Low-income Subsidy Research Articles

Medicare Part D: Major Shifts With the Inflation Reduction Act and a Way Forward.

The Inflation Reduction Act (IRA) of 2022 introduced major changes in the Part D benefit that aim to improve medication access and correct several of the financial misalignments in the current Part D benefit. The changes address financial obligations of Medicare beneficiaries, the federal government, Part D plan sponsors (i.e., insurance companies), and drug manufacturers. The changes include new brand and biologic manufacturer obligations to beneficiaries eligible for the low-income subsidy. Effects on the drug supply chain and stakeholder behaviors remain to be seen but current financial arrangements inform likely responses. Currently, the Pharmacy Benefit Managers (PBMs) nestled between the plans, drug manufacturers, and pharmacies heavily influence manufacturers' list prices and squeeze community pharmacies. With the IRA restructuring of Part D, plans are likely to interject more administrative obstacles before beneficiaries can obtain higher-cost therapies, while drug manufacturers might alter their patient assistance programs. Manufacturers have already begun to change their assistance programs at many safety net pharmacies. Many Medicare beneficiaries who relied on these deeply discounted medications will face significant late enrollment penalties if they do enroll in Part D plans, creating a major barrier to participation. Providers and policymakers should understand the Part D changes and leverage the skills of pharmacists to support community and team-based care that improves access to medications and ensures that medications are doing more good than harm.

Completed suicide risk factors among people living with HIV in Hunan Province identified through a psychological autopsy case–control study

Accumulating evidence has shown an increased risk of suicide among people living with HIV/AIDS (PLWHA). However, few studies have explored the risk factors associated with completed suicide among PLWHA. This study aimed to identify the characteristics and causes of completed suicide among PLWHA to guide future targeted suicide prevention and intervention programs. A 1:1 matched case–control psychological autopsy study was conducted among PLWHA in Hunan Province. We recruited 63 PLWHA who died by suicide from January 1, 2013, to December 31, 2019, and 63 living controls matched for age, gender, and employment. Two informants for each participant were interviewed to collect data on participants’ sociodemographic characteristics, depressive symptoms, HIV-related stress, hopelessness, and social support. The median survival time from HIV diagnosis to completed suicide was 3.9 months (IQR: 0.57–14.13). Most completed suicides occurred within six months of HIV diagnosis (71.4%), with poisoning (34.9%) and hanging (22.2%) as the primary methods. After controlling for confounding factors, we identified four risk factors of completed suicide: not receiving antiretroviral treatment (OR = 6.805; 95% CI: 1.227 to 37.738), receiving low-income subsidy (OR = 16.272; 95% CI: 3.245 to 81.598), HIV-related stress (OR = 1.332; 95% CI: 1.089 to 1.629), and hopelessness (OR = 2.910; 95% CI: 1.378 to 6.144). PLWHA are at a high risk of suicide within the first six months of HIV diagnosis, indicating an urgent need for immediate suicide screening and timely intervention. Suicide risk is affected by multiple factors, including sociodemographic, clinical, and psychological factors, indicating the need for a multifactorial approach to suicide prevention, which may involve early initiation of ART treatment and provision of economic and psychosocial support.

HPR101 Out-of-Pocket Costs and Initiation of HCV Treatment Among US Medicare Beneficiaries Receiving Low-Income Subsidy

HPR101 Out-of-Pocket Costs and Initiation of HCV Treatment Among US Medicare Beneficiaries Receiving Low-Income Subsidy

Trends and disparities in antiretroviral therapy prescription rates among US Medicare beneficiaries with HIV.

