The Impact of Sharing Drug Rebates at the Point of Sale on Out-of-Pocket Payments for Enrollees in Employer-Sponsored Insurance.

OBJECTIVES: This study aimed to estimate the impact of sharing drug rebates at the point of sale on out-of-pocket spending by linking estimated rebates to administrative claims data for employer-sponsored insurance enrollees in 2018. METHODS: We applied the drug rebate rate to the retail price of each brand name drug fill, allocated the reductions to out-of-pocket spending based on cost-sharing provisions, and aggregated each individual's out-of-pocket spending across drug fills. We assumed that generic drugs have no rebates for employer-sponsored insurance. We assessed the impact of sharing rebates at the point of sale on out-of-pocket spending overall, for the therapeutic classes and specific drugs with the highest average out-of-pocket spending per user, and by health plan type. RESULTS: Across 4 simulations with different assumptions about the degree of cross-fill effects, we found that 10.4% to 12.2% of enrollees in our sample would have realized savings on out-of-pocket spending if rebates were shared to the point of sale. Among those with savings, approximately half would save $50 or less, and 10% would save > $500 annually. We calculated that a premium increase of $1.06 to $1.41 per member per month among the continuously enrolled, insured population would be sufficient to finance the out-of-pocket savings in our sample. CONCLUSIONS: Our study suggests that, for a small percentage of enrollees, sharing drug rebates at the point of sale would likely improve the affordability of high-priced brand name drugs, especially drugs that face significant competition.

New Linked Employee-Employer Data Show Workforce Composition Is Associated With Health Insurance Offers Among Small Employers.

Decades of research shows that small firms are much less likely to offer health insurance than large firms, but less is known about differences among small employers. We examine this issue using the Medical Expenditure Panel Survey-Insurance Component with Administrative Records (MEPS-ICAR), a unique employer-employee linked data set that is constructed by matching the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC) to Internal Revenue Service administrative records and the Decennial Census. Multivariate analyses show that among firms with fewer than 50 workers, the probability that workers receive an insurance offer is positively associated with higher median workforce incomes, and conditional offers of dependent coverage increase when the majority of workers are married or from a family with at least three members. This first application of the MEPS-ICAR highlights the significance of workforce characteristics in shaping small employer insurance benefits and the data's usefulness for expanding analyses of policy changes, wage-benefit tradeoffs, and health insurance benefits.

Health expenditure estimation and functional form: applications of the generalized gamma and extended estimating equations models.

Health-care expenditure regressions are used in a wide variety of economic analyses including risk adjustment and program and treatment evaluations. Recent articles demonstrated that generalized gamma models (GGMs) and extended estimating equations (EEE) models provide flexible approaches to deal with a variety of data problems encountered in expenditure estimation. To date there have been few empirical applications of these models to expenditures. We use data from the US Medical Expenditure Panel Survey to compare the bias, predictive accuracy, and marginal effects of GGM and EEE models with other commonly used regression models in a cross-validation study design. Health-care expenditure distributions vary in the degree of heteroskedasticity, skewness, and kurtosis by type of service and population. To examine the ability of estimators to address a range of data problems, we estimate models of total health expenditures and prescription drug expenditures for two populations, the elderly and privately insured adults. Our findings illustrate the need for researchers to examine their assumptions about link functions: the appropriate link function varies across our four distributions. The EEE model, which has a flexible link function, is a robust estimator that performs as well, or better, than the other models in each distribution.

Net Spending On Retail Specialty Drugs Grew Rapidly, Especially For Private Insurance And Medicare Part D.

Specialty drugs are expensive, but spending on specialty drugs is difficult to measure because of proprietary rebate payments by manufacturers to insurers, pharmacy benefit managers, and state Medicaid agencies. Our study extends recent research that documented growing use of and spending on specialty drugs by incorporating manufacturer rebates for both public and private payers. Although specialty drugs make up a small portion of retail prescriptions filled, we found that they accounted for 37.7 percent of retail and mail-order prescription spending net of rebates in 2016-17. From 2010-11 to 2016-17, spending net of rebates tripled for Medicare Part D beneficiaries and more than doubled for people with private insurance. Medicaid spending net of rebates rose more slowly. These results can help inform decision makers as they strive to balance the costs and benefits of innovative drugs.

