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Introduction
Skills and Expertise
Publications
Publications (76)
This cross-sectional study assesses pharmacy participation in the 340B Drug Pricing Program following the 2010 expansion and the extent to which growth has occurred in socioeconomically disadvantaged neighborhoods.
Background
Among the 1.2 million people living with HIV (PLWH) in the U.S., many are covered by Medicare, a federally funded health insurance program for elderly (≥65 years) and disabled (< 65 years) individuals. Medicare has emerged as a major source of HIV care for PLWH. Given limited research in this population, a better understanding of patient...
BACKGROUND: Few studies have examined oral anticancer treatment utilization patterns among Medicare beneficiaries. OBJECTIVE: To assess treatment utilization patterns of newly initiated oral anticancer agents across national samples of Medicare beneficiaries for 5 cancer types: chronic myeloid leukemia (CML), multiple myeloma (MM), metastatic prost...
Background:
Increasing doses of oral antiparkinson medications are indicated in advanced Parkinson's disease (PD), but little is known about sustainment of high-dose regimens.
Objective:
To investigate sustainment of high-dose oral medication regimens in Medicare beneficiaries with incident advanced PD.
Methods:
This retrospective cohort study...
Background:
Current understanding of the health care costs of Parkinson's disease (PD) and the incremental burden of advanced disease is incomplete.
Objectives:
The aim of this study was to assess the direct economic burden associated with advanced versus mild/moderate PD in a prevalent national sample of elderly U.S. Medicare beneficiaries with...
Background: Specialty drugs are typically subject to high out-of-pocket (OOP) costs, especially for Medicare Part D patients and commercially insured patients facing high deductibles and/or coinsurance. Financial assistance offered by charities or manufacturers often helps reduce OOP burden. Studies in several disease areas have shown that high OOP...
Introduction
Lack of a gold standard definition for advanced Parkinson's Disease (APD), coupled with absence of disease severity information in diagnostic codes, hinders use of large administrative databases for conducting population health and comparative effectiveness studies.
Methods
Using pharmacy claims data, we created an algorithm to identi...
Objectives
Disease-modifying therapies (DMTs) reduce relapse rates and disability progression for relapsing multiple sclerosis (MS). Although 25% to 30% of all US patients with MS are Medicare beneficiaries, limited information exists on this population. This is the first study using national Medicare data to (1) describe characteristics of patient...
Objectives:
Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is)-innovative yet costly cholesterol-lowering agents-have been subject to substantial prior authorization (PA) requirements and low approval rates. We aimed to investigate trends in insurer approval and reasons for rejection for PCSK9i prescriptions as well as associations...
Aim:
To estimate risk factors associated with early hypoglycaemia and its impact on adherence to and persistence with therapy in Medicare Part D beneficiaries with type 2 diabetes who are initiating basal insulin (BI).
Materials and methods:
This retrospective analysis used a 5% sample of Medicare files from 2007-2013, identifying beneficiaries...
Background:
Asthma in older adults is associated with high rates of morbidity and mortality; similarly, asthma can be severe enough among younger adults to warrant disability benefits. Reasons for poor outcomes in both groups of patients may include discontinuation and lack of adherence to controller therapies.
Objective:
To examine characterist...
Importance
Targeted therapies for advanced renal cell carcinoma (RCC) have shown increased tolerability and survival advantages over older treatments in clinical trials, but understanding of real-world survival improvements is still emerging.
Objective
To compare overall and RCC-specific survival associated with use of targeted vs nontargeted ther...
There is a substantial literature assessing the impact of entry restrictions created by state certificate-of-need (CON) programs on hospital and nursing home markets, but comparatively little research has focused on CON for home health agencies (HHAs). We assessed the impact of state CON programs for HHAs, and for potential substitute service provi...
Purpose
The number of novel oral anticancer agents is increasing, but financial barriers may limit access. We examined associations between out-of-pocket (OOP) costs and reduced and/or delayed treatment initiation.
