Disparity implications of Medicare eligibility criteria for medication therapy management services.
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ABSTRACT:
SUBMITTER: Wang J
PROVIDER: S-EPMC2910569 | biostudies-other | 2010 Aug
REPOSITORIES: biostudies-other
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Disparity implications of Medicare eligibility criteria for medication therapy management services.
Wang Junling J Mullins C Daniel CD Brown Lawrence M LM Shih Ya-Chen Tina YC Dagogo-Jack Samuel S Hong Song Hee SH Cushman William C WC
Health services research 20100524 4
<h4>Objective</h4>To determine whether there would be racial and ethnic disparities in meeting eligibility criteria for medication therapy management (MTM) services implemented in 2006 for Medicare beneficiaries.<h4>Data sources/study setting</h4>Secondary data analyses of the Medical Expenditure Panel Survey (2004-2005).<h4>Study design</h4>Logistic regression and recycled predictions were used to test the disparities in meeting eligibility criteria across racial and ethnic groups. The eligibil ...[more]
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Project description:Background/objectivesPrevious research indicates that eligibility criteria for medication therapy management (MTM) services in Medicare prescription drug (Part D) plans, defined under the Medicare Modernization Act (MMA), are associated with racial/ethnic disparities and ineffective in identifying individuals with medication utilization issues. Our study's objective was to determine the comparative effectiveness of MTM eligibility criteria under MMA and in the Affordable Care Act (ACA) in identifying patients with medication utilization issues across racial/ethnic groups.DesignACA and MMA MTM eligibility criteria were compared on proportions of eligible individuals among patients with medication utilization issues. Multinomial logistic regression was conducted to control for patient/community characteristics. Need-based and demand-based analyses were used to determine disparities due to need and demand for healthcare. Main/sensitivity analyses were conducted for the range of eligibility thresholds.SettingMedicare data (2012-2013) linked to Area Health Resources Files.ParticipantsA total of 964 610 patients 65 years or older.MeasurementsMedication safety/adherence measures, developed primarily by the Pharmacy Quality Alliance, were used to determine medication utilization issues.ResultsHigher proportions of patients were eligible based on ACA than MMA MTM eligibility criteria. For example, in 2013, proportions based on ACA and MMA MTM eligibility criteria would be 99.7% and 26.2%, respectively, in the main analysis (p < .001); in the demand-based main analysis, ACA criteria were associated with 13.6% and 9.8%, respectively, higher effectiveness than MMA criteria among non-Hispanic blacks and Hispanics than non-Hispanic whites.ConclusionACA MTM eligibility criteria are more effective than MMA criteria in identifying older patients needing MTM, particularly among minorities. J Am Geriatr Soc 67:581-587, 2019.
| S-EPMC6438366 | biostudies-literature
Project description:ImportanceAlthough independent charity patient assistance programs improve patient access to costly prescription drugs, recent federal investigations have raised questions about their potential to increase pharmaceutical spending and to violate the federal Anti-Kickback Statute. Little is known about the design of the programs, patient eligibility, or drug coverage.ObjectiveTo examine the eligibility criteria of the independent charity patient assistance programs and the drugs covered by them.Design, setting, and participantsDescriptive cross-sectional study of the 6 largest independent charities offering patient assistance programs for patients including, but not limited to, Medicare beneficiaries in 2018. These charities offered 274 different disease-specific patient assistance programs. Drugs were identified for subgroup analysis that had any use reported on the Medicare Part D spending dashboard and any off-patent brand-name drugs that incurred more than $10 000 in Medicare spending per beneficiary in 2016.ExposuresSupport by independent charity patient assistance programs.Main outcomes and measuresThe primary outcomes were the characteristics of patient assistance programs, including assistance type, insurance coverage (vs uninsured), and income eligibility. The secondary outcomes were the cost of the drugs covered by the patient assistance programs and the coverage of expensive off-patent brand-name drugs vs substitutable generic drugs.ResultsAmong the 6 independent charity foundations included in the analysis, their total revenue in 2017 ranged from $24 million to $532 million, and expenditures on patient assistance programs ranged from $24 million to $353 million, representing on average, 86% of their revenue. Of the 274 patient assistance programs offered by these organizations, 168 (61%) provided only co-payment assistance, and the most common therapeutic area covered was cancer or cancer treatment-related symptoms (113 patient assistance programs; 41%). A total of 267 programs (97%) required insurance coverage as an eligibility criterion (ie, excluded uninsured patients). The most common income eligibility limit was 500% of the federal poverty level. The median annual cost of the drugs per beneficiary covered by the programs was $1157 (interquartile range, $247-$5609) compared with $367 (interquartile range, $100-$1500) for the noncovered drugs. Off-patent brand-name drugs (cost: >$10 000) were covered by a mean of 3.1 (SD, 2.0) patient assistance programs, whereas their generic equivalents were covered by a mean of 1.2 (SD, 1.0) patient assistance programs.Conclusions and relevanceIn 2018, among 274 patient assistance programs operated by the 6 independent charity foundations, the majority did not provide coverage for uninsured patients. Medications that were covered by the patient assistance programs were generally more expensive than those that were not covered.
