In a new research letter published in JAMA, Behr et al examined which Medicare Fee for Service Beneficiaries received monoclonal antibodies (mABs) for COVID-19 infections. mABs had been seen to be very effective at preventing hospitalizations for pre-Omicron but they had been in very short supply. mABs are an infusion medication that requires an IV bag to be drained into a patient. This is a treatment protocol that is not done at home. It is also a treatment that is effective in a fairly narrow window post infection.
We know it is effective at minimizing hospitalizations. We know it is rare. We know there is a narrow window to use. So who got it? Ideally, in the real world the people who should be targeted at the ones who are most likely to have higher probabilities of adverse events including hospitalization and later on death. So who got it?
From November 2020 to August 2021, 1 902 914 fee-for-service Medicare beneficiaries had a diagnosis of COVID-19 and were not hospitalized or deceased within 7 days of diagnosis. Of these, 7.2% received mAb therapy (Table). The likelihood of receiving mAb therapy was higher among those with fewer chronic conditions (23.2% of beneficiaries with 0 chronic conditions vs 6.3%, 6.0%, and 4.7% with 1-3, 4-5, and ≥6 chronic conditions, respectively; adjusted odds ratio, 7.43 [95% CI, 7.21-7.66] for 0 vs ≥6). Patients receiving treatment were also less likely to be Black (6.2% vs 7.4% of non-Hispanic white patients; adjusted odds ratio, 0.77 [95% CI, 0.75-0.79]) or dually enrolled in Medicaid (4.6% vs 8.1%, adjusted odds ratio 0.74 [95% CI, 0.72-0.75]).
TLDR: Relatively healthy white, non-poor Medicare Fee for Service beneficiaries were significantly and notably more likely to receive mABs than individuals with significant pre-existing conditions, African American and Dual-Eligible beneficiaries.
When I read this paper, I had just gotten off a call with a co-author discussing a potential grant application focused on administrative burden in health insurance choice. So my head is in the administrative burden space. These results make sense. There are a lot of hoops to jump through, and each chance to jump is also a chance to fall.
First someone needs an early enough diagnosis after plausible exposure and symptoms starting to fall into the plausibly effective treatment window. This means both getting a test and getting fast results. There are likely socio-economic factors that change the probability of that event happening correlated with the resources people are able to mobilize.
Then once there is a quick diagnosis returned, a physician is needed to prescribe mABs.
Once there is a prescription, the patient might have to change locations from where they received the prescription to someplace where the infusion can be administered. Having a car is likely very helpful.
There are likely other steps involved in the process but each step means people will fall off. This is good descriptive evidence that suggests that the people who are falling out of the process are the people who are most likely to benefit from mABs. This is bad for both an equity lens and a resource allocation lens. mABs are good at preventing hospitalizations which are a scarce resource. mABs being administered to relatively healthy folks means the number of doses needed to prevent one hospitalization is way higher than it should be if there is a targeting regimen in place that gets doses to people with comorbidities and complex situations.
Proof, that the racist based health system works exactly as designed – what a relief for the thug party.
It’s anti-poor for sure.
Administrative burden is such a huge factor in so many health care choices, I’m glad someone is looking at it critically. I just switched to a direct primary care provider even though I’ve got decent health insurance because dealing with a normal physician’s practice is so clunky.
You are the Lebron James of Thinking About This Stuff. That’s a good thing in my book. I am going to spend the rest of today wishing I were as good at my job as you are.
It might be interesting to see Florida’s numbers in relation to locations where mABs were made available in the state. Especially since FL’s government seem to really be pushing these as all they needed, don’t bother with that nasty vax folks! HHS has a therapeutics locator for the monoclonal antibody treatment Evusheld, as well as the oral antiviral therapies Paxlovid and molnupiravir.
COVID-19 Therapeutics Locator (arcgis.com)
but of course that is current (not past) availability.
From Aug 25th 2021,
Governor Ron DeSantis Announces Opening of New Monoclonal Antibody Treatment State Site at The Villages (flgov.com)
“Today, Governor Ron DeSantis opened a new monoclonal antibody treatment site at The Villages. This treatment site will be open seven days a week from 9 a.m. to 5 p.m. and has the capacity to serve more than 300 patients per day. ”
Only thing surprising about The Villages getting it’s own site is that it wasn’t 24 hours a day.
Yeah, fee-for-service, what I call Traditional Medicare can be a lot more expensive than the Advantage plans. There are more moving parts, you have to choose and pay for a Plan B and a Plan D, which means taking what you hope is an educated guess about what your medical needs will be in the next twelve months.
With Advantage plans, there is just the initial decision, “which plan?,” and you’re done (for a year at least). If you are financially less able, or easily overwhelmed by fine print, the Advantage plans are going to look good to you.
It’s a little Orwellian, naming the option that could very well prevent you from the key specialist should you acquire a weird medical condition, the “Advantage Plan,” but there you are.
In the study of policy making, is there a term for programs that divide up the targeted population in a way in which the more sophisticated and financially better-off are sequestered from the rest?
I am thinking here not only of the Traditional/Advantage divide but also of the ABLE program.
This is a savings program for people with disabilities that is modeled after 529 college savings plans. You can save up to $100,000 and not have that affect your eligibility for SSI and Medicaid.
It’s a boon for middle-class families with a disabled child. You can deposit whatever the gift tax exclusion maximum is each year, and it’s simpler and cheaper than the other alternative, setting up a special needs trust.
But in my more paranoid moments, I wonder if part of Congress’s goal in setting up this program was to mollify the segment of the disability community most likely and capable of pushing for a stronger safety net. You are less likely to panic about how little Social Security (SSI and/or SSDI) your child will have if you have created a nice ABLE account for them. And if you are not panicking, you are probably disinclined to organize to lobby Congress.
So why get upset about the poor shmucks who are getting shortchanged by how medical coverage is structured? You’re sitting pretty so even though you are the one sophisticated enough to push for change, you have no motivation.
I hope that made sense, Ohio Dad has interrupted me half a dozen times. Also, my comment is probably a little off-topic but off- topic is one of my specialities.
@Ohio Mom: I did not know about ABLE plans. THANK YOU!!
@sab: In Ohio, they are called STABLE.https://ohio.gov/residents/resources/stable-account
Each state has their own version.
@Ohio Mom: When my dad was in his last days, he worked on setting up an ABLE account for my autistic brother. It’s good that it exists, but its complicated, especially for people who have various kinds of guardians (guardian of the person, guardian of the estate, various powers of attorney, …). The guardians wanted nothing to do with being responsible for the ABLE account, and us survivors are several states away. It’s pretty much essential that various legal and financial professionals have to be involved to have any chance of it working. :-/
Yes, this is another illustration that those who have the means are able to take advantage of programs (and treatments) that those who don’t aren’t. It’s not based on efficient delivery to those who need it most. Atrios’s mantra that social programs should simply be universal – just pay for it via higher taxes on the wealthy, rather than means testing or requiring complicated paperwork – should be better understood and advocated for. (Who cares if Bezos’s kid gets free college if Bezos is taxed at a 75% marginal rate??)