Medicare beneficiaries' knowledge of and choices regarding Part D, 2005 to the present

A digital divide in the COVID-19 pandemic: information exchange among older Medicare beneficiaries and stakeholders during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic resulted in unprecedented challenges for older adults. Medicare enrollment was already an overwhelming process for a high fraction of older adults pre-pandemic. Therefore, the purpose of this qualitative study was to gain understanding from community organizations and stakeholders about their pre-pandemic and during-pandemic experiences while adapting to continue offering insurance advice to seniors, what resources are available to seniors, and what needs to be done to help seniors make higher quality insurance choices in the Medicare program. In addition, we wanted to explore how the COVID-19 pandemic may have changed the ways that these stakeholders interacted with Medicare beneficiaries.

METHODS

We employed a qualitative strategy to gain a deep understanding of the challenges that these organizations may have faced while offering advice/counseling to older adults. We accomplished this by interviewing a group of 30 stakeholders from different states.

RESULTS

Every stakeholder mentioned that some older adults have difficulty making Medicare decisions, and 16 stakeholders mentioned that their system is complex and/or overwhelming for older adults. Twenty-three stakeholders mentioned that Medicare beneficiaries are often confused about Medicare, and this is more noticeable among new enrollees. With the onset of the pandemic, 22 of these organizations mentioned that they had to move to a virtual model in order to assist beneficiaries, especially at the beginning of the pandemic. However, older adults seeking advice/meetings have a strong preference for in-person meetings even during the pandemic. Given that the majority of the beneficiaries that these stakeholders serve may not have access to technology, it was difficult for some of them to smoothly transition to a virtual environment. With Medicare counseling moving to virtual or telephone methods, stakeholders discussed that many beneficiaries had difficulty utilizing these options in a variety of ways.

CONCLUSIONS

Findings from our interviews with stakeholders provided information regarding experiences providing Medicare counseling pre- and during-COVID-19 pandemic. Some of the barriers faced by older adults included a complex and overwhelming system, a strong preference for in-person meetings among beneficiaries, challenges with technology, and an increased risk of information overload and misinformation. While bias may exist within the study and sample, given that technology-savvy beneficiaries may not seek help from organizations our study participants work in, they show how the current Medicare system may impact vulnerable older adults who may need support with access to high-speed internet and digital literacy.

Evaluation of a poverty-focused educational program and simulation for pharmacists

BACKGROUND AND PURPOSE

Limited literature explores the impact that poverty-focused educational simulations can have on practicing clinicians. This study used a poverty simulation, specifically created to resemble the lives of Medicare patients, to sensitize practicing pharmacists to the situations faced by people living in poverty. The study evaluated how a poverty-focused educational program impacted practicing pharmacists' actual knowledge gain, intention to assist patients with limited income, and satisfaction with the educational program.

EDUCATIONAL ACTIVITY AND SETTING

A quasi-experimental one-group pre-/posttest design of practicing pharmacists was utilized. The intervention was a live continuing educational (CE) program at a pharmacy alumni event and a pharmacy convention. The CE program was delivered in person and included a Medicare poverty simulation and a 75-min didactic lecture. Pre- and posttests were used to assess outcomes. The primary outcome was change in knowledge as measured by test scores. Secondary outcomes included intention to assist future low-income patients and participant satisfaction with the educational program.

FINDINGS

Eighty-nine pharmacists participated in the educational program. Participants' mean knowledge increased from 2.76 (SD = 0.97) to 3.61 (SD = 1.21) (P < .001) out of 5. The majority (88.3%) agreed they were interested in assisting patients with limited income in the future. Most participants strongly agreed that the program was satisfactory and contributed to their learning.

SUMMARY

This is the first identifiable study that incorporated a poverty simulation into an educational program for practicing pharmacists. The study may help inform the development of future educational programs for practicing pharmacists.

