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Value Propositions - April 2018

VBCR - April 2018, Vol 7, No 1 - Value Propositions

Affordable Care Act Linked to Reduced Out-of-Pocket Medical Costs Among Low-Income Americans

Affordable Care Act Linked to Reduced Out-of-Pocket Medical Costs Among Low-Income Americans

Although many Americans still experience high-burden out-of-pocket costs and insurance premiums for healthcare, enactment of the Affordable Care Act (ACA) has been associated with significantly reduced out-of-pocket medical costs, particularly among low-income Americans. These findings from a recent study by Anna L. Goldman, MD, MPA, Cambridge Health Alliance, Cambridge, MA, and colleagues led them to assert that a repeal or considerable reversal of the ACA would be especially harmful to poor and low-income patients in the United States.

Because repeal of the ACA has been under consideration multiple times in the past year, Dr Goldman and colleagues sought to determine whether ACA implementation—which has been associated with increased access to affordable medical care—reduced out-of-pocket medical expenses and household premium contributions among Americans aged 18 to 64 years.

Using data from the Medical Expenditure Panel Survey, Dr Goldman and colleagues analyzed family contributions to private health insurance premiums and assessed the family income and out-of-pocket healthcare costs of 83,431 adults from January 1, 2012, through December 31, 2015. They designated 2012 and 2013 as the pre-ACA period, and considered 2014 and 2015 the post-ACA period.

The data sample was stratified by income into 4 groups—lowest income (family incomes ≤138% of the federal poverty level); low income (family incomes 139%-250% of the federal poverty level); middle income (family incomes 251%-400% of the federal poverty level); and higher income (family incomes >400% of the federal poverty level).

Dr Goldman and colleagues found that during the first 2 years of ACA implementation, mean out-of-pocket costs decreased by 11.9% across the whole study sample, 21.4% in the lowest-income group, 18.5% in the low-income group, and 12.8% in the middle-income group. A moderate increase in mean premium spending was seen across the whole sample and in the higher-income group (12.1% and 22.9%, respectively), whereas combined out-of-pocket costs and premium spending decreased by 16% in the lowest-income group.

“Implementation of the ACA was associated with reduced out-of-pocket spending, particularly for low-income persons. However, many of these individuals continue to experience high-burden out-of-pocket and premium spending,” Dr Goldman and colleagues concluded. Goldman AL, et al. JAMA Intern Med. 2018 Jan 22. Epub ahead of print.


Anticitrullinated Protein Antibody Status Tied to Financial Burden in Patients with RA

Anticitrullinated Protein Antibody Status Tied to Financial Burden in Patients with RA

Patients with rheumatoid arthritis (RA) that is anticitrullinated protein antibody (ACPA)-positive are prone to facing higher economic burden than patients without the serologic biomarker, according to the results of a recent study by Jason Shafrin, PhD, Precision Health Economics, Los Angeles, CA, and colleagues.

Because previous research into the relationship between ACPA status and patients with RA only focused on treatment efficacy, Dr Shafrin and colleagues sought to determine whether financial burden in this patient population varies as a result of ACPA status.

Using insurance claims and electronic medical record data from IMS PharMetrics Plus that spanned from 2010 to 2015, they narrowed down 859 patients from a pool of 647,171, based on whether the patients met the study’s eligibility criteria. These criteria included having RA, being aged ≥18 years, and receiving an anticyclic citrullinated peptide (anti-CCP) antibody test within 6 months of diagnosis.

Dr Shafrin and colleagues used generalized linear regression models to measure their primary and secondary outcomes, which were RA-related medical expenses and healthcare use metrics, respectively. Age, sex, ACPA-positive status (ie, anti-CCP ≥20 AU/mL), and Charlson Comorbidity Index score were controlled as explanatory variables.

Of the 859 patients whose data were analyzed, only 212 (24.7%) were ACPA-positive. Adjusted results showed that, compared with patients with ACPA-negativity, those who were ACPA-positive were more likely to use conventional (49.6% vs 71.2%, respectively; P <.001) or biologic (11.8% vs 20.3%, respectively; P <.001) disease-modifying antirheumatic drugs in the first year after their RA diagnosis. Likewise, ACPA-positivity was linked to a greater frequency of physician visits compared with ACPA-negativity (5.58 annual visits vs 3.91 annual visits, respectively; P <.001).

