Plan Payment Research Articles

Potential Consequences of Reforming Medicare Into a Competitive Bidding System

Potential Consequences of Reforming Medicare Into a Competitive Bidding System

Medicare and the Affordable Care Act

The recently enacted Patient Protection and Affordable Care Act made modest changes to improve Medicare and obtained a substantial share of funding for the Act's broader reforms from future spending reductions in the program. Drug benefits and preventive services were improved. While painful, the spending reductions will have only moderate impacts on beneficiaries and should help achieve the goals of health care reform: encouraging better primary and preventive care, making providers conscious of finding ways to increase the productivity of care delivered and changing the relative levels of payment across certain providers. Additional costs to beneficiaries will arise from changes in private plan payments and increasing income-related premiums.

Economic Impact of Potential CYP450 Pharmacokinetic Drug–Drug Interactions Among Chronic Low Back Pain Patients Taking Opioids

Chronic low back pain (cLBP) patients who take at least 1 CYP450-metabolized opioid analgesic agent concurrent with at least 1 other CYP450-metabolized medication experience a drug-drug exposure (DDE), which puts them at risk for a pharmacokinetic drug-drug interaction (PK DDI). This study compared utilization of healthcare resources and associated payments in cLBP patients with and without incident DDEs with the potential to cause PK DDIs. A retrospective database analysis examined the associated clinical events, healthcare utilization (measured in terms of claims for office visits, outpatient visits, emergency department visits, and hospitalization), and cost to the health plan, as defined as the sum of health plan payments for resources used. Patients were grouped into 2 cohorts by age (those under 65 and those 65 years and over). In the 6 months after exposure, total healthcare payments were significantly higher for DDE patients than those without DDEs (no-DDE), in both in the younger ($7,086, SD = $8,370) and $6,353, SD = $8,352, respectively, P < 0.001) and the older cohorts ($7,806 vs. $7,043, respectively, P = 0.013). Younger and older patients with DDE had significantly higher prescription payments than those without DDE ($2,041, SD = $2,706 vs. $1,565, SD = $2,349, respectively, P < 0.001 for younger and $2,482, SD = $2,481 vs. $2,286, SD = $2,521, respectively, P = 0.044 for older patients). Both older and younger patients with DDE had significantly more claims for office visits and higher associated payments than similar patients without DDE. Patients in the study who experienced DDEs that placed them at risk for PK DDIs had significantly greater utilization rates of healthcare resources and higher associated payments in the 6-month observation period following exposure.

Gold and Silver health plans: Accommodating demand heterogeneity in managed competition

AbstractNew regulation of health insurance markets creates multiple levels of health plans, with designations like “Gold” and “Silver.” The underlying rationale for the heavy-metal approach to insurance regulation is that heterogeneity in demand for health care is not only due to health status (sick demand more than the healthy) but also to other, “taste” related factors (rich demand more than the poor). This paper models managed competition with demand heterogeneity to consider plan payment and enrollee premium policies in relation to efficiency (net consumer benefit) and fairness (the European concept of “solidarity”). Specifically, this paper studies how to implement a “Silver” and “Gold” health plan efficiently and fairly in a managed competition context. We show that there are sharp tradeoffs between efficiency and fairness. When health plans cannot or may not (because of regulation) base premiums on any factors affecting demand, enrollees do not choose the efficient plan. When taste (e.g., income) can be used as a basis of payment, a simple tax can achieve both efficiency and fairness. When only health status (and not taste) can be used as a basis of payment, health status-based taxes and subsidies are required and efficiency can only be achieved with a modified version of fairness we refer to as “weak solidarity.” An overriding conclusion is that the regulation of premiums for both the basic and the higher level plans is necessary for efficiency.

An economic history of Medicare part C.

Twenty-five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee-for-service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector. In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program's structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer-sponsored health insurance with managed care over the same time period. Beneficiaries' access to private plans has been inconsistent over the program's history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years. Major changes in Medicare Advantage's payment rules are needed in order to simultaneously encourage the participation of private plans, the provision of high-quality care, and to save Medicare money.

