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High Cost Sharing and Specialty Drug Initiation Under Medicare Part D: A Case Study in Patients With Newly Diagnosed Chronic Myeloid Leukemia
Jalpa A. Doshi, PhD; Pengxiang Li, PhD; Hairong Huo, PhD, MS; Amy R. Pettit, PhD; Rishab Kumar; Brendan M. Weiss, MD; and Scott F. Huntington, MD, MPH

High Cost Sharing and Specialty Drug Initiation Under Medicare Part D: A Case Study in Patients With Newly Diagnosed Chronic Myeloid Leukemia

Jalpa A. Doshi, PhD; Pengxiang Li, PhD; Hairong Huo, PhD, MS; Amy R. Pettit, PhD; Rishab Kumar; Brendan M. Weiss, MD; and Scott F. Huntington, MD, MPH
A Medicare claims analysis of patients newly diagnosed with chronic myeloid leukemia revealed that high cost sharing was associated with reduced and/or delayed tyrosine kinase inhibitor initiation under Part D.
ABSTRACT

Objectives:
Specialty drugs often offer medical advances but are frequently subject to high cost sharing. This is particularly true with Medicare Part D, where after meeting a deductible, patients without low-income subsidies (non-LIS) typically face 25% to 33% coinsurance (initial coverage phase with “specialty tier” cost sharing), followed by ~50% coinsurance (coverage gap phase), and then 5% coinsurance (catastrophic phase). Yet, no studies have examined the impact of such high cost sharing on specialty drug initiation under Part D. Oral tyrosine kinase inhibitors (TKIs) have revolutionized the treatment of chronic myeloid leukemia (CML), making it an apt case study.

Study Design: A retrospective claims-based analysis utilizing 2011 to 2013 100% Medicare claims.

Methods: TKI initiation rates and time to initiation were compared between fee-for-service non-LIS Part D patients newly diagnosed with CML and their LIS counterparts who faced nominal cost sharing of ≤$5.

Results: The first 30-day TKI fill “straddled” benefit phases, for a mean out-of-pocket cost of $2600 or more for non-LIS patients. Non-LIS patients were less likely than LIS patients to have a TKI claim within 6 months of diagnosis (45.3% vs 66.9%; P <.001) and those initiating a TKI took twice as long to fill it (mean = 50.9 vs 23.7 days; P <.001). Cox regressions controlling for sociodemographic, clinical, and plan characteristics confirmed descriptive findings (hazard ratio, 0.59; 95% CI, 0.45-0.76). Extensive sensitivity analyses confirmed the robustness of our findings.

Conclusions: High cost sharing was associated with reduced and/or delayed initiation of TKIs. We discuss policy strategies to reduce current financial barriers that adversely impact access to critical therapies under Medicare Part D.

Am J Manag Care. 2016;22(4 Suppl):S78-S86
Take-Away Points
 
We used 100% Medicare claims data to examine initiation of tyrosine kinase inhibitors (TKIs) in patients newly diagnosed with chronic myeloid leukemia.
  • Patients not eligible for low-income subsidies, who faced mean out-of-pocket costs of $2600 or more for the first 30-day fill, were less likely to have an initial TKI claim within 6 months of diagnosis and took twice as long to initiate TKI treatment compared with patients receiving low-income subsidies who faced nominal cost sharing (≤$5).
  • High cost sharing was associated with reduced and/or delayed initiation of TKIs under Medicare Part D. 
  • Changes in Part D policies have the potential to increase access to lifesaving cancer treatments.
Specialty drugs commonly offer significant medical advances for chronic and/or life-threatening diseases, but they frequently carry high out-of-pocket costs that may impede patients’ access to treatment.1 The relationship between high out-of-pocket costs and specialty drug treatment access is particularly relevant for Medicare beneficiaries, who face complex cost-sharing arrangements under Medicare Part D’s prescription drug benefit. Per CMS regulations, Part D plans may place any drug that exceeds a designated cost threshold ($600 per month from 2011-2015) on a “specialty tier,” which typically requires patients to pay 25% to 33% coinsurance during each calendar year’s initial coverage phase.2,3 Once patients’ total drug spending exceeds an initial coverage limit ($2840-$2960 from 2011-2015),4 they enter a coverage gap phase, which requires even higher cost sharing (45%-50% coinsurance from 2011-2015)5 until their total out-of-pocket Part D spending reaches a certain threshold ($4550-$4700 from 2011-2015). After patients reach that catastrophic coverage limit, they pay 5% coinsurance for the remainder of that calendar year.4 Today, virtually all Part D plans using tiered benefit structures have a specialty tier.2