Medicare Decision-making, Understanding, and Satisfaction Among Cancer Survivors

With increased age as a leading risk factor for cancer, many patients depend on Medicare benefits to manage their disease. As such, this study explores (1) Medicare decision-making, (2) Medicare satisfaction, and (3) understanding of Medicare coverage among cancer patients. This cross-sectional study used focus group and survey methodology to explore patient decision-making regarding Medicare benefit selection and patient understanding and satisfaction of Medicare. Focus group findings informed a subsequent survey which was completed by 172 Medicare beneficiaries between December 2018 and January 2019. Quantitative and qualitative analyses were conducted. Findings suggest that although Medicare beneficiaries believe they understand their coverage and are largely satisfied with benefits, many cannot accurately identify the appropriate components of the program particularly regarding how drug benefits are structured. In-depth qualitative analyses from the focus group indicated not only a lack of understanding but a fear of unexpected out-of-pocket costs or coverage challenges. This study illustrates the ongoing challenges with educating Medicare beneficiaries regarding benefits, coverage, and financial obligations of the program. For cancer patients, in-depth and meaningful educational opportunities are critical as is access to multiple components of the Medicare program that can prove vital to the treatment and management of their disease.

Qualitative exploration of factors influencing the plan selection process by Medicare beneficiaries

BACKGROUND: Because Medicare plan coverage and costs change annually and older adults, the major beneficiaries of Medicare, are faced with multiple health conditions and changing medical needs, Medicare beneficiaries should evaluate their options during open enrollment every year. However, because of the complexity of plan selection, it may be challenging for Medicare beneficiaries to make an appropriate decision from among competing options. OBJECTIVES: To (a) identify factors that beneficiaries consider having influenced their plan selection decision and (b) describe the decision-making process according to the consumer decision-making model (CDM). The 2 research questions guiding this study included (a) factors Medicare beneficiaries considered having influenced their Medicare plan selection decision and (b) characteristics of decision-making processes employed by Medicare beneficiaries. METHODS: This is a phenomenological qualitative study. Semistructured in-person or telephone interviews with Alabama residents who have Medicare as the sole insurance provider were conducted between June and August 2019. Participant recruitment continued until reaching the saturation point. Each interview session consisted of structured questions identifying characteristics of participants and open-ended questions used to elicit participant Medicare plan decisionmaking process and factors affecting their decision. Data were analyzed using content analysis with a process of qualitative inductive coding. RESULTS: Twenty participants were interviewed. Twenty codes were identified and categorized into 5 themes regarding the factors influencing plan selection decisions by beneficiaries. When making a plan selection, participants were influenced by plan attributes (including cost, coverage, access to doctors, region, quality rating, and transportation); information resources and personal assistance; knowledge about Medicare; status and changes in personal situation; and experience with Medicare. Additionally, we identified 7 codes relating to beneficiary characteristics during decision-making processes, including being proactive, setting priorities, limiting choices, evaluating plans against personal needs, acquiescing to recommendations, sticking to the status quo, and weighing trade-offs. We consulted the CDM and created a conceptual model demonstrating a 5-step Medicare plan selection decision-making process and the factors influencing that process. DISCLOSURES: This study was supported by the Auburn University Undergraduate Research Program. The authors declare no conflicts of interest. CONCLUSIONS: This study created a step-by-step decision flowchart of Medicare plan selection to illustrate the complexity of the plan selection that Medicare beneficiaries must use. We uncovered the plan selection decision-making process among Medicare beneficiaries and factors affecting that process. Drawing from the CDM and the study findings, we developed a conceptual model. Findings will help researchers and community agencies target Medicare beneficiaries with different needs for assistance and design decision-making interventions/tools to help beneficiaries make rational decisions when selecting Medicare plans. These findings suggest that health care professionals should be involved in assistance programs to maximize efficiency of Medicare plan selection and to improve monitoring and consulting mechanisms to ensure the reliability of assistance information and services.

Trends in Older Adults' Knowledge of Medicare Advantage Benefits, 2010 to 2016

BACKGROUND/OBJECTIVES

The Medicare Advantage (MA) program insures a rapidly growing proportion of older adults, and may be more appealing due to lower cost sharing. However, the extent to which older adults are informed of their plan benefits and how plan knowledge has changed over time is unclear. We evaluated temporal trends and characteristics associated with not knowing MA coverage for dental, vision, and nursing home (NH) services.

DESIGN

Longitudinal cohort study.

SETTING

Medicare Current Beneficiary Survey (MCBS), 2010 to 2016.

PARTICIPANTS

Adults aged 65 years or older enrolled in MA plans and not in Medicaid.

