The 340B Program and Health Disparities Among Medicare Beneficiaries With Chronic Asthma.

The study objective was to determine whether the discounts provided under the 340B program help address disparities in drug treatment and adverse outcomes among Medicare Fee-For-Service (FFS) beneficiaries initially Medicare-diagnosed with moderate to severe chronic asthma. Using Medicare FFS claims data from 2017 to 2019, we conducted a cross-sectional study that compared risk-adjusted differences in 5 treatment measures and 5 adverse outcomes among beneficiaries treated within 340B and non-340B hospital systems that met the disproportionate share (DSH) criteria and the ownership classification requirement to qualify as a 340B DSH hospital. Our analysis focused on potential disparities that are historically associated with challenges to accessing quality health care. We did not observe fewer disparities in drug treatments or adverse outcomes for beneficiaries with moderate to severe asthma treated at 340B hospital systems compared to non-340B hospital systems. These results raise questions as to whether 340B hospital systems are effectively using discounts to focus on improved access and outcomes for vulnerable beneficiaries.

Association of the Oncology Care Model With Value-Based Changes in Use of Radiation Therapy.

PURPOSE: Radiation utilization for breast cancer and metastatic bone disease varies in modality, fractionation, and cost, despite evidence demonstrating equal effectiveness and consensus recommendations such as Choosing Wisely that advocate for higher value care. We assessed whether the Oncology Care Model (OCM), an alternative payment model for practices providing chemotherapy to patients with cancer, affected the overall use and value of radiation therapy in terms of Choosing Wisely recommendations. METHODS AND MATERIALS: We used Centers for Medicare & Medicaid Services administrative data to identify beneficiaries enrolled in traditional fee-for-service Medicare who initiated chemotherapy episodes at OCM and propensity-matched comparison practices. Difference-in-difference (DID) analyses evaluated the effect of OCM on overall use of postoperative radiation for breast cancer, use of intensity modulated radiation therapy and hypofractionation for breast cancer, and fractionation patterns for treatment of metastatic bone disease from breast or prostate cancer. We performed additional analyses stratified by the presence or absence of a radiation oncologist in the practice. RESULTS: Among 27,859 postoperative breast cancer episodes, OCM had no effect on overall use of radiation therapy after breast surgery (DID percentage point difference = 0.4%; 90% confidence interval [CI], -1.7%, 2.4%) or on use of intensity modulated radiation therapy in this setting (DID = -0.6; 90% CI, -3.1, 2.0). Among 19,366 metastatic bone disease episodes, OCM had no effect on fractionation patterns for palliation of bone metastases (DID for ≤10 fractions = -1.1%; 90% CI, -2.6%, 0.4% and DID for single fraction = -0.2%; 90% CI, -1.9%, 1.6%). Results were similar for practices with and without a radiation oncologist. We did not evaluate the effect of OCM on hypofractionated radiation after breast-conserving surgery owing to evidence of differential baseline trends. CONCLUSIONS: OCM had no effect on use of radiation therapy after breast-conserving surgery for breast cancer or on fractionation patterns for metastatic bone disease. Future payment models directly focused on radiation oncology providers may be better poised to improve the value of radiation oncology care.

Association of Participation in the Oncology Care Model With Medicare Payments, Utilization, Care Delivery, and Quality Outcomes.

