Significance and Factors Associated with Antipsychotic Polypharmacy Utilization Among Publicly Insured US Adults.

Antipsychotic polypharmacy (APP) lacks evidence of effectiveness in the care of schizophrenia or other disorders for which antipsychotic drugs are indicated, also exposing patients to more risks. Authors assessed APP prevalence and APP association with beneficiary race/ethnicity and payer among publicly-insured adults regardless of diagnosis. Retrospective repeated panel study of fee-for-service (FFS) Medicare, Medicaid, and dually-eligible white, black, and Latino adults residing in California, Georgia, Iowa, Mississippi, Oklahoma, South Dakota, or West Virginia, filling antipsychotic prescriptions between July 2008 and June 2013. Primary outcome was any monthly APP utilization. Across states and payers, 11% to 21% of 397,533 antipsychotic users and 12% to 19% of 9,396,741 person-months had some APP utilization. Less than 50% of person-months had a schizophrenia diagnosis and up to 19% had no diagnosed mental illness. Payer modified race/ethnicity effects on APP utilization only in CA; however, the odds of APP utilization remained lower for minorities than for whites. Elsewhere, the odds varied by race/ethnicity only in OK, with Latinos having lower odds than whites (odds ratio 0.76; 95% confidence interval 0.60-0.96). The odds of APP utilization varied by payer in several study states, with odds generally higher for Dual eligibles, although the differences were generally small; the odds also varied by year (lower at study end). APP was frequently utilized but mostly declined over time. APP utilization patterns varied across states, with no consistent association with race/ethnicity and small payer effects. Greater use of APP-reducing strategies are needed, particularly among non-schizophrenia populations.

Patterns of Postoperative Visits Among Medicare Fee-for-service Beneficiaries.

OBJECTIVE: To describe patterns of postoperative visits reported for Medicare fee-for-service (FFS) patients. BACKGROUND: Payment for most surgical procedures bundles postoperative visits within a global period of either 10 or 90 days after a procedure. There is concern that payments for some procedures are excessive because the number of postoperative visits provided is less than the number of postoperative visits used to help determine payment. To obtain data to inform this concern, Medicare required select surgeons to report on their postoperative visits starting July 1, 2017. METHODS: We analyzed Medicare FFS claims data from surgeons who billed Medicare for 1 or more of the 293 common procedure codes between July 1, 2017 and December 31, 2017 in the 9 states where surgeons were required to report postoperative visits. We examined the share of procedures with any reported postoperative visits and the proportion of expected postoperative visits provided. To address concerns about underreporting, we also examined procedures performed by a subset of surgeons actively reporting postoperative visits. RESULTS: We linked 663,681 procedures to 422,432 postoperative visits. The share of procedures with any postoperative visits was higher for procedures with 90-day global periods (70.1%) than for procedures with 10-day global periods (3.7%). The proportions of expected postoperative visits provided for 90-day global and 10-day global periods were 0.37 and 0.04 respectively. Among surgeons actively reporting postoperative visits, the proportions of expected postoperative visits provided were modestly higher (procedures with 90-day global periods=0.46 and 10-day global periods=0.16). CONCLUSIONS: The proportion of expected postoperative visits that were provided is low. These results support the need for a reassessment of payment for surgical procedures.

Shifts in Medicaid and Uninsured Payer Mix at Safety-Net and Non-Safety-Net Hospitals During the Great Recession.

EXECUTIVE SUMMARY: There has been ongoing concern regarding the viability of safety-net hospitals (SNHs), which care for vulnerable populations. The authors examined payer mix at SNHs and non-SNHs during a period covering the Great Recession using data from the 2006 to 2012 Healthcare Cost and Utilization Project State Inpatient Databases from 38 states. The number of privately insured stays decreased at both SNHs and non-SNHs. Non-SNHs increasingly served Medicaid-enrolled and uninsured patients; in SNHs, the number of Medicaid stays decreased and uninsured stays remained stable. These study findings suggest that SNHs were losing Medicaid-enrolled patients relative to non-SNHs before the Medicaid expansion under the Affordable Care Act (ACA). Postexpansion, Medicaid stays will likely increase for both SNHs and non-SNHs, but the increase at SNHs may not be as large as expected if competition increases. Because hospital stays with private insurance and Medicaid help SNHs offset uncompensated care, a lower-than-expected increase could affect SNHs' ability to care for the remaining uninsured population. Continued monitoring is needed once post-ACA data become available.

Variation in dermatologist visits by sociodemographic characteristics.

