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: 4.57). 08/2011; 59(10):1922-33. DOI: 10.1111/j.1532-5415.2011.03537.x
Source: PubMed


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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    • "Previous studies have shown that Part D has had an impact on the use of drugs with a strong evidence base and clear guidelines recommending their use [21,23,24,27] as well as for drugs without a strong evidence base [21]. We find that the magnitude of the increase in use of antidementia medications associated with Part D is similar to that found for lipid-lowering and antidiabetic medications [27], as well as for drugs to treat heart failure [22] and depression [23]. "
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    ABSTRACT: Background Cholinesterase inhibitors and memantine are prescribed to slow the progression dementia. Although the efficacy of these drugs has been demonstrated, their effectiveness, from the perspective of patients and caregivers, has been questioned. Little is known about whether the demand for cholinesterase inhibitors and memantine are sensitive to out-of-pocket cost. Using the 2006 implementation of Medicare Part D as a natural experiment, this study examines the impact of changes in drug coverage on use of cholinesterase inhibitors and memantine by comparing use before and after Medicare Part D implementation among older adults who did and did not experience a change in coverage. Methods Retrospective analyses of claims data from 35,102 community-dwelling Medicare beneficiaries in Pennsylvania aged 65 or older. Beneficiaries were continuously enrolled in a Medicare Advantage plan from 2004 to 2007. Outcome variables were any use of donepezil (Aricept®), galantamine (Razadyne®), rivastigmine (Exelon®), tacrine (Cognex®), or memantine (Namenda®) each year and the number of 30-day prescriptions filled for these drugs. Independent variables included type of drug benefit pre–Part D (No coverage, $150 cap, $350 cap, and No cap as the reference group), time period, and their interaction. Sensitivity analyses were conducted to test if there are differences in use by drug class or if beneficiaries with a diagnosis of dementia pre–Part D experienced an increase in use post–Part D. Results The No coverage group had a 38% increase in the odds ratio of any use of antidementia medications (P = 0.0008) post–Part D relative to the No cap group. All four coverage groups had significant increases in number of 30-day prescriptions (P < 0.001) over the study period. In adjusted models that included the sub-sample with any use pre–Part D, the No coverage group had a 36% increase in prescriptions (P = 0.002) and the $350 cap group had a 15% increase (P = 0.003) after adjusting for trends in the No cap group. Results from the sensitivity analysis for the sub-sample with a diagnosis of dementia pre–Part D show that each group had significant increases in 30-day prescriptions compared to the No cap control group (P < 0.05). Conclusions Use of cholinesterase inhibitors and memantine in our sample increased and a greater increase in use was observed among Medicare beneficiaries who experienced improvements in drug coverage under Medicare Part D.
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