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Original Investigation
Health Care Policy and Law
January 4, 2022

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

Author Affiliations
  • 1Yale School of Medicine, New Haven, Connecticut
  • 2Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco
  • 3Division of Cardiology, San Francisco VA Medical Center, San Francisco, California
  • 4Division of Health Care Delivery Research, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
  • 5Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut
  • 6Yale National Clinicians Scholar Program, Yale School of Medicine, New Haven, Connecticut
  • 7Center on Aging, University of Connecticut School of Medicine, Farmington
  • 8Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 9Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
  • 10Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
JAMA Intern Med. Published online January 4, 2022. doi:10.1001/jamainternmed.2021.7457
Key Points

Question  What are the hypothetical annual out-of-pocket costs of guideline-recommended medications for the treatment of older adults with multiple chronic conditions in 2009 and 2019?

Findings  In this cross-sectional study of hypothetical older adults with 8 common chronic conditions enrolled in 3599 Medicare prescription drug plans in 2009 and 3618 Medicare prescription drug plans in 2019, the median inflation-adjusted out-of-pocket costs for guideline-recommended medications decreased between 2009 and 2019, with the exception of costs for conditions for which brand-name medications without generic alternatives became guideline recommended. For a cluster of 5 commonly comorbid conditions (chronic obstructive pulmonary disease, hypertension, osteoarthritis, osteoporosis, and type 2 diabetes), the median annual cost was $1999 in 2019, a 12% decrease from 2009.

Meaning  In this study, although inflation-adjusted out-of-pocket costs of guideline-recommended medications for older adults with multiple chronic conditions generally decreased between 2009 and 2019, costs remained high and may have presented a substantial financial burden for Medicare beneficiaries.

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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