Prevalence, expenditures, utilization, and payment for persons with MS in insured populations

Abstract

Insured enrollees with MS are two to three times more expensive than average insured enrollees. If the premiums that employers or governments pay health insurers and the capitation amounts that insurers pay health care providers do not account for these higher costs, a disincentive is created for the enrollment and care of persons with MS.

Pharmacy Benefit Forecast for a New Interferon Beta-1a for the Treatment of Multiple Sclerosis: Development of a First-Line Decision Tool for Pharmacy-Budget Planning Using Administrative Claims Data

“…19 The annual rates of MS prevalence derived from our study population are similar to those reported by Pope et al, 6 using 2 years of claims data. Pope' s prevalence rates were slightly lower for the 55 to 64 years age group (26/10,000 in Pope compared to 32/10,000 here).…”

“…Pope' s prevalence rates were slightly lower for the 55 to 64 years age group (26/10,000 in Pope compared to 32/10,000 here). 6 We surmise that an increased percentage of females or a higher concentration of members aged 35 to 54 years would increase estimates of the potential population of users. Accordingly, we would anticipate budget impact to be higher in these scenarios as well.…”

Managed Approaches to Multiple Sclerosis in Special Populations

“…One of the most promising approaches to fair compensation for the medical care of MS may be supplementing this strategy with functional status measures, if possible. Pope et al (2002) found that costs were 2-3 times higher for insured enrollees with MS compared with average insured members. 51 For example, calculated annual all-cause medical expenditures were estimated as $7,677 per privately insured enrollee with MS versus $2,394 for all privately insured enrollees, $13,048 per Medicare beneficiary with MS compared with $6,006 for all Medicare beneficiaries, and $7,352 per Medicaid disabled recipient with MS versus $4,088 per disabled recipient without MS.…”

“…Pope et al (2002) found that costs were 2-3 times higher for insured enrollees with MS compared with average insured members. 51 For example, calculated annual all-cause medical expenditures were estimated as $7,677 per privately insured enrollee with MS versus $2,394 for all privately insured enrollees, $13,048 per Medicare beneficiary with MS compared with $6,006 for all Medicare beneficiaries, and $7,352 per Medicaid disabled recipient with MS versus $4,088 per disabled recipient without MS. The results of this analysis identified 2 important implications: (a) despite the tendency to under-identify persons with MS in claims data, MS prevalence rates are actually higher than anticipated; and (b) MS patient access to care and appropriate capitated payment levels to care providers must be adequate.…”

“…Importantly, if the premiums that employers or governments pay insurers and the capitation amounts that insurers pay health care providers do not account for these higher costs, a disincentive may be created for the enrollment and care of persons with MS. Further supplementing diagnostic-based risk adjustment with functional status measurement identifies and directs greater resources to the most disabled and highest-cost patients with MS. A complete carve-out of MS-related services represents another possible approach to provider reimbursement for care. 51 As MS is a chronic, disabling, and potentially progressive disease, programs that promote symptom management, medication adherence, and a health-promoting lifestyle are important in the overall management of MS. One example of a disease therapy management (DTM) program that incorporated regarding immunomodulating agents and osteoporosis prevention in both English and Spanish is provided to all members, and referrals to an MS specialist are arranged for those who have never been evaluated by one. All members at increased risk for falling are referred to a rehabilitation professional for an evaluation as part of a falls prevention program.…”