Andrew W. Mulcahy

Pharmaceutical Pricing in Emerging Markets: Effects of Income, Competition and Procurement

This paper analyzes determinants of ex-manufacturer prices for originator and generic drugs across countries. We focus on drugs to treat HIV/AIDS, TB, and malaria in middle and low-income countries (MLICs), with robustness checks to other therapeutic categories and the full income range of countries. We examine the effects of per capita income, income dispersion, competition from originator and generic substitutes, and whether the drugs are sold to retail pharmacies versus tendered procurement by non-government organizations. The cross-national income elasticity of prices is 0.27 across the full income range of countries but is 0.0–0.10 between MLICs, implying that drugs are least affordable relative to income in the lowest income countries. Within-country income inequality contributes to relatively high prices in MLICs. Although generics are priced roughly 30% lower than originators on average, the variance is large. Additional generic competitors only weakly affect prices, plausibly because generic quality uncertainty leads to competition on brand rather than price. Tendered procurement that imposes quality standards attracts multinational generic suppliers and significantly reduces prices of originator and generic drugs, compared with their respective prices to retail pharmacies. ©2013 The Authors. Health Economics Published by John Wiley & Sons Ltd.

Effect of Teledermatology on Access to Dermatology Care Among Medicaid Enrollees

IMPORTANCE Access to specialists such as dermatologists is often limited for Medicaid enrollees. Teledermatology has been promoted as a potential solution; however, its effect on access to care at the population level has rarely been assessed. OBJECTIVES To evaluate the effect of teledermatology on the number of Medicaid enrollees who received dermatology care and to describe which patients were most likely to be referred to teledermatology. DESIGN, SETTING, AND PARTICIPANTS Claims data from a large California Medicaid managed care plan that began offering teledermatology as a covered service in April 2012 were analyzed. The plan enrolled 382 801 patients in Californias Central Valley, including 108 480 newly enrolled patients who obtained coverage after the implementation of the Affordable Care Act. Rates of dermatology visits by patients affiliated with primary care practices that referred patients to teledermatology and those that did not were compared. Data were collected from April 1, 2012, through December 31, 2014, and assessed from March 1 to October 15, 2015. MAIN OUTCOMES AND MEASURES The percentage of patients with at least 1 visit to a dermatologist (including in-person and teledermatology visits) and total visits with dermatologists (including in-person and teledermatology visits) per 1000 patients. RESULTS Of the 382 801 patients enrolled for at least 1 day from 2012 to 2014, 8614 (2.2%) had 1 or more visits with a dermatologist. Of all patients who visited a dermatologist, 48.5% received care via teledermatology. Among the patients newly enrolled in Medicaid, 75.7% (1474 of 1947) of those who visited a dermatologist received care via teledermatology. Primary care practices that engaged in teledermatology had a 63.8% increase in the fraction of patients visiting a dermatologist (vs 20.5% in other practices; P < .01). Compared with in-person dermatology, teledermatology served more patients younger vs older than 17 years (2600 of 4427 [58.7%] vs 1404 of 4187 [33.5%]), male patients (1849 of 4427 [41.8%] vs 1526 of 4187 [36.4%]), nonwhite patients (2779 of 4188 [66.4%] vs 1844 of 3478 [53.0%]), and individuals without comorbid conditions (1795 of 2464 [72.8%] vs 1978 of 3024 [65.4%]) (P < .001 for all comparisons). Conditions managed across settings varied; teledermatology physicians were more likely to care for viral skin lesions and acne (3405 of 7287 visits [46.7%]), whereas in-person dermatologists were more likely to care for psoriasis and skin neoplasms (10 062 of 27 347 visits [36.8%]). CONCLUSIONS AND RELEVANCE The offering of teledermatology appeared to improve access to dermatology care among Medicaid enrollees and played an especially important role for the newly enrolled.

Antibiotic Prescribing for Acute Respiratory Infections in Direct-to-Consumer Telemedicine Visits.

