OOP Costs Research Articles

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.

The price of dialysis access: Implications of access type and patient-centric approaches to cost

Purpose: This study explores out-of-pocket (OOP) costs for patients and provider reimbursement for dialysis access creation. It aims to illustrate the financial characteristics of four dialysis access modalities to consider in decision-making for clinicians, patients, and payers. Materials and methods: Retrospective data from the Merative™ MarketScan Commercial Claims and Encounters Databases from 2017 to 2022 was analyzed for patients who received an arteriovenous fistula (AVF), arteriovenous graft (AVG), peritoneal dialysis catheter (PDC), or percutaneous AVF (pAVF). ANOVA and Tukey HSD were used to assess cost differences among the four access modalities overall and in the context of insurance type and service site. Results: Database extraction resulted in 20,863 unique procedures, comprising of 15,043 AVF, 4759 AVG, 896 PDC, and 165 pAVF. Mean age was 59.2 years (±14.19) and 60.53% of the cohort was male. EPO/PPO plans were the most represented (53.06%) and most procedures were performed in the hospital outpatient department (91.99%). There were significant differences found among OOP cost and reimbursement with respect to procedure type, insurance type, and service site. Overall, pAVF had both the highest cost and reimbursement. Conclusion: Patient OOP costs and provider reimbursement differ significantly based on procedure, insurance type, and service site. While pAVF creation is recognized with high reimbursements due to its complexity and the advanced technology required, it also has the highest OOP costs for patients. To help facilitate adoption of new technologies like pAVF, advocacy efforts should focus on encouraging payers to lower the OOP financial barriers for patients to receive these newer but costlier procedures.

When the Bough Breaks: The Financial Burden of Childbirth and Postpartum Care by Insurance Type.

Out-of-pocket (OOP) costs related to childbirth and postpartum care may cause financial hardship, depending on type of insurance and income. We estimated OOP spending on childbirth and postpartum care and financial strain 1 year after birth, comparing Medicaid-insured births with commercially insured births. The Postpartum Assessment of Health Survey followed up with respondents to the Centers for Disease Control and Prevention (CDC) Pregnancy Risk Assessment Monitoring System after a 2020 birth in six states and New York City. The survey included questions on health care costs and financial well-being. Our analytic sample consisted of 4,453 postpartum people, 1,544 with a Medicaid-insured birth and 2,909 with a commercially insured birth. We observe significant financial hardship from childbirth that persists into the postpartum year, with significant differences by insurance and income. We find Medicaid is highly financially protective relative to commercial insurance; 81.4% of Medicaid-insured births were free to the patient, compared with 15.7% of commercially insured births (p < 0.001). Six of ten commercially insured births (59%) cost over $1,000 OOP. Among respondents reporting OOP costs for childbirth, we found that Medicaid enrollees are more likely to have borrowed money from friends or family to pay for childbirth (8% vs. 1%, p < 0.001) and one in five had not made any payments 1 year postpartum (26% vs. 5% of commercially insured births, p < 0.001). Among the commercially insured, those with incomes under 200% of the federal poverty level (FPL) fared worse financially than those above 200% FPL on a number of indicators, including debt in collection (33% vs. 13%, p < 0.001) and financial worry (55% vs. 34%, p < 0.001). The cost of childbirth and postpartum health care results in significant and persistent financial hardship, particularly for families with lower income with commercial insurance. Medicaid offers greater protection for families with low income by offering reduced cost sharing for childbirth and postpartum health care, but even minimal cost sharing in Medicaid causes financial strain.

Effects of the Affordable Care Act on Contraception, Pregnancy, and Pregnancy Termination Rates.