MEASUREMENTS

Insurance knowledge was determined from separate items asking if individuals had coverage through their MA plan for dental, vision, and NH care. Responses were dichotomized between responding yes/no and not knowing. Demographic, clinical, and functional characteristics were assessed from the MCBS.

RESULTS

The proportion of older adults in MA who did not know if their plan covered NH care increased from 38.0% in 2010 to 45.5% in 2016. However, proportions of not knowing dental benefits decreased from 6.4% in 2010 to 3.4% in 2016 and not knowing vision benefits decreased from 8.2% in 2010 to 5.9% in 2016. We found significant associations of race, education, income, region, and disability with knowledge of MA benefits.

CONCLUSIONS

As enrollment in MA plans has grown, older adults in MA plans increasingly report that they know their plan's vision and dental benefits, although they decreasingly know about NH care. Older adults from racial and ethnic minority groups, with lower levels of education and income and who reside in certain regions or have functional disability, are less likely to know their plan benefits. This may imply decreasing preparedness for future long-term care needs. J Am Geriatr Soc 68:2343-2347, 2020.

Did the Medicare Prescription Drug Program Lead to New Racial and Ethnic Disparities? Examining Long-term Changes in Prescription Drug Access among Minority Populations

This study examined whether the Medicare Part D program was associated with racial/ethnic disparities in prescription drug access among elderly individuals who reported adequate access to physicians. Using a population-based survey of New Jersey residents, a difference-in-differences model estimated elderly blacks (OR = 3.20; p = .05) and Hispanics (OR = 4.29; p = .05) had higher odds than whites of reporting prescription access problems in the post, but not the pre-Part D period. The presence of prescription insurance did not lead to a significant decrease in access problems. Part D beneficiaries are required to make complicated decisions on cost-sharing and medication choices that require active involvement by physicians and pharmacists. Lack of guidance may critically impact minorities and economically vulnerable patients and cannot be addressed by extending coverage alone.

Social and Health-Related Factors Associated with Enrollment in Medicare Advantage Plans in Older Adults

OBJECTIVES

We assessed the characteristics of older Mexican American enrollees in traditional fee-for-service (FFS) and Medicare Advantage (MA) plans and the factors associated with disenrollment from FFS and enrollment in MA plans.

DESIGN

Longitudinal study linked with Medicare claims data.

SETTING

The Hispanic Established Populations for the Epidemiologic Study of the Elderly.

PARTICIPANTS

Community-dwelling Mexican American older adults (N = 1455).

MEASUREMENTS

We examined insurance status using the Medicare Beneficiary Summary File and estimated the association of sociodemographic and clinical factors with insurance plan switching.

RESULTS

Among Mexican American older adults, FFS enrollees were more likely to be born in Mexico, speak Spanish, have lower levels of education, and have more disability than MA enrollees. Older adults with a larger number of limitations of instrumental activities of daily living (odds ratio [OR] = .50; 95% confidence interval [CI] = .26-.98) and more social support (OR = .70; 95% CI = .45-.98) were less likely to switch from FFS to MA compared with older adults with no limitations and less social support. Additionally, older adults living in counties with a greater number of MA plans were more likely to switch from FFS to MA (OR = 2.1; 95% CI = 1.45-3.16), compared with counties with a lower number of MA plans. In counties with a higher number of MA plans, older adults with more social support had lower odds of switching from FFS to MA (OR = .48; 95% CI = .28-.82) compared with older adults with less social support.

CONCLUSION

Compared with those enrolled in MA, older Mexican American adults enrolled in Medicare FFS are more socioeconomically disadvantaged and more likely to demonstrate poor health status. Stronger social support and increased physical limitations were strongly associated with less frequent switching from FFS to MA plans. Additionally, increased availability of MA plans at the county level is a significant driver of enrollment in MA plans. J Am Geriatr Soc 68:313-320, 2020.

Psychometric evaluation of the Medicare Advantage and prescription drug plan disenrollment reasons survey

OBJECTIVES

To develop and assess the reliability and validity of composite measures of reasons for disenrollment from Medicare Advantage (MA) and prescription drug plans (PDPs).

DATA SOURCE

Medicare beneficiaries who responded to the Medicare Advantage and Prescription Drug Plan Disenrollment Reasons Survey.

