Healthcare utilization and cost of cancer-related care prior to allogeneic hematopoietic cell transplantation for hematologic malignancies in the US: a retrospective real-world analysis

Background Hematopoietic cell transplantation (HCT) is a potentially curative therapy as well as a costly procedure. Published studies have examined the cost of HCT in the US and the complications that follow but little is known about the cancer-related healthcare costs and resource utilization prior to the procedure and none of the studies have examined the variability in cost based on the type of hematologic malignancy involved. The aim of this study was to estimate mean cancer-related costs and resources incurred before the HCT is performed from the time the hematologic malignancy first develops. Methods The IBM® MarketScan® Research Databases were used to identify adult patients ≥18 years of age with commercial or Medicare supplemental insurance who had undergone allogeneic HCT for hematologic malignancies from January 1, 2008 to December 31, 2017. Healthcare utilization and costs were assessed during the 6 months prior to diagnosis (pre-diagnostic period) and the follow-up period from diagnosis just prior to the HCT (pre-HCT period). Multivariable regression models were constructed to estimate total all-cause costs and cancer-related costs as well as healthcare utilization by type in each time period. Results A total of 2663 commercially insured patients and 266 with Medicare supplemental insurance were included in the study population. The mean-adjusted incremental cancer-related costs for commercially insured patients was $399,011 in the overall observation period including the pre-diagnostic and pre-HCT periods combined, 9% of which was incurred in the pre-diagnostic period. The corresponding mean-adjusted incremental cancer-related costs for Medicare supplemental patients was $195,575 for the same time period but the patterns of healthcare utilization were similar to the commercially insured population. Inpatient care accounted for approximately one-half the cost in both patient populations. By type of hematologic malignancy, costs were lowest for myeloproliferative disorders ($211,561) and highest for acute lymphocytic leukemia ($462,072) in the commercially insured population. Conclusion This study demonstrates that overall patients with hematologic malignancies requiring HCT have considerable cancer-related healthcare resource utilization and costs leading up to HCT compared to the period of time prior to developing cancer.

Assessing the Factors Affecting Cesarean Section Selection in Iranian Women Using Multilevel Count Models with Excess Zeros

Background: Iran has ranked second in the frequency of cesarean delivery (CD) and this rate in 2014 has increased by 56 percent. The CD has multiple complications for the woman and newborn, and due to the women's readmission after surgery impose additional costs to the countries. Although CD has many complications and is not recommended by obstetrician and midwives; some factors affect the choice of this method of delivery. Methods: We used data from the Iranian Institute for Health Sciences Research (IIHSR) in 2015. We studied the effects of factors such as socioeconomic and demographic factors and supplemental insurance status in the choice of CD. We used multilevel Zero-Inflated models for the modeling of data. Results: The employed women resident in urban areas with the high-income and age greater than 34-yr old and supplemental insurance more likely chose CD. On the other hand, women with high education level, women who use at least one media (e.g. Radio, television, etc.) and women that use contraceptive methods have chosen the less CD. Conclusion: Our findings highlighted the importance of supplemental insurance and socio-economic status in choosing a CD by women. However, in some cases especially in the rich class of society, the high cost of this type of delivery does not affect the choice decrease of it, and governments should adopt rigorous policies in using this method.

Financial Toxicity and Impact on Health-Related Quality of Life in Patients with Plasma Cell Disorders