To investigate the effects of the Affordable Care Act (ACA) and its elimination of cost-sharing on contraception utilization, pregnancy rates, and abortion rates. We conducted a retrospective cohort study within a healthcare system serving over 4.5 million insured members across 21 medical centers and 250 clinics. The study included women aged 18-45 with continuous health plan membership for at least two years in the pre-ACA (2007-2012) and post-ACA (2013-2018) periods. We analyzed out-of-pocket (OOP) costs for contraception, including oral contraceptives and long-acting reversible contraception (LARC), before and after the ACA's implementation. We then examined how the elimination of OOP costs affected contraception use, pregnancy rates, and abortion rates. The study identified 1,523,962 women of childbearing age. In 2013, cost sharing for contraception sharply declined, with average annual OOP costs dropping from $88-$94 pre-ACA to nearly zero post-ACA. Contraceptive use increased overall, rising from 30.2% pre-ACA to 31.9% by the study's end, with a notable rise in LARC use. In interrupted time-series analyses, while contraception use continued to increase post-ACA, new pregnancy rates declined at a faster rate than pre-ACA, and abortion rates continued to fall, though at a slightly slower pace than pre-ACA (p<0.05 for all trends). The Affordable Care Act's elimination of contraception cost-sharing led to increased contraception use, particularly LARC methods, and contributed to declines in both pregnancy and abortion rates. This suggests that improving access to effective contraception is a key strategy in reducing unintended pregnancies.

Urban-rural differences in preferences for traditional Chinese medicine services among chronic disease patients: a discrete choice experiment

BackgroundWith the increasing prevalence of chronic diseases, the demand for medical services from chronic disease patients has become diversified and personalized. The advantages and role of traditional Chinese medicine in the prevention and treatment of chronic diseases gradually emerging. The preferences and willingness to pay for traditional Chinese medicine services (TCMS) among patients with chronic diseases, as well as any disparities between urban and rural patients, have not been examined in past studies.ObjectiveThis study aimed to investigate the preferences of chronic disease patients for TCMS, explore the value/importance that patients place on different treatment attributes, and evaluate whether there are urban-rural differences in their preferences and willingness to pay for TCMS.MethodsA total of 317 patients from Jiangsu Province, China participated in a discrete choice experiment that elicited the preferences for TCMS. The choice questions were constructed by six attributes: out-of-pocket (OOP) cost, institution, medical provider, treatment method, treatment duration, treatment efficacy. Mixed logit models were used to estimate the stated preference and marginal willingness to pay for each attribute.ResultsThe choice preferences of chronic disease patients for TCMS in this study were influenced by the four attributes: institution, treatment method, and treatment efficacy, and OOP cost. Improvements in treatment efficacy were the most concerning, followed by being treated in traditional Chinese medicine (TCM) hospital. Patients were willing to pay more to get better treatment outcomes. Compared with primary care institutions, patients were willing to pay more for treatment in TCM hospitals. The preferences for economic attribute (OOP cost) varied between urban and rural areas, and rural patients tended to favor scenarios that imposed a lower economic burden on them.ConclusionThe chronic disease patients’ preferences for TCMS were determined mainly by treatment efficacy but also by institution, treatment method and OOP cost. The urban-rural difference in preference identified in this study highlights that effective policy interventions should consider the characteristics of patients’ demand in different regions.

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.

Use of and spending on medical equipment among cancer survivors.

210 Background: Cancer survivors are increasingly older, with rising rates of functional impairment, comorbidity burden, and needs. Patients often require medical equipment, but administrative barriers and lack of payer coverage can limit access and increase cost sharing for patients. Prior work on financial burdens has largely focused on direct medical costs and costs of prescription drugs. We sought to characterize patterns of use and costs associated with medical equipment use among US cancer survivors. Methods: We used the US National Health Interview Survey (NHIS)—a nationally representative survey of the US population— to identify self-reported use of medical equipment (‘’such as a cane, a wheelchair, a special bed etc.’’) among cancer survivors from 1997-2018. We then used the Medical Expenditure Panel Survey (MEPS) — which includes additional data on health care costs and spending among people sampled from the NHIS— to evaluate out-of-pocket (OOP) and total spending on equipment (e.g., orthopedic items, prosthesis, bathroom aids, disposable supplies etc.) among cancer survivors from 2016-2020. We describe trends in prevalence of use, and compared OOP costs and percentage of cost sharing responsibility (OOP cost/total spending) for equipment relative to other medical care, such as prescription drugs. Results: We identified 55,625 cancer survivors in the NHIS, representing 19.1 million weighted individuals from 1997-2018. The weighted number of cancer survivors using medical equipment increased during the study period from 0.9 million in 1997 to 2.3 million 2018, a 2.4-fold increase. The number of survivors not requiring equipment increased by 1.7-fold during the same period. The adjusted prevalence of equipment use among survivors increased from 5.1% in 1999 to 7.9% in 2018, a 2.8 percentage-point increase (P &lt; .001 for trend). We identified 32,106 cancer survivors (56.6% women, 55.9% ≥65 years) in MEPS from 2016-2020. Among users, mean annual total spending on equipment was 1,205, and mean OOP costs for equipment were 672. For comparison, mean annual OOP costs for prescription drugs was $541. The cost sharing responsibility for equipment (56%) was higher than that for all other comparison groups: prescription drugs (10%), outpatient visits (11%), occupational/physical therapy (18%), emergency room visits (20%), and hospitalization (3%). Conclusions: The number of US cancer survivors who use medical equipment has more than doubled during the past 20 years. For these patients, OOP costs for equipment are greater than that for prescription drugs, with patients responsible for over half the total spending. These data are particularly notable given that patterns of use and spending reported here do not capture survivors unable to access necessary equipment due to administrative, financial, and/or other barriers. Interventions to assess need, ensure access, and decrease associated financial burden are urgently needed.