IMPORTANCE: In 2016, the US Centers for Medicare & Medicaid Services initiated the Oncology Care Model (OCM), an alternative payment model designed to improve the value of care delivered to Medicare beneficiaries with cancer. OBJECTIVE: To assess the association of the OCM with changes in Medicare spending, utilization, quality, and patient experience during the OCM's first 3 years. DESIGN, SETTING, AND PARTICIPANTS: Exploratory difference-in-differences study comparing care during 6-month chemotherapy episodes in OCM participating practices and propensity-matched comparison practices initiated before (January 2014 through June 2015) and after (July 2016 through December 2018) the start of the OCM. Participants included Medicare fee-for-service beneficiaries with cancer treated at these practices through June 2019. EXPOSURES: OCM participation. MAIN OUTCOMES AND MEASURES: Total episode payments (Medicare spending for Parts A, B, and D, not including monthly payments for enhanced oncology services); utilization and payments for hospitalizations, emergency department (ED) visits, office visits, chemotherapy, supportive care, and imaging; quality (chemotherapy-associated hospitalizations and ED visits, timely chemotherapy, end-of-life care, and survival); and patient experiences. RESULTS: Among Medicare fee-for-service beneficiaries with cancer undergoing chemotherapy, 483 319 beneficiaries (mean age, 73.0 [SD, 8.7] years; 60.1% women; 987 332 episodes) were treated at 201 OCM participating practices, and 557 354 beneficiaries (mean age, 72.9 [SD, 9.0] years; 57.4% women; 1 122 597 episodes) were treated at 534 comparison practices. From the baseline period, total episode payments increased from $28 681 for OCM episodes and $28 421 for comparison episodes to $33 211 for OCM episodes and $33 249 for comparison episodes during the intervention period (difference in differences, -$297; 90% CI, -$504 to -$91), less than the mean $704 Monthly Enhanced Oncology Services payments. Relative decreases in total episode payments were primarily for Part B nonchemotherapy drug payments (difference in differences, -$145; 90% CI, -$218 to -$72), especially supportive care drugs (difference in differences, -$150; 90% CI, -$216 to -$84). The OCM was associated with statistically significant relative reductions in total episode payments among higher-risk episodes (difference in differences, -$503; 90% CI, -$802 to -$204) and statistically significant relative increases in total episode payments among lower-risk episodes (difference in differences, $151; 90% CI, $39-$264). The OCM was not significantly associated with differences in hospitalizations, ED visits, or survival. Of 22 measures of utilization, 10 measures of quality, and 7 measures of care experiences, only 5 were significantly different. CONCLUSIONS AND RELEVANCE: In this exploratory analysis, the OCM was significantly associated with modest payment reductions during 6-month episodes for Medicare beneficiaries receiving chemotherapy for cancer in the first 3 years of the OCM that did not offset the monthly payments for enhanced oncology services. There were no statistically significant differences for most utilization, quality, and patient experience outcomes.

The healthfulness of food and beverage purchases after the federal food package revisions: The case of two New England states.

OBJECTIVE: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented new food packages to improve dietary intake among WIC participants. This paper examines how the healthfulness of food purchases among low-income households changed following this reform. METHODS: Point-of-sale data for 2137 WIC-participating and 1303 comparison households were obtained from a regional supermarket chain. The healthfulness of purchased foods and beverages was determined per their saturated fat, sugar, and sodium content. A pre-post assessment (2009-2010) of the product basket healthfulness was completed using generalized estimating equation models. Data were analyzed in 2015. RESULTS: At baseline, healthy products accounted for most of the food volume purchased by WIC participants, but beverages were dominated by moderation (less healthy) items. With new subsidies for fruit, vegetables and whole grains, the WIC revisions increased the volume of healthy food purchases of WIC-participating households by 3.9% and reduced moderation foods by 1.8%. The biggest improvements were reductions in moderation beverages (down by 24.7% in volume), driven by milk fat restrictions in the WIC food package revisions. The healthfulness of the product basket increased post-WIC revisions; mainly due to a reduction in the volume of moderation food and beverages purchased (down by 15.5%) rather than growth in healthy products (up by 1.9%). No similar improvements were seen in a comparison group of low-income nonparticipants. CONCLUSIONS: After the WIC revisions, the healthfulness of participant purchases improved, particularly for beverages. Efforts to encourage healthy eating by people receiving federal food assistance are paying off.

Dietary Quality of Americans by Supplemental Nutrition Assistance Program Participation Status: A Systematic Review.