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Project description:ImportanceIn 2021, the US Preventive Services Task Force (USPSTF) broadened its age and smoking pack-year requirement for lung cancer screening.ObjectivesTo compare the 2021 USPSTF lung cancer screening criteria with other lung cancer screening criteria and evaluate whether the sensitivity and specificity of these criteria differ by race.Design, setting, and participantsThis study included 912 patients with lung cancer and 1457 controls without lung cancer enrolled in an epidemiology study (INHALE [Inflammation, Health, Ancestry, and Lung Epidemiology]) in the Detroit metropolitan area between May 15, 2012, and March 31, 2018. Patients with lung cancer and controls were 21 to 89 years of age; patients with lung cancer who were never smokers and controls who were never smokers were not included in these analyses. Statistical analysis was performed from August 31, 2020, to April 13, 2021.Main outcomes and measuresThe study assessed whether patients with lung cancer and controls would have qualified for lung cancer screening using the 2013 USPSTF, 2021 USPSTF, and 2012 modification of the model from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCOm2012) screening criteria. Sensitivity was defined as the percentage of patients with lung cancer who qualified for screening, while specificity was defined as the percentage of controls who did not qualify for lung cancer screening.ResultsParticipants included 912 patients with a lung cancer diagnosis (493 women [54%]; mean [SD] age, 63.7 [9.5] years) and 1457 control participants without lung cancer at enrollment (795 women [55%]; mean [SD] age, 60.4 [9.6] years). With the use of 2021 USPSTF criteria, 590 patients with lung cancer (65%) were eligible for screening compared with 619 patients (68%) per the PLCOm2012 criteria and 445 patients (49%) per the 2013 USPSTF criteria. With the use of 2013 USPSTF criteria, significantly more White patients than African American patients with lung cancer (324 of 625 [52%] vs 121 of 287 [42%]) would have been eligible for screening. This racial disparity was absent when using 2021 USPSTF criteria (408 of 625 [65%] White patients vs 182 of 287 [63%] African American patients) and PLCOm2012 criteria (427 of 625 [68%] White patients vs 192 of 287 [67%] African American patients). The 2013 USPSTF criteria excluded 950 control participants (65%), while the PLCOm2012 criteria excluded 843 control participants (58%), and the 2021 USPSTF criteria excluded 709 control participants (49%). The 2013 USPSTF criteria excluded fewer White control participants than African American control participants (514 of 838 [61%] vs 436 of 619 [70%]). This racial disparity is again absent when using 2021 USPSTF criteria (401 of 838 [48%] White patients vs 308 of 619 [50%] African American patients) and PLCOm2012 guidelines (475 of 838 [57%] White patients vs 368 of 619 [60%] African American patients).Conclusions and relevanceThis study suggests that the USPSTF 2021 guideline changes improve on earlier, fixed screening criteria for lung cancer, broadening eligibility and reducing the racial disparity in access to screening.
