Medicare Advantage Program Linked to Higher Inhaler Adherence in Patients With COPD

Medicare Advantage beneficiaries with chronic obstructive pulmonary disease (COPD) who received an invitation to enroll in a program that reduced maintenance inhaler cost sharing and provided medication management had higher inhaler adherence, according to a study published in JAMA Internal Medicine.¹

The researchers noted that improper use and cost-related nonadherence prevent patients with COPD from successfully using maintenance inhalers, which reduces the frequency and severity of exacerbations. More specifically, about 1 in 3 Medicare patients using inhalers reported cost-related nonadherence, and more than half reported inhaler misuse.

CMS initiated the Value-Based Insurance Design model in 2017 to help reduce Medicare expenditures, advance health equity in Medicare Advantage, and enhance care quality.² As part of the CMS model, Humana Inc, a large Medicare Advantage insurer, launched a national program in 2020 to provide medication management services and reduce beneficiary cost sharing for COPD maintenance inhalers.¹ Eligible beneficiaries randomly received an invitation by phone and mail to enroll in the program; those who did not receive an invitation could still call to enroll if they learned about the program through other means.

The program reduced cost sharing for eligible maintenance inhalers to $0 if they were filled at a preferred retail or mail order pharmacy or to $10 if they were filled at any other in-network pharmacy; eligible inhalers included single agents or combinations of inhaled glucocorticoids, long-acting β-agonists, and long-acting muscarinic antagonists. Additionally, program enrollees received up to 3 medication management telephone calls focusing on educational barriers to using the inhaler as prescribed.

Conversely, there is limited evidence of the program's impact. Therefore, the researchers examined the program's effects on inhaler adherence, exacerbations, racial disparities, and health care spending by comparing Medicare Advantage beneficiaries with COPD invited to the program with a control group.

Medicare Advantage beneficiaries withCOPD) who were invited to enroll in a program that reduced inhaler costs and provided medication management had higher inhaler adherence. | Image Credit: DALU11 - stock.adobe.com

The researchers analyzed Humana claims data from January 2019 to December 2021. Eligible beneficiaries were those enrolled in a participating Humana Medicare Advantage plan, those who had previously enrolled in a Humana plan for at least 3 months, and those who received medical and prescription drug coverage through a plan with Part D coverage. Additionally, they needed to have a COPD diagnosis within 2 years of available preperiod data, filled a short-acting or maintenance inhaler at least once in the year before randomization, and an adherence level below 80% according to the proportion of days covered (PDC).

The primary outcome was maintenance inhaler adherence, measured by the PDC; the researchers also calculated the proportion of those who had full adherence to at least 1 maintenance inhaler, meaning they had a PDC of 80% or greater. Additionally, they analyzed 3 secondary outcomes: total spending, the number of short-acting inhaler fills, and the annual number of acute moderate to severe COPD exacerbations. The researchers also conducted an intention-to-treat analysis, assessing the impact of being assigned to the invited group on the outcomes, regardless of whether the patients enrolled in the program.

The study population consisted of 19,113 patients, with 9512 (49.8%) assigned to the control group and 9601 (50.2%) assigned to the invited group. Of the patients, 10,497 (55.2%) were female, and the mean (IQR) age was 74 (69-80) years. In terms of race, 15,506 patients (81.1%) were White, 1809 (5%) were Black, and 1798 (9.4%) were another or unknown race.

Of the patients analyzed, 29.4% of the invited group and 5.1% of the control group enrolled in the program (adjusted difference, 24.4%; 95% CI, 23.4%-25.4%). Additionally, the PDC for maintenance inhaler adherence was 32.0% in the invited group and 28.4% in the control group. Through the intention-to-treat analysis, the researchers determined the adjusted adherence difference to be 3.8% (95% CI, 3.1%-4.5%) higher in the invited group than in the control group. Also, the adjusted adherence difference from enrolling in the program due to the invitation was 15.5% (95% CI, 12.8%-18.1%); this represented a 55% increase relative to the control group's mean.

Additionally, the moderate to severe exacerbation rate was 454.2 per 1000 patients in the invited group and 445.6 per 1000 patients in the control group. Consequently, there was no statistically significant effect of program invitation (adjusted invitation effect, 2.0 exacerbations per 1000 patients; 95% CI, –23.4 to 27.4) or enrollment (adjusted program effect, 8.2 exacerbations per 1000 patients; 95% CI, –96.2 to 112.5) on exacerbations.

Also, mean (SD) out-of-pocket prescription drug spending was lower among the invited group ($619.5 [$863.1]) than the control group ($675.0 [$887.3]; adjusted invitation effect, –$49.5; 95% CI, –$68.9 to –$30.0; adjusted program effect, –$203.0; 95% CI, –$282.8 to –$123.2). However, there was no statistically significant effect on mean total spending (invited group: $19,038.3 [$31,219.4]; control group: $19,156.1 [$32,799.3]; adjusted invitation effect, –$125.8; 95% CI, –$953.1 to $701.4; adjusted program effect, –$516.4; 95% CI, –$3910.5 to $2877.7).

As for racial differences, the adjusted adherence difference between the invited and control groups was 3.7% (95% CI, 2.9%-4.4%) among White patients and 5.5% (95% CI, 3.3%-7.7%) among Black patients; the researchers noted that this difference was not statistically significant (adjusted invitation effect difference, 1.8%; 95% CI, –0.5% to 4.1%; P = .13).

Also, the adjusted adherence difference from enrolling in the program after receiving an invitation was 19.5% (95% CI, 12.4%-26.7%) among Black patients and 15.1% (95% CI, 12.1%-18.1%) among White patients (adjusted program effect difference, 4.4%; 95% CI, –3.3% to 12.2%). Similarly, the PDC for maintenance inhaler adherence among Black patients was 32.1% in the invited group and 25.8% in the control group; the PDC for maintenance inhaler adherence among White patients was 32.2% in the invited group and 28.8% in the control group.

Lastly, there was a significant reduction in out-of-pocket prescription drug spending for White patients (adjusted invitation effect, –$44.3; 95% CI, –$66.4 to –$24.2; adjusted program effect, –$186.6; 95% CI, –$273.6 to –$99.6). Black patients did not experience this (adjusted invitation effect, –$12.4; 95% CI, –$87.2 to $62.3; adjusted program effect, –$44.1; 95% CI, –$307.9 to $219.7). However, the researchers noted that this difference was not statistically significant (adjusted invitation effect difference, $32.8; 95% CI, –$44.6 to $110.2; adjusted program effect difference, $142.5; 95% CI, –$135.2 to $420.3).

The researchers acknowledged their study's limitations, one being that all analyzed beneficiaries were enrolled in participating Medicare Advantage plans from a single insurer; this may limit the generalizability of the findings to other Medicare populations. Despite their limitations, the researchers used their findings to suggest next steps for insurers.

“To better align insurance coverage with clinical benefit, insurers might consider selectively lowering cost sharing and providing medication management services for clinically effective, high-value services,” the authors concluded.

References

1. Agarwal SD, Metzler E, Chernew M, et al. Reduced cost sharing and medication management services for COPD: a randomized clinical trial. JAMA Intern Med. Published online July 29, 2024. doi:10.1001/jamainternmed.2024.3499

2. Medicare Advantage Value-Based Insurance Design model. CMS. https://www. cms.gov/priorities/innovation/innovation-models/vbid