High-deductible Research Articles

Barriers to the Use of Endari™ in an Urban Adult Sickle Cell Center

Background In 2017, the US Food and Drug Administration (FDA) approved Endari (L-glutamine oral powder) for patients age five years and older with sickle cell disease (SCD) to reduce sickle cell-related acute pain events and hospitalizations1. This was applauded as the first medication approval for SCD in almost 20 years, following Hydroxyurea (HU) in 1998. We report our experience with barriers to accessibility to a new medication such as Endari, and patients' adherence in adults with SCD in an urban adult sickle cell center. Methods After prospectively establishing internal guidelines for the use of Endari, adult patients with SCD seen in clinic at a large urban adult SCD center were prescribed Endari via a local specialty pharmacy, over a 14 month period. Upon return to clinic, patients were asked about barriers to obtaining the medication and adherence to the twice a day dosing. Adherence was also evaluated by calculating the mean possession ratio (MPR) utilizing pharmacy records. Results 111 patients with SCD (57% females) were prescribed Endari over a 14 month period (Table 1): 83% with severe disease genotypes (Hb SS/Sβ0), 17% with "milder" genotypes (Hb SC/Sβ+). Mean age was 36 years old. 74% of patients were on concomitant HU and 1% on chronic transfusions (>6 months). At the end of the 14 month period, 21 patients (19%) were actively taking Endari, 47 (42%) had discontinued it, 39 (35%) never filled the prescription, and 4 (4%) had received but never initiated therapy. Of the 39 who never filled the initial prescription, barriers included denial of prior authorizations (38% of patients), high deductibles (21%), and inability of pharmacy to contact patient after approval was obtained (23%) (Table 2). Reasons for discontinuing Endari included poor adherence (36%), as defined by patients who did not refill after the initial/subsequent prescriptions (mean refill 1.79 times) and/or missed follow up appointments, side effects (13%), no perceived benefit (4%), and pregnancy/breastfeeding (4%) (Table 3). Average MPR for the 21 patients that are still taking Endari is 0.73, similar to the adherence reported in the landmark phase III trial (77.4%)1. Discussion This is the first study that addresses both acceptance of a new medication by the sickle cell population and the barriers to obtaining it. We identified significant barriers to the initiation of Endari in our urban adult SCD patient population and a high rate of self-discontinuation. Patients who discontinued Endari, did so after a median of 47 days after the initial prescription. The most common reasons for not initiating therapy, present in ~ 70% of the cases, were insurance-related issues, such as prior authorization denial or high deductible/co-pays. In 30% of the cases patients were not reachable or had other issues for not filling it, despite obtaining prior authorization, which may indicate a lack of interest on their part. A small number of patients (6) reported discontinuing due to side effects. After 14 months, only 21/111, ~20% of the original cohort of patients prescribed Endari, reported taking it. The MPR of the patients that were taking the medication was 0.73, similar to the adherence in the Endari study (77.4%)1. Prospective studies are needed to confirm if this pattern is reproducible in other patients' populations across the country and to investigate whether the introduction of a new drug affects adherence to HU. As experienced with HU, several years elapsed from initial FDA approval to its being more accepted and widely used, and adherence remains sub-optimal. From our report, it is critical to evaluate and mitigate barriers to initiation and adherence to Endari, to ensure it is available to and accepted by the patient population it gained approval and was intended for. 1. N Engl J Med.2018 Jul 19;379(3):226-235 Disclosures Ogu: Vertex Pharmaceuticals: Consultancy. Minniti:Doris Duke Foundation: Research Funding.

The Role of Commercial Health Insurance Characteristics in Bariatric Surgery Utilization.

