Prescription drug coverage satisfaction, cost-reducing behavior, and medication nonadherence among Medicare beneficiaries with type 2 diabetes

Filling Diabetes Medications Through VA or Medicare, or Both: Factors in Decision Making, Challenges, and Informational Needs

BACKGROUND

Veterans' dual use of VA and Medicare Part D to fill diabetes medications is common and has advantages as well as disadvantages.

OBJECTIVE

To understand the factors Veterans and their care partners consider when choosing whether to fill their diabetes medications through VA only, Part D only, or both, as well as their medication acquisition challenges and informational needs.

APPROACH

Semi-structured interviews between April and September 2023. Transcripts were analyzed via descriptive content analysis with deductive and inductive approaches.

PARTICIPANTS

In total, 24 Veterans and 12 care partners.

MAIN MEASURES

Drivers of choice, medication acquisition challenges, and informational needs that Veterans and care partners report when choosing where to fill their diabetes medications.

KEY RESULTS

Cost, followed by formulary access, were main drivers of where Veterans and their care partners chose to fill their diabetes medications. Drive time, convenience, and preference for a particular provider were also considered, and care partners expressed a desire to streamline all of a Veteran's care to VA or Medicare for convenience and time savings. Veterans and care partners had mixed experiences with dual use, with some expressing frustration related to communication challenges between providers and incompatibilities between different health systems. Health-related risks associated with dual use were rarely mentioned. Veteran and care partner informational needs included relative costs and availability of medications on the formularies, and there was a preference to have direct access to information alongside telephone-based pharmacy support.

CONCLUSIONS

Cost and then medication access as well as drive time, convenience, and preference for a particular provider influenced Veteran and care partner choices on where to fill medications. Care partners often preferred one system. Differences and incompatibilities between VA and Medicare at times led to frustration and challenges filling medications. Information and support are needed to help Veterans and their care partners.

Lack of Prescription Drug Benefit Knowledge and Problems Paying Medical Bills Among Medicare Beneficiaries

AIMS AND OBJECTIVES

Approximately 50% of Americans report having low health insurance literacy, leading to uncertainty when choosing their insurance coverage to best meet their healthcare needs. Therefore, we aimed to evaluate the association between lack of prescription drug benefit knowledge and problems paying medical bills among Medicare beneficiaries.

METHODS

We analysed the 2021 Medicare Current Beneficiary Survey Public Use File of 5586 Medicare beneficiaries aged ≥ 65 years. The binary dependent variable was whether beneficiaries had problems paying medical bills in the past year. The categorical independent variable was how much beneficiaries knew about the Medicare prescription drug benefit. A survey-weighted multivariable logit model, adjusted for covariates (e.g., socio-demographics, comorbidities, private insurance coverage, and satisfaction with out-of-pocket costs), was conducted to examine the association between the independent variable and problems paying medical bills.

RESULTS

Approximately 4.3% of study beneficiaries (~2.0 million beneficiaries) reported problems paying medical bills. Of those without and with problems paying medical bills, 27.7% and 39.6%, respectively, reported knowing little/almost nothing about prescription drug benefits. Beneficiaries aged 65-74 years (marginal effect [ME] = 2.1%, p < 0.01), with comorbidities (e.g., ≥ 4 conditions, ME = 3.8%, p < 0.001), dissatisfaction with out-of-pocket costs (ME = 10.1%, p < 0.001), without private insurance (e.g., employer-sponsored insurance, ME = 2.5%, p < 0.01), or with little/almost no knowledge of prescription drug benefits (ME = 1.9%, p < 0.05) were more likely to report problems paying medical bills compared to their counterparts.

CONCLUSION

Tailored programmes aimed at improving beneficiaries' knowledge of prescription drug benefits, reducing out-of-pocket costs and preventing comorbidities may be considered for the at-risk population to address the problem.

Patient Out-of-Pocket Costs for Type 2 Diabetes Medications When Aging Into Medicare

Importance

For people with type 2 diabetes (T2D), out-of-pocket medication costs may influence medication choice, adherence, and overall diabetes management and progression. Little is known about how these costs change as insured people enter Medicare at age 65 years, when coinsurance in the coverage gap and catastrophic phases of Part D coverage can be increased greatly by use of insulin and newer, branded medications (eg, dipeptidyl peptidase 4 inhibitors, glucagon-like peptide 1 agonists, and sodium-glucose cotransporter 2 inhibitors).

Objective

To identify whether reaching age 65 years is associated with T2D medication out-of-pocket costs and utilization.

Design, Setting, and Participants

This retrospective cohort study (2012-2020) featuring 7 years of follow-up used prescription drug claims data from the TriNetX Diamond Network. Participants included people in the US with diagnosed T2D, and claims for T2D medications were observed both before and after age 65 years. Data analysis was performed from October 2022 to September 2023.

