Thomas Shaffer

Out-of-pocket health care expenditure burden for Medicare beneficiaries with cancer

BACKGROUND: There is increasing concern regarding the financial burden of care on cancer patients and their families. Medicare beneficiaries often have extensive comorbidities and limited financial resources, and may face substantial cost sharing even with supplemental coverage. In the current study, the authors examined out‐of‐pocket (OOP) spending and burden relative to income for Medicare beneficiaries with cancer.

Association of chronic obstructive pulmonary disease maintenance medication adherence with all-cause hospitalization and spending in a Medicare population.

BACKGROUND Although maintenance medications are a cornerstone of chronic obstructive pulmonary disease (COPD) management, adherence remains suboptimal. Poor medication adherence is implicated in poor outcomes with other chronic conditions; however, little is understood regarding links between adherence and outcomes in COPD patients. OBJECTIVE This study investigates the association of COPD maintenance medication adherence with hospitalization and health care spending. METHODS Using the 2006 to 2007 Chronic Condition Warehouse administrative data, this retrospective cross-sectional study included 33,816 Medicare beneficiaries diagnosed with COPD who received at least 2 prescriptions for ≥1 COPD maintenance medications. After a 6-month baseline period (January 1, 2006 to June 30, 2006), beneficiaries were followed through to December 31, 2007 or death. Two medication adherence measures were assessed: medication continuity and proportion of days covered (PDC). PDC values ranged from 0 to 1 and were calculated as the number of days with any COPD maintenance medication divided by duration of therapy with these agents. The association of adherence with all-cause hospital events and Medicare spending were estimated using negative binomial and γ generalized linear models, respectively, adjusting for sociodemographics, Social Security disability insurance status, low-income subsidy status, comorbidities, and proxy measures of disease severity. RESULTS Improved adherence using both measures was significantly associated with reduced rate of all-cause hospitalization and lower Medicare spending. Patients who continued with their medications had lower hospitalization rates (relative rate [RR] = 0.88) and lower Medicare spending (-

Association of Antipsychotic Use With Hospital Events and Mortality Among Medicare Beneficiaries Residing in Long-Term Care Facilities

3764), compared with patients who discontinued medications. Similarly, patients with PDC ≥0.80 exhibited lower hospitalization rates (RR = 0.90) and decreased spending (-

Does Medication Adherence Lower Medicare Spending Among Beneficiaries with Diabetes

2185), compared with patients with PDC <0.80. CONCLUSIONS COPD patients with higher adherence to prescribed regimens experienced fewer hospitalizations and lower Medicare costs than those who exhibited lower adherence behaviors. Findings suggested the clinical and economic importance of medication adherence in the management of COPD patients in the Medicare population.

Residential and Health Care Transition Patterns Among Older Medicare Beneficiaries Over Time

OBJECTIVE Antipsychotic (AP) utilization has grown significantly in long-term care (LTC) settings. Although a growing literature associates AP use with higher mortality in elderly with dementia, the association of APs with hospital events is unclear. The authors examine prevalence and trends in AP use by Medicare beneficiaries residing in LTC and the association of APs and other drug use variables with hospital events and mortality. DESIGN Retrospective analysis using sequential multivariate Cox proportional hazards models. SETTING Medicare Current Beneficiary Survey linked to Institutional Drug Administration and Minimum Data Set files. PARTICIPANTS A total of 2,363 LTC Medicare beneficiaries, 1999-2002. MEASUREMENTS Trends in LTC AP use overall and by type and duplicative use; association of AP utilization and two outcomes: hospital events and all-cause mortality. RESULTS AP use rose markedly from 1999 to 2002 (26.4%-35.9%), predominantly due to increased use of atypical agents. After controlling for sociodemographic and clinical factors, AP use is not related to hospital events (hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.82-1.63 p = 0.7951). AP use is associated with reduced mortality in unadjusted and intermediate models, but loss of significance in the final model (HR = 0.83, 95% CI = 0.69-1.00, p = 0.0537) suggests that disease and drug burden factors may confound the AP-mortality relationship. CONCLUSION This study provides no evidence of increased hospital events or mortality in LTC residents who use AP medications. Findings contribute to a growing body of evidence that APs, particularly atypical agents, may be associated with reduced mortality in LTC residents.

Impact of maintenance therapy on hospitalization and expenditures for Medicare beneficiaries with chronic obstructive pulmonary disease.