The aim of this study was to understand relationships among insurance plan type, out-of-pocket cost sharing, and the utilization of bariatric surgery among commercially insured patients. Only 1% of eligible persons undergo bariatric operations, and this underutilization is often attributed to lack of insurance coverage. But even among the insured, underinsurance is now recognized as a major barrier to accessing medical care. The relationships among commercial insurance design, out-of-pocket cost sharing, and elective surgery utilization, particularly in bariatrics, are not well understood. Retrospective review of 73,002 commercially insured members of the IBM MarketScan commercial claims database who underwent bariatric surgery from 2014 to 2017. The exposure variables were insurance plan type and out-of-pocket cost sharing. The outcome was utilization of bariatric surgery. We also examined seasonal trends in bariatric surgery utilization stratified by average levels of cost sharing. Utilization of bariatric surgery was higher in plans with lower cost sharing, such as PPOs (20 operations/100,000 enrollees) than in HDHPs (high-deductible health plans, 12.1 operations/100,000 enrollees). Overall, every $1000 increase in cost sharing was associated with 5 fewer bariatric operations per 100,000 insured lives; this association was strongest in plans with high cost sharing (high-deductible and consumer-directed health plans). Members of all plan types had higher surgical utilization in quarter 4 relative to quarter 1 of each year; these seasonal variations were also most pronounced in plans with high cost sharing. Insurance plan types with higher cost sharing have lower utilization of bariatric surgery. Underinsurance may represent a newly identified barrier to surgical care that should be addressed by advocates and policymakers.

Association Between Switching to a High-Deductible Health Plan and Discontinuation of Type 2 Diabetes Treatment

High-deductible health plans (HDHPs) are a common cost-savings option for employers but may lead to underuse of necessary treatments because beneficiaries bear the full cost of health care, including medications, until a deductible is met. To evaluate the association between switching from a non-HDHP to an HDHP and discontinuation of antihyperglycemic medication and to assess whether the association differs in patients using branded vs generic antihyperglycemic medications. This retrospective matched cohort study used administrative claims from MarketScan databases to identify commercially insured adult patients with type 2 diabetes who used at least 1 antihyperglycemic medication in 2013. Patients in the HDHP cohort (n = 1490) were matched by propensity scores to a non-HDPH control cohort (n = 1490). Data were collected and analyzed from January 1, 2013, through December 31, 2014. Switching from a non-HDHP in 2013 to a full replacement HDHP in 2014 (no non-HDHP option offered) vs staying on a non-HDHP. Difference-in-differences models estimated discontinuation of branded and generic antihyperglycemic medications. Among the 2980 patients included in the analysis (1932 men [64.8%]; mean [SD] age, HDHP cohort: 52.6 [6.9] years; non-HDHP cohort: 52.7 [7.3] years), no difference between the HDHP and non-HDHP cohorts was found in unadjusted follow-up discontinuation rates for all antihyperglycemic medications (255 [22.7%] vs 255 [23.3%]; P = .72); however, among patients using branded medication, a significantly greater proportion of patients in the HDHP group did not refill branded medications (81 of 396 [20.5%] vs 61 of 437 [14.0%]; P = .009). Difference-in-differences models were not statistically significant. These findings suggest switching to an HDHP is associated with discontinuation specifically of branded medications. Unintended health consequences may result and should be considered by employers making health care benefit decisions.

8 Emergency Department Chest Pain Visits and Downstream Cardiac Testing Before and After High-Deductible Health Plan Enrollment

8 Emergency Department Chest Pain Visits and Downstream Cardiac Testing Before and After High-Deductible Health Plan Enrollment

Costs after incident breast cancer diagnosis among high-deductible health plan members.

