Effect of the Medicare Part D Coverage Gap on Medication Use Among Patients With Hypertension and Hyperlipidemia
ABSTRACT Prior studies of the Medicare Part D coverage gap are limited in generalizability and scope.
To determine the effect of the coverage gap on drugs used for asymptomatic (antihypertensive and lipid-lowering drugs) and symptomatic (pain relievers, acid suppressants, and antidepressants) conditions in elderly patients with hypertension and hyperlipidemia.
Quasi-experimental study using pre-post design and contemporaneous control group.
Medicare claims files from 2005 and 2006 for 5% random sample of Medicare beneficiaries.
Part D plan enrollees with hypertension or hyperlipidemia aged 65 years or older who had no coverage, generic-only coverage, or both brand-name and generic coverage during the gap in 2006. Patients who were fully eligible for the low-income subsidy served as the control group.
Monthly 30-day supply prescriptions available, medication adherence, and continuous medication gaps of 30 days or more for antihypertensive or lipid-lowering drugs; monthly 30-day supply prescriptions available for pain relievers, acid suppressants, or antidepressants before and after coverage gap entry.
Patients with no gap coverage had a decrease in monthly antihypertensive and lipid-lowering drug prescriptions during the coverage gap. Nonadherence also increased in this group (antihypertensives: odds ratio [OR], 1.60 [95% CI, 1.50 to 1.71]; lipid-lowering drugs: OR, 1.59 [CI, 1.50 to 1.68]). The proportion of patients with no gap coverage who had continuous medication gaps in lipid-lowering medication use and antihypertensive use increased by an absolute 7.3% (OR, 1.38 [CI, 1.29 to 1.46]) and 3.2% (OR, 1.35 [CI, 1.25 to 1.45]), respectively, because of the coverage gap. Decreases in use were smaller for pain relievers and antidepressants and larger for acid suppressants in patients with no gap coverage. Patients with generic-only coverage had decreased use of cardiovascular medications but no change in use of drugs for symptomatic conditions. No measures changed in the brand-name and generic coverage groups. Results of sensitivity analyses were consistent with the main findings.
Because this study was nonrandomized, unobserved differences may still exist between study groups.
The Part D coverage gap was associated with decreased use of medications for hypertension and hyperlipidemia in patients with no gap coverage and generic-only gap coverage. The proposed phasing out of the gap by 2020 will benefit such patients; however, use of low-value medications may also increase.
Penn-Pfizer Alliance and American Heart Association.
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ABSTRACT: Objectives: To evaluate the effects of the Medicare Part D coverage gap on pharmacy use among a national sample of Medicare beneficiaries and on medication adherence among 2 subsamples with heart failure and/or diabetes. Study Design: Pre-post design, with comparison group and propensity score weighting. Methods: We used a 5% random sample of elderly Medicare beneficiaries enrolled in stand-alone Part D plans in 2007. The comparison group had full coverage in the gap, whereas the 2 study groups had either no coverage or generic-only coverage in the gap. Main outcomes included probability of filling a prescription, monthly pharmacy spending and number of prescriptions filled, and adherence measured by medication possession ratios. Results: Relative to the comparison group, beneficiaries without drug coverage in the gap reduced the number of prescriptions filled per month by 16.0% (95% confidence interval [CI], 15.5%-16.5%); those with generic drug coverage in the gap reduced it by 10.8% (95% CI, 10.3%-11.4%). Most of the reduction was attributable to reduced use of brand-name drugs. Beneficiaries with heart failure reduced adherence to heart failure drugs by 3.6% (95% CI, 2.9%-4.2%) and beneficiaries with diabetes reduced antidiabetic medication adherence by 10.3% (95% CI, 9.4%-11.3%). Conclusions: Medicare beneficiaries reduced medication use (mainly brand-name drugs) after entering the coverage gap. This result suggests that while beneficiaries' financial burden would continue because of the coverage gap, the gap would not result in a large reduction in medication adherence for essential drugs for diabetes and heart failure.The American journal of managed care 01/2013; 19(6):e214-e224. · 2.17 Impact Factor