Patient Preferences for Attributes of Androgen Deprivation Therapies in Prostate Cancer: A Discrete Choice Experiment with Latent Class Analysis.

Medical androgen deprivation therapy (ADT) options have expanded for patients with advanced prostate cancer (PC). Historically, ADT was primarily available in long-acting injectable formulations. In 2020, the first oral formulation was US Food and Drug Administration-approved for adults with advanced PC. This study's aim was to assess patient preferences for attributes of medical ADT, including mode of administration, side effects, impact on sexual interest, and out-of-pocket (OOP) costs, and to segment respondents into distinct groups based on their treatment choice patterns. A cross-sectional survey was conducted among US residents aged > 40years with PC, employing a discrete choice experiment to assess preferences for ADT attributes. For each choice task, respondents were asked to select the hypothetical treatment profile that they preferred out of two presented. Latent class analysis (LCA) was conducted to estimate attribute-level preference weights and calculate attribute relative importance for groups of respondents with similar treatment preferences. A total of 304 respondents completed the survey (mean age 64.4years). LCA identified four preference groups, named according to the attribute each group considered most important: Sexual interest, Cost-sensitive, Favors daily pill, and Favors injection. Most respondents in the Sexual interest group were < 65years, while the Cost-sensitive group was mostly ≥ 65years. Favors daily pill had the highest proportion of ADT-naïve individuals. On average, respondents in these groups preferred an oral medication. Favors injection, which had the highest proportion of ADT-experienced individuals, preferred infrequent intramuscular injections, lower chance of post-ADT testosterone recovery, and lower OOP cost. Respondents differed in their preferences regarding ADT attributes, highlighting the need for patient involvement in their treatment decisions. Effective communication between healthcare providers and patients about the benefits and risks of available therapies should be encouraged to ensure that patients receive the PC treatment that best meets their needs.

Inequities in Unexpected Cost-Sharing for Preventive Care in the United States

Unexpected out-of-pocket (OOP) costs for preventive care reduce future uptake. Because adherence to service guidelines differs by patient populations, understanding the role of patient demographics and social determinants of health (SDOH) in the incidence and size of unexpected cost-sharing is necessary to address these disparities. This study examined the associations between patient demographics and cost-sharing for common preventive services. This cross-sectional study used a national sample of insurance claims for recommended preventive services provided to privately insured adult patients between 2017 and 2020. The relationships between patient demographics and OOP costs were adjusted for service type, insurance type, geographic location, and time trends using regression analysis. Analyses were conducted in 2024. The sample included 1,736,063 unique preventive care encounters of 1,078,010 individuals. Among preventive encounters, 40.3% resulted in OOP costs. Lower-educated patients had 9.4% (OR=1.094; 95% CI=1.082, 1.106) higher odds of incurring OOP costs than patients with college degrees. Low-income patients (annual household income of $49,999 or less) had 10.7% (OR=0.893; 95% CI=0.880, 0.906) lower odds of incurring OOP costs than high-income patients. Conditional on incurring costs, lower educated patients paid $15.07 (95% CI= -$15.24, -$14.91) less than higher educated patients, and low-income patients paid $11.76 (95% CI=$11.58, $11.95) more than high-income patients. Significant differences across racial and ethnic groups were observed. The likelihood and size of OOP costs for preventive care varied considerably by patient demographics; this may contribute to inequitable access to high-value care.