120 Background: High-deductible health plans (HDHP) are associated with breast cancer treatment delays of up to 10 months, but their impact on health outcomes is unknown. We hypothesized that, compared with women in generous plans, HDHP members would present with more advanced disease and thus experience higher total costs of early care. Methods: We studied 2004-2014 claims data from a large US health insurer. We included women aged 25-64 who were in traditional low-deductible (≤$500) health plans for 1 baseline year then experienced either an employer-mandated switch to HDHPs (≥$1000) for up to 4 or years or an employer-mandated continuation in low deductible plans. We defined the HDHP switch date as the index date. We then restricted to women who developed incident breast cancer after the index date. Using baseline characteristics, we closely matched HDHP members with incident breast cancer to contemporaneous women with incident breast cancer who remained in low-deductible plans. We measured total costs of all health care services in the 60 days after incident breast cancer diagnosis as a proxy for the intensity of incident breast cancer care. We used negative binomial regression adjusted for baseline characteristics to compare total 60-day costs among HDHP and control members. We also subset analyses to low-income women. Results: We included 1514 HDHP members and 9283 matched controls. 60-day costs after incident breast cancer diagnosis were $24,151 (95% CI: $22,766, $25,535) among HDHP members and $22,474 ($21,952, $22,996) among controls, an absolute difference of $1677 ($197, $3156) and a relative difference of 7.5% (8.1%, 14.1%). Low-income HDHP members had corresponding absolute and relative differences of $2653 ($368, $4939) and 12.5% (1.5%, 23.5). Conclusions: HDHP members with incident breast cancer had 7.5% higher health care costs in the 60 days after incident breast cancer than women with more generous coverage, a finding driven 12.5% higher costs among low-income HDHP members. Results raise concerns that delays in breast cancer care among HDHP members are associated with more advanced disease and adverse outcomes.

Perioperative vestibular assessment and testing

Vestibular disorders can be difficult to accurately diagnose and manage. A careful history and focused physical examination are typically adequate to establish a diagnosis and initiate medical treatment. Vestibular testing is an important component of the work-up, but it is particularly essential for patients being considered for surgical intervention for a vestibular disorder, where the testing can be used to more definitively confirm a suspected diagnosis and to determine baseline vestibular organ function. In this article, we will first briefly review key components of the history and physical examination of patients with vestibular complaints. We will then discuss the most commonly used vestibular tests and their role in the preoperative assessment of patients undergoing vestibular surgery, including nystagmography, caloric testing, rotary chair testing, video head impulse testing, and vestibular evoked myogenic potential testing.

High-Deductible Health Plans and Cancer Survivorship: What Is the Association With Access to Care and Hospital Emergency Department Use?

To examine the associations among high-deductible health plan (HDHP) enrollment, cancer survivorship, and access to care and utilization. The 2010 to 2017 National Health Interview Survey was used to identify privately insured adults ages 18 to 64 years (cancer survivors, n = 4,321; individuals without a cancer history, n = 95,316). We used multivariable logistic regressions to evaluate the associations among HDHP/health savings account (HSA) status, delayed/forgone care for financial reasons, and hospital emergency department (ED) visits among cancer survivors compared with individuals without a cancer history. Among cancer survivors, HDHPs with or without HSA (8.9% and 13.9%, respectively; both P < .05) were associated with more delayed/forgone care compared with low-deductible health plans (LDHPs) (7.9%). HSA enrollment was associated with less delayed/forgone care among HDHP cancer survivors (P < .05). ED visits were similar by insurance type. Among individuals without a cancer history, HDHP with or without HSA (9.5% and 10.8%, respectively; both P < .05) were both associated with more delayed/forgone care compared with LDHPs (5.9%). HSA enrollment also was associated with less delayed/forgone care among HDHP enrollees without a cancer history. A small difference in ED visits was observed between HDHPs without HSA (15.3%) and LDHPs (14.1%; P < .05) or HDHPs with HSA (13.4%; P < .05) among individuals without a cancer history. HDHP enrollment and HSA status affect access to care and hospital ED visits similarly by cancer history. HDHP enrollment may serve as a barrier to access to care among cancer survivors, although HSA enrollment coupled with an HDHP may mitigate the impact on access. HDHPs and HSA status were not associated with ED visits among cancer survivors. Improvement to care coordination efforts may be needed to reduce ED visits among privately insured cancer survivors.