Decomposing changes in the growth of U.S. prescription drug use and expenditures, 1999-2016.

OBJECTIVE: To analyze factors associated with changes in prescription drug use and expenditures in the United States from 1999 to 2016, a period of rapid growth, deceleration, and resumed above-average growth. DATA SOURCES/STUDY SETTING: The Medical Expenditure Panel Survey (MEPS), containing household and pharmacy information on over five million prescription drug fills. STUDY DESIGN: We use nonparametric decomposition to analyze drug use, average payment per fill, and per capita expenditure, tracking the contributions over time of socioeconomic characteristics, health status and treated conditions, insurance coverage, and market factors surrounding the patent cycle. DATA COLLECTION/EXTRACTION METHODS: Medical Expenditure Panel Survey data were combined with information on drug approval dates and patent status. PRINCIPAL FINDINGS: Per capita utilization increased by nearly half during 1999-2016, with changes in health status and treated conditions accounting for four-fifths of the increase. In contrast, per capita expenditures more than doubled, with individual characteristics only explaining one-third of the change. Other drivers of spending during this period include the changing pipeline of new drugs, drugs losing exclusivity, and changes in generic competition. CONCLUSIONS: Long-term trends in treated conditions were the fundamental drivers of medication use, whereas factors involving the patent cycle accelerated and decelerated spending growth relative to trends in use.

Despite Coverage Gains, One-Third Of People In Small-Firm Low-Income Families Were Uninsured In 2014-15.

Obtaining health insurance coverage has historically been challenging for workers at small firms and the self-employed. Using data from the Medical Expenditure Panel Survey, we found that the overall uninsurance rate for these workers and their families declined by 5 percentage points over the past decade, but one-third of those with lower incomes remained uninsured in 2014-15.

High-Deductible Health Plan Enrollment Increased From 2006 To 2016, Employer-Funded Accounts Grew In Largest Firms.

Over the past decade, employers have increasingly turned to high-deductible health plans (HDHPs) to limit health insurance premium growth. We used data from private-sector establishments for 2006 and 2016 from the Medical Expenditure Panel Survey-Insurance Component to examine trends in HDHP enrollment and heterogeneity in HDHPs by firm size. We studied insurance plan offerings along the following dimensions: whether employers fund accounts to help defray employees' out-of-pocket health care spending, the availability of non-HDHP plan choices, and single and family deductible levels. We extend the literature by examining these characteristics by detailed firm-size categories and by including all plans with deductibles that met or exceeded Internal Revenue Service thresholds to be qualified for health savings accounts. We found that in 2016, 78.0 percent of HDHP enrollees in the smallest firms (those with fewer than 25 employees) lacked an employer-funded account, compared to 35.2 percent in the largest firms (those with 1,000 or more employees). Overall, HDHP enrollees in the largest firms had significant advantages relative to workers in smaller firms along all of the dimensions examined.

The availability and marginal costs of dependent employer-sponsored health insurance.

In this study, we examine differences by firm size in the availability of dependent coverage and the incremental cost of such coverage. We use data from the Medical Expenditure Panel Survey - Insurance Component (MEPS-IC) to show that among employees eligible for single coverage, dependent coverage was almost always available for employees in large firms (100 or more employees) but not in smaller firms, particularly those with fewer than 10 employees. In addition, when dependent coverage was available, eligible employees in smaller firms were more likely than employees in large firms to face two situations that represented the extremes of the incremental cost distribution: (1) they paid nothing for single or family coverage or (2) they paid nothing for single coverage but faced a high contribution for family coverage. These results suggest that firm size may be an important factor in policy assessments, such as analyses of the financial implications for families excluded from subsidized Marketplace coverage due to affordable offers of single coverage or of potential rollbacks to public coverage for children.