STUDY DESIGN

Separate multilevel factor analyses of MA and PDP data suggested groupings of survey items to form composite measures, for which internal consistency and interunit reliability were estimated. The association of each composite with an overall plan rating was examined to evaluate criterion validity.

PRINCIPAL FINDINGS

Five composites were identified: financial reasons for disenrollment; problems with prescription drug benefits and coverage; problems getting information and help from the plan; problems getting needed care, coverage, and cost information; and problems with coverage of doctors and hospitals. Beneficiary-level internal consistency reliability exceeded 0.70 for all but one composite (financial reasons); plan-level internal consistency reliability exceeded 0.80 for all composites; average interunit reliability for plans with ≥ 30 survey completes exceeded 0.75 for 3 of 5 composites. As expected, greater endorsement of reasons for disenrollment was associated with lower overall plan ratings.

CONCLUSIONS

The Disenrollment Reasons Survey provides a reliable and valid assessment of beneficiaries' reasons for leaving their plans. Multiple reasons for disenrollment may indicate especially poor experiences.

Comparative Usability Study of a Newly Created Patient-Centered Tool and Medicare.gov Plan Finder to Help Medicare Beneficiaries Choose Prescription Drug Plans

Introduction:

In response to reported difficulties in selecting a Medicare Part D prescription drug plan, we designed a patient-centered online Part D plan selection tool (CHOICE1.0) to simplify the selection process and to provide personalized, expert recommendations.

Methods:

This ethnographic comparative usability study observed 44 patients using the first version of the tool during Medicare 2016 Open Enrollment. Participants were observed as they chose their drug plan using Medicare.gov and 1 of 3 versions of CHOICE1.0 that varied in amount of expert guidance. Descriptive statistics were used to analyze exit survey data. The observations were video-recorded, and field notes were analyzed thematically.

Results:

Participants were significantly more satisfied with CHOICE1.0 for choosing a plan, understanding information, and ease of use compared to Medicare.gov. Those using expert versions of CHOICE1.0 were more likely to indicate their intention to switch plans than those using Medicare.gov, though they wanted to know the source and content.

Conclusion:

The more patient-centered prescription drug choice tool improved user experience and enabled users to choose plans more consistent with expert recommendations.

Patient Experiences in Selecting a Medicare Part D Prescription Drug Plan

INTRODUCTION

Medicare beneficiaries often report that the process of choosing a prescription drug plan is frustrating and confusing and many do not enroll in the plan that covers their drugs at the lowest cost.

METHODS

We conducted 4 focus groups to understand beneficiaries' experiences in selecting a drug plan to identify what resources and factors were most important to them. Participants were patients served by a multispecialty delivery system and were primarily affluent and Caucasian.

RESULTS

While low cost was essential to many, other characteristics like having the same plan as a partner, company reputation, convenience, and anticipation of possible future health problems were sometimes more important. Although some used resources including insurance brokers, counselors, and websites beyond Medicare.gov, many expressed a desire for greater assistance with and greater simplicity in the choice process.

CONCLUSION

Although older adults would likely benefit from greater assistance in choosing Medicare Part D prescription drug plans, more research is necessary to understand how to help with decision-making in this context.

Awareness of the Medicare Part D Low-Income Subsidy among Older non-Hispanic Blacks and Hispanics

Using nationally representative data from the Health and Retirement Study, this study examined (1) whether awareness of the Medicare Part D Low-Income Subsidy (LIS) varies by race and ethnicity among beneficiaries age 65 and older (N = 1,504), and (2) the impact of factors associated with health benefits knowledge and need for assistance on LIS awareness. Logistic regression results showed that compared with older non-Hispanic Whites, older non-Hispanic Blacks (odds ratio [OR] = .61, p < .001) and Hispanics (OR = .55, p < .01) were less likely to be aware of the LIS. Ethnic differences in LIS awareness were largely explained by language or Spanish-speaking preference (OR = 1.07, p = .808). However, accounting for demographics, health and socioeconomic status, and language did not reduce racial disparities (OR = .63, p < .01). Differences in LIS awareness among racial and ethnic minority groups highlight the need for culturally and linguistically sensitive community-based education, communication, programs, and services that increase knowledge of and access to this critical support.

