Decreased antihyperglycemic drug use driven by high out-of-pocket costs despite Medicare coverage gap closure

<a>Objectives</a>: <a>Using the 2016 Medicare part D coverage gap as an example, we explored effects of increased out-of-pocket costs on adherence to branded </a>dipeptidyl peptidase-4 inhibitors (DPP-4i) in patients without financial subsidies, relative to subsidized patients who do not experience increased spending during the gap. We also explored seasonality of re-initiation, as discontinuers may be more likely to reinitiate in January when benefits reset. Methods: DPP-4i or sulfonylureas initiators, aged >66 years, from a 20% sample of 2015-2016 Medicare claims were identified. We used difference-in-differences Poisson regression to compare adherence before and after entering the coverage gap between non-subsidized and subsidized patients. Among discontinuers, monthly hazard ratios (HRs) for re-initiation relative to January 2016 were derived with Cox models. As a second control, we repeated analyses using sulfonylureas, generic low-cost alternatives. Results: In 2016, 8,096 subsidized and 6,173 non-subsidized DPP-4i initiators entered the coverage gap. Non-subsidized patients, copayment in the coverage gap was 45% ($227 per DPP-4i prescription), and adherence decreased from 68.4% to 49.0% after gap entry. Accounting for adherence differences in subsidized patients, non-subsidized patients demonstrated reduced adherence to DPP-4is [Difference-in-difference:-16.9%;CI(-18.7%,-15.1%)] but not sulfonylureas [-1.6%(-3.4%,0.2%)]. Re-initiation was lowest in the months before January (HR=0.4-0.5) among non-subsidized DPP-4i patients, demonstrating a strong seasonal pattern. Conclusions: Increased out-of-pocket costs negatively affect adherence and re-initiation of branded antihyperglycemic drugs among patients without financial subsidies. Despite closure of the coverage gap, affordability remains a concern given increasing list prices for many drugs on Medicare and the growing use of deductibles and coinsurance by commercial health plans.

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Decreased antihyperglycemic drug use driven by high out-of-pocket costs despite Medicare coverage gap closure

10.2337/figshare.12453773.v1 ◽

2020 ◽

Author(s):

Mugdha Gokhale ◽

Stacie B. Dusetzina ◽

Virginia Pate ◽

Danielle S Chun ◽

John B. Buse ◽

...

Keyword(s):

Low Cost ◽

Seasonal Pattern ◽

Cox Models ◽

Part D ◽

Dipeptidyl Peptidase 4 ◽

Coverage Gap ◽

Hazard Ratios ◽

Dipeptidyl Peptidase 4 Inhibitors ◽

Before And After ◽

Out Of Pocket Costs

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Work disability patterns before and after incident acute myocardial infarction and subsequent risk of common mental disorders: A Swedish cohort study

Scientific Reports ◽

10.1038/s41598-019-52487-w ◽

2019 ◽

Vol 9 (1) ◽

Author(s):

K. Bokenberger ◽

S. Rahman ◽

M. Wang ◽

M. Vaez ◽

T. E. Dorner ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Mental Disorders ◽

Work Disability ◽

Common Mental Disorders ◽

Depression And Anxiety ◽

Cox Models ◽

Hazard Ratios ◽

Antidepressant Prescription ◽

Before And After

Abstract This study investigated the extent to which work disability patterns including sickness absence and disability pension (SA/DP) before and after acute myocardial infarction (AMI) were associated with subsequent common mental disorders (CMDs) such as depression and anxiety in AMI patients without previous CMD. Total 11,493 patients 26–64 years with incident AMI during 2008–10 were followed up for CMD (measured as antidepressant prescription) through 2013. Four SA/DP trajectory groups during the 3-years pre-AMI and 1-year post-AMI were identified. Hazard ratios (HRs) with 95% confidence intervals for subsequent CMD were estimated in Cox models. Higher pre-AMI SA/DP annual levels (>1–12 months/year) were associated with 40–60% increased CMD rate than the majority (78%) with low increasing levels (increasing up to 1 month/year). Regarding post-AMI findings, constant high (~25–30 days/month) SA/DP levels within the first 3 months was associated with a 76% higher CMD rate, compared to constant low (0 days/month). A gradually decreasing post-AMI SA/DP pattern over a 12-month period suggested protective influences for CMD (HR = 0.80). This is the first study to demonstrate that pre- and post-AMI work disability patterns are associated with subsequent CMD risk in AMI patients. Work disability patterns should be considered as an indicator of AMI prognosis in terms of CMD risk.