The Personal Financial Burden Associated with Musculoskeletal Trauma

Little is known about the effect of orthopaedic trauma on the financial health of patients. We hypothesized that some patients who sustain musculoskeletal trauma experience considerable financial hardship during treatment, and we also assessed for factors associated with increased personal financial burden. We surveyed 236 of 393 consecutive patients who were approached at 1 of 2 American College of Surgeons level-I trauma centers between 2016 and 2017 following the completion of treatment for a musculoskeletal injury (60% response rate). Two validated measures (financial burden composite score and dichotomized worry score) were used to assess the financial hardship that patients experienced with the injury. There were 236 participants in the study, the mean age was 56.3 years (range, 19 to 94 years), and 48.7% of patients were male. Of the 236 patients, 97.9% had medical insurance, yet the mean financial burden composite score (and standard deviation) was 2.4 ± 2.2 (0 indicated low and 6 indicated high). In this study, 25.0% of patients had high levels of worry about financial problems that resulted from the injury. Fifty-four percent of patients used their savings to pay for their care, and 23% of patients borrowed money or took out a loan. Twenty-three percent of patients missed payment on other bills. Fifty-seven percent of patients were required to cut expenses in general. Patients with higher composite financial burden scores had a significantly increased likelihood of high financial worry (odds ratio [OR], 1.8 [95% confidence interval (CI), 1.5 to 2.2]; p < 0.001). Factors associated with increased financial hardship were high-deductible health plan insurance (coefficient, 0.3 [95% CI, 0.002 to 0.528]; p = 0.048), Medicaid insurance (coefficient, 0.6 [95% CI, 0.342 to 0.863]; p < 0.001), failure to complete high school (coefficient, 0.475 [95% CI, 0.033 to 0.918]; p = 0.035), increased number of surgical procedures (coefficient, 0.067 [95% CI, 0.005 to 0.129]; p = 0.035), and prior medical or student loans (coefficient, 0.769 [95% CI, 0.523 to 1.016]; p < 0.001). Despite a high rate of insurance, patients with orthopaedic trauma in our study had high rates of worry and financial distress. Asking about financial hardship may help to identify those patients with a higher personal financial burden and may promote allocation of additional social support and services.

349-OR: Major Cardiovascular Outcomes among At-Risk High-Deductible Health Plan Members

High-deductible health plan (HDHP) effects on major cardiovascular outcomes are unknown. We studied a 2004-2014 national sample of 63,363 HDHP members aged 40-64 years with diabetes, cardiovascular disease, hypertension, or hyperlipidemia, who were continuously enrolled for 1 year in a low-deductible (≤$500) plan followed by 3 years in a HDHP (≥$1000) after an employer-mandated switch. We matched HDHP members to 539,445 contemporaneous controls who had the same cardiovascular risk factors and whose employers offered only low-deductible plans. Using a controlled interrupted-time-series design, we analyzed cumulative rates of myocardial infarction, stroke, and amputation. We modelled weighted cumulative event rates using aggregate-level segmented regression. HDHP members experienced no detectable absolute change in myocardial infarction (-0.9 events per 10,000 members, 95% confidence interval: -2.7, 0.8) at 3 years of follow-up relative to the end of the baseline year compared to controls. Stroke and amputation declined by 3.4 (-4.0, -2.9) and 6.7 (-9.0, -4.4) events per 10,000 members, respectively, among HDHP members versus controls over the same period. At-risk patients who were switched to HDHPs did not experience increases in major cardiovascular outcomes over 3 follow-up years. Future research should follow patients longer and examine outcomes among low-income populations. Disclosure J. Wharam: None. F. Zhang: None. C. Lu: None. A.F. Hernandez: Consultant; Self; AstraZeneca, Boehringer Ingelheim Pharmaceuticals, Inc., Merck &amp; Co., Inc., Novartis Pharmaceuticals Corporation. Research Support; Self; AstraZeneca, GlaxoSmithKline plc., Merck &amp; Co., Inc., Novartis Pharmaceuticals Corporation. J. Wallace: None. D. Ross-Degnan: None. J.P. Newhouse: Board Member; Self; Aetna Inc. Funding National Institutes of Health

State Mandate Laws for Autism Coverage and High-Deductible Health Plans.

