Variability of COPD inhaler coverage in Medicare Part D.

OBJECTIVES: Stand-alone prescription drug plans (S-PDPs) and Medicare Advantage prescription drug (MA-PD) plans are incentivized to cover outpatient medications differently. This could affect the coverage of inhalers that prevent costly exacerbations of chronic obstructive pulmonary disease (COPD), with impacts for the Medicare program and its beneficiaries. This study compared the coverage of guideline-recommended COPD inhalers between S-PDPs and MA-PD plans. STUDY DESIGN: A cross-sectional analysis of the formularies for all 689 S-PDPs and 2578 MA-PD plans offered in 2017. METHODS: We assessed each prescription drug plan's coverage of inhalers in 6 therapeutic categories recommended by the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report and compared the use of prior authorization, step therapy, and coinsurance between S-PDPs and MA-PD plans. RESULTS: In 2017, all S-PDPs and MA-PD plans covered at least 1 inhaler from each GOLD therapeutic category, except for long-acting ß agonist/long-acting muscarinic antagonist combination inhalers. S-PDPs were more likely to require coinsurance for inhalers across all therapeutic categories, whereas MA-PD plans required prior authorization more frequently for 3 of the 6 therapeutic categories. S-PDPs required coinsurance more frequently than MA-PD plans for inhalers that treat mild (20.8% vs 11.4%; P < .001), moderate (40.0 vs 13.2%; P < .001), and severe (45.4% vs 11.0%; P < .001) disease. CONCLUSIONS: Medicare Part D S-PDPs are more likely than MA-PD plans to require coinsurance for outpatient COPD inhalers, especially for severe disease. This likely reflects their different financial incentives and is an important consideration for providers and policy makers aiming to improve outpatient COPD management.

Reducing Electrolyte Testing in Hospitalized Children by Using Quality Improvement Methods.

BACKGROUND AND OBJECTIVES: Despite studies indicating a high rate of overuse, electrolyte testing remains common in pediatric inpatient care. Frequently repeated electrolyte tests often return normal results and can lead to patient harm and increased cost. We aimed to reduce electrolyte testing within a hospital medicine service by >25% within 6 months. METHODS: We conducted an improvement project in which we targeted 6 hospital medicine teams at a large academic children's hospital system by using the Model for Improvement. Interventions included standardizing communication about the electrolyte testing plan and education about the costs and risks associated with overuse of electrolyte testing. Our primary outcome measure was the number of electrolyte tests per patient day. Secondary measures included testing charges and usage rates of specific high-charge panels. We tracked medical emergency team calls and readmission rates as balancing measures. RESULTS: The mean baseline rate of electrolyte testing was 2.0 laboratory draws per 10 patient days, and this rate decreased by 35% after 1 month of initial educational interventions to 1.3 electrolyte laboratory draws per 10 patient days. This change has been sustained for 9 months and could save an estimated $292 000 in patient-level charges over the course of a year. Use of our highest-charge electrolyte panel decreased from 67% to 22% of testing. No change in rates of medical emergency team calls or readmission were found. CONCLUSIONS: Our improvement intervention was associated with significant and rapid reduction in electrolyte testing and has not been associated with unintended adverse events.