High Out-of-pocket Health Care Cost Burden Among Medicare Beneficiaries With Diabetes, 1999-2017

Economic outcomes of diabetes self-management education among older Medicare beneficiaries with diabetes

BACKGROUND

Diabetes self-management education (DSME) has significant clinical benefits on diabetic glycemic control and reduction in the onset of complications. However, the economic benefits of DSME in older Medicare beneficiaries are not well known. The objective of this study is to examine the effect of DSME on different types of costs in older Medicare beneficiaries with diabetes.

METHODS

This was a pooled cross-sectional study using the Medicare Current Beneficiary Survey (MCBS). The use of DSME was reported by survey respondents. Economic outcomes included total medical costs, total diabetes-related medical costs, total prescription costs, and total anti-diabetic prescription costs were measured based on Medicare claims and prescription drug events data from the perspective of the Medicare system. All costs were adjusted to 2012 U.S. dollars using the Consumer Price Index (CPI). Generalized linear models, with a log link and gamma distribution, were used to examine the effect of DSME on different costs.

RESULTS

A total of 3,003 older Medicare beneficiaries with diabetes were included, among whom 35.50% (n = 1,066) had DSME. Individuals who did not have DSME had significantly higher total prescription costs than those who had DSME ($4,398.19 vs. $3,966.82, P =.0134). After adjusting for covariates, compared to those who did not have DSME, those who had DSME had 16.36% (95% CI: 9.69% to 22.54%) lower total medical costs and 12.83% (95% CI: 6.41% to 18.80%) lower total prescription costs.

CONCLUSION

This study found that DSME is associated with significantly lower spending in total medical and prescription costs for older Medicare beneficiaries. Given the economic benefits associated with DSME, different healthcare providers should further promote and increase the awareness of DSME to ensure sustained activities, enrollment, and patient retention in older Medicare beneficiaries with diabetes.

Impact of general practitioner appointment frequency on disease management in type 2 diabetes mellitus patients

AIMS

We investigated the association between the frequency of visits to general practitioners (GPs) and the degree of disease control in patients with T2DM.

METHODS

This study included patients diagnosed with T2DM who visited their GPs between 2014 and 2018. A total of 89,674 patients, accounting for 1,203,035 visits, were included. Different clinical features such as glycated hemoglobin (HbA1c%), blood pressure (BP), and c-LDL levels were analyzed. Multifactorial control of T2DM was defined as HbA1c ≤ 7 %, BP ≤ 140/90 mmHg, and LDL cholesterol ≤ 100 mg/dL. Generalized Estimating Equations models were implemented in order to deal with repeated measures for the same patient.

RESULTS

The median age of the patients is 70 years, with 52.8 % being male. An increase in the number of visits per year significantly improves the likelihood of achieving multifactorial diabetes control. Patients with more than 3-visits per year (55.6 %) have a Relative Risks (RR) of 1.258 (95 % Confidence Interval: 1.120-1.414). Frequent visits are associated with better multifactorial control and better c-LDL management. Patients visiting more than 3-times annually tend to achieve better outcomes in multifactorial and c-LDL control.

CONCLUSION

Increasing the frequency of primary care visits significantly enhances multifactorial and cholesterol control among T2DM patients.

American Diabetes Association Professional Practice Committee, ElSayed NA, McCoy RG, Aleppo G, Balapattabi K, Beverly EA, Briggs Early K, Bruemmer D, Echouffo-Tcheugui JB, Ekhlaspour L, Garg R, Khunti K, Lal R, Lingvay I, Matfin G, Napoli N, Pandya N, Pekas EJ, Pilla SJ, Polsky S, Segal AR, Seley JJ, Stanton RC, Bannuru RR. 13. Older Adults: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Estimating financial and health burden by initial Medicare plan choice and history of cancer

Understanding the downstream consequences of initial Medicare plan selection is necessary to ensure access to and affordability of health care services, especially for older adults with serious illness. We used 2008-2020 data from the Health and Retirement Study to estimate financial and health burden by initial Medicare plan selection (traditional Medicare without supplemental coverage, traditional Medicare plus supplemental coverage, or Medicare Advantage) and self-reported history of cancer. Initially choosing benefits with greater financial protections (either traditional Medicare plus supplemental coverage or Medicare Advantage) relative to traditional Medicare without supplemental coverage was associated with lower levels of out-of-pocket spending and a lower likelihood of reporting cost-related medication nonadherence and fair or poor health. Policymakers should consider improving the adequacy of traditional Medicare coverage to ensure the affordability of health care services and reduce the burden of serious illness among older adults, especially those with a history of cancer.

