Higher OOP Costs Research Articles

Patient out-of-pocket expenditure in primary care comparing high income, middle income and low-income countries

Background: Out-of-pocket health expenditures (OOPHE) in primary care can pose a significant financial burden on individuals and households, particularly in low- and middle-income countries. Understanding the factors influencing OOPHE is crucial for developing effective policies to improve healthcare access and affordability. Objective: This systematic review aimed to identify and analyze the factors influencing OOPHE in primary care settings across high-, middle-, and low-income countries. Methods: A comprehensive search of electronic databases was conducted to identify relevant studies. Included studies were assessed for quality and data were extracted to identify key factors influencing OOPHE. Results: Demographic characteristics, socioeconomic factors, healthcare utilization, system factors, and cultural factors were all found to influence OOPHE. Lower income levels, limited insurance coverage, frequent healthcare utilization, and higher disease severity were consistently associated with higher OOP costs. Conclusion: The findings highlight the significant burden of OOP expenditures on individuals and households. Policymakers should prioritize strategies to expand health insurance coverage, improve access to primary care services, negotiate lower prices for healthcare goods, and address underlying socioeconomic factors. Further research is needed to explore the impact of specific interventions and the role of cultural factors in shaping OOP expenditures.

Do hospitalizations push households into poverty in India: evidence from national data.

High percentage of OOP (Out-of-Pocket) costs can lead to poverty and exacerbate existing poverty, with 21.9% of India's 1.324 billion people living below the poverty line. Factors such as increased patient cost-sharing, high-deductible health plans, and expensive medications contribute to high OOP costs. Understanding the poverty-inducing impact of healthcare payments is essential for formulating effective measures to alleviate it. The study used data from the 75th round of the National Sample Survey Organization (Household Social Consumption in India: Health) from July 2017-June 2018, focusing on demographic-socio-economic characteristics, morbidity status, healthcare utilization, and expenditure. The analysis included 66,237 hospitalized individuals in the last 365 days. Logistic regression model was used to examine the impact of OOP expenditures on impoverishment. Logistic regression analysis shows that there is 0.2868 lower odds of experiencing poverty due to OOP expenditures in households where there is the presence of at least one child aged 5 years and less present in the household compared to households who do not have any children. There is 0.601 higher odds of experiencing poverty due to OOP expenditures in urban areas compared to households in rural areas. With an increasing duration of stay in the hospital, there is a higher odds of experiencing poverty due to OOP health expenditures. There is 1.9013 higher odds of experiencing poverty due to OOP expenditures if at least one member in the household used private healthcare facility compared to households who never used private healthcare facilities. In order to transfer demand from private to public hospitals and reduce OOPHE, policymakers should restructure the current inefficient public hospitals. More crucially, there needs to be significant investment in rural areas, where more than 70% of the poorest people reside and who are more vulnerable to OOP expenditures because they lack coping skills.

Health in Crisis: A Paradox of Access for Syrian Refugees and Lebanese Hosts

Background: This study examines the health security of both Lebanese citizens and Syrian refugees in Lebanon. It also assesses the readiness and resilience of the healthcare system in response to the multi-layered crisis that began in late 2019. Methods: A qualitative case study design was employed, utilizing 2 unstructured interviews with health experts/hospital staff, semi-structured interviews with 20 Lebanese participants and a document review. Thematic analysis was used to analyze the data. Results: The study found that Syrian refugees have access to health services under terms, conditions and restrictions including out-of-pocket (OOP) payment. In contrast, Lebanese citizens find traditional health guarantor systems largely ineffective, leading to high OOP costs for most healthcare services, with few exceptions. This study reveals a paradox in healthcare access within Lebanon’s fragile environment. Syrian refugees have greater access to health services, with minimal out-of-pocket (OOP) costs to a certain extent, compared to Lebanese citizens themselves who remain entrenched in inadequate health support services and poor public administration. Conclusion: To address this, targeted interventions and policies are crucial for policymakers and stakeholders, including the private and public sectors, local non-governmental organizations (NGOs), and the international community. Reforms are needed, spearheaded by the Ministry of Public Health (MoPH), other relevant ministries, and government payers, to refinance the traditional guarantor system and restore Lebanese citizens’ health security. Additionally, unifying health coverage across all government payers is vital.

