Medicaid prescription restrictions and hospitalization rates in arthritis patients

¶ … Medicaid Prescription Restrictions Relative to the Total Costs of Treatments for Arthritis Patients

This proposal outlines a research project that is estimated to take about two years to complete and aims to make a major contribution on a specific issue related to public policies related to the treatment of arthritis for U.S. citizens that receive subsidized health care coverage in the form of Medicaid or Medicare. This research model has been specifically prepared for the Arthritis Foundation (AF) which was founded in 1948 and is a non-profit organization that is dedicated to addressing the needs of individuals living with arthritis in the United States. There are an estimated 300,00 children, as well as 50 million adults, living with arthritis and this condition represents one of the nation's leading causes of disability in the U.S. Thus, given the prevalence of this condition within society, not only can effective public policy management decision significantly improve the health and well-being of millions of Americans, it can also save the American public millions in unnecessary healthcare costs that could potentially be replaced by more effective treatment regimens as well save the expenses that are associated with lost productivity and wages that are commonly associated with patients missing work because of their symptoms.

Saving money was also a central concern when the Medicaid and Medicare agencies decided to restrict the prevalence of prescription medications, such as pain-relieving drugs, to patients that rely on publically funded healthcare programs to pay for their prescription medications. However, this decision may have been accompanied by some unintended consequences and counterproductive developments that manifested after the decision was implemented. For example, researchers have identified a seemingly correlated trend of more arthritis related hospitalizations that corresponds the medication restriction. This proposal outlines a research project that can further investigate this correlation and could serve as the basis to assist in the implementation of more effective public policies.

pocket (OOP) costs, Medicare Advantage and Prescription Drug (MAPD), hospitalization rates.

Organizational Background

The Arthritis Foundation (AF) was founded in 1948 and is a non-profit organization that is dedicated to addressing the needs of individuals living with arthritis in the United States. There are an estimated 300,00 children, as well as 50 million adults, living with arthritis and this condition represents one of the nation's leading causes of disability in the U.S. The AF works to assist people with arthritis through multiple channels in order to mitigate some of the everyday struggles that people who live with this condition commonly endure. The foundation improves the lives of patients first by offering them the relevant information about their condition, which can sometimes be life changing for clients by itself. However, the AF also provides many other essential resources that are managed internally, such as providing resources, improving the access to care, facilitating research efforts, and building community relationship. For example, the AF, through its local offices nationwide, sponsors different events all year round to raise funds and increase awareness, such as hosting local walks and charity events.

The AF also grants two types of patient's registries which include the arthritis Internet registry (AIR) and the Childhood Arthritis and Rheum Alliance (CARRA), which are vital to creating the capacity to monitor and control symptoms, as well as provides an accurate population database that can improve research efforts by examining different patterns and collecting biological data from patients. The organization also provides services that include advocacy objectives to help this population have a voice on keys issues, both at the state and federal levels, to address issues such as relationships with regulators and insurers who can play an important role in treating the condition.

An additional resource that organization also provides, and serves as a primary organizational objective, is a dedication to scientific discovery which continues to provide leadership and helps to fund cutting-edge scientific efforts that attempt to discover more information about arthritis and potential treatments. FA provides help and support so that the organization can offer patients everything from trusted information to powerful tools that can help them connect with a network of concerned people. The foundation also works with many health care providers directly in order to strengthen its educational outreach and collective service offerings. There are many families in the U.S. who are currently living with juvenile arthritis and are in need of unique and urgent care for the estimated 300,00 children that have arthritis and the organization is dedicated to managing its resources in order to assist these families and their caregivers in the most effective and efficient manner possible.

Statement of Need/Objective Statement

One of the main leading causes of disability in the United States is Arthritis, which contributes to this condition being one of the costliest medical conditions in healthcare if the disease and its symptoms are not taken care of (Remmes Martin, Shreffler, Schoster & Callanhan, 2012). People with Arthritis have twice as high spending on prescription drugs and hospitalizations on average than those people with other chronic diseases which makes it important for individuals to get diagnosed and treated as soon as feasibly possible (Roebuck, Dougherty, Kaestner & Miller, 2015). However, there are many challenges in the healthcare system that can hinder the ability to effectively manage the symptoms related to the disease.

For example, the Medicaid program has issued a restriction on prescription drugs available to treat arthritis in order to decrease and control the rising prescription drug cost trend (Ramondetta et al., 2015). Decisions made about restricting certain drugs to patients are, at least in part, often based upon the health care plans assessment of the total costs associated with the treatment (Roebuck, Dougherty, Kaestner & Miller, 2015). However, a potential implication of the restriction of certain medications is the increased costs associated with hospitalization care when patients cannot control their pain levels (Ramondetta et al., 2015). Therefore, it has been argued that the restrictions on medications can lead to a higher volume of patients being admitted to the hospital, which in turn can result in the increase of net total medical costs of treatments; many patients often underuse medication due to the high costs of the drugs and them are required to pay these expenses out-of-pocket as a result of being either uninsured or underinsured (Remmes Martin, Shreffler, Schoster & Callanhan, 2012).

