Benefits and Cost of a $35 Insulin Cost-Sharing Cap for Medicare Patients

BACKGROUND: To improve insulin affordability, Congress is considering capping insulin cost-sharing to $35 per 30-day supply for Medicare patients. The potential benefits and cost of this cap are unclear. Additionally, it is unknown whether the benefits of this cap would vary between Medicare patients with type 1 versus type 2 diabetes. METHODS: We conducted a cross-sectional analysis of the IQVIA Longitudinal Prescription Database, which reports prescriptions dispensed from 92% of U.S. pharmacies, and the Optum Clinformatics Data Mart, a national claims database from Medicare Advantage patients. The IQVIA analysis included patients who only had dispensed insulin prescriptions paid by Medicare in 2019. We estimated the proportion of Medicare patients who would benefit from an insulin cost-sharing cap of $35 per 30-day supply. Among these patients, we calculated the mean annual decrease in insulin out-of-pocket spending. We summed this decrease across patients to estimate the cap's cost to the federal government. The Optum analysis included Medicare Advantage patients with diabetes and at least 1 dispensed insulin prescription in 2019. We used linear regression to compare the proportion of patients who would benefit from a $35 cap and annual savings among these patients by diabetes type, adjusting for demographic characteristics and payer type. RESULTS: The IQVIA analysis included 2,227,229 patients who only had dispensed insulin prescriptions paid by Medicare in 2019. Mean (SD) age was 69.2 (11.4) years. The $35 cap would benefit 887,051 (39.0%) of patients, lowering annual insulin out-of-pocket spending by $338, from $687 to $349. Across all patients in the sample, aggregate savings (i.e., the cap's cost to the federal government) would be $299,402,402, or a mean of $134.4 per patient. Among the 60,300 Medicare Advantage patients in the Optum Analysis, mean age was 72.6 (9.3) years; 2,686 (4.5%) had type 1 diabetes and 57,614 (95.6%) had type 2 diabetes. The $35 cap would benefit a higher proportion of patients with type 1 diabetes (64.0%) compared with patients with type 2 diabetes (59.4%). Among patients with type 1 diabetes who would benefit from the cap, annual savings would be greater ($284) compared with their counterparts with type 2 diabetes ($231; p<.001 in adjusted analyses for all comparisons). CONCLUSIONS: A $35 insulin cost-sharing cap would benefit a sizable proportion of Medicare patients using insulin and may particularly lower out-of-pocket spending for patients with type 1 diabetes. The estimated cost of this cap to the federal government would be $134.4 per Medicare patient using insulin.

Association Between Infection Control Resource Use and the Number of Penalties Under Medicare’s Hospital-Acquired Condition Reduction Program

Background: The Hospital-Acquired Condition Reduction Program (HACRP) is a pay-for-performance Medicare program that promotes reducing patient harm, particularly healthcare-associated infections (HAIs). We examined the association between infection-control–related activities and the number of penalties a hospital received between fiscal years 2015 and 2018. Methods: We used logistic regression with ordered categories to assess infection control resource use and the number of penalties, an ordered categorical dependent variable with 5 categories ranging from 0 to 4, as of 2018. Data sources included National Healthcare Safety Network, American Hospital Association Annual Survey, Medicare Impact and Cost Report files, and Data.Medicare.gov. We excluded hospitals lacking data to calculate any HACRP score or component score for HAI and hospitals missing observations for model variables (301 hospitals). We assessed the following model variables: teaching hospital status, infection preventionists (IP) per 1,000 beds, surveillance hours per week per bed, other infection control activities per week per bed, nurse-to-bed ratio, housekeeping expenditure per 10,000 beds, nursing position vacancies per bed, bed size, electronic health record (EHR) implementation, number of skilled nursing beds, rural or urban location, and Medicare patient case-mix (cmi_quartiles). Results: In our model, negative logit model point estimates indicated that increased values of the variable are associated with a lower odds of having a higher number of penalties. The final data set consisted of 3,004 US hospitals. Lower penalties were significantly associated with higher IP-to-bed ratio. Although the point estimates were <1, an association between lower penalties and higher nurse-to-bed ratios or electronic health records was not demonstrated (Table 1). Conclusions: Our results suggest that after controlling for selected hospital structural factors, incremental resources related to infection control have a protective association with HCARP penalties.Funding: NoneDisclosures: None