Methods
This retrospective claims-based study used 2014 to 2015 data from a large, proprietary, integrated database and included Medic...
Angiogenesis is a critical step during tumor progression. Anti-angiogenic therapy has only provided modest benefits in delaying tumor progression despite its early promise in cancer treatment. It has been postulated that anti-angiogenic therapy may promote the emergence of a more aggressive cancer cell phenotype by generating increased tumor hypoxi...
High out-of-pocket costs may limit access to oral therapies covered by patients’ prescription drug benefits. We explored financial barriers to treatment initiation in patients newly diagnosed with metastatic renal cell carcinoma (mRCC) by comparing Medicare Part D patients with low out-of-pocket costs due to receipt of full low-income subsidies (LI...
Objective: To assess the impact of Medicaid prescription copayment policies on antipsychotic and other medication use among patients with schizophrenia.
Method: The study sample included fee-for-service adult Medicaid patients with schizophrenia. Medicaid claims records from 2003-2005 from 42 states and D.C. were linked with county-level data from...
Objective:
To examine the impact of cost-sharing increases on continuity of specialty drug use in Medicare beneficiaries with multiple sclerosis (MS) or rheumatoid arthritis (RA).
Data sources/study setting:
Five percent Medicare claims data (2007-2010).
Study design:
Quasi-experimental study examining changes in specialty drug use among a gro...
Background: The proportion of outpatient surgeries performed in physician offices has been increasing over time, raising concern about the impact on outcomes.
Objective: To use a private insurance claims database to compare 7-day and 30-day hospitalization rates following relatively complex outpatient surgical procedures across physician offices, f...
OBJECTIVES: Medicare Part D specialty drug users not qualifying for low-income subsidies (non-LIS beneficiaries) face high and variable cost sharing during the calendar year. We examined their out-of-pocket (OOP) cost patterns under the existing Part D cost-sharing policies and proposed changes to these policies.
METHODS: Using 100% Medicare claim...
In 2001, the U.S. government released a rule that allowed states to “opt-out” of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist. To date, 17 states have opted out. The majority of the opt-out states cited increased access to anesthesia care as the primary rationale for their decision. In t...
Objectives:
Medication adherence is often suboptimal, especially among patients on multiple chronic medications. We examined the association between synchronized medication refill schedules-which typically reduce organizational effort and logistical demands-and adherence.
Study design:
Retrospective study among patients enrolled in Medicare Adva...
Background: Chronic lymphocytic leukemia (CLL) is the most common leukemia among adults in Western countries with a median age of 72 years at diagnosis. Data from recent randomized clinical trials of novel agents, such as ibrutinib, have shown significant improvements in overall survival (OS) among older CLL patients. Prior to the introduction of k...
Introduction: Chronic lymphocytic leukemia (CLL) is the most common leukemia among adults in Western countries with a median age of 72 years at diagnosis. Prior to the introduction of kinase inhibitor therapies, chemoimmunotherapy (CIT) combinations, monoclonal antibody monotherapies, and chemotherapy combinations were the predominant therapy regar...
Background
Cost sharing is widely used to encourage therapeutic substitution. This study aimed to examine the impact of increases in patient cost‐sharing differentials for brand name and generic drugs on statin utilization on entry into the Medicare Part D coverage gap.
Method and Results
Using 5% Medicare Chronic Condition Warehouse files from 20...
Synchronizing medication refills—renewing all medications at the same time from the same pharmacy—is an increasingly popular strategy to improve adherence to medication regimens, but there has been little research regarding its effectiveness. In light of increasing policy interest, we evaluated the impact of a pilot refill synchronization program i...
OBJECTIVE:Since 2007, the Centers for Medicare and Medicaid Services have published 5-star quality rating measures to aid consumers in choosing Medicare Advantage Prescription Drug Plans (MAPDs). We examined the impact of these star ratings on Medicare Advantage Prescription Drug (MAPD) enrollment before and after 2012, when star ratings became tie...
