Showing papers by "Dana P. Goldman published in 2004"

Pharmacy Benefits and the Use of Drugs by the Chronically Ill

Abstract: ContextMany health plans have instituted more cost sharing to discourage use of more expensive pharmaceuticals and to reduce drug spending.ObjectiveTo determine how changes in cost sharing affect use of the most commonly used drug classes among the privately insured and the chronically ill.Design, Setting, and ParticipantsRetrospective US study conducted from 1997 to 2000, examining linked pharmacy claims data with health plan benefit designs from 30 employers and 52 health plans. Participants were 528 969 privately insured beneficiaries aged 18 to 64 years and enrolled from 1 to 4 years (960 791 person-years).Main Outcome MeasureRelative change in drug days supplied (per member, per year) when co-payments doubled in a prototypical drug benefit plan.ResultsDoubling co-payments was associated with reductions in use of 8 therapeutic classes. The largest decreases occurred for nonsteroidal anti-inflammatory drugs (NSAIDs) (45%) and antihistamines (44%). Reductions in overall days supplied of antihyperlipidemics (34%), antiulcerants (33%), antiasthmatics (32%), antihypertensives (26%), antidepressants (26%), and antidiabetics (25%) were also observed. Among patients diagnosed as having a chronic illness and receiving ongoing care, use was less responsive to co-payment changes. Use of antidepressants by depressed patients declined by 8%; use of antihypertensives by hypertensive patients decreased by 10%. Larger reductions were observed for arthritis patients taking NSAIDs (27%) and allergy patients taking antihistamines (31%). Patients with diabetes reduced their use of antidiabetes drugs by 23%.ConclusionsThe use of medications such as antihistamines and NSAIDs, which are taken intermittently to treat symptoms, was sensitive to co-payment changes. Other medications—antihypertensive, antiasthmatic, antidepressant, antihyperlipidemic, antiulcerant, and antidiabetic agents—also demonstrated significant price responsiveness. The reduction in use of medications for individuals in ongoing care was more modest. Still, significant increases in co-payments raise concern about adverse health consequences because of the large price effects, especially among diabetic patients.

Can Patient Self-Management Help Explain the SES Health Gradient?

Abstract: There are large differences in health outcomes by socioeconomic status (SES) that cannot be explained fully by traditional arguments, such as access to care or poor health behaviors. We consider a different explanation - better self-management of disease by the more educated. We examine differences by education in treatment adherence among patients with two illnesses, diabetes and HIV, and then assess the subsequent impact of differential adherence on health status. One unique component of this research is that for diabetes we combine two different surveys - one cohort study and one randomized clinical trial - that are usually used exclusively by either biomedical or/and social scientists separately. For both illnesses, we find significant effects of adherence that are much stronger among patients with high SES. After controlling for other factors, more educated HIV+ patients are more likely to adhere to therapy, and this adherence made them experience improvements in their self-reported general health. Similarly, among diabetics, the less educated were much more likely to switch treatment, which led to worsening general health. In the randomized trial setting, intensive treatment regimens that compensated for poor adherence led to better improvements in glycemic control for the less educated. Among two distinct chronic illnesses, the ability to maintain a better health regimen is an important independent determinant of subsequent health outcomes. This finding is robust across clinical trial and population-based settings. Because this ability varies by schooling, self-maintenance is an important reason for the steep SES gradient in health outcomes.

Are The Young Becoming More Disabled

Abstract: This paper investigates trends in disability in the U.S. population, particularly among people under age fifty. Even as the elderly have become less disabled, reported disability has risen for younger Americans, especially those ages 30–49. We suggest some possible explanations for rising disability levels, such as obesity, technological advances in medicine, and changing disability insurance laws. Obesity and its attendant disorders seem particularly associated with these trends, although the data are not definitive. Whatever its sources, rising disability among the young could have adverse consequences for public programs such as disability insurance, Medicare, and Medicaid.

Effective HIV treatment and the employment of HIV(+) adults.

Abstract: Objective To examine whether highly active antiretroviral therapy (HAART) helps HIV-infected patients return to work, remain employed, and maintain hours of work.