Our objective was to evaluate antiretroviral therapy (ART) prescription rates over time among US Medicare enrolees with HIV and to describe disparities in ART prescription and associated factors. We constructed successive cross-sectional cohorts including adult enrollees with HIV and fee-for-service coverage and Part D enrolment in US Medicare between 2007 and 2019. We calculated the percentage of receipt of any ART prescription (ART%) in a calendar year by sex, age, and original Medicare entitlement and calculated age-sex standardized ART% over time. We used multivariable logistic regression to assess the association between ART prescription and sociodemographic factors and chronic conditions by age strata (<65, ≥65 years) in 2019. ART% increased over time and was highest among people with HIV aged 50-64 years in 2019: 95% in males and 92% in females. Multivariable analysis showed that female sex was associated with less ART%, with odds ratios (ORs) of 0.65 (95% confidence interval [CI] 0.60-0.70) and 0.34 (95% CI 0.30-0.39), than male sex in those aged <65 and ≥65 years, respectively. The youngest and oldest enrollees had lower ART use (e.g., OR 0.43 [95% CI 0.34-0.54] for 18-29 vs. 50-64 years; OR 0.34 [95% CI 0.30-0.39] for ≥80 vs. 65-69 years). The top conditions associated with less ART included dementia and alcohol use disorder. Other factors included no Part D low-income subsidy, non-Hispanic white race, and Midwest residence. ART use increased over time in US Medicare enrollees. Non-Hispanic white, female, and the youngest and oldest enrollees received less ART. Multimorbidity, substance use, and dementia were associated with less ART use. Research to overcome these disparities is needed.

Non-cost-related sources of medication nonadherence in the Medicare population.

Significant research and attention to date have focused on cost-related medication nonadherence as rising prescription drug prices worsen affordability and access for many Americans. This study investigated self-reported sources of medication nonadherence, measuring both cost- and non-cost-related medication nonadherence among community-dwelling Medicare Part D beneficiaries in 2022. A total of 13.7% of beneficiaries (4 589 843) reported some type of medication nonadherence; 7.5% reported medication nonadherence related to cost and 6.2% reported for non-cost reasons. Beneficiaries reporting food insecurity, poor functional status, and lack of understanding of the Part D benefit were more likely to report both types of medication nonadherence after adjustment for sociodemographic factors. Beneficiaries receiving the Low-Income Subsidy had lower odds of reporting cost-related but greater odds of reporting non-cost-related medication nonadherence. These findings suggest that non-cost-related sources of medication nonadherence, such as beneficiary preferences or beliefs, understanding of their health situation or insurance coverage, and ability to fill a prescription, are significant contributors to overall nonadherence. Non-cost-related medication nonadherence should be considered alongside recent changes to the Part D benefit and in future Part D Centers for Medicare and Medicaid Services (CMS) Innovation Center models, such as the proposed Medicare $2 Drug List Model, in order to maximize the impact of these initiatives.

Impact of the Inflation Reduction Act on Patient Access and Out-of-Pocket Costs

The Inflation Reduction Act (IRA) represents a recent policy enactment that will influence prescription drug pricing. This paper examines the IRA's elements and their impact on patients' access to medications, specifically around programs funded by the Centers for Medicare and Medicaid. This review analyzed grey literature on patient medication access concerning the IRA, along with the legislation itself. It finds that the IRA contains six key provisions with the potential to impact patients' access to medications and stakeholder business practices: insulin and vaccine cost share, OOP cost limits, premium stabilizations, drug negotiations, and low-income subsidy programs. Although the IRA presents cost-saving provisions, it may exert downstream effects on new drug innovation, increased medication utilization management by payers and pharmacy benefit managers (PBMs), and how healthcare providers, manufacturers, and payers/(PBMs) work together to balance patient well being with fair economic returns for all stakeholders.

Quality of Treatment Selection for Medicare Beneficiaries With Cancer.

The Medicare part D Low-Income Subsidy (LIS) improves access to oral cancer drugs, but provides no assistance for clinician-administered/part B drugs. This analysis assessed the association between LIS participation and receipt of optimal cancer treatment. We investigated initial systemic therapy using SEER-Medicare data (2015-2017) and National Comprehensive Cancer Network (NCCN) Evidence Blocks (EB) as the standard for treatment recommendations. We included cancer clinical scenarios wherein (1) ≥one treatment was optimal (higher efficacy and safety scores) versus other treatments; (2) identifiable in SEER-Medicare (eg, not defined by clinical data unavailable in registry data or claims); and (3) both EB and ASCO Value Framework agreed regarding optimal treatment. We fit logistic regression models to assess the association between receipt of systemic therapy (v no therapy) and patient and provider characteristics. Contingent on receipt of treatment, we modeled the likelihood of receiving a treatment ranked (by EB scores) within the highest or lowest quartile for that cancer type. Nine thousand two hundred and ninety patients were included across 11 clinical scenarios. Fifty-seven percent (5,336) of patients received any systemic therapy and 43% (3,954) received no systemic therapy. Compared with non-LIS participants, LIS participants were less likely to receive any systemic therapy versus no systemic therapy (odds ratio, 0.64 [95% CI, 0.57 to 0.72]). Contingent on receiving systemic therapy, LIS participants received treatment ranked within the worst quartile 24.8% of the time, compared with 21.9% of non-LIS patients (adjusted prevalence difference, 4.3% [95% CI, 0.5 to 8.2]). LIS participants were less likely to receive systemic therapy at all and were more likely to receive treatments that receive low NCCN EB scores.