A national survey of ethnic differences in knowledge and understanding of supplementary health insurance

Background

Knowledge and understanding of what health insurance covers is an important public health issue. In Israel, whereas national health insurance covers all residents, optional supplemental health insurance (SHI) can be purchased from the healthcare providers, for additional, special services. The purpose of this study was to identify disparities between Jews and Arabs in their knowledge and understanding of SHI.

Methods

National, cross-sectional, telephone survey using a structured questionnaire, among random samples of 814 Jews and 800 Arabs. Knowledge and understanding of health insurance was assessed by a score based on correct answers to 8 questions. Log-linear regression was used to estimate association between health insurance knowledge and population group, after controlling for potential confounding independent variables.

Results

Ninety one percent of Jews and 62% of Arabs reported owning SHI. Among both groups, knowledge levels were low on a 0–8 scale. However, the average score for Jews was statistically higher (Mean = 3.50, S.D = 1.69) as compared with Arabs (Mean = 2.78, S.D = 1.70) (p < 0.001). The adjusted health insurance knowledge score was significantly higher among Jews than Arabs (Prevalence ratio = 1.10; 95% CI = 1.06–1.13), indicating that differences remain even after controlling for socio-demographic characteristics and SHI ownership.

Conclusions

There is a large gap between the public’s understanding of what is covered by SHI and the services that it covers in practice. Low SHI knowledge and understanding may lead to frustration, and limit access to additional health care among populations that suffer from socio-economic inequalities. These findings emphasize the need to provide clearer and more culturally sensitive information on health insurance coverage.

Electronic supplementary material

The online version of this article (doi:10.1186/s13584-017-0137-4) contains supplementary material, which is available to authorized users.

Assessing student knowledge, confidence, accuracy, and proficiency in providing Medicare Part D assistance

PURPOSE

To assess the impact of coordinated didactic, simulation-based, and experiential learning on pharmacy students' knowledge and confidence with Medicare Part D and their accuracy and proficiency with the Medicare Plan Finder Tool.

EDUCATIONAL ACTIVITY

Forty-two pharmacy students participated in a two-semester Medicare Part D elective course in which didactic, simulation-based and experiential learning methods were employed. Students' knowledge, confidence, accuracy, and proficiency were assessed at three course time points: first day of class, last day of in-class education, and after completion of outreach.

FINDINGS

Student confidence with Part D and efficiency using the Plan Finder Tool significantly improved at each successive time point (p<0.01). Student knowledge was significantly improved both on the last day of class and after outreach completion as compared to the first day of class (p<0.01).

SUMMARY

Basic Part D knowledge improved with the didactic and simulation-based portion of the course. The experiential component improved student confidence and efficiency in helping Medicare beneficiaries.

Does the Medicare Part D Decision-Making Experience Differ by Rural/Urban Location?

PURPOSE

Although much has been written about Medicare Part D enrollment, much less is known about beneficiaries' personal experiences with choosing a Part D plan, especially among rural residents. This study sought to address this gap by examining geographic differences in Part D enrollees' perceptions of the plan decision-making process, including their confidence in their choice, their knowledge about the program, and their satisfaction with available information.

METHODS

We used data from the 2012 Medicare Current Beneficiary Survey and included adults ages 65 and older who were enrolled in Part D at the time of the survey (n = 3,706). We used ordered logistic regression to model 4 outcomes based on beneficiaries' perceptions of the Part D decision-making and enrollment process, first accounting only for differences by rurality, then adjusting for sociodemographic, health, and coverage characteristics.

FINDINGS

Overall, half of all beneficiaries were not very confident in their Part D knowledge. Rural beneficiaries had lower odds of being confident in the plan they chose and in being satisfied with the amount of information available to them during the decision-making process. After adjusting for all covariates, micropolitan residents continued to have lower odds of being confident in the plan that they chose.

CONCLUSIONS

Policy-makers should pay particular attention to making information about Part D easily accessible for all beneficiaries and to addressing unique barriers that rural residents have in accessing information while making decisions, such as reduced Internet availability. Furthermore, confidence in the decision-making process may be improved by simplifying the Part D program.

