Prescription Drug Fills Research Articles

Medicaid expansion and opioid prescriptions: Evidence from the Medical Expenditure Panel Survey.

Evidence is mixed on whether increased access to insurance, specifically through the ACA's Medicaid expansion, exacerbated the opioid public health crisis through increased opioid prescribing. Using survey data on retail prescription drug fills from 2008 to 2019, we did not find a significant relationship between Medicaid expansion and opioid prescribing in the newly eligible Medicaid population. It may be that the dangers of opioids were known well enough by the time of the Medicaid expansion that lack of access to care was no longer a binding constraint on opioid prescription receipt.

Associations Between Annual Medicare Part D Low-Income Subsidy Loss and Prescription Drug Spending and Use

The Medicare Part D Low Income Subsidy (LIS) program provides millions of beneficiaries with drug plan premium and cost-sharing assistance. The extent to which LIS recipients experience subsidy losses with annual redetermination cycles and the resulting associations with prescription drug affordability and use are unknown. To examine how frequently annual LIS benefits are lost among Medicare Part D beneficiaries and how this is associated with prescription drug use and out-of-pocket costs. In this cohort study of Medicare Part D beneficiaries from 2007 to 2018, annual changes in LIS recipients among those automatically deemed eligible (eg, due to dual eligibility for Medicare and Medicaid) and nondeemed beneficiaries who must apply for LIS benefits were analyzed using Medicare enrollment and Part D event data. Subsidy losses were classified in 4 groups: temporary losses (<1 year); extended losses (≥1 year); subsidy reductions (change to partial LIS); and disenrollment from Medicare Part D after subsidy loss. Temporary losses could more likely represent subsidy losses among eligible beneficiaries. Multinomial logit models were used to examine associations between beneficiary characteristics and subsidy loss; linear regression models were used to compare changes in prescription drug cost and use in the months after subsidy losses vs before. Analyses were conducted between November 2022 and November 2023. Subsidy loss at the beginning of each year among subsidy recipients in December of the prior year. The main outcomes were out-of-pocket costs and prescription drug fills overall and for 4 classes: antidiabetes, antilipid, antidepressant, and antipsychotic drugs. In 2008, 731 070 full LIS beneficiaries (17%) were not deemed automatically eligible (39% were aged <65 years; 59% were female). Nearly all beneficiaries deemed automatically eligible (≥99%) retained the subsidy annually from 2007 to 2018, compared with 78% to 84% of nondeemed beneficiaries. Among nondeemed beneficiaries, disabled individuals younger than 65 years and racial and ethnic minority groups were more likely to have temporary subsidy losses vs none. Temporary losses were associated with an average 700% increase in out-of-pocket drug costs (+$52.72/mo [95% CI, 52.52-52.92]) and 15% reductions in prescription fills (-0.58 fills/mo [95% CI, -0.59 to -0.57]) overall. Similar changes were found for antidiabetes, antilipid, antidepressant, and antipsychotic prescription drug classes. Beneficiaries who retained their subsidy had few changes. The conclusions of this cohort study suggest that efforts to help eligible beneficiaries retain Medicare Part D subsidies could improve drug affordability, treatment adherence, and reduce disparities in medication access.

Trends in Medicare oral anticancer drug utilization among relapsed and refractory chronic myeloid leukemia patients.