Out-of-Pocket Prescription Drug Savings for Medicare Beneficiaries with Asthma and COPD Under the Inflation Reduction Act.

High and rising prescription drug costs for asthma and chronic obstructive pulmonary disease (COPD) contribute to medication nonadherence and poor clinical outcomes. The recently enacted Inflation Reduction Act includes provisions that will cap out-of-pocket prescription drug spending at $2,000 per year and expand low-income subsidies. However, little is known about how these provisions will impact out-of-pocket drug spending for Medicare beneficiaries with asthma and COPD. To estimate the impact of the Inflation Reduction Act's out-of-pocket spending cap and expansion of low-income subsidies on Medicare beneficiaries with obstructive lung disease. We calculated the number of Medicare beneficiaries ≥ 65years with asthma and/or COPD and out-of-pocket prescription drug spending > $2,000/year, and then estimated their median annual out-of-pocket savings under the Inflation Reduction Act's spending cap. We then estimated the number of beneficiaries with incomes > 135% and ≤ 150% of the federal poverty level who would become newly eligible for low-income subsidies under this policy. Respondents to the 2016-2019 Medical Expenditure Panel Survey (MEPS). Annual out-of-pocket prescription drug spending. An annual estimated 5.2 million Medicare beneficiaries had asthma and/or COPD. Among them, 360,160 (SE ± 38,021) experienced out-of-pocket drug spending > $2,000/year, with median out-of-pocket costs of $3,003/year (IQR $2,360-$3,941). Therefore, median savings under the Inflation Reduction Act's spending cap would be $1,003/year (IQR $360-$1,941), including $738/year and $1,137/year for beneficiaries with asthma and COPD, respectively. Total annual estimated savings would be $504 million (SE ± $42M). In addition, 232,155 (SE ± 4,624) beneficiaries would newly qualify for low-income subsidies, which will further reduce prescription drug costs. The Inflation Reduction Act will have major implications on out-of-pocket prescription drug spending for Medicare beneficiaries with obstructive lung disease resulting in half-a-billion dollars in total out-of-pocket savings per year, which could ultimately have implications on medication adherence and clinical outcomes.

Opioid and Nonopioid Analgesic Prescribing Patterns of Hepatologists for Medicare Beneficiaries.

Opioids are commonly prescribed to patients with chronic liver disease, but little is known regarding medication prescribing patterns of hepatologists. Opioid use increased until national guidelines limited opioid prescriptions in early 2016. We aimed to describe rates of opioid and nonopioid analgesics to Medicare beneficiaries by hepatologists from 2013 to 2017 and identify demographic characteristics associated with higher prescribing. Prescription data from 2013 to 2017 by 761 hepatologists identified in the Centers for Medicare and Medicaid Services Part D Public Use File were analyzed. Annual prescription volumes were compared for providers with >10 annual prescriptions of a given drug type. Provider characteristics associated with opioid prescriptions were identified through multivariate logistic regression analyses. The proportion of hepatologists prescribing >10 annual opioid prescriptions decreased from 29% to 20.6%. Median annual opioid prescriptions per hepatologist significantly decreased from 24 to 20. Tramadol remained the most prescribed analgesic. Nonopioid analgesic prescription volume did not increase significantly. Provider characteristics associated with increased opioid prescriptions included male sex, practice location in the South and Midwest (vs West), more years in practice, and a greater proportion of beneficiaries who are white or with low-income subsidy claims. Characteristics associated with fewer prescriptions included non-university-based practice, having a greater proportion of female beneficiaries, and later prescription year. Hepatologists are prescribing less opioids. However, the prevalence of tramadol use and the lack of increase in nonopioid analgesic use highlights the need for advancing the science and training of pain management in chronic liver disease and targeted implementation of nonopioid treatment programs.

Group-based trajectory modeling to identify adherence patterns for direct oral anticoagulants in Medicare beneficiaries with atrial fibrillation: a real-world study on medication adherence.

