Private insurance and the utilization of chemical dependency treatment

This study examines how different types of health coverage influence the likelihood of entering treatment for an alcohol problem, and the extent that people in treatment are able to use their insurance to help cover the costs of care. Survey data are analyzed from a sample of problem drinkers drawn from the general population and chemical dependency treatment programs in the same community. We find that, in comparison to being on Medicaid and being uninsured, having private coverage does not significantly alter the odds of treatment entry. Being in a private managed care plan, as compared to traditional indemnity coverage, also does not appear to impact the chances of treatment entry. However, having private coverage, as compared to being on Medicare, doubles the odds of treatment entry. For problem drinkers who obtain treatment, those with private coverage are as or more likely than other insured groups to report that insurance helped to pay treatment expenses. Even so, 10% of those privately insured report having paid for all of their treatment costs out of pocket. We conclude that, while prior studies have rarely found that having insurance significantly impacts alcohol treatment entry, the type of coverage one possesses may matter in some cases. Our results concerning Medicare coverage may point to potential problems with making treatment affordable to some problem drinkers outside the private insurance system.     

The burden of hepatorenal syndrome among commercially insured and Medicare patients in the United States

Background: This study evaluated the characteristics, healthcare resource utilization (HCRU), and costs, from the payer perspective, of hepatorenal syndrome (HRS) patients covered by commercial and Medicare insurance. Mortality was assessed as a secondary outcome.

Methods: Patients were identified from claims databases of commercially insured patients (OptumHealth Care Solutions Inc.) in 1998–2014 and Medicare beneficiaries in 2009–2013 (5% Standard Analytic Files). At the time of their first inpatient admission (“index date”) with an HRS diagnosis (ICD-9 code 572.4), commercially insured patients must be aged 18–64 and Medicare patients must be aged 65 and older.

Results: A total of 784 commercially insured and 1061 Medicare HRS patients met the sample selection criteria. Patients were disproportionately male (commercial: 63.0%; Medicare: 57.9%) with a mean age of 54.1 among commercially insured and 74.1 among Medicare patients. Within the first 30 days, the average hospital length of stay (LOS) was 12.3 days among commercially insured and 10.8 days among Medicare patients. Based on Kaplan–Meier analyses, 36% of commercially insured and 26% of Medicare patients were readmitted within the next 30 days. During follow-up, many patients received dialysis (commercial: 33.0%; Medicare: 22.1%) or liver transplant (commercial: 10.7%; Medicare: 1.6%). Average costs within the 90?day follow-up were $157,665 for commercially insured and $48,322 for Medicare patients, with 68.3% and 78.3% of the costs incurred within the first 30 days. The primary cost driver was inpatient visits (commercial: 90.3% of costs; Medicare: 83.1% of costs), with differences between the populations consistent with lower mortality, higher dialysis rates, and higher transplant rates (both liver and kidney) among the commercially insured. Using US population and prevalence statistics, these results suggest that HRS imposes an annual total direct medical cost burden of approximately $3.0–$3.8 billion to payers over the period.

Conclusions: HRS imposes a significant economic burden.     

The association between insurance status and diagnostic imaging for acute abdominal pain among emergency department patients in the United States, 2005–2014

Introduction and objectives: Acute abdominal pain (AAP) is one of the most common complaints in the emergency department (ED). Rapid diagnosis is essential and is often achieved through imaging. Computed tomography (CT) is widely considered an exemplary test in the diagnosis of AAP in adult patients. As previous studies show disparities in healthcare treatment based on insurance status, our objective was to assess the association between insurance status and frequency of CT ordered for adult patients presenting to the ED with AAP from 2005 to 2014.

Methods: This study used the National Hospital and Ambulatory Medical Care Survey: Emergency Department Record (NHAMCS) database, which collects data over a randomly assigned 4 week period in the 50 states and DC, to perform an observational retrospective analysis of patients presenting to the ED with AAP. Patients with Medicaid, Medicare or no insurance were compared to patients with private insurance. The association between insurance status and frequency of CT ordered was measured by obtaining odds ratios along with 95% CIs adjusted for age, gender and race/ethnicity.

Results: Individuals receiving Medicaid are 20% less likely to receive CT than those with private insurance (OR 0.8, CI 0.6–0.99, p?=?.046). Those on Medicare or who are uninsured have no difference in odds of obtaining a CT scan compared to patients with private insurance. Additional findings are that black patients are 42% less likely to receive a CT scan than white patients.

Conclusions and implications: Patients on Medicaid are significantly less likely to receive a CT when presenting to the ED with AAP. Differences in diagnostic care may correlate to inferior health outcomes in patients without private insurance.     

Docetaxel chemotherapy in metastatic castration-resistant prostate cancer: cost of care in Medicare and commercial populations

Objective: To estimate the healthcare costs and characteristics of docetaxel chemotherapy episodes of care for men with metastatic castration-resistant prostate cancer (mCRPC).

Methods: This study used the Medicare 5% sample and MarketScan Commercial (2010–2013) claims data sets to identify men with mCRPC and initial episodes of docetaxel treatment. Docetaxel episodes included docetaxel claim costs from the first claim until 30 days after the last claim, with earlier termination for death, insurance disenrollment, or the end of a 24-month look-forward period from initial docetaxel index date. Docetaxel drug claim costs were adjusted for 2011 generic docetaxel introduction, while other costs were adjusted to 2015 values using the national average annual unit cost increase.