e19058 Background: The treatment landscape for patients with relapsed and refractory (RR) chronic myeloid leukemia (CML) has changed significantly in recent years, with the introduction of targeted oral anticancer therapies. Current guidelines from the National Cancer Comprehensive Network (NCCN) recommend tyrosine-kinase inhibitors (TKIs) for second line and subsequent therapy. Recent real-world data evaluating treatment patterns in RR CML is limited. Study objective was to evaluate treatment patterns and trends in utilization of oral anticancer agents among Medicare beneficiaries diagnosed with RR CML, from 2017-2019. Methods: Retrospective study using Medicare Part D Prescription Drug Event Files, which contain records on prescription drug fills among Medicare beneficiaries enrolled in Fee-for-Service and Medicare Advantage plans. Beneficiaries diagnosed with RR CML (C9212 ICD-10) and prescribed oral anti-cancer therapy (Bosutinib, Dasatanib, Nilotinib, Ponatinib or Imatinib Mesylate) were identified and followed for at least 12 months, from index diagnosis until end of study period (December 31, 2019) or death. Trends in utilization by oral therapy, by number of beneficiary utilizers and prescription drug claims, were evaluated from 2017 to 2019. Results: Overall, 327 Medicare beneficiaries with a diagnosis of RR MM were prescribed an oral TKI therapy (Bosutinib, Dasatanib, Nilotinib, Ponatinib or Imatinib Mesylate) throughout the study period (2017-2019). The number of beneficiaries prescribed at least 1 oral therapy increased between 2017 and 2019, from 154 to 212 (Table). Total utilization also increased: from 210 prescription drug claims in 2017 to 296 in 2019. Throughout the study period, Imatinib Mesylate had the largest market share among all oral therapies, however the share decreased over time (from 35.7% in 2017 to 30.7% in 2019). Nilotinib had the largest gain in market share during this period, from 15.7% to 20.9%. Conclusions: Study findings suggest utilization of oral therapies are increasing over time, and shifting from Imatinib Mesylate to newer therapeutic agents. Given the high costs for these novel therapies, future research should examine trends in patient out-of-pocket spending, as well as factors impacting patient adherence.[Table: see text]

An algorithm using administrative data to measure adverse childhood experiences (ADM‐ACE)

ObjectiveTo develop an algorithm using administrative data to measure adverse childhood experiences (ADM‐ACE) within routinely collected health insurance claims and enrollment data.Data SourcesWe used claims and enrollment data from Tennessee's Medicaid program (TennCare) in 2018.Study DesignWe studied five types of ACEs: maltreatment and peer violence, foster care and family disruption, maternal mental illness, maternal substance use disorder, and abuse of the mother. We used diagnosis and procedure codes, prescription drug fills, and enrollment files to develop the ADM‐ACE, which we applied to measure the prevalence of ACEs and to examine prevalence by demographic characteristics among our sample of children in TennCare. We compared ADM‐ACE prevalence to child welfare records and survey results from Tennessee.Data Collection/Extraction MethodsOur study sample included children aged 0–17 years who were linked to their mothers if also enrolled in TennCare in 2018 (N = 763,836 children).Principal FindingsApproximately 19.2% of children in TennCare had indicators for ADM‐ACEs. The prevalence of ACEs was higher among children who were younger (p < 0.001), non‐Hispanic white or black (compared to Hispanic) (p < 0.001), and children residing in rural versus urban counties (p < 0.001). The prevalence of maltreatment identified through the ADM‐ACE (1.6%) falls between the percent of children in Tennessee who were reported to child welfare authorities and the percent for whom reports of maltreatment were substantiated. Comparison with survey reports from Tennessee parents suggests an advantage in measuring maternal mental illness with the ADM‐ACE using health insurance claims data.ConclusionsThe ADM‐ACE can be applied to health encounter data to study and monitor the prevalence of certain ACEs, their association with health conditions, and the effects of policies on reducing exposure to ACEs or improving health outcomes for children with ACEs.

Emerging Marketing Research on Healthcare and Medical Decision Making: Toward a Consumer-Centric and Pluralistic Methodological Perspective

Emerging Marketing Research on Healthcare and Medical Decision Making: Toward a Consumer-Centric and Pluralistic Methodological Perspective

Differences in Diabetic Prescription Drug Utilization and Costs Among Patients With Diabetes Enrolled in Colorado Marketplace and Medicaid Plans, 2014-2015