High Out-of-Pocket Cost Burden of Mental Health Care for Adult Outpatients in the United States.

This report describes characteristics of patients who had high out-of-pocket (OOP) spending on mental health care relative to income. A sample of 8,923 U.S. adults with outpatient mental health visits was drawn from the 2018-2021 Medical Expenditure Panel Survey. Respondents who spent ≥10% of their disposable family incomes on OOP mental health visits were defined as having a high OOP cost burden. Using weighted percentages, the authors found that 2.4% of psychiatric outpatients had a high OOP burden; among those below the federal poverty level, 12.8% had a high OOP burden. Patients with a high (vs. low) OOP burden were statistically significantly more likely to be uninsured (7.5% vs. 2.4%) or diagnosed as having a substance use disorder (8.7% vs. 2.8%) or bipolar disorder (14.5% vs. 8.0%). Despite federal policies extending the availability of insurance for mental health care, many low-income psychiatric outpatients experience high OOP cost burden.

Preferences for a Clostridioides difficile vaccine among adults in the United States

IntroductionClostridioides difficile (C.diff) infection (CDI) causes significant morbidity and mortality among older adults. Vaccines to prevent CDI are in development; however, data on the target population's preferences are needed to inform vaccination recommendations in the United States (US). This study assessed US adults' willingness to receive a C.diff vaccine and examined how vaccine attributes influence their choices. MethodsA cross-sectional online survey with a discrete choice experiment (DCE) was conducted among US adults aged ≥50 years. DCE attributes included effectiveness, duration of protection, reduction in symptom severity, out-of-pocket (OOP) costs, number of doses, and side effects. The DCE included 11 choice tasks, each with two hypothetical vaccine profiles and an opt-out (i.e., no vaccine). Attribute-level preference weights were estimated using hierarchical Bayesian modeling. Attribute relative importance (RI) was compared between select subgroups. ResultsOf 1216 adults in the analyses, 29.9% reported they knew either ‘a little’ (20.7%) or ‘a lot’ (9.2%) about C.diff before the study. A C.diff vaccine was chosen 58.0% of the time (vs. opt-out) across choice tasks. It was estimated that up to 75.0% would choose a vaccine when OOP was $0. Those who were immunocompromised/high-risk for CDI (vs. not) more frequently chose a C.diff vaccine. Decreases in OOP costs (RI = 56.1), improvements in vaccine effectiveness (RI = 17.7), and reduction in symptom severity (RI = 10.3) were most important to vaccine choice. The rank ordering of attributes by importance was consistent across subgroups. ConclusionOOP cost, improvements in vaccine effectiveness, and reduction in CDI severity were highly influential to vaccine selection. Most adults aged ≥50 years were receptive to a C.diff vaccine, especially with little-to-no OOP cost, suggesting that mandating insurance coverage of vaccination with no copayment may increase uptake. The limited awareness about C.diff among adults presents an opportunity for healthcare providers to educate their patients about CDI prevention.

Cost trends of metastatic renal cell carcinoma therapy: the impact of oral anticancer agents and immunotherapy.