Suboptimal adherence to direct oral anticoagulants (DOACs) among atrial fibrillation (AF) patients remains currently a major concern due to the increased risk of cardiac and thromboembolic events. To identify longitudinal distinct trajectories of DOAC adherence and sociodemographic and clinical factors associated witheach trajectory. Patients with AF who were prescribed withDOAC from July 2016-December 2017 were identified among patients enrolled in the Medicare Advantage Plan. Patients were followed up for a year after the index date to calculate the monthly proportion of days covered (PDC). The monthly PDC was incorporated into the logistic group-based trajectory model to evaluate distinct patterns of adherence. A multinomial regression model was carried out to assess various predictors associated with each trajectory. Sub-group analysis was conducted among incident DOAC users. Total of 1969 patients with AF, four distinct trajectories of adherence were selected: adherent 36.8%, gaps in adherence 9.3%, gradual decline in adherence 29.7%, and rapid decline in adherence 24.2%. Significant predictors associated with suboptimal adherence trajectories were age (75 years or older), gender (male vs female), low-income subsidy health plan, prevalent users, and presence of comorbidities. Among 933 incident users, three adherence trajectories were identified: adherent trajectory (31.8%), rapid decline in adherence (32.5%), and gradual decline in adherence (35.6%). The significant predictors among incident users were gender (male vs female), low-income subsidy health plan, HAS-BLED score ≥ 2, and presence of coronary artery disease. Adherence to DOACs was suboptimal among the total population and incident users.

Disparities in Access to Highly Rated Skilled Nursing Facilities among Medicare Beneficiaries with Opioid Use Disorder

ObjectivesTo investigate disparities in admissions to highly rated skilled nursing facilities (SNFs) between Medicare beneficiaries with and without opioid use disorder (OUD). DesignNationwide, retrospective observational cohort. Setting and ParticipantsMedicare Fee-for-Service beneficiaries aged ≥18 years admitted to SNFs following hospitalization during 2016-2020 (n = 30,922 with OUD and n = 137,454 without OUD). MethodsData used were 100% Medicare inpatient claims, nursing home administrative databases, and Nursing Home Compare. We identified hospitalized patients with and without OUD and matched them on age, sex, Part D low-income subsidy (LIS), and residential county. We compared the overall and component (quality, staffing, and health inspections) star ratings of SNFs that beneficiaries entered. Beneficiary-level regression models were conducted adjusting for race and ethnicity, Medicare-Medicaid dual status, comorbidity score, hospital length of stay, and state and year fixed effects. ResultsThe overall study sample had a mean (SD) age of 71.4 (11.4) years, 63.9% were female, and 57.4% had LIS. Among beneficiaries with OUD, 50.3% entered SNFs with above-average (4 or 5) overall rating compared with 51.3% among those without OUD. Distributions of above-average ratings among beneficiaries with and without OUD were as follows: 63.9% vs 62.2% for quality, 32.8% vs 34.9% for health inspections, and 46.2% vs 45.0% for staffing, respectively. Adjusted regression models indicated that beneficiaries with OUD were less likely to be admitted to facilities with above-average overall (OR 0.90, 95% CI 0.87-0.92), health inspection (OR 0.90, 95% CI 0.88-0.93), and staffing (OR 0.91, 95% CI 0.89-0.94) ratings compared with beneficiaries without OUD, whereas quality (OR 0.98, 95% CI 0.95-1.01) ratings did not differ. Conclusions and ImplicationsDespite mixed results on component ratings, our findings suggest a concerning disparity in the overall quality of SNFs admitting Medicare beneficiaries with OUD. Enhancing equitable access to high-quality SNF care for individuals with OUD is imperative amid rising demand and legal protections under the American Disabilities Act.

Affordability and adherence gains for Medicare Part D low-income subsidy recipients when low-income subsidy benefits expanded in 2024.