BACKGROUND: Access to dermatologists is an ongoing concern for Medicaid enrollees. Understanding current use is a key step toward designing and implementing policies to improve access. OBJECTIVE: We sought to quantify how often Medicaid enrollees visit dermatologists and receive treatment for skin-related conditions compared with patients with other coverage or without health insurance. METHODS: We conducted a retrospective cross-sectional analysis of multiyear federal survey data (Medical Expenditure Panel Survey). The sample included Medical Expenditure Panel Survey respondents younger than 65 years from 2008 to 2012. RESULTS: In unadjusted comparisons, we found that 1.4% of Medicaid enrollees had an ambulatory visit to a dermatologist annually, compared with 1.2% of uninsured individuals and 5.5% of individuals with private coverage. In adjusted models, we found that health insurance source, age, sex, race/ethnicity, and geography are associated with the likelihood of having visits to a dermatologist. Compared with individuals with private coverage, Medicaid enrollees are less likely to receive a diagnosis for a skin condition by any provider and are less than half as likely to have skin-related diagnoses made by dermatologists. LIMITATIONS: We have relatively few Medical Expenditure Panel Survey respondents for a subset of specific diagnoses. CONCLUSIONS: Our findings emphasize the need for efforts to reduce disparities in access to dermatologists.

Insurance coverage of emergency care for young adults under health reform.

BACKGROUND: The Affordable Care Act (ACA) established nationwide eligibility for young adults 19 to 25 years of age to retain coverage under their parents' private health plans. We conducted a study to determine how the implementation of this provision changed rates of insurance coverage for young adults seeking medical care for major emergencies. METHODS: We evaluated more than 480,000 nondiscretionary visits made to emergency departments from 2009 through 2011, as recorded in a large, geographically diverse data set of hospital claims, to estimate how the ACA provision affected private insurance coverage of such visits by young adults (19 to 25 years of age). To adjust for underlying trends in insurance coverage, we compared changes in the target age group with changes among adults 26 to 31 years of age, who were unaffected by the provision (control group). RESULTS: After the ACA provision took effect, private coverage of nondiscretionary visits to emergency departments by young adults increased by 3.1 percentage points (95% confidence interval [CI], 2.3 to 3.9; relative increase, 5.2%; P<0.001), as compared with similar visits in the control group. The percentage of visits by uninsured young adults also fell significantly (-1.7 percentage points; 95% CI, -2.8 to -0.7; relative decrease, 9.1%; P<0.001). The rates of nondiscretionary visits that were covered by Medicaid or other nonprivate insurers remained relatively steady throughout the study period. The coverage expansion led to an estimated 22,072 visits to emergency departments by newly insured young adults and $147 million in associated costs that were covered by private insurance plans during a 1-year period. CONCLUSIONS: Enactment of the dependent-coverage provision was associated with a significant increase in the proportion of young adults who were protected from the financial consequences of a serious medical emergency. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services.).

Access and Quality of Care in Direct-to-Consumer Telemedicine.

BACKGROUND: Direct-to-consumer (DTC) telemedicine serves millions of patients; however, there is limited research on the care provided. This study compared the quality of care at Teladoc ( www.teladoc.com ), a large DTC telemedicine company, with that at physician offices and compared access to care for Teladoc users and nonusers. MATERIALS AND METHODS: Claims from all enrollees 18-64 years of age in the California Public Employees' Retirement System health maintenance organization between April 2012 and October 2013 were analyzed. We compared the performance of Teladoc and physician offices on applicable Healthcare Effectiveness Data and Information Set measures. Using geographic information system analyses, we compared Teladoc users and nonusers with respect to rural location and available primary care physicians. RESULTS: Of enrollees offered Teladoc (n = 233,915), 3,043 adults had a total of 4,657 Teladoc visits. For the pharyngitis performance measure (ordering strep test), Teladoc performed worse than physician offices (3% versus 50%, p < 0.01). For the back pain measure (not ordering imaging), Teladoc and physician offices had similar performance (88% versus 79%, p = 0.20). For the bronchitis measure (not ordering antibiotics), Teladoc performed worse than physician offices (16.7 versus 27.9%, p < 0.01). In adjusted models, Teladoc users were not more likely to be located within a healthcare professional shortage area (odds ratio = 1.12, p = 0.10) or rural location (odds ratio = 1.0, p = 0.10). CONCLUSIONS: Teladoc providers were less likely to order diagnostic testing and had poorer performance on appropriate antibiotic prescribing for bronchitis. Teladoc users were not preferentially located in underserved communities. Short-term needs include ongoing monitoring of quality and additional marketing and education to increase telemedicine use among underserved patients.

Pharmaceutical pricing in emerging markets: effects of income, competition, and procurement.