Results: This study identified 281 Medicare-insured and 155 commercially insured men, with 325 and 172 docetaxel episodes, respectively. The average number of cycles (unique docetaxel infusion days) per episode was 6.9 for Medicare and 6.3 for commercial cohorts. The average cost per episode was $28,792 for Medicare and $67,958 for commercial cohorts, with docetaxel drug costs contributing $2,588 and $13,169 per episode, respectively. The average cost per episode on docetaxel infusion days was $8,577 (30%) for Medicare and $28,412 (42%) for commercial. Non-docetaxel infusion day costs included $7,074 (25%) for infused or injected drugs for Medicare, $10,838 (16%) for commercial cohorts, and $6,875 (24%) and $9,324 (14%) for inpatient admissions, respectively.

Limitations: The applicability is only to the metastatic castration-resistance clinical setting, rather than the metastatic hormone-sensitive setting, and the lack of data on the cost effectiveness of different sequencing strategies of a range of systemic therapies including enzalutamide, abiraterone, radium-223, and taxane chemotherapy.

Conclusion: The majority of docetaxel episode costs in Medicare and commercial mCRPC populations were non-docetaxel drug costs. Future research should evaluate the total cost of care in mCPRC.     

Frequent emergency department presentations among people who inject drugs: A record linkage study

BackgroundPeople who inject drugs (PWID) have been described as frequent users of health services such as emergency departments (EDs), however few studies have described demographic factors, patterns of substance use and previous health service use associated with frequent use of EDs in this population.MethodsUsing a combination of self-reported data from a cohort of PWID and administrative ED data obtained through record linkage, we identified longitudinal factors associated with the use of ED services. Bivariate and multivariate analyses were conducted using negative binomial regression to identify exposures associated with both cumulative ED presentations, and logistic regression to identify exposures of frequent ED presentations (defined as three or more annual presentations).ResultsAmong 612 PWID, over half (58%) presented to EDs at least once and over a third (36%) presented frequently between January 2008 and June 2013. Frequent and cumulative ED presentations were associated with reporting the main drug of choice as cannabis (AOR:1.42, 95%CI:1.07–1.89 and AIRR:2.96, 95%CI:1.44–6.07 respectively) or methamphetamine (AOR:1.62, 95%CI:1.17–2.2 and AIRR:2.42, 95%CI:1.08–5.46 respectively) compared to heroin, and past month use of mental health (AOR:1.42, 95%CI:1.08–1.85 and AIRR:3.32, 95%CI:1.69–6.53 respectively) and outpatient services (AOR:1.47, 95%CI: 1.00–2.16 and AIRR:0.95, 95%CI 1.52–10.28 respectively).ConclusionPWID who are frequent users of EDs are likely to have complex health and substance use-related needs. EDs should actively refer people who present with cannabis and methamphetamine dependence to harm reduction services. Harm reduction services should ensure people referred from EDs are screened for co-occurring mental health conditions and receive adequate support.     

Health outcomes and economic impact of therapy conversion to a biphasic insulin analog pen among privately insured patients with type 2 diabetes mellitus

STUDY OBJECTIVE: To evaluate claims-related treatment adherence, health care resource utilization, and associated costs of therapy conversion from an insulin vial and syringe to a premixed biphasic insulin analog pen device among privately insured patients with type 2 diabetes mellitus. DESIGN: Retrospective, longitudinal, intrapatient (before and after) analysis. DATA SOURCE: PharMetrics database of medical and pharmaceutical claims from 57 commercial health plans across the United States. PATIENTS: Four hundred eighty-six adult patients with a confirmed diagnosis of type 2 diabetes who converted from an insulin analog vial and syringe (233 patients) or a human insulin vial and syringe (253 patients) to a biphasic insulin analog pen device between July 1, 2001 and December 31, 2002. MEASUREMENTS AND MAIN RESULTS: All patients had no previous use of the pen device. Primary end points were medication possession ratio (MPR), a measure of adherence; hypoglycemic events; associations between treatment adherence and hypoglycemic events, and adherence and all-cause health care costs; and all-cause-attributable, hypoglycemia-attributable, and other diabetes-attributable costs. After conversion, MPR increased significantly from 59% to 68% (p<0.01). A significant decrease in the likelihood of experiencing a hypoglycemic event was also observed after conversion (odds ratio [OR] 0.40, 95% confidence interval [CI] 0.27-0.61, p<0.05), with hypoglycemic occurrences reduced nearly two thirds among subjects with optimal adherence indicated by an MPR of 80% or greater (incidence rate ratio 0.36, 95% CI 0.11-0.76, p<0.05). Significant decreases in hypoglycemia-attributable emergency department visits (OR 0.36, 95% CI 0.16-0.84, p<0.05) and physician visits (OR 0.39, 95% CI 0.20-0.77, p<0.05) were observed. Total mean all-cause annual treatment costs were reduced by $1748/patient (p<0.01), hypoglycemia-attributable costs were reduced by $908/patient (p<0.01), and other diabetes-attributable costs were reduced by $643/patient (p<0.01). Patients with an MPR of 80% or greater were associated with significant reductions in all-cause health care costs (OR 0.55, 95% CI 0.31-0.80, p<0.05). CONCLUSION: Privately insured patients with type 2 diabetes may exhibit considerable improvements in clinical and economic outcomes after insulin therapy conversion from vial and syringe to a premixed biphasic insulin analog pen device.