Payer costs for inpatient treatment of pathologic fracture, surgery to bone, and spinal cord compression among patients with multiple myeloma or bone metastasis secondary to prostate or breast cancer.

Patients with bone metastasis secondary to prostate or breast cancer or multiple myeloma are predisposed to skeletal-related events (SREs), such as surgery or radiation to the bone, pathologic fracture, and spinal cord compression. Inpatient costs of these and other SREs represent an estimated 49%-59% of total costs related to SREs. However, information on payer costs for hospitalizations associated with SREs is limited, especially for costs associated with specific SREs by tumor type. To examine costs from a payer perspective for SRE-associated hospitalizations among patients with multiple myeloma or bone metastasis secondary to prostate or breast cancer. Patients with SRE hospitalizations were selected from the MarketScan commercial and Medicare databases (January 1, 2003, through June 30, 2009). Sampled patients had at least 2 medical claims with primary or secondary ICD-9-CM diagnosis codes for prostate cancer, breast cancer, or multiple myeloma and at least 1 subsequent hospitalization with principal diagnosis or procedure codes indicating bone surgery, pathologic fracture, or spinal cord compression. For patients with prostate cancer or breast cancer, a diagnosis code for bone metastasis was also required. If secondary diagnoses or procedure codes for SREs were present in the claim, they were used to more precisely identify the type of SRE for which the patient was treated, resulting in 3 mutually exclusive categories: spinal cord compression with or without pathologic fracture and/or surgery to the bone; pathologic fracture with or without surgery to the bone; and only surgery to the bone. Related readmissions within 30 days of a previous SRE-associated hospitalization date of discharge were excluded to minimize the risk of underestimating costs. Mean health plan payments per hospitalization, measured as net reimbursed amounts paid by the health plan to a hospital after subtracting patient copayments and deductibles, were analyzed by cancer type and type of SRE. A total of 555 patients contributed 572 hospitalizations that met the study criteria for prostate cancer, 1,413 patients contributed 1,542 hospitalizations for breast cancer, and 1,361 patients contributed 1,495 hospitalizations for multiple myeloma. The mean age range was 61 to 72 years, and the mean length of stay per admission was 5.9 to 11.6 days across the 3 tumor types. The ranges of mean health plan payment per hospital admission across tumor types were $43,691-$59,854 for spinal cord compression, with or without pathologic fracture and/or surgery to the bone; $22,390-$26,936 for pathologic fracture without spinal cord compression, with or without surgery to the bone; and $31,016-$42,094 for surgery to the bone without pathologic fracture or spinal cord compression. The inpatient costs associated with treating SREs are significant from a payer perspective. Our study used a systematic process for patient selection and mutually exclusive categorization by SRE type and provides a per episode estimate of the inpatient financial impact of cancer related SREs assessed in this study from a third-party payer perspective.

Efficiency and Economic Benefits of a Payer‐based Electronic Health Record in an Emergency Department

The objective was to evaluate the use of a payer-based electronic health record (P-EHR), which is a clinical summary of a patient's medical and pharmacy claims history, in an emergency department (ED) on length of stay (LOS) and plan payments. A large urban ED partnered with the dominant health plan in the region and implemented P-EHR technology in September 2005 for widespread use for health plan members presenting to the ED. A retrospective observational study design was used to evaluate this previously implemented P-EHR. Health plan and electronic hospital data were used to identify 2,288 ED encounters. Encounters with P-EHR use (n = 779) were identified between September 1, 2005, and February 17, 2006; encounters from the same health plan (n = 1,509) between November 1, 2004, and March 31, 2005, were compared. Outcomes were ED LOS and plan payment for the ED encounter. Analyses evaluated the effect of using the P-EHR in the ED setting on study outcomes using multivariate regressions and the nonparametric bootstrap. After covariate adjustment, among visits resulting in discharge (ED-only), P-EHR visits were 19 minutes shorter (95% confidence interval [CI] = 5 to 33 minutes) than non-P-EHR visits. Among visits resulting in hospitalization, the P-EHR was associated with an average 77-minute shorter ED LOS (95% CI = 28 to 126 minutes), compared to non-P-EHR visits. The P-EHR was associated with an average of $1,560 (95% CI = $43 to $2,910) lower total plan expenditures for hospitalized visits. No significant difference in total payments was observed among discharged visits. In the study ED, the P-EHR was associated with a significant reduction in ED LOS overall and was associated with lower plan payments for visits that resulted in hospitalization.