Rural-Urban Differences in Satisfaction with Medicare Part D: Implications for Policy

Rural residents are more likely to be enrolled in traditional fee-for-service Part D Medicare prescription drug plans, and they face particular challenges in accessing pharmaceutical care. This study examines rural/urban differences in satisfaction with Medicare Part D coverage. Using data from the 2012 Medicare Current Beneficiary Survey (N = 3,107 beneficiaries aged 65 and older), we find that rural residents have significantly lower satisfaction with Part D coverage but that regional variation in satisfaction is largely explained by differences in health services use and type of Part D plan (stand-alone versus Medicare Advantage). We conclude by suggesting a multifaceted approach to improving satisfaction with Part D for rural residents.

Impact of medicare part D plan features on use of generic drugs

BACKGROUND

Little is known about how Medicare Part D plan features influence choice of generic versus brand drugs.

OBJECTIVES

To examine the association between Part D plan features and generic medication use.

METHODS

Data from a 2009 random sample of 1.6 million fee-for-service, Part D enrollees aged 65 years and above, who were not dually eligible or receiving low-income subsidies, were used to examine the association between plan features (generic cost-sharing, difference in brand and generic copay, prior authorization, step therapy) and choice of generic antidepressants, antidiabetics, and statins. Logistic regression models accounting for plan-level clustering were adjusted for sociodemographic and health status.

RESULTS

Generic cost-sharing ranged from $0 to $9 for antidepressants and statins, and from $0 to $8 for antidiabetics (across 5th-95th percentiles). Brand-generic cost-sharing differences were smallest for statins (5th-95th percentiles: $16-$37) and largest for antidepressants ($16-$64) across plans. Beneficiaries with higher generic cost-sharing had lower generic use [adjusted odds ratio (OR)=0.97, 95% confidence interval (CI), 0.95-0.98 for antidepressants; OR=0.97, 95% CI, 0.96-0.98 for antidiabetics; OR=0.94, 95% CI, 0.92-0.95 for statins]. Larger brand-generic cost-sharing differences and prior authorization were significantly associated with greater generic use in all categories. Plans could increase generic use by 5-12 percentage points by reducing generic cost-sharing from the 75th ($7) to 25th percentiles ($4-$5), increasing brand-generic cost-sharing differences from the 25th ($25-$26) to 75th ($32-$33) percentiles, and using prior authorization and step therapy.

CONCLUSIONS

Cost-sharing features and utilization management tools were significantly associated with generic use in 3 commonly used medication categories.

Development and evaluation of a student-led Medicare Part D Planning Clinic

OBJECTIVE

To describe the creation of a student-led Medicare Part D Planning Clinic and to present satisfaction survey data evaluating the clinic.

DESIGN

Prospective pre- and post-assessment satisfaction surveys.

SETTING

University of Arkansas for Medical Sciences Institute on Aging.

PATIENTS, PARTICIPANTS

Medicare beneficiaries in 2011 in Arkansas.

INTERVENTIONS

The Medicare Part D Planning Clinic aids seniors in making a well-informed decision on which Medicare Part D plan is best for them. Pharmacy students learn about Medicare Part D choices and interact with older adults assisting them in identifying the best plan.

MAIN OUTCOME MEASURE(S)

Potential mean and overall savings and satisfaction ratings.

RESULTS

Forty-eight patients were seen at the clinic in 2011, and 25 of those patients were shown to have potential savings if they switched plans with an average potential annual savings of $1,157 per patient and a total potential annual savings of $28,929. Among both new and current Part D beneficiaries, 100% indicated they were very satisfied with the service, and among current Part D beneficiaries who completed the surveys, the percent that believed they would have to delay or not fill a prescription because of cost was 18.8% on the pre-assessment survey and 9.1% on the post-assessment survey.

CONCLUSION

Offering these services is an effective way to potentially save out-of-pocket expenses among seniors, and seniors find this service satisfying and helpful.

Association of teriparatide adherence and persistence with clinical and economic outcomes in Medicare Part D recipients: a retrospective cohort study

Background

Improper medication adherence is associated with increased morbidity, healthcare costs, and fracture risk among patients with osteoporosis. The objective of this study was to evaluate the healthcare utilization patterns of Medicare Part D beneficiaries newly initiating teriparatide, and to assess the association of medication adherence and persistence with bone fracture.