Immunotherapy (IO) and oral anticancer agents (OAA) have improved outcomes for metastatic renal cell carcinoma (mRCC), but there is a need to understand real-world costs from the perspective of payers and patients. We used retrospective fee-for-service Medicare 100% claims data to study patients diagnosed with mRCC in 2015-2019. We identified initial treatment type and costs (the year after diagnosis) and analyzed differences in monthly and 12-month costs over time and between OAA, IO, and combination groups and the association between Out-Of-Pocket (OOP) costs and adherence. We identified 15 407 patients with mRCC (61% male; 85% non-Hispanic White). A total of 6196 received OAA, IO, or combination OAA/IO as initial treatment. OAA use decreased (from 31% to 11%) with a simultaneous rise in patients receiving IO (3% to 26%) or combination IO/OAA therapy (1% to 11%). Medicare payments for all patients with mRCC increased by 41%, from $60 320 (95%confidence interval = 58 260 to 62 380) in 2015 to $85 130 (95% confidence interval = 82 630 to 87 630) in 2019. Payments increased in patients who received OAA, IO, or combination OAA/IO but were stable in those with other/no treatment. Initial higher OOP responsibility ($200-$1000) was associated with 13% decrease in percent days covered in patients receiving OAA in the first 90 days of treatment, compared with those whose OOP responsibility was less than $200. From 2015 to 2019, costs for Medicare patients with mRCC rose substantially due to more patients receiving IO or IO/OAA combined therapy and increases in costs among those receiving those therapies. Increased OOP costs was associated with decreased adherence.

Physician preferences for treatment of low-density lipoprotein cholesterol among patients with atherosclerotic cardiovascular disease (ASCVD)–A discrete choice experiment

ObjectiveApproximately 80 % of patients with atherosclerotic cardiovascular disease (ASCVD) do not achieve the guideline-based target for low-density lipoprotein (LDL-C) levels in current clinical practice, particularly the 95 % of ASCVD patients receiving oral statin monotherapy. The objective was to determine physician prescribing preferences for LDL-C lowering therapies beyond statins for patients with ASCVD. MethodsA discrete choice experiment (DCE) survey was administered to cardiologists and primary care physicians in the United States, presenting a series of treatment choices systematically varied across 8 treatment attributes: % LDL-C reduction, myalgias, other side effects, route and frequency of administration, time to prior authorization, patient monthly out-of-pocket cost (mOOP), and adherence. Data were analyzed using logistic regression to estimate preference weights for each attribute. ResultsA total of 200 cardiologists and 50 primary care physicians (PCPs) completed the survey. Both exhibited similar prescribing preferences, highly valuing efficacy in reducing LDL-C levels and minimization of patients OOP cost. Each additional 10 % reduction in LDL-C was associated with a 69 % relative increase in physician preference. By contrast, a 10 % relative decrease in preference was observed for each $10 additional monthly mOOP. Compared to PCPs, cardiologists tended to place more emphasis on LDL-C reduction, being more willing to accept higher mOOP or side effects. Although oral therapies were preferred, injectable therapies, like the PCSK9 siRNA-like drug, administered less frequently that allowed for greater LDL-C reduction were seen as having considerable utility, especially among patients with a history of medication nonadherence. ConclusionThese results document considerable preference similarities among cardiologist and PCP prescribers of LDL-C lowering therapies for ASCVD. Broad availability of several therapies with varying administration frequencies and product profiles are likely of great value to prescribing physicians aiming to achieve target LDL-C concentrations. Considering all aspects of treatment, most participants preferred a PCSK9 siRNA-like drug.

Coronary artery disease and heart failure: Late-breaking trials presented at American Heart Association scientific session 2023.

The late-breaking science presented at the 2023 scientific session of the American Heart Association paves the way for future pragmatic trials and provides meaningful information to guide management strategies in coronary artery disease and heart failure (HF). The dapagliflozin in patient with acute myocardial infarction (DAPA-MI) trial showed that dapagliflozin use among patients with acute MI without a history of diabetes mellitus or chronic HF has better cardiometabolic outcomes compared with placebo, with no difference in cardiovascular outcomes. The MINT trial showed that in patients with acute MI and anemia (Hgb < 10 g/dL), a liberal transfusion goal (Hgb ≥ 10 g/dL) was not superior to a restrictive strategy (Hgb 7-8 g/dL) with respect to 30-day all-cause death and recurrent MI. The ORBITA-2 trial showed that among patients with stable angina and coronary stenoses causing ischemia on little or no antianginal therapy, percutaneous coronary intervention results in greater improvements in anginal frequency and exercise times compared with a sham procedure. The ARIES-HM3 trial showed that in patients with advanced HF who received a HeartMate 3 levitated left ventricular assist device and were anticoagulated with a vitamin K antagonist, placebo was noninferior to daily aspirin with respect to the composite endpoint of bleeding and thrombotic events at 1 year. The TEAMMATE trial showed that everolimus with low-dose tacrolimus is safe in children and young adults when given ≥ 6 months after cardiac transplantation. Providing patients being treated for HF with reduced ejection fraction (HFrEF) with specific out-of-pocket (OOP) costs for multiple medication options at the time of the clinical encounter may reduce 'contingency planning' and increase the extent to which patients are taking the medications decided upon. The primary outcome, which was cost-informed decision-making, defined as the clinician or patient mentioning costs of HFrEF medication, occurred in 49% of encounters with the checklist only control group compared with 68% of encounters in the OOP cost group.