Initial access to specialty drug treatment is particularly important for those who are newly diagnosed with cancer, where prompt treatment is often essential. This is an increasingly common scenario given that oncology drugs represent one of the largest areas of specialty drug growth in terms of both innovation and spending.6 Although the majority of Medicare patients experience high cost sharing for specialty drugs under Part D, patients who qualify for full low-income subsidies (LIS) face nominal cost sharing (≤$5) throughout the year. Thus, cancer treatment under Part D provides an ideal case study to explore the relationship between high cost sharing for specialty drugs and treatment initiation, with LIS patients serving as a natural control group.

We focused on newly diagnosed patients with chronic myeloid leukemia (CML) for several reasons. First, nearly half of new CML diagnoses occur in individuals 65 years or older.7 Second, the treatment of CML has been revolutionized by tyrosine kinase inhibitors (TKIs), a class of “targeted” specialty drugs that act on a unique oncogenic protein in CML cells known as the BCR-ABL fusion protein. These highly active oral medications limit the growth and progression of CML, transforming it into a chronic condition. With continuous and typically lifelong treatment, TKIs allow most patients with CML to enjoy a near-normal life expectancy compared with a median survival of less than 3 years in the pre-TKI era.8,9 Third, all TKIs are covered under Medicare Part D. Unlike conditions for which some treatment options with lower out-of-pocket costs may be available (eg, infused drugs covered under Medicare’s Part B benefit), elderly patients with CML do not have an equivalent lower-cost option. In this study, we examined the association between high cost sharing and TKI treatment initiation in a sample of patients with Medicare Part D who had been newly diagnosed with CML.

 

METHODS
Study Design

This retrospective claims-based study examined TKI initiation among patients covered by Medicare Part D, newly diagnosed with CML. We compared initiation of TKIs among non-LIS Medicare beneficiaries subject to high levels of cost sharing under Part D at the time of initial CML diagnosis (non-LIS group), against a contemporaneous comparison group of newly diagnosed full-LIS patients who faced only nominal cost sharing (LIS group).

Although both the initial coverage phase and the coverage gap phase involve high out-of-pocket costs, our primary analysis focused on patients with a new CML diagnosis during the initial coverage phase only, for 2 key reasons. First, since exiting the initial coverage phase is triggered by reaching an out-of-pocket spending threshold, individuals who had already reached the coverage gap phase at the time of CML diagnosis would have done so because of substantial out-of-pocket spending on other prescriptions, potentially biasing our selection process toward patients with significant comorbidity (ie, requiring multiple and/or expensive medications). Second, those patients would likely be balancing other substantial medical/prescription expenses and health conditions that might influence their decisions to initiate a TKI, thereby limiting our ability to interpret the degree to which initiation decisions may have been related specifically to the out-of-pocket expense for the TKI.

Data Source

We used a data extract of the 2011 to 2013 100% Medicare Chronic Condition Data Warehouse files, which contain data on all fee-for-service Medicare beneficiaries in the United States. We specifically extracted the Medicare inpatient (Part A), outpatient (Part B), and prescription drug (Part D) data files linked with beneficiary summary files and Part D prescription drug plan characteristics files for patients with at least 1 diagnosis of CML (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 205.1).

