Medicaid Spending Research Articles

Examining the Impact of State-Level Factors on HIV Testing for Medicaid Enrollees With Schizophrenia.

People with schizophrenia experience unique barriers to routine HIV testing, despite increased risk of HIV compared with the general US population. Little is known about how health care delivery system factors affect testing rates or whether there are testing differences for people with schizophrenia. Nationally representative sample of Medicaid enrollees with and without schizophrenia. Using retrospective longitudinal data, we examined whether state-level factors were associated with differences in HIV testing among Medicaid enrollees with schizophrenia compared with frequency-matched controls during 2002-2012. Multivariable logistic regression estimated testing rate differences between and within cohorts. Higher HIV testing rates for enrollees with schizophrenia were associated with higher state-level Medicaid spending per enrollee, efforts to reduce Medicaid fragmentation, and higher federal prevention funding. State-level AIDS epidemiology predicted more frequent HIV testing for enrollees with schizophrenia versus controls. Living in rural settings predicted lower HIV testing, especially for people with schizophrenia. Overall, state-level predictors of HIV testing rates varied among Medicaid enrollees, although rates were generally higher for those with schizophrenia than controls. Increased HIV testing for people with schizophrenia was associated with coverage of HIV testing when medically necessary, higher Centers for Disease Control and Prevention prevention funding, and higher AIDS incidence, prevalence, and mortality when compared with controls. This analysis suggests that state policymaking has an important role to play in advancing that effort. Overcoming fragmented care systems, sustaining robust prevention funding, and consolidating funding streams in innovative and flexible ways to support more comprehensive systems of care delivery deserve attention.

Inflationary Rebates For Generic Drugs Sold Through Medicaid Saved Billions During 2017-20.

State Medicaid programs cover nearly all Food and Drug Administration-approved prescription drugs in exchange for mandatory manufacturer rebates, including rebates that offset price increases beyond inflation. These inflationary rebates originally applied to brand-name drugs only, but in 2017 Congress expanded them to include generics. Using public Medicaid medication spending and utilization data and three different measures of drug prices, we found that nearly half of generic drugs were subject to inflationary rebates during the period 2017-20, offsetting 2-12percent of the $53.6billion in generic drug spending during that time. Rebates were larger among non-orally administered drugs and those with the highest prices. Generic inflationary rebates offset substantial Medicaid spending during that period, suggesting that many generic prices increased above inflation despite the new policy. This might change now that inflationary rebates have been expanded to Medicare under the Inflation Reduction Act of 2022, although additional policies that ensure competitive markets would better protect all US patients from rising generic drug prices.

Health Care Use and Spending Among Need-Based Subgroups of Medicare Beneficiaries With Full Medicaid Benefits

Beneficiaries dual eligible for Medicare and Medicaid account for a disproportionate share of expenditures due to their complex care needs. Lack of coordination between payment programs creates misaligned incentives, resulting in higher costs, fragmented care, and poor health outcomes. To inform the design of integrated programs by describing the health care use and spending for need-based subgroups in North Carolina's full benefit, dual-eligible population. This cross-sectional study using Medicare and North Carolina Medicaid 100% claims data (2014-2017) linked at the individual level included Medicare beneficiaries with full North Carolina Medicaid benefits. Data were analyzed between 2021 and 2022. Need-based subgroups: community well, home- and community-based services (HCBS) users, nursing home (NH) residents, and intensive behavioral health (BH) users. Medicare and Medicaid utilization and spending per person-year (PPY). The cohort (n = 333 240) comprised subgroups of community well (64.1%, n = 213 667), HCBS users (15.0%, n = 50 095), BH users (15.2%, n = 50 509), and NH residents (7.5%, n = 24 927). Overall, 61.1% reported female sex. The most common racial identities included Asian (1.8%), Black (36.1%), and White (58.7%). Combined spending for Medicare and Medicaid was $26 874 PPY, and the funding of care was split evenly between Medicare and Medicaid. Among need-based subgroups, combined spending was lowest among community well at $19 734 PPY with the lowest portion (38.5%) of spending contributed by Medicaid ($7605). Among NH residents, overall spending ($68 359) was highest, and the highest portion of spending contributed by Medicaid (70.1%). Key components of spending among HCBS users' combined total of $40 069 PPY were clinician services on carrier claims ($14 523) and outpatient facility services ($9012). Federal and state policy makers and administrators are developing strategies to integrate Medicare- and Medicaid-funded health care services to provide better care to the people enrolled in both programs. Substantial use of both Medicare- and Medicaid-funded services was found across all need-based subgroups, and the services contributing a high proportion of the total spending differed across subgroups. The diversity of health care use suggests a tailored approach to integration strategies with comprehensive set benefits that comprises Medicare and Medicaid services, including long-term services and supports, BH, palliative care, and social services.

