Part D and dually eligible patients with mental illness: medication access problems and use of intensive services

Pharmaceutical policies: effects of regulating drug insurance schemes

BACKGROUND

Drug insurance schemes are systems that provide access to medicines on a prepaid basis and could potentially improve access to essential medicines and reduce out-of-pocket payments for vulnerable populations.

OBJECTIVES

To assess the effects on drug use, drug expenditure, healthcare utilisation and healthcare outcomes of alternative policies for regulating drug insurance schemes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers between November 2014 and September 2020, including a citation search for included studies on 15 September 2021 using Web of Science. We screened reference lists of all the relevant reports that we retrieved and reports from the Background section. Authors of relevant papers, relevant organisations, and discussion lists were contacted to identify additional studies, including unpublished and ongoing studies.

SELECTION CRITERIA

We planned to include randomised trials, non-randomised trials, interrupted time-series studies (including controlled ITS [CITS] and repeated measures [RM] studies), and controlled before-after (CBA) studies. Two review authors independently assessed the search results and reference lists of relevant reports, retrieved the full text of potentially relevant references and independently applied the inclusion criteria to those studies. We resolved disagreements by discussion, and when necessary by including a third review author. We excluded studies of the following pharmaceutical policies covered in other Cochrane Reviews: those that determined how decisions were made about which conditions or drugs were covered; those that placed restrictions on reimbursement for drugs that were covered; and those that regulated out-of-pocket payments for drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies and assessed risk of bias for each study, with disagreements being resolved by consensus. We used the criteria suggested by  Cochrane Effective Practice and Organisation of Care (EPOC)  to assess the risk of bias of included studies. For randomised trials, non-randomised trials and controlled before-after studies, we planned to report relative effects. For dichotomous outcomes, we reported the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For interrupted time series and controlled interrupted time-series studies, we computed changes along two dimensions: change in level; and change in slope. We undertook a structured synthesis following the EPOC guidance on this topic, describing the range of effects found in the studies for each category of outcomes.

MAIN RESULTS

We identified 58 studies that met the inclusion criteria (25 interrupted time-series studies and 33 controlled before-after studies). Most of the studies (54) assessed a single policy implemented in the United States (US) healthcare system: Medicare Part D. The other four assessed other drug insurance schemes from Canada and the US, but only one of them provided analysable data for inclusion in the quantitative synthesis. The introduction of drug insurance schemes may increase prescription drug use (low-certainty evidence). On the other hand, Medicare Part D may decrease drug expenditure measured as both out-of-pocket spending and total drug spending (low-certainty evidence). Regarding healthcare utilisation, drug insurance policies (such as Medicare Part D) may lead to a small increase in visits to the emergency department. However, it is uncertain whether this type of policy increases or decreases hospital admissions or outpatient visits by beneficiaries of the scheme because the certainty of the evidence was very low. Likewise, it is uncertain if the policy increases or reduces health outcomes such as mortality because the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

The introduction of drug insurance schemes such as Medicare Part D in the US health system may increase prescription drug use and may decrease out-of-pocket payments by the beneficiaries of the scheme and total drug expenditures. It may also lead to a small increase in visits to the emergency department by the beneficiaries of the policy. Its effects on other healthcare utilisation outcomes and on health outcomes are uncertain because of the very low certainty of the evidence. The applicability of this evidence to settings outside US healthcare is limited.

Impact of Medicare Part D on mental health treatment and outcomes for dual eligible beneficiaries with HIV

Depression is common among women with HIV and untreated depression can result in poor quality of life and worsen HIV outcomes. Women with HIV who are dually enrolled in Medicaid and Medicare faced a potential disruption in medication access when Medicare Part D was implemented in 2006. The goal of this study was to estimate the effects of Medicare Part D implementation on antidepressant use, depressive symptoms, and hospitalization in Medicaid-Medicare dual eligible women with HIV. This study used 2003-2008 data from the Women's Interagency HIV Study. The effects of Medicare Part D were estimated using a difference-in-differences approach, adjusting for temporal trends using a matched control group of Medicaid-only enrollees. Before Medicare Part D implementation, dual eligibles differed from Medicaid-only enrollees in antidepressant use and hospitalization, despite having identical prescription drug coverage through Medicaid. For dual enrollees, the transition to Medicare Part D was not associated with changes in antidepressant use, depressive symptoms, or hospitalization. We did not find disruptive effects on antidepressant use and related outcomes among dual eligibles in this study. Stable antidepressant use may be due to better access to medical care for dual eligibles through Medicare both before and after Medicare Part D implementation, which may have eclipsed any effects of the transition. It may also signal that classification of antidepressants as a protected drug class under Medicare Part D was effective in preventing psychiatric medication disruption.