Patterns of antibiotic prescribing behavior show that both telemedicine and office-based clinicians over-prescribed antibiotics to treat acute respiratory infections, but telemedicine clinicians tended to prescribe broad-spectrum antibiotics.

Early Marketplace Enrollees Were Older And Used More Medication Than Later Enrollees; Marketplaces Pooled Risk

Little is known about the health status of the 7.3 million Americans who enrolled in insurance plans through the Marketplaces established by the Affordable Care Act in 2014. Medication use may provide an early indicator of the health needs and access to care among Marketplace enrollees. We used data from January-September 2014 on more than one million Marketplace enrollees from Express Scripts, the largest pharmacy benefit management company in the United States. We compared the characteristics and medication use between early and late Marketplace enrollees and between all Marketplace enrollees and enrollees with employer-sponsored insurance. Among Marketplace enrollees, we found that those who enrolled earlier (October 2013-February 2014) were older and used more medication than later enrollees. Marketplace enrollees, as a whole, had lower average drug spending and were less likely to use most medication classes than the employer-sponsored comparison group. However, Marketplace enrollees were more likely to use medicines for hepatitis C and particularly for HIV.

Medicare's Step Back from Global Payments — Unbundling Postoperative Care

Owing to concerns about the accuracy of payments for postoperative care, the Centers for Medicare and Medicaid Services has announced that surgeries for which it has bundled payments for care during a 10- or 90-day global period will be shifted to a 0-day global period.

Variation in dermatologist visits by sociodemographic characteristics

Background: Access to dermatologists is an ongoing concern for Medicaid enrollees. Understanding current use is a key step toward designing and implementing policies to improve access. Objective: We sought to quantify how often Medicaid enrollees visit dermatologists and receive treatment for skin‐related conditions compared with patients with other coverage or without health insurance. Methods: We conducted a retrospective cross‐sectional analysis of multiyear federal survey data (Medical Expenditure Panel Survey). The sample included Medical Expenditure Panel Survey respondents younger than 65 years from 2008 to 2012. Results: In unadjusted comparisons, we found that 1.4% of Medicaid enrollees had an ambulatory visit to a dermatologist annually, compared with 1.2% of uninsured individuals and 5.5% of individuals with private coverage. In adjusted models, we found that health insurance source, age, sex, race/ethnicity, and geography are associated with the likelihood of having visits to a dermatologist. Compared with individuals with private coverage, Medicaid enrollees are less likely to receive a diagnosis for a skin condition by any provider and are less than half as likely to have skin‐related diagnoses made by dermatologists. Limitations: We have relatively few Medical Expenditure Panel Survey respondents for a subset of specific diagnoses. Conclusions: Our findings emphasize the need for efforts to reduce disparities in access to dermatologists.

Associations Between the Patient Protection and Affordable Care Act Medicaid Primary Care Payment Increase and Physician Participation in Medicaid

Importance The Patient Protection and Affordable Care Act (ACA) increased 2013 to 2014 Medicaid payment rates for qualifying primary care physicians (PCPs) and services to higher Medicare payment levels, with the goal of improving primary care access for Medicaid enrollees. Objectives To evaluate the payment increase policy and to assess whether it was associated with changes in Medicaid participation rates or Medicaid service volume among PCPs. Design, Setting, and Participants This study used 2012 to 2015 IMS Health aggregated medical claims and encounter data from PCPs eligible for the payment increase practicing in all states except Alaska and Hawaii and included 20 723 PCPs with observations in each month from January 1, 2012, to December 31, 2015. Data are for professional services performed in ambulatory settings, including office, hospital outpatient department, and emergency department. Regression models were used to test whether outcomes differed in months subject to higher payment rates relative to months before the increase and after the expiration of the increase in some states. The models controlled for time-invariant physician characteristics and time-varying characteristics, such as Medicaid enrollment. Interaction terms were included to estimate differential associations in subgroups of states (eg, by Medicaid managed care penetration) and physicians (eg, by specialty). Main Outcomes and Measures Physician-month records subject to higher Medicaid payment rates were flagged using state-specific implementation and end dates for the payment increase. Five outcomes were measured for each physician-month observation, including (1) an indicator for seeing any patients enrolled in Medicaid, (2) an indicator for seeing more than 5 patients enrolled in Medicaid, (3) the Medicaid share of total patients, (4) a count of new patient evaluation and management visits furnished to patients enrolled in Medicaid, and (5) a count of existing patient evaluation and management visits furnished to patients enrolled in Medicaid. Results Among 20 723 PCPs, the payment increase had no association with PCP participation in Medicaid or Medicaid service volume. The estimated average marginal effects for all 5 outcomes were not statistically distinguishable from 0. This null result was robust to sensitivity analyses, including different time trend specifications and analyses focusing on the payment increase implementation and expiration time frames. Descriptively, the Medicaid share of patients increased by about 25% from 2012 to 2015, although the share did not increase differentially in states and months subject to higher payment rates. Conclusions and Relevance The limited duration and design of the payment increase may have dampened its effectiveness. Future efforts to improve access through payment changes or other means can benefit from better understanding of the outcomes of this policy.