Profiting from Most-Favored-Customer Procurement Rules: Evidence from Medicaid

Using a difference-in-difference approach, we find that an increase to Medicaid’s minimum drug rebate under the Affordable Care Act in 2010 lowered non-Medicaid drug spending by 2.5 percent. A stylized bargaining model shows that this is likely driven by the interaction of this reform with Medicaid’s “most-favored customer” clause (MFCC). By examining the response of drugs that faced a change in incentives equivalent to the removal of Medicaid’s MFCC, we estimate that removing the Medicaid MFCC would have reduced overall 2010 non-Medicaid drug spending by an additional 3.5 percent, though it would have likely also increased Medicaid spending. (JEL C78, H51, I18, I38, L65)

Explanations for variations in hospital expenditures among four large California counties

ObjectiveTo investigate competing explanations for why Medicare Fee for Service (FFS) and private sector payments lead to hospital cost variations in Californian counties.Data sourcesRatios of private to Medicare hospital costs were obtained from state-based all-payer claims databases. Demographics were estimated from the U.S. Census Bureau and the California Health Interview Survey. Medicaid and Medicare spending was obtained from Kaiser Family Foundation. Medicare Advantage enrollment was obtained from the California Department of Health Care Services and market consolidation was estimated using the Herfindahl–Hirschman Index (HHI).Study designPer capita costs, demographics, Medicaid and Medicare spending, Medicare Advantage enrollment, and HHI scores were compared for San Francisco (SF), Sacramento, Los Angeles (LA), and San Diego (SD).Principal findingsLA hospitals had the lowest per capita private insurer costs, but the highest Medicare FFS costs. The findings might be explained by a lower HHI for LA, indicating a more competitive market, than SD, SF, and Sacramento.ConclusionsMedicare FFS hospital costs do not provide an accurate representation of health care spending in Californian counties. In more competitive markets, private insurance companies can negotiate lower prices, while oversupply may allow facilities to increase volume in Medicare FFS.

Prevalence of and Spending on Ear, Nose, Throat, and Respiratory Infections Among Children With Chronic Complex Conditions.

Ear, nose, throat, and respiratory infections (ENTRI) may affect children with complex chronic conditions (CCC) differently than their peers. We compared ENTRI prevalence and spending in children with and without CCCs. Retrospective analysis of 3,880,456 children ages 0-to-18 years enrolled in 9 US state Medicaid programs in 2018 contained in the IBM Watson Marketscan Database. Type and number of CCCs were distinguished with Feudtner's system. ENTRI prevalence, defined as ≥1 healthcare encounters for ENTRI, and Medicaid spending on ENTRI were compared by CCC using chi-square tests and logistic regression. ENTRIs were greater in children with vs. without a CCC (57.7% vs 43.5% [P < .001]). Children with a CCC (5.5%, n=213,425) accounted for nearly one-fourth ($145.8 million [US]) of total spending on ENTRI. Aside from throat and sinus infection, ENTRI prevalence increased with number of CCCs (P < .001). For example, as number of CCCs increased from zero to ≥3, lower-airway infection increased from 12.5% to 37.5%, P < .001 (OR 4.10; 95% CI 3.95-4.26). ENTRI spending attributable to inpatient care increased from 9.7% to 92.8% (P < .001) as the number of CCCs increased from zero to ≥3. Most children with a CCC pursued care for ENTRI in 2018 and these children accounted for a disproportionate share of ENTRI spending. Children with multiple CCCs had a high prevalence of lower-airway infection; most of their ENTRI spending was for inpatient care. Providers can use these findings to counsel patients and families and to inform future investigations on how best to manage ENTRI in children with CCCs.