The lowest-income beneficiaries enrolled in the Medicare Part D prescription drug program receive "full subsidies" that waive the premium and deductible and impose minimal copayments. Those with slightly higher incomes and assets may be eligible for "partial subsidies." Prior to 2024, individuals receiving partial subsidies faced reduced Part D premiums and deductibles and paid 15% coinsurance. Under provisions of the Inflation Reduction Act, recipients of partial subsidies were upgraded to full subsidies beginning in 2024. The objective of this pilot study was to assess whether the new policy is likely to reduce cost-related nonadherence to prescribed medications- a common problem faced by older adults even among those receiving subsidies. To compare cost-related nonadherence among partial- vs full-subsidy recipients with similar characteristics. We used 2019 Medicare Current Beneficiary Survey data for the study. The Medicare Current Beneficiary Survey is uniquely suited for this work because it contains administrative data on low-income subsidy enrollment plus extensive survey-based information on financial resources necessary to establish program eligibility and rates of cost-related nonadherence. Explanatory variables included sociodemographic characteristics, economic resources, work status, and health variables. We found that the partial-subsidy group reported significantly more cost-related nonadherence (39% vs 22%; P = 0.01) arising both from a lower propensity to fill some prescriptions (23% vs 12%; P = 0.03) and to more delays in filling others (29% vs 8%; P = 0.03). The differences were more pronounced for women and racial and ethnic minority groups in contrast to men and majority populations, respectively. Because the study samples were small, we could not conduct a detailed regression analysis. The magnitude of cost-related nonadherence effects associated with partial-subsidy cost sharing suggests that the Inflation Reduction Act policy to expand low-income subsidies may boost medication adherence, most notably among women and racial and ethnic minority groups.

Prevalence and Factors Associated with De-escalation of Anti-TNFs in Older Adults with Rheumatoid Arthritis: A Medicare Claims-Based Observational Study.

The aim was to evaluate prevalence and factors associated with anti-tumor necrosis factor (anti-TNF) de-escalation in older adults with rheumatoid arthritis (RA). We identified adults ≥66 years of age with RA on anti-TNF therapy within 6 months after RA diagnosis with at least 6-7 months duration of use (proxy for stable use), using 20% Medicare data from 2008-2017. Patient demographic and clinical characteristics, including concomitant use of glucocorticoid (GC), were collected. Anti-TNF use was categorized as either de-escalation (identified by dosing interval increase, dose reduction, or cessation of use) or continuation. We used (1) an observational cohort design with Cox regression to assess patient characteristics associated with de-escalation and (2) a case-control design with propensity score-adjusted logistic regression to assess the association of de-escalation with different clinical conditions and concomitant medication use. We identified 5106 Medicare beneficiaries with RA on anti-TNF, 65.5% of whom had de-escalation. De-escalation was more likely with older age (hazard ratio [HR] 1.01, 95% confidence interval [CI] 1.01-1.02) or greater comorbidity (HR 1.07, 95% CI 1.05-1.09), but was less likely with low-income subsidy status (HR 0.85, 95% CI 0.78-0.92), adjusting for patient sex and race/ethnicity. Lower odds of de-escalation were associated with serious infection (odds ratio [OR] 0.79, 95% CI 0.66-0.94), new heart failure diagnosis (OR 0.70, 95% CI 0.52-0.95), and long-term GC use (OR 0.84, 95% CI 0.74-0.95), whereas higher odds were associated with concomitant methotrexate use (OR 1.16, 95% CI 1.03-1.31). Anti-TNFs are de-escalated in two-thirds of older adults with RA in usual care. Further study is needed on RA outcomes after anti-TNF de-escalation.

Medicare Advantage enrollees' reports of unfair treatment during health care encounters.

We investigated unfair treatment among 1863 Medicare Advantage (MA) enrollees from 21 MA plans using 2022 survey data (40% response rate) in which respondents indicated whether they were treated unfairly in a health care setting based on any of 10 personal characteristics. We calculated reported unfair treatment rates overall and by enrollee characteristics. Nine percent of respondents reported any unfair treatment, most often based on health condition (6%), disability (3%), or age (2%). Approximately 40% of those reporting any unfair treatment endorsed multiple categories. People who qualified for Medicare via disability reported unfair treatment by disability, age, income, race and ethnicity, sex, sexual orientation, and gender/gender identity more often than those who qualified via age. Enrollees dually eligible for Medicare and Medicaid or eligible for a Low-Income Subsidy (DE/LIS) reported unfair treatment by disability, income, language/accent, race and ethnicity, culture/religion, and sex more often than non-DE/LIS enrollees. Compared with White respondents, racial and ethnic minority respondents more often reported unfair treatment by race and ethnicity, language/accent, culture/religion, and income. Female respondents were more likely than male respondents to report unfair treatment based on age and sex.