Pharmaceutical demand response to utilization management

Prescription drug insurance increasingly imposes prior authorization (requiring providers to request coverage before claim approval) to manage utilization. Prior authorization has been criticized because of its administrative burden on providers. The primary alternative to managing utilization is imposing out-of-pocket (OOP) payment to incentivize beneficiaries to seek lower-cost care, effectively providing beneficiaries with partial insurance. Would beneficiaries prefer indirectly paying for prior authorization through higher premiums; or would they prefer prior authorization was replaced by higher OOP costs? This tradeoff depends on how much OOP costs could be displaced by prior authorization, which depends on their relative impact on demand. I estimate the effect of prior authorization and OOP costs on pharmaceutical demand in Medicare Part D, addressing endogeneity caused by unobserved drug quality and selection into plans. Despite criticism of prior authorization, I find that Medicare beneficiaries would prefer higher premiums to pay for prior authorization, over higher OOP costs.

The high cost of supplements, complementary therapy, and alternative medicine in patients with breast cancer.

25 Background: Nutritional and dietary supplements, complementary therapies (CT: acupuncture, yoga), and alternative medicine (AM: tinctures, holistic medicines) can have high out-of-pocket (OOP) costs, driving financial toxicity. We evaluated costs associated with the use of supplements, CT, and AM in patients with breast cancer. Methods: Between 6/7-7/12/2022, Breastcancer.org members completed an anonymous online survey assessing self-identified “unexpectedly high” OOP costs encountered during care. Adjusted multivariable analysis (MVA) evaluated patient characteristics associated with high costs due to supplements, CT, and AM. Results: Among 1,710 eligible patients, 1,437 completed the survey (84% participation rate). Median age was 45 years (IQR: 35-56), and most identified as women (94%) and non-Hispanic White (NHW, 61%). One-quarter (25%) reported high OOP costs from supplements. In MVA, those with an annual income ≥$200k (OR 0.85, 95%CI 0.78-0.93, p<0.01) were less likely than those with income <$50k to report supplements as a financial burden. Those with employer-provided insurance (OR 0.92, 95% CI 0.87-0.98, p=0.02) had lower burdens than those on Medicare. Those with higher educational attainment had higher burdens than those with high school (HS) education or less (some college/post HS (OR 1.08, 95% CI 1.01-1.17, p=0.03), college grad (OR 1.15, 95% CI 1.07-1.24, p<0.01), postgraduate (OR 1.13, 95% CI 1.04-1.24, p<0.01). High OOP costs related to CT were reported by 18% of respondents. In adjusted MVA, self-identified Asian (OR 1.24, 95% CI 1.08-1.44, p<0.01) patients and those with private insurance (OR 1.08, 95% CI 1.01-1.09, p=0.02) were less burdened by CT costs compared to NHW patients and those on Medicare. High OOP costs related to AM were reported by 18% of respondents. In MVA, patients ≥46 years (OR 0.94, 95% CI 0.90-0.99, P=0.02) and those with income ≥$200k (OR 0.91, 95% CI 0.84-0.98, p<0.01) were less burdened by AM costs [compared to those ≤45 and with income <$50k]. Those on Medicaid (OR 1.11, 95% CI 1.04-1.18, p<0.01) had higher burdens than those on Medicare. Those who reported high OOP costs from AM were more likely to alter their use of prescribed medication (i.e., skip pills, not fill prescriptions, etc) to cut costs compared to those who did not report this burden (73% vs. 48%, p<0.01). Those who reported high costs from supplements were more likely to take fewer pills as a cost-cutting measure (28% vs 19%, p<0.01). Conclusions: High costs from supplements, CT, and AM pose a financial burden for up to a quarter of patients with breast cancer, and these burdens may not affect everyone equally. Downstream effects of financial toxicity from tinctures and holistic medicines specifically may decrease adherence to prescribed medications. Discussion regarding the risks, benefits, and costs of supplements, CT, and AM is an essential part of patient-centered cancer education.

Out-of-Pocket Expenditures for Imaging Examinations: Perspectives From National Patient Surveys Over Two Decades.

