MONITORING FOR WASTE: EVIDENCE FROM MEDICARE AUDITS

This paper examines the tradeoffs of monitoring for wasteful public spending. By penalizing unnecessary spending, monitoring improves the quality of public expenditure and incentivizes firms to invest in compliance technology. I study a large Medicare program that monitored for unnecessary healthcare spending and consider its effect on government savings, provider behavior, and patient health. Every dollar Medicare spent on monitoring generated $24-29 in government savings. The majority of savings stem from the deterrence of future care, rather than reclaimed payments from prior care. I do not find evidence that the health of the marginal patient is harmed, indicating that monitoring primarily deters low-value care. Monitoring does increase provider administrative costs, but these costs are mostly incurred upfront and include investments in technology to assess the medical necessity of care.

Cost-efficiency and budget-neutral expanded access modeling of the novel PD-1 inhibitor toripalimab versus pembrolizumab in recurrent or metastatic nasopharyngeal carcinoma

AIMS

To estimate, in the setting of recurrent or metastatic nasopharyngeal carcinoma (R/M NPC) for an assumed 1,207 incident US cases in 2024, (1) the cost-efficiency of a toripalimab-gemcitabine-cisplatin regimen compared to a similar pembrolizumab regimen; and (2) the budget-neutral expanded access to additional toripalimab cycles and regimens afforded by the accrued savings.

METHODS

Simulation modeling utilized two cost inputs (wholesale acquisition cost (WAC) at market entry and an ex ante toripalimab price point of 80% of pembrolizumab average sales price (ASP)) and drug administration costs over 1 and 2 years of treatment with treatment rates ranging from 45% to 90%. In the absence of trial data for pembrolizumab-gemcitabine-cisplatin in R/M NPC, it is assumed that such a regimen would be comparable to toripalimab-gemcitabine-cisplatin in efficacy and safety.

RESULTS

In the models utilizing the WAC, toripalimab saves $2,223 per patient per cycle and $40,014 over 1 year of treatment ($77,805 over 2 years). Extrapolated to the 1,207-patient panel, estimated 1-year savings range from $21,733,702 (45% treatment rate) to $43,467,404 (90% rate). Reallocating these savings permits budget-neutral expanded access to an additional 2,359 (45% rate) to 4,717 (90% rate) toripalimab maintenance cycles or to an additional 126 (45% rate) to 252 (90%) full 1-year toripalimab regimens with all agents. Two-year savings range from $42,259,976 (45% rate) to $84,519,952 (90% rate). Reallocating these efficiencies provides expanded access, ranging from an additional 4,586 (45% rate) to 9,172 (90% rate) toripalimab cycles or to an additional 128-257 full 2-year toripalimab regimens. The ex ante ASP model showed similar results.

CONCLUSION

This simulation demonstrates that treatment with toripalimab generates savings that enable budget-neutral funding for up to an additional 252 regimens with toripalimab-gemcitabine-cisplatin for one full year, the equivalent of approximately 21% of the 2024 incident cases of R/M NPC in the US.

Cost-effectiveness analysis of transcatheter aortic valve implantation in aortic stenosis patients at low- and intermediate-surgical risk in Japan

OBJECTIVE

To analyze the cost-effectiveness of transcatheter aortic valve implantation (TAVI) using the SAPIEN 3 (Edwards Lifesciences, Irvine, CA) compared to surgical aortic valve replacement (SAVR) in low- and intermediate-risk patients from a Japanese public healthcare payer perspective.

METHODS

A Markov model cost-effectiveness analysis was developed. Clinical and utility data were extracted from a systematic literature review. Cost inputs were obtained from analysis of the Medical Data Vision claims database and supplemented with a targeted literature search. The robustness of the results was assessed using sensitivity analyses. Scenario analyses were performed to determine the impact of lower mean age (77.5 years) and the effect of two different long-term mortality hazard ratios (TAVI versus SAVR: 0.9-1.09) on both risk-level populations. This analysis was conducted according to the guidelines for cost-effectiveness evaluation in Japan from Core 2 Health.

RESULTS

In intermediate-risk patients, TAVI was a dominant procedure (TAVI had lower cost and higher effectiveness). In low-risk patients, the incremental cost effectiveness ratio (ICER) for TAVI was ¥750,417/quality-adjusted-life-years (QALY), which was below the cost-effectiveness threshold of ¥5 million/QALY. The ICER for TAVI was robust to all tested sensitivity and scenario analyses.

CONCLUSIONS

TAVI was dominant and cost-effective compared to SAVR in intermediate- and low-risk patients, respectively. These results suggest that TAVI can provide meaningful value to Japanese patients relative to SAVR, at a reasonable incremental cost for patients at low surgical risk and potentially resulting in cost-savings in patients at intermediate surgical risk.

Healthcare resource utilization and associated costs in patients with metastatic urothelial carcinoma: a real-world analysis using German claims data

AIMS

This retrospective claims data study characterized real-world treatment patterns, healthcare resource utilization (HCRU), and costs in patients with metastatic urothelial carcinoma (mUC) in Germany.

MATERIALS AND METHODS

Continuously insured adults with incident mUC diagnosis (=index; ICD-10: C65-C68/C77-C79) in 2015-2019 were identified from two German claims databases. Patients who received first-line (1 L) treatment within 12 months of index were divided into three mutually exclusive sub-cohorts: platinum-based chemotherapy (PB-CT), non-PB-CT, and immunotherapy (IO). Patient characteristics were assessed during a 24-month baseline period; treatments, HCRU, and costs (of the health insurance fund) per patient-year (ppy) were described during 12-month follow-up.

RESULTS

We identified 3,226 patients with mUC (mean age, 73.8 years; male, 70.8%; mean Elixhauser Comorbidity Index, 17.6); 1,286 (39.9%) received 1 L treatment within 12 months of index. Of these, 825 (64.2%) received PB-CT, 322 (25.0%) non-PB-CT, and 139 (10.8%) IO. On average, treated patients had 5.1 hospitalizations ppy. Most UC-related hospitalizations ppy were observed in the PB-CT cohort (5.8), followed by the non-PB-CT (4.2) and IO (2.3) cohorts. Mean UC-related hospitalization costs ppy were €22,218 in the treated cohort, €24,294 in PB-CT, €19,079 in IO, and €18,530 in non-PB-CT cohorts. Cancer-related prescription costs ppy averaged €6,323 in treated patients, and €25,955 in IO, €4,318 in non-PB-CT, and €4,270 in PB-CT cohorts.

LIMITATIONS

We recognized limitations in our study's sample selection due to unavailable mUC disease status data. We addressed this through an upstream feasibility study conducted in consultation with clinical experts to determine a suitable proxy. Proxies were also used to delineate treatment lines, switches, and discontinuations due to data absence. Furthermore, due to data restrictions, collective dataset analysis was not possible, prompting a meta-analysis for pooled results.

CONCLUSIONS

The study shows that mUC is associated with significant HCRU and costs across different types of 1 L systemic therapy.

Treatment patterns and healthcare resource utilization in patients with metastatic hormone-sensitive prostate cancer and nonmetastatic castration-resistant prostate cancer in China: a real-world observational study

AIM

This study assessed the treatment patterns, healthcare resource utilization (HRU), costs, and annual prevalence and incidence of metastatic hormone-sensitive prostate cancer (mHSPC) and nonmetastatic castration-resistant prostate cancer (nmCRPC) in China.

METHODS

A retrospective study was conducted using electronic medical records (EMR) of patients with prostate cancer from three tertiary-care hospitals in China between January 2014 and March 2021. Descriptive statistics were used to analyze study outcomes.

RESULTS

In total, 1086 patients with mHSPC and 679 patients with nmCRPC were included. From 2015 to 2020, the annual percentage of prevalent and incident cases of mHSPC decreased from 22.4% to 20.0% and 11.1% to 6.9%, respectively; for nmCRPC, these increased from 3.8% to 13.6% and 3.3% to 8.4%. Androgen-deprivation therapy and first-generation antiandrogens (bicalutamide or flutamide) were the most frequently prescribed prostate cancer-related medications at baseline and follow-up in patients with mHSPC. Bicalutamide was the most frequently prescribed prostate cancer-related medication during follow-up in patients with nmCRPC. For mHSPC, inpatient admission costs were the highest, with the median (interquartile range) costs per person-month being USD 403.00 (USD 85.50-1226.20), whereas outpatient visit costs were the highest for nmCRPC (USD 372.60 [USD 139.50-818.50]).

LIMITATIONS

EMR-based study design did not capture treatment patterns, HRU and associated costs, and healthcare encounters that occurred outside of participating hospitals, which could have led to underestimation of the true disease burden.

CONCLUSIONS

A contrasting trend of a decline in the prevalence and incidence of mHSPC and an increase in these for nmCRPC was observed between 2015 and 2020 in China. Androgen-deprivation therapy and first-generation antiandrogens were the most frequently prescribed prostate cancer-related medications. Healthcare resource utilization was driven by inpatient costs in mHSPC and outpatient costs in nmCRPC.

Exploring kidney dialysis costs in the United States: a scoping review

AIMS

The increasing prevalence of end-stage renal disease (ESRD) in the United States (US) represents a considerable economic burden due to the high cost of dialysis treatment. This review examines data from real-world studies to identify cost drivers and explore areas where dialysis costs could be reduced.

METHODS

We identified and synthesized evidence published from 2016-2023 reporting direct dialysis costs in adult US patients from a comprehensive literature search of MEDLINE, Embase, and grey literature sources (e.g. US Renal Data System reports).

