Bradley Cathy J, Liang Rifei, Lindrooth Richard C, Sabik Lindsay M, Perraillon Marcelo C
Department of Health Systems, Management, and Policy, University of Colorado Cancer Center, Aurora.
Department of Health Systems, Management, and Policy, Colorado School of Public Health, Aurora.
JAMA Health Forum. 2025 Jan 3;6(1):e244868. doi: 10.1001/jamahealthforum.2024.4868.
Medicare Advantage (MA) plans are designed to incentivize the use of less expensive drugs through capitated payments, formulary control, and preauthorizations for certain drugs. These conditions may reduce spending on high-cost therapies for conditions such as cancer, a condition that is among the most expensive to treat.
To determine whether patients insured by MA plans receive less high-cost drugs than those insured by traditional Medicare (TM).
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from the linked Colorado All Payer Claims Database and Colorado Central Cancer Registry. This population-based cohort included adults 65 years and older insured by Medicare with prescription coverage who reside in Colorado and were diagnosed with colorectal (CRC) or non-small cell lung cancer (NSCLC) between January 2012 and December 2021. The data were analyzed between December 2023 and August 2024.
Enrollment in TM or MA insurance plans.
Claims for chemotherapy and oral targeted agents were identified. Thresholds for high-cost drugs were based on the distribution of drug costs. Inverse probability weighted logistic regression for receiving any cancer drug and for receiving a high-cost cancer drug was estimated, controlling for patient and ecological characteristics. The sample was stratified by cancer site and local/regional and distant stage.
Of 4240 patients included in the analysis (mean [SD] age, 75 [7] years; 2327 [54.9%] female), 1991 were diagnosed with CRC and 2249 with NSCLC. A total of 1647 patients had local or regional CRC, and 344 had distant CRC; 1351 patients had local or regional NSCLC, and 898 had distant NSCLC. In the covariate-adjusted analysis, patients diagnosed with local or regional CRC who were insured by MA were 6.0 percentage points less likely to receive a cancer drug than similar patients insured by TM. Patients diagnosed with distant NSCLC were 10.0 percentage points less likely to receive a cancer drug if insured by MA. Among patients who received a cancer drug, patients insured by MA were less likely to receive a high-cost drug for local or regional CRC (by 10.0 percentage points) and distant CRC (by 9.0 percentage points).
In this cohort study, high-cost drugs were more commonly prescribed among patients enrolled in TM and diagnosed with CRC. A similar pattern was not observed for patients with NSCLC, perhaps because clinical evidence suggests survival benefits to be associated only with certain drugs, all of which are expensive. Nonetheless, MA was modestly associated with reduced high-cost drug utilization and may reduce overall treatment costs.
医疗保险优势（MA）计划旨在通过按人头付费、药品目录控制和某些药物的预先授权来激励使用成本较低的药物。这些条件可能会减少用于治疗癌症等疾病的高成本疗法的支出，而癌症是治疗成本最高的疾病之一。
确定参加MA计划的参保患者是否比参加传统医疗保险（TM）的参保患者使用的高成本药物更少。
设计、设置和参与者：这项队列研究使用了科罗拉多州全支付者索赔数据库和科罗拉多州中央癌症登记处的关联数据。这个基于人群的队列包括65岁及以上参加医疗保险且有处方药覆盖的成年人，他们居住在科罗拉多州，在2012年1月至2021年12月期间被诊断患有结直肠癌（CRC）或非小细胞肺癌（NSCLC）。数据于2023年12月至2024年8月进行分析。
参加TM或MA保险计划。
确定化疗和口服靶向药物的索赔。高成本药物的阈值基于药物成本的分布。估计接受任何癌症药物和接受高成本癌症药物的逆概率加权逻辑回归，并控制患者和生态特征。样本按癌症部位以及局部/区域和远处分期进行分层。
在纳入分析的4240名患者中（平均[标准差]年龄为75[7]岁；2327名[54.9%]为女性），1991名被诊断患有CRC，2249名被诊断患有NSCLC。共有1647名患者患有局部或区域CRC，344名患有远处CRC；1351名患者患有局部或区域NSCLC，898名患有远处NSCLC。在协变量调整分析中，被诊断患有局部或区域CRC且参加MA保险的患者比参加TM保险的类似患者接受癌症药物的可能性低6.0个百分点。被诊断患有远处NSCLC且参加MA保险的患者接受癌症药物的可能性低10.0个百分点。在接受癌症药物治疗的患者中，参加MA保险的患者接受局部或区域CRC（低10.0个百分点）和远处CRC（低9.0个百分点）高成本药物的可能性较小。
在这项队列研究中，参加TM且被诊断患有CRC的患者中更常开具高成本药物。在NSCLC患者中未观察到类似模式，可能是因为临床证据表明生存获益仅与某些药物相关，而所有这些药物都很昂贵。尽管如此，MA与高成本药物使用减少适度相关，可能会降低总体治疗成本。