As a result, one public health trend that has been identified is that more patients are being emitted to the hospitals for arthritis related conditions which is correlated with the implementations of the restrictions placed on medications used to treat pain (Remmes Martin, Shreffler, Schoster & Callanhan, 2012). These restrictions that have been made in prescription drug plans offered by the Medicaid health care plans for arthritis were enacted in an effort to decrease prescription drug costs on the whole (Ramondetta et al., 2015). However, while these restrictions have decreased the overall prescription drug costs, on the other hand, these measures have also worked to increase the total medical care average cost for patients with arthritis (Remmes Martin, Shreffler, Schoster & Callanhan, 2012). The restrictions resulted in people discontinuing or minimizing their prescription drug use when compared with Medicaid patients use the medications in a study a year earlier when there were no restrictions on these drugs in place (Wilson, Axelsen & Tang, 2005). This has led many to believe that the increased hospitalization rates are directly related to these restrictions which were focused on spending in Medicaid programs and this is not necessarily caused by an increase in arthritis cases (Lin, Bharel, Zhang, O'Connell & Clark, 2015).

According to Roebuck et al. (2015), an increase of one percent in prescription drug costs is estimated to be associated with a decrease in total Medicaid costs (Roebuck, Dougherty, Kaestner & Miller, 2015). Yet, even though spending on prescription drug cost has decreased, it is argued that the medical cost of patients that are hospitalized has increased significantly, resulting in higher total costs to the Medicaid system in the long run (Lin, Bharel, Zhang, O'Connell & Clark, 2015). However, the increased hospitalization rates could also be the result of frequent visits by homeless and low-income families that have limited resources available and have been impacted the most by the restrictions placed upon Medicaid health care plans (Lin, Bharel, Zhang, O'Connell & Clark, 2015). Therefore, one consideration that may have not been sufficiently controlled for, is the fact that studies are only focusing on the populations that have a low-income status (Lin, Bharel, Zhang, O'Connell & Clark, 2015).

Other studies have also focused on populations with individuals that were only enrolled in the Medicaid program and essentially excluded any other demographics in the research (Nielson & Barratt, 2009). Therefore, some have claimed that including only low-income people in the populations studied is not an accurate reflection of trends in the general population (Lin, Bharel, Zhang, O'Connell & Clark, 2015). A more comprehensive approach to conducting this type of research would be to not only look at patients enrolled in Medicaid programs, which are typically exclusively from low socioeconomic statuses, but to also include a more representative sample of patients that were covered by other health care plans as well.

Therefore, through expanded population and demographic sampling techniques, a more precise picture of the general population could be created and more accurately illustrate the trends that are present in the population from a broader general public heath perspective that includes a more representative sample of the U.S. population (Nielson & Barratt, 2009). Such research could help researchers gain insights as to the effects of the drug restrictions and determine more precisely if the general population is experiencing the same trends equally, or if these trends impact people from low socioeconomic statuses disproportionately, which could help decision makers to draft more informed public policies (Lin, Bharel, Zhang, O'Connell & Clark, 2015).

Project Description/Narrative

Hypothesis and specific aims:

This research effort has been designed to study the effects of the restrictions placed on prescription drugs for arthritis and whether these restrictions may lead to increases in hospitalization rates of arthritis patients. It is hypothesized that lower costs related to prescription drugs for arthritis will be correlated with a decrease in the hospitalization rate for patients suffering symptoms related to arthritis. The specific aims will be to identify potential negative consequences that arise from the restrictions placed on prescriptions for arthritis patients.

Methods

Sample selection/description of primary data sources:

The methodology that will be used in the study will include a cross-sectional sample that will be used for a data analysis that will include data from a particular community within a specific time that will be scheduled (Reichenheim & Coutino, 2010). A systematic sampling will be compiled and the sample will be further restricted to individuals that are 18 years and older who are enrolled in either the Medicaid and Medicare programs and who may also be specifically interested in the potential healthcare association between osteoarthritis and rheumatoid arthritis. No prescription discount card or other prescription drug benefits will be offered and individuals will only be selected from households in which incomes are less than or equal to 100% of federal poverty level in this specific location. The study will be conducted in Irvine, TX, and will focus on the potential association between prescription drug use for arthritis and the direct and indirect healthcare costs that might be associated with Medicaid and Medicare beneficiaries that have been diagnosed with arthritis.

Data Collection:

The data will be collected and coded by healthcare outcomes which will include factors such as the number of emergency department visits, ambulatory physician visits, the length of hospital stays and total health expenditures. Both the independent and dependent variables will be compiled based on data that will be collected from the Arizona HealthQuery (ARHQ) database of medical records that includes data that represents both the public and private healthcare sectors. This data will be compiled in an estimated period that equals roughly one year from people that are enrolled in Medicaid and Medicare programs. The ARHQ includes data for services covered by Arizona Health Care Cost Containment System (AHCCCS) and Medicare and Medicaid as well as precise data outlining the fee for services agreements that are managed for the Medicare and Medicaid enrollees.