| S-EPMC8759029 | biostudies-literature
Project description:BackgroundMedication therapy management (MTM) program evaluations have revealed mixed outcomes, with some studies finding favorable outcomes and others finding no differences between patients who received MTM versus those who did not. One possible reason for outcomes variability is differences in delivery of MTM programs. The Chronic Care Model (CCM) provides a framework for how health care organizations can improve care for the chronically ill through 6 elements: organization of health care, delivery system design, clinical information systems, decision support, self-management, and linkages to community resources.ObjectiveTo apply the CCM to understand variation in MTM delivery and formulate policy recommendations.MethodsThis study used a mixed-methods descriptive analysis of MTM delivery. Investigators conducted visits to a purposeful sample of MTM practices to observe MTM and interview participants. The pharmacists and staff of these practices completed a modified Assessment of Chronic Illness Care (ACIC). Pairs of investigators analyzed interview transcripts to identify themes. Demographics and ACIC scores were summarized using descriptive statistics. After analysis, investigators discussed overarching themes and policy implications organized by CCM elements.ResultsSeven practices participated, and 87 participants were interviewed. Based on ACIC scores, MTM patient volume, and payer mix, practices were categorized as Early Maturity Level or Later Maturity Level. From the model, organization of health care themes included whether MTM was the practice's core competence, belief/confidence in the MTM process, lack of formal rewards, and the influence of organizational goals and external environment. Delivery system design themes pertained to the extent that MTM processes were formalized. Clinical information systems themes were the extent to which systems were influenced by payers, efficiency strategies, and the accuracy and availability of information. In considering clinical decision support themes, alert design limitations and variation in user approaches to alerts based on experience were noted. We observed strong support for patient self-management; when present, barriers were attributed to the patient, MTM provider, or payer. Referral to community resources was minimal. Numerous policy implications were identified.ConclusionsOur research identified numerous ways by which MTM delivery varies, particularly by MTM practice maturity level. These findings provide evidence for several policy changes that could be considered to optimize MTM delivery, encourage alignment with the CCM, and promote practice maturation.DisclosuresThis research and a portion of Snyder's salary were supported by grant number K08HS022119 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Snyder reports consulting fees from Westat for an evaluation of the CMS Enhanced MTM program. The other authors have nothing to disclose. Portions of this research have been presented as abstracts at the following conferences: (a) 2017 Academy Health Annual Research Meeting; June 25-27, 2017; New Orleans, LA; (b) 2015 American Society of Health-System Pharmacists Clinical Midyear Meeting; December 4-8, 2015; New Orleans, LA; and
| S-EPMC7543051 | biostudies-literature
Project description:Medication therapy management (MTM) refers to the activities provided by pharmacists that patients recognize as evidence of care being provided. It encompasses the services that patients value and consider valuable. Many developing nations like Yemen have had poor implementation of MTM services. Thus, this research assessed the Knowledge, Attitudes, and Practices (KAP) of Yemen pharmacists regarding MTM. We conducted a cross-sectional study using a self-administered questionnaire among pharmacists in Sana'a, Yemen. They were recruited through convenience sampling. The alpha level of 0.05 was used to determine statistical significance. Four hundred and sixty-one (461) pharmacists completed the questionnaire. About 70% were working in community pharmacies and 57.3% had (1-5) years of experience in pharmacy practice. The younger pharmacists had a higher level of knowledge than pharmacists with older age with median and IQR of 1.2(1.2-1.4) and 1.2(1-1.4) respectively (p < 0.001). Yemen pharmacists have positive attitudes toward MTM indicating a moderated level of attitudes with a median and IQR of 3.8(3.5-4). Hospital pharmacists expressed more positive attitudes toward MTM (P < 0.001) than pharmacists from other areas of practice. Only 11% of sampled pharmacists frequently offered MTM services. The top MTM service reported by Yemen pharmacists was "Performing or obtaining necessary assessments of the patient's health status". However, "Formulating a medication treatment plan" received the least provided MTM service among Yemen pharmacists. Even though MTM services are not commonly utilized in pharmacy practice, Yemeni pharmacists have positive attitudes concerning MTM. Efforts are needed to enhance their MTM knowledge and the value of providing MTM services as well as to develop a culture of continuing pharmacy education about MTM among pharmacists.