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Dipeptidyl Peptidase-4 Inhibitors as a Third-Line Oral Antihyperglycaemic Agent in Patients with Type 2 Diabetes Mellitus: The Impact of Ethnicity

International Journal of Endocrinology ◽

10.1155/2014/354040 ◽

2014 ◽

Vol 2014 ◽

pp. 1-5

Author(s):

X. Zhang ◽

B. Brooks ◽

L. Molyneaux ◽

E. Landy ◽

R. Banatwalla ◽

...

Keyword(s):

Type 2 Diabetes ◽

Dipeptidyl Peptidase ◽

Dipeptidyl Peptidase 4 ◽

Asian Patients ◽

Dipeptidyl Peptidase 4 Inhibitors ◽

Before And After ◽

Third Line ◽

And Gender ◽

The Impact

Aims. The aim of this study is to examine the efficacy of adding a dipeptidyl peptidase-4 (DPP-4) inhibitor to patients with type 2 diabetes inadequately controlled by metformin and sulphonylurea combination treatment. The response of Asian and non-Asian patients to this regimen was also examined.Methods. The medical and computerized records of 80 patients were examined. These patients had baseline HbA1c levels ranging from 7.0 to 12.5% and had a DPP-4 inhibitor add-on therapy for a minimum period of 12 weeks. The primary endpoint was the change in HbA1c level before and after DPP-4 inhibitor treatment.Results. During oral triple therapy, there was a reduction of HbA1c from 8.3% (7.7–8.9) to 7.2% (6.8–7.6) and 26 patients (32.5%) achieved an HbA1c <7%. Poor baseline glycaemic control, lower BMI, and younger age were associated with a better response, but duration of diabetes and gender did not affect outcome. The HbA1c reduction was not different between Asians and non-Asians group [−1.00% (0.6–1.3) vs −0.90% (0.4–1.6)].Conclusions. DPP-4 inhibitor as a third-line add-on therapy can achieve significant glycaemic improvement in patients with type 2 diabetes inadequately controlled on the combination of metformin and sulphonylurea. The improvement in HbA1c was similar between Asian and non-Asian patients.

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Closing the part D coverage gap and out-of-pocket costs for multiple sclerosis drugs

Neurology Clinical Practice ◽

10.1212/cpj.0000000000000929 ◽

2020 ◽

pp. 10.1212/CPJ.0000000000000929

Author(s):

Daniel M Hartung ◽

Kirbee Johnston ◽

Dennis Bourdette ◽

Randi Chen ◽

Chien-Wen Tseng

Keyword(s):

Multiple Sclerosis ◽

Price Increase ◽

Drug Benefit ◽

Part D ◽

Benefit Design ◽

Coverage Gap ◽

Donut Hole ◽

Calculated Average ◽

Out Of Pocket Costs ◽

List Prices

ABSTRACTObjective:To determine whether closing the Part D coverage gap (“donut hole”) between 2010 and 2019 lowered patients’ out-of-pocket costs for disease-modifying therapies (DMTs) for multiple sclerosis (MS).Methods:Using nationwide Medicare Formulary and Drug Pricing Files, we analyzed Part D drug benefit design and DMT prices in 2010, 2016, and 2019. We calculated average monthly list prices for DMTs available in each year (4 DMTs in 2010, 11 DMTs in 2016, and 14 DMTs in 2019). We projected patients’ annual out-of-pocket cost for each DMT alone under a standard Part D plan in that year. We estimated potential savings attributable to closing the coverage gap between 2010 to 2019 (beneficiaries’ cost-sharing dropped from 100% to 25%) under three scenarios; no increase in price, an inflation-indexed price increase (3% annually), and the observed price increase.Results:Median monthly DMT prices rose from $2804, $5987, to $7009 over the years 2010, 2016, and 2019 respectively. Median projected annual out-of-pocket costs rose from $5916, $6229, to $6618. With unchanged or inflation-indexed DMT prices changes, closing the coverage gap would have reduced annual out-of-pocket costs by $2260 (38% reduction) and $1744 (29% reduction) respectively. Despite having the lowest monthly price, generic glatiramer acetate had among the highest out-of-pocket costs ($6731 to $6939 a year) in 2019.Conclusions:Medicare Part D beneficiaries can pay thousands of dollars yearly out-of-pocket for DMTs. Closing the Part D coverage gap did not reduce out-of-pocket costs for patients because of simultaneous increases in DMT prices.