Methods

This retrospective cohort study assessed medical and pharmacy claims of 761 Medicare members initiating teriparatide in 2008 and 2009. Baseline characteristics, healthcare use, and healthcare costs 12 and 24 months after teriparatide initiation, were summarized. Adherence, measured by Proportion of Days Covered (PDC), was categorized as high (PDC ≥ 80%), moderate (50% ≥ PDC < 80%), and low (PDC < 50%). Non-persistence was measured as refill gaps in subsequent claims longer than 60 days plus the days of supply from the previous claim. Multivariate logistic regression evaluated the association of adherence and persistence with fracture rates at 12 months.

Results

Within 12 months of teriparatide initiation, 21% of the cohort was highly-adherent. Low-adherent or non-persistent patients visited the ER more frequently than did their highly-adherent or persistent counterparts (χ2 = 5.01, p < 0.05 and χ2 = 5.84, p < 0.05), and had significantly lower mean pharmacy costs ($4,361 versus $13,472 and $4,757 versus $13,187, p < 0.0001). Furthermore, non-persistent patients had significantly lower total healthcare costs. The healthcare costs of highly-adherent patients were largely pharmacy-related. Similar patterns were observed in the 222 patients who had fractures at 12 months, among whom 89% of fracture-related costs were pharmacy-related. The regression models demonstrated no significant association of adherence or persistence with 12-month fractures. Six months before initiating teriparatide, 50.7% of the cohort had experienced at least 1 fracture episode. At 12 months, these patients were nearly 3 times more likely to have a fracture (OR = 2.9, 95% C.I. 2.1-4.1 p < 0.0001).

Conclusions

Adherence to teriparatide therapy was suboptimal. Increased pharmacy costs seemed to drive greater costs among highly-adherent patients, whereas lower adherence correlated to greater ER utilization but not to greater costs. Having a fracture in the 6 months before teriparatide initiation increased fracture risk at follow-up.

Medicare beneficiary knowledge of the Part D program and its relationship with voluntary enrollment

BACKGROUND

The 2003 Medicare Modernization Act established the Part D drug benefit in 2006. Because the benefit involves a voluntary enrollment process with numerous plan options, there has been concern about whether beneficiaries have adequate knowledge of the program, but research on this issue has been limited.

OBJECTIVES

To examine Medicare beneficiary knowledge of the Part D program and estimate how knowledge affected voluntary enrollment decisions at the program's outset.

METHODS

We linked data from the 2005 Medicare Current Beneficiary Survey with CMS administrative data regarding beneficiary 2006 drug coverage and market characteristics. We estimated a multivariate logistic regression model to explore the relationship between Part D knowledge and beneficiaries' voluntary enrollment in a Part D plan.

RESULTS

At the inception of the Medicare Part D benefit, no single knowledge test question was correctly answered by more than three-fourths of beneficiaries. Correct responses to five knowledge test questions were positively associated with enrollment: "everyone has plan choices" (adjusted odds ratio = 1.4); "plans can change costs once per year" (aOR = 1.2); "beneficiaries must use plan pharmacies" (aOR = 1.5); "beneficiaries must pay a penalty if they enroll late" (aOR = 1.3); "assistance is available for low income beneficiaries" (aOR = 1.2).

CONCLUSION

Beneficiary understanding of the Part D program in early 2006 was limited. Beneficiary knowledge of Part D program details was associated with enrollment in Medicare Part D. Efforts to educate Medicare beneficiaries about Part D may improve rates of prescription drug coverage.

Validity of reported Medicare Part D enrollment in the Medical Expenditure Panel Survey

The authors validate reported Part D coverage in the Medical Expenditure Panel Survey (MEPS) and assess the impact of misreporting on descriptive and behavioral analyses. MEPS participants with Medicare coverage during 2006 to 2007 were matched to Medicare administrative data. A summary measure of Part D coverage based on several questions has substantial validity (κ = .70) and an agreement rate of 85.1%. Some beneficiaries confused Part D and private drug coverage, leading to both under- and overreported Part D coverage. Accuracy varies little by sociodemographic group. Standard regression models of the determinants of Part D enrollment were estimated with both MEPS-based and administrative data-based measures of Part D enrollment. In this analysis, the signs of the marginal effects were the same, the magnitudes were similar, and mostly the same variables had statistically significant effects in both regressions. Thus, behavioral analyses are largely unaffected by misreporting.