Predictors of adherence to direct oral anticoagulants after cardiovascular or bleeding events in Medicare Advantage Plan enrollees with atrial fibrillation.

Direct oral anticoagulants (DOACs) are recommended for patients with atrial fibrillation (AF) given their improved safety profile. Suboptimal adherence to DOACs remains a significant concern among individuals with AF. However, the extent of adherence to DOACs following a cardiovascular or bleeding event has not been fully evaluated. To evaluate the pattern of adherence trajectories of DOACs after a cardiovascular or bleeding event and to investigate the sociodemographic and clinical predictors associated with each adherence trajectory by using claims-based data. This retrospective study was conducted among patients with AF prescribed with DOACs (dabigatran/apixaban/rivaroxaban) between July 2016 and December 2017 and who were continuously enrolled in the Texas-based Medicare Advantage Plan. Patients who experienced a cardiovascular or bleeding event while using the DOACs were further included in the analysis. The sample was limited to patients who experienced a clinical event such as a cardiovascular or bleeding event while using the DOACs. The clinical events considered in this study were cardiovascular (stroke, congestive heart failure, myocardial infarction, systemic embolism) and bleeding events. To assess adherence patterns, each patient with a DOAC prescription was followed up for a year after experiencing a clinical event. The monthly adherence to DOACs after these events was evaluated using the proportion of days covered (PDC). A group-based trajectory model incorporated the monthly PDC to classify groups of patients based on their distinct patterns of adherence. Predictors associated with each trajectory were assessed using a multinomial logistic regression model, with the adherent trajectory serving as the reference group in the outcome variable. Among the 694 patients with AF who experienced clinical events after the initiation of DOACs, 3 distinct adherence trajectories were identified: intermediate nonadherent (30.50%), adherent (37.7%), and low adherent (31.8%); the mean PDC was 0.47 for the intermediate nonadherent trajectory, 0.93 for the adherent trajectory, and 0.01 for low adherent trajectory. The low-income subsidy was significantly associated with lower adherence trajectories (odds ratio [OR] = 4.81; 95% CI = 3.07-7.51) and with intermediate nonadherent trajectories (OR = 1.57; 95% CI = 1.06-2.34). Also, nonsteroidal anti-inflammatory drug use was significantly associated with lower adherence trajectories (OR = 5.10; 95% CI = 1.95-13.36) and intermediate nonadherent trajectories (OR = 3.17; 95% CI = 1.26-7.93). Other predictors significantly associated with both nonadherent trajectories are type of DOACs (OR = 0.53; 95% CI = 0.35-0.79), presence of coronary artery disease (OR = 1.89; 95% CI = 1.01-3.55), and having 2 or more clinical events (OR = 1.65; 95% CI = 1.09-2.50). Predictors identified provide valuable insights into the suboptimal adherence of DOACs among Medicare Advantage Plan enrollees with AF, which can guide the development of targeted interventions to enhance adherence in this high-risk patient population.

The cost of influence: How gifts to physicians shape prescriptions and drug costs

This paper investigates the influence of gifts – monetary and in-kind payments – from drug firms to US physicians on prescription behavior and drug costs. Using causal models and machine learning, we estimate physicians’ heterogeneous responses to payments on antidiabetic prescriptions. We find that payments lead to increased prescription of brand drugs, resulting in a cost rise of $23 per dollar value of transfer received. Paid physicians show higher responses when they treat higher proportions of patients receiving a government-funded low-income subsidy that lowers out-of-pocket drug costs. We estimate that introducing a national gift ban would reduce diabetes drug costs by 2%.

Area Vulnerability and Disparities in Therapy for Patients With Metastatic Renal Cell Carcinoma.