Adherence to oral anticoagulants in patients with non-valvular atrial fibrillation: the role of patients’ characteristics and out-of-pocket payments

ABSTRACT Background Recent practice guidelines favor direct oral anticoagulants (DOACs) over warfarin for primary stroke prevention in patients with non-valvular atrial fibrillation (NVAF). However, challenges persist in Iraq’s private pharmaceutical sector. DOACs have been sold at high and inconsistent retail prices and lack insurance coverage, leading to significant out-of-pocket (OOP) costs. The objective of this study is to investigate the impact of OOP costs on oral anticoagulants (OAC) adherence among NVAF patients. Research design and methods This multicenter cross-sectional study interviewed 359 eligible patients attending three private cardiology clinics within Iraq’s southern region from December 2022 to February 2023. The 8-item Morisky Adherence Scale evaluated patient adherence. Statistical analyses, including descriptive analysis, ANOVA, and chi-square. p < 0.05 was considered statistically significant. Results The most frequently prescribed OAC were DOACs (62.8%). Patient adherence level to OAC was chiefly medium (54.6%) with no significant difference in adherence based on OAC type. Patient adherence was significantly associated with monthly income (p = 0.001), number of daily pills (p = 0.006), and OACs’ average monthly cost (p = 0.011). Conclusion Addressing the issue of cost-related non-adherence to OACs requires multiple actions. These include ensuring comprehensive health insurance coverage for OACs, increasing the use of affordable generic alternatives, and establishing effective cost-related discussions between healthcare providers and patients.

Patient out-of-pocket costs for guideline-recommended treatments for erectile dysfunction: a medicare cost modeling analysis.

Patient out-of-pocket (OOP) cost represents an access barrier to erectile dysfunction (ED) treatment. We determined OOP cost for men with ED covered by Fee-for-Service Medicare. Coverage policies were obtained from the Medicare Coverage Database for treatments recommended by the 2018 American Urological Association (AUA) guidelines. OOP cost was retrieved from the 2023 Centers for Medicare & Medicaid Services Final Rule. OOP cost for treatments without Medicare coverage were extracted from GoodRx® or literature and inflated to 2022 dollars. Annual prescription costs were calculated using the published estimate of 52.2 yearly instances of sexual intercourse. Medicare has coverage for inflatable penile prostheses (IPP; strong recommendation), non-coverage for vacuum erection devices (VED; moderate recommendation) and phosphodiesterase type-5 inhibitors (PDE5i; strong recommendation), and no policies for intracavernosal injections (ICI; moderate recommendation), intraurethral alprostadil (IA; conditional recommendation), or low-intensity extracorporeal shock wave therapy (ESWT; conditional recommendation). Annual IA prescription is most costly ($4022), followed by ICI prescription ($3947), one ESWT course ($3445), IPP ($1600), PDE5i prescription ($696), and one VED ($213). PDE5i and IPP, both strongly recommended by AUA guidelines, are associated with lower OOP cost. Better understanding of patient financial burden may inform healthcare decision-making.