Increasing prices of antidiabetic medications in the US have raised substantial concerns about the effects of drug affordability on diabetes care. There has been little rigorous evidence comparing the experiences of patients with diabetes across different types of insurance coverage. To compare the utilization patterns and costs of prescription drugs to treat diabetes among low-income adults with Medicaid vs those with Marketplace insurance in Colorado during 2014 and 2015. This cross-sectional study included diabetic patients enrolled in Colorado Medicaid and Marketplace plans who were aged 19 to 64 years and had incomes between 75% and 200% of the federal poverty level during 2014 and 2015. Data analysis was conducted from September 2020 to April 2021. Health insurance through Colorado Medicaid or Colorado's state-based Marketplace. Primary outcomes were drug utilization (prescription drug fills) and drug costs (total costs and out-of-pocket costs). The secondary outcome was months with an active prescription for noninsulin antidiabetic medications. An all payer claims database was combined with income data, and linear models were used to adjust for clinical and demographic confounders. Of 22 788 diabetic patients included in the study, 20 245 were enrolled in Medicaid and 2543 in a Marketplace plan. Marketplace-eligible individuals were older (mean [SD] age, 52.12 [10.60] vs 47.70 [11.33] years), and Medicaid-eligible individuals were more likely to be female (12 429 [61.4%] vs 1413 [55.6%]). Medicaid-eligible patients were significantly more likely than Marketplace-eligible patients to fill prescriptions for dipeptidyl peptidase 4 inhibitors (adjusted difference, -3.7%; 95% CI, -5.3 to -2.1; P < .001) and sulfonylureas (adjusted difference, -6.6%; 95% CI, -8.9 to -4.3; P < .001). Overall rates of insulin use were similar in the 2 groups (adjusted difference, -2.3%; -5.1 to 0.5; P = .11). Out-of-pocket costs for noninsulin medications were 84.4% to 95.2% lower and total costs were 9.4% to 54.2% lower in Medicaid than in Marketplace plans. Out-of-pocket costs for insulin were 76.7% to 94.7% lower in Medicaid than in Marketplace plans, whereas differences in total insulin costs were mixed. The percentage of months of apparent active medication coverage was similar between the 2 groups for 4 of 5 drug classes examined, with Marketplace-eligible patients having a greater percentage of months than Medicaid-eligible patients for sulfonylureas (adjusted difference, 5.3%; 95% CI, 0.3%-10.4%; P = .04). In this cross-sectional study, drug utilization across multiple drug classes was higher and drug costs were significantly lower for adults with diabetes enrolled in Medicaid than for those with subsidized Marketplace plans. Patients with Marketplace coverage had a similar percentage of months with an active prescription as patients with Medicaid coverage.

Discharges against medical advice and 30-day healthcare costs: an analysis of commercially insured adults.

Aim: Prior literature detailing the consequences of a discharge against medical advice (DAMA) has not focused on costs. We examine costs following a DAMA. Materials & methods: This retrospective cohort study utilized the IQVIA PharMetrics® Plus database to identify adults hospitalized during 2007-2015. We compared 30-day postdischarge healthcare costs between matched DAMA and routinely discharged groups. Results: Thirty-day healthcare costs for the DAMA group were US$1078 (95% CI: US$434-1730) higher, driven by inpatient readmissions (US$979; 95% CI: US$415-1543) and emergency department visits (US$79; 95% CI: US$56-102). Costs due to prescription drug fills were lower in the DAMA group. Conclusion: A DAMA was associated with higher 30-day postdischarge healthcare costs compared with routine discharges.

Healthcare Resource Utilization Following a Discharge Against Medical Advice: An Analysis of Commercially Insured Adults.