The relationship between influenza vaccination habits and location of vaccination.

Objectives Although use of non-medical settings for vaccination such as retail pharmacies has grown in recent years, little is known about how various settings are used by individuals with different vaccination habits. We aimed to assess the relationship between repeated, annual influenza vaccination and location of vaccination. Study Design: We conducted a cross-sectional survey of 4,040 adults in 2010. Methods: We fielded a nationally representative survey using an online research panel operated by Knowledge Networks. The completion rate among sampled panelists was 73%. Results: 39% of adults reported that they have never received a seasonal influenza vaccination. Compared to those who were usually or always vaccinated from year to year, those who sometimes or rarely received influenza vaccinations were significantly more likely to be vaccinated in a medical setting in 2009–2010. Conclusions: Results indicate that while medical settings are the dominant location for vaccination overall, they play an especially critical role in serving adults who do not regularly receive vaccinations. By exploring vaccination habits, we can more appropriately choose among interventions designed to encourage the initiation vs. maintenance of desired behaviors.

Medical Costs for Osteoporosis-Related Fractures in High-Risk Medicare Beneficiaries: FRACTURE COSTS IN MEDICARE BENEFICIARIES

To estimate the incremental direct medical care costs associated with first fracture observable in high‐risk older adults.

Simulated Effects of Policies to Reduce Diabetes Risk Among Adults With Schizophrenia Receiving Antipsychotics

OBJECTIVE Second-generation antipsychotics increase the risk of diabetes and other metabolic conditions among individuals with schizophrenia. Although metabolic testing is recommended to reduce this risk, low testing rates have prompted concerns about negative health consequences and downstream medical costs. This study simulated the effect of increasing metabolic testing rates on ten-year prevalence rates of prediabetes and diabetes (diabetes conditions) and their associated health care costs. METHODS A microsimulation model (N=21,491 beneficiaries) with a ten-year time horizon was used to quantify the impacts of policies that increased annual testing rates in a Medicaid population with schizophrenia. Data sources included California Medicaid data, National Health and Nutrition Examination Survey data, and the literature. In the model, metabolic testing increased diagnosis of diabetes conditions and diagnosis prompted prescribers to switch patients to lower-risk antipsychotics. Key inputs included observed diagnoses, prescribing rates, annual testing rates, imputed rates of undiagnosed diabetes conditions, and literature-based estimates of policy effectiveness. RESULTS Compared with 2009 annual testing rates, ten-year outcomes for policies that achieved universal testing reduced exposure to higher-risk antipsychotics by 14%, time to diabetes diagnosis by 57%, and diabetes prevalence by .6%. These policies were associated with higher spending because of testing and earlier treatment. CONCLUSIONS The model showed that policies promoting metabolic testing provided an effective approach to improve the safety of second-generation antipsychotic prescribing in a Medicaid population with schizophrenia; however, the policies led to additional costs at ten years. Simulation studies are a useful source of information on the potential impacts of these policies.