In the United States, health insurance coverage and quality mediate access to health care, a key social determinant of health.
Objective:
To perform a scoping review regarding the impact of insurance coverage and benefit design on health care access and both clinical and quality of life outcomes in people with MS (pwMS).
Methods:
Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines were followed. A literature search was conducted from January 2010 to February 2022. Included studies were in English, peer-reviewed, US-based, and evaluated elements of insurance and their relationship with access and quality outcomes for adult pwMS.
Results:
Our search identified 1619 articles, of which 32 met inclusion criteria. Privately insured pwMS were more likely to be on disease-modifying therapy (DMT). Increased out-of-pocket spending was associated with lower DMT adherence and greater discontinuation rates. Access to specialty pharmacy programs was associated with improved DMT adherence.
Conclusion:
Health insurance coverage and design strongly influences health care for pwMS in the United States and may be a modifiable social determinant of health. Increased pharmaceutical cost-sharing is associated with declines in DMT utilization and adherence. Further study is needed to better characterize the impacts of other core elements of health insurance, including prior authorization requirements and step therapy.
WallinMTCulpepperWJCampbellJD, et al. The prevalence of MS in the United States: A population-based estimate using health claims data. Neurology2019; 92(10): e1029–e1040.
2.
BeboBCintinaILaRoccaN, et al. The economic burden of multiple sclerosis in the United States: Estimate of direct and indirect costs. Neurology2022; 98(18): e1810–e1817.
EsperGJHartungDAvitzurO. The patient protection and affordable care act and chronic neurological illnesses: Benefits and challenges. JAMA Neurol2015; 72(7): 739–740.
6.
ObamaB. United States health care reform: Progress to date and next steps. JAMA2016; 316(5): 525–532.
BourdetteDNHartungDMWhithamRH. Practices of US health insurance companies concerning MS therapies interfere with shared decision-making and harm patients. Neurol Clin Pract2016; 6(2): 177–182.
9.
BourdetteDPattiF. US health insurance is an obstacle to disease-modifying treatments in MS. Neurology2016; 4: 346–347.
10.
ClaflinSBCampbellJAMasonDF, et al. The effect of national disease-modifying therapy subsidy policy on long-term disability outcomes in people with multiple sclerosis. Mult Scler2022; 28(5): 831–841.
11.
KalincikTDioufISharminS, et al. Effect of disease-modifying therapy on disability in relapsing-remitting multiple sclerosis over 15 years. Neurology2021; 96(5): e783–e797.
12.
HardingKWilliamsOWillisM, et al. Clinical outcomes of escalation vs early intensive disease-modifying therapy in patients with multiple sclerosis. JAMA Neurol2019; 76(5): 536–541.
13.
SimacekKFKoJJMoretonD, et al. The impact of disease-modifying therapy access barriers on people with multiple sclerosis: Mixed-methods study. J Med Intern Res2018; 20(10): e11168.
14.
KyleMAFraktAB. Patient administrative burden in the US health care system. Health Serv Res2021; 56(5): 755–765.
15.
TriccoACLillieEZarinW, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med2018; 169(7): 467–473.
MindenSLKinkelRPMachadoHT, et al. Use and cost of disease-modifying therapies by Sonya Slifka Study participants: Has anything really changed since 2000 and 2009?Mult Scler J Exp Transl Clin2019; 5(1): 8820888.
18.
WangGMarrieRASalterAR, et al. Health insurance affects the use of disease-modifying therapy in multiple sclerosis. Neurology2016; 87(4): 365–374.
19.
LivingstonTFayMIyerR, et al. Quantifying differences in health care consumption for the management of multiple sclerosis within privately and publicly insured health care programs. J Manag Care Spec Pharm2016; 22(12): 1385–1391.
20.
CisternasMBartolomeLGitarB, et al. Health care resource utilization and disease modifying treatment use in multiple sclerosis patients by age and insurance type. Curr Med Res Opin2021; 37(4): 597–604.
21.
CerghetMDobieELafataJE, et al. Adherence to disease-modifying agents and association with quality of life among patients with relapsing-remitting multiple sclerosis. Int J MS Care2010; 12(2): 51–58.
22.
MargolisJMFowlerRJohnsonBH, et al. Disease-modifying drug initiation patterns in commercially insured multiple sclerosis patients: A retrospective cohort study. BMC Neurol2011; 11: 122.
23.
ShaoHStoeckerCMonnetteAM, et al. Cost sharing of disease-modifying treatments (DMTs) as policy lever to improve DMTs’ access in multiple sclerosis. Value Health2018; 21(9): 1083–1089.
BriggsFBSThompsonNRConwayDS. Prognostic factors of disability in relapsing remitting multiple sclerosis. Mult Scler Relat Disord2019; 30: 9–16.
26.
JonesSMAmtmannD. Health care worry is associated with worse outcomes in multiple sclerosis. Rehabil Psychol2014; 59(3): 354–359.
27.
PozniakAHaddenLRhodesW, et al. Change in perceived health insurance coverage among people with multiple sclerosis. Int J MS Care2014; 16(3): 132–139.
28.
MillerDMMossBRoseS, et al. Obtaining patient priorities in a multiple sclerosis comprehensive care center: Beyond patient-reported outcomes. J Patient Exp2020; 7(4): 541–548.
29.
SadighGSwitchenkoJLavaN, et al. Longitudinal changes of financial hardship in patients with multiple sclerosis. Mult Scler Relat Disord2021; 53: 103037.