Persistent medication affordability problems among disabled Medicare beneficiaries after Part D, 2006-2011

BACKGROUND

Disabled Americans who qualify for Medicare coverage typically have multiple chronic conditions, are highly dependent on effective drug therapy, and have limited financial resources, putting them at risk for cost-related medication nonadherence (CRN). Since 2006, the Part D benefit has helped Medicare beneficiaries afford medications.

OBJECTIVE

To investigate recent national trends in medication affordability among this vulnerable population, stratified by morbidity burden.

DESIGN AND SUBJECTS

We estimated annual rates of medication affordability among nonelderly disabled participants in a nationally representative survey (2006-2011, n=14,091 person-years) using multivariate logistic regression analyses.

MEASURE

Survey-reported CRN and spending less on other basic needs to afford medicines.

RESULTS

In the 6 years following Part D implementation, the proportion of disabled Medicare beneficiaries reporting CRN ranged from 31.6% to 35.6%, while the reported prevalence of spending less on other basic needs to afford medicines ranged from 17.7% to 21.8%. Across study years, those with multiple chronic conditions had consistently worse affordability problems. In 2011, the prevalence of CRN was 37.3% among disabled beneficiaries with ≥ 3 morbidities as compared with 28.1% among those with fewer morbidities; for spending less on basic needs, the prevalence was 25.4% versus 15.7%, respectively. There were no statistically detectable changes in either measure when comparing 2011 with 2007.

CONCLUSIONS

Disabled Medicare beneficiaries continue to struggle to afford prescription medications. There is an urgent need for focused policy attention on this vulnerable population, which has inadequate financial access to drug treatments, despite having drug coverage under Medicare Part D.

Effects of Medicare Part D on guideline-concordant pharmacotherapy for bipolar I disorder among dual beneficiaries

OBJECTIVE

In January 2006 insurance coverage for medications shifted from Medicaid to Medicare Part D private drug plans for the six million individuals enrolled in both programs. Dual beneficiaries faced new formularies and utilization management policies. It is unclear whether Part D, compared with Medicaid, relaxed or tightened psychiatric medication management, which could affect receipt of recommended pharmacotherapy, and emergency department use related to treatment discontinuities. This study examined the impact of the transition from Medicaid to Part D on guideline-concordant pharmacotherapy for bipolar I disorder and emergency department use.

METHODS

Using interrupted-time-series analysis and Medicaid and Medicare administrative data from 2004 to 2007, the authors analyzed the effect of the coverage transition on receipt of guideline-concordant antimanic medication, guideline-discordant antidepressant monotherapy, and emergency department visits for a nationally representative continuous cohort of 1,431 adults with diagnosed bipolar I disorder.

RESULTS

Sixteen months after the transition to Part D, the proportion of the population with any recommended use of antimanic drugs was an estimated 3.1 percentage points higher than expected once analyses controlled for baseline trends. The monthly proportion of beneficiaries with seven or more days of antidepressant monotherapy was 2.1 percentage points lower than expected. The number of emergency department visits per month temporarily increased by 19% immediately posttransition.

CONCLUSIONS

Increased receipt of guideline-concordant pharmacotherapy for bipolar I disorder may reflect relatively less restrictive management of antimanic medications under Part D. The clinical significance of the change is unclear, given the small effect sizes. However, increased emergency department visits merit attention for the Medicaid beneficiaries who continue to transition to Part D.

Implementation of Medicare Part D and statin use among the elderly population with diabetes

Objective

The American Diabetes Association treatment guidelines recommend that patients with diabetes over 40 years of age with one or more risk factors for cardiovascular disease be prescribed statin medication. Despite the guideline, use of statins among elderly patients with diabetes is low. Medicare Part D was implemented in 2006 to increase affordability and access to prescription medications for Medicare enrollees. The main objective of this study was to analyse trend in statin users with diabetes before and after implementation of Part D.

Methods

Data were obtained from the Medical Expenditure Panel Survey for 2004–2008. Patients who were diabetic (ICD-9 code 250) and either elderly (≥65 years) or near elderly (57–64 years) were included in the analysis. Chi-square analysis was used to compare statin users before and after Part D for both the elderly and near-elderly populations. For elderly patients, trends in statin users were analysed for subpopulations based on gender, race/ethnicity, income, education level and perceived health status. A logistic regression analysis was conducted to identify factors that predicted use of statin.