Estimated Medicaid Spending on Original and Citrate-Free Adalimumab From 2014 Through 2021

This cross-sectional study assesses Medicaid spending associated with citrate-free vs original adalimumab.

Estimates of Medicaid and Non-Medicaid Net Prices of Top-Selling Brand-name Drugs Incorporating Best Price Rebates, 2015 to 2019

The US spends far more on brand-name prescription drugs than other comparable countries. However, studies of prescription drug spending in the US are often limited because there can be substantial differences in the confidential rebates that drug manufacturers pay to Medicaid vs other payers. To demonstrate an approach for improved estimation of Medicaid rebates through case studies of 18 top-selling drugs to better understand trends in net Medicaid and non-Medicaid spending and prices for brand-name drugs. This was a cross-sectional study of US pricing data from 2015 to 2019 derived from Medicaid State Drug Utilization data SSR Health, Medi-Span, the Federal Supply Schedule, and IQVIA. Pricing data for 18 top-selling brand-name drugs measured consistently in both SSR Health, which captures US sales reported by publicly traded companies, and IQVIA's top US prescription drugs by nondiscounted spending in 2015 to 2019. Data were accessed and analyzed from January 2019 to June 2021. Gross and net Medicaid and non-Medicaid drug spending for the sample of 18 drugs and prices corresponding to a 30-day supply of medication. Medicaid aggregate gross spending for the 18 drugs in the sample increased 173%, from $3.6 billion in 2015 to $9.9 billion in 2019, and estimated net spending after discounts increased by 119%, from $1.4 billion to $3.0 billion. Medicaid inflation-linked rebates reduced average gross price per 30-day supply by an estimated 43% in 2019, and up to 67% for individual drugs. In addition to the basic rebate, the best price provision reduced the average gross price per 30-day supply by an estimated 3% in 2019 and up to 54% for individual drugs. Between 2015 and 2019 across all study drugs, estimated average non-Medicaid net 30-day prices were between 1.9 and 2.6 times higher than Medicaid net prices. Excluding adalimumab-a spending anomaly because of the entry of a new high-cost formulation-net prices weighted by average gross spending decreased annually by 1% from 2015 through 2019 for Medicaid, while increasing by 2% for non-Medicaid payers. In this cross-sectional study of 18 top-selling brand-name drugs, excluding 1 anomaly, Medicaid average net prices declined from 2015 to 2019. Simultaneously, for non-Medicaid payers, net price increased more than previously published marketwide growth rates, raising the importance of restraining drug price growth in non-Medicaid markets. Rigorous and transparent methods to estimate Medicaid discounts are imperative to understand patterns in Medicaid and non-Medicaid prices and develop policies that better align drug prices with clinical benefits.

Summaries of Articles

Summaries of Articles

State responses to federal matching grants: The case of medicaid

While Medicaid is currently financed by open-ended matching, in which the federal government’s contribution is uncapped, there has been interest in transforming the financing structure to block grants, which limits federal cost-sharing to a fixed amount. To understand the implications of this reform, I measure the effect of match rates on Medicaid spending by using the variation induced by a kink in the match rate formula. I find that a percentage point increase in the federal match raises per-beneficiary spending by 3 to 6 percent and that these results are driven by high-spending states. Using this estimate, I discuss the welfare impact of a block grant reform.

Medicaid Spending on Antiretrovirals From 2007 Through 2019.