Substantial Churn In Health Insurance Offerings By Small Employers, 2014-15.

New data for 2014-15 from the Medical Expenditure Panel Survey-Insurance Component longitudinal survey show substantial churn in insurance offers by small employers (those with fifty or fewer workers), with 14.6 percent of employers that offered insurance in 2014 having dropped it in 2015 and 5.5 percent of those that did not offer it adding coverage.

Determinants of Potentially Inappropriate Medication Use among Community-Dwelling Older Adults.

OBJECTIVE: To examine the determinants of potentially inappropriate medication (PIM) use. DATA SOURCES/STUDY SETTING: U.S. nationally representative data on (n = 16,588) noninstitutionalized older adults (age ≥65) with drug use from the 2006-2010 Medical Expenditure Panel Survey. STUDY DESIGN: We operationalized the 2012 Beers Criteria to identify PIM use during the year, and we examined associations with individual-level characteristics hypothesized to be quality enabling or related to need complexity. PRINCIPAL FINDINGS: Almost one-third (30.9 percent) of older adults used a PIM. Multivariate results suggest that poor health status and high-PIM-risk conditions were associated with increased PIM use, while increasing age and educational attainment were associated with lower PIM use. Contrary to expectations, lack of a usual care source of care or supplemental insurance was associated with lower PIM use. Medication intensity appears to be in the pathway between both quality-enabling and need-complexity characteristics and PIM use. CONCLUSION: Our results suggest that physicians attempt to avoid PIM use in the oldest old but have inadequate focus on the high-PIM-risk conditions. Educational programs targeted to physician practice regarding high-PIM-risk conditions and patient literacy regarding medication use are potential responses.

Gender differences in drug use and expenditures in a privately insured population of older adults.

We examine gender differences in use and expenditures for prescription drugs among Medicare and privately insured older adults aged 65 and over, using data on a nationally representative sample of prescription drug purchases collected for the Medical Expenditure Panel Survey Household Component. Overall, women spent about $1,178 for drugs, about 17% more than the $1,009 in average expenditures by men. Older women constituted 50.7% of the population and had average annual aggregate expenditures for prescribed medicines of $6.93 billion compared to $5.77 billion for men. Women were more likely than men to use drugs from a number of therapeutic classes-analgesics, hormones and psychotherapeutic agents-and therapeutic subclasses-thyroid drugs, COX-2 inhibitors and anti-depressants. Women also had higher average prescriptions per user for a number of therapeutic classes-hormones, psychotherapeutic agents and analgesics-and therapeutic subclasses-anti-diabetic drugs and beta blockers. Prescribed medications are, arguably, the most important healthcare technology in preventing illness, disability, and death in older adults. It is critical that older women and men have proper access to prescribed medicines. Given the financial vulnerability of this priority population, particularly women, the expanded drug coverage available under the Medicare Modernization Act is of particular relevance in meeting this goal.

New cardiovascular drugs: patterns of use and association with non-drug health expenditures.

The potential role of new drugs in reducing expenditures for non-drug health services has received considerable attention in recent policy debates. We estimate expenditure models to determine whether the use of newer drugs to treat cardiovascular conditions is associated with lower (or higher) non-drug expenditures for these conditions. We fail to substantiate the findings of previous research that newer drugs are associated with reductions in non-drug expenditures. We find, however, that increases in the number of drugs used, or the mix of drugs of different ages, are associated with increased non-drug expenditures and find that the number or mix of drugs used are important confounders in the estimated association between drug age and non-drug expenditures.

Expected linking error resulting from item parameter drift among the common Items on Rasch calibrated tests.