Gender Homophily in Referral Networks: Consequences for the Medicare Physician Earnings Gap

I assess the extent to which the gender gap in physician earnings may be driven by physicians’ preference for referring to specialists of the same gender. Analyzing administrative data on 100 million Medicare patient referrals, I provide robust evidence that doctors refer more to specialists of their own gender. I show that biased referrals are predominantly driven by physicians’ decisions rather than by endogenous sorting of physicians or patients. Because most referring doctors are male, the net impact of same-gender bias by both male and female doctors generates lower demand for female relative to male specialists, pointing to a positive externality for increased female participation in medicine. (JEL H51, I11, J16, J31, J44)

2009-2017 RACIAL AND ETHNIC DISPARITIES IN MEDICARE PATIENT EXPERIENCE AND INFLUENZA IMMUNIZATION

We sought to understand the extent to which racial and ethnic disparities in the immunization rates and case-mix adjusted patient experiences of access (getting needed care and getting care quickly) of Black, Hispanic, and non-Hispanic White Medicare beneficiaries have changed over time. Accordingly, we analyzed 2009-2017 CAHPS data from 2,725,614 Medicare beneficiaries. In 2009, flu immunization rates for Black and Hispanic beneficiaries were lower than non-Hispanic White beneficiaries by 17 and 14 percentage points, respectively. Over 9 years, these gaps were reduced to 12 and 8 points, respectively (p&lt;.01 for all comparisons). In 2009, Black beneficiaries had 2-point and 5-point disparities on getting needed care and getting care quickly (on a 0-100 scale) respectively, relative to non-Hispanic Whites. For getting needed care, there was no significant change over time in the gap between Blacks and non-Hispanic Whites. For getting care quickly, the gap between Blacks and non-Hispanic Whites narrowed to 3 points in 2017. In 2009, Hispanic beneficiaries had 2-point and 5-point disparities on getting needed care and getting care quickly, respectively, compared to non-Hispanic Whites. The gap on getting needed care widened by 1 point to a 2017 disparity of 3 points. For getting care quickly, there was no significant change over time in the gap between Hispanics and non-Hispanic Whites. These findings suggest that flu immunization rates for Black and Hispanic Medicare beneficiaries have improved significantly relative to non-Hispanic Whites; however, substantial disparities remain. For the patient experience measures, the findings are more mixed.

The impact of depression in cancer patients on healthcare utilization.

243 Background: The Oncology Care Model (OCM) has set several initiatives to improve payment and care delivery in the Medicare patient population, including screening for depression in cancer patients. We evaluated the prevalence of depression in OCM patients and the relationship between depression and healthcare utilization. Methods: This cross-sectional study used patient-reported outcome (PRO) surveys administered in the outpatient setting as part of OCM at the University of Alabama at Birmingham (UAB). Depression scores and Eastern Cooperative Oncology Group performance status were obtained from PRO surveys. Moderate to severe depression was defined as a score ≥10 on the Patient Health Questionnaire 2/9 (PHQ-2/9). Sex, marital status, phase of care, race, disease aggressiveness (stage, progression, cancer type), number of emergency department (ED) visits and inpatient admissions within a 3-month period from survey completion were abstracted from the electronic health record. The relationship between depression and hospital visits was assessed using rate ratios and 95% confidence limits from Poisson regression models adjusting for clinical and demographic characteristics. Results: Of 856 patients surveyed, 68% of patients were female, and 27% of patients were non-Caucasian. Notably, almost 14% of patients had moderate to severe depression (PHQ-2/9≥10). The cancer-specific prevalence of at least moderate depression was 2% in breast, 1% in gastrointestinal, 2% in genitourinary, 5% in gynecologic, and 2% in hematologic cancers. In adjusted models, the inpatient admission and ED visit rate in the 3 months following PRO survey completion did not differ by depression category (RR: 1.22; CI: 0.93-1.61). Conclusions: Over 13% of cancer patients report clinically significant depression during routine screening, which highlights the continued need for outpatient counseling and behavioral services. Although rates of inpatient admissions and ED visits were not impacted by the presence of depression, further analysis is needed to evaluate the impact of treating depression on healthcare utilization over time.