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.
Administrative burden, antibodies and disparitiesPost + Comments (8)