Health reforms as examples of multilevel interventions in cancer care

To increase access and improve system quality and efficiency, President Obama signed the Patient Protection and Affordable Care Act with sweeping changes to the nation's health-care system. Although not intended to be specific to cancer, the act's implementation will profoundly impact cancer care. Its components will influence multiple levels of the health-care environment including states, communities, health-care organizations, and individuals seeking care. To illustrate these influences, two reforms are considered: 1) accountable care organizations and 2) insurance-based reforms to gather evidence about effectiveness. We discuss these reforms using three facets of multilevel interventions: 1) their intended and unintended consequences, 2) the importance of timing, and 3) their implications for cancer. The success of complex health reforms requires understanding the scientific basis and evidence for carrying out such multilevel interventions. Conversely and equally important, successful implementation of multilevel interventions depends on understanding the political setting and goals of health-care reform.

Endocrine therapy use among elderly hormone receptor-positive breast cancer patients enrolled in Medicare Part D

BACKGROUND

Clinical guidelines recommend that women with hormone-receptor positive breast cancer receive endocrine therapy (selective estrogen receptor modulators [SERMs] or aromatase inhibitors [AIs]) for five years following diagnosis.

OBJECTIVE

To examine utilization and adherence to therapy for SERMs and AIs in Medicare Part D prescription drug plans.

DATA

Linked Surveillance, Epidemiology, and End Results (SEER)-Medicare data.

STUDY DESIGN

We identified 15,542 elderly women diagnosed with hormone-receptor positive breast cancer in years 2003-2005 (the latest SEER data at the time of the study) and enrolled in a Part D plan in 2006 or 2007 (the initial years of Part D). This permitted us to compare utilization and adherence to therapy at various points within the recommended five-year timeframe for endocrine therapy. SERM and AI use was measured from claim records. Non-adherence to therapy was defined as a medication possession ratio of less than 80 percent.

PRINCIPAL FINDINGS

Between May 2006 and December 2007, 22 percent of beneficiaries received SERM, 52 percent AI, and 26 percent received neither. The percent receiving any endocrine therapy decreased with time from diagnosis. Among SERM and AI users, 20-30 percent were non-adherent to therapy; out-of-pocket costs were higher for AI than SERM and were strongly associated with non-adherence. For AI users without a low income subsidy, adherence to therapy deteriorated after reaching the Part D coverage gap.

CONCLUSIONS

Many elderly breast cancer patients were not receiving therapy for the recommended five years following diagnosis. Choosing a Part D plan that minimizes out-of-pocket costs is critical to ensuring beneficiary access to essential medications.

Assessment of medicare part d communications to beneficiaries

BACKGROUND

Older Americans receive healthcare benefits through the federal Medicare program. The Centers for Medicare & Medicaid Services provides comprehensive information to Medicare beneficiaries regarding benefits, plan options, and enrollment policies primarily through the annual Medicare & You handbook and the Medicare website. Few studies have assessed the overall readability and, therefore, the usefulness of this handbook for adequately educating beneficiaries. Healthcare communications written at higher levels than the readers' comprehension levels cannot be well understood.

OBJECTIVE

To measure the readability of the 2008 Medicare & You handbook provided to all Medicare beneficiaries.

METHOD

For our analysis, the 2008 version of the Medicare & You handbook was downloaded from the Centers for Medicare & Medicaid Services website. Passages of ≥250 words were saved individually in Windows Notepad as text files. Shorter passages (ie, <250 words) were combined with the next continuing passage. Each file was then uploaded into the Internet-based Lexile analyzer (the Lexile Framework for Reading). Figures, pictures, and tables were not included in the analysis.

RESULTS

Approximately 70% of analyzed passages were written at approximately the 5th- to 12th-grade levels (Lexile scores: 790L-1290L), whereas 30% of the passages were written at levels above grade 12 (Lexile scores: 1310L-1910L).

CONCLUSION

Medicare beneficiaries who have less than a high-school level education may find the passages analyzed in this study difficult to read and comprehend as discussed, indicating the need for simplified communication. Our study provides recommendations to improve the handbook for better comprehension by beneficiaries.