Exploring the Association Between Surgical Out-of-Pocket Costs and Healthcare Quality Outcomes: A Retrospective Cohort Study

OBJECTIVES

Rising out-of-pocket (OOP) costs paid by healthcare consumers can inhibit access to necessary healthcare. Yet, it is unclear if higher OOP payments are associated with better care quality. This study aimed to identify the individual and socio-contextual predictors of OOP costs and to explore the association between OOP costs and quality of care outcomes for 4 surgical procedures.

METHODS

A retrospective cohort analysis was conducted using data from Medibank Private health insurance members aged ≥18 years who underwent hip replacement, knee replacement, cholecystectomy, and radical prostatectomy during 2015 to 2020 across >300 hospitals in Australia. Healthcare quality outcomes investigated were hospital-acquired complications, unplanned intensive care unit admissions, prolonged length of stay, and readmissions within 28 days. Socio-contextual determinants of OOP costs examined were patient demographics, socioeconomic status, health insurance, and procedure complexity. Generalized linear mixed modeling examined the risk of each outcome, adjusting for covariates and considering patient clustering within surgeons and hospitals.

RESULTS

Patients were more likely to pay OOP costs if they were aged 65 to 74 years compared with aged 18 to 44 years for all 4 surgical procedures. No association between OOP payments and the risk of hospital-acquired complications, intensive care unit admission, or hospital readmission was identified. Patients who paid OOP costs were less likely to have a prolonged length of stay for all 4 procedure types.

CONCLUSIONS

Higher OOP payments were not linked to improved care quality except for shorter hospital stays. Greater transparency on OOP costs is needed to inform consumer decisions.

Total and Out-of-Pocket Costs Surrounding Emergency Department Care Among Older Adults Enrolled in Traditional Medicare and Medicare Advantage

STUDY OBJECTIVE

We sought to quantify differences in total and out-of-pocket health care costs associated with treat-and-release emergency department (ED) visits among older adults with traditional Medicare and Medicare Advantage.

METHODS

We conducted a repeated cross-sectional analysis of treat-and-release ED visits using 2015 to 2020 data from the Medicare Current Beneficiary Survey. We measured total and out-of-pocket health care spending during 3 time periods: the 30 days prior to the ED visit, the treat-and-release ED visit itself, and the 30 days after the ED visit. Stratified by traditional Medicare or Medicare Advantage status, we determined median total costs and the proportion of costs that were out-of-pocket.

RESULTS

Among the 5,011 ED visits by those enrolled in traditional Medicare, the weighted median total (and % out-of-pocket) costs were $881.95 (13.3%) for the 30 days prior to the ED visit, $419.70 (10.1%) for the ED visit, and $809.00 (13.8%) for the 30 days after the ED visit. For the 2,595 ED visits by those enrolled in Medicare Advantage, the weighted median total (and % out-of-pocket) costs were $484.92 (24.0%) for the 30 days prior to the ED visit, $216.66 (21.9%) for the ED visit, and $439.13 (22.4%) for the 30 days after the ED visit.

CONCLUSION

Older adults insured by Medicare Advantage incur lower total health care costs and face similar overall out-of-pocket expenses in the time period surrounding emergency care. However, a higher proportion of expenses are out-of-pocket compared with those insured by traditional Medicare, providing evidence of greater cost sharing for Medicare Advantage plan enrollees.

Lifetime Medical Spending Attributed to Incident Type 2 Diabetes in Medicare Beneficiaries: A Longitudinal Study Using 1999-2019 National Medicare Claims

OBJECTIVE

To estimate lifetime incremental medical spending attributed to incident type 2 diabetes (T2D) among Medicare beneficiaries by age at diagnosis, sex, and race/ethnicity.

