using linear regression on plan and enrollee demographic characteristics. Key plan characteristics included whether a plan had a health savings account (HSA) or a health reimbursement arrangement (HRA). Key demographic variables included age, race/ethnicity, census block income range, census block highest educational attainment, and sex. We separately investigate new enrollment decisions (i.e., not previously enrolled in an HDHP) and re-enrollment decisions, as well as decisions among single enrollees and families of differing sizes. The study also adjusted models for additional plan characteristics, employer and year fixed effects, and census division. Robust standard errors were clustered at the employer level. RESULTS: The sample comprised 30,832 plans and 318,334 enrollees. Among enrollees with new enrollment decisions, 24.6 % chose an HDHP; 93.8 % of HDHP enrollees chose to re-enroll in an HDHP. The study found the presence of a plan HRA to be associated with a higher probability of new and re-enrollment in an HDHP. We found that older enrollees with SUD were less likely to newly enroll in an HDHP, while enrollees who were non-White, living in lower-income census blocks, and living in lower educational attainment census blocks were more likely to newly enroll in an HDHP. Higher levels of health care utilization in the prior year were associated with a lower probability of newly enrolling in an HDHP but associated with a higher probability of re-enrolling. CONCLUSION: Given the emerging evidence that HDHPs may discourage SUD treatment, greater HDHP enrollment could exacerbate health disparities.

Commercial Health Plan and Enrollee Out-of-Pocket Spending on Accelerated Approval Products in 2019.

This cross-sectional study examines spending by health care plans and enrollees on products with accelerated approval.

The intracorrelation of family health insurance and job lock.

This paper tests for the presence of job lock and "health insurance plan lock" stemming from the health shock of a child family member. Using the onset of an acute, unanticipated health shock, I estimate a 7-14 percent decreased likelihood of all family members leaving their current health insurance network and health plan within one year of the emergency. This corresponds to a reduced one-year job mobility rate of approximately 13 percent for the health plan's primary policyholder. Furthermore, the non-portability of health insurance products may contribute to the observed job and health plan lock.

Legitimacy of Cost Concern for Health Insurance Coverage of Gender-Affirming Surgeries: Comparison of the Interest in Keeping Insurance Cost Down versus the Cost-Effectiveness of Including Gender-Affirming Surgeries in Employer Health Insurance Plans.

This RCD discusses the recent development in Lange v Houston County. In this case, the United States District Court for The Middle District Of Georgia Macon Division found that an Exclusion Policy, prohibiting health insurance coverage of gender-affirming surgery for an employee, Anna Lange, violated Title VII of the Civil Rights Act. On appeal, the Defendants argued that the District Court erred in its decision and relied on the cost burden of gender-affirming surgery as one of their defenses. This RCD highlights that cost is a common defense tactic used by defendants in these cases. However, the author argues that these concerns are unfounded and meritless given the cost-effectiveness of including gender-affirming surgeries in health insurance plans, as highlighted in the RCD.

Do High-Deductible Health Plans Incentivize Changing the Timing of Substance Use Disorder Treatment?

A high-deductible health plan (HDHP) may incentivize enrollees to limit health care use at the beginning of a plan year, when they are responsible for 100% of costs, or to increase the use of care at the end of the year, when enrollees may have less cost exposure. We investigated both the impact of the deductible reset that occurs at the beginning of a plan year and the option to enroll in an HDHP on the use of substance use disorder (SUD) treatment services over the course of a health plan year. We found decreases in SUD treatment use following the increase in cost exposure related to a deductible reset. There was no variation in this behavior between HDHP offer enrollees and comparison enrollees who were not offered an HDHP. These findings reinforce that cost-sharing poses a barrier to SUD care and continuity of care, which can increase the risk of adverse clinical outcomes.

Health Insurer Strategies to Reduce Specialty Drug Spending-Copayment Adjustment and Alternative Funding Programs.

This Viewpoint describes programs intended to help patients with commercial insurance that, instead, employers, health plans, and other payers use to reduce their spending on specialty drugs.

Employer-Based Health Insurance and Employee Compensation.

This Viewpoint expounds on how the cost of health insurance is consuming an ever-greater share of total compensation for employers and employees, stagnating real incomes and calling into question its real value.

Trabalho doméstico remunerado e resistência: interseccionando raça, gênero e classe / Paid domestic work and resistance: intersecting race, gender, and class / Trabajo doméstico remunerado y resistencia: intersección entre raza, género y clase