Risk equalisation in voluntary health insurance markets

The design and regulation of individual health insurance in voluntary markets for which a risk solidarity objective applies is an increasingly important topic for many countries (e.g., Australia, Ireland, and some sectors in the United States). There is controversy in all countries with regard to the extent governments should intervene in private markets. This chapter outlines how Ireland has structured its voluntary health insurance market to meet its solidarity goals, particularly through the use of premium rate regulation and cross-subsidies to health plans (risk equalization). The design of health plan payments balances concern for fairness against creating incentives for risk selection. The analysis confirms that there is still some way to go to improve the risk equalization system in Ireland. The Irish example is a powerful case study for policy-makers in other individual voluntary health insurance markets who seek to meet specific risk solidarity objectives.

Comparing CMS Spending for a Special Needs Plan’s Enrollees with Medicare Fee-for-Service

The objective of this analysis was to compare the capitation payments that the Centers for Medicare & Medicaid Services (CMS) makes to SCAN for enrollees in its largest SNP with the payments that CMS would have otherwise made to providers if those individuals incurred claims in the FFS program. The analysis found that, controlling for individuals’ demographic and clinical characteristics, CMS’s payments to SCAN for its enrollees were lower than CMS’s payments to providers for Part A and Part B services delivered to FFS beneficiaries. The analysis was run twice – first with the actual payments received by SCAN and second adjusting the SCAN Health Plan payments to reflect ultimate payment policy (full risk adjustment and no frailty factor). In both cases we have made adjustments for CMS’s payments to physicians and for durable medical equipment (DME) under the FFS program, as discussed in detail in the technical appendix. In the first case, CMS’s average annual payment to SCAN for each enrollee was $1,522 lower than CMS’s average annual payment for services for each FFS beneficiary. That implies about $129 million and $137 million in savings to the Medicare program from SCAN enrollees in calendar years 2006 and 2007, respectively. In the second case, CMS’s average annual payment to SCAN for each enrollee was $2,300 lower than CMS’s average annual payment for services for each FFS beneficiary. That implies about $195 million and $207 million in savings to the Medicare program from SCAN enrollees during 2006 and 2007, respectively, had these payment rules been in place. As healthcare reform discussions continue to take shape, these findings suggest that further exploration of certain MA plan types that care for the frailest or most clinically complex Medicare beneficiaries may be warranted.

Implementation of Mental Health Parity: Lessons From California

Implementation of Mental Health Parity: Lessons From California

Improving Health Plan Payment Rates

Improving Health Plan Payment Rates

National assessment of medicare prescription plan coverage gaps among patients with atrial fibrillation in the US