Key findings

Between 2004 and 2008 patients who reported using statins increased from 55.05 to 61.25% for the elderly and from 54.99 to 55.89% for the near elderly. The elderly population had a significant increase in the percentage of patients reporting use of statins after the implementation of Part D (P = 0.002). Logistic regression identified post-Part D period (0.75, 95% confidence interval (CI) 0.60–0.94; P = 0.013), female gender (1.28, 95% CI 1.05–1.57; P = 0.013) and African-American race/ethnicity (1.53, 95% CI 1.19–1.96; P < 0.00) as significant predictors of reporting statin use among study population.

Conclusion

The study results imply that Part D may have influenced an increase in prescriptions of statins to elderly patients with diabetes. Logistic regression and trend analysis indicate that Part D was unable to reduce disparities in prescriptions for racial and gender subgroups.

Clinically unintended medication switches and inability to prescribe preferred medications under Medicare Part D

Medicare Part D has expanded medication access; however, there is some evidence that dually eligible psychiatric patients have experienced medication access problems. The aim of this study was to characterize medication switches and access problems for dually eligible psychiatric patients and associations with adverse events, including emergency department visits, hospitalizations, homelessness, and incarceration. Reports on 986 systematically sampled, dually eligible patients were obtained from a random sample of practicing psychiatrists. A total of 27.6% of previously stable patients had to switch medications because clinically indicated and preferred refills were not covered or approved. An additional 14.0% were unable to have clinically indicated/preferred medications prescribed because of drug coverage/approval. Adjusting for case-mix, switched patients (p = 0.0009) and patients with problems obtaining clinically indicated medications (p = 0.0004) had significantly higher adverse event rates. Patients at greatest risk were prescribed a medication in a different class or could not be prescribed clinically-indicated atypical antipsychotics, other antidepressants, mood stabilizers, or stimulants. Patients with problems obtaining clinically preferred/indicated antipsychotics had a 17.6 times increased odds (p = 0.0039) of adverse events. These findings call for caution in medication switches for stable patients and support prescription drug policies promoting access to clinically indicated medications and continuity for clinically stable patients.

Case managers and the use of Medicare, Part D

PURPOSE/OBJECTIVES

The purpose of this study was to examine the experiences and opinions of community-based mental health case managers with the Medicare prescription drug benefit. A qualitative approach, consisting of analysis of data from 3 case manager focus groups, was used to achieve an understanding of the role that case managers played in beneficiaries' access to and use of prescription medicines.

PRIMARY PRACTICE SETTINGS

Two urban nonprofit community-based mental health agencies.

FINDINGS/CONCLUSIONS

Adults who are disabled by mental illness depend on case managers for information about their prescription drug insurance, help with formulary and plan switching information, and assistance with tasks related to medication adherence in the community. Common themes in the case managers' discussion were managing beneficiary problems, stress for beneficiaries, information and paperwork issues, and cynicism regarding health care reform.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The critical role of case managers in the use of Medicare Part D is not well understood or appreciated. Case managers need to be informed about Medicare Part D and ready to advocate for their clients in the community. In addition, it is important for case managers to understand how Medicare Part D affects not only older adults, but also adults living with serious and persistent mental illness.

Changes in drug use and out-of-pocket costs associated with Medicare Part D implementation: a systematic review

Medicare Part D was implemented 4 years ago. Despite the fact that public-use Part D data were unavailable until late 2008, researchers have used alternate data to examine the effect of Part D on drug use and out-of-pocket costs. In a systematic review of Medline from 2006 to October 2009, the literature about drug use and costs after implementation and during the transition period and coverage gap was summarized. Studies presenting original results regarding drug use and costs after Part D implementation were included. Case reports and series and simulation studies were excluded. Of 552 originally identified articles, 26 met selection criteria: 13 regarding the overall effect of Part D in the year(s) after implementation, seven describing the Part D transition period, and six concerning the coverage gap. Part D implementation was associated with a 6% to 13% increase in drug use and a 13% to 18% decrease in patient costs. The transition period was associated with no significant changes in use or costs for elderly dual-eligible beneficiaries, but effects in other populations were mixed. Entry into the coverage gap was associated with a 9% to 16% decrease in drug use and increases in costs of up to 89%. In summary, studies examining disparate data regarding the implementation of Part D found consistent positive effects on drug use and costs but revealed unfavorable trends in the coverage gap. The effect of the Part D transition period remains unclear. Although public-use data will validate these results, policymakers can use the existing evidence to inform changes and enhancements to Part D immediately.