JAMA Health Forum最新文献

Importance: Medicare Advantage (MA) plans are designed to incentivize the use of less expensive drugs through capitated payments, formulary control, and preauthorizations for certain drugs. These conditions may reduce spending on high-cost therapies for conditions such as cancer, a condition that is among the most expensive to treat.

Objective: To determine whether patients insured by MA plans receive less high-cost drugs than those insured by traditional Medicare (TM).

Design, setting, and participants: This cohort study used data from the linked Colorado All Payer Claims Database and Colorado Central Cancer Registry. This population-based cohort included adults 65 years and older insured by Medicare with prescription coverage who reside in Colorado and were diagnosed with colorectal (CRC) or non-small cell lung cancer (NSCLC) between January 2012 and December 2021. The data were analyzed between December 2023 and August 2024.

Exposure: Enrollment in TM or MA insurance plans.

Main outcomes and measures: Claims for chemotherapy and oral targeted agents were identified. Thresholds for high-cost drugs were based on the distribution of drug costs. Inverse probability weighted logistic regression for receiving any cancer drug and for receiving a high-cost cancer drug was estimated, controlling for patient and ecological characteristics. The sample was stratified by cancer site and local/regional and distant stage.

Results: Of 4240 patients included in the analysis (mean [SD] age, 75 [7] years; 2327 [54.9%] female), 1991 were diagnosed with CRC and 2249 with NSCLC. A total of 1647 patients had local or regional CRC, and 344 had distant CRC; 1351 patients had local or regional NSCLC, and 898 had distant NSCLC. In the covariate-adjusted analysis, patients diagnosed with local or regional CRC who were insured by MA were 6.0 percentage points less likely to receive a cancer drug than similar patients insured by TM. Patients diagnosed with distant NSCLC were 10.0 percentage points less likely to receive a cancer drug if insured by MA. Among patients who received a cancer drug, patients insured by MA were less likely to receive a high-cost drug for local or regional CRC (by 10.0 percentage points) and distant CRC (by 9.0 percentage points).

Conclusions and relevance: In this cohort study, high-cost drugs were more commonly prescribed among patients enrolled in TM and diagnosed with CRC. A similar pattern was not observed for patients with NSCLC, perhaps because clinical evidence suggests survival benefits to be associated only with certain drugs, all of which are expensive. Nonetheless, MA was modestly associated with reduced high-cost drug utilization and may reduce overall treatment costs.

Importance: The prevalence of pharmacies owned by integrated insurers and pharmacy benefit managers (PBMs), or insurer-PBMs, is of growing regulatory concern. However, little is known about the role of these pharmacies in Medicare, in which pharmacy network protections may influence market dynamics.

Objective: To evaluate the prevalence of insurer-PBM-owned pharmacies and the extent to which insurer-PBMs steer patients to pharmacies they own in Medicare.

Design, setting, and participants: This cross-sectional study used Medicare Part D claims data on prescription fills for a 20% random sample of US beneficiaries enrolled from January 1 through December 31, 2021. Data were analyzed from March to November 2024.

Exposures: Prescription fills.

Main outcomes and measures: The main outcome was the share of spending filled by insurer-PBM-owned pharmacies overall, by pharmacy type (specialty and nonspecialty), and by drug class. For the top 100 specialty and nonspecialty molecules by claim volume, 2 quantities were identified for 4 major insurer-PBMs (Cigna, CVS, Humana, and UnitedHealth Group): share of the index firm's insurer claims filled by its owned pharmacies and share of other firms' insurer claims filled by the index firm's owned pharmacies. Differences between these quantities were assessed to evaluate the degree to which insurer-PBMs steered patients to their own pharmacies.

Results: Among 10 455 726 patients (54.8% women; mean [SD] age, 71.8 [10.7] years), 34.1% of all pharmacy and 37.1% of specialty pharmacy spending occurred through Cigna, CVS, Humana, or UnitedHealth Group pharmacies. Among specialty molecules, market shares varied by drug class (antivirals: 18.5%; antipsychotics: 29.5%; cancer: 32.5%; disease-modifying antirheumatic drugs: 41.1%; multiple sclerosis: 64.8%; pulmonary arterial hypertension and idiopathic pulmonary fibrosis: 89.7%). Across molecule-firm combinations, a 19.8 (95% CI, 18.0-21.6)-percentage point and 13.9 (95% CI, 13.1-14.7)-percentage point greater share of claims were filled at insurer-PBM-owned pharmacies than would be expected without steering for specialty and nonspecialty categories, respectively.