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Diabetes by Air, Land, and Sea: Effect of Deployments on HbA1c and BMI

Military Medicine ◽

10.1093/milmed/usz311 ◽

2019 ◽

Vol 185 (3-4) ◽

pp. 486-492

Author(s):

Irene Folaron ◽

Mark W True ◽

William H Kazanis ◽

Jana L Wardian ◽

Joshua M Tate ◽

...

Keyword(s):

Military Service ◽

Medical Condition ◽

Armed Forces ◽

The United States ◽

Chronic Medical Condition ◽

Future Research ◽

Military Health ◽

Dipeptidyl Peptidase 4 ◽

Dipeptidyl Peptidase 4 Inhibitors ◽

Before And After

Abstract Introduction Service members (SMs) in the United States (U.S.) Armed Forces have diabetes mellitus at a rate of 2–3%. Despite having a chronic medical condition, they have deployed to environments with limited medical support. Given the scarcity of data describing how they fare in these settings, we conducted a retrospective study analyzing the changes in glycated hemoglobin (HbA1c) and body mass index (BMI) before and after deployment. Materials and Methods SMs from the U.S. Army, Air Force, Navy, and Marine Corps with diabetes who deployed overseas were identified through the Military Health System (MHS) Management Analysis and Reporting Tool and the Defense Manpower Data Center. Laboratory and pharmaceutical data were obtained from the MHS Composite Health Care System and the Pharmacy Data Transaction Service, respectively. Paired t-tests were conducted to calculate changes in HbA1c and BMI before and after deployment. Results SMs with diabetes completed 11,325 deployments of greater than 90 days from 2005 to 2017. Of these, 474 (4.2%) SMs had both HbA1c and BMI measurements within 90 days prior to departure and within 90 days of return. Most (84.2%) required diabetes medications: metformin in 67.3%, sulfonylureas in 19.0%, dipeptidyl peptidase-4 inhibitors in 13.9%, and insulin in 5.5%. Most SMs deployed with an HbA1c < 7.0% (67.1%), with a mean predeployment HbA1c of 6.8%. Twenty percent deployed with an HbA1c between 7.0 and 7.9%, 7.2% deployed with an HbA1c between 8.0 and 8.9%, and 5.7% deployed with an HbA1c of 9.0% or higher. In the overall population and within each military service, there was no significant change in HbA1c before and after deployment. However, those with predeployment HbA1c < 7.0% experienced a rise in HbA1c from 6.2 to 6.5% (P < 0.001), whereas those with predeployment HbA1c values ≥7.0% experienced a decline from 8.0 to 7.5% (P < 0.001). Those who deployed between 91 and 135 days had a decline in HbA1c from 7.1 to 6.7% (P = 0.010), but no significant changes were demonstrated in those with longer deployment durations. BMI declined from 29.6 to 29.3 kg/m2 (P < 0.001), with other significant changes seen among those in the Army, Navy, and deployment durations up to 315 days. Conclusions Most SMs had an HbA1c < 7.0%, suggesting that military providers appropriately selected well-managed SMs for deployment. HbA1c did not seem to deteriorate during deployment, but they also did not improve despite a reduction in BMI. Concerning trends included the deployment of some SMs with much higher HbA1c, utilization of medications with adverse safety profiles, and the lack of HbA1c and BMI evaluation proximal to deployment departures and returns. However, for SMs meeting adequate glycemic targets, we demonstrated that HbA1c remained stable, supporting the notion that some SMs may safely deploy with diabetes. Improvement in BMI may compensate for factors promoting hyperglycemia in a deployed setting, such as changes in diet and medication availability. Future research should analyze in a prospective fashion, where a more complete array of diabetes and readiness-related measures to comprehensively evaluate the safety of deploying SMs with diabetes.

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Work disability before and after incident myocardial infarction and subsequent common mental disorder

European Journal of Public Health ◽

10.1093/eurpub/ckz187.111 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

K Bokenberger ◽

S Rahman ◽

M Wang ◽

M Vaez ◽

T E Dorner ◽

...