Using national surveys, we longitudinally studied imaging costs-and specifically those paid out-of-pocket (OOP) by patients-over two decades. Using 2000 to 2019 Medical Expenditure Panel Survey data, we identified all imaging-focused encounters (mammography, radiography, ultrasonography, and CT and MR [surveyed together in Medical Expenditure Panel Survey]) and calculated mean overall and OOP encounter costs. Effects of sociodemographic, personal, and clinical factors were measured using logistic regression and generalized linear modeling. We identified 102,717 patients (mean 45.6 years; 64.8% female; 58.8% White) undergoing 229,010 imaging-focused encounters. Between 2000 and 2019, mean costs of mammography, radiography, and ultrasonography increased 14.5%, 24.5%, and 40% and total mean cost of CT or MR decreased by 15.1%. OOP costs were incurred by 51%. Overall mean OOP costs increased 89.8% from 2000 to 2019. Mean OOP costs for mammography decreased by 32.9%; mean OOP costs for radiography, ultrasonography, and CT or MR increased 81%, 123.2%, and 61%, respectively. Patients were less likely to incur OOP costs when older, of racial and ethnic minorities, female, or recipients of public only (versus private) insurance. Among those with OOP costs, the presence of comorbidities, lack of insurance, younger age, and history of cancer significantly increased OOP costs. Mean overall patient OOP costs for imaging examinations increased significantly and substantially over the last two decades. Lack of insurance, younger age, history of cancer, and other comorbidities were associated with higher OOP costs. As diagnostic imaging utilization increases, patient financial hardship considerations merit further attention.

Impact of High-Deductible Health Plans on Breast Reconstruction: Considerations for Financial Toxicity.

High-deductible health plans (HDHPs) are used within the United States to curb unnecessary health care spending; however, the resulting increased out-of-pocket (OOP) costs may be associated with financial toxicity. The aim was to assess the impact of HDHPs on use and seasonality of mastectomy and breast reconstruction procedures. The hypothesis is that the high OOP costs of HDHPs will lead to decreased overall service use and greater fourth-quarter use after the deductible has been met. MarketScan was queried from 2014 to 2017 for episodes of mastectomy, breast reconstruction (immediate and delayed), breast revision, and reduction. Only patients continuously enrolled for the full calendar year after the index operation were included. HDHPs and low-deductible health plans (LDHPs) were compared based on OOP cost sharing. Outcomes included surgery use rates, seasonality of operations, and median/mean OOP costs. Annual mastectomy and breast reconstruction use rates varied little between LDHPs and HDHPs. Mastectomies, delayed breast reconstruction, and elective breast procedures (P < 0.001) all showed significant increases in fourth-quarter use, whereas immediate breast reconstruction did not. Regardless of timing and reconstruction method, HDHPs had significantly greater median OOP costs compared to LDHPs (all P < 0.001). Mastectomy and breast reconstruction rates did not differ between LDHPs and HDHPs, but seasonality for all breast procedures was measured with the exception of immediate breast reconstruction, suggesting that women are rational economic actors. Regardless of service timing and reconstruction modality, HDHP patients had greater OOP costs compared to LDHP patients, which serves as a good starting point for provider engagement in financial toxicity.

Predictors of adherence to oral anticancer medications: An analysis of 2010-2018 US nationwide claims.

BACKGROUND: Various factors, including patient demographic and socioeconomic characteristics, patient out-of-pocket (OOP) costs, therapy-related factors, clinical characteristics, and health-system factors, can affect patient adherence to oral anticancer medications (OAMs). OBJECTIVE: To determine the proportion of patients initiating oral anticancer therapy who were adherent to OAMs and to identify significant predictors of adherence to OAMs, including patient OOP costs and patient demographics. METHODS: A retrospective cohort study was conducted using data from Optum Clinformatics Data Mart commercial claims database for 2010-2018. Patients with a new pharmacy claim for an OAM between July 1, 2010, and December 31, 2017, were followed for 6 months to ascertain their medication adherence, which was defined as a proportion of days covered value of at least 0.8. Average monthly patient OOP costs for OAM prescriptions were categorized as lower OOP costs (quartiles 1-3) and higher OOP costs (quartile 4). Separate multivariable logistic regressions were conducted to identify predictors of OAM nonadherence for each cancer type. RESULTS: Out of 37,938 patients with cancer, 51.9% were adherent to OAMs, with adherence ranging from 32.8% among those with liver cancer to 70.4% among those with brain tumor. The average monthly OOP costs of OAMs also differed by cancer type, ranging from $749 (SD = $1,014) among patients with blood cancer to $106 (SD = $439) among those with prostate cancer. Higher patient OOP costs were associated with higher odds of OAM nonadherence for many cancer types, including renal cancer (adjusted odds ratio [AOR] = 3.91; 95% CI = 2.80-5.47) and breast cancer (AOR = 1.26; 95% CI = 1.13-1.41). Additionally, patients with inpatient hospitalizations during the 6 months following OAM initiation had significantly higher odds of OAM nonadherence for all cancer types except for stomach cancer. Among patients with stomach cancer, male sex was associated with lower odds of OAM nonadherence (AOR = 0.60; 95% CI = 0.37-0.97). Among patients with renal or stomach cancer, those who had Medicare low-income subsidy had higher odds of OAM nonadherence compared with those with commercial insurance coverage. Among patients with blood cancers, Black and Hispanic patients had higher odds of OAM nonadherence compared with White patients (AOR = 1.48; 95% CI = 1.25-1.75 and AOR = 1.38; 95% CI = 1.13-1.68, respectively). CONCLUSIONS: Overall adherence to OAMs was suboptimal, and for several cancer types, adherence was worse among patients with higher OOP costs, those who were hospitalized, and those who received Medicare low-income subsidy. Policies addressing cost and access to OAMs and health-system strategies to address barriers to the effective use of OAMs are needed to improve patient access to these vital medications. DISCLOSURES: This study was funded by joint funding from the Pharmacy Quality Alliance and the National Pharmaceutical Council (NPC). Drs Vyas and Kogut were partially supported by this joint funding. Mr Descoteaux was supported by this joint funding for performing data analysis. The content is solely the responsibility of the authors and does not necessarily represent the official views of PQA or NPC. Dr Campbell completed this work during his employment at Pharmacy Quality Alliance; he is now an employee of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ.