A discharge against medical advice (DAMA) is associated with adverse health outcomes. Its association with postdischarge healthcare resource utilization (HcRU) outside an inpatient setting is unknown. This information can help us understand how a DAMA may affect healthcare-seeking behavior following a hospital stay. We evaluated the relationship between a DAMA and 30-day postdischarge HcRU. This retrospective cohort study uses a 10% random sample of enrollees in the IQVIA PharMetrics® Plus database. We included individuals aged 18 to 64 years with an inpatient admission during 2007-2015 and continuous insurance coverage. We defined comparison groups as DAMA and routine discharge. Both groups were matched on baseline covariates. We quantified the association between a DAMA and 30-day HcRU, as well as 90-day for sensitivity analysis, with use of generalized linear models for binary outcomes (inpatient readmissions, emergency department [ED] visits) and count outcomes (physician office visits, nonphysician outpatient encounters, prescription drug fills). Of the 457,530 individuals in the unmatched sample, 2,245 (0.5%) had a DAMA. In the matched sample, a DAMA was positively associated with an ED visit (adjusted odds ratio, 2.28; 95% confidence interval, 1.90-2.72) but not with an inpatient readmission. There were no differences between groups based on the count outcomes. A DAMA was positively associated with 90-day HcRU (ie, inpatient readmission, ED visit, and prescription drug fills). The relationship between a DAMA and HcRU varied with the HcRU category and postdischarge time interval. This examination of HcRU in the inpatient and outpatient settings provides important information about outcomes following a DAMA.

Chronic non-cancer pain and its association with healthcare use and costs among individuals with obstructive sleep apnea.

Aim: To evaluate the impact of chronic non-cancer pain (CNCP) on healthcare useand costs among individuals diagnosed with obstructive sleep apnea (OSA). Materials&methods: Using the IQVIA PharMetrics® Plus database, we identified individuals (18-64years old) during 2007-2014, divided into two groups: OSA+CNCP versus OSA-only. Generalized linear models were used to analyze binary and count outcomes. Results: Relative to OSA-only controls, OSA+CNCP cases had increased odds for inpatient and emergency department visits and higher rates for physician office visits, non-physician outpatient visits, and prescription drug fills. Relative to controls, direct healthcare costs for cases were higher, primarily driven by inpatient and non-physician outpatient visit costs. Conclusion: Relative to OSA-only controls, OSA+CNCP cases displayed increased healthcare use and costs across all points of service.

Part D coverage gap reform: trends in drug use and expenditures.

This study analyzed annual trends in the distribution of beneficiaries entering each benefit phase and the utilization of and expenditures for prescription drugs among Medicare Part D beneficiaries from 2008 to 2015. Retrospective, repeated cross-sectional analysis using Medicare Current Beneficiary Survey data. The study population included elderly Part D beneficiaries without a low-income subsidy, with continuous enrollment in a Part D plan, and with at least 1 prescription fill for a given year. We assessed annual trends for 3outcomes: (1) proportion of beneficiaries entering each benefit phase and the number of days taken to enter these phases, (2) number of 30-day prescription drug fills, and (3)total and out-of-pocket spending on prescription drugs. The proportion of beneficiaries reaching the catastrophic coverage phase increased after the Affordable Care Act (ACA), and they reached the threshold earlier in the year. The overall number of 30-day drug fills increased over the study period, although no statistically significant changes in utilization were seen among those reaching the catastrophic coverage phase. Total drug spending steadily increased over time, particularly after the ACA, with the largest increase seen in those reaching the catastrophic threshold; however, out-of-pocket spending significantly decreased. Although this study provides support for reductions in financial barriers to prescription drugs under the ACA, substantial increases in both total drug spending and the proportion of high-cost beneficiaries in the Part D program indicate a growing burden of Part D spending on the Medicare program, which is expected to continue to grow in the future.

Canadian Medication Cost Savings Associated with Combinatorial Pharmacogenomic Guidance for Psychiatric Medications.

