Samara Rosenfeld

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Medicaid expansion has resulted in the increased identification of undiagnosed HIV infections along with the use of HIV prevention services such as preexposure prophylaxis drugs.

In fact, expanding Medicaid eligibility was associated with a 13.9% increase in HIV diagnoses, according to new study findings.

The results suggested the changes in new HIV diagnoses, awareness of HIV status, and preexposure prophylaxis were not specifically due to higher incidence or an increase in infection risk.

Dolores Albarracín, Ph.D., and a team of investigators aimed to understand whether increased insurance coverage and access to healthcare could increase identification of undiagnosed HIV infection and use of HIV prevention services. They used the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Atlas from 2010-2017 to gather the HIV diagnoses per 100,000 population for each county-year. The data were classified into five transmission categories: heterosexual contact, injection drug use, male-to-male sexual contact, male-to-male sexual contact and injection drug use, and other. To study the effects on the use of PrEP, the number of people who had at least one day of prescribed PrEP in a year per 100,000 county residents were obtained from the AIDSVu.

The mean for all HIV cases was lower for the expansion states than non-expansion states. The use of PrEP was also greater in such areas. Medicaid expansions were associated with a statistically significant increase in HIV diagnoses, with an average of .508 new cases per 100,000 population, which represented a 13.9% increase from pre-expansion levels (

=.037). Particularly, infections contracted via injection drug use and among low-income, rural counties with a high share of pre-Affordable Care Act uninsured rates, were most likely to be affected by the expansions.

Medicaid expansions were linked with improvements in the knowledge of HIV status and preexposure prophylaxis use. Expansions did not affect incident HIV, substance use, or sexually transmitted infection rates, aside from gonorrhea, which decreased after expansions.

Expanding public health insurance may be a way to curb the HIV epidemic, the study investigators noted.

"Increasing community awareness of HIV and increasing individuals' awareness of their HIV status is key to reducing new infections," Albarracín, said. "This study provides important evidence suggesting that increasing health insurance coverage may play a critical role in curbing the spread of HIV."

Effect of Medicaid Expansions on HIV Diagnoses and Pre-Exposure Prophylaxis Use

Articles

Expanding public health insurance may help curb the HIV epidemic.

Expanding Medicaid Eligibility Increases HIV Diagnoses

Lack of insurance or shifts between having insurance and uninsurance from preconception to postpartum are associated with less chances a woman receives early prenatal care or recommended postpartum care compared with those who have continuous insurance.

Because many low-income women experience disruptions in health insurance during pregnancy and the first year postpartum, Lindsay K. Admon, M.D., M.Sc., and colleagues characterized the association between healthcare use and four patterns of insurance coverage across the perinatal period among that population. They used pooled 2015-2017 data from the Pregnancy Risk Surveillance and Monitoring System, which is a survey of postpartum women in 40 states and New York City that includes health insurance status at preconception, delivery, and postpartum. The team limited the sample to those who had complete insurance information and household incomes less than 138% of the federal poverty line, which was the minimum required by federal statute to qualify for pregnancy-related Medicaid.

Admon and the investigators characterized insurance at each time point into Medicaid, private, or uninsured categories. Then, they generated four insurance patterns across the time points: continuous insurance, shifts between private and Medicaid, shifts between insurance and uninsurance, and continuous uninsurance. The team examined three healthcare use outcomes: prenatal care in the first trimester, in-hospital birth, and postpartum visit attendance.

Overall, the sample comprised more than 39,000 women with a mean age of 27.4 years old. Of those included, 43.6% were continuously insured, 21.3% experienced shifts between private and Medicaid coverage, 32.8% had shifts between insurance and uninsurance, and 2.4% were continuously uninsured. Among the continuously uninsured, a majority (60.1%) were Spanish-speaking Hispanic women (95% CI, 52.9-66.8). For those who experienced a shift between insurance and uninsurance or continuous uninsurance, they were significantly less likely to receive prenatal care in the first trimester (marginal differences, −12.5% [95% CI, –14.8 to 10.2] and −24.2% [95% CI, –30.8 to –17.6], respectively) or a postpartum visit (marginal differences, −2.1% [95% CI, –3.7 to –.5] and −9.6% [95% CI, –15.9 to –3.4], respectively) compared to those who had continuous insurance (adjusted probabilities, 77.8% [95% CI, 76.8-78.8] and 84.3% [95% CI, 83.4-85.2], respectively; 

Most women (more than 98.4%) across the first three categories of insurance had in-hospital births, while 80% of those with continuous uninsurance had an in-hospital birth (marginal difference compared with continuous insurance, -19.4%; 95% CI, -24.5 to -14.2; 

The Patient Protection and Affordable Care Act’s Medicaid expansion has improved perinatal insurance continuity for low-income women, the investigators reported. Other ways to improve access to care for postpartum women include efforts to extend Medicaid through the first year postpartum.