Exposure

Reaching age 65 years, according to participants' year of birth.

Main Outcomes and Measures

The primary outcome was patient out-of-pocket costs for T2D drugs per quarter (inflation adjusted to 2020 dollars). Utilization, measured as binary utilization of specific classes, and the number of claims for mutually exclusive classes and combinations of classes were also examined. All outcomes were examined using regression discontinuity design.

Results

In claims data for 129 997 individuals with T2D diagnosed at ages 58 to 72 years (mean [SD] age, 65.50 [2.95] years; 801 235 female [50.9%]), reaching age 65 years was associated with an increase of $23.04 (95% CI, $19.86-$26.22) in mean quarterly out-of-pocket costs for T2D drugs, and an increase of $56.36 (95% CI, $51.48-$61.23) at the 95th percentile of spending, after utilization adjustment. Utilization decreased by 5.3% at age 65 years, from 3.40 claims per quarter (95% CI, 3.38-3.42 claims per quarter) to 3.22 claims per quarter (95% CI, 3.21-3.24 claims per quarter), but a shift in composition of utilization, including increased insulin use, was associated with additional increases in patient costs.

Conclusions and Relevance

In this cohort study of individuals with T2D, the increase in spending upon reaching age 65 years (when most people enroll in Medicare) was associated with patient coinsurance in the coverage gap and catastrophic coverage phases of Medicare Part D. The increased patient cost burden at age 65 years and a modest reduction in overall T2D drug utilization suggest that as people with T2D age into Medicare, there is potentially an increase in nonadherence and diabetes complications.

Expert Opinion on Current Trends in the Use of Insulin in the Management of People with Type 2 Diabetes from the South-Eastern European Region and Israel

Despite the availability of various antihyperglycaemic therapies and comprehensive guidelines, glycaemic control in diabetes management has not improved significantly during the last decade in the real-world clinical setting. Treatment inertia arising from a complex interplay among patient-, clinician- and healthcare-system-related factors is the prime reason for this suboptimal glycaemic control. Also, the key factor leading to inadequate glycaemic levels remains limited communication between healthcare professionals (HCPs) and people with type 2 diabetes (PwT2D). Early insulin administration has several advantages including reduced glucotoxicity, high efficacy and preserved β-cell mass/function, leading to lowering the risk of diabetes complications. The current publication is based on consensus of experts from the South-Eastern European region and Israel who reviewed the existing evidence and guidelines for the treatment of PwT2D. Herein, the experts emphasised the timely use of insulin, preferably second-generation basal insulin (BI) analogues and intensification using basal-plus therapy, as the most-potent glucose-lowering treatment choice in the real-world clinical setting. Despite an increase in the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs), the experts urged timely insulin initiation for inadequate glycaemic control in PwT2D. Furthermore, the combination of BI and GLP-1 RA addressing both fasting plasma glucose and post-prandial excursions as a free- or fixed-ratio combination was identified to reduce treatment complexity and burden. To minimise discontinuation and improve adherence, the experts reiterated quality, regular interactions and discussions between HCPs and PwT2D/carers for their involvement in the diabetes management decision-making process. Clinicians and HCPs should consider the opinions of the experts in accordance with the most recent recommendations for diabetes management.

Patient attitudes, experiences, and satisfaction with healthcare and office visit utilization among Medicare beneficiaries with type 2 diabetes

OBJECTIVES

To examine patient attitudes, experiences, and satisfaction with healthcare associated with office visit utilization among Medicare beneficiaries with type 2 diabetes.

METHODS

We analyzed the 2019 Medicare Current Beneficiary Survey Public Use File of beneficiaries aged ≥65 years with type 2 diabetes (n = 1092). The ordinal dependent variable was defined as 0, 1 to 5, and ≥6 office visits. An ordinal partial proportional odds model was conducted to examine associations of beneficiaries' attitudes, experiences, and satisfaction with healthcare and office visit utilization.

RESULTS

Among the beneficiaries, approximately 17.7%, 22.8%, and 59.5% reported having 0, 1 to 5, and ≥6 office visits, respectively. Being male (OR = 0.67, p = 0.004), Hispanic (OR = 0.53, p = 0.006), divorced/separated (OR = 0.62, p = 0.038) and living in a non-metro area (OR = 0.53, p < 0.001) were associated with a lower likelihood of attending more office visits. Trying to keep sickness to themselves (OR = 0.66, p = 0.002) and dissatisfaction with the ease and convenience of getting to providers from home (OR = 0.45, p = 0.010) were associated with a lower likelihood of having more office visits.

DISCUSSION

The proportion of beneficiaries foregoing office visits is concerning. Attitudes concerning healthcare and transportation challenges can be barriers to office visits. Efforts to ensure timely and appropriate access to care should be prioritized for Medicare beneficiaries with diabetes.