| S-EPMC10997124 | biostudies-literature
Project description:STUDY OBJECTIVES:Centers for Medicare and Medicaid Services (CMS) reimbursement for positive airway pressure (PAP) devices for obstructive sleep apnea treatment is dependent on patients meeting adherence expectations within the first 3 months on therapy. Adherence is defined as usage of the device for at least 4 hours per night on 70% of nights during a consecutive 30-day period. We hypothesize that the adherence pattern may be established beyond this initial period, which may limit the opportunity to treat many patients. METHODS:Treatment and adherence data from PAP devices were monitored via wireless modems for 42 consecutive PAP-naïve military veterans who completed 1 year of nightly monitoring. Their baseline characteristics were as follows: age (mean ± standard deviation) 58.5 ± 12.5 years; body mass index 33.7 ± 5.7 kg/m2; diagnostic apnea-hypopnea index (pretreatment) 28.1 ± 18.5 events/h; apnea-hypopnea index on PAP: 4.3 ± 3.3 events/h. We examined daily, monthly, quarterly, semiannual, and annual reports, and the best 30-day adherence report for each quarter. RESULTS:In the first 3 months, 19 of 42 participants were adherent by CMS criteria, and 23 of 42 participants were not. Of the 19 adherent participants, 13 remained adherent and 6 became nonadherent or stopped PAP treatment for the remainder of the year. In the 23 initially nonadherent participants, 16 stopped PAP treatment, and 7 participants (30.4%) became adherent (using CMS criteria) during the rest of the year. Thus, PAP adherence during the first 3 months was predictive for the rest of the year in only 68.4%. PAP nonadherence during the first 3 months was predictive for further nonadherence in only 69.6% of the cases. Overall, this led to a 65% sensitivity and 72% specificity of using adherence at 3 months in predicting adherence at 1 year. CONCLUSIONS:CMS adherence criteria affecting PAP coverage are restrictive and can result in the withholding of therapy in many patients who otherwise might become adherent. CLINICAL TRIAL REGISTRATION:Registry: ClinicalTrials.gov, Title: Remote Monitoring in Obstructive Sleep Apnea, Identifier: NCT01678560, URL: https:// clinicaltrials.gov/ct2/show/NCT01678560.
| S-EPMC6374085 | biostudies-literature
Project description:BackgroundPatients with cancer history are usually excluded from hepatocellular carcinoma (HCC) clinical trials. However, whether previous malignancy affects the oncological outcomes of HCC patients has not been fully assessed. This study aimed to evaluate whether prior cancer compromised the survival of HCC patients.MethodsPatients with HCC were extracted from the Surveillance, Epidemiology, and End Results database between 2004 and 2015, and then they were classified into groups with and without prior cancer. The Kaplan-Meier and multivariate Cox regression analysis were adopted to evaluate whether prior cancer impacted clinical outcomes after propensity score matching (PSM) adjusting baseline differences. Validation was performed in the cohort from our institution.ResultsWe identified 2642 HCC patients with prior cancer. After PSM, the median overall survival (OS) time were 14.5 and 12.0 months respectively for groups with and without prior cancer. Prior cancer did not compromise prognosis in patients with HCC (p = 0.49). The same tendency was found in subgroups stratified by tumor stages and cancer interval period: OS was similar between groups with and without prior cancer (both p values> 0.1). In the multivariate Cox regression model, prior cancer did not adversely impact patients' survival (HR: 1.024; 95% CI: 0.961-1.092). In the validation cohort from our institution, prior cancer had no significant association with worse outcomes (p = 0.48).ConclusionFor HCC patients, prior cancer did not compromise their survival, regardless of tumor stage and cancer interval period. Exclusion criteria for HCC clinical trials could be reconsidered.
