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. 2022 Feb 1;182(2):185-195.
doi: 10.1001/jamainternmed.2021.7457.

Assessment of Hypothetical Out-of-Pocket Costs of Guideline-Recommended Medications for the Treatment of Older Adults With Multiple Chronic Conditions, 2009 and 2019

Tianna Zhou  1 , Patrick Liu  1 , Sanket S Dhruva  2   3 , Nilay D Shah  4 , Reshma Ramachandran  5   6 , Karina M Berg  7 , Joseph S Ross  6   8   9   10
Affiliations

Assessment of Hypothetical Out-of-Pocket Costs of Guideline-Recommended Medications for the Treatment of Older Adults With Multiple Chronic Conditions, 2009 and 2019

Tianna Zhou et al. JAMA Intern Med. .

Abstract

Importance: Most adults 65 years or older have multiple chronic conditions. Managing these conditions with prescription drugs can be costly, particularly for older adults with limited incomes.

Objective: To estimate hypothetical out-of-pocket costs associated with guideline-recommended outpatient medications for the initial treatment of 8 common chronic diseases among older adults with Medicare prescription drug plans (PDPs).

Design, setting, and participants: This retrospective cross-sectional study used 2009 and 2019 Medicare prescription drug plan formulary files to estimate annual out-of-pocket costs among hypothetical patients enrolled in Medicare Advantage or stand-alone Medicare Part D plans. A total of 3599 PDPs in 2009 and 3618 PDPs in 2019 were included after inclusion and exclusion criteria were applied. Costs associated with guideline-recommended medications for 8 of the most common chronic diseases (atrial fibrillation, chronic obstructive pulmonary disease [COPD], heart failure with reduced ejection fraction, hypercholesterolemia, hypertension, osteoarthritis, osteoporosis, and type 2 diabetes), alone and in 2 clusters of commonly comorbid conditions, were examined.

Main outcomes and measures: Annual out-of-pocket costs for each chronic condition, inflation adjusted to 2019 dollars.

Results: Among 3599 Medicare PDPs in 2009, 1998 were Medicare Advantage plans and 1601 were stand-alone plans; among 3618 Medicare PDPs in 2019, 2719 were Medicare Advantage plans and 899 were stand-alone plans. For an older adult enrolled in any Medicare PDP in 2019, the median annual out-of-pocket costs for individual conditions varied, from a minimum of $32 (IQR, $6-$48) for guideline-recommended management of osteoporosis (a decrease from $128 [IQR, $102-$183] in 2009) to a maximum of $1579 (IQR, $1524-$2229) for guideline-recommended management of atrial fibrillation (an increase from $91 [IQR, $73-$124] in 2009). For an older adult with a cluster of 5 commonly comorbid conditions (COPD, hypertension, osteoarthritis, osteoporosis, and type 2 diabetes) enrolled in any PDP, the median out-of-pocket cost in 2019 was $1999 (IQR, $1630-$2564), a 12% decrease from $2284 (IQR, $1920-$3107) in 2009. For an older adult with all 8 chronic conditions (atrial fibrillation, COPD, diabetes, hypercholesterolemia, heart failure, hypertension, osteoarthritis, and osteoporosis) enrolled in any PDP, the median out-of-pocket cost in 2019 was $3630 (IQR, $3234-$5197), a 41% increase from $2571 (IQR, $2185-$3719) in 2009.

Conclusions and relevance: In this cross-sectional study, out-of-pocket costs for guideline-recommended outpatient medications for the initial treatment of 8 common chronic diseases varied by condition. Although costs generally decreased between 2009 and 2019, particularly with regard to conditions for which generic drugs were available, out-of-pocket costs remained high and may have presented a substantial financial burden for Medicare beneficiaries, especially older adults with conditions for which brand-name drugs were guideline recommended.

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Conflict of interest statement

Conflict of Interest Disclosures: Ms Zhou reported receiving grants from the National Institutes of Health (NIH) Medical Student Research Training Fellowship during the conduct of the study. Dr Dhruva reported receiving grants from Arnold Ventures, the Greenwall Foundation, the National Evaluation System for Health Technology Coordinating Center, and the National Heart, Lung, and Blood Institute (NHLBI) of the NIH and serving as a member of the California Technology Assessment Forum of the Institute for Clinical and Economic Review outside the submitted work. Dr Shah reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ), the Center for Medicare and Medicaid Innovation under the Transforming Clinical Practice Initiative, the National Science Foundation, the NHLBI of the NIH, the Patient-Centered Outcomes Research Institute for the development of a clinical data research network, and the US Food and Drug Administration (FDA) via the Mayo Clinic for the establishment of the Yale-Mayo Clinic Center for Excellence in Regulatory Science and Innovation program outside the submitted work. Dr Ross reported receiving grants from the AHRQ, the Centers for Medicare & Medicaid Services, the FDA, Johnson & Johnson, the Laura and John Arnold Foundation, the Medical Device Innovation Consortium, Medtronic, and the NHLBI of the NIH outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Out-of-Pocket Costs for Cluster A Conditions in 2019
Includes costs for all prescription drug plans. Cluster A conditions include chronic obstructive pulmonary disease, type 2 diabetes, hypertension, osteoarthritis, and osteoporosis. The box plot lines, from left end of each box to the right end, represent the 25th percentile, median percentile, and 75th percentile. The whiskers extend to the minimum and maximum values but no further than 1.5 times the IQR from the 25th and 75th percentiles. Dots beyond the end of the whiskers represent outliers.
Figure 2.
Figure 2.. Out-of-Pocket Costs for Cluster B Conditions in 2019
Includes costs for all prescription drug plans. Cluster B conditions include atrial fibrillation, chronic obstructive pulmonary disease, type 2 diabetes, hypercholesterolemia, heart failure with reduced ejection fraction (assuming the patient was prescribed an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), hypertension, osteoarthritis, and osteoporosis. The box plot lines, from the left end of each box to the right end, represent the 25th percentile, median percentile, and 75th percentile. The whiskers extend to the minimum and maximum values but no further than 1.5 times the IQR from the 25th and 75th percentiles. Dots beyond the end of the whiskers represent outliers.
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References

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