Most states have passed insurance mandates requiring health plans to cover services for children with autism spectrum disorder (ASD). Research reveals that these mandates increased treated prevalence, service use, and spending on ASD-related care. As employer-sponsored insurance shifts toward high-deductible health plans (HDHPs), it is important to understand how mandates affect children with ASD in HDHPs relative to traditional, low-deductible plans. Insurance claims for 2008-2012 for children covered by 3 large US insurers (United Healthcare, Aetna, and Humana) available through the Health Care Cost Institute were used to compare the effects of mandates on ASD-related spending for children in HDHPs and traditional health plans. Relative to children in traditional plans, mandates were associated with higher average monthly spending increases for children in HDHPs. Mandate-attributable spending differences between children enrolled in HDHPs relative to traditional plans were $77 for ASD-specific services (95% confidence interval [CI]: $10 to $144), $125 for outpatient health services (95% CI: $26 to $223), and $144 for all health services (95% CI: $36 to $253). These spending differentials were driven by differences in plan spending and not out-of-pocket (OOP) spending. Spending on ASD-related services attributable to autism mandates was higher among children in HDHPs, but higher spending did not translate into a greater OOP burden. For families with consistently high health care expenditures on ASD-related services, high-deductible products may be worth considering in the context of mandate laws. Families in mandate states with children with ASD enrolled in HDHPs were able to increase service use without paying more OOP.

Behavioral Pediatrics Meets Behavioral Economics: Autism, Mandates, and High Deductibles

* Abbreviation: ASD — : autism spectrum disorder We do not yet know what causes autism spectrum disorder (ASD), but we do know that early intensive behavioral intervention for children with ASD can improve outcomes.1,2 The cost is high, but, from a societal point of view, the benefit will likely outweigh the cost both financially and clinically.3,4 Yet financial barriers, particularly among patients with private insurance, can prevent children and families from receiving needed services.5 Recognizing this, policy makers in many states passed laws mandating that commercial insurers cover ASD-specific interventions. Mandates improved access to care by increasing use of ASD-specific services, particularly in younger children, suggesting that the new policy was effective and increased access to autism treatment of children covered by commercial insurance.6 In addition, more children were diagnosed with ASD in the states with ASD mandates, suggesting that providers were more likely to make the diagnosis when the payment system allowed for early treatment.7 Neither of these findings are surprising; the experience with Medicaid’s Early and Periodic Screening Diagnostic and Treatment suggested that expanding benefits expands access.8 … Address correspondence to David Keller, MD, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 E 16th Ave, B065, Denver, CO 80045. E-mail: david.keller{at}childrenscolorado.org

13-OR: Trends in Life-Threatening Hyperglycemia-Related Complications among Commercially-Insured Diabetes Patients Before and After the 2010 Rise in Insulin Prices

U.S. insulin pricing began increasing dramatically in 2010, possibly caused by rising artificial insulin production and market domination by several pharmaceutical companies. Studies over the last 20 years have shown that such high prices are associated with patient rationing of insulin. The commercially-insured population includes patients with both type 1 and 2 diabetes who have experienced increasing cost sharing over the last decade, often in the form of high deductible health plans. This rise in insulin pricing combined with higher cost sharing might increase life-threatening diabetes-related complications. We hypothesized that diabetic ketoacidosis (DKA) and hyperosmolar coma (HOC) would increase after the sharp rise in insulin prices that began in 2010. We applied an interrupted times series design, with 2010 used as the change point given previous research showing that insulin prices began rising sharply in this year. We studied a large commercially insured population with an average annual number of diabetes patients of 507,578 during 2005-2014. Patients with diabetes were identified using a standard algorithm based on ICD9 codes and oral antidiabetes medicines. We calculated annual emergency department visit rates for combined DKA and HOC in this population. We use a first-order autoregressive segmented regression model to determine if there was a change in the complication trend from before to after 2010. The estimated 2005 rate of DKA and HOC emergency department visits was 50.9 per 10,000 diabetes patients (p&amp;lt;0.001), which decreased to 36.2 per 10,000 by 2009 (trend: -3.7 per 10,000 per year; p&amp;lt;0.001). However, from 2010-2014 the complication rate rose by 5.2 per 10,000 per year (p=0.002) relative to the 2005-2009 trend. In conclusion, life-threatening hyperglycemia-related complications among commercially-insured diabetes patients increased after the 2010 insulin price increase. Disclosure A. Meiri: None. K. Callaway: None. J. Wharam: None. Funding National Institutes of Health; Centers for Disease Control and Prevention

