Stand-alone Prescription Drug Plans Research Articles

Racial-Ethnic Disparities in Uptake of New Hepatitis C Drugs in Medicare.

Chronic hepatitis C is an important public health concern. Recently launched drugs to treat hepatitis C virus (HCV) infection are effective but costly. Uptake of innovative and expensive prescription drugs may not be even across patient groups. We examined racial-ethnic disparities in uptake of new HCV drugs in the first year of their use (year 2014) in Medicare. The study population was Medicare beneficiaries who had chronic hepatitis C in 2013 or 2014 and who were continuously enrolled in Part D stand-alone Prescription Drug Plans in 2014. We examined trends in monthly uptake of new HCV drugs and adjusted annual uptake rates by race. We used logistic regressions to obtain adjusted odds ratios and adjusted differences in annual uptake rates. Monthly uptake of new HCV drugs was lower among Black Medicare patients than Whites or Hispanics in 2014. The racial gap in monthly uptake became narrower toward the end of the year. Adjusted odds of using new HCV drugs were 11% lower for Blacks with cirrhosis than Whites (odds ratio (OR)=0.89; 95% confidence interval (CI), 0.84-0.95), and 16% lower for Blacks with HCV/HIV coinfection than Whites (OR=0.81; 95% CI, 0.72-0.92). Annual uptake rates were not significantly different for Whites and Hispanics. Black Medicare patients with cirrhosis or HCV/HIV coinfection had lower uptake rates than Whites in 2014. As utilization of new HCV drugs increases, continuing efforts will be necessary to ensure equal delivery of the drugs.

Can a More User-Friendly Medicare Plan Finder Improve Consumers' Selection of Medicare Plans?

To evaluate the efficacy for consumers of two potential enhancements to the Medicare Plan Finder (MPF)-a simplified data display and a "quick links" home page designed to match the specific tasks that users seek to accomplish on the MPF. Participants (N=641) were seniors and adult caregivers of seniors who were recruited from a national online panel. Participants browsed a simulated version of the MPF, made a hypothetical plan choice, and reported on their experience. Participants were randomly assigned to one of eight conditions in a fully factorial design: 2 home pages (quick links, current MPF home page)×2 data displays (simplified, current MPF display)×2 plan types (stand-alone prescription drug plan [PDP], Medicare Advantage plan with prescription drug coverage [MA-PD]). The quick links page resulted in more favorable perceptions of the MPF, improved users' understanding of the information, and increased the probability of choosing the objectively best plan. The simplified data display resulted in a more favorable evaluation of the website, better comprehension of the displayed information, and, among those choosing a PDP only, an increased probability of choosing the best plan. Design enhancements could markedly improve average website users' understanding, ability to use, and experience of using the MPF.

Eligibility For And Enrollment In Medicare Part D Medication Therapy Management Programs Varies By Plan Sponsor.

Medicare Part D prescription drug plans must offer medication therapy management to beneficiaries with multiple chronic conditions and high drug expenditures. However, plan sponsors have considerable latitude in setting eligibility criteria. Newly available data indicate that enrollment rates in medication therapy management among stand-alone prescription drug plans and Medicare Advantage drug plans averaged only 10percent in 2012. The enrollment variation across plan sponsors-from less than 0.2percent to more than 57.0percent-was associated with the restrictiveness of their eligibility criteria. For example, enrollment was 16.4percent in plans requiring two chronic conditions versus 9.2percent in plans requiring three, and 12.7percent in plans requiring the use of any Part D drug versus 4.4percent in plans requiring the use of drugs in specific classes. This variation represents inequities in access to medication therapy management across plans and results in missed opportunities for interventions that might improve therapeutic outcomes and reduce spending. The new Part D Enhanced Medication Therapy Management model of the Centers for Medicare and Medicaid Services has the potential to significantly increase the impact of medication therapy management by aligning financial incentives with improvements in medication use and encouraging innovation.