Supporting file including Table A-G and Fig A. Table A: Sensitivity Analysis on Analytical Technique: Association of Star Rating and MAPD Contract Enrollment Before and After 2012 (Panel Data Fixed Effect Model). Table B: Sensitivity Analysis on Sample Selection: Association of Star Rating and MAPD Contract Enrollment Before and After 2012 (Panel D...
Objective:
To examine associations between specialty tier-level cost sharing and utilization of biologics for rheumatoid arthritis during Medicare Part D's initial coverage period (ICP).
Methods:
Retrospective study using 2007-2010 5% sample Medicare files to examine RA patients with use of a Part D RA biologic in the prior year. Patients withou...
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 ~5...
Background:
Studies indicate adherence to biologics among patients with psoriasis is low, yet little is known about their use in the Medicare population.
Objective:
We sought to investigate real-world utilization patterns in a national sample of Medicare beneficiaries with psoriasis initiating infliximab, etanercept, adalimumab, or ustekinumab....
Background:
Despite ongoing policy debate, little is known about the growth in orthopedic surgery practices with onsite magnetic resonance imaging (MRI) capacity, or practice characteristics associated with the acquisition of in-office MRI equipment.
Methods:
In July 2012, American Academy of Orthopaedic Surgeons (AAOS) member practices received...
Between December 2005 and October 2009, FDA approved six targeted therapies shown to significantly extend survival for advanced renal cell carcinoma (RCC) patients in clinical trials. This study aimed to examine changes in survival between the pretargeted and targeted therapy periods in advanced RCC patients in a real-world setting. Utilizing the 2...
Supplementary Table 1. Psoriasis Patient Characteristicsa
Supplementary Table 2. Psoriasis Therapy Prevalencea
Supplementary Table 3. Psoriasis Severity
Supplementary Table 4. Factors Associated with Biologic Use Among Patients Receiving Therapy Indicated for Moderate to Severe Psoriasisa
Background:
Concerns have been raised about physician ownership of onsite advanced imaging equipment as allowed under Stark laws by the in-office ancillary service exception (IOASE).
Methods:
A web-based survey of orthopedic practices in the United States was used to assign a first date of onsite MRI capacity acquisition (if any) to specific ort...
Psoriasis is a common chronic inflammatory disorder, primarily of the skin. Despite an aging population, knowledge of the epidemiology of psoriasis and its treatments among the elderly is limited. We examined the prevalence of psoriasis and its treatments, with a focus on biologics and identification of factors associated with biologic use, using a...
Objectives:
Specialty drugs often represent major medical advances for patients with few other effective options available, but high costs have attracted the attention of both payers and policy makers. We reviewed the evidence regarding the impact of cost sharing on utilization of specialty drugs indicated for rheumatoid arthritis (RA), multiple s...
Using US Medicaid data, we found that 52% of adult Medicaid patients with acute respiratory tract infections filled prescriptions for antimicrobial drugs in 2007. Factors associated with lower likelihood of use were higher county-level availability of primary care physicians and state-level participation in a campaign for appropriate antimicrobial...
Sample selection diagram and sensitivity and subgroup analyses (odds ratios for primary care physician density and Centers for Disease Control and Prevention Get Smart campaign).
Prior studies of the Medicare Part D coverage gap are limited in generalizability and scope.
To determine the effect of the coverage gap on drugs used for asymptomatic (antihypertensive and lipid-lowering drugs) and symptomatic (pain relievers, acid suppressants, and antidepressants) conditions in elderly patients with hypertension and hyperlipidem...
OBJECTIVES: The impact of Medicare's Part D coverage gap (donut hole) on antihypertensive and antilipidemic drug utilization was examined among patients with diabetes or coronary heart disease (CHD) and compared to changes in drug use for symptomatic (GI, depression, and pain) conditions.