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ABSTRACT: BACKGROUND: Since its implementation in 2006, Medicare Part D has evolved from a program that offered basic access to covered drugs for beneficiaries to one that has the potential to affect patient outcomes. OBJECTIVES: The purpose of this article was to highlight key research findings on Medicare Part D published in 2012 and major public policy initiatives for Part D for 2013. METHODS: PubMed/MEDLINE was searched for research studies on Part D published in 2012 in biomedical/scientific, peer-reviewed, English-language journals. For policy updates, sources included the Federal Register, the 2013 Final Call Letter, guidance from the Centers for Medicare and Medicaid Services, and 2012 publications on Part D policy identified in PubMed. RESULTS: Part D has been associated with higher medication use and lower out-of-pocket (OOP) costs of many long-term medications; however, differences within subgroups of beneficiaries have been observed. Studies on health outcomes have been inconclusive. Part D policy changes in 2013 have addressed problems with the benefit, namely coverage of benzodiazepines and barbiturates; reducing coinsurance in the coverage gap; reducing fraud, waste, and abuse; medication therapy management program standardization; and an expanded appeals process. CONCLUSIONS: Research continues to suggest that Part D is effective in increasing medication utilization and lowering OOP costs. Further work is needed to clarify the effects of Part D on nondrug health care service utilization and health outcomes. Policy changes for 2013 addressed specific improvements in the Medicare Part D benefit while potentially generating cost-savings for Medicare and Medicaid. Future challenges include alleviating access burden to medications during the phase-out of the coverage gap, minimizing disparities among Part D beneficiaries, and coordinating the Part D benefit with Medicare parts A and B via Medicare Accountable Care Organizations. A more integrated and coordinated Medicare benefit among all of its components would benefit overall health outcomes and increase cost-savings.Clinical Therapeutics 03/2013; 35(4). DOI:10.1016/j.clinthera.2013.02.024 · 2.59 Impact Factor
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ABSTRACT: Medication nonadherence is a significant public health problem that affects the health and well-being of older Americans while burdening the US healthcare system. Pharmacy claims data have gained importance in deriving objective medication (re)fill adherence measures; however, little is known about application of such measures in older Americans. The objective of this study was to assess the types and characteristics of pharmacy claims-derived medication (re)fill adherence measures used in older Americans. A comprehensive literature search strategy was employed to identify all articles using pharmacy claims data to measure (re)fill adherence to prescription medications in older Americans aged 65+ years. Included were articles reporting original research studies conducted and published in the USA in English between 1 January 2000 and 1 November 2012. The basic search used multiple key terms indicating adherence, combined with the term "medication" and the term "pharmacy claims or administrative claims." Due to the variety of measure names used in the literature, a more specific search was added to repeat the basic search for 29 previously used medication (re)fill adherence measure names. Articles identified through the database search were manually reviewed to select only articles meeting the inclusion criteria. The search resulted in a total of 36 articles. Information on medication (re)fill measurements were extracted and summarized. The 36 articles used 20 differently named measures under the three main concepts: medication adherence, persistence, and discontinuation. Measures of medication adherence cumulatively assessed the proportion of time at which medications were (not) filled over a predefined observation period (e.g., medication possession ratio). Measures of medication persistence assessed the continuity of medication filling over a specified time period, while medication discontinuation measures focused on termination of medication (re)fills. Overall, almost two thirds of all identified articles used a single medication (re)fill adherence measure. Among them, 77 % used a medication possession measure. The term "medication possession ratio" (MPR) was used most frequently (65 %), followed by the "proportion of days covered" (PDC; 30 %). No single measure can be generally recommended for the use in older Americans. The challenges in using pharmacy claims-based medication (re)fill adherence measures in older Americans include a lack of consensus terminology and algorithms among measures of the same concepts, insufficient transparency of individual measure operationalization, and inadequate consideration of unique characteristics of the older population, such as temporary nursing home care. Although medication (re)fill adherence measures may be well suited for measuring medication adherence in older Americans, little guidance is available on how to use them in this population. Further efforts need to be given to the development and standardization of pharmacy claims-based medication (re)fill measures that are specifically tailored toward use in older Americans.Drugs & Aging 04/2013; 30(6). DOI:10.1007/s40266-013-0074-z · 2.50 Impact Factor