@schaeffer.usc.edu @keck.usc.edu

For my commentary on this very insightful study @JAMANetworkOpen
, link here: jamanetwork.com/journals/jam...

The study itself is here: jamanetwork.com/journals/jam...

@KeckMedicineUSC
@USCSchaeffer

Fin/

8/ Most importantly, we still don't know whether dialysis patients are helped or harmed by MA.

Unfortunately, our healthcare system isn't organized to put patient interests first. This study was a very interesting glimpse into how patients are ignored.

7/ Third, I worry that focusing on MA plans ignores the clear financial incentive that dialysis organizations have to steer patients into MA plans

And that dialysis organizations have way more power to influence patients than MA plans

6/ Clinicians were alarmed - Add this to a deluge of evidence that business interests are running away from clinicians to the potential detriment of patients

Clinician leaders ARE an important bulwark, and we should be wary of ignoring the professionalism of clinicians

5/ What are my additional takeaways from this interesting study?

First, it's important to recognize that MA is a story of heterogeneity - the large dialysis organizations are profiting heavily, but are the smaller ones? I'm not so sure

4/ Steering patients into MA is a no-brainer given how profitable it is

MA plans are profiting heavily as are dialysis organizations

3/ The authors found broad agreement that advertising could be misleading, false, and/or overwhelming

In some cases, participants described behavior that is hard to interpret as anything other than a bribe to induce MA enrollment

(here, DO = dialysis organization)

2/ This study was very broad! They interviewed over 50 executives and staff from MA plans, kidney care management companies, and dialysis organizations

Although it is a real limitation that patient perspectives weren't included. Hopefully forthcoming in paper 2?

20% of patients dont have a prescription drug plan

I’ve yet to meet an esrd patient on zero meds

Thanks to @jilliancaldwell.bsky.social who led this massive project and others @stanfordmedicine.bsky.social @schaeffer.usc.edu @keck.usc.edu

FIN

Tl;dr: TDAPA improved access to calcimimetics by improving prescription drug coverage

Read more @JAMAHealthForum

LINK: jamanetwork.com/journals/jam...

23/

I'm cautiously optimistic that this will IMPROVE access to phosphate binders, based on our historical experience with calcimimetics

22/

This doesn't just impact the past - this year, @CMSGov
was legislatively obligated to roll all phosphate binders (which are oral only) into the bundle. That is, binders are now in TDAPA

This came with some trepidation by industry and in some cases legal action

21/

In summary:
1) High OOP costs can prevent patients from getting their meds!
2) At least 20% of ESRD patients don't have a prescription drug plan, and >40% have no subsidies for copays
3) TDAPA is a reasonable mechanism to expand drug coverage

20/

Limitations cont'd
3) We didn't include outcomes (but will in future work)
4) The diff-in-diff estimator doesn't control for confounders that are not time invariant
5) technically, we violated the parallel trends (again they were small but statistically significant)

19/

Some limitations to our work
1) we could not observe unpaid prescription fills (i.e., did patients get calcimimetics through charity or pay 100% of list price?)
2) we only studied traditional Medicare and not Medicare Advantage

18/