Insurance Coverage and Perinatal Health Care Use Among Low-Income Women in the US, 2015-2017

More needs to be done to give healthcare access to low-income women.

Insurance Affects Low-Income Pregnant, Postpartum Women

As brand-name drug prices rise, several large pharmaceutical companies have launched authorized generic versions at steeply reduced list prices.

Authorized generics are exact copies of the brand-name drug without the associated brand labeling. The market for such drugs has increased substantially since 1967. Authorized generic drugs do not need to undergo additional testing or approval process, unlike a traditional generic drug that must meet bioequivalence testing standards through an abbreviated new drug application. The new drug application holder instead must notify the U.S. Food and Drug Administration if it intends to market an authorized generic.


In a viewpoint by Stacie B. Dusetzina, Ph.D., and colleagues, the experts said three strategies underlie authorized generic entry. For one, brand-name drug manufacturers can seek to introduce an authorized generic at the time that a traditional generic drug is first marketed or later. The Hatch-Waxman Act encourages rapid generic entry by giving a 180-day exclusivity period to the first company that files an abbreviated new drug application that successfully challenges the patent on a brand-name drug. The company can gain market share while keeping the generic drug’s price high. Then the manufacturer of the brand-name drug can attempt to limit the market share for the first traditional generic drug by introducing an authorized generic during the 180-day exclusivity period.

Another strategy, Dusetzina and the team wrote, is tied to “pay-for-delay” agreements between a brand-name drug manufacturer and a traditional generic drug manufacturer. Under “reverse payment” agreements, the manufacturer of the brand-name drug compensates the generic manufacturer for not marketing the drug.

The third strategy involves the marketing of authorized generics when substantial patient life remains on the brand-name drugs. The manufacturers use authorized generic entry with large list price reductions to ward off pressure for the federal government to take more steps to decrease the price of prescription drugs.

“Ultimately, the benefits of authorized generics should be judged by whether they meaningfully reduce spending on prescription drugs for payers and patients. Otherwise, they are a misleading distraction from more effective measures to decrease drug prices and increase access,” the team concluded.

Authorized Generics and Their Evolving Role in Prescription Drug Pricing and Access

Authorized generics must meaningfully reduce spending on prescription drugs.

How Authorized Generics Reduce Drug Pricing

Findings of a new study suggest differences exist in specialist referral patterns by race among Medicare beneficiaries.

The findings provided additional evidence that physicians may make different treatment decisions for their Black and White patients.

Bruce E. Landon, M.D., M.B.A., and colleagues examined whether differences existed between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians and physicians in the six specialties patients were most frequently referred. The team used data on 100% of traditional Medicare beneficiaries from 51 hospital referral regions for 2009-2010 to examine patient-sharing networks among physicians. They identified the hospital referral regions for which the percentage of Black patients identified in the Beneficiary Summary File was at least 10%. There were 17 markets identified and the investigators restricted the analyses to the 12 markets with the greatest total number of physicians — all had at least 750 physicians.

Physicians encounters were defined based on paid claims in the carrier file. Landon and the team excluded claims for non-direct patient care specialties or specialties where individual physicians were not typically selected by patients.

The investigators constructed networks using three approaches: one based only on encounters for White patients, one based only on encounters for Black patients, and one based on encounters for Black and White patients. The analyses were focused on shared care between primary care physicians and those from the most frequently visited specialties — cardiology, pulmonary disease, gastroenterology, orthopedic surgery, general surgery, and neurology.

Of the 12 selected markets, size ranged from Manhattan, New York (187,054 Black or White beneficiaries seen by at least two physicians within an episode of care; 9,794 total physicians) to Tallahassee, Florida (44,644 Black or White beneficiaries seen by at least two physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% in Huntsville, Alabama to 46.8% in Chicago, Illinois.

The mean number of specialists a primary care physician shared patients with was lower for Black patients than for White patients. The mean primary care physician-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. The degree difference narrowed after sampling White patients to equalize the numbers of patients seen, but they still were not equivalent in most markets.

Among White patients, specialist networks were much larger than those based just on Black patients (for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per primary care physician (123 for Black patients vs 211 for White patients).

Overall, the test for differences in referral patterns was statistically significant for all six specialties examined in seven of the 12 markets and in five specialties for another three markets.

The reasons for the differences may be multifactorial and additional work is needed to better understand the associations, the investigators noted.

Assessment of Racial Disparities in Primary Care Physician Specialty Referrals

Physicians may make different treatment decisions for patients of different races.

Samara Rosenfeld

Articles

Expanding Medicaid Eligibility Increases HIV Diagnoses

Insurance Affects Low-Income Pregnant, Postpartum Women

How Authorized Generics Reduce Drug Pricing

Specialist Referral Patterns Vary Based on Race