Determinants in Initial Treatment Choice for Diabetic Macular Edema

To assess how patient choices (out-of-pocket costs, insurance plan, geographic region) impact initiation of therapy for diabetic macular edema (DME). Retrospective cohort study using administrative medical claims data from a large, national insurer. All patients newly diagnosed with DME from 2013 through 2016 were observed for 90 days after diagnosis or until first treatment was received. Multivariate logistic regression was used to create odds ratios comparing different baseline demographic and patient-related factors. The primary outcome was the odds of receiving the different possible initial treatments for DME (anti-vascular endothelial growth factor [VEGF], focal laser treatment, steroids, or observation), no treatment, and not following up. Of the 6220 newly diagnosed DME patients, 3010 (48.4%) underwent a follow-up examination within 90 days of diagnosis, and of those, 1453 patients (48.3%) received treatment in the observation window, including 614 (20.4%) with bevacizumab, 191 (6.3%) with ranibizumab or aflibercept, 560 (18.6%) with focal laser, 38 (1.3%) with steroid injection, and 50 (1.7%) with an injection of an unspecified drug. Having a copay (vs. $0) lowered the odds of receiving any treatment (odds ratio [OR] = 0.60; 95% confidence interval [CI], 0.51-0.71; P<0.001) and of receiving each treatment individually (anti-VEGF treatment: OR = 0.72; 95% CI, 0.59-0.88; bevacizumab: OR = 0.73; 95% CI, 0.59-0.91; ranibizumab or aflibercept: OR, 0.70; 95% CI, 0.49-0.99; focal laser: OR = 0.44; 95% CI, 0.35-0.55; P < 0.001). Contrary to having a copay, having a high deductible and type of insurance plan were not associated with initiating treatment (P > 0.41 for all comparisons). Patients in the Northeast showed lower odds of initiating anti-VEGF treatment (OR = 0.60; 95%CI, 0.44-0.82; P < 0.001) and specifically bevacizumab (OR = 0.47; 95% CI, 0.33-0.67; P < 0.001). Furthermore, Northeast patients who were treated with anti-VEGF showed a higher odds of receiving ranibizumab or aflibercept compared with bevacizumab (OR = 2.39; 95% CI, 1.31-4.37; P < 0.001). Southern Midwest patients showed a higher odds of treatment (anti-VEGF: OR = 1.35; 95%CI, 1.02-1.77; P < 0.001; bevacizumab: OR = 1.40; 95% CI, 1.04-1.87; focal laser: OR = 1.39; 95% CI, 1.01-1.89; P < 0.001). Patient choices such as copays and where they live are important factors in determining the initial choice of treatment for DME.

Intertemporal substitution in health care demand: Evidence from the RAND Health Insurance Experiment

Nonlinear cost-sharing in health insurance encourages intertemporal substitution because patients can reduce their out-of-pocket costs by concentrating spending in years when they hit the deductible. We develop a test for intertemporal substitution and apply it to data from the RAND Health Insurance Experiment, where people were randomly assigned either to a free care plan or to a cost-sharing plan which had coinsurance up to a maximum dollar expenditure (MDE). Hitting the MDE—leading to an effective price of zero—has a bigger effect on health care demand than does being in free care, because people who hit the MDE face low current prices but high future prices, and so stock up on health care. As a result, short-lasting price changes induce nearly twice as big a response as do long-lasting changes. These findings help reconcile disparate estimates of the price elasticity of demand for health care in the existing literature. Failing to account for intertemporal substitution can lead researchers to overstate cost savings from high deductible health plans by 20% or more.