Conclusions and relevance: This cross-sectional study found that insurer-PBM firms represented an important portion of the Medicare Part D market, especially for certain drug classes, and that insurer-PBM firms steered patients to their own pharmacies, despite certain pharmacy network protections in Medicare. These findings underscore the need to understand the impacts of insurer-PBM and pharmacy integration on medication access and costs for Medicare patients.

Importance: Consolidation of physician practices by hospitals and private equity (PE) firms has increased rapidly. This trend is of particular importance within primary care. Despite its significance, there is no systematic evidence on the emerging trends in ownership affiliation of primary care physicians (PCPs) and its association with prices paid for physician services.

Objective: To describe trends in hospital affiliation and PE affiliation in primary care and examine variation in negotiated prices paid by commercial insurers to hospital-affiliated, PE-affiliated, and independent PCPs.

Design, setting, and participants: Data from PitchBook and IQVIA were used to examine hospital and PE affiliation PCPs. PCPs and their affiliations were linked to novel cross-sectional Transparency in Coverage data. A total of 226.6 million negotiated prices were analyzed for evaluation and management office visits (Current Procedural Terminology codes 99202 to 99205 and 99212 to 99215) across 4 national insurers (Aetna, Blue Cross Blue Shield, Cigna, and United Healthcare). Linear regressions were used to examine the association between hospital-affiliated, PE-affiliated, and independent PCPs and cross-sectional prices paid for physician services, with fixed effects for service, state, and insurers. Data were collected from January to June 2024, and data were analyzed from July to October 2024.

Main outcomes and measures: The proportion of PCPs that are affiliated with hospitals and PE from 2009 to 2022. Using cross-sectional data from 2022, negotiated prices paid to physicians (physician professional fee) for office visits.

Results: A total of 198 097 PCPs were analyzed. PCPs affiliated with hospitals increased from 25.2% (28 216 of 111 793) in 2009 to 47.9% in 2022 (82 890 of 172 964). Over the same period, 1.5% (2483 of 172 964) of PCPs became affiliated with PE firms. Relative to independent PCPs, negotiated prices for office visits were $14.91 (95% CI, 8.92-27.64) or 10.7% (95% CI, 10.1-11.4) higher for hospital-affiliated PCPs (P < .001) and $9.56 (95% CI, 2.24-14.55) or 7.8% (95% CI, 4.7-10.8) higher for PE-affiliated PCPs (P < .001).

Conclusions and relevance: In this cross-sectional study, nearly one-half of all PCPs were affiliated with hospitals, while PE-affiliated PCPs were growing and concentrated in certain regional markets. Relative to PCPs in independent settings, hospital-affiliated PCPs and PE-affiliated PCPs had higher prices for the same services.

Importance: Dual-eligible older adults rely on Medicaid to pay for Medicare premiums and cost sharing in addition to supplemental services including dental and long-term care. However, the unique experiences of dual-eligible older adults with Medicaid unwinding remain unknown.

Objective: To assess the awareness and experiences of dual-eligible older adults with Medicaid redetermination.

Design, setting, and participants: A cross-sectional national survey of community-dwelling US adults aged 65 years or older with incomes less than or equal to 100% of the federal poverty level, via internet and telephone, was conducted from January 23 through February 19, 2024. Participants were recruited from NORC probability-based and 2 additional national nonprobability panels.

Main outcomes and measures: Weighted percentage values for respondent awareness of Medicaid redeterminations, experiences navigating reenrollment, and cost-related barriers to accessing care.

Results: Of 843 respondents, most were female (62.9%), aged 65 to 74 years (62.3%), and had completed up to high school education (72.3%). Overall, 16.1% (95% CI, 12.4%-19.9%) had heard a lot and 34.6% (95% CI, 28.9%-40.4%) a little about states returning to Medicaid renewals; 49.0% (95% CI, 43.0%-55.0%) heard nothing at all. A total of 45.1% completed a Medicaid renewal, 37.0% did not complete a renewal, and 17.7% did not know about renewal requirements. A total of 87.7% maintained Medicaid, 5.9% lost Medicaid but got it back, and 5.5% lost Medicaid and did not get it back. In the last 6 months, 7.7% reported delaying or forgoing care due to cost. Delayed or forgone care was more common among those who lost Medicaid and did not get it back (18.4%) and those who lost Medicaid but got it back (30.6%) compared with those who maintained Medicaid (5.5%). Cost-related barriers were more common for dental (25.1%) and home health services (18.5%), which are frequently covered by Medicaid.

Conclusions and relevance: The findings highlight a need to address informational gaps and navigational barriers related to Medicaid unwinding among older adults with dual eligibility for Medicare and Medicaid. Addressing these gaps may help to avoid Medicaid losses that contribute to difficulties accessing care.