Presentation (CTI)

OBJECTIVES: The Inflation Reduction Act (IRA) establishes a $2,000 annual out-of-pocket (OOP) cap for Medicare Part D beneficiaries beginning in 2025. The Patient Advocate Foundation (PAF) subsidizes drug costs for nearly 3 million Americans, yet many disease funds are exhausted early, leaving patients without support. This study modeled patient-level savings and coverage expansion under IRA OOP limits using real-world PAF administrative claims data.
METHODS: We analyzed 2023-2024 PAF claims (~130,000 unique patient spells; ~$300 million total spend) from the top-five cost conditions: breast cancer, HIV/AIDS, multiple myeloma, prostate cancer, and pulmonary fibrosis. Quantile regression models adjusted for age, gender, ethnicity, and income captured spending variability. Simulations applied IRA OOP caps ($2,000 for 2025; $2,100 for 2026) to truncate spending above thresholds. Coverage expansion was estimated using cap-based (savings ÷ IRA cap) and mean-based (savings ÷ mean post-IRA spending) approaches. Analyses were conducted using R version 4.5.1.
RESULTS: Under the $2,000 cap, projected aggregate savings ranged from $12.9 million (prostate cancer) to $80.3 million (HIV/AIDS). Mean per-patient savings were highest for multiple myeloma ($4,373) and breast cancer ($2,736). Coverage expansion potential varied substantially by disease: multiple myeloma demonstrated the largest percentage gain (219-247% cap & mean based respectively), followed by breast cancer (137-172%), pulmonary fibrosis (125-142%), HIV/AIDS (83-114%), and prostate cancer (39-49%). High-cost conditions & high-spend percentiles experienced the greatest benefit, while median spenders saw limited direct impact.
CONCLUSIONS: The IRA's Medicare Part D OOP cap significantly reduces financial burden for high-spending beneficiaries and may substantially enhance PAF fund efficiency. Projected impacts vary by disease, with multiple myeloma and breast cancer funds experiencing the largest savings and coverage expansion potential. Findings demonstrate alignment between policy intent and affordability outcomes, providing policymakers with actionable insights on maximizing equity and fiscal efficiency.