RESULTS

Most identified data related to Medicare expenditures. Overall Medicare spending in 2020 was $29B for hemodialysis and $2.8B for peritoneal dialysis (PD). Dialysis costs accounted for almost 80% of total Medicare expenditures on ESRD beneficiaries. Private insurance payers consistently pay more for dialysis; for example, per person per month spending by private insurers on outpatient dialysis was estimated at $10,149 compared with Medicare spending of $3,364. Dialysis costs were higher in specific high-risk patient groups (e.g. type 2 diabetes, hepatitis C). Spending on hemodialysis was higher than on PD, but the gap in spending between PD and hemodialysis is closing. Vascular access costs accounted for a substantial proportion of dialysis costs.

LIMITATIONS

Insufficient detail in the identified studies, especially related to outpatient costs, limits opportunities to identify key drivers. Differences between the studies in methods of measuring dialysis costs make generalization of these results difficult.

CONCLUSIONS

These findings indicate that prevention of or delay in progression to ESRD could have considerable cost savings for Medicare and private payers, particularly in patients with high-risk conditions such as type 2 diabetes. More efficient use of resources is needed, including low-cost medication, to improve clinical outcomes and lower overall costs, especially in high-risk groups. Widening access to PD where it is safe and appropriate may help to reduce dialysis costs.

Real-world treatment patterns and healthcare resource utilization among migraine patients: A German claims database analysis

AIMS

Despite migraine being one of the most common neurological diseases, affected patients are often not effectively treated. This analysis describes the burden of migraine in Germany and assesses real-world treatment patterns and healthcare resource utilization (HCRU) of preventive-treated migraine patients from the perspective of the Statutory Health Insurance.

METHODS

A retrospective analysis was conducted using InGef Research Database claims data from 2018-2019. Migraine patients were stratified into cohorts by acute and preventive treatment status. Patients on preventive treatment were further stratified according to type of prophylaxis received. Disease burden in preventively treated migraine patients was reported via treatment patterns, pathways, and comorbidities. HCRU was assessed through outpatient provider visits, hospitalizations, and sick leave.

RESULTS

160,164 adult migraine patients were identified, of which 55,378 (34.6%) were prescribed preventive treatment with conventional (n = 25,984, 46.9%), calcitonin gene-related peptide monoclonal antibody (CGRP mAb) (n = 613, 1.1%), or off-label therapies (n = 28,781, 52.0%). 936 (1.7%) patients received Botulinum Neurotoxin Type A (BoNTA). CGRP mAb-treated patients had a high rate of triptan prescriptions (2018: 95.5%; 2019: 88.9%), migraine-related hospitalizations (2018: 33.0%; 2019: 21.0%), and sick leave (2018: 26.8%; 2019: 22.5%). A high proportion of CGRP mAb- and BoNTA-treated patients was diagnosed with abdominal and pelvic pain (34.3% and 36.2%) and low back pain (34.1% and 35.3%). These patients also showed a high prevalence of depressive episodes (49.1% and 50.1%) and chronic pain disorders (37.5% and 32.9%).

LIMITATIONS

This study focused on descriptive analyses which do not allow for assessment of causality when comparing treatment groups.

CONCLUSIONS

Disease burden was high in patients receiving CGRP mAbs suggesting that patients treated preventively with CGRP mAbs shortly after product launch in Germany were severely affected chronic migraine patients. The same may be true for patients receiving BoNTA who also showed an increased disease burden.

Budget impact analysis of comprehensive genomic profiling for untreated advanced or recurrent solid cancers in Japan

AIMS

In Japan, the use of comprehensive genomic profiling (CGP) is only available for cancer patients who have no standard of care (SoC), or those who have completed SoC. This may lead to missed treatment opportunities for patients with druggable alterations. In this study, we evaluated the potential impact of CGP testing before SoC on medical costs and clinical outcome in untreated patients with advanced or recurrent biliary tract cancer (BTC), non-squamous non-small cell lung cancer (NSQ-NSCLC), or colorectal cancer (CRC) in Japan between 2022 and 2026.

MATERIALS AND METHODS

We constructed a decision-tree model reflecting the healthcare environment of Japan, to estimate the clinical outcome and medical costs impact of CGP testing by comparing two groups (with vs without CGP testing before SoC). The epidemiological parameters, detection rates of druggable alterations, and overall survival were collected from literature and claims databases in Japan. Treatment options selected based on druggable alterations were set in the model based on clinical experts' opinions.

RESULTS

In 2026, the number of untreated patients with advanced or recurrent BTC, NSQ-NSCLC, and CRC was estimated to be 8,600, 32,103, and 24,896, respectively. Compared with the group without CGP testing before SoC, CGP testing before SoC increased druggable alteration detection and treatment rate with matched therapies in all three cancer types. The medical costs per patient per month were estimated to increase with CGP testing before SoC in the three cancer types by 19,600, 2,900, and 2,200 JPY (145, 21, and 16 USD), respectively.

LIMITATIONS

Only those druggable alterations with matched therapies were considered in the analysis model, while the potential impact of other genomic alterations provided by CGP testing was not considered.

CONCLUSIONS

The present study suggested that CGP testing before SoC may improve patient outcomes in various cancer types with a limited and controllable increase in medical costs.

THE IMPACT OF ELIGIBILITY FOR MEDICAID VERSUS SUBSIDIZED PRIVATE HEALTH INSURANCE ON MEDICAL SPENDING, SELF-REPORTED HEALTH, AND PUBLIC PROGRAM PARTICIPATION

We use a regression discontinuity design to understand the impact of a sharp change in eligibility for Medicaid versus subsidized marketplace insurance at 138 percent of the federal poverty line on coverage, medical spending, health status, and other public program participation. We find a 5.5 percentage point shift from Medicaid to private insurance, with no net change in coverage. The shift increases individual health spending by $341 or 2 percent of income, with larger increases at higher points in the spending distribution. Two-thirds of the increase is from premiums and one-thirdfrom out-of-pocket medical spending. Self-rated health and other public program participation appear unchanged. We find no evidence of bunching below the eligibility threshold, which suggests either that individuals are willing to pay more for private insurance or that optimization frictions are high.

The health and budget impact of sodium-glucose co-transporter-2 inhibitors (SGLT2is) in the Netherlands

OBJECTIVES

Type-2 Diabetes Mellitus (T2DM) increases both the patient risk of cardiovascular disease (CVD) and renal outcomes, such as chronic kidney disease (CKD). Recent clinical trials of the glucose-lowering drug-class of sodium-glucose co-transporter-2 inhibitors (SGLT2is) have shown benefits in preventing CVD events and progression of CKD, leading to an update of the Dutch T2DM treatment guideline for patients at risk. The aim of this study is to assess the health and economic impact of the guideline-recommended utilisation of SGLT2is in the Netherlands.

METHODS

The patient population at risk was determined by multiplying Dutch T2DM prevalence rates with the total numbers of inhabitants of the Netherlands in 2020. Subsequently, two analyses, comparing a treatment setting before and after implementation of the new guideline for SGLT2is, were conducted. Clinical and adverse event rates in both settings as well as direct healthcare costs were sourced from the literature. Total costs were calculated by multiplying disease prevalence, event rates and costs associated to outcomes. One-time disutilities per event were included to estimate the health impact. The potential health and economic impact of implementing the updated guideline was calculated.

RESULTS

Using a 5-year time horizon, the guideline-suggested utilisation of SGLT2is resulted in a health impact equal to 4,835 quality adjusted life years gained (0.0031 per patient per year) and €461 million cost-savings. The costs of treatment with SGLT2is were €813 million. Hence the net budget impact was €352 million for the total Dutch T2DM population, which translated to €0,57 per patient per day.

CONCLUSION

SGLT2is offer an option to reduce the number of CVD and CKD related events and associated healthcare costs and health losses in the Netherlands. Further research is needed to include the benefits of improved T2DM management options from a broader societal perspective.

Productivity loss outcomes and costs among patients with cholangiocarcinoma in the United States: an economic evaluation

BACKGROUND

Cholangiocarcinoma (CCA) is associated with poor prognosis. Healthcare-related management likely presents a substantial economic burden associated with time away from work in patients with CCA.

OBJECTIVES

To assess productivity loss, associated indirect costs, and all-cause healthcare resource utilization and costs owing to workplace absenteeism, short-term disability, and long-term disability in CCA patients with work absence and disability benefits eligibility in the United States.

METHODS

US retrospective claims data from Merative MarketScan Commercial and Health and Productivity Management Databases. Eligible patients were adults with ≥1 non-diagnostic medical claim for CCA in the index period (1 January 2011-31 December 2019) and had ≥6 months of continuous medical and pharmacy benefit enrolment before and ≥1 month of follow-up and full-time employee work absence and disability benefits eligibility after the index date. Outcomes were assessed in patients with CCA, intrahepatic CCA (iCCA), and extrahepatic CCA (eCCA) in absenteeism, short-term disability, and long-term disability cohorts (measured per patient per month [PPPM] for a month of 21 workdays), with costs standardized to 2019 USD.

RESULTS

One thousand and sixty-five patients with CCA were included (iCCA: n = 624 [58.6%]; eCCA: n = 380 [35.7%]). The mean age was 51.9-53.9 years across cohorts. In patients with iCCA and eCCA, respectively, the number of mean all-cause days absent PPPM for illness was 6.0 and 4.3, and 12.9 and 6.6% had ≥1 CCA-related short-term disability claim. Median indirect costs PPPM owing to absenteeism, short-term disability, and long-term disability, respectively, in patients with iCCA were $622, $635, and $690, and $304, $589, and $465 in patients with eCCA. Patients with iCCA vs. eCCA had higher inpatient, outpatient medical, outpatient pharmacy, and all-cause healthcare costs PPPM.

CONCLUSIONS

Patients with CCA had high productivity losses, indirect costs, and medical costs. Outpatient services costs contributed greatly to the higher healthcare expenditure observed in patients with iCCA vs. eCCA.

Consequences of India's population aging to its healthcare financing and provision

OBJECTIVES

To conduct a comprehensive literature review on the state of population aging, healthcare financing, and provision in India.