Antiretroviral (ARV) medications to treat human immunodeficiency virus (HIV) are a major contributor to Medicaid prescription drug spending. Despite having been used for over 3 decades, the first generic ARVs only recently became available, and many newer versions continue to be sold at high prices despite within-class competition. We estimated Medicaid spending on ARVs from 2007 through 2019. Using public Medicaid State Drug Utilization data, we identified trends in ARV spending and use from 2007 through 2019. We estimated net spending and average prices (spending per 30-day supply), accounting for statutory Medicaid rebates, including a 15%-23% base rebate plus additional rebates if a drug's price increased faster than inflation. Among 48 ARVs, estimated net Medicaid spending from 2007 through 2019 was $25 billion for 17 million 30-day supplies. Annual use increased 118%, from 0.7 million 30-day supplies in 2007 to 1.6 million in 2019. During this time, estimated annual net spending increased 178%, from $1.1 billion to $3.0 billion, and average net prices increased 28%, from $1432 to $1830 per 30-day supply. Annual Medicaid net spending on ARVs nearly tripled from 2007 to 2019, due to a combination of expanded use and rising prices. Medicaid did not extract expected benefits from its mandatory inflationary rebates because they were offset by use of newer, more expensive ARVs. To better control spending related to products with incremental innovation, the US government should be authorized to assure that launch prices for new drugs are aligned with the added benefit they offer over existing therapies.

The Responsiveness of Medicaid Spending to the Federal Subsidy

The Responsiveness of Medicaid Spending to the Federal Subsidy

Social Determinants of Health Influence Future Health Care Costs in the Medicaid Cohort of the District of Columbia Study.

Social determinants of health are an important predictor of future health care costs but little is known about their impact on Medicaid spending. This study analyzes the role of social determinants of health (SDH) in predicting future health care costs for adult Medicaid beneficiaries with similar past morbidity burdens and past costs. We enrolled into a prospective cohort study 8,892 adult Medicaid beneficiaries who presented for treatment at an emergency department or clinic affiliated with two hospitals in Washington, DC, between September 2017 and December 31, 2018. We used SDH information measured at enrollment to categorize our participants into four social risk classes of increasing severity. We used Medicaid claims for a 2-year period; 12 months pre- and post-study enrollment to measure past and future morbidity burden according to the Adjusted Clinical Groups system. We also used the Medicaid claims data to characterize total annual Medicaid costs one year prior to and one year after study enrollment. The 8,892 participants were primarily female (66%) and Black (91%). For persons with similar past morbidity burdens and past costs (p < 0.01), the future morbidity burden was significantly higher in the upper two social risk classes (1.15 and 2.04, respectively) compared with the lowest one. Mean future health care spending was significantly higher in the upper social risk classes compared with the lowest one ($2,713, $11,010, and $17,710, respectively) and remained significantly higher for the two highest social risk classes ($1,426 and $3,581, respectively), given past morbidity burden and past costs (p < 0.01). When we controlled for future morbidity burden (measured concurrently with future costs), social risk class was no longer a significant predictor of future health care costs. SDH are statistically significant predictors of future morbidity burden and future costs controlling for past morbidity burden and past costs. Further research is needed to determine whether current payment systems adequately account for differences in the care needs of highly medically and socially complex patients.

Financial Contributions and Experiences of Non-Spousal, Employed Family Caregivers.

The economic impacts of caring for an older adult may be amplified for employed family and unpaid caregivers. We examine out-of-pocket spending among employed, retired, and unemployed caregivers. Among employed caregivers, we identify correlates of spending and assess whether spending and work productivity loss contribute to financial burden. Analyses use the 2015 National Health and Aging Trends Study (NHATS) and National Study of Caregiving. We find that employed caregivers incur more out-of-pocket spending on caregiving than retired and unemployed counterparts. Employed caregivers spending more than $500 out-of-pocket provide more hours of care and assist older adults with greater impairment. Among employed family caregivers, caregiver and care recipient Medicaid enrollment, spending, and work productivity loss are associated with financial burden. Findings suggest that caregiving exacerbates economic well-being among employed caregivers, particularly for those with socioeconomic vulnerability.

Reduction in Medicaid Rebates Paid by Pharmaceutical Manufacturers for Outpatient Infused, Injected, Implanted, Inhaled, or Instilled Drugs: The 5i Loophole.