ObjectiveTo estimate Canadian pharmacy cost savings associated with psychiatric medication prescribing that is guided by combinatorial pharmacogenomic testing in patients switching or augmenting their psychiatric medication.MethodsPharmacy claims data from a United States (US) pharmacy benefit manager were analyzed for 1662 patients who recently augmented or switched to a different antidepressant or antipsychotic medication and underwent combinatorial pharmacogenomic testing. Costs of prescription medications were translated to the Canadian healthcare system by matching drug names and doses using the Ontario Drug Benefit Formulary. One-year costs (2017 CAD) were compared between patients whose clinician prescribed antidepressants or antipsychotics that were consistent (congruent) or inconsistent (incongruent) with the combinatorial pharmacogenomic test recommendations.ResultsPatients whose psychiatric medication treatment was congruent with the combinatorial pharmacogenomic test report saved $1061 CAD per member per year (PMPY) on prescription medication costs relative to patients whose medications were incongruent with their test report (p<0.0001). For patients ages <65 and ≥65, prescription medication costs were $979 and $1178 CAD PMPY lower, respectively, for patients who followed the report recommendations (p=0.0004 and p=0.13). Prescription drug fills from the US pharmacy claims were concordant with the Canadian Formulary; 62% of fills matched at both the drug name and dose strength, 81% matched at drug name, and >99% matched at the therapeutic chapter.ConclusionsAntidepressant and antipsychotic prescribing that was congruent with combinatorial pharmacogenomic test guidance was associated with significant cost savings on Canadian prescription medications according to the Ontario Drug Benefit Formulary.

Decomposing changes in the growth of U.S. prescription drug use and expenditures, 1999-2016.

To analyze factors associated with changes in prescription drug use and expenditures in the United States from 1999 to 2016, a period of rapid growth, deceleration, and resumed above-average growth. The Medical Expenditure Panel Survey (MEPS), containing household and pharmacy information on over five million prescription drug fills. We use nonparametric decomposition to analyze drug use, average payment per fill, and per capita expenditure, tracking the contributions over time of socioeconomic characteristics, health status and treated conditions, insurance coverage, and market factors surrounding the patent cycle. Medical Expenditure Panel Survey data were combined with information on drug approval dates and patent status. Per capita utilization increased by nearly half during 1999-2016, with changes in health status and treated conditions accounting for four-fifths of the increase. In contrast, per capita expenditures more than doubled, with individual characteristics only explaining one-third of the change. Other drivers of spending during this period include the changing pipeline of new drugs, drugs losing exclusivity, and changes in generic competition. Long-term trends in treated conditions were the fundamental drivers of medication use, whereas factors involving the patent cycle accelerated and decelerated spending growth relative to trends in use.

PDG58 CLOSING THE MEDICARE PART D COVERAGE GAP: TRENDS IN DRUG UTILIZATION AND EXPENDITURES, 2008- 2015

Under the Affordable Care Act (ACA), the Medicare Part D coverage gap has been phasing out gradually since 2011. This study analyzes trends in prescription drug utilization and expenditures from 2008 to 2015. Data on non-disabled Part D seniors who did not receive the Low-Income Subsidy were obtained from the 2008-2015 Medicare Current Beneficiary Survey. Drug utilization was measured using the mean annual number of 30-day prescription drug fills per person. Drug expenditures were measured at two levels: mean annual total and out-of-pocket spending per person. All analyses were conducted separately for four different populations: all beneficiaries, those not reaching the coverage gap, those entering the coverage gap without reaching the catastrophic threshold, and those reaching the catastrophic threshold. Overall, the use of prescription drugs increased after the ACA, although no significant changes were among those reaching the catastrophic threshold. Total drug spending steadily increased after the ACA except for those not reaching the coverage gap; the largest increase was among those reaching the catastrophic threshold (43% increase from 2009 to 2015). However, out-of-pocket drug spending significantly decreased in the post-ACA period with the largest decrease in those not entering the coverage gap. For those reaching the catastrophic threshold, out-of-pocket spending incurred during the catastrophic coverage phase significantly increased. Despite increasing utilization and total costs of prescription drugs after the ACA, out-of-pocket drug costs significantly decreased. Our findings provide evidence the ACA’s coverage gap reform has helped to reduce financial barriers to prescription drugs for Part D beneficiaries. However, the findings of substantial increases in total drug spending over time, especially among those reaching the catastrophic threshold, may indicate a growing burden on the Medicare program. Potential changes to the Part D program and drug pricing models may be needed to reduce the growing total spending.