Healthcare Utilization and Costs Among US Adolescents With Alopecia Areata.

Background: Alopecia areata (AA) is an autoimmune disease of hair loss affecting people of all ages. Alopecia totalis (AT) and universalis (AU) involve scalp and total body hair loss, respectively. AA significantly affects quality of life, but evidence on the economic burden in adolescents is limited.Objectives: To assess healthcare resource utilization (HCRU) and all-cause direct healthcare costs, including out-of-pocket (OOP) costs, of US adolescents with AA.Methods: IBM MarketScan® Commercial and Medicare databases were used to identify patients aged 12-17 years with ≥2 claims with AA/AT/AU diagnosis (prevalent cases), from October 1, 2015, to March 31, 2018, enrolled for ≥12 months before and after the first AA diagnosis (index). Patients were matched 1:3 to non-AA controls on index year, demographics, plan type, and Charlson Comorbidity Index. Per patient per year HCRU and costs were compared post-index.Results: Patients comprised 130 AT/AU adolescents and 1105 non-AT/AU adolescents (53.8% female; mean age, 14.6 years). Post-index, AT/AU vs controls had more outpatient (14.5 vs 7.1) and dermatologist (3.6 vs 0.3) visits, higher mean plan costs ($9397 vs $2267), including medical ($7480 vs $1780) and pharmacy ($1918 vs $487) costs, and higher OOP costs ($2081 vs $751) (all P<.001). The non-AT/AU cohort vs controls had more outpatient (11.6 vs 8.0) and dermatologist (3.4 vs 0.4) visits, higher mean plan costs ($7587 vs $4496), and higher OOP costs ($1579 vs $805) (all P<.001).Discussion: This large-sample, real-world analysis found that adolescents with prevalent AA had significantly higher HCRU and all-cause costs than matched controls. The greater burden was driven by more frequent outpatient visits, and higher payer medical and pharmacy costs in comparison with controls. Oral corticosteroid use was higher among patients with AT/AU; topical and injectable corticosteroid use was higher for non-AT/AU. Although the data preclude the identification of AA-attributable costs, the matched-control design allows an estimation of incremental all-cause costs associated with AA.Conclusions: Adolescents with AA incurred substantial incremental healthcare costs, with greater costs incurred among those with AT/AU. Study findings suggest that AA incurs costs as a medical condition with a high burden on adolescent patients and health plans.

Chronic Myeloid Leukemia: Part I—Real-World Treatment Patterns, Healthcare Resource Utilization, and Associated Costs in Later Lines of Therapy in the United States