The Medicare Part D prescription plan has a coverage gap from $2250 to $5100 per year (2006 thresholds) in which patients pay full drug costs (the "donut hole"). We examined prescription costs in patients aged >or=65 years with atrial fibrillation (AF), and the proportions entering/exiting the donut hole in 2006. This retrospective cohort study used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database from January 2005 to December 2006. Medicare Advantage patients aged >or=65 years who were hospitalized with a primary/secondary discharge diagnosis of AF, or had >or=2 outpatient AF claims without hospitalization in 2005, were identified. Total 2006 prescription costs were calculated by summing health plan payments and patient copayments. Of 16,655 patients included in the analysis, 1527 were hospitalized with a primary AF diagnosis, 6067 with a secondary AF diagnosis, and 9061 had outpatient-managed AF in 2005. Mean 2006 per-patient prescription costs were $3457.16. In total, 58.8% of patients reached the $2250 threshold in a mean of 199 days; including 59.9% of primary AF hospitalization, 63.5% of secondary AF hospitalization, and 55.5% of patients with outpatient-managed AF. Of the overall population, 21.2% reached the $5100 threshold in a mean of 257 days; including 21.3% of primary AF hospitalization, 27.3% of secondary AF hospitalization, and 17.2% of patients with outpatient-managed AF. AF-related drugs accounted for only 15% of the total prescription costs, with the majority of costs relating to the treatment of non-AF comorbidities. In 2006, total annual prescription costs in this population of Medicare Advantage AF patients were considerable. In this sample population, over half of patients would have had prescription costs in excess of the 2006 Part D donut hole threshold. The costs of AF treatment itself were relatively low, with the majority of prescription costs relating to the treatment of non-AF comorbidities.

Impact of postherpetic neuralgia and painful diabetic peripheral neuropathy on healthcare costs

The burden of chronic neuropathic pain has not been well studied and data are not available to accurately compare different neuropathic pain conditions. This retrospective study sought to determine utilization of healthcare services and costs for patients with postherpetic neuralgia (PHN) and painful diabetic peripheral neuropathy (DPN). Two large managed care claims databases were merged, one with patients < 65 y.o. and one with patients ≥ 65 y.o. Cases were selected based on appropriate ICD-9 codes. Controls were identified using propensity score matching based on demographic and clinical characteristics. Controls were also required to have the same underlying conditions as cases (PHN controls - herpes zoster patients without PHN; painful DPN controls – diabetic patients without diabetes-related neurologic complications). One-year health care costs were calculated by summing plan payments beginning with patients' index date through one year. Excess costs were calculated by subtracting costs for controls from cases. Databases included 1,852 matched case-control pairs for PHN and 4,727 for painful DPN. One-year costs [mean, (SD)] for matched PHN and painful DPN cases were $10,206 ($23,840) and $22,754 ($41,481), respectively. Univariate mean excess total costs (p-value) were substantial and significant at $3,986 (<0.0001) for PHN and $6,287 (<0.0001) for painful DPN. Although medications provide the mainstay of neuropathic pain treatment, they were the smallest component of univariate excess total costs (PHN, 5.0%; painful DPN, 19.2%). In regression models, excess total costs remained significant at $3,976 (<0.0001) for PHN and $6,246 (<0.0001) for painful DPN. Management of these conditions can be challenging and many patients cannot tolerate or are refractory to existing treatments. This translates into significant healthcare costs and a substantial public health burden. (Supported by funding from NeurogesX, Inc.) The burden of chronic neuropathic pain has not been well studied and data are not available to accurately compare different neuropathic pain conditions. This retrospective study sought to determine utilization of healthcare services and costs for patients with postherpetic neuralgia (PHN) and painful diabetic peripheral neuropathy (DPN). Two large managed care claims databases were merged, one with patients < 65 y.o. and one with patients ≥ 65 y.o. Cases were selected based on appropriate ICD-9 codes. Controls were identified using propensity score matching based on demographic and clinical characteristics. Controls were also required to have the same underlying conditions as cases (PHN controls - herpes zoster patients without PHN; painful DPN controls – diabetic patients without diabetes-related neurologic complications). One-year health care costs were calculated by summing plan payments beginning with patients' index date through one year. Excess costs were calculated by subtracting costs for controls from cases. Databases included 1,852 matched case-control pairs for PHN and 4,727 for painful DPN. One-year costs [mean, (SD)] for matched PHN and painful DPN cases were $10,206 ($23,840) and $22,754 ($41,481), respectively. Univariate mean excess total costs (p-value) were substantial and significant at $3,986 (<0.0001) for PHN and $6,287 (<0.0001) for painful DPN. Although medications provide the mainstay of neuropathic pain treatment, they were the smallest component of univariate excess total costs (PHN, 5.0%; painful DPN, 19.2%). In regression models, excess total costs remained significant at $3,976 (<0.0001) for PHN and $6,246 (<0.0001) for painful DPN. Management of these conditions can be challenging and many patients cannot tolerate or are refractory to existing treatments. This translates into significant healthcare costs and a substantial public health burden. (Supported by funding from NeurogesX, Inc.)