METHODS

To obtain relevant records in the Indian context, multiple publications were searched from databases, such as Scopus, ScienceDirect, Web of Science, Medline/PubMed, JSTOR, and Google Scholar using the following keywords: "Population Ageing," "Population Aging," "Health System," "Demographic Dividend," "Non-communicable Diseases," "Double Burden of Diseases," "Health Spending," "Sustainable Health Financing," and "Health Coverage." Data on different health indices were collected from different websites of the government of India and international organizations (e.g. World Bank, UN, WHO, and Statista).

RESULTS

As people live longer, India faces a double burden of disease, with the rising incidence of non-communicable diseases (NCDs) amidst the presence of widespread communicable diseases. The combined problem of the double burden of diseases and population aging poses a severe sustainability challenge for its healthcare financing and the entire health system. Healthcare financing based on progressive taxation and large-scale prepayment coverage is an effective solution for sustaining the health system. However, due to the prevalence of indirect taxes, India's tax system is regressive. Hence, community-based health insurance (CBHI) schemes can be a feasible solution to cover the large mass of poor working in the informal sector.

CONCLUSIONS

India needs to address the alterations in its healthcare needs and demands brought on by the advancing demographic shift. To achieve so, the country's healthcare system must be reformed to accommodate strong national policies focusing on universal access to critical care especially geriatric and palliative care.

Multigenerational Impacts of Childhood Access to the Safety Net: Early Life Exposure to Medicaid and the Next Generation's Health

We examine multi-generational impacts of positive in utero health interventions using a new research design that exploits sharp increases in prenatal Medicaid eligibility that occurred in some states. Our analyses are based on U.S. Vital Statistics Natality files, which enables linkages between individuals' early life Medicaid exposure and the next generation's health at birth. We find evidence that the health benefits associated with treated generations' early life program exposure extend to later offspring. Our results suggest that the returns on early life health investments may be substantively underestimated.

The economic impact of obesity in Kuwait: a micro-costing study evaluating the burden of obesity-related comorbidities

OBJECTIVE

44% of Kuwait's population live with obesity and the health consequences place a significant burden on the public health system. This study provides an assessment of the cost burden of obesity-related comorbidities (ORC).

METHODS

A retrospective micro-costing analysis was conducted to quantify the direct cost associated with ORCs. ORCs and their cost categories were informed by a systematic literature review and validated by a local steering committee comprising three experts. Seventy public sector clinicians and eight hospital procurement staff were surveyed to provide healthcare resource utilization estimates and medical resource cost data, respectively. The annual cost of each ORC and the cost drivers were also validated by the steering committee.

RESULTS

Individuals in Kuwait with any single ORC incurred direct healthcare costs ranging 1,748-4,205 KWD annually. Asthma, chronic kidney disease and type 2 diabetes were the costliest ORCs, incurring an annual cost that exceeds 3,500 KWD per patient. Hypertension, angina and atrial fibrillation were the least costly ORCs. In general, costs were driven by drug costs and resources allocated to address treatment-related adverse events.

LIMITATIONS

In the absence of an official patient registry in Kuwait, our study provides a conservative estimate of direct costs derived from a nationwide survey. Additionally, the cost estimates in this study assumes that a patient with obesity will only experience one ORC. In reality, multi-morbid states may incur additional costs that are not currently captured.

CONCLUSIONS

Our study confirms that ORCs generate a significant financial burden to the public payer. The study provides an economic case for policymakers to recognize the exigency for obesity prevention and control in accordance with the ORC prevalence, and the need for sustainable investments towards body-mass index management to prevent individuals from developing multiple comorbidities.

Emergent challenges and opportunities in drug discovery and commercialization

We review medical economics literature presented at the 2023 annual AEA-ASSA convention, the largest gathering of economists worldwide. Pharmacoeconomic papers addressed a wide range of issues, including gender and racial gaps in clinical trials, hospital credit financing, drug rebates, covid-19 vaccine equality, and the opioid epidemic. Yet, they had some common identifiable themes. We examine them in the context of the "twin towers" of biopharmaceutical innovation: discovery and commercialization. Implementation outcomes and relative success of innovative solutions - whether in terms of products and services, structural design and arrangements, or policies - depend on how adequately they respond to questions and challenges that arise in drug discovery and commercialization, and who gains from them. That innovation's beneficiaries might not equally gain from its intended advantages is another unifying theme in the reviewed literature. Against this backdrop, biopharmaceutical innovation can breed new challenges and opportunities. And health policy can perform a critical, leveling function that reduces cost, increases access, and ensures quality of biopharmaceutical solutions.

The budget impact of utilizing the Oncotype DX Breast Recurrence Score test from a US healthcare payer perspective

BACKGROUND AND OBJECTIVES

The Oncotype DX Breast Recurrence Score test is used to estimate distant recurrence risk of hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-) early-stage breast cancer and inform decisions on the use of adjuvant chemotherapy. A model-based budget impact analysis compared the Oncotype DX test in combination with clinical-pathological risk against using clinical-pathological risk alone for HR+/HER2- node-negative (N0) and node-positive (N1; 1-3 axillary lymph nodes) early-stage breast cancer patients.

MATERIALS AND METHODS

Test and medical costs associated with treatment of breast cancer were assessed through a US healthcare payer perspective. Distributions of patients by Recurrence Score result and distant recurrence probabilities with chemo-endocrine and endocrine therapy were derived from the TAILORx (N0) and RxPONDER (N1) trials. Changes in budget impact were evaluated over a 5-year horizon for a 1,000,000-member hypothetical health plan.

RESULTS

With the Oncotype DX test, there was an incremental budget impact of $261,067 (per member per month (PMPM): $0.004), in the N0 population, and $56,143 (PMPM: $0.001) in the N1 population over the 5-year period. The largest budget impact reduction in the N0 population was attributed to reduced breast cancer recurrence costs (incremental: -$633,457, PMPM: -$0.011), while chemotherapy sparing reduced costs in the N1 population (incremental: -$94,884, PMPM: -$0.002).

CONCLUSION

The clinical benefit of using the Oncotype DX test to inform adjuvant chemotherapy decisions has been shown in multiple randomized controlled trials. This analysis demonstrated that while using the Oncotype DX test to inform adjuvant chemotherapy decisions may slightly increase US healthcare costs over an initial 5-year time horizon (driven by a cost increase in the first year with cost savings reflected in remaining 4 years), there is significant scope for cost savings when assessing beyond this period due to avoided downstream costs of distant recurrence and long-term chemotherapy adverse events. PMPM costs also remain low across all populations examined, demonstrating a close-to-neutral budget impact.

Budget impact of introducing oral semaglutide to the public healthcare benefit package in Saudi Arabia

BACKGROUND

The Kingdom of Saudi Arabia (KSA) has embarked on a Health Sector Transformation Program as part of the Kingdom's Vision 2030 initiatives with the facilitation of access to healthcare services for the millions in KSA with diabetes an essential part of the Program. Decision-making tools, such as budget impact models, are required to consider the addition of new medications like oral semaglutide that have multifaceted health benefits and address barriers related to therapeutic inertia to reduce diabetes-related complications.

OBJECTIVE

To determine the financial impact of the introduction of oral semaglutide as a treatment option for people with type 2 diabetes mellitus (T2DM) in KSA.

METHODS

From the public payer's perspective, the budget impact model estimates the costs before and after the introduction of oral semaglutide over a 5-year time horizon. The budget impact of introducing oral semaglutide (primary comparator) compared with three different classes of diabetes medicines: glucagon-like peptide-1 receptor agonists (GLP-1), sodium-glucose transport protein 2 inhibitors (SGLT 2i) and dipeptidyl peptidase 4 inhibitors (DDP-4i) have been calculated based on the projected market shares. The model includes the cost of care through the incorporation of health outcomes that have an impact on the national payer's budget in Saudi Riyals (SAR).

RESULTS

The budget impact over the five-year time horizon indicates a medication cost increase (17,424,788 SAR), and cost offsets which include a difference in diabetes management costs (-3,625,287 SAR), CV complications costs (-810,733 SAR) and weight loss savings of 453,936 SAR. The cumulative total cost difference is 12,427,858 SAR (0.66%).

CONCLUSION

The introduction of oral semaglutide 14 mg as a second-line treatment option after metformin is indicated as budget-neutral to slightly budget-inflating for the public pharmaceutical formulary of KSA. The price difference is offset by positive health outcomes and costs. This conclusion was confirmed through a probabilistic sensitivity analysis.

Do non-citizens migrate for welfare benefits? Evidence from the Affordable Care Act Medicaid expansion

We explore if low-educated noncitizens, who have a considerably high uninsured rate, internally migrate to states with more generous public insurance benefits. We utilize the state-level variation in accessing Medicaid benefits and employ a difference-in-differences methodology that compares in-migration and out-migration rates of non-citizens in states that adopted Medicaid expansion, both before and after the policy implementation, to the outcomes of non-citizens in states that did not adopt the expansion. We find that interstate in-migration (out-migration) rates of Medicaid expansion states did not increase (decrease) relative to that of non-expansion states after the expansion.

INFORMATION GAPS AND HEALTH INSURANCE ENROLLMENT: Evidence from the Affordable Care Act Navigator Programs

We studied the impact of Affordable Care Act navigator programs on health insurance coverage, using the 80 percent cut in program funding under the Trump administration as a natural experiment. Our study design exploited county-level differences in the program prior to funding cuts. We did not find that cuts to the program significantly decreased rates of marketplace coverage or any health insurance coverage by 2019; however, our estimates could not rule out marketplace coverage declines of up to 2.7 percent (point estimate -1.3 percent, 95 percent CI: 2.7 percent to 0.1 percent), or total coverage declines of up to 1.8 percentage points (point estimate -0.8 percentage points or -1.2 percent, 95 percent CI: -1.8 to 0.2). Cuts to the navigator program significantly decreased marketplace coverage and total coverage among lower-income adults, and significantly decreased total coverage among adults under age 45, Hispanic adults, and adults who speak a language other than English at home. We found no significant impact of the cuts on Medicaid enrollment (95 percent CI: -1.9 percentage points to 0.5 percentage points); most uninsured people in the states we studied lived in locations that had not implemented Medicaid eligibility expansions. These findings suggest that before the funding cuts, navigators were helping underserved consumers obtain coverage.

