Healthcare resource utilization and costs of commercial and Medicare-enrolled adult patients with Multiple Sclerosis in Urban and Rural settings

Abstract

Background: Multiple sclerosis (MS) is a chronic progressive neurological disease that affects almost 1 million people in the United States, with an economic burden of over $85 billion USD. Previous studies have demonstrated that rural MS patients have reduced access to a neurologist compared to urban MS patients, but how this disparity impacted these patients was not explored. However, healthcare resource utilization and cost in MS patients in rural and urban areas has not been previously studied. Objective: The primary objective of this study was to describe the healthcare resource utilization (HCRU) and healthcare costs of commercial and Medicare-enrolled patients with MS in rural and urban settings. Methods: We conducted a retrospective cohort study using health insurance claims from the Merative MarketScan® Commercial and Medicare Supplemental Databases. MS cases were identified as having ≥2 MS outpatient (OP) claims, dated ≥30 days apart, within a 1-year period or ≥1 MS inpatient (IP) claim (ICD-10: G35) during the index/case identification period. The index date was defined as the first occurrence of meeting case criteria during December 31st, 2017, to December 31st, 2022. We examined all-cause HCRU by summarizing the number of IP admissions, OP services, emergency department (ED) visits, and OP pharmacy fills in the 6 months post-index. Additionally, we assessed all-cause health care costs, including IP, OP, ED, and pharmacy, over 1 year following index using the Kaplan-Meier sample average estimator to account for censoring. We reported total healthcare costs as the sum of IP, OP, ED and OP pharmacy costs. Analyses were conducted separately for the commercial and Medicare supplemental groups; all-cause HCRU and costs were summarized overall and by rural and urban status. Results: Our cohort consisted of 47,636 commercially insured patients and 3,318 Medicare patients. During the 6 months following index date, rural commercial patients had a slightly elevated mean number of IP admissions (1.4) and length of stay (LOS) (4.4 days) than the urban patients (1.3, 4.4). This trend is not repeated in the Medicare Supplemental population. In that population, the rural cohort had a lower mean number of IP admissions (1.3) and LOS (5.00) compared to the urban cohort (1.4, 5.9). For ED visits, in both the commercial and Medicare cohorts, the rural patients had lower average ED visits than the urban patients (Commercial: 1.5 vs. 1.6 rural vs urban) (Medicare: 1.7 vs. 1.8). OP visits follow this trend with the rural cohort having fewer visits among those that did have OP visits 6 months post-index in both insurance cohorts (Commercial: 9.4 vs. 10.0 rural vs urban) (Medicare: 12.7 vs. 14.4). However, there is a difference seen in the OP pharmacy fills. For both commercial and Medicare insurance, the rural cohorts had higher mean and median OP pharmacy fills than the urban cohorts The commercial rural patients had a mean of 31.5 (SD 20.8) 30-day standardized pharmacy fills and a median of 27.3 (IQR 15.9 – 42.6) compared to the urban patients with a mean of 27.7 (SD 19.4) and median of 23.4 (IQR 13.4 – 37.3). The Medicare rural patients had a mean of 38.1 (SD 23.9) 30-day standardized pharmacy fills and a median of 35.9 (IQR 22.3 – 48.9), compared to the urban patients with a mean of 36.6 (SD 20.2) and a median of 34.2 (IQR 22.3 – 48.7). Conclusion: Rural patients tended towards lower average healthcare resource utilization (HCRU), and thus, lower costs than the urban patients, with some notable exceptions. Rural patients had higher mean and median pharmacy fills and higher costs in both insurance categories. This may point to rural MS patients relying more on prescription drugs to compensate for reduced access to medical services. MS patients require complicated care and insight into their HCRU and costs, which can aid healthcare decision-makers in optimizing care for these patients.