Background: Alopecia areata (AA) is an autoimmune disease of hair loss affecting people of all ages. Alopecia totalis (AT) and universalis (AU) involve scalp and total body hair loss, respectively. AA significantly affects quality of life, but evidence on the economic burden in adolescents is limited. Objectives: To assess healthcare resource utilization (HCRU) and all-cause direct healthcare costs, including out-of-pocket (OOP) costs, of US adolescents with AA. Methods: IBM MarketScan® Commercial and Medicare databases were used to identify patients aged 12-17 years with ≥2 claims with AA/AT/AU diagnosis (prevalent cases), from October 1, 2015, to March 31, 2018, enrolled for ≥12 months before and after the first AA diagnosis (index). Patients were matched 1:3 to non-AA controls on index year, demographics, plan type, and Charlson Comorbidity Index. Per patient per year HCRU and costs were compared post-index. Results: Patients comprised 130 AT/AU adolescents and 1105 non-AT/AU adolescents (53.8% female; mean age, 14.6 years). Post-index, AT/AU vs controls had more outpatient (14.5 vs 7.1) and dermatologist (3.6 vs 0.3) visits, higher mean plan costs ($9397 vs $2267), including medical ($7480 vs $1780) and pharmacy ($1918 vs $487) costs, and higher OOP costs ($2081 vs $751) (all P&lt;.001). The non-AT/AU cohort vs controls had more outpatient (11.6 vs 8.0) and dermatologist (3.4 vs 0.4) visits, higher mean plan costs ($7587 vs $4496), and higher OOP costs ($1579 vs $805) (all P&lt;.001). Discussion: This large-sample, real-world analysis found that adolescents with prevalent AA had significantly higher HCRU and all-cause costs than matched controls. The greater burden was driven by more frequent outpatient visits, and higher payer medical and pharmacy costs in comparison with controls. Oral corticosteroid use was higher among patients with AT/AU; topical and injectable corticosteroid use was higher for non-AT/AU. Although the data preclude the identification of AA-attributable costs, the matched-control design allows an estimation of incremental all-cause costs associated with AA. Conclusions: Adolescents with AA incurred substantial incremental healthcare costs, with greater costs incurred among those with AT/AU. Study findings suggest that AA incurs costs as a medical condition with a high burden on adolescent patients and health plans.

Indirect and Out-of-Pocket Disease-associated Costs in Pediatric Inflammatory Bowel Disease: A Cross-sectional Analysis.

Data on pediatric inflammatory bowel disease (IBD)-associated indirect and out-of-pocket (OOP) costs are limited. We aimed to estimate indirect (lost work hours and productivity) and OOP pediatric IBD-associated costs in Canada. In a nation-wide cross-sectional analysis, caregivers of children with IBD were invited to complete a questionnaire on lost work hours and OOP costs related to IBD in the 4 weeks prior to the survey. Participants were reinvited to periodically answer the same questionnaire every 3-9 months for 2 years. Lost productivity was calculated using the Human Capital method. Costs were reported in 2018 inflation-adjusted Canadian dollars. Predictors of high cost users (top 25%) were examined using binary logistic regression. Consecutive 243 (82 incident cases) of 262 (92.7%) approached participants completed the first survey with a total of 450 surveys longitudinally completed over 2 years. The median annual indirect cost per patient was $5966 (IQR $1809-$12,676), with $5721 (IQR $1366-$11,545) for Crohn's disease (CD) and $7007 (IQR $2428-$14,057) for ulcerative colitis (UC) ( P = 0.11). The annual median per patient OOP costs were $4550 with $4550 for CD and $5038 for UC ( P = 0.53). Longer travel distance to clinic was associated with higher OOP costs (odds ratio = 4.55; P &lt; 0.0001; 95% confidence interval: 1.99-10.40). Indirect and OOP IBD-associated costs are substantial and more likely to affect families living in remote communities.

Clinical staff and cancer patient perspectives on the challenges of out-of-pocket expenses and navigation of cancer treatment costs.

e18823 Background: Cancer care delivery has been described as a “system in crisis” in part due to lack of affordable care. In 2019, out-of-pocket (OOP) costs alone were estimated to be over $16 billion in the US. Transparency and early conversations about expected OOP costs may prevent financial toxicity and improve patient-centered care. Methods: We conducted a qualitative study to explore perceptions of OOP costs and technology use to promote cost transparency. Semi-structured, in-depth interviews were held with various healthcare professionals (HCPs) – including oncologists, nurse patient navigators, financial counselors, social workers, and pharmacists – and patients enrolled in fee-for-service Medicare receiving cancer drug therapy at a large, urban cancer center or affiliated community practice. HCPs were asked about common issues patients have regarding cancer treatment costs and how they search for patient financing opportunities. Patients were asked about difficulty with treatment costs not covered by insurance, conversations with care team members about how much they should expect to pay for treatment, and how they learned about their OOP costs. All interviews were led by a health economist/policy expert and a qualitative research assistant between October 2020 and June 2021. Results: We interviewed 13 HCPs and 3 patients. HCPs averaged 16 years of experience working with cancer patients (range: 1-39 years). Patients were ≥50 years old and had at least a high school degree or the equivalent. We identified at least 10 roles that may be involved in discussing or identifying resources to lower expected OOP costs (i.e., cost navigation) for cancer patients receiving systemic infused or oral treatments. OOP treatment costs were identified as a top concern for patients and HCPs, echoing known challenges; however, how OOP costs are determined and navigated varies tremendously per patient. Emergent themes in the data include: lack of transparency in OOP costs and the navigation process, a need for cost conversations at the start of treatment, challenges with obtaining financial assistance, and numerous barriers impeding cost navigation. There are opportunities for technology to streamline support for navigation tasks. Conclusions: Helping patients understand and seek assistance to cover high OOP costs is critical for many patients with high-priced cancer treatments. However, it is a complex process that often requires engagement from multiple care team members who may encounter barriers to providing this help. Patients who cannot afford their OOP costs may benefit greatly from close partnership with an HCP who assists with navigation throughout the process. Technology is needed to support a variety of backend tasks to help HCPs determine expected OOP costs and maintain the focus of the oncologist’s role – to provide the patient with the best possible treatment.

