Evaluating the effect of carve-in or carve-out insurance designs on adherence to oral anticoagulation in patients with atrial fibrillation: a comparison of Medicare Advantage versus Medicare Fee-for-Service insurance plansNewman, Terri (2020) Evaluating the effect of carve-in or carve-out insurance designs on adherence to oral anticoagulation in patients with atrial fibrillation: a comparison of Medicare Advantage versus Medicare Fee-for-Service insurance plans. Master's Thesis, University of Pittsburgh. (Unpublished)
AbstractAtrial Fibrillation (AF) is a highly prevalent cardiac arrhythmia that affects nearly 6 million adults in the United States. AF is a potent risk factor for stroke and this risk increases with age. Given the aging population in the US, AF-related stroke represents a significant public health burden. Treatment with oral anticoagulation (OAC) is recommended for stroke prevention and is an important public health intervention to reduce stroke occurrences. Despite this benefit, 50% of high-risk AF patients do not receive OAC. The literature shows that health insurance can affect initiation and adherence to OAC in AF patients, however there is limited information assessing to what extent different Medicare Part D insurance designs can affect adherence to OAC. Jung and colleagues suggest that insurance designs that carve-in pharmacy benefits with medical benefits such as Medicare Advantage Prescription Drug Plan (MA-PD) can improve medication adherence compared to plans that carve-out pharmacy benefits such as Stand-Alone Prescription Drug Plans (PDP). Insurers that provide carve-in benefits may be incentivized to improve adherence to OAC in order to offset medical costs that could be incurred through the development of a stroke. In this study, we conducted multivariate logistic regressions among propensity-score matched samples to evaluate the effect of enrollment in PDP vs. MA-PD on adherence to OAC and OAC use. We used 2014-2016 Medicare Claims Data from Centers of Medicare and Medicaid Services (PDP) and UPMC Health Plan data (MA-PD). We found that enrollment in a PDP was associated with significantly lower odds of adherence (OR 0.68, 95% CI 0.60-0.76) and OAC use (OR 0.59, 95% CI 0.50-0.69) compared to MA-PD. Our results suggest that insurance plans that carve-in pharmacy benefits can improve adherence to OAC and ultimately prevent downstream stroke events. Public health significance: Identifying factors to improve OAC use and adherence in AF patients can improve population health by preventing downstream stroke events and costly hospitalizations. Policymakers should consider the benefits of carve-in insurance designs in order to improve OAC adherence in the AF population. Share
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