When nonretail pharmacy sales exceed 70% of sales, manufacturers of infused, injected, implanted, inhaled, or instilled (5i) drugs are required to calculate average manufacturer price (AMP) under a different methodology than that used for drugs predominantly distributed through retail channels. Specifically, the modified methodology includes pharmacy benefit manager (PBM) rebates in the calculation of AMP for 5i drugs. The modified methodology reduces manufacturers' Medicaid rebate liability and increases net costs to the Medicaid program. The authors identified 15 5i drugs predominantly dispensed through the nonretail setting. Using 2013-2017 data from Medicaid, Medicare, SSR Health, and 340B program eligibility, they estimated differences in AMP, Medicaid rebates, and net Medicaid costs under both the standard and 5i AMP methodologies. AMP was 42% lower, on average, under the 5i methodology than under the standard methodology. From 2013-2017, Medicaid rebates under the 5i methodology were 82% lower than under the standard methodology, resulting in manufacturers of these 15 drugs reducing their Medicaid rebate liability by $1.1 billion in five years. Inclusion of PBM rebates in the calculation of AMP for 5i drugs significantly reduced Medicaid rebates, resulting in higher Medicaid spending. This may incentivize manufacturers to shift sales to nonretail channels. To remove this incentive, policy makers should consider excluding PBM rebates from the calculation of AMP for 5i drugs.

Disparities in Health Care Spending and Utilization Among Black and White Medicaid Enrollees

Administrative records indicate that more than half of the 80 million Medicaid enrollees identify as belonging to a racial and ethnic minority group. Despite this, disparities within the Medicaid program remain understudied. For example, we know of no studies examining racial differences in Medicaid spending, a potential measure of how equitably state resources are allocated. To examine whether and to what extent there are differences in health care spending and utilization between Black and White enrollees in Medicaid. This cross-sectional study used calendar year 2016 administrative data from 3 state Medicaid programs and included 1 966 689 Black and White Medicaid enrollees. Analyses were performed between January 28, 2021, and October 18, 2021. Self-reported race. Rates and racial differences in health care spending and utilization (including Healthcare Effectiveness Data and Information Set [HEDIS] access measures). Of 1 966 689 Medicaid adults and children (mean [SD] age, 20.3 [17.1] years; 1 119 136 [56.9%] female), 867 183 (44.1%) self-identified as non-Hispanic Black and 1 099 506 (55.9%) self-identified as non-Hispanic White. Results were adjusted for age, sex, Medicaid eligibility category, zip code, health status, and usual source of care. On average, annual spending on Black adult (19 years or older) Medicaid enrollees was $317 (95% CI, $259-$375) lower than White enrollees, a 6% difference. Among children (18 years or younger), annual spending on Black enrollees was $256 (14%) lower (95% CI, $222-$290). Adult Black enrollees also had 19.3 (95% CI, 16.78-21.84), or 4%, fewer primary care encounters per 100 enrollees per year compared with White enrollees. Among children, the differences in primary care utilization were larger: Black enrollees had 90.1 (95% CI, 88.2-91.8) fewer primary care encounters per 100 enrollees per year compared with White enrollees, a 23% difference. Black enrollees had lower utilization of most other services, including high-value prescription drugs, but higher emergency department use and rates of HEDIS preventive screenings. In this cross-sectional study of US Medicaid enrollees in 3 states, Black enrollees generated lower spending and used fewer services, including primary care and recommended care for acute and chronic conditions, but had substantially higher emergency department use. While Black enrollees had higher rates of HEDIS preventive screenings, ensuring equitable access to all services in Medicaid must remain a national priority.

66-OR: Diabetes Quality of Care among Medicaid Patients and Variation by Medicaid State Spending: A Natural Experiments for Translation for Diabetes 2 Study