Cancer History, Health Insurance Coverage, and Cost-Related Medication Nonadherence and Medication Cost-Coping Strategies in the United States

ObjectivesTo evaluate the relationship between cancer history and cost-related medication nonadherence (CRN) as well as cost-coping strategies, by health insurance coverage. MethodsWe used the 2013 to 2016 National Health Interview Survey to identify adults aged 18 to 64 years with (n = 3599) and without (n = 56 909) a cancer history. Cost-related changes in medication use included (1) CRN, measured as skipping, taking less, or delaying medication because of cost, and (2) cost-coping strategies, measured as requesting lower cost medication or using alternative therapies to save money. Separate multivariable logistic regressions were used to calculate the adjusted odds ratios (AORs) of CRN and cost-coping strategies associated with cancer history, stratified by insurance. ResultsCancer survivors were more likely than adults without a cancer history to report CRN (AOR 1.26; 95% confidence interval [CI] 1.10-1.43) and cost-coping strategies (AOR 1.10; 95% CI 0.99-1.19). Among the privately insured, the difference in CRN by cancer history was the greatest among those enrolled in high-deductible health plans (HDHPs) without health savings accounts (HSAs) (AOR 1.78; 95% CI 1.30-2.44). Among adults with HDHP and HSA, cancer survivors were less likely to report cost-coping strategies (AOR 0.62; 95% CI 0.42-0.90). Regardless of cancer history, CRN and cost-coping strategies were the highest for those uninsured, enrolled in HDHP without HSA, and without prescription drug coverage under their health plan (all P<.001). ConclusionsCancer survivors are prone to CRN and more likely to use cost-coping strategies. Expanding options for health insurance coverage, use of HSAs for those with HDHP, and enhanced prescription drug coverage may effectively address CRN.

PDG24 IMPACT OF BYPASSING MEDICATION DEDUCTIBLES AMONG MEMBERS ENROLLED IN HIGH DEDUCTIBLE HEALTH PLANS

Rising out-of-pocket medication costs are a deterrent to treatment access. Lower medication adherence adversely affects downstream health outcomes and total medical costs. Herein, we investigated the extent to which an add-on to high deductible health plans (HDHPs) – a product that waives the deductible for certain tiers of preventative medications in seven drug classes (respiratory, cholesterol, diabetes, hypertension, osteoporosis, mental health, and prenatal vitamins) – influences prescription pickup rates and medication adherence as well as healthcare costs and utilization. The study population included data from a large, commercial insurer for 241,108 members enrolled in HDHPs between 2014 and June 2018. Of these members, 3.3% adopted the add-on to their HDHP at some point in the study period. Difference-in-difference models were used to evaluate the impact of the HDHP add-on across all endpoints, and accounted for the longitudinal study design. In certain models, we observed that the adoption of the HDHP add-on statistically significantly decreased per member per month medical costs by more than 10%. These models also showed a statistically significant reduction in emergency room and total inpatient visits among members who acquired the HDHP add-on. After stratifying mixed models by preventative medication class, we found that waiving the deductible of preventative respiratory medications significantly increased the medication pickup rate. The HDHP add-on adoption was also associated with an increased adherence to hypertension and osteoporosis medications. Overall, our results provide suggestive evidence that including an add-on product to HDHPs that waives the deductible for certain tiers of preventative medications may increase adherence to and pickup rates of certain medication classes and decrease both healthcare utilization and cost.

Out-of-pocket costs are on the rise for commonly prescribed neurologic medications.