How Did the Affordable Care Act Affect Risky Health Behaviors?

BACKGROUND

The Affordable Care Act (ACA) expanded insurance coverage in the USA through Medicaid expansions, insurance marketplaces, subsidies, and mandates in 2014. Insurance coverage at such a large scale may affect individuals' risky health behaviors such as smoking, excessive drinking, overeating, not exercising, and illicit substance use. Those effects are not easy to predict, and they may be positive or negative. On one hand, as more people have access to health care, they may improve their health behaviors with advice from medical professionals, educational materials, tobacco cessation treatments, and healthy behavior incentive programs provided by Medicaid. On the other hand, this increase in access can also lead to moral hazard where reduced costs of health care through insurance can make individuals choose less healthy behaviors.

OBJECTIVES

In this study, I asked whether the ACA changed risky health behaviors.

METHODS

I used a difference-in-difference-in-differences regression model where time, state Medicaid expansion status, and local area pre-ACA uninsured rate together constituted my identification strategy. In all my models, I controlled for a large set of individual-level and area-specific variables.

RESULTS

I did not find any statistically significant negative effects on risky health behaviors that would have supported the existence of moral hazard that dominates other effects. On the other hand, I found significant improvements in smoking and excessive drinking in 2017 and 2018. These results are robust to using only the subsamples of poor childless adults and the newly insured.

CONCLUSIONS

Early effects of the ACA's insurance coverage expansions did not lead to any significant changes in risky health behaviors except for improvements in smoking and excessive drinking in 2017 and 2018. Further research is needed for the later years as more individuals became aware of these benefits.

VOLUNTARY REGULATION: EVIDENCE FROM MEDICARE PAYMENT REFORM

Government programs are often offered on an optional basis to market participants. We explore the economics of such voluntary regulation in the context of a Medicare payment reform, in which one medical provider receives a single, predetermined payment for a sequence of related healthcare services, instead of separate service-specific payments. This "bundled payment" program was originally implemented as a 5-year randomized trial, with mandatory participation by hospitals assigned to the new payment model; however, after two years, participation was made voluntary for half of these hospitals. Using detailed claim-level data, we document that voluntary participation is more likely for hospitals that can increase revenue without changing behavior ("selection on levels") and for hospitals that had large changes in behavior when participation was mandatory ("selection on slopes"). To assess outcomes under counterfactual regimes, we estimate a stylized model of responsiveness to and selection into the program. We find that the current voluntary regime generates inefficient transfers to hospitals, and that alternative (feasible) designs could reduce these inefficient transfers and raise welfare. Our analysis highlights key design elements to consider under voluntary regulation.

When Should There Be Vertical Choice in Health Insurance Markets?

We study the welfare effects of offering choice over coverage levels-"vertical choice"-in regulated health insurance markets. We emphasize that heterogeneity in efficient coverage level is not sufficient to motivate choice. When premiums cannot reflect individuals' costs, it may not be in consumers' best interest to select their efficient coverage level. We show that vertical choice is efficient only if consumers with higher willingness-to-pay have a higher efficient level of coverage. We investigate this condition empirically and find that as long as a minimum coverage level can be enforced, the welfare gains from vertical choice are either zero or economically small.

Healthcare resource utilization and costs in individuals with Huntington's disease by disease stage in a US population

AIMS

To quantify healthcare resource utilization (HRU) and costs by disease stage in individuals with Huntington's disease (HD) in a US population.

MATERIALS AND METHODS

This retrospective cohort study used administrative claims data from the IBM MarketScan Commercial, Multi-State Medicaid, and Medicare Supplemental Databases between 1 January 2009 and 31 December 2018. Individuals with an HD claim between 1 January 2010 and 31 December 2017 were selected. Index date was the date of first HD diagnosis. Individuals were required to have continuous enrollment for ≥ 12 months pre-index, 3 months post-index, and have no pre-index HD claims. All-cause HRU and costs per patient per month (PPPM) (overall and stratified by disease stage) were assessed for individuals with HD.

RESULTS

A total of 2,669 individuals with HD were identified. Of these, 1,432 (53.7%), 689 (25.8%), and 548 (20.5%) had early-, middle-, and late-stage HD at baseline, respectively. Mean HRU PPPM by post-index HD stage increased with disease stage for outpatient visits, pharmacy claims, and HD-related pharmacy claims (p < 0.05 for all). Mean inpatient visits and emergency room visits PPPM were highest in individuals with middle-stage HD (p <0.05 for all). Mean total all-cause healthcare cost PPPM for individuals with HD was $2,889, and it was significantly higher in middle-stage individuals, at $7,988, compared with early- and late-stage individuals, at $3,726 and $5,125, respectively; p <0.0001.

LIMITATIONS

In the absence of disease staging information in administrative claims data, staging was based on the presence of clinical markers in claims. Our evaluations didn't include the indirect costs of HD, which may be substantial as HD typically affects people at their peak earning potential.

CONCLUSIONS

HRU and costs of care are high among individuals with HD, particularly among those with middle- and late-stage disease. This indicates that the disease burden in HD increases with disease stage, highlighting the need for interventions that can slow or prevent disease progression.

Oncology drugs and added benefit: insights from 3 European health technology assessment agencies on the role of efficacy endpoints

OBJECTIVE

This study aimed to understand the impact of different efficacy endpoints on reimbursement decisions made by health technology assessment (HTA) bodies.

MATERIALS AND METHODS

European Medicines Agency (EMA) oncology product marketing authorizations were screened to identify products that completed review by 3 HTA bodies during 2016-2019: United Kingdom's National Institute for Health and Care Excellence, Germany's Gemeinsamer Bundesausschuss, and France's Haute Autorité de Santé. Each decision's endpoint information, including overall survival (OS) and progression-free survival (PFS), was extracted. Each endpoint's influence on added benefits rating (the degree of added benefit as judged by the HTA agency) and full reimbursement (i.e. reimbursed population to label) decisions was tested using bivariate analyses.

RESULTS

An increasing trend was observed toward HTA submissions with immature OS data (36.8% and 71.4% in 2016 and 2019, respectively), which was a predictor of limited added benefit (p < .001). Regarding data availability, 63% of submissions provided OS, 2% provided PFS without OS; and 35% provided neither. OS availability significantly influenced added benefit (p < .001) but not full reimbursement (p > .05) decisions, whereas PFS without OS had no significant impact compared with either OS or PFS data for either outcome (p = .99).

CONCLUSIONS

The trend toward fewer products filing mature OS data over time suggests sponsors may be increasingly confident achieving reimbursement with surrogate endpoint data, although mature OS data provided the strongest correlation to positive reimbursement decisions. Notably, in some locally advanced settings, OS data maturity will take a long time to obtain. To expedite patient access to new medicines, payers should consider the acceptance of surrogate endpoints predictive of clinical benefit.

Comprehensive genomic profiling in advanced/metastatic colorectal cancer: number needed to test and budget impact of expanded first line use

AIMS

Use of comprehensive genomic profiling (CGP) in metastatic colorectal cancer (mCRC) is limited. We estimated impacts of expanded 1 L CGP, using the Tempus xT test, on detection of actionable alterations and testing budgets in a modeled US health plan over two-years.

MATERIALS AND METHODS

A decision analytic model was developed to estimate the impact of replacing 20% of usual testing (a mix of CGP and non-CGP) with Tempus xT CGP. Actionable alterations for matched treatments or clinical trial included KRAS, NRAS, RAF, BRAF, deficient mismatch repair (dMMR)/microsatellite instability (MSI), NTRK, RET, EGFR, HER2, MET, PIK3CA and POLE1. Costs included initial and repeat testing, physician-associated and administrative costs.

RESULTS

In a hypothetical five-million-member plan, 50% Medicare and 50% commercial, 1,112 new cases of mCRC were expected per year. Of these, 566 (51%) would undergo 1 L molecular testing, with 55 re-tested upon progression. Based on current testing rates, there were an expected 521 missed opportunities for genomically informed treatment (47% of new cases), with 442 missed due to lack of testing and 79 due to testing without CGP. Replacing 20% of usual testing with Tempus xT CGP was associated with up to a $0.003 per member per month testing cost increase (net total cost of $202,102 for the five-million-member plan) and 15.5 additional patients with an opportunity for genomically informed care (12.7 patients for treatment and 2.8 for clinical trial). The testing total cost (initial test, repeat test, biopsy and physician services, and administrative cost) to put one additional patient with mCRC on matched therapy or matched clinical trial was estimated to be $13,005. Number needed to test to identify one actionable alteration with Tempus xT CGP versus usual testing was 7.8 patients.

LIMITATIONS

Conservative assumptions were made for inputs with limited evidence. Based on high concordance rates with dMMR/MSI status, tumor mutational burden (TMB) status was not calculated separately.

CONCLUSIONS

Replacing 20% of usual testing with Tempus xT CGP was associated with a small incremental testing cost and can identify meaningfully more actionable alterations.

Economic evaluation of a vision-based patient monitoring and management system in addition to standard care for adults admitted to psychiatric intensive care units in England

BACKGROUND AND AIMS

Treating patients in psychiatric intensive care units (PICUs) is costly for the English National Health Service (NHS), requiring significant staff time. Oxevision, a non-contact system, providing vision-based patient monitoring and management (VBPMM) has been introduced in some NHS mental health trusts which aims to help clinicians to deliver safer and more efficient care. The objective of this early economic evaluation was to explore the impact of introducing VBPMM with standard care, versus standard care alone on health and economic outcomes in PICUs across England.