Background: Medicaid patients have high rates of diabetes complications. We examined quality of diabetes care among Medicaid patients and variation by Medicaid state spending. Methods: Using 2015-16 United Healthcare claims (eligibility, medical, pharmacy) and lab data, we identified Medicaid patients with diabetes &amp;gt;21 yrs of age receiving care in practices with &amp;gt;1000 Medicaid patients (diabetes defined by diagnostic codes, A1c &amp;gt;6.5% or glycemic prescriptions) . Over an 18-month study period, we examined A1c testing, statin use, retinal and nephropathy screening rates. Logistic regression covariates included a categorical variable for per-beneficiary Medicaid spending terciles by state (low, middle or high) , age, gender, race, ethnicity, language, Medicaid eligibility category, indicator for type 1 vs. 2 diabetes, indicator for chronic eye diseases, comorbidity indicators, and a count of number of enrolled months. We adjusted for clustering at the 3-digit zip code level and excluded states with vision care carve-outs. Results: Among 46,5Medicaid patients with diabetes, the overall unadjusted completion rates for individual diabetes care measures varied from 39% (retinal screening) to 86% (nephropathy screening) ; 27% (7,540) of patients completed all 4 care measures. Adjusted completion rates for all 4 measures did not vary by Medicaid spending level. As compared to Whites, Asian/Pacific Islanders and patients with missing race were more likely to complete all 4 measures (5.1% and 3.7% higher respectively, p=0.00) , while Native Americans were less likely (-6.1%, p=0.04) . Medicaid patients with dual Medicare were more likely to complete all 4 measures than TANF members (4.8%, p=0.00) . Conclusions: Only 1 in 4 Medicaid patients with diabetes received all 4 diabetes care measures in our study. Interventions are needed to increase adherence to diabetes processes of care for underserved Medicaid patients with diabetes. Disclosure T.Moin: None. J.Harwood: None. O.Duru: None. C.Tseng: None. C.Mangione: n/a. Funding CDC/NIH/NIDDK U18DP006128

Employing Family Caregivers: An Innovative Health Care Model.

Employing Family Caregivers: An Innovative Health Care Model.

Supplemental Nutrition Assistance Program Participation is Associated with Lower Health Care Spending among Working Age Adults without Dependents.

Prior evidence suggests an association among food insecurity, poor health, and increased health care spending. In this study, we are using a natural experiment to confirm if longer participation in the Supplemental Nutrition Assistance Program (SNAP) is associated with reduced Medicaid spending among a highly impoverished group of adults. In 2013, the mandatory work requirements associated with SNAP benefits were lifted for able-bodied adults without dependents (ABAWDs). Using 2013 to 2015 Medicaid and SNAP data of 24,181 Minnesotans aged 18-49, we examined if changes in SNAP enrollment duration affect health care expenditures. In fully adjusted within-participant regression models, for each additional month of SNAP, average annual health care spending was $98.8 lower (95% CI: -131.7, -66.0; p&lt;.001) per person. Our data suggests that allowing ABAWDs to receive SNAP even in months they are not working may be critical to their health as well as cost-effective.

Global consequences of the US FDA's accelerated approval of cancer drugs.

The accelerated approval system is a fast-track drug approval pathway created by the US Food and Drug Administration (FDA) in 1992 in response to the HIV-AIDS crisis to allow expedited access to life-saving drugs and fulfil an unmet medical need. Nowadays, this pathway is most commonly used for cancer drug approval. 1 Sachs RE Gavulic KA Donohue JM Dusetzina SB Recent trends in Medicaid spending and use of drugs with US Food and Drug Administration accelerated approval. JAMA Health Forum. 2021; 2e213177 Google Scholar In theory, the accelerated approval pathway strikes a balance between early access to therapies and the need for robust evidence generation. This pathway allows drugs to be approved early on the basis of improvement in surrogate outcomes that are reasonably likely to translate to clinical benefit. This approval is conditional, with a mandate that drugs are tested in a post-approval confirmatory trial to substantiate the presumed clinical benefit, in the absence of which approval will be withdrawn. Several challenges and limitations of this pathway for the US regulatory and clinical environment have been previously described. 2 Gyawali B Ross JS Kesselheim AS Fulfilling the mandate of the US Food and Drug Administration's accelerated approval pathway: the need for reforms. JAMA Intern Med. 2021; 181: 1275-1276 Google Scholar Here, we discuss the often-overlooked consequences of the accelerated approval pathway for global oncology. Consequences of US FDA approval decisions in high-income countriesAkhade and colleagues1 highlight the global consequences of approving cancer medicines on the basis of uncertain evidence through the US Food and Drug Administration (FDA)'s accelerated approval pathway. Traditionally, the concern for US regulatory standards has remained inside the USA. However, Akhade and colleagues show that the consequences can be far reaching. Their Comment has substantial implications, especially considering the nomination of a new FDA commissioner and the opportunity that this nomination brings to enforce a suitable efficacy standard. Full-Text PDF