Medicare Patients Under 65 with PAH Face High Burden and Costs | 2024 ATS

Patients with pulmonary arterial hypertension who are covered by Medicare who are who under the age of 65 and are eligible for the low-income subsidy have higher costs than those with fee-for-service Medicare who are not eligible, according to a new poster presented recently at the American Thoracic Society 2024 International Conference.

Pulmonary arterial hypertension is a rare, progressive and life-threatening disease in which blood vessels in the lungs narrow, causing strain on the heart. About 40,000 people in the United States are living with PAH. The five-year mortality rate is about 43%.

Anna Watzker

“Patients who are disabled (i.e., are eligible for Medicare after receiving Social Security Disability Insurance for 24 months and are under the age of 65) and also receive low-income subsidy are one of the most vulnerable patient groups,” Anna Watzker, associate director, outcomes research at Merck, said by email. Merck sponsored this research. “Not only do they have advanced disease, requiring prolonged disability insurance due to the inability to work, but are also socioeconomically disadvantaged that may lead to additional hardships to pay for the necessary healthcare services.

Watzker said that despite the subsidy, these patients incur higher healthcare costs. “But there may be other factors at play that our study was not able to address (e.g., disease severity, comorbidity burden, lifestyle).”

Watzker and her colleagues wanted to assess the costs for patients less than 65 years of age with pulmonary arterial hypertension who have coverage through Medicare fee-for-services plans based on eligibility for Part D low-income subsidy.

This retrospective study used the 100% Medicare Research Identifiable Files between Jan. 1, 2019, and Dec. 31, 2019, to identify patients less than 65 years of age who were disabled. Direct medical and pharmacy costs were summarized on a per-patient-per-month (PPPM) basis in terms of payer-paid amounts and out-of-pocket amounts. Part D payer-paid amounts reflect all costs not paid by patients.

The analysis included 2,139 patients with pulmonary arterial hypertension who were eligible Medicare’s low income subsidy, as well as 412 patients who were not eligible for the subsidy.

Researchers found that total payer-paid costs, both medical and drug-related, incurred by patients eligible for low income subsidy were $2,105 higher than for patients not eligible for the subsidy. For both groups, the highest payer-paid costs were attributed to medication costs, followed by hospitalizations and outpatient hospital visits.

Patients without low-income subsidy had on average $1,302 per patient per month out-of-pocket costs; 76% of this was for medications. Patients not eligible for subsidy face out-of-pocket costs of more than $1,000 per month.

Researchers said the data suggests that social determinants of health may impact healthcare utilization of patients with pulmonary arterial hypertension. Additionally, low-income patients may face issues with access to care and have more advanced disease at presentation

Limitations of the study include the fact that the claims data used did not capture information about disease severity and other clinical factors that could contribute to higher costs.

“Future studies should focus on exploring the disparities in this population further in order to aid healthcare delivery and improve outcomes,” Watzker said.

Previous research has found that social determinants of health are an important consideration when treating patients with pulmonary arterial hypertension, but there are gaps in knowledge about race/ethnicity and the determinants that impact outcomes, according to a study published in September 2023 issue of Clinics in Chest Medicine.

“A better understanding of how to reduce the barriers to equitable access and implementation of PAH care is needed. Through collaboration between at-risk populations, patient advocacy groups (such as the Pulmonary Hypertension Association), and PAH specialists, researchers and professional societies, an improved understanding of barriers to PAH equity is needed to successfully implement PAH interventions,” researchers of this study wrote.

There also appears to be limited research on patient costs in this disease. One study published in March 2022 in BMC Pulmonary Medicine looked at the economic burden of pulmonary arterial hypertension on patients in Spain. Several other studies looked at hospital and healthcare resources use.