METHODS: The sample consisted of beneficiaries from the 5% M...
Small rural hospitals face considerable financial and personnel resource shortages which hinder their efforts to implement complex health information technology (HIT) systems. A survey on the use of HIT was completed by 85% of Iowa's 82 Critical Access Hospitals (CAH). Analyses indicate that low IT staffing in CAHs is a barrier to implementing HIT...
This study examines the effect of physician-owned hospitals (POHs) on Medicare per enrollee expenditures at the metropolitan area (MSA) level nationwide, spanning the 8-year time period from 1998 to 2005. The study uses fixed effects panel data estimation with instrumental variables to account for the bias introduced by endogenous POH market entry...
This study examined adherence, discontinuation, and switching of rheumatoid arthritis (RA) biologics over a 1-year period after initiation of the biologic treatment in Medicaid patients with RA.
The study sample consisted of Medicaid patients with RA in California, Florida and New York who had newly initiated etanercept (n=1359), anakinra (n=267),...
The Centers for Medicare and Medicaid Services (CMS) has implemented the CMS-Hierarchical Condition Category (CMS-HCC) model to risk adjust Medicare capitation payments. This study intends to assess the performance of the CMS-HCC risk adjustment method and to compare it to the Charlson and Elixhauser comorbidity measures in predicting in-hospital a...
To examine changes in utilization and expenditures for infliximab in rheumatoid arthritis (RA) patients associated with the 2 changes implemented by the Medicare Prescription Drug Improvement and Modernization Act (MMA) of 2003, specifically 1) reductions in physician reimbursement for Part B drugs between 2003 and 2005 and 2) availability of alter...
The Balanced Budget Act (BBA) of 1997 allowed some rural hospitals meeting certain requirements to convert to Critical Access Hospitals (CAHs) and changed their Medicare reimbursement from prospective to cost-based. Some subsequent CAH-related laws reduced restrictions and increased payments, and the number of CAHs grew rapidly.
To examine factors...
To improve rural access to care, the Balanced Budget Act of 1997 allowed eligible rural hospitals to convert to critical access hospitals (CAHs), which changed their Medicare payment from a prospective payment system (PPS) to a cost-based system. The objective of this paper is to examine the effects of CAH conversion on rural hospital operating rev...
Specialty hospitals, particularly those specializing in surgery and owned by physicians, have generated a relatively high degree of policy attention over the past several years. The main focus of policy debates has been in two areas: the extent to which specialty hospitals might compete unfairly with incumbent general hospitals and the extent to wh...
Background:
Health information technology (HIT) is designed to help reduce medical errors and improve quality of care and efficiency by providing the right information for the right patients in the right place at the right time. Nevertheless, substantial variation currently exists in the adoption of electronic medical records (EMRs) resulting in d...
The objective of this paper is to describe the market structure of health plans (HPs) and physician organizations (POs) in California, a state with high levels of managed care penetration and selective contracting. First we calculate Herfindahl-Hirschman (HHI) concentration indices for HPs and POs in 42 California counties. We then estimate a multi...
The Medicare Rural Hospital Flexibility Program of the 1997 Balanced Budget Act allowed hospitals meeting certain criteria to convert to critical access hospitals (CAH) and changed their Medicare reimbursement mechanism from prospective payment system (PPS) to cost-based.
To examine the impact of CAH conversion on hospital patient safety.
Secondary...
Patients with acute myocardial infarction have higher mortality rates in rural hospitals than in urban hospitals, suggesting substandard quality of care in the rural setting. We examined characteristics of patients experiencing myocardial infarction and used an instrumental variable technique to adjust for unmeasured confounding when comparing mort...
Hospital specialization has become a controversial topic, culminating in a moratorium issued in 2003 by Congress directing the Centers for Medicare and Medicaid Services to cease payments to new physician-owned specialty hospitals for those Medicare and Medicaid patients referred by physicians with a financial interest in the facility. This paper f...
