Medicare Part D prescription drug benefits and administrative burden in the care of dually eligible psychiatric patients

Coping with Administrative Workload: a Pilot Study in the Usefulness of a Workshop for Psychiatric Trainees

OBJECTIVE

Administrative workload may have detrimental effects on medical postgraduate trainee satisfaction, capacity, and quality of care. Best-practice guidelines to help trainees cope have yet to be developed. This study explores perceptions of factors that influence the experience or amount of administrative workload at the personal and workplace level and evaluates the usefulness of a workshop on coping with this workload.

METHODS

A workshop was developed based on the Job Demands-Resources model, including a survey on perceptions of administrative workload; presentation on coping at personal (e.g., time management) and workplace (e.g., dealing with institutional rules) levels; personal plan of change during a group discussion; and reflective questionnaire after the session and again after 2 months. Perceptions of psychiatry trainee participants (N = 48) were collected.

RESULTS

Trainees estimated they spent half their time on administration (average 50%, SD = 15%). They wanted to spend less time (average 23%, SD = 11%) on most administrative duties, except for health record keeping. Personal factors that trainees experienced as helpful to cope included time management and analytical skills. Perfectionism was perceived as impeding. Supportive job factors included helpful supervisors, competent administrative staff, trust in a team, allocated timeslots, and information technology support. High workload and cumbersome procedures were mentioned as impeding. On average, trainees rated the workshop quality and the likelihood of bringing change to their practice with a 7 out of 10.

CONCLUSION

Psychiatry trainees' participation in a workshop on coping with administrative load during their training may be a worthwhile investment in the long term.

Medicare part D and long-term care: a systematic review of quantitative and qualitative evidence

BACKGROUND

In the largest overhaul to Medicare since its creation in 1965, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established Part D in 2006 to improve access to essential medication among disabled and older Americans. Despite previous evidence of a positive impact on the general Medicare population, Part D's overall effects on long-term care (LTC) are unknown.

OBJECTIVE

The purpose of this systematic review was to evaluate the literature regarding Part D's impact on the LTC context, specifically costs to LTC residents, providers and payers; prescription drug coverage and utilization; and clinical and administrative outcomes.

DATA SOURCES

Four electronic databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Business Fulltext Elite and Science Citation Index Expanded], selected US government and non-profit websites, and bibliographies were searched for quantitative and qualitative studies characterizing Part D in the LTC context. Searches were limited to studies that may have been published between 1 January 2006 (date of Part D implementation) and 8 January 2013.

STUDY SELECTION

Systematic searches identified 1,624 publications for a three-stage (title, abstract and full-text) review. Included publications were in English language; based in the US; assessed Part D-related outcomes; and included or were directly relevant to LTC residents or settings. News articles, reviews, opinion pieces, letters or commentaries; case reports or case series; simulation or modeling studies; and summaries that did not report original data were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

A standardized form was used to abstract study type, study design, LTC setting, sources of data, method of data collection, time periods assessed, unit of observation, outcomes and results. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies.

RESULTS

Eleven quantitative and eight qualitative studies met inclusion criteria. In the seven years since its implementation, Part D decreased out-of-pocket costs among enrolled nursing home residents and potentially increased costs borne by LTC facilities. Coverage of prescription drugs frequently used by older adults was adequate, except for certain drugs and alternative formulations of importance to LTC residents. The use of medications that raise safety concerns was decreased, but overall drug utilization may have been unaffected. Although there was uncertain impact on clinical outcomes, quantitative studies demonstrated evidence of unintended health consequences. Qualitative studies consistently revealed increased administrative burden among providers.

LIMITATIONS

Empirical evidence of Part D's LTC impact was sparse. Due to limitations in available types of data, quantitative studies were generically lacking in methodological rigor. Qualitative studies suffered from lack of clarity of reporting. As future studies use clinical Medicare data, study quality is expected to improve.

CONCLUSION

Although LTC-specific policies continue to evolve, it appears that the prescription drug benefit may require further modifications to more effectively provide for LTC residents' unique medication needs and improve their health outcomes. Adjustments may be needed for Part D to be more compatible with LTC prescription drug delivery processes.

Uncompensated medical provider costs associated with prior authorization for prescription medications in an HIV clinic

Although prior authorization (PA) for prescription medications is widely employed for cost-containment for third-party insurers, it is a frustrating aspect of outpatient clinical care that imposes uncompensated costs to medical providers. To characterize these costs, we monitored the PA-associated administrative and operational process at the University of Alabama at Birmingham 1917 HIV Clinic over a 2-year period. A total of 288 PAs were processed with a mean (+/- standard deviation [SD]) of 3.1+/-5.8 days delay in the patient's access to medication. A mean (+/-SD) of 26.8+/-18.4 min was spent by the nurse practitioner and 6.5+/-2.9 min was spent by a clerk per PA. Nearly three-quarters (73%) of PAs were approved, 18% were denied, and 10% were voided. The mean (+/-SD) pages of paperwork was 5.8+/-6.5. The overall cost was $41.60 per PA. Although evidence supports that PA reduces third-party expenditures, it significantly delays medication accessibility for patients and imposes high costs that negatively impact operating margins for health care providers.

Assessment of Changes in Utilization of Health-Care Services after Implementation of a Prior Authorization Policy for Atypical Antipsychotic Agents

BACKGROUND:

In 2004, the Georgia Medicaid program implemented a prior authorization (PA) policy for certain atypical antipsychotic agents, resulting in an average savings of $2.7 million per year.