This paper analyzes determinants of ex-manufacturer prices for originator and generic drugs across countries. We focus on drugs to treat HIV/AIDS, TB, and malaria in middle and low-income countries (MLICs), with robustness checks to other therapeutic categories and the full income range of countries. We examine the effects of per capita income, income dispersion, competition from originator and generic substitutes, and whether the drugs are sold to retail pharmacies versus tendered procurement by non-government organizations. The cross-national income elasticity of prices is 0.27 across the full income range of countries but is 0.0-0.10 between MLICs, implying that drugs are least affordable relative to income in the lowest income countries. Within-country income inequality contributes to relatively high prices in MLICs. Although generics are priced roughly 30% lower than originators on average, the variance is large. Additional generic competitors only weakly affect prices, plausibly because generic quality uncertainty leads to competition on brand rather than price. Tendered procurement that imposes quality standards attracts multinational generic suppliers and significantly reduces prices of originator and generic drugs, compared with their respective prices to retail pharmacies.

Comparing New Prescription Drug Availability and Launch Timing in the United States and Other OECD Countries.

Prescription drug research and development is, particularly in its most expensive later stages, an increasingly global endeavor undertaken by large, multinational firms. However, the availability of the resulting new drugs in individual countries and the timing of their launch can vary because of regulatory differences, business decisions, and other factors. The now-enacted Inflation Reduction Act of 2022 and other policy proposals aim to lower U.S. prices for brand-name drugs that are between three and four times as expensive as in other higher-income countries. Some stakeholders assert that lower U.S. prices will prevent U.S. patients from accessing some drugs sold in other countries or delay the launch of new drugs in the United States. To address these concerns, the author uses 2018 to 2022 data to compare the availability and timing of entry of new prescription drugs between the United States and other high-income countries.

Comparing Insulin Prices in the United States to Other Countries: Updated Results Using 2022 Data.

Manufacturers' list prices for insulin have increased dramatically over the past decade in the United States. In this study, the authors present results from a comparison of U.S. and international prices for insulins using a price index approach. They compare prices for all insulins and different categories of insulin in the United States and 33 comparison Organisation for Economic Co-operation and Development countries. They present separate comparisons using U.S. manufacturer gross prices reflected at pharmacies and estimated manufacturer net prices after applying rebates paid by manufacturers. This study updates a prior RAND Corporation study, Comparing Insulin Prices in the United States to Other Countries: Results from a Price Index Analysis, with more-recent data and includes new supplementary analyses, editorial changes, and updates to reflect the evolving insulin market landscape.

International Prescription Drug Price Comparisons: Estimates Using 2022 Data.

Understanding the extent to which prescription drug prices are higher in the United States than in other countries-after accounting for differences in the volume and mix of drugs-is useful when developing and targeting policies to address both growth in drug spending and the financial impact of prescription drugs on consumers. This study summarizes findings from comparisons of drug prices in the United States and other high-income countries based on 2022 data and presents results for specific types of drugs, including brand-name originator drugs and unbranded generic drugs, and from sensitivity analyses.

Prescription Drug Supply Chains: An Overview of Stakeholders and Relationships.

The authors describe the stakeholders involved in prescription drug supply chains and the flows of products, payments, and information between stakeholders. Many stakeholders and steps are involved in the life cycle of a prescription drug as it moves from chemical synthesis and formulation through dispensing or administration to patients. The specific steps involved in prescription drug supply chains often differ depending on the type of drug, the channel of distribution, and the patient's source of prescription drug coverage. Although the authors present a typical supply chain for retail pharmacy drugs, they also highlight the important supply chain distinctions for specific distribution channels and for specific types of drugs. Disparate sources exist describing each component of the supply chain, but, to the authors' knowledge, this study is the first to compile them to facilitate understanding of their interdependence and complexity. The typical stakeholders, relationships, and financial incentives in prescription drug supply chains vary depending on the characteristics of a drug and how it reaches patients. Even within a specific type of drug and a particular distribution channel, differences in business practices complicate a universal description of drug supply chains. There are four common core components of drug supply chains: manufacturing, distribution, coverage and payment, and prescribing and demand. Although prescription drugs are generally available to dispense when prescribed in the United States, there are important exceptions that warrant further investigation. The ability of policymakers to identify, assess, and respond to shortages and disruptions in supply chains is hampered by incomplete data.

Variation in Estimated Surgical Procedure Times Across Patient Characteristics and Surgeon Specialty.