Trends in high deductible health plan enrolment and spending among commercially insured members with and without chronic conditions: a Natural Experiment for Translation in Diabetes (NEXT-D2) Study

ObjectivesTo examine trends in high deductible health plan (HDHP) enrolment among members with diabetes and cardiovascular disease (CVD) compared with healthy members and compare out-of-pocket (OOP) and total spending for...

809-P: The Impact of High-Deductible Health Plans (HDHPS) and Out-of-Pocket (OOP) Costs on Access to Care in Diabetes

Background: HDHP use and high OOP costs are associated with decreased healthcare resource use (HCRU) and access to care, among those with lower incomes, or racial and ethnic minorities. The potential impact on diabetes care is a public health concern, given that regular access to medications is critical to avoid severe complications. The objective of this study was to characterize the impact of HDHPs and high OOP costs on access to care and HCRU among Americans with diabetes, and the interaction of race/ethnicity and income. Methods: A systematic review was performed using Medline/EMBASE to identify records from the past 10 years, describing the impact of HDHPs, or high OOP costs or copayments, on access to care (e.g., not pursuing care because of cost) or HCRU (e.g., medication use, physician visits). The focus of the review was on Americans with diabetes; whether the impact of race/ethnicity and income was reported was also captured. Results: From 2707 abstracts, 2 described the impact of HDHPs among those with diabetes and 9, high OOP/copayment costs. Four studies (36.4%) reported the impact of race/ethnicity: Black and non-Hispanic patients with diabetes tended to be at higher risk of non-adherence than white patients. Three studies (27.2%) reported the impact of income: Lower-income patients with diabetes were at higher risk of non-adherence and decreased HCRU, versus higher-income patients. Only one study reported on both race/ethnicity and income, but not the interaction of these. Conclusions: These findings suggest that HDHP use and high OOP costs are associated with decreased HCRU and adherence among Americans with diabetes. This effect may be more pronounced among those of non-white race/ethnicity or with low income. Notably, no studies reported the impact of HDHPs and high OOP costs on access to care. Understanding how race/ethnicity and income interact will be important to fully recognize the impact of HDHPs and high OOP costs on outcomes among Americans with diabetes. Disclosure S. M. Szabo: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. E. Kuti: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc. M. Friesen: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. D. Reardon: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc. E. Jaykus: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc. R. Corepal: Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc. B. M. K. Donato: Employee; Self; Boehringer Ingelheim Pharmaceuticals, Inc. Funding Boehringer Ingelheim

Total and out-of-pocket costs for patients undergoing hematopoietic cell transplantation.

