The Impact of Coverage Restrictions on Antipsychotic Utilization Among Low-Income Medicare Part D Enrollees

Prior research demonstrates substantial access problems associated with utilization management and formulary exclusions for antipsychotics in Medicaid, but the use and impact of coverage restrictions for these medications in Medicare Part D remains unknown. We assess the effect of coverage restrictions on antipsychotic utilization in Part D by exploiting a unique natural experiment in which low-income beneficiaries are randomly assigned to prescription drug plans with varying levels of formulary generosity. Despite considerable variation in use of coverage restrictions across Part D plans, we find no evidence that these restrictions significantly deter utilization or reduce access to antipsychotics for low-income beneficiaries.

Out-of-plan medication in Medicare Part D

OBJECTIVES

To determine the extent to which Medicare Part D enrollees fill unadjudicated prescriptions for diabetes, hypertension, and hyperlipidemia medications outside of the Part D benefit.

STUDY DESIGN

Retrospective analysis of prescriptions filled by community-dwelling beneficiaries continually enrolled in a Medicare Part D plan in 2009.

METHODS

We used the Medicare Current Beneficiary Survey to compare self-reported prescription fills for oral antidiabetes medications, renin-angiotensin-aldosterone system inhibitors, and statins to adjudicated prescription drug event data recorded by Part D plan sponsors. For unadjudicated prescriptions with no evidence of Part D payment, we determined whether the fills were paid for in cash, filled through VA pharmacies or discount generic programs, or had other reported sources of coverage.

RESULTS

A total of 6.2% of all prescriptions filled by Part D beneficiaries were unadjudicated, ranging from 5.3% of all oral antidiabetes medications to 6.8% of statins. Cash prescriptions accounted for more than half of all out-of-plan use, but we found little evidence of unadjudicated out-of-plan use of discount generics. Prescriptions filled at VA pharmacies and those with other reported sources of coverage each accounted for about 1% of total fills.

CONCLUSIONS

Out-of-plan medication use accounts for a small share of total prescriptions filled by Part D beneficiaries. Nevertheless, CMS should continue to work with plan sponsors to develop initiatives that facilitate the collection of beneficiaries' complete utilization data, as a more complete reporting could improve the quality of care delivered to Part D enrollees.

Plan choice and changes in access to care over time for SSI-eligible children with disabilities

This paper analyzes how voluntary enrollment in the fee-for-service (FFS) system versus a partially capitated managed care plan affects changes in access to care over time for special needs children who receive Supplemental Security Income (SSI) due to a disability. Four indicators of access are evaluated, including specialty care, hospital care, emergency care, and access to a regular doctor. We employ the Heckman two-step estimation procedure to correct for the potential nonrandom selection bias linked to plan choice. The findings show that relative to their counterparts in the partially capitated managed care plan, SSI children enrolled in the FFS plan are significantly more likely to encounter an access problem during either of the time periods studied. Similarly, FFS enrollees are significantly more likely than partially capitated managed care participants to experience persistent access problems across three of the four dimensions of care. Possible explanations for the deterioration in access associated with FFS include the lack of case management services, lower reimbursement relative to the partially capitated managed care plan, and provider availability.