OBJECTIVE To measure 3-year medication possession ratios (MPRs) for renin-angiotensin-aldosterone system (RAAS) inhibitors and statins for Medicare beneficiaries with diabetes, and to assess whether better adherence is associated with lower spending on traditional Medicare services controlling for biases common to previous adherence studies. DATA SOURCE Medicare Current Beneficiary Survey data from 1997 to 2005. STUDY DESIGN Longitudinal study of RAAS-inhibitor and statin utilization over 3 years. DATA COLLECTION The relationship between MPR and Medicare costs was tested in multivariate models with extensive behavioral variables to control for indication bias and healthy adherer bias. PRINCIPAL FINDINGS Over 3 years, median MPR values were 0.88 for RAAS-I users and 0.77 for statin users. Higher adherence was strongly associated with lower Medicare spending in the multivariate analysis. A 10 percentage point increase in statin MPR was associated with U.S.

Coverage and use of prescription drugs in nursing homes: implications for the medicare modernization act.

832 lower Medicare spending (SE=219; p<.01). A 10 percentage point increase in MPR for RAAS-Is was associated with U.S.

Lessons Learned: Who Didn’t Enroll In Medicare Drug Coverage In 2006, And Why?

285 lower Medicare costs (SE=114; p<.05). CONCLUSIONS Higher adherence with RAAS-Is and statins by Medicare beneficiaries with diabetes results in lower cumulative Medicare spending over 3 years. At the margin, Medicare savings exceed the cost of the drugs.

Drug Use Patterns in Severely Mentally Ill Medicare Beneficiaries: Impact of Discontinuities in Drug Coverage

PURPOSE To describe annual care transition patterns across residential and health care settings and assess consistency in care transition patterns across years. DESIGN AND METHODS This retrospective cohort study used the Medicare Current Beneficiary Survey (2000-2005). The sample comprised beneficiaries aged 65 years and older (N = 57,684 person-years of observation). We defined annual care transition patterns by combining 4 types of settings: C (community), F (facility), S (skilled nursing facility-SNF), and H (hospital). We compared weighted frequencies of transition patterns across years. We counted repeated/multiple transitions that involved movement into hospital and SNF settings and compared them by demographic characteristics. RESULTS Care transition patterns remained consistent from year to year. Approximately 22% of the study population experienced a transition annually. The most frequent transition pattern was transition to the hospital and back. Care transition patterns were enormously heterogeneous with more than 230 unique patterns; approximately 1 in 4 community-dwelling (∼23%) and most facility-dwelling (∼60%) beneficiaries with at least one transition had a unique transition pattern. Beneficiaries residing in a facility were more likely to undergo multiple transitions to hospitals and SNFs compared with community-dwelling beneficiaries. IMPLICATIONS The study provides a description of annual care transition patterns across six years. Knowledge of the consistency of care transition patterns may serve as a baseline from which to compare future patterns and aid in designing interventions targeted at specific transitions.

Over-the-Counter Drug Use by Medicare Beneficiaries in Nursing Homes: Implications for Practice and Policy

BACKGROUND Chronic obstructive pulmonary disease (COPD) is associated with high levels of hospitalization and health care expenditures among the aged. Adherence to appropriate maintenance drug regimens has been reported to reduce hospitalization and health care spending in clinical trials. However, little research has been conducted to compare use versus nonuse of these medications in terms of health-related outcomes in routine practice. OBJECTIVE The purpose of this study was to compare differences between users and nonusers of maintenance medications in terms of selected outcomes for a nationally representative sample of Medicare beneficiaries with COPD. METHODS The study sample was selected from Medicare Current Beneficiary Surveys conducted between 1997 and 2005. Beneficiaries with COPD who used ≥1 maintenance medication annually were compared with nonusers on 3 claims-based outcomes: any hospitalization, any rehospitalization within 31 days, and total annual Medicare expenditures. RESULTS The study sample consisted of 6322 Medicare beneficiaries who contributed a total of 9161 person-year observations for analysis. Over the 9-year study period, 39.9% (3659/9161) of the person-year observations were recorded for maintenance medication users, and 60.1% (5502/9161) were recorded for nonusers. Most of the observations for medication users involved beneficiaries who were female (50.1% [1833/3659]), non-Hispanic white (85.4% [3124/3659]), and ≥65 years of age (88.2% [3228/3659]); most of the observations for nonusers involved beneficiaries who were male (51.9% [2855/5502]), non-Hispanic white (82.7% [4550/5502]), and ≥65 years of age (88.1% [4848/5502]). Annually, 40% of the sample filled prescriptions for COPD maintenance medications. In multivariate models, maintenance drug users were less likely than nonusers to be hospitalized (odds ratio [OR] = 0.70; 95% CI, 0.61 to 0.79) or rehospitalized (OR= 0.74; 95% CI, 0.63 to 0.87), and had significantly lower annual Medicare expenditures (-