In state assessment programs that employ Rasch-based common item linking procedures, the linking constant is usually estimated with only those common items not identified as exhibiting item difficulty parameter drift. Since state assessments typically contain a fixed number of items, an item classified as exhibiting parameter drift during the linking process remains on the exam as a scorable item even if it is removed from the common item set. Under the assumption that item parameter drift has occurred for one or more of the common items, the expected effect of including or excluding the "affected" item(s) in the estimation of the linking constant is derived in this article. If the item parameter drift is due solely to factors not associated with a change in examinee achievement, no linking error will (be expected to) occur given that the linking constant is estimated only with the items not identified as "affected"; linking error will (be expected to) occur if the linking constant is estimated with all common items. However, if the item parameter drift is due solely to change in examinee achievement, the opposite is true: no linking error will (be expected to) occur if the linking constant is estimated with all common items; linking error will (be expected to) occur if the linking constant is estimated only with the items not identified as "affected".

Narrow- and Broad-Spectrum Antibiotic Use among U.S. Children.

OBJECTIVES: To provide updated estimates of narrow- and broad-spectrum antibiotic use among U.S. children. DATA SOURCES: Linked nationally representative data from the 2004-2010 Medical Expenditure Panel Survey Household Component and the 2000 Decennial Census. STUDY DESIGN: Relationships between individual-, family-, and community-level characteristics and the use of antibiotics overall and in the treatment of respiratory tract infections (RTIs) are examined using multinomial choice models. PRINCIPAL FINDINGS: More than one quarter (27.3 percent) of children used at least one antibiotic each year with 12.8 percent using broad-spectrum and 18.5 percent using narrow-spectrum antibiotics. Among children with use, more than two-thirds (68.6 percent) used antibiotics to treat RTIs. Multivariate models revealed many differences across groups in antibiotic use, overall and in the treatment of RTIs. Differential use was associated with a broad range of factors related to need (e.g., age, health status), resources (e.g., insurance status, parental income, and education), race-ethnicity, and Census region. CONCLUSIONS: Despite encouraging reports regarding the declining use of antibiotics, large differences in use associated with resources, race-ethnicity, and Census regions suggest a need for further improvement in the judicious and appropriate prescribing of antibiotics for U.S. children.

Does increased adherence to medications change health care financial burdens for adults with diabetes?

BACKGROUND: The aim of the present study was to investigate increased out-of-pocket drug costs and financial burdens of achieving adherence to oral antidiabetic medications and medications for prevalent comorbidities. METHODS: Concurrent adherence to medications, out-of-pocket drug costs, and financial burdens were measured among non-elderly adults with diabetes in the Medical Expenditure Panel Survey. "Financial burden" was defined as spending on health care exceeding 10% of family income. This study simulated the increased out-of-pocket drug costs and financial burdens that would result if non-adherent adults in our sample had obtained sufficient medications to be adherent. For each adult, for all therapeutic classes in which they were non-adherent, we calculated the additional days supplied required to become adherent, as well as out-of-pocket spending on these additional days supplied. RESULTS: Approximately one-quarter adhered to all required medications. Among non-adherent adults with employer-sponsored insurance and public insurance, the mean annual out-of-pocket drug costs of achieving adherence were US$171 and US$68, respectively, which was generally affordable. However, 35.6% of the uninsured lived in families that spent 10% or more of their income on health care. Mean simulated additional out-of-pocket drug costs of achieving adherence were US$310 for the uninsured. These additional drug costs would increase those spending 10% or more of income to 39.6% of the uninsured. CONCLUSIONS: Efforts to reduce the costs faced by the uninsured and insured will make adherence more affordable and, therefore, more attainable for some adults with diabetes.

Prevalence of potentially inappropriate medication use in older adults using the 2012 Beers criteria.