RESEARCH DESIGN AND METHODS

We used the 1999-2019 100% Medicare fee-for-service claims database to identify a cohort of beneficiaries with newly diagnosed T2D in 2001-2003 using ICD codes. We matched this cohort with a nondiabetes cohort using a propensity score method and then followed the two cohorts until death, disenrollment, or the end of 2019. Lifetime medical spending for each cohort was the sum of expected annual spending, a product of actual annual spending multiplied by the annual survival rate, from the age at T2D diagnosis to death. Lifetime incremental medical spending was calculated as the difference in lifetime medical spending between the two cohorts. All spending was standardized to 2019 U.S. dollars.

RESULTS

Medicare beneficiaries with newly diagnosed T2D, despite having a shorter life expectancy, had 36-40% higher lifetime medical spending compared with a comparable group without diabetes. Lifetime incremental medical spending ranged from $16,115 to $122,146, depending on age at diagnosis, sex, and race/ethnicity, declining with age at diagnosis, and being highest for Asian/Pacific Islander and non-Hispanic Black beneficiaries.

CONCLUSIONS

The large lifetime incremental medical spending associated with incident T2D underscores the need for preventing T2D among Medicare beneficiaries. Our results could be used to estimate the potential financial benefit of T2D prevention programs both overall and among subgroups of beneficiaries.

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.

Diabetes control in public assistance recipients and free/low-cost medical care program beneficiaries in Japan: a retrospective cross-sectional study

Introduction

Previous research has highlighted the association between socioeconomic factors and diabetes management. This study aimed to elucidate the blood glucose control status among individuals with low income (ie, recipients of public assistance (PARs) and free/low-cost medical care (FLCMC) programme beneficiaries) and to investigate the effects of public subsidies for medical expenses on treatment adherence among low-income patients with diabetes.

Methods

We conducted a secondary analysis of medical records from 910 outpatients with diabetes who underwent pharmacological treatment for >90 days. Data on predictive variables, such as glycated haemoglobin (HbA1c) level and control variables, including sex, age and insurance type, were obtained retrospectively. The HbA1c levels among public health insurance (PHI)-only beneficiaries, FLCMC programme beneficiaries and PARs were compared using logistic regression analysis.

Results

The analysis included 874 individuals, among whom the majority were men (61.7%) and aged≥65 years (58.4%). Logistic regression analysis revealed that among individuals aged ˂65 years, the adjusted ORs for HbA1c levels above 9% were significantly higher in FLCMC programme beneficiaries (OR=5.37, 95% CI: 2.23 to 12.82) and PARs (OR=5.97, 95% CI: 2.91 to 12.74) than in PHI-only beneficiaries. Among patients aged ˂65 years with HbA1c levels above 7%, the adjusted OR was significantly higher in FLCMC programme beneficiaries (OR=3.82, 95% CI: 1.65 to 10.43) than in PHI-only beneficiaries. Additionally, the adjusted OR was significantly higher in FLCMC programme beneficiaries aged ˂65 years (OR=2.57, 95% CI: 1.02 to 7.44) than in PARs.

Conclusions

This study highlights the predictive value of public assistance or the FLCMC programme for poor blood glucose control and suggests the inadequacy of current medical expense subsidies to eliminate health disparities in diabetes control.

Vitamin D and Risk of Incident Type 2 Diabetes in Older Adults: An Updated Systematic Review and Meta-Analysis