Sample Selection

We applied several selection criteria to capture our main sample of Medicare patients with newly diagnosed CML. Patients were included if they had: a) at least 1 inpatient or outpatient claim with a diagnosis of CML (ICD-9-CM code 205.1) between July 1, 2011, and June 30, 2013 (the first of which represented the “index date”); b) continuous enrollment in both fee-for-service Medicare and a stand-alone Part D prescription plan in the 180 days (6 months) before and after the index date (pre-index period and postindex period, respectively); c) ≥2 CML claims occurring at least 30 days apart (ie, the index claim and at least 1 other claim during the postindex period); d) a claim for a molecular oncogene diagnostic test during the 30 days before or the 30 days after the index date; and e) an index date that fell within the beneficiary’s Part D initial coverage phase.

Patients were excluded if they had: a) any CML claims during the pre-index period; b) any claim for a TKI during the pre-index period; c) any diagnosis of acute lymphocytic leukemia (ALL), defined as ≥2 ALL claims 30 days apart during the pre- or postindex period; or d) any change in LIS status during the pre- or postindex period.

Outcome Variables

Our main outcome variable was time to TKI initiation, defined as the number of days elapsed between the index date (first CML diagnosis claim during the study period) and the date that the first TKI prescription was filled during the 6-month postindex period. Patients who did not have a TKI claim during the 6-month postindex period were considered censored. We also measured the percentage of patients filling a TKI prescription within 6 months of diagnosis and time to TKI initiation among TKI users. All TKIs approved for CML and available during our 2011 to 2013 study period (imatinib [Gleevec], dasatinib [Sprycel], nilotinib [Tasigna], bosutinib [Bosulif], and ponatinib [Iclusig]) were included in the outcome definition.

Statistical Analyses

Descriptive statistics were generated for the main sample. Multivariable Cox regressions were used to examine the difference in time to TKI initiation between non-LIS and LIS patients. Model covariates included sociodemographic characteristics capturing patient age, sex, race, Census region of residence (Northeast, Midwest, South, West), and county-level per capita income. Clinical characteristics included CML disease complexity (mild, moderate, or severe; classified according to the algorithm used by Darkow et al [2007]10), number of drug classes filled during the pre-index period, Charlson comorbidity score as adapted by the National Cancer Institute,11 diagnosis of end-stage renal disease (yes/no), and whether the index CML claim was an inpatient claim. Plan characteristics included the Part D drug benefit type (defined standard benefit, actuarially equivalent standard, enhanced alternative, other), TKI formulary coverage (the proportion of TKI drugs available on the market that were covered by the plan during the index claim year), and TKI utilization management tools (the proportion of covered TKIs requiring prior authorization, quantity limits, or step therapy). Finally, covariates for the year of the index CML diagnosis were included to control for any temporal trends.

We conducted extensive sensitivity analyses to test the robustness of our results. First, we examined an alternative way of measuring time to TKI initiation. Since physicians may assign a working diagnosis of CML but delay TKI initiation until the diagnosis is confirmed via molecular oncogene testing, we examined time to initiation based on the days elapsed between the date of the second (rather than the first) CML claim and the date of the first TKI claim. Second, we examined an alternative model specification by using plan formulary-level fixed effects variables, including indicators of the plan formulary identifier for the plans in which patients were enrolled. This approach enabled us to compare non-LIS and LIS patients facing the same formulary, while controlling for a series of patient confounders, in order to isolate the effects of cost-sharing differences and to rule out the influence of other formulary restrictions (eg, formulary coverage, prior authorization, quantity limits, and step therapy requirements for TKIs and other medications). Third, we removed the sample selection requirement that a patient’s index date fall within the initial coverage phase and allowed inclusion of all patients meeting our other primary sample selection criteria, regardless of the Part D coverage phase during which they were first diagnosed with CML.

Finally, we also conducted extensive sensitivity analyses to test the degree to which our sampling criteria were effective in achieving our goal of capturing patients newly diagnosed with CML. That is, we sought to maximize sensitivity (identifying all patients newly diagnosed with CML) while also maximizing specificity (excluding patients who may have had a CML claim prior to receiving a revised final diagnosis of a different form of cancer, as well as patients who may have received a TKI for another condition).

 
Copyright AJMC 2006-2017 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
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