With regard to healthcare costs, ACPA-positive patients had higher annual RA-related expenses than their ACPA-negative counterparts ($7941 vs $5243, respectively; P = .002). Medical RA-related costs, specifically, were also higher among ACPA-positive patients than ACPA-negative patients ($4380 vs $3427, respectively; P = .168); patients who were ACPA-positive had considerably higher prescription, outpatient, and overall costs than patients who were ACPA-negative, and were more likely to utilize healthcare resources.

Overall, RA-associated costs were 51% higher among patients with RA who were ACPA-positive than among those who were ACPA-negative, demonstrating that financial burden does vary among this patient population based on their ACPA status. According to Dr Shafrin and colleagues, these outcomes also suggest that patients with RA who are ACPA-positive may have higher disease burden and receive more aggressive treatment than those who are ACPA-negative. However, because of a decreased occurrence of comorbidities, there may be a correlative relationship between an ACPA-positive status and better overall health.

In addition, Dr Shafrin and colleagues noted that their results correspond with existing literature on the increased severity of disease progression and joint damage associated with ACPA-positivity versus ACPA-negativity.

“Providers may wish to inform patients diagnosed with ACPA-positive RA about the likely future disease and economic burden in hopes that both stakeholders can be more proactive in addressing them,” Dr Shafrin and colleagues concluded. Shafrin J, et al. J Manag Care Spec Pharm. 2018;24:4-11.


Medical Costs Substantial for Patients with RA, Especially with Biologic DMARD Use

Medical Costs Substantial for Patients with RA, Especially with Biologic DMARD Usee

Results from a recent study show that patients with rheumatoid arthritis (RA) face considerable overall and disease-related costs annually, with the cost of RA care representing more than 50% of healthcare costs for patients receiving biologic disease-modifying antirheumatic drugs (DMARDs) in particular.

Citing a lack of data on the direct medical costs of RA therapies in the past 20 years, Andrew Hresko, Tufts University School of Medicine, Boston, MA, and colleagues sought to address this gap in knowledge by conducting a systematic literature review of RA-related costs that US patients with the disease have faced since biologic DMARDs were first introduced in the late 1990s.

“Biologic DMARDs offer alternatives for patients unresponsive to traditional synthetic DMARDs, but carry an increased financial burden. Detailed understanding of the cost of care for RA patients since the advent of bDMARDs is of importance to policy makers, administrators, and physicians, as the high cost of RA treatments impacts the use of limited medical resources,” they said.

Using MEDLINE, they selected 541 studies for consideration—12 of which met the inclusion criteria of their meta-analysis, which included an analysis of data after 1999, involving total direct costs of RA therapy, and focusing on patients in the United States. Four of the 12 studies specifically referred to patients receiving therapy with biologic DMARDs.

Mr Hresko and colleagues found that overall medical costs for patients with RA receiving any type of therapy were $12,509 (95% confidence interval [CI], $7451-$21,001) annually. Patients receiving biologic DMARDs, however, had expenses almost triple that, with annual costs totaling $36,053 (95% CI, $32,138-$40,445).

Annual RA-specific costs were $3723 (95% CI, $2408-$5762) for patients receiving any type of therapy, and $20,262 (95% CI, $17,480-$23,487) for patients receiving biologic DMARDs; these annual costs accounted for 30% and 56% of overall care costs for each of these groups, respectively.

Although Mr Hresko and colleagues noted their study’s limitations, which included varying methodologies in the studies reviewed, a dearth of personalized patient-level data, and no assessment of the indirect costs of RA (eg, time lost at work, caregiver expenses), they were able to theorize what the results of their analysis inferred.

“These findings suggest that costs associated with RA are in line with those for other prominent chronic diseases....Our findings also suggest that the burden of RA patients on the U.S. healthcare system may become outsized compared to the disease’s relatively small prevalence and compared to patients with these other chronic conditions as more patients use biologic DMARDs in the future,” Mr Hesko and colleagues posited. Hresko A, et al. Arthritis Care Res (Hoboken). 2018 Jan 5. Epub ahead of print.

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Last modified: May 4, 2018
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