Medicaid enrollment among previously uninsured Americans and associated outcomes by race/ethnicity—United States, 2008‐2014

ObjectivesTo examine the person‐level impact of Medicaid enrollment on costs, utilization, access, and health across previously uninsured racial/ethnic groups.Data SourceMedical Expenditure Panel Survey, 2008‐2014.Study DesignWe pooled multiple 2‐year waves of data to examine the direct impact of Medicaid enrollment among uninsured Americans. We compared changes in outcomes among nonpregnant, uninsured individuals who gained Medicaid (N = 963) to those who remained uninsured (N = 9784) using a difference‐in‐differences analysis.Principal FindingsMedicaid enrollment was associated with significant increases in total health care costs and total prescription drug costs and a significant decrease in out‐of‐pocket costs. Among those who gained Medicaid, prescription drug use increased significantly relative to those who remained uninsured. Medicaid enrollment was also associated with a significant increase in reporting a usual source of care, a decrease in foregone care, and significant improvements in severe psychological distress. Changes in total prescription drug costs and total prescription drug fills differed significantly across each racial/ethnic group.ConclusionsAmong a national sample of uninsured individuals, Medicaid enrollment was associated with substantial favorable changes in out‐of‐pocket costs, prescription drug use, and access to care. Our findings suggest Medicaid is an important tool to reduce insurance‐related disparities among Americans.

PGI12 - Burden of Illness of Chronic Hepatitis C in Medicaid

To estimate annual health services utilization and cost impacts of chronic hepatitis C virus (HCV) infection in Medicaid. Using 2012 Medicaid Analytic Extract data from 16 states, the cohort of 72,409 patients with HCV was drawn from the population of 5,035,716 individuals, ages 18-64 with continuous Medicaid coverage. HCV patients were stratified by liver disease severity (non-cirrhotic, compensated cirrhosis, or end-stage liver disease); eligibility (blind/disabled or other adults); and plan type (fee-for-service or managed care). Mean values of health services utilization measures were calculated. Healthcare costs were derived from fee-for-services claims. A control group of Medicaid recipients without HCV was constructed using coarsened exact matching on sociodemographic and clinical characteristics. Overall HCV prevalence was 1.4%. Blind/disabled HCV patients averaged 1.1-1.2 more hospitalizations and 3.3-4.6 more hospital days compared to non-HCV blind/disabled enrollees. Similarly, among other HCV-infected adults, hospitalizations were greater by 1.0 and hospital days were greater by 2.6-4.6. Other health services were also significantly higher for HCV patients, including emergency department visits, physician’s office/clinic visits, and prescription drug fills. Total healthcare costs were $53,159 ($35,280) for blind/disabled HCV (non-HCV) enrollees, and $26,788 ($9,610) for other adults with (and without) HCV. The difference in healthcare costs attributed to HCV ranged from $10,561 (99% CI: $7,272-$13,849) for non-cirrhotic blind/disabled adults to $46,264 (99% CI: $41,264-$51,263) for other adults with end-stage liver disease. The average incremental cost of HCV infection among adults in Medicaid was estimated at $17,671 per patient per year. These results were all highly statistically significant (p<0.001). The clinical and economic impacts of HCV among Medicaid beneficiaries in 2012 were considerable. Innovative direct-acting antiviral medicines with cure rates at or above 95% introduce the opportunity to greatly reduce or eliminate this burden.

Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial.

IntroductionAlthough traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH.MethodsWe conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014.ResultsCompared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider–specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health “good” or better.ConclusionHomeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department of Veterans Affairs VA and community health systems.

Healthcare utilization and expenditures for United States Medicare beneficiaries with systemic vasculitis.

