医疗保险D部分改善患者获得COVID-19抗病毒治疗的财务价值:一项模拟研究

IF 2.3 4区 医学 Q2 HEALTH CARE SCIENCES & SERVICES
Andrew S Aguilar, Tyler Engel, Wesley Furnback, Gabriela Dieguez, David J Campbell, Benjamin Diner, Sean D Sullivan, William Dorling
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引用次数: 0

摘要

背景:Nirmatrelvir-ritonavir是一种被批准用于轻度至中度COVID-19成人的治疗方法,这些患者进展为重度COVID-19(包括住院或死亡)的风险很高。年龄是严重COVID-19的主要风险因素,因此获得治疗对享有医疗保险的人群尤为重要。D部分计划必须在处方中包括COVID-19抗病毒药物。然而,与医疗保险优势处方药计划(MAPD)不同,它承担医疗和药房成本的风险,独立处方药计划(pdp)在优先级中有财务上的抑制因素。随着2025年报销过渡到D部分计划,重要的是计划要了解在不同处方级别提供治疗对预算的影响。目的:研究D部分首选层获得尼马特韦-利托那韦的挑战及其对COVID-19治疗放弃率和住院率的影响。方法:结合精算和预算影响模型,我们使用Milliman处方药综合数据库中的真实处方数据,估计了D部分处方层中nirmatrelvir-ritonavir对计划预算、治疗放弃和住院治疗的潜在影响。分别总结了2025年PDP、MAPD和医疗服务收费计划的潜在影响。结果:nirmatrelvir-ritonavir的专业级放置导致医疗保险计划节省21.4亿美元,而优先级放置为22.2亿美元。考虑到D部分计划净负债的增加,nirmatrelvir-ritonavir位于首选品牌级别,通过将患者放弃率降低62%和与covid -19相关的住院费用降低21.4亿美元,与专科级别的定位相比,为医疗保险计划额外节省了8070万美元。这些节省包括:(1)在扣除医疗费用抵消后,MAPD计划的净成本减少了6510万美元,(2)pdp的D部分净负债增加了7.109亿美元,以及(3)由于减少了与covid -19相关的住院治疗,医疗保险按服务收费节省了7.265亿美元。结论:尼马特韦-利托那韦的覆盖范围,在任何级别上,总体上都是医疗保险计划的成本节约。较低患者费用分担的首选保险可节省额外费用,并通过降低住院率和死亡率改善患者预后。在确定处方层级时,个人医疗保险计划应考虑尼马特韦-利托那韦对卫生系统的总体临床和成本影响。需要更好地协调对pdp的激励措施,以解决扩大治疗可及性的财务障碍,从而改善临床结果并为医疗保险计划节省资金。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
The financial value of improving patient access to COVID-19 antiviral therapy in Medicare Part D: A simulation study.

Background: Nirmatrelvir-ritonavir is an approved treatment for mild to moderate COVID-19 in adults who are at high risk for progression to severe COVID-19, including hospitalization or death. Age is the leading risk factor for severe COVID-19, making treatment access particularly important for the Medicare population. Part D plans must include COVID-19 antivirals on formularies. However, unlike Medicare Advantage prescription drug (MAPD) plans, which assume risk for both medical and pharmacy costs, standalone prescription drug plans (PDPs) have a financial disincentive to cover them in the preferred tier. As reimbursement transitions to Part D plans in 2025, it is important for plans to understand the budget impact of providing treatment access at different formulary tiers.

Objective: To examine challenges to preferred tier access to nirmatrelvir-ritonavir in Part D and their impact on COVID-19 treatment abandonment and hospitalization rates.

Methods: Using a combination of actuarial and budget impact models, we estimated the potential impact of Part D formulary tier placements of nirmatrelvir-ritonavir on plan budgets, therapy abandonment, and hospitalizations using real-world prescription data from Milliman's Prescription Drug Consolidated Database. Potential impacts were summarized separately for PDP, MAPD, and the Medicare fee-for-service program in 2025.

Results: Specialty tier placement of nirmatrelvir-ritonavir resulted in savings to the Medicare program of $2.14 billion compared with $2.22 billion for preferred tier placement. Compared with placement in the specialty tier, nirmatrelvir-ritonavir positioned at the preferred brand tier saves the Medicare program an additional $80.7 million by reducing patient abandonment by 62% and COVID-19-related hospitalization costs by $2.14 billion after accounting for the increase in net Part D plan liabilities. These savings consist of (1) a net cost reduction, after accounting for medical cost offsets, of $65.1 million for MAPD plans, (2) an increase in net Part D liability of $710.9 million for PDPs, and (3) cost savings to Medicare fee-for-service from reduced COVID-19-related hospitalizations of $726.5 million.

Conclusions: Coverage of nirmatrelvir-ritonavir, on any tier, is cost-saving for the Medicare program overall. Preferred coverage with lower patient cost-sharing results in additional savings and improved patient outcomes from lower hospitalizations and mortality rates. Individual Medicare plans should consider the overall clinical and cost impacts of nirmatrelvir-ritonavir on the health system when determining formulary tier placement. Better alignment of incentives for PDPs is needed to address the financial barriers to expanding access for therapies that can improve clinical outcomes and produce savings to the Medicare program.

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来源期刊
Journal of managed care & specialty pharmacy
Journal of managed care & specialty pharmacy Health Professions-Pharmacy
CiteScore
3.50
自引率
4.80%
发文量
131
期刊介绍: JMCP welcomes research studies conducted outside of the United States that are relevant to our readership. Our audience is primarily concerned with designing policies of formulary coverage, health benefit design, and pharmaceutical programs that are based on evidence from large populations of people. Studies of pharmacist interventions conducted outside the United States that have already been extensively studied within the United States and studies of small sample sizes in non-managed care environments outside of the United States (e.g., hospitals or community pharmacies) are generally of low interest to our readership. However, studies of health outcomes and costs assessed in large populations that provide evidence for formulary coverage, health benefit design, and pharmaceutical programs are of high interest to JMCP’s readership.
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