Medicare Beneficiaries' High Out-of-Pocket Costs: Cost Burdens by Income and Health Status

Purpose Orally administered anticancer medications are among the fastest growing components of cancer care. These medications are expensive, and cost-sharing requirements for patients can be a barrier to their use. For Medicare beneficiaries, the Affordable Care Act will close the Part D coverage gap (doughnut hole), which will reduce cost sharing from 100% in 2010 to 25% in 2020 for drug spending above $2,960 until the beneficiary reaches $4,700 in out-of-pocket spending. How much these changes will reduce out-of-pocket costs is unclear. Methods We used the Medicare July 2014 Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information Files from the Centers for Medicare & Medicaid Services for 1,114 stand-alone and 2,230 Medicare Advantage prescription drug formularies, which represent all formularies in 2014. We identified orally administered anticancer medications and summarized drug costs, cost-sharing designs used by available plans, and the estimated out-of-pocket costs for beneficiaries without low-income subsidies who take a single drug before and after the doughnut hole closes. Results Little variation existed in formulary design across plans and products. The average price per month for included products was $10,060 (range, $5,123 to $16,093). In 2010, median beneficiary annual out-of-pocket costs for a typical treatment duration ranged from $6,456 (interquartile range, $6,433 to $6,482) for dabrafenib to $12,160 (interquartile range, $12,102 to $12,262) for sunitinib. With the assumption that prices remain stable, after the doughnut hole closes, beneficiaries will spend approximately $2,550 less. Conclusion Out-of-pocket costs for Medicare beneficiaries taking orally administered anticancer medications are high and will remain so after the doughnut hole closes. Efforts are needed to improve affordability of high-cost cancer drugs for beneficiaries who need them.

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PHP22 ASSOCIATION OF SELF-REPORTED HEALTH STATUS WITH COST-RELATED MEDICATION NONADHERENCE AND OUT-OF-POCKET PHARMACY SPENDING AMONG SENIOR MEDICARE BENEFICIARIES

Value in Health ◽

10.1016/j.jval.2011.02.094 ◽

2011 ◽

Vol 14 (3) ◽

pp. A15

Author(s):

Y. Tang

Keyword(s):

Health Status ◽

Medicare Beneficiaries ◽

Medication Nonadherence ◽

Reported Health ◽

Self Reported Health Status

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Health Care Utilization, Care Satisfaction, and Health Status for Medicare Advantage and Traditional Medicare Beneficiaries With and Without Alzheimer Disease and Related Dementias

JAMA Network Open ◽

10.1001/jamanetworkopen.2020.1809 ◽

2020 ◽

Vol 3 (3) ◽

pp. e201809 ◽

Cited By ~ 4

Author(s):

Sungchul Park ◽

Lindsay White ◽

Paul Fishman ◽

Eric B. Larson ◽

Norma B. Coe

Keyword(s):

Health Care ◽

Health Status ◽

Alzheimer Disease ◽

Health Care Utilization ◽

Care Utilization ◽

Medicare Advantage ◽

Medicare Beneficiaries ◽

Care Satisfaction

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Sex differences in health status, healthcare utilization, and costs among individuals with elevated blood pressure: the LARK study from Western Kenya

BMC Public Health ◽

10.1186/s12889-021-10995-3 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Neha Sikka ◽

Allison DeLong ◽

Jemima Kamano ◽

Sylvester Kimaiyo ◽

Vitalis Orango ◽

...

Keyword(s):

Blood Pressure ◽

Sex Differences ◽

Health Status ◽

Healthcare Utilization ◽

Elevated Blood Pressure ◽

Elevated Blood ◽

Western Kenya ◽

Men And Women ◽

Reported Health ◽

Out Of Pocket Costs

Abstract Background Elevated blood pressure is the leading risk factor for global mortality. While it is known that there exist differences between men and women with respect to socioeconomic status, self-reported health, and healthcare utilization, there are few published studies from Africa. This study therefore aims to characterize differences in self-reported health status, healthcare utilization, and costs between men and women with elevated blood pressure in Kenya. Methods Data from 1447 participants enrolled in the LARK Hypertension study in western Kenya were analyzed. Latent class analysis based on five dependent variables was performed to describe patterns of healthcare utilization and costs in the study population. Regression analysis was then performed to describe the relationship between different demographics and each outcome. Results Women in our study had higher rates of unemployment (28% vs 12%), were more likely to report lower monthly earnings (72% vs 51%), and had more outpatient visits (39% vs 28%) and pharmacy prescriptions (42% vs 30%). Women were also more likely to report lower quality-of-life and functional health status, including pain, mobility, self-care, and ability to perform usual activities. Three patterns of healthcare utilization were described: (1) individuals with low healthcare utilization, (2) individuals who utilized care and paid high out-of-pocket costs, and (3) individuals who utilized care but had lower out-of-pocket costs. Women and those with health insurance were more likely to be in the high-cost utilizer group. Conclusions Men and women with elevated blood pressure in Kenya have different health care utilization behaviors, cost and economic burdens, and self-perceived health status. Awareness of these sex differences can help inform targeted interventions in these populations.

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Effects of Medicare Drug Subsidies on Adherence for Diabetics: Evidence From a Regression Discontinuity Design

Innovation in Aging ◽

10.1093/geroni/igaa057.896 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 280-280

Author(s):

Alexandra Glynn ◽

Inmaculada Hernandez ◽

Eric Roberts

Keyword(s):

Medication Adherence ◽

Low Income ◽

Regression Discontinuity ◽

Drug Costs ◽

Financial Strain ◽

Medicare Beneficiaries ◽

Poverty Level ◽

Improve Medication Adherence ◽

Part D ◽

Out Of Pocket Costs

Abstract Out-of-pocket prescription drug costs are rapidly rising, particularly for insulin, which is a life-saving drug used by 3.1 million diabetics on Medicare. High out-of-pocket costs place an accentuated financial strain on older adults with diabetes, many of whom have low incomes, and may impede medication adherence, leading to poor health outcomes. The Medicare Part D Low-Income Subsidy (LIS) program limits drug co-pays to under $8.50 per prescription and caps out-of-pocket drug costs for lowest-income recipients (<135% Federal Poverty Level, FPL), resulting in pronounced differences in out-of-pocket costs for those with marginally different incomes. Using detailed income data from the Health and Retirement Study linked to Medicare claims (2008-2016), we employed a regression discontinuity (RD) design to isolate the effects of differences in out-of-pocket costs at eligibility thresholds for the LIS. Diabetic beneficiaries whose income exceeded the LIS eligibility threshold had lower Part D spending (-$945/year, p=0.03, n=2,367) and adherence to oral antidiabetic drugs (-8%, p=0.02). We conducted secondary analyses at the eligibility threshold for Medicaid, as individuals whose income exceeds the eligibility limit for Medicaid (100% of FPL in most states) are significantly less likely to receive the LIS. Above the Medicaid eligibility threshold (n=2,295), annual spending on insulin was $395 lower (p=0.002) and proportion of insulin use was 6% lower (p=0.04). These results suggest low-income Medicare beneficiaries who are not shielded from out-of-pocket costs via the LIS are particularly sensitive to drug costs. Policy proposals to limit out-of-pocket costs could improve medication adherence to high-cost drugs for vulnerable beneficiaries.

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