Costs of skin and skin structure infections due to Staphylococcus aureus: an analysis of managed- care claims

ABSTRACTObjectives: The incidence of skin and skin structure infections (SSSIs) due to Staphylococcus aureus (SA) is increasing. The objective of this study was to assess the costs of a treatment episode for SA-SSSIs.Methods: This retrospective analysis used a managed-care claims database to assess the duration and costs of incident SA-SSSI episodes treated with selected antibiotics (IV vancomycin, oral linezolid, and daptomycin, termed ‘study antibiotics’). Patients were included if they had an ICD-9-CM diagnosis of an SSSI and SA between January 1, 2002 and December 31, 2005. Treatment episodes began on the date of the first antibiotic and ended when the patient had fourteen consecutive days without a study antibiotic or SSSI hospitalization. Costs, represented by health plan payments for SSSIs and overall, were updated to 2005 US dollars. A generalized linear model (GLM) assessed predictors of costs.Results: A total of 1997 patients met the selection criteria. Mean (± SD) age was 46.3 (± 12.6) years and 55.9% of patients were male. Average episode length was 24 days, and over 95% of patients received IV vancomycin or oral linezolid as their initial study antibiotic. Patients remained on study antibiotics for an average of 16.4 days, and only 5% of patients were switched to another study antibiotic. Mean (± SD) overall episode costs were $8865 (± $20 003), primarily composed of inpatient and outpatient medical services. Treatment failure (i.e., study antibiotic switching or hospitalization), younger age, a diagnosis of bacteremia, osteomyelitis, or multiple complications during the episode, treatment with daptomycin, and greater Charlson co-morbidity score were significant positive predictors of overall costs. Alternatively, treatment with oral linezolid and hospitalization before the start of the outpatient treatment episode were significant negative predictors of overall costs. Mean (± SD) SSSI-related costs were $4551 (± $11 058).Limitations: Medical charts and laboratory test results were not available to confirm SSSI and SA diagnoses, and no information was available regarding antibiotics received in the inpatient setting.Conclusions: The costs of treating SA-SSSIs are substantial and vary by failure rates, co-morbidities, and type of antibiotic therapy.

The economic burden of chronic obstructive pulmonary disease (COPD) in a U.S. Medicare population

Although the economic burden of COPD has gained attention in recent years, data on the costs of COPD among U.S. Medicare beneficiaries are lacking. This study used administrative claims and eligibility records from a large U.S. multi-state Medicare managed care database. Study patients were 65+ years of age with paid claims during 2004. The COPD cohort comprised patients with 1+ inpatient/ER claims or 2+ outpatient claims (>30 days apart) for COPD (ICD-9-CM codes 491.xx, 492.x, 496). The comparison cohort included patients without COPD matched 3:1 to the COPD cohort on age, sex, enrollment months, and Medicare plan. Excess costs of COPD were estimated as the difference in overall health plan payments between the two cohorts during 2004. Attributable costs were calculated using medical claims with listed diagnoses of COPD or other respiratory-related conditions and pharmacy claims for respiratory medications. A total of 8370 patients were included in the COPD cohort and were matched to 25,110 comparison cohort patients. For both groups, mean (SD) age was 78 (8) years, 54% were female, and duration of eligibility was 11 (2) months. COPD patients were more likely to utilize healthcare services and had excess total healthcare costs about $20,500 higher (P<0.0001) than the comparison cohort. Comorbidities were high in the COPD cohort, accounting for 46% of the observed excess cost. The attributable cost of COPD averaged about $6,300; other respiratory-related costs averaged about $4,400. In this U.S. Medicare managed care population, COPD posed a substantial burden in terms of both respiratory-related and total healthcare costs. A comparison of these cost-of-illness estimates to those for elderly COPD patients in other countries would be of great interest, given the increasing age of populations in most Western countries.

