Medicare Part D's Effect on the Under- and Overuse of Medications: A Systematic Review

Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts 02120, USA.
Journal of the American Geriatrics Society (Impact Factor: 4.22). 08/2011; 59(10):1922-33. DOI: 10.1111/j.1532-5415.2011.03537.x
Source: PubMed

ABSTRACT To evaluate the literature regarding the effect of Medicare Part D on the under- and overuse of specific medications and corresponding health outcomes.
Systematic review.
Medline search of the peer-reviewed literature from January 1, 2006, to October 8, 2010.
Medicare beneficiaries who obtained drug insurance from the Part D program.
The review evaluated changes in the use of specific drugs or drug classes after implementation of Part D, as described in original, peer-reviewed articles.
Nineteen articles met inclusion criteria. Part D's implementation was associated with greater use of essential medications such as clopidogrel and statins, especially in beneficiaries who had been previously uninsured, but increases in inappropriate antibiotic use for the treatment of acute respiratory tract infections and increases in claims for the often overused proton pump inhibitor drug class were also observed. In the Part D transition period, dually eligible beneficiaries' drug use remained largely unchanged. When beneficiary cost sharing increased in the coverage gap, use of essential and overused medications declined.
Increasing drug coverage led to greater use of underused essential medications and inappropriate, or overused, medications under Medicare Part D. Despite efforts to have it do so, the Part D benefit did not sufficiently discriminate between essential and nonessential medication use.

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    ABSTRACT: To examine the relationship between receiving the Medicare Part D low-income subsidy (LIS) and cost-related medication nonadherence (CRN). Cross-sectional. Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey collected in spring 2007. Part D-enrolled Medicare beneficiaries who responded to the CAHPS survey. Respondents were categorized into three LIS groups: deemed LIS (Medicare and Medicaid dual-eligible and individuals receiving Supplemental Security Income), LIS applicants (other low-income individuals who applied for and received LIS), and non-LIS. Adjusted logistic models were used to assess the likelihood of CRN according to LIS status. Sample weights were applied in all analyses to account for complex sampling design. Of 171,573 Part D-enrolled respondents (weighted N = 14,572,827; response rate 48%), 17.2% reported CRN. Specifically, 14.7% of non-LIS respondents, 22.2% of deemed-LIS respondents, and 24.0% of LIS applicants reported CRN. LIS groups had higher unadjusted odds of CRN than the non-LIS respondents, but fully adjusted odds of CRN were lower in the deemed-LIS (adjusted odds ratio = 0.66, 95% confidence interval = 0.59, 0.74) than the LIS applicants or the non-LIS respondents. Subgroup analyses revealed that sociodemographic and health-related characteristics were associated with higher CRN in all three groups. The lower adjusted odds of CRN in deemed-LIS is reassuring, suggesting that autoenrollment provides meaningful assistance in removing cost-related barriers to medication use, but certain sociodemographic characteristics were associated with higher odds of CRN. Efforts to improving outreach to these subgroups and tracking of CRN are warranted.
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