METHODS

The model uses a cost calculator approach to evaluate the potential benefits of introducing VBPMM, capturing differences in observation hours and critical events such as assaults. Effectiveness data were primarily based on a 24-month observational before and after study undertaken in an NHS mental health trust using VBPMM. Outcomes reported in this study are incremental costs and reduction in clinical events presented as per occupied bed days, per patient, per average ward, and for the English NHS overall. Scenario analysis was conducted to test the uncertainty of results using statistical significance of key inputs.

RESULTS AND CONCLUSIONS

The analysis indicates that introducing VBPMM may be cost saving compared with standard care alone. The biggest driver of estimated cost savings was from the potential reduction in one to one observation hours, which may have significant impact in PICUs. Limitations of the analysis include the single center data underpinning the analysis and assumptions made about transferability of clinical data to different sized wards. Scenario analysis was conducted, and the results were robust to statistically significant changes in input parameters. This study suggests that introducing VBPMM on PICUs has the potential to reduce costs and improve efficiency of resource allocation, but results should be confirmed with additional clinical study evidence.

Methodological Challenges in Estimating the Lifetime Medical Care Cost Externality of Obesity

There is a great deal of variability in estimates of the lifetime medical care cost externality of obesity, partly due to a lack of transparency in the methodology behind these cost models. Several important factors must be considered in producing the best possible estimate, including age-related weight gain, differential life expectancy, identifiability, and cost model selection. In particular, age-related weight gain represents an important new component to recent cost estimates. Without accounting for age-related weight gain, a study relies on the untenable assumption that people remain the same weight throughout their lives, leading to a fundamental misunderstanding of the evolution and development of the obesity crisis. This study seeks to inform future researchers on the best methods and data available both to estimate age-related weight gain and to accurately and consistently estimate obesity's lifetime external medical care costs. This should help both to create a more standardized approach to cost estimation as well as encourage more transparency between all parties interested in the question of obesity's lifetime cost and, ultimately, evaluating the benefits and costs of interventions targeting obesity at various points in the life course.

Utilization Management in the Medicare Part D Program and Prescription Drug Utilization

Medicare Part D has significantly enhanced access to prescription drugs among Medicare beneficiaries. However, the recent rapid rise of utilization management policies in the Medicare Part D program may have adversely affected access to prescription drugs. I study the effects of expected and observed exposure to utilization management in prescription drug utilization using Medicare Part D claims data from 2009 to 2016 and an instrumental variables strategy based on the interaction of lagged health status and the set of plans available to each beneficiary. I find that the expected share of spending subject to utilization management increases the observed share, with the smallest effect for prior authorization. Increases in the expected share of drug spending subject to prior authorization increases Part D spending by $122.27 per percentage point, with almost three-quarters of this increase being paid by the Medicare program, rather than beneficiaries or plans. Comparable increases in step therapy and quantity limit exposure increase spending by $46 and decrease spending by $31, respectively. Interestingly, increased exposure to prior authorization and quantity limits increases the average price per 30-day prescription.

Demographic Transition, Human Capital and Economic Growth in China

We assess the impact of demographic changes on human capital accumulation and aggregate output using an overlapping generations model with endogenous savings and human capital investment decisions. We focus on China as it has experienced rapid changes in demographics as well as human capital levels between 1970 and 2010. Additionally, further variations in demographics are expected due to the recently introduced two-child policy. Model simulations indicate that education shares and income per capita will be lower with a fertility rebound as compared to status quo fertility. We find education policy to be effective in mitigating these adverse outcomes associated with higher fertility. While long-run declines in output per capita can be offset by a 4.7% increase in the government education budget, it requires a 28% increase to achieve the same outcome in the short-run.

Disentangling Moral Hazard and Adverse Selection in Private Health Insurance

Moral hazard and adverse selection create inefficiencies in private health insurance markets and understanding the relative importance of each factor is critical for addressing these inefficiencies. We use claims data from a large firm which changed health insurance plan options to isolate moral hazard from plan selection, estimating a discrete choice model to predict household plan preferences and attrition. Variation in plan preferences identifies the differential causal impact of each health insurance plan on the entire distribution of medical expenditures. Our estimates imply that 53% of the additional medical spending observed in the most generous plan in our data relative to the least generous is due to adverse selection. We find that quantifying adverse selection by using prior medical expenditures overstates the true magnitude of selection due to mean reversion. We also statistically reject that individual health care consumption responds solely to the end-of-the-year marginal price.

The Basic vs. Ability-to-Pay Approach: Evidence From China's Critical Illness Insurance on Whether Different Measurements of Catastrophic Health Expenditure Matter

Alleviating catastrophic health expenditure (CHE) is one of the vital objectives of health systems, as defined by the World Health Organization. However, no consensus has yet been reached on the measurement of CHE. With the aim of further relieving the adverse effects of CHE and alleviating the problem of illness-caused poverty, the Critical Illness Insurance (CII) program has been operational in China since 2012. In order to verify whether the different measurements of CHE matter under China's CII program, we compare the two-layer CII models built by using the basic approach and the ability-to-pay (ATP) approach at a range of thresholds. Exploiting the latest China family panel studies dataset, we demonstrate that the basic approach is more effective in relieving CHE for all insured households, while the ATP approach works better in reducing the severity of CHE in households facing it. These findings have meaningful implications for policymaking. The CII program should be promoted widely as a supplement to the current Social Basic Medical Insurance system. To improve the CII program's effectiveness, it should be based on the basic approach, and the threshold used to measure CHE should be determined by the goal pursued by the program.

Cost-effectiveness of opicapone and entacapone in reducing OFF-time in Parkinson's disease patients treated with levodopa/carbidopa

AIMS

To assess from a US payer perspective the relative cost-effectiveness of the catechol-O-methyltransferase inhibitors opicapone and entacapone when used adjunctively to levodopa/carbidopa (LD/CD) in patients with Parkinson's disease (PD), based on the drugs' effects to reduce absolute OFF-time hours in PD patients.

MATERIALS AND METHODS

A Markov model was created to estimate cost-effectiveness of adjunctive opicapone treatment compared with adjunctive entacapone treatment in a synthetic cohort of 1,000 patients with PD taking LD/CD. Clinical inputs were derived from clinical trials, published literature, and expert opinion. Cost data (in 2018 US dollars) were obtained from the Centers for Medicare & Medicaid Services, the Kaiser Family Foundation, and Analy$ource. Cost-effectiveness outcomes included incremental cost per OFF-time hours avoided, cost per life year gained, and cost per quality-adjusted life year (QALY) gained. Outcomes were projected over a 25-year lifetime horizon and discounted at 3% annually.

RESULTS

Opicapone treatment was associated with an average of 1,187 fewer OFF-time hours per patient and an increase of 0.07 QALYs compared with entacapone. Total lifetime costs for opicapone were $3,100 higher than entacapone, resulting in an incremental cost-effectiveness ratio of $46,900 per QALY. One-way sensitivity analyses showed the model was most sensitive to mean OFF-time hours associated with opicapone and entacapone. Probabilistic sensitivity analysis suggested a 60-65% probability that opicapone was cost-effective relative to entacapone at any willingness-to-pay threshold ≥$5,000.

LIMITATIONS

There exists a single head-to-head clinical trial comparing the effectiveness of opicapone with entacapone, thus the clinical inputs regarding relative treatment effect of the drugs to reduce OFF-time hours in PD patients receiving LD/CD were derived from that single non-inferiority trial.

CONCLUSIONS

Add-on treatment with opicapone in PD patients receiving LD/CD appeared to be cost-effective compared with entacapone.

Cost-effectiveness of tofacitinib compared with infliximab, adalimumab, golimumab, vedolizumab and ustekinumab for the treatment of moderate to severe ulcerative colitis in Germany

OBJECTIVES

Tofacitinib is an oral, small molecule Janus kinase (JAK) inhibitor for the treatment of ulcerative colitis (UC). This study assessed the cost-effectiveness of tofacitinib versus other available treatments for patients with moderate to severe UC following an inadequate response to conventional treatment and who are either naïve to or have failed previous biologics in Germany.

METHODS

A Markov cohort model was developed to evaluate the differences in long-term costs and outcomes between tofacitinib and its comparators from the perspective of German statutory health insurance (SHI) for patients either naïve or exposed to biologics. Tofacitinib was compared to infliximab, infliximab biosimilar, adalimumab, adalimumab biosimilar, golimumab, vedolizumab, ustekinumab, and conventional therapy. Health states modeled were remission, treatment response, active UC, and post-colectomy. Patients not responding to treatment could switch to a different treatment. Treatment efficacy for induction and maintenance phases were assessed by a systematic literature review (SLR) and network meta-analysis (NMA). The model included costs associated with drug administration, adverse events, and medical resource use. Extensive deterministic and probabilistic sensitivity analyses (DSA and PSA) were conducted.

RESULTS

Over a life-time horizon, patients treated with tofacitinib gained 0.035-0.083 quality-adjusted life-years (QALYs) and had direct cost savings to the SHI of €4,228-€17,184 compared to biologic treatments other than adalimumab biosimilar. When compared to adalimumab biosimilar, treatment with tofacitinib resulted in an incremental cost-effectiveness ratio (ICER) of €17,497 per QALY gained and can be considered a cost-effective alternative. Compared with conventional therapy, tofacitinib resulted in a lower ICER than all other biologics. The DSA showed that the model results were most influenced by differences in treatment efficacy. The PSA suggested confidence in the base-case results considering uncertainty around parameters.

CONCLUSIONS

The results of this economic model suggest tofacitinib is a cost-effective treatment option for patients with moderate to severe UC in Germany.