Disability forecasts and future Medicare costs.

Abstract: The traditional focus of disability research has been on the elderly, with good reason. Chronic disability is much more prevalent among the elderly, and it has a more direct impact on the demand for medical care. It is also important to understand trends in disability among the young, however, particularly if these trends diverge from those among the elderly. These trends could have serious implications for future health care spending because more disability at younger ages almost certainly translates into more disability among tomorrow's elderly, and disability is a key predictor of health care spending. Using data from the Medicare Current Beneficiary Survey (MCBS) and the National Health Interview Study (NHIS), we forecast that per-capita Medicare costs will decline for the next fifteen to twenty years, in accordance with recent projections of declining disability among the elderly. By 2020, however, the trend reverses. Per-capita costs begin to rise due to growth in disability among the younger elderly. Total costs may well remain relatively flat until 2010 and then begin to rise because per-capita costs will cease to decline rapidly enough to offset the influx of new elderly people. Overall, cost forecasts for the elderly that incorporate information about disability among today's younger generations yield more pessimistic scenarios than those based solely on elderly data sets, and this information should be incorporated into official Medicare forecasts.

Obesity and Disability: The Shape of Things to Come

Abstract: This research brief summarizes studies that found that individuals who are obese face greater challenges in terms of disability and chronic disease than do their non-obese counterparts.

Health Status and Medical Treatment of the Future Elderly

Abstract: : The Centers for Medicare & Medicaid Services (CMS) must generate accurate predictions of future spending for planning purposes. To investigate a better method for understanding how medical breakthroughs and demographic trends will affect future Medicare costs, CMS contracted with RAND to develop models to project how changes in health status, disease, and disability among the next generation of elderly will affect future spending.

Price Regulation in Secondary Insurance Markets

Abstract: Secondary life insurance markets are growing rapidly. From nearly no transactions in 1980, a wide variety of similar products in this market has developed, including viatical settlements, accelerated death benefits, and life settlements and as the population ages, these markets will become increasingly popular. Eight state governments, in a bid to guarantee sellers a “fair” price, have passed regulations setting a price floor on secondary life insurance market transactions, and more are considering doing the same. Using data from a unique random sample of HIV+ patients, we estimate welfare losses from transactions prevented by binding price floors in the viatical settlements market (an important segment of the secondary life insurance market). We find that price floors bind on HIV patients with greater than 4 years of life expectancy. Furthermore, HIV patients from states with price floors are significantly less likely to viaticate than similarly healthy HIV patients from other states. If price floors were adopted nationwide, they would rule out transactions worth $119 million per year. We find that the magnitude of welfare loss from these blocked transactions would be highest for consumers who are relatively poor, have weak bequest motives, and have a high rate of time preference.

Employee Responses to Health Insurance Premium Increases

Abstract: Objective: To determine the sensitivity of employees’ health insurance decisions—including the decision to not choose health maintenance organization or fee-for-service coverage—during periods of rapidly escalating healthcare costs. Study Design: A retrospective cohort study of employee plan choices at a single large firm with a “cafeteria-style” benefits plan wherein employees paid all the additional cost of purchasing more generous insurance. Methods: We modeled the probability that an employee would drop coverage or switch plans in response to employee premium increases using data from a single large US company with employees across 47 states during the 3-year period of 1989 through 1991, a time of large premium increases within and across plans. Results: Premium increases induced substantial plan switching. Single employees were more likely to respond to premium increases by dropping coverage, whereas families tended to switch to another plan. Premium increases of 10% induced 7% of single employees to drop or severely cut back on coverage; 13% to switch to another plan; and 80% to remain in their existing plan. Similar figures for those with family coverage were 11%, 12%, and 77%, respectively. Simulation results that control for known covariates show similar increases. When faced with a dramatic increase in premiums—on the order of 20%—nearly one fifth of the single employees dropped coverage compared with 10% of those with family coverage. Conclusions: Employee coverage decisions are sensitive to rapidly increasing premiums, and single employees may be likely to drop coverage. This finding suggests that sustained premium increases could induce substantial increases in the number of uninsured individuals.

