Health care burden of access barriers to epilepsy care in the United States: A claims-based analysis of payer channels

Objective

To describe access challenges, barriers to antiseizure medications (ASMs), and impact of ASM formulary policies for patients with epilepsy (PWE).

Methods

Observational study of de-identified claims from an all-payer claims database (2014–2021) and a formulary/payer policy database. Adults prescribed ≥ 1 ASM following initial epilepsy diagnosis, with continuous medical/pharmacy benefits, were included. Demographic characteristics, proximity to/use of a neurology health care professional (HCP), health care resource utilization (HCRU), and costs were assessed.

Results

In total, 35,351, 33,339, and 24,722 PWE with commercial, Medicare, and Medicaid insurance, respectively, were included. The Medicare group was older, had a higher comorbidity index score, more males, and fewer non-White and Hispanic individuals versus other groups. Most (> 58 %) commercially-insured PWE had coverage to all six first-generation ASMs examined, six to 12 second-generation ASMs, and all four third-generation ASMs; coverage rates were higher for Medicaid while data for Medicare were incomplete. Most commercial and Medicaid PWE had no access requirements to first-generation ASMs; approximately two-thirds and half of patients had access requirements for second- and third-generation ASMs, respectively. Although > 90 % of PWE used a neurology HCP during follow-up, only about one-third lived within proximity. Of PWE with formulary data (N = 77,787), > 80 % and < 8.0 % were prescribed second- and third-generation ASMs, respectively. There were no clear patterns in epilepsy-related HCRU/cost.

Conclusions

Data revealed difficulties in neurologist access and predominant use of second-generation ASMs, despite access restrictions for many PWE, suggesting obstacles in accessing treatment and specialist care.