No Brasil, o trabalho doméstico remunerado é essencialmente feminino e emprega cerca de 5,9 milhões de mulheres, correspondendo a 16,8% da ocupação feminina. Desse contingente, 61 % são compostos por mulheres negras. As empregadas domésticas estiveram historicamente submetidas a uma série de aspectos excludentes, como baixa remuneração, contratações à margem da legalidade e discriminação de gênero e raça. Esta pesquisa objetivou compreender a resistência enquanto categoria fundamental para compreensão do trabalho doméstico. Ao falar sobre essa categoria, destacamos a subjetividade que constitui os fenômenos sociais, partindo de uma compreensão dialética e histórica do sujeito e da relação indivíduo-sociedade, inserida em uma historicidade. Os resultados encontrados, coletados por meio de documentos, notícias, reportagens, participações no sindicato da categoria e da realização de entrevistas com cinco domésticas apontam a existência de formas de resistência no campo do trabalho doméstico, compondo movimentos de oposição e reação ao modus operandi colonial e às hierarquias de gênero-raça-classe que formam a sociedade brasileira. A psicologia sócio-histórica foi escolhida como abordagem teórico-metodológica, pois possibilita compreender do homem como ser ativo, social e histórico. Ao investigar as formas de resistência presentes nesse tipo de trabalho, compreende-se a trabalhadora doméstica não como mera consequência da realidade social em que se insere, mas como sujeito ativo que constitui essa realidade e é simultaneamente constituído por ela. Com esta pesquisa, pretende-se contribuir com a crítica à ideologia dominante que subalterniza essas trabalhadoras e as relega à subcidadania, uma condição sem reconhecimento e direitos.(AU)

In Brazil, paid domestic work is essentially female and employs about 5.9 million women, corresponding to 16.8% of the female occupation. Of this contingent, 61% is made up of black women. Domestic workers have historically been subjected to a series of exclusionary aspects, such as low remuneration, hiring outside the legal system and gender and race discrimination. This research aimed to understand resistance as a fundamental category for understanding domestic work. When talking about this category, we highlight the subjectivity that constitutes social phenomena, starting from a dialectical and historical understanding of the subject and the individual-society relationship, inserted in a historicity. The results found, collected from documents, news, reports, participation in the category union and interviews with five domestic workers, point to the existence of forms of resistance in the field of domestic work, composing movements of opposition and reaction to the colonial modus operandi and the gender-race-class hierarchies that make up Brazilian society.Socio-historical psychology was chosen as a theoretical-methodological approach, since it provides an understanding of man as an active, social and historical being. When investigating the forms of resistance present in this type of work, the domestic worker is understood not as a mere consequence of the social reality in which she is inserted, but, as an active subject, who constitutes this reality and is simultaneously constituted by it. This research intends to contribute to the criticism of the dominant ideology that subordinates these workers and relegates them to a sub-citizenship, a condition without recognition and rights.(AU)

El trabajo doméstico remunerado en Brasil es predominantemente femenino y emplea casi 5,9 millones de mujeres, lo que corresponde al 16,8% de la ocupación femenina. El 61% de este grupo está compuesto por mujeres negras. Históricamente, las trabajadoras del hogar han sido sometidas a una serie de aspectos excluyentes, como la baja remuneración, la contratación fuera del sistema legal y la discriminación de género y raza. Esta investigación tuvo como objetivo comprender la resistencia como categoría fundamental para entender el trabajo doméstico. Al hablar de esta categoría, se destaca la subjetividad que constituye los fenómenos sociales a partir de una comprensión dialéctica e histórica del sujeto y la relación individuo-sociedad, insertada en una historicidad. Los datos recogidos de documentos, noticias, participación en la categoría unión y entrevistas con cinco sirvientas permitieron concluir que existen formas de resistencia en el ámbito del trabajo doméstico, que se componen de movimientos de oposición y reacción al modus operandi colonial y a jerarquías de género-raza-clase que conforman la sociedad brasileña. La psicología sociohistórica fue el enfoque teórico-metodológico utilizado, ya que proporciona una comprensión del ser humano como ser activo, social e histórico. El análisis de las formas de resistencia presentes en este tipo de trabajo permite identificar la trabajadora doméstica no como una mera consecuencia de la realidad social en la cual se inserta, sino como sujeto activo que constituye esta realidad y, a la vez, es constituido por ella. Se espera que esta investigación pueda contribuir a la crítica de la ideología dominante que subordina a estas trabajadoras, relegándolas a una subciudadanía, una condición sin reconocimiento y sin derechos.(AU)

How The "Great Resignation" and COVID Unemployment Have Eroded the Employer Sponsored Insurance Model and Access to Healthcare.

Pre-pandemic, employer-sponsored health insurance (ESI) covered 175 million workers and their dependents, the equivalent of 49% of the country's total population. ESI, a valuable tax preference to employer and employee alike, spurred worker job dependence on employers resulting in access to healthcare dependent upon continued employment. With the advent of the pandemic and the dramatic increase in unemployment, the number of uninsured increased by more than 2.7 million people. Then, unemployment proliferated further by an unprecedented exit from the workforce dubbed the "Great Resignation." Over 47 million Americans voluntarily quit their jobs in a movement characterized as a general labor strike. The pandemic opened the floodgates to workers' concerns about COVID safety in the workplace, wage stagnation despite increases in the cost of living, enduring job dissatisfaction, and increased demand for a remote-working environment. Data shows that the unemployed shifted to the Affordable Care Act marketplace or to the public payer option, Medicaid, for coverage. This shift signals a change, post-pandemic, away from the destabilizing system of access to care based on employment and unwanted job dependence and provides a policy argument favoring the more stabilizing influence of public insurance options in the health insurance market.