Effect of telemedicine use on medical spending and health care utilization among patients with gastrointestinal cancer

BackgroundWe sought to assess the impact of telemedicine on healthcare utilization and medical expenditures among patients with a diagnosis of gastrointestinal (GI) cancer. MethodsPatients with newly diagnosed GI cancer from 2013 to 2020 were identified from the IBM MarketScan database (IBM Watson Health) . Healthcare utilization, total medical outpatient insurance payments within 1 year post-diagnosis, and out-of-pocket (OOP) expenses among telemedicine users and non-users were assessed after propensity score matching (PSM). ResultsAmong the 32,677 patients with GI cancer (esophageal, n = 1862, 5.7%; gastric, n = 2009, 6.1%; liver, n = 2929, 9.0%; bile duct, n = 597, 1.8%; pancreas, n = 3083, 9.4%; colorectal, n = 22,197, 67.9%), a total of 3063 (9.7%) utilized telemedicine. After PSM (telemedicine users, n = 3064; non-users, n = 3064), telemedicine users demonstrated a higher frequency of clinic visits (median: 5.0 days, IQR 4.0–7.0 vs non-users: 2.0 days, IQR 2.0–3.0, P < .001) and fewer potential days missed from daily activities (median: 7.5 days, IQR 4.5–12.5 vs non-users: 8.5 days, IQR 5.5–13.5, P < .001). Total medical spending per month and utilization of emergency room (ER) visits for telemedicine users were higher vs non-users (median: $10,658, IQR $5112–$18,528 vs non-users: $10,103, IQR $4628–$16,750; 46.8% vs 42.6%, both P < .01), whereas monthly OOP costs were comparable (median: $273, IQR $137–$449 for telemedicine users vs non-users: $268, IQR $142–$434, P = .625). ConclusionTelemedicine utilization was associated with increased outpatient clinic visits yet reduced potential days missed from daily activities among patients with GI cancer. Telemedicine users tended to have more ER visits and total medical spending per month, although monthly OOP costs were comparable with non-users.

Health insurance plans offered at NCI-designated cancer centers.

9052 Background: The health insurance landscape in the US represents an expensive and complex challenge to patients and physicians alike. Little is known about health insurance plans (HIPs) offered to physicians, particularly at NCI-designated cancer centers, which represent centers seeking to meet the highest standards. Methods: We collected data on the HIPs offered to physicians at NCI-designated cancer centers by reviewing institution websites from 11/2023 - 01/2024. We abstracted data on the insurance premium, deductible, out-of-pocket (OOP) maximum, and coinsurance for hospitalizations, limited to three HIPs per institution. We derived estimates using the lowest charge. We calculated inpatient stay costs based on standard hospital stay costs ($2,883 per day over an average of 4.5 days). We compared HIPs between public and private cancer centers. We used US Census Bureau population density data and regression models to explore associations among population density and OOP costs. Results: Among 65 NCI-designated cancer centers reviewed, 61 (93.8%) had readily available information about HIPs provided. Most institutions provided HIPs for all hospital employees, while 2 institutions only covered physicians. On average, each cancer center offered 3.67 HIPs, involving 1.67 insurers (54.1% offered a single insurer). Among 153 HIPs overall, 51.6% were preferred provider organization (PPOs) and one-third (33.3%) were health maintenance organization (HMOs). Only 22.9% of HIPs were high-deductible health plans (HDHP). The majority of cancer centers offered PPO plans (75.4%), HMO plans (57.4%), HDHP plans (55.7%), and some (24.6%) offered other plans, such as point of service and exclusive provider organization. Average costs for different kinds of HIPs are presented in the Table. A higher percentage of public cancer centers provided HMOs (60.5% vs. 50.0%, p=0.76) and PPOs (84.3% vs. 60.5%, p=0.09) than private centers, yet differences did not reach significance. Centers located in regions with higher state population density were more likely to have higher HMO OOP costs (beta=2.72; p=.006) and lower PPO OOP costs (beta=-2.98; p=.012). Conclusions: We found that most NCI-designated cancer centers had readily available information about HIPs provided to physicians. For these centers, physicians had limited HIP options offered, particularly in private institutions, which offered fewer HMO and PPO plans. We also demonstrated associations among state population density and OOP max in HMO and PPO plans. Our study provides a current synopsis of HIPs and identifies disparities among them, contributing to a foundation for future research. [Table: see text]

Financial toxicity (FT), quality of life (QoL), and medication adherence patient-reported outcomes (PROs) in CLL on first-line (1L) oral oncolytics.