Cost-effectiveness of valbenazine compared with deutetrabenazine for the treatment of tardive dyskinesia

AIMS

To evaluate clinical and economic outcomes associated with valbenazine compared with deutetrabenazine in patients with tardive dyskinesia (TD) using a model that accounts for multiple dimensions of patient health status.

MATERIALS AND METHODS

A discretely integrated condition event model was developed to evaluate the cost-effectiveness of treatment with valbenazine and deutetrabenazine in a synthetic cohort of 1,000 patients with TD who were receiving antipsychotic medication to treat an underlying psychiatric disorder. Clinical inputs were derived from relevant clinical trials or from publicly available sources. Patients were assessed over 1 year using ≥50% improvement from baseline in Abnormal Involuntary Movement Scale (AIMS) total score as the primary definition of response. Response at 1 year using Clinical Global Impression of Change (CGIC) score ≤2 was also assessed. Health outcomes included quality-adjusted life years (QALYs), life years, proportion responding to treatment at 1 year, and number of psychiatric relapses.

RESULTS

Regardless of the definition used for response, patients treated with valbenazine were more likely to have responded to treatment at 1 year, lived longer, and accrued more QALYs than patients who received deutetrabenazine. Using the AIMS response criterion, the incremental cost-effectiveness ratio was $9,951/QALY for valbenazine compared with deutetrabenazine. By comparison, using the CGIC response criterion valbenazine dominated deutetrabenazine with valbenazine-treated patients accumulating more QALYs (3.4 vs 3.3 years) and incurring lower lifetime costs ($252,311 vs $283,208) than deutetrabenazine-treated patients.

LIMITATIONS

There are no head-to-head trials of valbenazine and deutetrabenazine, so probabilities of response used in the model were calculated based on an indirect treatment comparison of results from individual trials with one drug or the other, using only those metrics reported across trials.

CONCLUSIONS

In patients with TD, treatment with valbenazine is highly cost-effective compared with deutetrabenazine.

Healthcare resource utilization and costs for hip dislocation following primary total hip arthroplasty in the medicare population

AIM

To estimate 2-year healthcare resource utilization (HCRU) and costs of dislocation following primary total hip arthroplasty (THA).

MATERIALS AND METHODS

This retrospective evaluation used medical claims from the US Medicare database. Patients were eligible if they were ≥65 years old, underwent a primary elective inpatient THA between 1 January 2010 and 31 December 2016 (index), and had continuous Medicare coverage and enrollment ≥365 days prior to index (baseline). Exclusion criteria were prior THA, concomitant infection, non-Medicare primary payer, or enrolled in Medicare due to end-stage renal disease. One- and 2-year HCRU and costs across all service types and settings of care excluding retail pharmacy were evaluated. Propensity score matching and direct matching adjusted for confounding.

RESULTS

Among Medicare patients who underwent THA and met inclusion criteria (n = 450,355; mean age ∼74, and two-thirds female), 7,680 (1.7%) had a hip dislocation. After matching, 4,551 patients without and 4,551 patients with dislocation were selected. Percentage utilization, mean days of service, and claims payments amounts were significantly greater for patients with vs without THA dislocation for variables such as THA hospitalization, home health agency, skilled nursing facility, inpatient rehabilitation facility, other inpatient admission, long-term care hospital, and outpatient care. Findings were consistent for 1- and 2-year follow-up, although differences were more pronounced for 1-year. Per-patient-cost increases with dislocation were $19,590 over 1 year and $24,211 over 2 years. Two-thirds of the cost increase was due to other inpatient admission and the remaining one-third was due to skilled nursing facility, outpatient, inpatient rehabilitation facility, and home health agency costs.

LIMITATIONS

Administrative claims are not collected for research and lack clinical information. Results may not be generalizable to other patients or settings of care.

CONCLUSIONS

This large US retrospective database study demonstrated the substantial HCRU and cost burden of THA dislocation.

Long-term cost-effectiveness of a disease management program for patients with atrial fibrillation compared to standard care - a multi-state survival model based on a randomized controlled trial

AIM

To assess the long-term cost-effectiveness of an atrial fibrillation disease management program (i.e. the SAFETY program) from the Australian healthcare system perspective.

METHODS

A multistate Markov model was developed based on patient-level data from the SAFETY randomized controlled trial. Predicted long-term survival, dependent on hospital admission history, was estimated by extrapolating parametric survival models. Quality-adjusted life years (QALY) and life years (LY) were the primary and secondary outcome measures used to estimate the incremental cost-utility/effectiveness ratio (ICUR/ICER). Both deterministic and probabilistic sensitivity analyses (PSA) were undertaken.

RESULTS

The SAFETY program was associated with both higher costs ($94,953 vs. $78,433) and benefits [QALY (3.99 vs 3.60); LY (5.86 vs 5.24)], with an ICUR of $42,513/QALY or ICER of $26,356/LY, compared to standard care. Due to the extended survival, the SAFETY was associated with a greater number of hospitalizations (14.85 vs 11.65) and higher costs for medications ($25,084 vs $22,402) and outpatient care ($12,904 vs $11,524). The cost per hospitalization for an average length of stay, analytical time horizon, and cost of medication are key determinants of ICUR. The PSA showed that the intervention has a 70.4% probability of being cost-effective at a threshold of $50,000/QALY.

CONCLUSIONS

The SAFETY program has a high probability of being cost-effective for patients with atrial fibrillation. It is associated with uncertainty that further research could potentially eliminate; implementation with further evidence collection is recommended.

The implications of suboptimal year-1 outcomes with disease-modifying therapy in employees with multiple sclerosis

AIM

Multiple sclerosis (MS) poses a substantial employer burden in medically related absenteeism and disability costs due to the chronic and debilitating nature of the disease. Although previous studies have evaluated relapse, nonadherence, discontinuation, and switching individually, little is known about their overall collective prevalence and implications in employees with MS treated with disease-modifying therapies (DMTs). This study evaluated the proportion of employees with MS with suboptimal DMT year-1 outcomes and to quantify the clinical and economic burden of suboptimal year-1 outcomes from a US employer perspective.

MATERIALS AND METHODS

Employees with MS were selected from the Workpartners database. Eligibility criteria were: ≥2 MS diagnosis claims (ICD-9-CM 340.xx/ICD-10-CM G35) from January 1, 2010-March 31, 2019, ≥1 once-/twice-daily oral or self-injectable DMT claim (first claim = index), continuous eligibility 6-months pre-/1-year post-index, no baseline DMT, and age 18-64 years. Suboptimal year-1 outcomes included: non-adherence (proportion of days covered <80%), discontinuation (gap >60 days), switch, or relapse (MS-related hospitalization, emergency room visit, or outpatient visit with corticosteroid). A two-part logistic-generalized linear model evaluated costs.

RESULTS

Of 488 eligible patients, half (n = 247; 50.6%) had suboptimal year-1 outcomes (39.5% non-adherence, 9.8% discontinuation, 10.9% switching, 20.7% relapse; not mutually exclusive). Employees with suboptimal year-1 outcomes had higher all-cause medical ($12,730 vs. $6,428; p < 0.0001), MS-related medical ($5,444 vs. $2,652; p < 0.0001), non-DMT pharmacy ($2,920 vs. $2,169; p = 0.0199), sick leave ($1247 vs. $908; p = 0.0274), and short-term disability ($934 vs. $146; p = 0.0001) costs. Long-term disability ($751 vs. $0; p = 0.1250) and Workers' Compensation ($56 vs. $24; p = 0.1276) did not significantly differ.

LIMITATIONS

Administrative claims lack clinical information. Results may not be generalizable to other patients or care settings.

CONCLUSIONS

Half of the employees with MS in this sample had suboptimal year-1 outcomes (i.e. non-adherence, discontinuation, switching, or relapse). These suboptimal year-1 outcomes were associated with greater medical, sick leave, and short-term disability costs.

Burden of acromegaly in the United States: increased health services utilization, location of care, and costs of care

BACKGROUND

Limited information is available on the utilization and healthcare costs among patients with acromegaly. The purpose of this study was to assess the impact of acromegaly on healthcare utilization and costs by locations of care (LoC).

METHODS

Patients with acromegaly and controls were identified from an analysis of drug and medical claims filed from January 2010 to April 2019 from a US employer database. Each patient with acromegaly was matched with 20 random controls (without acromegaly) selected from the database. Claims were tracked for 12 months postdiagnosis (or matched date for controls). Outcomes by LoC, including costs, services, and likelihood of use, were compared using two-stage regression models or logistic regression models, controlling for demographic and job-related variables, and Charlson comorbidity index scores.

RESULTS

Claims from 60 patients with acromegaly and 1,200 controls were analyzed. Compared with the control group, patients with acromegaly had significantly higher likelihoods of receiving care in a physician's office [odds ratio > 1,000], inpatient [OR = 8.010], outpatient [OR = 12.656], laboratory [OR = 3.681], and 'other' locations [OR = 4.033] (all p < .001), except in an emergency department (ED). Significantly more services were performed at each LoC for those with acromegaly (p < .01) but not in an ED. Total costs were more than 5-fold higher for the acromegaly cohort compared with controls (p < .05). Costs by LoC were consistently higher (p < .001) for patients with acromegaly vs. controls, with mean annual cost differences greatest in outpatient hospital/clinic ($9,611 vs $1,355), inpatient ($8,646 vs $739), physicians' office ($4,762 vs $1,301), other ($2,001 vs $367), and laboratory ($508 vs $66). ED-related treatment costs were not significantly different between cohorts.

CONCLUSIONS

Compared with matched controls, patients with acromegaly were more likely to utilize healthcare services in nearly all LoCs and accrue higher expenditures at each LoC, with the exception of ED services.