Vitamin D deficiency is very common worldwide, particularly in old age, when people are at the highest risk of the negative adverse consequences of hypovitaminosis D. Additionally to the recognized functions in the regulation of calcium absorption, bone remodeling, and bone growth, vitamin D plays a key role as a hormone, which is supported by various enzymatic, physiological, metabolic, and pathophysiological processes related to various human organs and systems. Accruing evidence supports that vitamin D plays a key role in pancreatic islet dysfunction and insulin resistance in type 2 diabetes. From an epidemiological viewpoint, numerous studies suggest that the growing incidence of type 2 diabetes in humans may be linked to the global trend of prevalent vitamin D insufficiency. In the past, this association has raised discussions due to the equivocal results, which lately have been more convincing of the true role of vitamin D supplementation in the prevention of incident type 2 diabetes. Most meta-analyses evaluating this role have been conducted in adults or young older persons (50-60 years old), with only one focusing on older populations, even if this is the population at greater risk of both hypovitaminosis D and type 2 diabetes. Therefore, we conducted an update of the previous systematic review and meta-analysis examining whether hypovitaminosis D (low serum 25OHD levels) can predict incident diabetes in prospective longitudinal studies among older adults. We found that low 25OHD was associated with incident diabetes in older adults even after adjusting for several relevant potential confounders, confirming and updating the results of the only previous meta-analysis conducted in 2017.

U.S. food policy to address diet-related chronic disease

Poor diet is the leading cause of mortality in the U.S. due to the direct relationship with diet-related chronic diseases, disproportionally affects underserved communities, and exacerbates health disparities. Evidence-based policy solutions are greatly needed to foster an equitable and climate-smart food system that improves health, nutrition and reduces chronic disease healthcare costs. To directly address epidemic levels of U.S. diet-related chronic diseases and nutritional health disparities, we conducted a policy analysis, prioritized policy options and implementation strategies, and issued final recommendations for bipartisan consideration in the 2023-24 Farm Bill Reauthorization. Actional recommendations include: sugar-sweetened beverage taxation, Supplemental Nutrition Assistance Program (SNAP) fruit and vegetable subsidy expansion, replacement of ultra-processed foods (UPF) with sustainable, diverse, climate-smart agriculture and food purchasing options, and implementing "food is medicine."

Healthcare Cost Burden and Self-Reported Frequency of Depressive/Anxious Feelings in Older Adults

Using the 2018-2021 National Health Interview Survey data, we examined the associations between healthcare cost burden and depressive/anxious feelings in older adults. Nearly12% reported healthcare cost burden and 18% daily/weekly depressive/anxious feelings. Healthcare cost burden was higher among women, racial/ethnic minorities, those with chronic illnesses, mobility impairment, and those with Medicare Part D, but lower among individuals with Medicare-Medicaid dual eligibility, Medicare Advantage, VA/military insurance, and private insurance. Daily/weekly depressive/anxious feelings was higher among healthcare cost burden reporters. The COVID-19 pandemic-related medical care access problems were also associated with a higher risk of reporting healthcare cost burden and depression/anxiety.

Optimizing the frequency of physician encounters in follow - up care for patients with type 2 diabetes mellitus: a systematic review

BACKGROUND

Decisions on the frequency of physician encounters for patients with type 2 diabetes mellitus (T2DM) have significant impacts on both patients' health outcomes and burden on health systems, whereas definitive intervals for physician encounters are still lacking in most clinical guidelines. This study systematically reviewed the existing evidence evaluating different frequencies of physician encounters among T2DM patients.

METHODS

Systematic search of studies evaluating different visit frequencies for follow - up care in T2DM patients was performed in MEDLINE Ovid, Embase Ovid, and Cochrane library from database inception to 25 March 2022. Studies on the follow - up encounters driven by non - physicians and those on the episodic visits in the acute care settings were excluded in the screening. Citation searching was conducted via Google Scholar on the identified papers after screening. The risk of bias was assessed using Cochrane RoB2 tool for randomized controlled trials and Newcastle - Ottawa Scale for cohort studies. Findings were summarized narratively.

RESULTS

Among 6363 records from the database search and 231 references from the citation search, 12 articles were eligible for in - depth review. The results showed that for patients who had not achieved cardiometabolic control, intensifying encounter frequency could enhance medication adherence, shorten the time to achieve the treatment target, and improve the patients' quality of life. However, for the patients who had already achieved the treatment targets, less frequent encounters were equivalent to intensive encounters in maintaining their cardiometabolic control, and could save considerable healthcare costs without substantially lowering the quality of care and patients' satisfaction.