OBJECTIVES: To use the most recently available population-based data to estimate potentially inappropriate medication (PIM) prevalence under the 2012 update of the Beers list of PIMs and to provide a benchmark from which to measure future changes. DESIGN: Retrospective cohort study using nationally representative data. SETTING: 2006-2010 Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: Community-dwelling sample of U.S. older adults (N=18,475). MEASUREMENTS: The updated Beers criteria were operationalized, generating a "broad" PIM definition that incorporated form, route, or dose restrictions where clearly specified and a "qualified" definition that applied specific exceptions where mentioned in the rationale associated with each drug category. Bivariate analyses described PIM prevalence, comparing the two operational definitions, and examined time trends. RESULTS: Of older adults with prescription medications, 42.6% had at least one medication fill that met the broad definition, with nonsteroidal anti-inflammatory drugs (NSAIDs) having the highest prevalence (10.9%). The rate declined from 45.5% in 2006-2007 to 40.8% in 2009-2010. The categories with the largest absolute decline were NSAIDs, selected sulfonylureas, and estrogens. PIM prevalence was 30.9% using the qualified definition. CONCLUSION: Despite the overall high use of PIMs, there has been a decline observed in recent years. Future studies should test the effect of educational and clinical interventions on changes in PIM use and outcomes. The current study results can aid in targeting these interventions.

Many families may face sharply higher costs if public health insurance for their children is rolled back.

Millions of US children could lose access to public health care coverage if Congress does not renew federal funding for the Children's Health Insurance Program (CHIP), which is set to expire September 30, 2015­the end of the federal fiscal year. Additional cuts in public coverage for children in families with incomes above 133 percent of the federal poverty level are possible if the Affordable Care Act's "maintenance of effort" provisions regarding Medicaid and CHIP are allowed to expire as scheduled in 2019. The potential for a significant rollback of public coverage for children raises important policy questions regarding alternative pathways to affordable and high-quality coverage for low-income children. For many children at risk of losing eligibility for public coverage, the primary alternative pathway to coverage would be through their parents' employer-sponsored insurance, yet relatively little is known about the cost and quality of that coverage. Our estimates, based on data from the Insurance Component of the 2012 and 2013 Medical Expenditure Panel Surveys, show that many families would face sharply higher costs of covering their children. In many cases, the only employer-sponsored coverage available would be a high-deductible plan.

Looking inside the nation's medicine cabinet: trends in outpatient drug spending by Medicare beneficiaries, 1997 and 2001.

We examine trends in outpatient prescription drug spending by the Medicare civilian, noninstitutionalized population in 1997 and 2001 using nationally representative data from the Medical Expenditure Panel Survey. We find that the 72 percent increase in drug spending over this period, in excess of price inflation for all goods and services, is primarily attributable to increases in the number of prescriptions per drug user and in the price per prescription. We also find, however, that an increase in the number of users is the primary reason for growth in a number of the fastest-growing subclasses of drugs.

Moving the cut score on Rasch scored tests.

Empirically based item selection guidelines are presented for moving the cut score on equated tests consisting of n dichotomous items calibrated assuming the Rasch model. The cut score on a test form B, c(B), may be made higher than test form A's cut score, c(A), in the following ways: (1) select items for test form B such that the variance of test form B's item difficulties, sigma(2)(B), will be equal to test form A's sigma(2)(A), but test form B's mean item difficulty, mu(B), will be less that of test form A, mu(A); (2) given c(A) > n/2, select items for test form B such that mu(B) s(2)(A). To make c(B) lower than c(A), the direction of the changes listed above for the two tests item difficulties sigma(2) and mu should be reversed. Derivations of lemmas that underlie the guidelines are provided as well as a simulated example.

Evaluation of the 0.3 logits screening criterion in common item equating.

A number of state assessment programs that employ Rasch-based common item equating procedures estimate the equating constant with only those common items for which the two tests' Rasch item difficulty parameter estimates differ by less than 0.3 logits. The results of this study presents evidence that this practice results in an inflated probability of incorrectly dropping an item from the common item set if the number of examinees is small (e.g., 500 or less) and the reverse if the number of examinees is large (e.g., 5000 or more). An asymptotic experiment-wise error rate criterion was algebraically derived. This same criterion can also be applied to the Mantel-Haenszel statistic. Bonferroni test statistics were found to provide excellent approximations to the (asymptotically) exact test statistics.