To determine out-of-pocket costs for neurologic medications in 5 common neurologic diseases. Utilizing a large, privately insured, health care claims database from 2004 to 2016, we captured out-of-pocket medication costs for patients seen by outpatient neurologists with multiple sclerosis (MS), peripheral neuropathy, epilepsy, dementia, and Parkinson disease (PD). We compared out-of-pocket costs for those in high-deductible health plans compared to traditional plans and explored cumulative out-of-pocket costs over the first 2 years after diagnosis across conditions with high- (MS) and low/medium-cost (epilepsy) medications. The population consisted of 105,355 patients with MS, 314,530 with peripheral neuropathy, 281,073 with epilepsy, 120,720 with dementia, and 90,801 with PD. MS medications had the fastest rise in monthly out-of-pocket expenses (mean [SD] $15 [$23] in 2004, $309 [$593] in 2016) with minimal differences between medications. Out-of-pocket costs for brand name medications in the other conditions also rose considerably. Patients in high-deductible health plans incurred approximately twice the monthly out-of-pocket expense as compared to those not in these plans ($661 [$964] vs $246 [$472] in MS, $40 [$94] vs $18 [$46] in epilepsy in 2016). Cumulative 2-year out-of-pocket costs rose almost linearly over time in MS ($2,238 [$3,342]) and epilepsy ($230 [$443]). Out-of-pocket costs for neurologic medications have increased considerably over the last 12 years, particularly for those in high-deductible health plans. Out-of-pocket costs vary widely both across and within conditions. To minimize patient financial burden, neurologists require access to precise cost information when making treatment decisions.

Total and out-of-pocket costs of different primary management strategies in ovarian cancer

Communicating healthcare costs to patients is an important component of delivering high-quality value-based care, yet cost data are lacking. This is especially relevant for ovarian cancer, where no clinical consensus on optimal first-line treatment exists. The objective of this study was to generate cost estimates of different primary management strategies in ovarian cancer. All women who underwent treatment for ovarian cancer from 2006-2015 were identified from the MarketScan database (n=12,761) in this observational cohort study. Total and out-of-pocket costs were calculated with the use of all claims within 8 months from initial treatment and normalized to 2017 US dollars. The generalized linear model method was used to assess cost by strategy. Among patients who underwent neoadjuvant chemotherapy and those who underwent primary debulking, mean adjusted total costs were $113,660 and $107,153 (P<.001) and mean out-of-pocket costs were $2519 and $2977 (P<.001), respectively. Total costs for patients who had intravenous standard, intravenous dose-dense, and intraperitoneal/intravenous chemotherapy were $105,047, $115,099, and $121,761 (P<.001); and out-of-pocket costs were $2838, $3405, and $2888 (P<.001), respectively. Total costs for regimens that included bevacizumab were higher than those without it ($171,468 vs $104,482; P<.001); out-of-pocket costs were $3127 vs $2898 (P<.001). Among patients who did not receive bevacizumab, 25% paid ≥$3875, and 10% paid ≥$6265. For patients who received bevacizumab, 25% paid ≥$4480, and 10% paid ≥$6635. Among patients enrolled in high-deductible health plans, median out-of-pocket costs were $4196, with 25% paying ≥$6680 and 10% paying ≥$9751. Costs vary across different treatment strategies, and patients bear a significant out-of-pocket burden, especially those enrolled in high-deductible health plans.

Re: Does Enrollment in High-Deductible Health Plans Encourage Price Shopping?

Re: Does Enrollment in High-Deductible Health Plans Encourage Price Shopping?

Longitudinal patterns of employee high-deductible health plan choices

Employers in the United States have increasingly provided high-deductible health plans (HDHPs) to their employees to reduce health care spending. Prior studies on employees’ choice of HDHPs were based on one or two years of data. This limits the ability to study the dynamic change in employees’ HDHP choices. This study used group-based trajectory models to classify employees based on their longitudinal patterns of HDHP choices. We also identified employee characteristics associated with HDHP choice, evaluated risk segmentation between HDHP and preferred provider plan (PPO) enrollees and assessed the impact of plan benefit change on health care utilization. The analyses were based on five years of medical claims, pharmacy claims and eligibility information obtained from a large employer. We identified four groups of employees based on their longitudinal patterns of HDHPs choices: early HDHP adopters, late HDHP adopters, HDHP non-adopters and HDHP abandoners. We found that employees’ job type, family type, and health condition were associated with their longitudinal patterns of HDHP choices. We also found increased risk segmentation between HDHP and PPO enrollees over the five-year period. These findings on how employees respond to health plan changes over time could help employers with health plan benefit design.