Data Analysis:

One line of investigation will be employed to calculate the total health care expenditures related to arthritis in an attempt to determine whether the restrictiveness of the prescription drug policy is related to increases in medical care and/or prescription drug spending. The total health expenditures will include the total amount of money paid by the Medicaid and Medicare for a combination of different services including emergency department visits, hospital stays, and ambulatory department visits that are used to treat arthritis within the time frame outlined in the scope of the study.

The sample of Medicare enrollees with either primary or secondary diagnosis of rheumatoid arthritis or osteoarthritis can also be used to estimate any trends that might be present for enrollees with a leading diagnostic assessment of either type 1 of the 2 conditions (Orizio, Merla, Schulz & Gelatti, 2011). Previous research efforts that have employed similar methodologies have indicated that restricted drugs were associated with 16% fewer ambulatory visits and 35% more hospitalizations for those with rheumatoid arthritis, which would roughly equate to a 61% increase in total medical and prescription drug expenditures for the patients; it also found that those with osteoarthritis restricted formularies had 23% more ambulatory visits and 71% more hospitalization (Orizio, Merla, Schulz & Gelatti, 2011).

Therefore, in the data analysis, comparisons can be made to see whether Medicaid healthcare plans and Medicare healthcare plans in this sample are consistent with previous findings. The information acquired related to the effects of the restrictions placed on prescription drugs for arthritis patients and if decisions about health care plans have an impact on the number of people being admitted to the hospital could be used by decision makers to help guide the development of more effective public policies (Orizio, Merla, Schulz & Gelatti, 2011).

Ethics Statement:

The study intends to collect data about human subjects and this data will be acquired from the Arizona Health Query. Therefore, the research will be IRB approved and subject to the same requirements for ethics that the Arizona Health Query must uphold in their data collection procedures.

Data Sharing:

The data will be collected, coded, and recorded in an anonymous form and then can be hosted on a public server so that the general public can have access to it. The scope of the proposed data collection and analysis will include an estimated 400 individuals and will be collected exclusively from the Arizona Health Query and are made available to researchers and analysts without any fees or licensing restrictions.

Proposed Timeline:

The first month of the study will be used to gather general information and find qualified research assistants which will be employed to help gather data from the database, work on the different analyses included in the study, and also help prepare the final reports. The second month will then be used to travel to different geographic regions in the U.S. and gather regional data about Medicare and Medicaid programs and policies that could be used to help delineate various factors that are relevant relative to the restrictiveness of prescription drug policies and the consequences of such policies such as the volume of people being admitted to the hospital for arthritic ailments. The third month will be used solely for the coding and preliminary analysis of the data collected and will also be used to examine the data for any trends that might be present in either the aggregate database that is compiled as well as individual trends that might emerge in that analysis of different individual regions or various combinations of regional data collections. Finally, a more detailed data analysis will be conducted using an array of different perspectives from different experts and consultants and then whatever findings are revealed through this analysis will be prepared for publication. Furthermore, various reports will be created individually and specifically customized for the various stakeholder groups that might be interested in the study and its findings. The entire study, from its concept to the publication and presentation of the findings, is estimated to take roughly 2 years from start to finish.

Proposed Budget

Budget Justification

There are senior or key positions that will be required to effectively administer the project. The project manager will be responsible for the entire duration of the project and the completion of all the phases of the project management lifecycle that include the initiation phase, planning process, execution phase, monitoring and controlling, and the project's closing as well as the presentation of the results to the relevant stakeholders. Ultimately, this professional will be entirely responsible for the successful completion, or failure, of the entire project. As a result of the responsibilities that are demanded by this position, the project manager is the highest paid member of the project team.

There are also three positions that will be filled by external contracting organizations that include a professional research consulting firm, a local web development business, and a local travel consultant. MRC was chosen as the professional consulting firm and they are located in Houston, TX. They were chosen not only for their general expertise in medical research, but also with their professional experience relative to specifically to medical record analysis, their industry experience, and their network of contacts and knowledge of the internal workings of the industry. Furthermore, the local web developer will be responsible for building a collaboration website for the team to use and also to build the website for the public that will host the data and the findings upon the completion of the project. Also, the travel agent will be able to help plan and book the trips for the team members to visit other regional locations to gather information and data at these sites. Each of these positions will be filled on a contractual basis.

The members of the team that are academically affiliated will be compensated with an annual salary for two years each. Therefore, the salaries for both years of their employment are included in the budget proposal as well as a five-thousand-dollar fringe benefit allocation per team member per year. It was estimated that two postdoc positions will be required to handle many tasks as well as to manage the rest of the academic team's roles which will include a significant amount of oversight and the mentoring of other members of the team. Furthermore, four graduate students will also be selected to work on the project on a salary basis and they will also gain valuable professional experience for their contributions. Eight undergraduate students will also be selected to work on the project and will be rewarded with class credits for their contributions. Finally, a secretary will also be hired to handle the administrative and clerical tasks, as well as help to keep the team organized. This position will also be compensated on an annual salary basis.