Area-level measures of sociodemographic disadvantage may be associated with racial and ethnic disparities with respect to receipt of treatment for metastatic renal cell carcinoma (mRCC) but have not been investigated previously, to our knowledge. To assess the association between area-level measures of social vulnerability and racial and ethnic disparities in the treatment of US Medicare beneficiaries with mRCC from 2015 through 2019. This retrospective cohort study included Medicare beneficiaries older than 65 years who were diagnosed with mRCC from January 2015 through December 2019 and were enrolled in fee-for-service Medicare Parts A, B, and D from 1 year before through 1 year after presumed diagnosis or until death. Data were analyzed from November 22, 2022, through January 26, 2024. Five different county-level measures of disadvantage and 4 zip code-level measures of vulnerability or deprivation and segregation were used to dichotomize whether an individual resided in the most vulnerable quartile according to each metric. Patient-level factors included age, race and ethnicity, sex, diagnosis year, comorbidities, frailty, Medicare and Medicaid dual enrollment eligibility, and Medicare Part D low-income subsidy (LIS). The main outcomes were receipt and type of systemic therapy (oral anticancer agent or immunotherapy from 2 months before to 1 year after diagnosis of mRCC) as a function of patient and area-level characteristics. Multivariable regression analyses were used to adjust for patient factors, and odds ratios (ORs) from logistic regression and relative risk ratios (RRRs) from multinomial logistic regression are reported. The sample included 15 407 patients (mean [SD] age, 75.6 [6.8] years), of whom 9360 (60.8%) were men; 6931 (45.0%), older than 75 years; 93 (0.6%), American Indian or Alaska Native; 257 (1.7%), Asian or Pacific Islander; 757 (4.9%), Hispanic; 1017 (6.6%), non-Hispanic Black; 12 966 (84.2%), non-Hispanic White; 121 (0.8%), other; and 196 (1.3%), unknown. Overall, 8317 patients (54.0%) received some type of systemic therapy. After adjusting for individual factors, no county or zip code-level measures of social vulnerability, deprivation, or segregation were associated with disparities in treatment. In contrast, patient-level factors, including female sex (OR, 0.78; 95% CI, 0.73-0.84) and LIS (OR, 0.48; 95% CI, 0.36-0.65), were associated with lack of treatment, with particularly limited access to immunotherapy for patients with LIS (RRR, 0.25; 95% CI, 0.14-0.43). Associations between individual-level factors and treatment in multivariable analysis were not mediated by the addition of area-level metrics. Disparities by race and ethnicity were consistently and only observed within the most vulnerable areas, as indicated by the top quartile of each vulnerability deprivation index. In this cohort study of older Medicare patients diagnosed with mRCC, individual-level demographics, including race and ethnicity, sex, and income, were associated with receipt of systemic therapy, whereas area-level measures were not. However, individual-level racial and ethnic disparities were largely limited to socially vulnerable areas, suggesting that efforts to improve racial and ethnic disparities may be most effective when targeted to socially vulnerable areas.

Medicaid Eligibility Loss Among Dual-Eligible Beneficiaries Before and During COVID-19 Public Health Emergency

Medicaid coverage loss can substantially compromise access to and affordability of health care for dual-eligible beneficiaries. The extent to which this population lost Medicaid coverage before and during the COVID-19 public health emergency (PHE) and the characteristics of beneficiaries more at risk for coverage loss are currently not well known. To assess the loss of Medicaid coverage among dual-eligible beneficiaries before and during the first year of the PHE, and to examine beneficiary-level and plan-level factors associated with heightened likelihood of losing Medicaid. This repeated cross-sectional study used national Medicare data to estimate annual rates of Medicaid loss among dual-eligible beneficiaries before (2015 to 2019) and during the PHE (2020). Individuals who were dual eligible for Medicare and Medicaid at the beginning of a given year and who continuously received low-income subsidies for Medicare Part D prescription drug coverage were included in the sample. Multivariable regression models were used to examine beneficiary-level and plan-level factors associated with Medicaid loss. Data analyses were conducted between March 2023 and October 2023. Onset of PHE. Loss of Medicaid for at least 1 month within a year. Sample included 56 172 736 dual-eligible beneficiary-years between 2015 and 2020. In 2020, most dual-eligible beneficiaries were aged over 65 years (5 984 420 [61.1%]), female (5 868 866 [59.9%]), non-Hispanic White (4 928 035 [50.3%]), full-benefit eligible (6 837 815 [69.8%]), and enrolled in traditional Medicare (5 343 537 [54.6%]). The adjusted proportion of dual-eligible beneficiaries losing Medicaid for at least 1 month increased from 6.6% in 2015 to 7.3% in 2019 and then dropped to 2.3% in 2020. Between 2015 and 2019, dual-eligible beneficiaries who were older (ages 55-64 years: -1.4%; 95% CI, -1.8% to -1.0%; ages 65-74 years: -2.0%; 95% CI, -2.5% to -1.5%; ages 75 and older: -4.5%; 95% CI, -5.0% to -4.0%), disabled (-0.8%; 95% CI, -1.1% to -0.6%), and in integrated care programs were less likely to lose Medicaid. In 2020, the disparities within each of these demographic groups narrowed significantly. Notably, while Black (0.6%; 95% CI, 0.2% to 0.9%) and Hispanic (0.7%; 95% CI, 0.3% to 1.2%) dual-eligible beneficiaries were more likely to lose Medicaid than their non-Hispanic White counterparts between 2015 and 2019, such gap was eliminated for Black beneficiaries and narrowed for Hispanic beneficiaries in 2020. During the PHE, Medicaid coverage loss declined significantly among dual-eligible beneficiaries, and disparities were mitigated across subgroups. As the PHE unwinds, it is crucial for policymakers to implement strategies to minimize Medicaid coverage disruptions and racial and ethnic disparities, especially given that loss of Medicaid was slightly increasing over time before the PHE.