Keyword(s):

Myocardial Infarction ◽

Sickness Absence ◽

Work Disability ◽

Disability Pension ◽

Common Mental Disorders ◽

Common Mental Disorder ◽

Cox Models ◽

Hazard Ratios ◽

Antidepressant Prescription ◽

Before And After

Abstract Background This study investigated the extent to which work-disability patterns including sickness absence and disability pension (SA/DP) before and after acute myocardial infarction (AMI) were associated with subsequent common mental disorders (CMDs) such as depression and anxiety in AMI patients without previous CMD. Methods A cohort of 11,493 patients aged 26-64 years without previous CMD with incident AMI during 2008-2010 were followed up for CMD measured as antidepressant prescription through 2013. Four SA/DP trajectory groups during the 3 years pre-AMI and 1 year post-AMI were identified. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated in Cox models. Results Higher pre-AMI SA/DP levels (>1-12 months/year), compared to the majority of patients (78%) following low increasing annual levels (increasing up to 1 month/year) of pre-AMI SA/DP, were associated with a 40-60% increased CMD rate. Regarding post-AMI findings, constant high (∼25-30 days/month) and steeply decreasing SA/DP levels within the first 3 months were associated with a 76% and 35% higher CMD rate, respectively, compared to constant low (<1 days/month) levels. Conversely, a gradually decreasing pattern of post-AMI SA/DP over a 12-month period suggested protective influences for CMD (HR = 0.80), even after adjusting for sociodemographic and medical factors. Conclusions This is the first study to demonstrate that pre- and post-AMI work disability patterns are associated with subsequent CMD risk in AMI patients. Work disability patterns should be considered in clinical practice as an indicator of AMI prognosis in terms of CMD risk. Key messages Increasing and high persistent levels of pre-AMI work disability are associated with higher risk of subsequent CMD, while gradually decreasing post-AMI work disability has a favourable CMD prognosis. Pre- and post-AMI patterns of work disability (sickness absence and disability pension) can be a useful marker in terms of CMD prognosis.

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Abstract MP27: Weight Change, BMI, and Mortality Among Survivors of Myocardial Infarction: Analysis of Two Prospective US Cohort Studies

Circulation ◽

10.1161/circ.137.suppl_1.mp27 ◽

2018 ◽

Vol 137 (suppl_1) ◽

Author(s):

Laila Al-Shaar ◽

Yanping Li ◽

Eric Rimm ◽

JoAnn E Manson ◽

Frank Hu ◽

...

Keyword(s):

Myocardial Infarction ◽

Weight Change ◽

Normal Weight ◽

Health Study ◽

Obese Patients ◽

Cox Models ◽

Hazard Ratios ◽

Before And After ◽

Cvd Mortality

Background: The relation between BMI, weight change and mortality among survivors of Myocardial Infarction (MI) remains controversial, with some studies reporting favorable survival outcomes among overweight and obese patients, as compared to those with normal weight. We aim to examine the relationship between BMI reported shortly before and after MI diagnosis in addition to weight change with all-cause and cardiovascular disease (CVD) mortality among MI survivors. Methods: Using the data from Nurses’ Health Study (NHS) and Health Professionals Follow up Study (HPFS) cohorts, we studied 4278 participants who were free of CVD and cancer before their MI. Weight change (in BMI units) was categorized as loss of (> 4, 2-4, <2-0 (reference)), or gain of (0.1-2, or >2) units. Multivariable Cox models were used to estimate hazard ratios and 95 % confidence interval for mortality across BMI/weight change categories. Results: During up to 36 (NHS) and 28 (HPFS) years of follow-up post-MI, there were 2071 all-cause and 835 CVD deaths. Overweight patients with BMI before or after MI of 25-27.49 kg/m 2 had decreased mortality as compared to normal weight patients (22.5-24.9 kg/m 2 ). All-cause mortality increased progressively with higher BMI. Obese patients (BMI≥30) had the highest risk of CVD mortality (HR=1.35; 95% CI, 1.06-1.73). Among MI patients who had never smoked (N=1484) or were younger than 65 years of age at the time of diagnosis (N=1873), no survival advantage was observed for overweight/obese patients. Compared to stable weight (a BMI reduction of 0-1.99 units) from before to after MI, a reduction of 2-4 or >4 BMI units was associated with increased mortality (HR=1.12; 95% CI, 0.96-1.29 and 1.42; 95% CI, 1.17-1.71 respectively, Figure). Conclusions: We observed a J-shaped association between BMI and mortality among all MI patients, but not among those who had never smoked or were younger than 65 years of age. Weight loss associated with acute MI, potentially related to disease severity, is an important predictor of higher mortality.

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