The Medicare federal insurance program is the most common United States insurer of patients with systemic vasculitis (SV). We compared healthcare utilization and expenditures for Medicare beneficiaries with versus without SV. This national, retrospective study used 2010 claims and enrollment data for a 100% cohort of Medicare Part A and B beneficiaries with ≥1 claim including a diagnosis for a form of SV (n = 176,498), and a randomly selected group of non-SV beneficiaries (n = 46,561). Outcomes included annual counts of events in 16 categories of medical services (e.g., inpatient stays, physician visits, tests, and imaging events), and total annual Medicare and patient medical expenditures. We used linear regression with bootstrapped standard errors to compare utilization and expenditures by SV status, before and after matching on age and sex. Prescription drug fills and expenditures for SV (n = 95,157) and non-SV (n = 24,992) beneficiaries with Part D drug benefits were also compared. After matching, Medicare spent $11,004 more per patient in 2010 for medical services, and $773 more on prescription drugs, for SV versus non-SV beneficiaries. SV beneficiaries spent $1547 more for medical services and $211 more for prescription drugs. Except for hospice, SV beneficiaries had greater utilization of all services, including two-to-three times more dialysis events, hospital readmissions, inpatient stays, skilled nursing facility stays, and medical tests. The average Medicare beneficiary with SV incurs about double the annual healthcare expenditures compared to their non-SV counterparts, attributable to increased utilization of almost all categories of care.

Elimination of the Out-of-Pocket Charge for Children's Primary Care Visits: An Application of Value-Based Insurance Design

To evaluate the impact of a value-based insurance design for primary care among children. A retrospective analysis of health care claims data on 25 950 children (<18years of age) was conducted. Individuals were enrolled in a large employer's health plans when zero out-of-pocket cost for primary care physician visits was implemented. A rigorous propensity score matching process was used to generate a control group of equal size from a database of other employer-sponsored insurees. Multivariate difference-in-differences models estimated the effect of zero out-of-pocket cost on 21 health services and cost outcomes 24months after intervention. Zero out-of-pocket cost for primary care was associated with significant increases (P<.01) in primary care physician visits (+32 per 100 children), as well as decreases in emergency department (-5 per 100 children) and specialist physician visits (-12 per 100 children). The number of prescription drug fills also declined (-20 per 100 children), yet medication adherence for 3 chronic conditions was unaffected. The receipt of well child visits and 4 recommended vaccinations were all significantly (P<.05) greater under the new plan design feature. Employer costs for primary care increased significantly (P<.01) in association with greater utilization ($29 per child), but specialist visit costs declined (-$12 per child) and total health care costs per child did not exhibit a statistically significant increase. This novel application of value-based insurance design warrants broader deployment and assessment of its longer term outcomes. As with recommended preventive services, policymakers should consider exempting primary care from health insurance cost-sharing.

PHP46 - FACTORS ASSOCIATED WITH HAVING PRESCRIPTION DRUG FILLS AMONG MEMBERS OF QUALIFIED HEALTH PLANS

To determine factors associated with having one or more prescription drug fills (PDFs) in members of qualified health plans (QHPs). This study used a large nationally representative administrative claims database supplemented with socioeconomic and community resource data. The sample consisted of 1,823,677 members of QHPs who were enrolled for ≥10 months in 2014. Logistic regression was used to determine factors associated with having PDFs. A total of 1,230,981 (67.5%) members had ≥1 PDF during the study period. Living in a neighborhood with higher education levels (i.e., percent population with at least bachelor’s degree) was associated with higher likelihood of having PDFs (OR: 1.04-1.12; reference: 0-12%). Lower median household income was associated with lower likelihood of having PDFs (OR: 0.73-0.90; reference $100,000+). Members from neighborhoods with a higher proportion of non-white race/ethnicities were less likely to have PDFs (non-Hispanic black, OR=0.80; Hispanic, OR=0.95; Asian, OR=0.58). Compared to Silver plan members, members of Gold plans were more likely to have PDFs (OR=1.07); but members of Platinum, Bronze, and Catastrophic plans were less likely to have PDFs (OR: 0.95, 0.65 and 0.83, respectively). Individual plan enrollment was associated with higher likelihood of having PDFs (OR=1.10), while on-exchange plan enrollment was associated with lower likelihood (OR=0.87). Other factors associated with lower likelihood of having PDFs were being male (OR=0.62); younger age (OR: 0.55-0.71; reference: 31-65); and living in a non-metropolitan area (OR: 0.89-0.95). This study provides evidence that the likelihood of having PDFs varies across member and plan characteristics, even after controlling for patient severity. Assuring appropriate treatment and adherence to medications for chronic conditions is inherent to achieving good health outcomes, thus it is important that QHPs identify and understand factors associated with lower likelihood of filling prescriptions in order to develop targeted interventions to achieve the most optimal outcomes in their members.