Predictors of Chapter 13 Completion Rates: The Role of Socioeconomic Variables and Consumer Debt Type

This study examined whether demographic or financial variables best predict completion of Chapter 13 bankruptcy plans. Multinomial logistic regression revealed that demographic variables were more important than financial variables in predicting completion. Completion of a Chapter 13 repayment plan was not associated with a debtor’s monthly income or expenses. Never married debtors, dependent children, a previous filing, and higher mortgage arrears increased the likelihood of dismissal. Longer job tenure and home ownership improved completion rates. Discharge was associated with higher unsecured debts. Results can help improve Chapter 13 completion rates. Debtors need guidance in setting up realistic repayment plans. Financial counselors could help ensure that repayment plans are feasible and to counsel debtors who miss a plan payment.

Materialism as a predictor variable of low income consumer behavior when entering into installment plan agreements

Abstract This paper explores the influence of materialism on consumer indebtedness among low income individuals who live in poor regions of Sao Paulo. A materialism scale was adapted to this context and used to describe the level of materialism among the population surveyed. Results obtained relative to the relationship between materialism and socio‐demographic variables are compared to those of previous studies. A logistic regression model was developed in order to characterize individuals who have an installment plan payment booklet—the main source of consumer credit for the population studied—and to differentiate them from those who do not, based on the materialism level, socio‐demographic variables and purchasing and consumer habits. The proposed model confirms materialism as a behavioral variable that is useful for forecasting the probability of an individual getting into debt in order to consume. Income had the biggest relative influence on the regression model, followed by materialism and age, controlled by gender. Copyright © 2008 John Wiley &amp; Sons, Ltd.

Payment Policy And The Growth Of Medicare Advantage

This paper reviews recent trends in Medicare Advantage, examining program costs, access to plans, enrollment, plan bids, and benchmarks. We find that current policy has favored the growth of particular types of plans. Bid data show that plans are paid, on average, 113 percent of what expenditures would have been under the traditional Medicare program. Although some of the plan payments are used to finance extra benefits for enrollees, paying plans at higher than fee-for-service levels could affect the sustainability of the Medicare program and result in increased costs for all taxpayers and beneficiaries.

Administrative claims analysis of utilization and costs of care in health plan members with atopic dermatitis who had prior use of a topical corticosteroid and who initiate therapy with pimecrolimus or tacrolimus.