CONCLUSION

Existing evidence suggested that the optimal frequency of physician encounters for patients with T2DM should be individualized, which can be stratified by patients' risk levels based on the cardiometabolic control to guide the differential scheduling of physician encounters in the follow - up. More research is needed to determine how to optimize the frequency of physician encounters for this large and heterogeneous population.

Budget Impact Analysis of Intensification with iGlarLixi Compared to Alternative Treatment Strategies Among Patients with Type 2 Diabetes Mellitus

INTRODUCTION

The clinical benefits of treating patients with type 2 diabetes mellitus (T2DM) with fixed-ratio combination of insulin iGlar (iGlar) plus lixisenatide (iGlarLixi) were demonstrated in clinical trials and real-world evidence studies; however, its cost impact to healthcare payers is unknown.

METHODS

A budget impact model was developed from a United States (US) payer's perspective for a hypothetical healthcare plan of 1 million people over a 1-year time horizon. In scenario analysis, patients with uncontrolled glycated hemoglobin (HbA1c) treated with 60 units or less of daily insulin (insulin cohort) or oral antidiabetic drugs (OADs) only (OAD cohort) were intensified to iGlarLixi/rapid-acting insulin (RAI)/glucagon-like peptide 1 receptor agonists (GLP-1RA) or iGlarLixi/iGlar/GLP-1RA, respectively. Model inputs from real-world data (RWD) included baseline market shares, proportion of patients intensifying to respective treatments, and dosing inputs; unit costs were obtained from published literature. One-way sensitivity analyses assessed the impact of individual parameters.

RESULTS

Intensification with iGlarLixi resulted in the lowest incremental per member per month (PMPM) budget impact compared to other intensifying drugs (iGlar, RAI, and GLP-1RA). In the insulin cohort, the incremental PMPM cost for intensification with iGlarLixi ($0.03) was the lowest among intensifying drugs; GLP-1RA ($72.20) and RAI ($4.81). Similarly, the incremental PMPM cost for intensification with iGlarLixi was the lowest ($1.25) in the OAD cohort among intensifying drugs; GLP-1RA ($321.65) and iGlar ($114.82). In scenario analyses, when equal market intensification shares for iGlarLixi and GLP-1RA were explored, the incremental PMPM cost for iGlarLixi ($0.03) remained lower than GLP-1RA ($2.28) and RAI ($10.44) in the insulin cohort.

CONCLUSIONS

Intensification with iGlarLixi was associated with lower costs compared to other treatment intensifications, as well as overall budget reductions compared to pre-intensification when considering cost savings attributable to reduction in HbA1c; therefore, its inclusion for the treatment of T2DM would represent a budget saving.

Dissatisfaction of Out-of-Pocket Costs and Problems Paying Medical Bills Among Medicare Beneficiaries With Type 2 Diabetes

Purpose

The purpose of the study was to examine the relationship between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills among Medicare beneficiaries with type 2 diabetes.

Methods

The 2019 Medicare Current Beneficiary Survey Public Use File, a nationally representative sample of Medicare beneficiaries aged ≥65 years with type 2 diabetes, was analyzed (n = 2178). A survey-weighted multivariable logit regression model was conducted to examine the association between satisfaction of Medicare coverage for out-of-pocket costs and problems paying medical bills, adjusted for sociodemographics and comorbidities.

Results

Among study beneficiaries, 12.6% reported problems paying medical bills. Among those with and without problems paying medical bills, 59.5% and 12.8%, respectively, were dissatisfied with out-of-pocket costs. In the multivariable analysis, beneficiaries who were dissatisfied with out-of-pocket costs were more likely to report problems paying medical bills than those who were satisfied. Younger beneficiaries, beneficiaries with lower incomes, those with functional limitations, and those with multiple comorbidities were more likely to report problems paying medical bills.

Conclusions

Despite having health care coverage, more than one-tenth of Medicare beneficiaries with type 2 diabetes reported problems paying medical bills, which raises concerns about delaying or forgoing needed medical care due to unaffordability. Screenings and targeted interventions that identify and reduce financial hardships associated with out-of-pocket costs should be prioritized.