Clinical Factors Associated With Remission of Obesity-Related Comorbidities After Bariatric Surgery.

Little is known about comorbidity remission after bariatric surgery during typical clinical care across diverse and geographically distributed populations. To estimate the improvement in obesity-related comorbidities after bariatric surgery and to identify clinical factors associated with these responses using a large representative population of patients. This retrospective cohort study included all patients (N = 33,718) with a recorded Current Procedural Terminology code for Roux-en-Y gastric bypass (RYGB) or adjustable gastric banding (AGB) in the MarketScan Commercial Claims and Encounters Medicare Supplemental Databases from January 1, 2005, to June 30, 2010, and who had continuous enrollment from 6 months or more before to 12 months after surgery. Comorbidities before and after surgery were identified using both diagnoses (from International Classification of Diseases, Ninth Revision [ICD-9] codes) and prescription drug fills. Remission was based on a record of the comorbidity within 6 months before surgery, without record of the condition 18 months after surgery, using both ICD-9 codes and medication fills, as applicable. Multivariable logistic regression models were developed to identify factors associated with remission of diabetes and hypertension. Among the 33,718 patients, 13 comorbidities with at least 1% prevalence before surgery were identified. Both RYGB and AGB led to statistically and clinically significant reductions in these comorbidities; remission rates for all comorbidities were higher after RYGB than AGB. For comorbidities that could be defined using both ICD-9 and prescription drug fill codes, prevalence was higher before and lower after surgery when measured by fill codes. Diagnoses using ICD-9 codes, but not prescription fill codes, increased in the 3 months before surgery. In multivariable logistic regression models for remission of diabetes mellitus after RYGB and AGB, age (RYGB: odds ratio [OR], 0.976; 95% CI, 0.965-0.988 and AGB: OR, 0.982; 95% CI, 0.971-0.933), procedure year (RYGB: OR, 1.11; 95% CI, 1.012-1.218 and AGB: OR, 1.185; 95% CI, 1.039-1.351), preoperative insulin use (RYGB: OR, 0.14; 95% CI, 0.114-0.171; AGB: OR, 0.174; 95% CI, 0.131-0.230), preoperative sulfonylurea use (RYGB: OR, 0.616; 95% CI, 0.505-0.752 and AGB: OR, 0.449; 95% CI, 0.357-0.566), and other antidiabetic medication use (RYGB: OR, 0.747; 95% CI, 0.568-0.981 and AGB: OR, 0.506; 95% CI, 0.359-0.715) were significantly associated with response after both procedures. For remission of hypertension, age (RYGB: OR, 0.964; 95% CI, 0.957-0.972 and AGB: OR, 0.968; 95% CI, 0.959-0.977), number of preoperative antihypertensive medications (RYGB: OR, 0.104; 95% CI, 0.067-0.161 and AGB: OR, 0.239; 95% CI, 0.140-0.408), and preoperative diuretic use (RYGB: OR, 1.729; 95% CI, 1.462-2.045 and AGB: OR, 1.648; 95% CI, 1.380-1.967) were significantly associated with response after both procedures. Analysis of a large, representative administrative database confirmed established predictors and revealed novel variables associated with comorbidity remission after bariatric surgery. Incorporating these factors into clinical tools to assess an individual patient's risk-to-benefit profile for these procedures could enhance patient selection and the overall use of surgery for the treatment of obesity and metabolic disease.