CONTEXT: The Supplemental Nutrition Assistance Program (SNAP) is an effective component in reducing food insecurity in the U.S. In the discussion of strategies to also help SNAP participants maximize diet quality, it is important to know their current dietary patterns and food choices. This paper provides a systematic review of recent U.S. studies on dietary quality, food consumption, and spending among SNAP participants as compared to income-eligible and higher-income nonparticipants. EVIDENCE ACQUISITION: The review, completed in 2014, summarized studies that were peer-reviewed, published between January 2003 and August 2014, and provided data on dietary quality and intake of SNAP participants and nonparticipants. EVIDENCE SYNTHESIS: Twenty-five studies were included in this review. Daily caloric, macronutrient, and micronutrient intake of SNAP participants did not differ systematically from those of income-eligible nonparticipants; however, differences in dietary quality emerged. Adult SNAP participants scored lower on the Healthy Eating Index than either group of nonparticipants. Children's diets were similar among SNAP participants and low-income nonparticipants, but were less nutritious than diets of higher-income children. The evidence regarding sugar-sweetened beverage consumption was mixed, with most studies indicating significantly higher beverage intake among SNAP participants compared with higher-income nonparticipants, but no difference compared to income-eligible nonparticipants. CONCLUSIONS: SNAP effectively alleviates food insecurity in terms of caloric, macronutrient, and micronutrient intake. Still, SNAP participants are struggling more than income-eligible and higher-income nonparticipants to meet key dietary guidelines. Future policies should ensure that this vital food assistance program addresses diet quality while reducing food insecurity.

Effects of reduced juice allowances in food packages for the women, infants, and children program.

OBJECTIVES: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented revisions to the composition and quantities of WIC food packages. Juice allowances were reduced by approximately half. This report describes changes in purchases of 100% juice and other beverages among WIC participants after the WIC revisions. METHODS: Scanner data from a New England supermarket chain were used to assess juice and other beverage purchases among 2137 WIC-participating households during a 2-year period (N = 36 051 household-months). Purchased beverage amounts were compared before (January-September 2009) and after (January-September 2010) implementation of the revised WIC packages. Generalized estimating equation models were used. RESULTS: Before the revisions, WIC juice accounted for two-thirds of purchased juice volume among WIC households. After implementation of the revisions, WIC juice purchases were reduced on par with allowance changes (43.5% of juice volume, 95% confidence interval [CI] 41.9%-45.1%). This reduction was only partly compensated for by an increase of 13.6% (8.4%-19.0%) in juice purchases using personal and other non-WIC funds. In total, juice purchases declined by 23.5% (21.4%-25.4%) from an adjusted monthly total of 238 oz to 182 oz per household. WIC households increased purchases of fruit drinks by 20.9% (14.9%-27.3%) and other noncarbonated beverages by 21.3% (12.1%-31.2%) but purchased 12.1% (8.1%-15.0%) less soft drinks. CONCLUSIONS: After the WIC revisions, total purchases of 100% juice among WIC households declined by about a quarter, with little compensation occurring from non-WIC funds for juice and other beverages. The public health impact of the shift in beverage purchase patterns could be significant.

Grocery store beverage choices by participants in federal food assistance and nutrition programs.

BACKGROUND: Sugar-sweetened beverages are a target for reduction in the 2010 Dietary Guidelines for Americans. Concerns have been raised about sugar-sweetened beverages purchased with Supplemental Nutrition Assistance Program (SNAP) benefits. PURPOSE: This paper describes purchases of non-alcoholic refreshment beverages among participants in the U.S. Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and SNAP. METHODS: Grocery store scanner data from a regional supermarket chain were used to assess refreshment beverage purchases of 39,172 households in January-June 2011. The sample consisted of families with a history of WIC participation in 2009-2011; about half also participated in SNAP. Beverage spending and volume purchased were compared for WIC sampled households either using SNAP benefits (SNAP) or not (WIC-only). Analyses were completed in 2012. RESULTS: Refreshment beverages were a significant contributor to expenditure on groceries by SNAP and WIC households. Sugar-sweetened beverages accounted for 58% of refreshment beverage purchases made by SNAP households and 48% of purchases by WIC-only households. Soft drinks were purchased most by all households. Fruit-based beverages were mainly 100% juice for WIC-only households and sugary fruit drinks for SNAP households. SNAP benefits paid for 72% of the sugar-sweetened beverage purchases made by SNAP households. Nationwide, SNAP was estimated to pay at least $1.7 to $2.1 billion annually for sugar-sweetened beverages purchased in grocery stores. CONCLUSIONS: Considerable amounts of sugar-sweetened beverages are purchased by households participating in WIC and SNAP. The SNAP program pays for most of the sugar-sweetened beverage purchases among SNAP households. The upcoming SNAP reauthorization could be a good time to reconsider the program priorities to align public funds with public health.