e18862 Background: Hematopoietic cell transplantation (HCT) is a medically complicated, expensive and resource intensive medical technology. High health care costs are usually associated with high Out-of-Pocket (OOP) costs. In this population-based study, using deidentified administrative claims data from OptumLabs Data Warehouse, we describe total and patient level costs for one-year pre and post HCT and describe the characteristics of those with top 25% cost. Methods: Patients who had undergone an autologous or allogeneic HCT in 2015 to 2019 and had continuous health plan coverage for one year prior and post the index date-the date of the first claim for HCT, were included. We examined total costs, patient paid (OOP) and plan paid costs for one year before and after HCT. We also examined inpatient, outpatient, and pharmacy costs for the one year before and after the HCT. Logistic regression models examined factors including age, gender, race/ ethnicity, Charlson comorbidity index, geographic region and costs in the year prior to HCT (baseline costs) for their association with high total costs and high OOP costs (top 25%). Results: A total of 3,346 patients (2,344 commercial plan (CPE) and 1,002 under Medicare Advantage plan (MAPE) enrollees) were included in the study. Median one year post HCT costs for CPE was $ 612,517 (IQR 413,348- 960,456) and for MAPE was $ 521,000 (IQR 347,388-736,685). Median one year post HCT OOP costs were $ 5,407 (IQR 1,584 -10,000) in CPE and $7,199 (IQR 3,485 -16,396) in MAPE group. 625 subjects in the CPE and 253 subjects in MAPE group had overall costs in the top 25%. Median baseline costs were $482,107 vs. $846,943 in the low vs. high cost group in CPE and $278,656 vs. $343,633 in MAPE. There was a low correlation between OOP costs and overall costs (r = 0.17 for CPE and 0.15 for MAPE; p &lt; 0.05). Younger age (OR for age 0.98; p &lt; 0.001) and higher baseline costs (OR1.89; p &lt; 0.001) predicted top 25% total costs post HCT in the CPE group. Not being African American (OR for African American 0.5; p = 0.02) and higher baseline costs (OR 1.07; p &lt; 0.001) predicted top 25% total costs post HCT in MAPE group. Age (OR 0.97; p &lt; 0.001), not being African American (OR 0.5; p = 0.001) and high baseline costs (OR 1.44; p &lt; 0.001) also predicted higher OOP costs in the CPE group. The only factor that was associated with lower likelihood of OOP costs in top 25% in MAPE group was being Hispanic (OR 0.6; p = 0.004). Conclusions: HCT is an expensive treatment modality. High costs prior to HCT are associated with high post HCT costs both for patients on commercial and Medicare Advantage plan. The magnitude of correlation between patient level and total costs was low, likely due to differences in benefit plan. A careful assessment of benefits and costs of HCT is needed for providing high-value care and allow optimum allocation of the finite resources while minimizing patient level financial burden.

High OOP costs lead to catastrophic healthcare expenditure in India

High OOP costs lead to catastrophic healthcare expenditure in India

Evaluating financial burdens of oral hormonal therapies for patients with prostate cancer.

70 Background: Numerous oral anticancer drugs approved for metastatic prostate cancer are expensive and put patients at risk for financial toxicity. Mechanisms available to mitigate these costs are complex to navigate. Furthermore, the ability to access these resources may not be the same for every insurance. We examined the out-of-pocket (OOP) liability of patients prescribed abiraterone or enzalutamide, the assistance mechanisms used, and the impact on timing of therapy. Methods: Patients with prostate cancer who were prescribed abiraterone or enzalutamide at our comprehensive cancer center between January 1, 2017 and March 31, 2019 were identified. Patients who filled prescriptions via an external pharmacy were excluded. Data regarding demographics, out of pocket costs and assistance mechanisms were evaluated. Results: We identified 219 patients. Of these, 33% had commercial insurance, 61% had Medicare part D, 3% had Medicaid and 8% had no insurance. Most patients (74%) were prescribed abiraterone and 26% enzalutamide. Among those with Medicare Part D, almost one third received significant financial assistance: 11% free drug from the manufacturer and 18% foundational grants. Patients with commercial insurance received a copay card from manufacturers 21% of the time. Patients with commercial insurance paid an average of $57 OOP; 94% with initial cost &lt; $100. Patients with Medicare part D paid an average of $582 OOP; 22% with initial cost &gt; $1000. Commercially insured patients started treatments in under 10 days from the prescription date 51% of the time vs 39% for Medicare patients. In contrast, 11% of commercially insured patients required &gt; 30 days to fill vs 19% on Medicare. Only 1% of commercially insured patients were unable to fill due to cost issues compared to 7% of patients on Medicare. Conclusions: Financial assistance mechanisms such as grants and free drug programs help alleviate some financial burden for patients, but many still experience high OOP costs. These burdens appear to be disproportionately experienced by patients with Medicare Part D. We observed that patients with Medicare Part D had higher OOP costs for oral prostate cancer therapies. Those who required assistance often experienced delays in obtaining medication. Further evaluation is planned into how high costs and delays in treatment impacts prostate cancer treatment and patient care. [Table: see text]

The financial burden of PARP inhibitors on patients, payors, and financial assistance programs: Who bears the cost?

