Insurance and Treatment Patterns in Pulmonary Arterial Hypertension: The Pulmonary Hypertension Association Registry

RATIONALE: Pulmonary arterial hypertension (PAH) medications are costly for patients and often subject to insurance-related restrictions that may limit access. The impact of insurance type on PAH treatment has not been studied previously. OBJECTIVES: To examine whether insurance type is associated with PAH medication use, time to initiation of combination therapy, and clinical outcomes. METHODS: We studied a prospective cohort of incident adult patients with PAH enrolled in the Pulmonary Hypertension Association Registry from 2015 to 2025. Insurance type was categorized as private insurance, Medicare, or Medicaid or similar public programs. We evaluated associations between insurance type and PAH medication regimen at the first follow-up visit, time to initiation of combination therapy, emergency department visit and hospitalization rates, and health-related quality of life outcomes using ordinal and logistic regression models and Cox proportional hazard models, as appropriate. RESULTS: The study cohort included 1,219 patients, of whom 40.0% had private insurance, 36.8% Medicare, and 23.2% Medicaid or similar programs. After multivariable adjustment, insurance type was not associated with treatment intensity (compared to Medicare, private insurance: OR, 1.15; 95% CI, 0.82-1.62; Medicaid: OR, 1.28; 95% CI, 0.84-1.96). Insurance was also not associated with time to initiation of combination therapy, hospitalization rates, or health-related quality of life. Use of financial assistance programs (non-profit or pharmaceutical company-sponsored) to pay for PAH medications was associated with higher odds of receiving more intensive medication therapy (OR, 1.69; 95% CI, 1.29-2.23) and earlier initiation of combination therapy (HR, 1.54; 95% CI, 1.16-2.04). CONCLUSIONS: In this multicenter cohort of patients treated at accredited pulmonary hypertension centers, patients received similar PAH treatment and had comparable outcomes regardless of insurance type or income. PAH medication assistance program use was associated with earlier combination therapy and more intensive treatment. PRIMARY SOURCE OF FUNDING: National Institutes of Health/National Institute of General Medical Sciences (T32 GM075766 [B.E.M.]) and the National Institutes of Health/National Heart, Lung, and Blood Institute (R01 HL173533 [N.A.-N.]).