Importance: The time involved in performing a procedure is a key factor in determining physician payments by Medicare. However, there are long-standing concerns regarding the accuracy of the time estimates generated by the American Medical Association/Specialty Society Relative Value Scale Update Committee surveys that are used in the valuation process, and there have been calls to use other data sources to estimate procedure times. Objective: To compare estimated procedure times that come from claims with the times used in Medicare's valuation process. Design and Setting: Building off prior work using Medicare fee-for-service claims, procedure times were estimated from linked anesthesia claims data for 1349 different Current Procedure Terminology codes that are typically performed with anesthesia. All procedures in the nation performed in 2018 for Medicare fee-for-service beneficiaries were included in the analysis. These estimated times were compared with the times used in the valuation process. Analysis took place from February to November 2021. Main Outcomes and Measures: Estimated procedure times using anesthesia claims were compared with the procedure time used in valuation by calculating an estimated-to-valuation procedure time ratio for each code. The valuation procedure time is publicly reported by Medicare. The mean and median ratio are presented over all procedures and for select high-volume codes as well as by patient characteristics (age, sex, and risk score) and specialty of the physician performing the procedure. Results: Across 4.9 million procedures in this analysis, the mean estimated procedure time was 27% lower than the time used in the valuation process. There were notable exceptions, for which the mean estimated procedure time equaled or exceeded the valuation time including total hip arthroplasty (5% longer) and total knee arthroplasty (equal duration). Within a given code, older patients and those with more illness had longer procedure times. There was substantial variation across specialties in the percent difference between mean estimated and valuation procedure times ranging from gastroenterology (36% shorter) and ophthalmology (35% shorter) to cardiac surgery (2% longer) and thoracic surgery (7% longer). Conclusions and Relevance: Claims-based procedure times could be used to improve the accuracy of valuations for procedures.

Projected US savings from biosimilars, 2021-2025.

OBJECTIVES: Biologics account for an increasing share of US prescription drug spending. Biosimilars could lower biologic prices through competition, but barriers to increasing both supply and uptake remain. We projected US biosimilar savings from 2021 to 2025 under different scenarios. STUDY DESIGN: We projected US spending on biologics over a 5-year period under 3 scenarios: (1) a baseline scenario holding quarter 4 (Q4) of 2020 market conditions constant; (2) under main assumptions allowing for biosimilar market growth and entry; and (3) an upper-bound scenario assuming greater biosimilar uptake, more robust price competition, and quicker biosimilar entry. METHODS: We first analyzed 2014-2020 US volume and price data from IQVIA's MIDAS database for biologics already facing biosimilar competition to inform model parameter values. We used these inputs to project biosimilar entry, biosimilar volume shares, biosimilar prices, and reference biologic prices. We calculated 2021-2025 new savings from biosimilar competition vs the Q4 2020 baseline. RESULTS: Estimated biosimilar savings from 2021 to 2025 under our main approach were $38.4 billion, or 5.9% of projected spending on biologics over the same period. Biologics first facing biosimilar competition from 2021 to 2025 accounted for $26.1 billion of savings, with $12.2 billion from evolving market conditions for already-marketed biosimilars. Furthermore, $24.6 billion of savings under our main approach were from downward pressure on reference biologic prices rather than lower biosimilar prices. Savings were substantially higher ($124.5 billion) under the upper-bound scenario. CONCLUSIONS: Biosimilar savings from 2021 to 2025 were $38.4 billion under our main assumptions. Greater savings may be feasible if managed care and other settings increase biosimilar utilization and promote competition.

Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods: Updated Results Using Calendar Year 2018 Data.

Medicare payments for most surgical procedures cover both procedures and post-operative visits occurring within a global period of either ten or 90 days following procedures. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, the Centers for Medicare & Medicaid Services (CMS) required select practitioners to report on post-operative visits after select procedures with 10- or 90-day global periods. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2018, building on prior research that analyzed data for procedures with July 1, 2017, through June 30, 2018, service dates. During calendar year 2018, 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed to expected post-operative visits provided for 90-day global period procedures was only 0.38. Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to the main analysis. Collectively, these findings suggest that a large share of expected post-operative visits are not delivered, and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.

Claims-Based Reporting of Post-Operative Visits for Procedures with 10- or 90-Day Global Periods: Updated Results Using Calendar Year 2019 Data.

Medicare payments for most surgical procedures cover both procedures and post-operative visits occurring within a global period of either 10 or 90 days following procedures. There have been concerns that fewer post-operative visits are provided than the number of post-operative visits considered when the procedure was valued. To help inform accurate valuation of procedures with global periods, the Centers for Medicare & Medicaid Services (CMS) required select practitioners to report on post-operative visits after select procedures with 10- or 90-day global periods. The authors of this article summarize patterns of post-operative visits for procedures furnished during calendar year 2019, building on prior research that analyzed data for procedures furnished from July 1, 2017, through June 30, 2018, and for the entire 2018 calendar year. During calendar year 2019, 96.5 percent of procedures with 10-day global periods did not have an associated post-operative visit. Approximately two-thirds of procedures with 90-day global periods had an associated post-operative visit; however, the ratio of observed to expected post-operative visits provided for 90-day global period procedures was only 0.38. Underreporting of post-operative visits might be driving these low rates. However, in sensitivity analyses limited to practitioners who were actively reporting their post-operative visits, post-operative patterns were largely similar to the main analysis. Collectively, these findings suggest that many expected post-operative visits are not delivered and that underreporting is unlikely to fully explain the low ratio of expected post-operative visits provided.