Hospitalization costs with degludec versus glargine U100 for patients with type 2 diabetes at high cardiovascular risk: Canadian costs applied to SAEs from a randomized outcomes trial

OBJECTIVES

The present cost-consequence analysis compared estimated hospitalization costs in a Canadian setting with insulin degludec (degludec) versus insulin glargine 100 units/mL (glargine U100) in patients with type 2 diabetes (T2D) at high cardiovascular (CV) risk.

METHODS

Medical terms were mapped across the different vocabularies, in order to assign unit costs from eligible hospital abstracts in Canadian Institute for Health Information data (International Statistical Classification of Diseases and Related Health Problems, 10^th Revision, Canada) to serious adverse events (SAEs; Medical Dictionary for Regulatory Activities) from the randomized DEVOTE trial comparing the two insulins degludec and glargine. Mean annual costs of SAE-related hospitalizations were estimated by treatment, the cost difference (degludec - glargine U100) was bootstrapped to compute confidence intervals (CIs) and p-values, and the cost ratio (degludec/glargine U100) was estimated using a Tweedie distribution.

RESULTS

The mean annual cost per patient for SAE-related hospitalizations was 4,074 CAD with degludec and 4,569 CAD with glargine U100 (cost difference: -495, 95% confidence interval [CI]: -966; -24, p = .039), for a cost ratio of 0.89 (95% CI: 0.81; 0.98, p = .016). Overall, cost ratios from sensitivity analyses varying individual methodological assumptions were consistent with the main analysis. Of the system organ classes from DEVOTE SAEs, cardiac disorders were the largest contributor to the costs savings with degludec versus glargine U100.

CONCLUSIONS

In patients with T2D at high CV risk, our findings suggest that there are likely to be lower hospitalization costs with degludec versus glargine U100 based on the SAEs observed in DEVOTE and in a Canadian setting.

Budget impact of ferric carboxymaltose treatment in patients with chronic heart failure and iron deficiency in Spain

OBJECTIVE

The treatment of iron deficiency (ID) with ferric carboxymaltose (FCM) improves the functional class and quality of life of chronic heart failure (CHF) patients with reduced left ventricular ejection fraction (LVEF), and reduces the rate of hospitalization due to worsening CHF. This study aims to evaluate the budget impact for the Spanish National Health System (SNHS) of treating ID in reduced LVEF CHF with FCM compared to non-iron treatment.

METHODS

We simulated a hypothetical cohort of 1000 CHF patients with ID and reduced LVEF based on the Spanish population characteristics. A decision-analytic model was also built using the data from the largest FCM clinical trial (CONFIRM-HF) that lasted for a year. We considered the use of healthcare resources from a national prospective study. A deterministic sensitivity analysis was carried out varying the corresponding baseline data by ±25%.

RESULTS

The cost of treating the simulated population with FCM was €2,570,914, while that of the non-iron treatment was €3,105,711, which corresponds to a cost saving of €534,797 per 1,000 patients in one year. Cost savings were mainly due to a decrease in the number of hospitalizations. All sensitivity analysis showed cost savings for the SNHS.

CONCLUSIONS

FCM results in an annual cost saving of €534.80 per patient, and would thus be expected to reduce the economic burden of CHF in Spain.

Fraudster's and victims' profiles and loss predictors' hierarchy in the mental healthcare industry in the US

BACKGROUND

Fraud- or theft-related crimes account for the highest number of crimes in the mental health industry in the US.

AIM

This exploratory study aims to demonstrate a fraudster's and respective victims' profiles as well as to identify the loss predictors' hierarchy in the mental health industry in the US.

MATERIALS AND METHODS

The Psychiatric Crime database and mixed-effects models are utilized for this purpose.

RESULTS

A typical fraudster's profile is defined as a 53-year old male psychiatrist who victimizes one or two of the largest federal insurance programs in states with high property crime ratios. The results revealed the year and state where the fraud is prosecuted explain the largest portion of the variance in loss size. Predictably, case-specific factors also have a significant impact on the loss. Specifically, Medicaid, the existence of collusion, and fraudster's age are associated with the fraud loss.

CONCLUSIONS

This study empirically justifies considering loss, due to healthcare fraud, from a multi-level perspective. Identified typical fraudster's and respective victim's profiles helped to elaborate on specific practical recommendations aimed at fraud prevention in the mental healthcare system in the US.

Subscriber continuity in health insurance plans: factors associated with re-enrollment and coverage changes

Aims: This study examined the extent to which Marketplace health insurance subscribers re-enroll a second year. Among re-enrollees, we sought to examine movement to more and less generous insurance plans (based on actuarial value), and the extent to which adverse selection, adverse retention, and aging in place are evident from re-enrollment choices made.Methods: Re-enrollment from 2015 to 2016 and 2016 to 2017 and movement to more and less generous insurance plans was examined using enrollment and insurance claims data from two US Federally-facilitated Marketplace insurance carriers operating in the state of New Mexico for 2015-2017. Insurance plans are assigned to metal levels based on estimated plan actuarial value: Bronze (60%), Silver (70%), and Gold (80%). Odds ratios (ORs) and 95% confidence intervals (OR CI) were estimated using logistic regressions for subscribers with base-year healthcare utilization. ORs were estimated for (1) re-enrollment in the year following the base year, and (2) movement to a higher or lower actuarial value plan.Results: Approximately 50% of subscribers re-enrolled with the same carrier for 2016 and 60% for 2017. Being enrolled 12 months was the strongest predictor for second year re-enrollment. Older individuals were more likely to re-enroll. Re-enrollment was lower for the insurance carrier with higher second year premium changes. Chronic condition utilization characteristics were positively associated with re-enrollment. Approximately 12% of Bronze subscribers moved to Silver or Gold, and had higher utilization after re-enrollment. Among Silver subscribers, 6% moved to Gold and 6% to Bronze. Approximately 37% of Gold subscribers moved to Silver or Bronze.Discussion: Re-enrollment was similar to published non-group insurance rates. Adverse selection and aging in place were observed. Evidence was weak for adverse retention. Some coverage change choices were rational, while others suggest subscribers may have difficulty making insurance choice decisions.

Effects of innovation and insurance coverage on price elasticity of demand for prescription drugs: some empirical lessons in pharmacoeconomics

AIM

Prescription drug prices in the United States are considered rather extreme. Americans spend over $460 billion on drugs annually, or almost 17 percent of total national healthcare spending. How innovation incentives and insurance coverage drive pricing, diffusion, and utilization of drugs, under conditions of risk and competition, are multi-dimensional issues in medical economics that remain under-explored in the current empirical literature. We seek to address these issues in reviewing relevant studies presented at the 2020 AEA-ASSA annual convention.

APPROACH

Drawn from the 2020 convention panel sessions devoted to health economics, empirical evidence was thematically analyzed for charted new research terrains and trajectories. Their theoretical and practical implications on efficiency, effectiveness, and value in drug production and consumption were then identified.

FINDINGS

With certain qualifications, evidence confirms price inelasticity of prescription drugs and medical treatments, along with substitution effects from high or continuously rising prices. While health insurance induces ex ante moral hazard, albeit on a larger scale than previously considered, losing dependent coverage can incentivize price-substitution to risky and illegal drugs, including those sold on the black market. At the firm level, drug patenting and exclusivity rights suggest that innovation incentives increase new or novel clinical trials and generic utilization to a considerable extent. But innovation can produce strong, offsetting effects. It can distort competition and cause (at times sharp) price increases from product-hopping, (compensatory) list pricing, industry mergers and acquisitions, and capture of positive spillovers by competitors, rather than by focal developers, in follow-on innovations. In fine, there remains room for opportunism among firms, particularly market incumbents, and many loopholes are unplugged by U.S. healthcare reform. These make drug utilization costly to the insured, and risky to those who are - or become - uninsured or underinsured for various reasons.

CONCLUSIONS

The fundamental disconnect between innovation cost and drug pricing demands public attention and policy intervention, which have proved largely elusive to date. Gaming the system in the name of scientific invention and discovery to reap additional benefits, at the expense of consumer health and income, brings to question the offsetting benefits of firm innovation. It also raises separate issues of fairness and equity. Innovation needs to be considered from the perspective of value lines and beyond conventional marketing incentives to drug utilization, with or without insurance coverage. Cost-effectiveness and cost-benefit analyses figure prominently under a value-based system of resource allocation, insurance, medical prescription, purchasing, and reimbursement.

Budget impact analysis of long acting injection for schizophrenia in Japan

Aims: To estimate the budgetary impact of providing additional reimbursement for long acting injections for schizophrenia patients in psychiatric hospital settings in Japan to improve patient outcomes in schizophrenia.Methods: Budget impact analysis of change in reimbursement policy using a prevalence-based model over a five-year time horizon. The results are reported as net change in expenditure and consequent cost/savings in Japanese yen at the time of analysis.Results: The budget impact analysis shows that an increase in reimbursement for LAIs could lead to cumulative savings of an estimated 36.6 billion JPY over five years. These savings result from a decrease in hospitalization costs and an increased usage of LAI (assumed to be 10%). Based on the sensitivity analysis, the saving estimates are most sensitive to change in market share of generic and branded oral antipsychotics.Limitations: Historical data were used to estimate the future costs of drug and hospitalization; however, it is not the best predictor of future, hence a source of potential bias. A good level of treatment adherence with oral antipsychotics was assumed, which is generally not the case; therefore, we might have overestimated the effectiveness of oral atypical antipsychotics. Additionally, the drug cost due to reimbursement might have also been overestimated because in clinical setting, the increase of LAI use may not have reached 10% of the market share. Lastly, patients' behavior was derived from models, which may have loosely approximated the reality.Conclusions: An additional reimbursement for the use of LAI in schizophrenia patients is likely to be cost neutral/cost saving and should be considered as a policy option to improve patient outcomes and budget sustainability.