BACKGROUND: Advances in novel therapies and supportive care have contributed to improved outcomes for patients with Multiple myeloma (MM) and Light Chain Amyloidosis (AL). This progress comes at a high price; with high financial costs to patients increasing distress, decreasing compliance, and even decreasing survival. Our aim was to screen patients for financial distress and understand its impact on various domains of health-related quality of life (HRQOL). METHODS: We conducted a prospective study of adult patients with MM or AL that received follow-up care at Mayo Clinic, Rochester, MN. Financial distress was measured using the validated COmprehensive Score for financial Toxicity (COST) questionnaire; high financial distress was defined as a score of 23 or less. HRQOL was measured using the Patient Reported Outcome Measurement Information System (PROMIS)-29 questionnaire. Baseline demographic information and clinical characteristics were abstracted from the medical record. Statistical analysis included descriptive statistics, Spearman correlations, and comparison of COST scores between groups by Jonckheere-Terpstra, Kruskal-Wallis, and Wilcoxon rank-sum tests for ordered, unordered, and binary categorical variables, respectively. RESULTS: Patients: To date 77 patients (MM 64 [83%], AL 13 [17%]) have been enrolled, 55% male, 53% age 65 or older (18% <55), 91% White (5% Black), 92% non-Hispanic, 56% at least some college, 47% income at least US$75K/year (25% <US 50K/year), 36% employed (49% retired), 73% married (14% divorced) and 22% traveled at least 300 miles to clinic. Clinical characteristics included 45% newly diagnosed, 55% relapsed/refractory disease. 66% had been transplanted previously. Insurance types included 52% Medicare (44% private insurance) with 27% overall reporting supplemental insurance. Financial Distress: The mean COST score was 26.5 (SD 10.0) with 42% reporting high financial distress. PROMIS-29 domain descriptive statistics appear in Table 1. Higher financial distress was significantly associated with higher anxiety, depression, and pain (all p<0.05). Group Differences: Financial distress significantly differed by gender, education, marital status, employment status, income, insurance type, and distance traveled reported in Table 2. Financial distress was higher: in women than men (p=0.003); in high school graduates vs those who attended some college or more (p=0.03); in divorced versus married individuals (p=0.02); among unemployed or disabled versus employed versus retired people (p=0.04); in those with income <US$50K/year versus US$50K-<$75K/year versus at least US$75K/year (p<0.001); among those with Medicaid vs private insurance versus Medicare (p=0.02); and for those whose distance from Mayo was at least 300 miles vs < 300 miles (p=0.03). Differences in age neared but failed to reach strict statistical significance (age 35-54: mean 22.4, SD 12.1; age 55-64: mean 26.5, SD 9.5; age 65+: mean 28.0, SD 9.2; p=0.051). Financial distress did not significantly differ by race, ethnicity, diagnosis, disease status (newly diagnosed/relapsed), prior transplant, or supplemental insurance, though some subgroups were small. CONCLUSION: Financial distress was prevalent in this well-educated and high earning MM and AL cohort that is able to receive tertiary care at Mayo Clinic. This financial distress was moderate to strongly associated with anxiety and pain intensity, and mild to moderately associated with depression and pain interference. Longitudinal assessment is ongoing. Disclosures Dispenzieri: Takeda: Research Funding; Celgene: Research Funding; Janssen: Research Funding; Pfizer: Research Funding; Alnylam: Research Funding; Intellia: Research Funding.

Partial identification in nonseparable count data instrumental variable models

Summary This paper investigates undesirable limitations of widely used count data instrumental variable models. To overcome the limitations, I propose a partially identifying single-equation model that requires neither strong separability of unobserved heterogeneity nor a triangular system. Sharp bounds (identified sets) of structural features are characterised by conditional moment inequalities. Numerical examples show that the size of an identified set can be very small when the support of an outcome is rich or instruments are strong. An algorithm for estimation and inference is presented. I illustrate the usefulness of the proposed model in an empirical application to effects of supplemental insurance on healthcare utilisation.

Externalities and Taxation of Supplemental Insurance: A Study of Medicare and Medigap

Most health insurance uses cost-sharing to reduce excess utilization. Supplemental insurance can blunt the impact of this cost-sharing, increasing utilization and exerting a negative externality on the primary insurer. This paper estimates the effect of private Medigap supplemental insurance on public Medicare spending using Medigap premium discontinuities in local medical markets that span state boundaries. Using administrative data on the universe of Medicare beneficiaries, we estimate that Medigap increases an individual’s Medicare spending by 22.2 percent. We calculate that a 15 percent tax on Medigap premiums generates savings of $12.9 billion annually with a standard error of $4.9 billion. (JEL G22, H24, H51, I13, J14)

Financial burden at end of life: Findings from interviews with caregivers of patients with cancer.

14 Background: Studies have described financial burden during and after cancer treatment, but little data are available on financial burden to patients and caregivers at end of life. We conducted a qualitative study with bereaved caregivers and discussed the impact of cancer-associated medical and nonmedical costs on family finances. Methods: From October-December 2017, we audio-recorded semi-structured phone interviews with 35 adults who were primary caregivers for a family member who died with cancer (July-December 2016). We asked about ability to meet costs of care. Drawing from previous studies, we defined substantial financial burden as incurring debt, selling assets or draining savings to meet health care costs. Two analysts coded transcripts using qualitative content analysis and summarized results as major themes. Results: Patients ranged from 30-88 years old, caregivers 34-85. Most caregivers were white (91%), female (63%) and spouses (89%). Ten patients (29%) were insured commercially, 24 (69%) had Medicare, and one (2%) had Medicaid. Ten caregivers (29%) reported substantial financial burden, irrespective of patients’ insurance coverage. Issues associated with substantial financial burden were: 1) insurance hurdles: “my husband’s dying and…I have to run interference with insurance companies, which is frustrating;” 2) limited financial resources: “It is hard when…you really don't have a lot of savings because…you never really made a lot of money” and 3) financial burden that continues after the patient’s death : “I went broke, basically, looking after my parents.” “We lost two incomes and we had to live on our savings.” Three other caregivers noted their family did not experience financial burden because they switched health insurance plans or had a supplemental insurance plan. Conclusions: In this pilot study of caregivers of advanced cancer patients, a substantial portion of commercially insured patients and Medicare enrollees with limited savings and income reported financial burden associated with cancer treatment and end-of-life care that persisted after the patient’s death. Future research is needed to determine best ways to mitigate financial burden among patients and their survivors.