In the United States, pimecrolimus cream and tacrolimus ointment are approved as second-line therapy for short-term and intermittent noncontinuous long-term treatment of atopic dermatitis (AD) in nonimmunocompromised patients aged 2 years or older who have failed to respond adequately to other topical prescription treatments (e.g., topical corticosteroids), or when those treatments are not advisable; pimecrolimus is indicated for mild to- moderate AD and tacrolimus for moderate-to-severe AD. Comparative data on the effects of pimecrolimus versus tacrolimus on AD-related health care utilization and costs among similar patients seen in typical clinical practice are currently unavailable. To compare utilization and costs of AD-related medical care in health plan members with AD who had prior use of a topical corticosteroid and who subsequently initiate therapy with pimecrolimus cream or tacrolimus ointment. This was an observational, retrospective study using an administrative claims database with dates of service from August 1, 2000, through October 31, 2003, and representing approximately 2.5 million members in health maintenance organizations, preferred provider organizations, and Medicare and Medicaid plans mostly located in the cities of Chicago, Kansas City, and Phoenix and in the states of Kentucky, Florida, and Texas. The study sample included all members with 1 or more pharmacy claims for a topical corticosteroid and a diagnosis of AD (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 691.XX (excluding 691.0X), or 692.XX (excluding 692.0X-692.8X)] who subsequently had 1 or more pharmacy claims for pimecrolimus or tacrolimus. AD-related utilization and medical care costs (plan payments plus member cost share) over 12 months of follow-up were compared between the pimecrolimus and tacrolimus groups. Because information on disease severity was not available in the administrative claims data, propensity matching was used to control for differences between groups in baseline demographic and clinical characteristics and pretreatment utilization of AD-related medical care services. Before matching, compared with the tacrolimus group (n = 197), members in the pimecrolimus group (n = 197) were older (mean age of 38 vs. 32 years, P = 0.022), had fewer topical corticosteroid pharmacy claims (mean 2.08 vs. 3.01, P = 0.002), and had fewer grams of corticosteroids dispensed (mean 132 vs. 193, P = 0.029) in the 12 months prior to treatment. After matching, there were 157 members in each group with no statistically significant differences in pretreatment characteristics. During the 12-month follow-up period, the mean (median) number of pharmacy claims was 1.8 (1.0) for pimecrolimus versus 2.0 (1.0) for tacrolimus and the mean (median) grams of study medication were 102 (60) and 105 (60), respectively. Members in the pimecrolimus group received a lower average number of prescriptions for any topical corticosteroids (1.37 vs. 2.04, P = 0.021) and for high-potency topical corticosteroids (0.61 vs. 1.04, P = 0.023) and were less likely to initiate alternative therapy (5% vs. 17%, P <0.001) or receive antistaphylococcal antibiotics (16% vs. 27%, P = 0.014). Members in the pimecrolimus group had lower average (median) AD-related expenditures (75% to 78% attributable to AD drug cost) compared with matched tacrolimus members ($263 [$270] vs. $361 [$398], P = 0.012). In health plan members with AD who had previously received at least 1 topical corticosteroid prescription, the customary use of pimecrolimus or tacrolimus was 1 to 2 prescriptions in 12 months of followup and only a median of 60 grams of topical medication. The difference in AD-related utilization and costs between pimecrolimus and tacrolimus was small, less than $100 per year, but favored pimecrolimus. Further research using validated measures of disease severity to control for potential confounding is needed to confirm the results of this observational study.

The Economic Impact of Epoetin Alfa Therapy on Delaying Time to Dialysis in Elderly Patients with Chronic Kidney Disease

The aim of this study was to evaluate the impact of epoetin alfa (EPO) therapy on delaying progression to renal dialysis and quantify the associated medical cost savings in elderly chronic kidney disease (CKD) patients. Elderly (>/=65 years) dialysis patients who had >/=1 hemoglobin (Hb) value and >/=1 glomerular filtration rate (GFR) value of <60 mL/min/1.73 m(2) were identified using health claims and laboratory data from the period January 1999 to February 2005. Exclusion criteria included: organ transplantation, blood transfusion, use of darbepoetin alfa, and dialysis for reasons other than CKD. Each EPO patient was matched by Hb and GFR to one control patient. The time from when matched patients had the same GFR value to dialysis was compared. The economic impact of EPO on delaying dialysis was monetized using standardized health plan payments, and adjusted to 2005 United States dollars. Sixty-eight patients (34 EPO and 34 matched controls) formed the study population. The average time to dialysis was 156 days longer for the EPO group compared to the matched control group (p = 0.003). Analysis by CKD severity revealed that EPO therapy in less severe CKD patients offered a greater delay in time to dialysis (Stage 4: 213 days difference, p = 0.003; Stage 5: 104 days difference, p = 0.160). EPO treatment resulted in cost savings of $43,374-$59,222 per patient compared to non-EPO matched controls. This retrospective matched cohort study suggests that EPO therapy has a beneficial impact on delaying progression to dialysis in elderly CKD patients, especially in those with less severe CKD.