How Does Prescription Drug Spending Affect Medication Adherence, Acute Care Use, and Health Care Costs in Heart Failure? Open Access

Abstract

Introduction: Studies show that prescription drug cost sharing adversely affects appropriate medication use in chronic disorders. Moreover, greater cost sharing has been linked to increased health care use and costs. However, these effects are poorly understood in heart failure (HF), the most common cause of hospitalization in Medicare. The aim of this study was to evaluate the association between prescription drug spending by Medicare beneficiaries with HF and (1) refill adherence, (2) hospital and emergency care use, and (3) inpatient and total health care costs.

Methods: Cross-sectional study of pooled data from the Medicare Current Beneficiary Survey, 2010-12. The sample consisted of community-dwelling participants with self-reported HF and continuous Part D drug coverage. Multivariate analysis included linear regression and generalized linear models. Sampling weights and variance estimation adjustments accounted for the complex survey design.

Results: Among patients without the low-income subsidy (LIS), percent of income spent on a β blocker was associated with the adjusted odds of non-adherence, OR=1.41, 95% CI [1.01, 1.98], p=.046, and decreased medication use, B=-3.63, SE=1.57, p=.022. No association was observed for anti-angiotensin drugs. Conditional on the effect of no Medicaid entitlement, average out-of-pocket payment per HF prescription was borderline associated with rates of HF-related hospitalization, RR=1.02, 95% CI [1.00, 1.05], p=.060, and hospitalized days, RR=1.04, 95% CI [1.00, 1.07], p=.057. Average prescription payment was not associated with the odds of HF-related hospitalization or emergency department use. Conditional on not receiving the LIS, predicted annual Medicare costs rose an average $126, 95% CI [-10, 261], p=.068, with each additional dollar spent per prescription. Average prescription spending was not associated with total or Medicare inpatient costs, or with total health care costs. Total out-of-pocket spending on HF drugs was not associated with any of the cost outcomes.

Conclusion: Among HF patients with Part D but no low-income assistance, there was a slight decline in β-blocker adherence and marginal evidence for greater hospital use and Medicare costs at higher prescription spending levels. Yet, most patients absorbed modest drug payments without dramatic spikes in related health care use and costs. This study contributes evidence to ongoing discussions about cost sharing in chronic disorders.

Table of Contents

 

 

 

Chapter 1: Introduction......................................................................................................1

 

              Figure 1.1: Conceptual framework....................................................................21

 

Chapter 2: Prescription Drug Spending and Medication Adherence in Heart Failure....45

 

              Table 2.1: Sample characteristics......................................................................59

 

              Table 2.2: Logistic regression of non-adherence...............................................61

 

              Table 2.3: Linear regression of medication possession ratio.............................62

 

              Figure 2.1: Sample selection procedure.............................................................63

 

Chapter 3: Prescription Drug Spending and Acute Care Use in Heart Failure................70

 

              Table 3.1: Sample characteristics.......................................................................85

 

              Table 3.2: Effect of average out-of-pocket payment on acute care use.............87

 

              Figure 3.1: Hospitalization by average patient payment per prescription.........89

 

              Figure 3.2: Marginal effects of drug spending on hospital use.........................90

 

Chapter 4: Prescription Drug Spending and Health Care Costs in Heart Failure...........96

 

              Table 4.1: Sample characteristics.....................................................................111

 

              Table 4.2: Effect of mean out-of-pocket payment on health care costs...........113

 

              Table 4.3: Effect of total out-of-pocket payments on health care costs...........114

 

              Table 4.4: Predicted Medicare costs by prescription drug spending quartile..115

 

              Figure 4.1: Predicted marginal effects.............................................................116

 

Chapter 5: Conclusion...................................................................................................124

 

 

 

About this Dissertation

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School	Laney Graduate School
Department	Nursing
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Health Care Management Health Sciences, Public Health Health Sciences, Nursing
Keyword	health care costs heart failure Medicare treatment adherence cost sharing
Committee Chair / Thesis Advisor	Gary, Rebecca, Emory University
Committee Members	Howard, David, Emory University Higgins, Melinda, Emory University Phillips, Victoria, Emory University Butler, Javed, University of Mississippi

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