Budget impact analysis for dapagliflozin in type 2 diabetes in Egypt

Introduction: Type 2 diabetes mellitus (T2DM) is a major health problem in Egypt with a high impact on morbidity, mortality, and healthcare resources. This study evaluated the budget impact and the long-term consequences of dapagliflozin versus other conventional medications, as monotherapy, from both the societal and health insurance perspectives in Egypt.Methods: A static budget impact model was developed to estimate the financial consequences of adopting dapagliflozin on the healthcare payer budget. We measured the direct medical costs of dapagliflozin (new scenario) as monotherapy, compared to metformin, insulin, sulphonylurea, dipeptidyl peptidase-4 (DPP-4) inhibitors, thiazolidinedione, and repaglinide (old scenarios) over a time horizon of 3 years. Myocardial infarction (MI), ischemic stroke, hospitalization for heart failure (HHF), and initiation of renal replacement therapy (RRT) rates were captured from DECLARE TIMI 58 trial. One-way sensitivity analyses were conducted.Results: The budget impact model estimated 2,053,908 patients eligible for treatment with dapagliflozin from a societal perspective and 1,207,698 patients from the health insurance (HI) perspective. The new scenario allows for an initial savings of EGP121 million in the first year, which increased to EGP243 and EGP365 million in the second and third years, respectively. The total cumulative savings from a societal perspective were estimated at EGP731 million. Dapagliflozin allows for savings of EGP71, EGP143, and EGP215 million in the first, second and third years respectively, from the HI perspective, with total cumulative savings of EGP430 million over the 3 years.Conclusion: Treating T2DM patients using dapagliflozin instead of conventional medications, maximizes patients' benefits and decreases total costs due to drug cost offsets from fewer cardiovascular and renal events. The adoption of dapagliflozin is a budget-saving treatment option, resulting in substantial population-level health gains due to reduced event rate and cost savings from the perspective of the national healthcare system.

Resource utilization associated with hospital and office-based insertion of a miniaturized insertable cardiac monitor: results from the RIO 2 randomized US study

Background: Previous studies support operational benefits when moving insertable cardiac monitor (ICM) insertions outside the cardiac catheterization/electrophysiology laboratories, but this has not been directly assessed in a randomized trial or when the procedure is specifically moved to the office setting. To gain insight, the RIO 2 US study collected resource utilization and procedure time intervals for ICM insertion in-office and in-hospital and these data were used to calculate costs associated with staff time and supply use in each setting.Methods and results: The Reveal LINQ In-Office 2 US study (randomized [1:1], multicenter, unblinded) included 482 patients to undergo insertion of the ICM in-hospital (in an operating room or CATH/EP laboratory) (n = 251) or in-office (n = 231). Detailed information on resource utilization was collected prospectively by the study and used to compare resource utilization and procedure time intervals during ICM insertion procedures performed in-office vs. in-hospital. In addition, costs associated with staff time and supply use in each setting were calculated retrospectively. Total visit duration (check-in to discharge) was 107 min shorter in-office vs. in-hospital (95% CI = 97-116 min; p < 0.001). Patient preparation and education in-office were more likely to occur in the same room as the procedure, compared with in-hospital (91.6% vs. 34.2%, p < 0.001 and 87.3% vs. 22.1%, p < 0.001, respectively). There was a reduction in registered nurse and cardiovascular/operating room technologist involvement in-office, accompanied by higher physician and medical assistant participation. Overall staff time spent per case was 75% higher in-hospital, leading to 50% higher staffing costs compared to in-office.Conclusions: ICM insertion in a physician's office vs. a hospital setting resulted in reduced patient visit time and reduced overall staff time, with a consequent reduction in staffing costs. Clinical trial registration: ClinicalTrials.gov NCT02395536.

The burden of osteoporosis in Saudi Arabia: a scorecard and economic model

Objectives: Aging populations are contributing to an increased volume of osteoporotic fractures. The goals of this study were to (1) develop a scorecard on epidemiological burden, policy framework, service provision, and service uptake for osteoporosis in Saudi Arabia and (2) estimate the direct costs of managing osteoporotic fractures in Saudi Arabia.Methods: Osteoporosis data specific to Saudi Arabia were collected through a systematic literature review and surveys with osteoporosis experts. The data were used to build a scorecard, as done previously for the European Union and select Latin American countries. The scorecard applied traffic light colour coding to identify areas of risk in Saudi Arabia's management of osteoporosis. The data were also used to parameterize a burden of illness model. The model estimated the direct medical costs of fractures among adults aged 50-89 years in Saudi Arabia. The model included hospitalization, testing, hip fracture surgery, and drug costs.Results: In Saudi Arabia, the Ministry of Health was aware of impending increases in the number of fractures and had prioritized osteoporosis on the national agenda. Accordingly, reimbursement restrictions for osteoporosis diagnosis and treatment were minimal. However, a national fracture registry and unified system for monitoring care were not in operation. This represents a critical gap in care that will continue to contribute to the underdiagnosis and undertreatment of osteoporosis if not addressed. In total, 174,225 osteoporosis-related fractures were estimated to occur in Saudi Arabia in 2019, with an annual cost of SR2.38 billion ($636 million USD; $1.55 billion PPP). Hospitalization was the primary cost driver.Conclusions: In 2019, Saudi Arabia was expected to incur SR2.38 billion ($636 million USD; $1.55 billion PPP) in costs owing to 174,225 osteoporosis-related fractures. The establishment of a national fracture registry and implementation of fracture liaison services will be paramount to reducing the fracture burden.

Evaluation of four disease management programs: evidence from blue cross blue shield of Louisiana

Aims: Chronic diseases impose a substantial healthcare burden. This study sought to evaluate the clinical and economic impact of new disease management (DM) programs, targeting four major chronic disease groups: diabetes, coronary heart disease (CHD)/hypertension (HTN), asthma/chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF)/chronic kidney disease (CKD).Materials and methods: Between March 1, 2015, and February 28, 2018, members with Blue Cross Blue Shield of Louisiana insurance were contacted and enrolled in a DM program if they were aged 18 years through 64 years, eligible for a DM program, and had not been previously enrolled in a DM program. Active enrollees of a DM program ("IN" group) were compared to members who were not yet enrolled ("OUT" group). Average per member per month (PMPM) costs were aggregated annually to document any descriptive trends. Multivariable model estimates were used to compare PMPM costs for all IN subjects and all OUT subjects. Total medical savings were evaluated for the following time intervals: 1-12 months, 13-24 months, and 25-36 months.Results: For all four DM programs, average costs PMPM trended upward over time for the OUT cohort, while they remained relatively stable for the IN cohort. Some evidence also showed that DM programs improved clinical outcomes, such as hemoglobin A1c values. A difference in difference analysis showed PMPM savings for all four programs combined of $31.61, $50.45, and $53.72 after 1, 2, and 3 years, respectively. Multivariable modeling results showed total savings after 3 years of $14,460,174 for all DM programs combined.Limitations: Although multivariable models adjusted for several clinical, demographic, and economic characteristics; it is possible that some important confounders were missing due to lack of data.Conclusions: DM programs implemented to control diabetes, CHD/HTN, CHF/CKD, and asthma/COPD are cost-effective and show some evidence of improved clinical outcomes.

The burden associated with thrombocytopenia and platelet transfusions among patients with chronic liver disease

Background: Thrombocytopenia (TCP), a common complication of chronic liver disease (CLD), can cause uncontrolled bleeding during procedures. As such, CLD patients with TCP and platelet counts <50,000/μL often receive prophylactic platelet transfusions before invasive procedures. However, platelet transfusions are associated with clinical complications, which may result in increased healthcare utilization and costs.Objective: This retrospective database analysis describes the clinical and economic burden in CLD patients with TCP, CLD patients without TCP, and CLD patients with TCP who receive platelet transfusions.Methods: Adult CLD patients with or without TCP were identified in the IBM MarketScan Commercial Claims and Medicare Supplemental data from 1 January 2012 to 31 December 2015. CLD patients with or without TCP were propensity-score matched (1:1) for the analysis of annual healthcare utilization and costs. Platelet transfusions among CLD patients with TCP were identified using procedure codes.Results: Of the 601,626 patients with CLD, 8,292 (1.4%) patients with TCP were matched to patients without TCP. Among CLD patients with TCP, 981 (11.8%) patients received ≥1 platelet transfusions and met inclusion/exclusion criteria. Compared to patients without TCP, CLD patients with TCP had more complications, including higher prevalence of neutropenia (11.4% vs 2.9%) and bleeding events (21.4% vs 10.9%), greater resource utilization including greater average hospital admissions (1.2 vs 0.7, p < .01), greater average ER visits (2.1 vs 1.3, p < .01), higher average outpatient office visits (20.1 vs 18.4, p < .01), and higher average healthcare costs including total costs (p < .01), inpatient costs (p < .01), ER visit costs (p < .01), and outpatient office visit costs (p < .01). The mean annual total costs in CLD and TCP patients with platelet transfusions were $206,396.Conclusions: CLD patients with TCP, and particularly those who received platelet transfusions, experienced significantly greater clinical and economic burden compared to CLD patients without TCP. Safer and more cost-effective treatments to increase platelets are necessary.

Implications of Increasing College Attainment for Aging in General Equilibrium

We develop an overlapping generations general equilibrium model of the U.S. economy with heterogeneous consumers who face idiosyncratic earnings and health risk to study the implications of increasing college attainment, decreasing fertility, and increasing longevity (2005-2100). While all three trends contribute to a higher old age dependency ratio, increasing college attainment has different implications because it increases labor productivity. Decreasing fertility and increasing longevity require the government to increase the average labor tax rate from 33.5 to 47.1 percent. Increasing college attainment lowers the required tax increase by 12.0 percentage points. The labor tax rate required to balance the government budget is higher under general equilibrium than in a small open economy with a constant interest rate, because the reduction in the interest rate lowers capital income tax revenues.