OBJECTIVE:

To determine whether implementation of a PA policy for atypical antipsychotic drugs increased health-care utilization in the Georgia Medicaid program from July 2003 to April 2006.

METHODS:

A single cohort observational study employing segmented regression and time series analysis was conducted to determine health-care services utilization, including emergency department (ED) visits, outpatient office visits, hospital admissions, and length of stay (LOS). Study subjects included continuously eligible adult Georgia Medicaid recipients with a schizophrenia-related diagnosis and documented use of an atypical antipsychotic medication (N = 12,120). Where applicable, analysis of a noncontinuously eligible population was also performed to investigate disenrollment bias in study results.

RESULTS:

A significant decline in post-policy trend for the average number of ED visits (absolute difference −0.042 per member per month (PMPM); relative difference −20.92%) and average number of hospital admissions PMPM (absolute difference −0.010 PMPM; relative difference −22.27%) was observed at the end of the study period. Baseline and pre-policy trends were found to be significant predictors for both endpoints. Significant models were not identified for average outpatient office visits PMPM or average LOS per admission.

CONCLUSIONS:

In contrast to other published studies on PA for atypical antipsychotics, patient outcomes improved after the initiation of the policy. To the extent that medical utilization reflects patient health outcomes and health status, the results of this study indicate that the PA program has potentially improved the health of schizophrenic patients in Georgia and lowered program costs.

Broadened use of atypical antipsychotics: safety, effectiveness, and policy challenges

Atypical antipsychotic medications are increasingly used for a wide range of clinical indications in diverse populations, including privately and publicly insured youth and elderly nursing home residents. These trends heighten policy challenges for payers, patients, and clinicians related to appropriate prescribing and management, patient safety, and clinical effectiveness. For clinicians and patients, balancing risks and benefits is challenging, given the paucity of effective alternative treatments. For health care systems, regulators, and policymakers, challenges include developing the evidence base on comparative risks and benefits; defining measures of treatment quality; and implementing policies that encourage evidence-based practices while avoiding unduly burdensome restrictions.

The effect of depression and cognitive impairment on enrollment in Medicare Part D

OBJECTIVES

To examine concerns that vulnerable populations, such as depressed or cognitively impaired beneficiaries would have challenges accessing Part D coverage.

DESIGN

Logistic regression analysis was used to assess whether elderly Medicare beneficiaries with depression or cognitive impairment differentially planned to and actually signed up for Part D.

SETTING

2004 and 2006 data from the Health and Retirement Study (HRS) were used, including a subsample that completed the Prescription Drug Study (PDS) in 2005.

PARTICIPANTS

Nine thousand five hundred ninety-three HRS respondents and 3,567 PDS respondents.

MEASUREMENTS

The outcome variables of interest were planned and actual enrollment in Part D. The independent variables were depression and cognitive impairment status. The analyses were adjusted using clinical and demographic predictors including age, sex, race or ethnicity, educational attainment, net worth, marital status, health status, number of health conditions being treated with prescription medications, and presence of a caregiver.

RESULTS

Although having depression or cognitive impairment was associated with a higher likelihood of planning to and actually signing up for Part D in unadjusted analyses, in adjusted analyses, having depression or cognitive impairment was not significantly associated with whether Medicare beneficiaries planned to enroll in or actually enrolled in Part D.

CONCLUSION

Vulnerable Medicare beneficiaries with depression or cognitive impairment were able to access Part D benefits to the same extent as nonvulnerable beneficiaries. More research is needed to determine how well Part D meets the needs of these populations.

Prior authorization for antidepressants in Medicaid: effects among disabled dual enrollees

BACKGROUND

Prior authorization is a popular, but understudied, strategy for reducing medication costs. We evaluated the impact of a controversial prior authorization policy in Michigan Medicaid on antidepressant use and health outcomes among dual Medicaid and Medicare enrollees with a Social Security Disability Insurance designation of permanent disability.

METHODS

We linked Medicaid and Medicare (2000-2003) claims for dual enrollees in Michigan and a comparison state, Indiana. Using interrupted time-series and longitudinal data analysis, we estimated the impact of the policy on antidepressant medication use, treatment initiation, disruptions in therapy, and adverse health events among continuously enrolled (Michigan, n = 28 798; Indiana, n = 21 769) and newly treated (Michigan, n = 3671; Indiana, n = 2400) patients.

RESULTS

In Michigan, the proportion of patients starting nonpreferred agents declined from 53% prepolicy to 20% postpolicy. The prior authorization policy was associated with a small sustained decrease in therapy initiation overall (9 per 10,000 population; P = .007). We also observed a short-term increase in switching among established users of nonpreferred agents overall (risk ratio, 2.88; 95% confidence interval, 1.87-4.42) and among those with depression (2.04; 1.22-3.42). However, we found no evidence of increased disruptions in treatment or adverse events (ie, hospitalization, emergency department use) among newly treated patients.

CONCLUSIONS

Prior authorization was associated with increased use of preferred agents with no evidence of disruptions in therapy or adverse health events among new users. However, unintended effects on treatment initiation and switching among patients already taking the drug were also observed, lending support to the state's previous decision to discontinue prior approval for antidepressants in 2003.