| S-EPMC7871582 | biostudies-literature
Project description:BackgroundSepsis remains a significant cause of morbidity and mortality in the United States, leading to the implementation of the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). SEP-1 identifies patients with "severe sepsis" via clinical and laboratory criteria and mandates interventions, including lactate draws and antibiotics, within a specific time window. We sought to characterize the patients affected and to study the implications of SEP-1 on patient care and outcomes.MethodsAll adults admitted to the University of Chicago from November 2008 to January 2016 were eligible. Modified SEP-1 criteria were used to identify appropriate patients. Time to lactate draw and antibiotic and IV fluid administration were calculated. In-hospital mortality was examined.ResultsLactates were measured within the mandated window 32% of the time on the ward (n = 505) compared with 55% (n = 818) in the ICU and 79% (n = 2,144) in the ED. Patients with delayed lactate measurements demonstrated the highest in-hospital mortality at 29%, with increased time to antibiotic administration (median time, 3.9 vs 2.0 h). Patients with initial lactates > 2.0 mmol/L demonstrated an increase in the odds of death with hourly delay in lactate measurement (OR, 1.02; 95% CI, 1.0003-1.05; P = .04).ConclusionsDelays in lactate measurement are associated with delayed antibiotics and increased mortality in patients with initial intermediate or elevated lactate levels. Systematic early lactate measurement for all patients with sepsis will lead to a significant increase in lactate draws that may prompt more rapid physician intervention for patients with abnormal initial values.
| S-EPMC6113629 | biostudies-literature
Project description:More than half of males in China are current smokers and evidence from western countries tells us that an unprecedented number of smoking-attributable deaths will occur as the Chinese population ages. We used the China Lung Cancer Policy Model (LCPM) to simulate effects of computed tomography (CT)-based lung cancer screening in China, comparing the impact of a screening guideline published in 2015 by a Chinese expert group to a version developed for the United States by the U.S. Centers for Medicare & Medicaid Services (CMS). The China LCPM, built using an existing lung cancer microsimulation model, can project population outcomes associated with interventions for smoking-related diseases. After calibrating the model to published Chinese smoking prevalence and lung cancer mortality rates, we simulated screening from 2016 to 2050 based on eligibility criteria from the CMS and Chinese guidelines, which differ by age to begin and end screening, pack-years smoked, and years since quitting. Outcomes included number of screens, mortality reduction, and life-years saved for each strategy. We projected that in the absence of screening, 14.98 million lung cancer deaths would occur between 2016 and 2050. Screening with the CMS guideline would prevent 0.72 million deaths and 5.8 million life-years lost, resulting in 6.58% and 1.97% mortality reduction in males and females, respectively. Screening with the Chinese guideline would prevent 0.74 million deaths and 6.6 million life-years lost, resulting in 6.30% and 2.79% mortality reduction in males and females, respectively. Through 2050, 1.43 billion screens would be required using the Chinese screening strategy, compared to 988 million screens using the CMS guideline. In conclusion, CT-based lung cancer screening implemented in 2016 and based on the Chinese screening guideline would prevent about 20,000 (2.9%) more lung cancer deaths through 2050, but would require about 445 million (44.7%) more screens than the CMS guideline.
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Project description:Health insurance is associated with increased utilization of cancer screening services. Data on breast, prostate and colorectal cancer screening were abstracted from the 2012 Behavioral Risk Factor and Surveillance System. This data in brief includes two sets of analyses: (i) the use of cancer screening in individuals within the low-income bracket and (ii) determinants for each of the three approaches to colorectal cancer screening (fecal occult blood test, colonoscopy and sigmoidoscopy+fecal occult blood test). Covariates included education attainment, residency, and access to health care provider. The data supplement our original research article on the effect of Medicare eligibility on cancer screening utilization "The impact of Medicare eligibility on cancer screening behaviors" [1].
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