30.
SadighGLavaNSwitchenkoJ, et al. Patient-reported financial toxicity in multiple sclerosis: Predictors and association with care non-adherence. Mult Scler2021; 27(3): 453–464.
31.
CallaghanBCReynoldsEBanerjeeM, et al. Out-of-pocket costs are on the rise for commonly prescribed neurologic medications. Neurology2019; 92(22): e2604–e2613.
32.
ParasrampuriaSSenAPAndersonGF. Comparing patient OOP spending for specialty drugs in Medicare Part D and employer-sponsored insurance. Am J Manag Care2020; 26(9): 388–394.
33.
PoudelNBanjaraBKamauS, et al. Factors influencing patients’ willingness-to-pay for disease-modifying therapies for multiple sclerosis. Mult Scler Relat Disord2021; 48: 102720.
34.
LageMJCarrollCAFairmanKA. Using observational analysis of multiple sclerosis relapse to design outcomes-based contracts for disease-modifying drugs: A feasibility assessment. J Med Econ2013; 16(9): 1146–1153.
35.
FarberRHanniganCAlcauskasM, et al. Emergency Department visits before the diagnosis of MS. Mult Scler Relat Disord2014; 3(3): 350–354.
36.
HartungDMJohnstonKAMcGregorJC, et al. The effect of out-of-pocket costs on initiation of disease-modifying therapies among medicare beneficiaries with multiple sclerosis. Mult Scler Relat Disord2020; 46: 102554.
37.
RomleyJGoldmanDEberM, et al. Cost-sharing and initiation of disease-modifying therapy for multiple sclerosis. Am J Manag Care2012; 18(8): 460–464.
38.
BanksAMPeterMEHolderGM, et al. Adherence to disease-modifying therapies at a multiple sclerosis clinic: The role of the specialty pharmacist. J Pharm Pract2020; 33(5): 605–611.
39.
DorALageMJTarrantsML, et al. Cost sharing, benefit design, and adherence: The case of multiple sclerosis. Adv Health Econ Health Serv Res2010; 22: 175–193.
40.
KimYARascatiKLPraslaK, et al. Retrospective evaluation of the impact of copayment increases for specialty medications on adherence and persistence in an integrated health maintenance organization system. Clin Ther2011; 33(5): 598–607.
41.
LiPHuTYuX, et al. Impact of cost-sharing increases on continuity of specialty drug use: A quasi-experimental study. Health Serv Res2018; 53(Suppl. 1): 2735–2757.
42.
LiPLadageVPBergerJ, et al. Disease-modifying therapy adherence and associated factors in a national sample of Medicare patients with multiple sclerosis. Value Health2020; 23(3): 328–334.
43.
StarnerCIAlexanderGCBowenK, et al. Specialty drug coupons lower out-of-pocket costs and may improve adherence at the risk of increasing premiums. Health Aff2014; 33(10): 1761–1769.
44.
GroenewegMForresterSHArnoldB, et al. One-year outcomes of an integrated multiple sclerosis disease management program. J Manag Care Spec Pharm2018; 24(5): 458–463.
45.
TanHYuJTabbyD, et al. Clinical and economic impact of a specialty care management program among patients with multiple sclerosis: A cohort study. Mult Scler2010; 16(8): 956–963.
46.
StocklKMShinJSGongS, et al. Improving patient self-management of multiple sclerosis through a disease therapy management program. Am J Manag Care2010; 16(2): 139–144.
47.
JonesLKGreskovicGGrassiDM, et al. Medication therapy disease management: Geisinger’s approach to population health management. Am J Health Syst Pharm2017; 74(18): 1422–1435.
48.
TangJBaileyJChangC, et al. Effects of specialty pharmacy care on health outcomes in multiple sclerosis. Am Health Drug Benefits2016; 9(8): 420–429.
49.
GleasonPPPhillipsJFenrickBA, et al. Dalfampridine prior authorization program: A cohort study. J Manag Care Pharm2013; 19(1): 18–25.
50.
FuscoNSilsBGraffJS, et al. Cost-sharing and adherence, clinical outcomes, health care utilization, and costs: A systematic literature review. J Manag Care Spec Pharm2023; 29(1): 4–16.
51.
ChernewMENewhouseJP. What does the RAND Health Insurance Experiment tell us about the impact of patient cost sharing on health outcomes?Am J Manag Care2008; 14(7): 412–414.
52.
RossJSKesselheimAS. Prescription-drug coupons—No such thing as a free lunch. N Engl J Med2013; 369(13): 1188–1189.
53.
HartungDMJohnstonKABourdetteDN, et al. Closing the Part D coverage gap and out-of-pocket costs for multiple sclerosis drugs. Neurol Clin Pract2021; 11(4): 298–303.
54.
MotheralBR. Pharmaceutical step-therapy interventions: A critical review of the literature. J Manag Care Pharm2011; 17(2): 143–155.
55.
AmezcuaLRiveraVMVazquezTC, et al. Health disparities, inequities, and social determinants of health in multiple sclerosis and related disorders in the US: A review. JAMA Neurol2021; 78(12): 1515–1524.
56.
WallaceJJiangKGoldsmith-PinkhamP, et al. Changes in racial and ethnic disparities in access to care and health among US adults at age 65 years. JAMA Intern Med2021; 181(9): 1207–1215.
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