ObjectivesPoly(ADP-ribose) polymerase (PARP) inhibitors are expensive and their use is expanding. We aimed to evaluate cost sharing patterns between patients, payors, and financial assistance programs. MethodsWe identified ovarian cancer patients prescribed a PARP inhibitor from 5/2015–9/2019 using our pharmacy database. Cost information was collected for patients who filled their prescription at our specialty pharmacy. We calculated descriptive statistics for monthly PARP inhibitor costs for patients, payors, and financial assistance programs. We used Wilcoxon rank sum tests to evaluate monthly costs based on insurance characteristics. ResultsSeventy-six patients filled 94 different PARP inhibitor prescriptions with 42 (45%) prescriptions obtained using any type of financial assistance program. We analyzed 232 prescription months for the 41 prescriptions with available cost data. This included 18 (44%) prescriptions for rucaparib, 18 (44%) for niraparib, and 5 (12%) for olaparib. The total monthly drug cost was average $12,422 and median $13,700. The monthly out-of-pocket (OOP) cost for patients was average $46 and median $0 (IQR $0–4). Payors had the highest monthly costs with average $12,019 and median $13,662 (IQR $9914-14,709). Financial assistance programs contributed average $358 and median $0 per month (IQR $0–150). Patients with public (p<0.01) or Medicare insurance (p<0.01) had higher OOP costs than without. ConclusionsOOP costs were generally low with 75% of patients paying <$5 per month. While limited by small sample size at a single institution, financial assistance programs appear to play a critical role to ensure access to PARP inhibitors as nearly 50% of patients utilized these programs.

Abstract 285: Association Of Patient Out-of-pocket Costs And Financial Assistance With Prescription Abandonment: The Case Of PCSK9 Inhibitors

Background: Specialty drugs are typically subject to high out-of-pocket (OOP) costs, especially for Medicare Part D patients and commercially insured patients facing high deductibles and/or coinsurance. Financial assistance offered by charities or manufacturers often helps reduce OOP burden. Studies in several disease areas have shown that high OOP costs are associated with prescription abandonment, defined as failure to purchase an insurer-approved prescription at the pharmacy. We examined how OOP costs and financial assistance were associated with abandonment of PCSK9i prescriptions. Methods: This retrospective study utilized 2015-2017 claims data from Decision Resources Group for Medicare and commercially insured patients. We defined PCSK9i abandonment rate as the percentage of patients with no evidence of a dispensed PCSK9i in the 90 days after their first PCSK9i prescription was approved by the insurer. Logistic regressions controlling for demographic, clinical, and treatment characteristics were used to estimate risk-adjusted rates of abandonment across different OOP cost levels. We conducted simulations to predict abandonment rates if a patient’s OOP cost level changed and/or they did not receive financial assistance, while holding all other covariates constant. Analyses were conducted separately in the Medicare and commercially insured patients. Result: Our final sample included 8,024 Medicare beneficiaries and 3,865 commercially-insured patients. We found that higher OOP cost was associated with higher risk-adjusted PCSK9i abandonment rates in both groups. For instance, Medicare beneficiaries with $0 OOP cost had a 7.4% risk-adjusted abandonment rate, compared to 9.8% for the $1-$9 group (odds ratio [OR]:1.37; 95% CI:1.04-1.81), 19.6% for the $10-$99 group (OR: 3.12; 95% CI: 2.62-3.72), 42.6% for the $100-$199 group (OR: 9.99; 95% CI: 7.60-13.14), 51.9% for the $200-$299 group (OR: 14.48; 95% CI: 11.14-19.76), 58.5% for $300-$399 group (OR: 19.7; 95% CI: 15.01-25.86), and 59% for the ≥$400 group (OR: 20.13; 95% CI: 14.96-27.09). All comparisons were significant at P&lt;0.05. About 4% of Medicare beneficiaries (n=288) and 32% of commercially insured patients (n=1,243) received financial assistance. Without it, their mean OOP costs would have increased from $31 to $386 for Medicare and $7 to $534 for commercial insurance and abandonment rates would have increased from 9.7% to 46.4% (change: 36.7% [95% CI: 31.4% -41.9%]) for Medicare and 4.4% to 27.4% (change: 23% [95% CI: 19.1% -26.9%] for commercial insurance. Conclusions: Higher OOP costs were associated with higher rates of PCSK9i abandonment. Lack of financial assistance was associated with increased abandonment. Our findings help inform current policy efforts to protect patients from high cost sharing, such as current bills in Congress aiming to reduce patient OOP burden under Medicare Part D.

Higher OOP costs reduce adherence to neurological therapies

Higher OOP costs reduce adherence to neurological therapies