Validating claims-based definitions for deprescribing: Bridging the gap between clinical and administrative data.

Limited research has evaluated the validity of claims-based definitions for deprescribing. Evaluate the validity of claims-based definitions of deprescribing against electronic health records (EHRs) for deprescribing of benzodiazepines (BZDs) after a fall-related hospitalization. We used a novel data linkage between Medicare fee-for-service (FFS) and Part D with our health system's EHR. We identified patients aged ≥66 years with a fall-related hospitalization, continuous enrollment in Medicare FFS and Part D for 6 months pre- and post-hospitalization, and ≥2 BZD fills in the 6 months pre-hospitalization. Using a standardized EHR abstraction tool, we adjudicated deprescribing for a sub-sample with a fall-related hospitalization at UNC. We evaluated the validity of claims-based deprescribing definitions (e.g., gaps in supply, dosage reductions) versus chart review using sensitivity and specificity. Among 257 patients in the overall sample, 44% were aged 66-74 years, 35% had Medicare low-income subsidy, 79% were female. Among claims-based definitions using gaps in supply, the prevalence of BZD deprescribing ranged from 8.2% (no refills) to 36.6% (30-day gap). When incorporating dosage, the prevalence ranged from 55.3% to 65.8%. Among the validation sub-sample (n = 47), approximately one-third had BZDs deprescribed in the EHR. Compared to EHR, gaps in supply from claims had good sensitivity, but poor specificity. Incorporating dosage increased sensitivity, but worsened specificity. The sensitivity of claims-based definitions for deprescribing of BZDs was low; however, the specificity of a 90-day gap was >90%. Replication in other EHRs and for other low-value medications is needed to guide future deprescribing research.

The optimal co-insurance rate for outpatient drug expenses of Iranian health insured based on the data mining method

ObjectiveA more equal allocation of healthcare funds for patients who must pay high costs of care ensures the welfare of society. This study aimed to estimate the optimal co-insurance for outpatient drug costs for health insurance.SettingThe research population includes outpatient prescription claims made by the Health Insurance Organization that outpatient prescriptions in a timely manner in 2016, 2017, 2018, and 2019 were utilized to calculate the optimal co-insurance. The study population was representative of the research sample.DesignAt the secondary level of care, 11 features of outpatient claims were studied cross-sectionally and retrospectively using data mining. Optimal co-insurance was estimated using Westerhut and Folmer's utility model.ParticipantsOne hundred ninety-three thousand five hundred fifty-two individuals were created from 21 776 350 outpatient claims of health insurance. Because of cost-sharing, insured individuals in a low-income subsidy plan and those with refractory diseases were excluded.ResultsInsureds were divided into three classes of low, middle, and high risk based on IQR and were separated to three clusters using the silhouette coefficient. For the first, second, and third clusters of the low-risk class, the optimal co-insurance estimates are 0.81, 0.76, and 0.84, respectively. It was equal to one for all middle-class clusters and 0.38, 0.45, and 0.42, respectively, for the high-risk class. The insurer's expenses were altered by $3,130,463, $3,451,194, and $ 1,069,859 profit for the first, second, and third clusters, respectively, when the optimal co-insurance strategy is used for the low-risk class. For middle risks, it was US$29,239,815, US$13,863,810, and US$ 14,573,432 while for high risks, US$4,722,099, US$ 6,339,317, and US$19,627,062, respectively.ConclusionsThese findings can improve vulnerable populations' access to costly medications, reduce resource waste, and help insurers distribute funds more efficiently.