(P004) MEDICARE ADVANTAGE AND COMMERCIAL INSURANCE IN IBD CARE: UTILIZATION TRENDS IN PUERTO RICO (2018-2022)

Background:
Inflammatory bowel disease (IBD) presents a significant burden on healthcare systems, with variability in healthcare utilization based on insurance type. In Puerto Rico (PR), both Medicare Advantage (MA) and commercial insurance (CI) are widely used,  with approximately 609,274 beneficiaries in MA and 1,155,269 in CI. Understanding the patterns of utilization is crucial for optimizing resource allocation and improving outcomes. Therefore, we aim to describe the proportion of healthcare utilization (HCU) attributable to MA or CI patients between 2018 and 2022.

Methods:
This cross-sectional, retrospective study used de-identified insurance claims from health insurers in PR. Cases identified had ICD-10 codes for IBD and fulfilled at one of the following criteria: 2 hospitalizations for IBD, 4 IBD-related physician visits, one IBD drug pharmacy claim plus one of the former, or 2 ambulatory center IBD claims plus one of the former. Variables include age, gender, insurance type, IBD diagnosis, physician visits, endoscopies, emergency room visits (ER), hospitalizations and surgery. Average HCU for both CI and MA were calculated by utilization category between 2018-2022. Results are presented as the percentage of the average use of each category of services. The study was approved by the MSC-IRB.

Results:
The average insured population during the study period was 1,764,543, with 6,293 IBD cases, giving a prevalence of 356.6 per 100,000. Among these, 83% of CI and 89% of MA patients had on average, 2 or fewer hospitalizations. Of the 7,633 hospitalizations during the study period, 68% were in MA patients and 32% in CI patients. On average, 91% of MA and 85% of CI patients had 4 or fewer visits with gastroenterologists. A total of 57% of all office visits were by CI patients. 88% and 83% of patients in both groups had 1 ER visit on average between 2018 and 2022. Of 1,327 ER claims, 68% were in MA patients. More than 95% of both groups underwent at least two diagnostic procedures, with 60% of all procedures performed in the CI  group.

Conclusion:
This study provides valuable insights into HCU patterns among IBD patients in PR by insurance type. Over the five-year period, patients with MA had a higher proportion of hospitalizations and ER visits compared to those with CI, despite similar patterns of outpatient care. It is relevant to highlight that 75% of CI beneficiaries are between 19y/o and 59y/o, while 75% of MA beneficiaries are over 60y/o. Differences in HCU may not necessarily be linked to access of care, but rather the complex health needs of the older population of MA. These findings highlight potential differences in healthcare needs and utilization between insured groups in PR. Further research is warranted to explore if these patterns represent a potential difference in access to healthcare services and their impact on patient outcomes.