e23157 Background: While oral oncolytics have transformed CLL treatment, high costs may cause significant FT adversely impacting patients beyond direct out-of-pocket (OOP) costs. The association of FT with QoL and medication adherence has not been characterized with oral oncolytics in CLL. Methods: Electronic PRO surveys were longitudinally administered to patients initiating any 1L oral oncolytic therapy for CLL within the last 6 months at two academic centers. PROs included FACIT-COST (significant FT: score &lt; 26), FACT-LEU QoL, MARS-5 (suboptimal adherence: score &lt; 25) and PROMIS PMAS to assess medication adherence. PROs were administered at baseline, 3 months, and 6 months after enrollment. Pearson’s correlation ( r) was calculated between PRO domains. Semi-structured, qualitative interviews were conducted after 3-month timepoints and analyzed. Results: 34 patients were enrolled: median age 65 yrs (range 33-80), 59% male, 6% Black, 9% Hispanic. Majority received BTK inhibitors (56%, acalabrutinib/zanubrutinib) followed by venetoclax (44%); 50% received concurrent obinutuzumab. Most had private insurance (50%) followed by Medicare (44%). Median time from 1L initiation to study enrollment: 1.5 months. PRO completion rates: 100% (baseline), 85% (3 mo) and 74% (6 mo). Summarized PRO and interview outcomes are displayed below. Conclusions: Patients with CLL on 1L oral oncolytics experienced worsening FT associated with poor medication adherence and worse QoL over time. PROs were discordant with qualitative interviews and suggested that FT may be driven by factors other than OOP costs. Although funding and patient assistance programs were beneficial, uncertainty over losing funding may be a long-term driver of FT and merits further study. [Table: see text]

Real-world evaluation of oncolytic biosimilar adoption on medication adherence and out-of-pocket costs among members of a national payor.

e23092 Background: Biosimilars provide quality, safe, effective, and lower-cost alternative treatment options that have no difference from their reference product. CVS Health® recently launched a biosimilar adoption strategy to expand access to biosimilars and drive sustainable cost savings and options for consumers. The purpose of this study is to compare treatment duration, adherence, and out-of-pocket (OOP) costs between individuals receiving oncology biosimilars versus oncology reference branded products. Methods: This retrospective cohort study included adult commercial fully insured and Medicare members of a large national payor with ≥1 claim for a physician-administered oncology biosimilar or reference branded product between 12/01/2020 and 11/30/2022. To assess adherence, we compared claims per month, defined as the total claims during the study divided by the number of months patients received medication and time on therapy, defined as the number of months between first claim in period and last claim in period (inclusive). OOP costs, defined as the sum of deductible and applicable coinsurance at the time of visit, were examined as a secondary endpoint. Continuous variables were compared with Student’s t-test; categorical variables were compared with a Chi-squared test. P values &lt; 0.05 were considered significant. Results: 2,597 individuals were included in the evaluation with between-group differences in age, gender, and agent received (all p &lt; 0.001). 41,182 claims were evaluated; 59.2% were for reference branded products. 3,817 medication combinations were evaluated; 64.2% received a reference branded product. Individuals receiving biosimilar agents had more total claims (mean [standard deviation, SD]: 13.9 [6.3] vs. 13.1 [7.5]; p = 0.003) and claims per month (1.4 [0.5] vs. 1.3 [0.6]; p &lt; 0.001). However, individuals receiving reference branded products had longer time on therapy (10.5 [4.1] vs. 10.0 [3.7] wk; p = 0.006). When examining oncology agents only (n = 1,992), individuals receiving biosimilar agents had more claims per month (1.4 [0.5] vs. 1.3 [0.6]; p &lt; 0.001). In contrast, individuals receiving reference branded products had longer time on therapy (11.0 [4.1] vs. 10.1 [3.7] wk; p &lt; 0.001). Individuals prescribed oncology support reference branded products and oncology treatment reference branded products experienced 475% and 350% higher OOP spend compared to individuals prescribed biosimilars (both p &lt; 0.001), respectively. Conclusions: This real-world evaluation leveraging administrative claims revealed that individuals receiving oncology biosimilars appear to experience shorter observed time on therapy, higher adherence, and lower OOP spend than individuals receiving reference branded products. Despite superior member-centric outcomes, reference branded products were prescribed more often than biosimilars.