Increased Medicare expenditures for physicians' services: what are the causes?

Abstract: In light of rising expenditures for physicians' services and the scheduled decreases in the amounts Medicare pays for such services, we identified the sources of change in the volume and intensity of Medicare physicians' services. We found that the per capita volume and intensity of physicians' services used by Medicare beneficiaries increased more than 30% between 1993 and 1998. Our analyses indicated that, at most, half of this increase was due to measurable changes in the demographic composition, places of residence, prevalence of health conditions, and managed care enrollment of beneficiaries. The other half was due to a general increase in the use of care across beneficiary categories.

The changing face of pharmacy benefit design.

Abstract: Employers, health plans, and pharmacy benefit managers—seeking to reduce rapid growth in pharmacy spending—have embraced multi-tier pharmacy benefit packages that use differential copayments to ste...

Can Patient Self-Management Help Explain the SES Health Gradient?

Abstract: There are large differences in health outcomes by socioeconomic status (SES) that cannot be explained fully by traditional arguments, such as access to care or poor health behaviors. We consider a different explanation - better self-management of disease by the more educated. We examine differences by education in treatment adherence among patients with two illnesses, diabetes and HIV, and then assess the subsequent impact of differential adherence on health status. One unique component of this research is that for diabetes we combine two different surveys - one cohort study and one randomized clinical trial - that are usually used exclusively by either biomedical or/and social scientists separately. For both illnesses, we find significant effects of adherence that are much stronger among patients with high SES. After controlling for other factors, more educated HIV+ patients are more likely to adhere to therapy, and this adherence made them experience improvements in their self-reported general health. Similarly, among diabetics, the less educated were much more likely to switch treatment, which led to worsening general health. In the randomized trial setting, intensive treatment regimens that compensated for poor adherence led to better improvements in glycemic control for the less educated. Among two distinct chronic illnesses, the ability to maintain a better health regimen is an important independent determinant of subsequent health outcomes. This finding is robust across clinical trial and population-based settings. Because this ability varies by schooling, self-maintenance is an important reason for the steep SES gradient in health outcomes.

Price Regulation in Secondary Insurance Markets

Abstract: Secondary life insurance markets are growing rapidly. From nearly no transactions in 1980, a wide variety of similar products in this market has developed, including viatical settlements, accelerated death benefits, and life settlements and as the population ages, these markets will become increasingly popular. Eight state governments, in a bid to guarantee sellers a "fair" price, have passed regulations setting a price floor on secondary life insurance market transactions, and more are considering doing the same. Using data from a unique random sample of HIV+ patients, we estimate welfare losses from transactions prevented by binding price floors in the viatical settlements market (an important segment of the secondary life insurance market). We find that price floors bind on HIV patients with greater than 4 years of life expectancy. Furthermore, HIV patients from states with price floors are significantly less likely to viaticate than similarly healthy HIV patients from other states. If price floors were adopted nationwide, they would rule out transactions worth $119 million per year. We find that the magnitude of welfare loss from these blocked transactions would be highest for consumers who are relatively poor, have weak bequest motives, and have a high rate of time preference.

Health Care in California

Abstract: California has led the nation in coverage gains related to the Affordable Care Act, but it struggles to provide health services for its large population of undocumented immigrants and hold down prices for everyone. This DataGraphic shows where residents get their health coverage, who's uninsured and why, and which areas of the state have the most heavily concentrated hospital and physician markets. It then turns its eye to state and local efforts to improve health outcomes through the prevention of heart attacks and maternal deaths and limits on childhood vaccines exemptions.

Health Care in California: A Policy Assessment

Abstract: Focusing in particular on California, this chart book provides an overview of key health care policy issues in the areas of cost and quality. RAND Health, a division of the RAND Corporation, has joined with the Communications Institute to produce a series of conferences intended to provide a factual basis for discussion and decisionmaking regarding health care policy. This chart book documents the factual core of these conferences.