Access to Oral Osteoporosis Drugs Among Female Medicare Part D Beneficiaries

BackgroundFor women living with osteoporosis, high out-of-pocket (OOP) drug costs may prevent drug therapy initiation. We investigate the association between oral osteoporosis OOP medication costs and female Medicare beneficiaries' initiation of osteoporosis drug therapy. MethodsWe used 2007 and 2008 administrative claims and enrollment data for a 5% random sample of Medicare beneficiaries. Our study sample included age-qualified, female beneficiaries who had no prior history of osteoporosis but were diagnosed with osteoporosis in 2007 or 2008. Additionally, we only included beneficiaries continuously enrolled in stand-alone prescription drug plans. We excluded beneficiaries who had a chronic condition that was contraindicated with osteoporosis drug utilization. Our final sample included 25,069 beneficiaries. Logistic regression analysis was used to examine the association between the OOP costs and initiation of oral osteoporosis drug therapy during the year of diagnosis. FindingsTwenty-six percent of female Medicare beneficiaries newly diagnosed with osteoporosis initiated oral osteoporosis drug therapy. Beneficiaries' OOP costs were not associated with the initiation of drug therapy for osteoporosis. However, there were significant racial disparities in beneficiaries' initiation of drug therapy. African Americans were 3 percentage points less likely to initiate drug therapy than Whites. In contrast, Asian/Pacific Islander and Hispanic beneficiaries were 8 and 18 percentage points, respectively, more likely to initiate drug therapy than Whites. Additionally, institutionalized beneficiaries were 11 percentage points less likely to initiate drug therapy than other beneficiaries. ConclusionsAccess barriers for drug therapy initiation may be driven by factors other than patients' OOP costs. These results suggest that improved osteoporosis treatment requires a more comprehensive approach that goes beyond payment policies.

Cost variability of suggested generic treatment alternatives under the Medicare Part D benefit.

The substitution of generic treatment alternatives for brand-name drugs is a strategy that can help lower Medicare beneficiary out-of-pocket costs. Beginning in 2011, Medicare beneficiaries reaching the coverage gap received a 50% discount on the full drug cost of brand-name medications and a 7% discount on generic medications filled during the gap. This discount will increase until 2020, when beneficiaries will be responsible for 25% of total drug costs during the coverage gap. To examine the cost variability of brand and generic drugs within 4 therapeutic classes before and during the coverage gap for each 2011 California stand-alone prescription drug plan (PDP) and prospective coverage gap costs in 2020 to determine the effects on beneficiary out-of-pocket drug costs. Equivalent doses of brand and generic drugs in the following 4 pharmacological classes were examined: angiotensin II receptor blockers (ARBs), bisphosphonates, HMG-CoA reductase inhibitors (statins), and proton pump inhibitors (PPIs). The full drug cost and patient copay/coinsurance amounts during initial coverage and the coverage gap of each drug was recorded based on information retrieved from the Medicare website. These drug cost data were recorded for 28 California PDPs. The highest cost difference between a brand medication and a Centers for Medicare Medicaid Services (CMS)-suggested generic treatment alternative varied between $110.53 and $195.49 at full cost and between $51.37 and $82.35 in the coverage gap. The lowest cost difference varied between $38.45 and $76.93 at full cost and between -$4.11 and $18.52 during the gap. Medicare beneficiaries can realize significant out-of-pocket cost savings for their drugs by taking CMS-suggested generic treatment alternatives. However, due to larger discounts on brand medications made available through recent changes reducing the coverage gap, the potential dollar savings by taking suggested generic treatment alternatives during the gap is less compelling and will decrease as subsidies increase.

Who Enrolls in the Medicare Part D Prescription Drug Benefit Program? Medication Use Among Patients With Heart Failure

BackgroundDispensing data from Medicare Part D standalone prescription drug plans are now available, but characteristics of enrollees with heart failure have not been well described.Methods and ResultsWe identified 81 874 patients with prevalent heart failure as of January 1, 2010, in a nationally representative 5% sample of Medicare beneficiaries. We classified patients according to enrollment in a Medicare Part D plan as of January 1, 2010. Demographic characteristics, comorbid conditions, and prescriptions were compared by enrollment status. A total of 49 252 (60.2%) were enrolled in a Medicare Part D plan as of January 1. Enrollees were more often women, black, and of lower socioeconomic status. Enrollees with heart failure more often filled prescriptions for loop diuretics than angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, β‐blockers, or aldosterone antagonists. During the first 4 months of 2010, 5444 (12.3%) reached the coverage gap, and 566 (1.3%) required catastrophic coverage beyond the gap.ConclusionsMedicare beneficiaries with heart failure differ significantly according to enrollment in Part D prescription drug plans and represent a population underrepresented in clinical efficacy trials. Many face the coverage gap, and few select Medicare Part D plans that provide coverage during the gap. Linking Medicare Part D event data with clinical registries could help to determine whether eligible enrollees are undertreated for heart failure.

Association of Medicare Part D Medication Out‐of‐Pocket Costs with Utilization of Statin Medications

To examine the association between statin out-of-pocket (OOP) costs and utilization among the Medicare Part D population. 2006-2008 administrative claims and enrollment data for the 5 percent Medicare sample. Sample included 346,583 beneficiary-year observations of statin users enrolled in stand-alone prescription drug plans, excluding low-income subsidy recipients. We estimated the association between a plan's OOP statin costs and statin utilization using an instrumental variable approach to account for potential bias due to plan selection. Adherence was defined as percentage of days covered (PDC) of at least 80 percent. Plan OOP costs were constructed for a representative market basket of statin medications. Analyses controlled for demographic characteristics, cardiovascular disease risk, co-morbidity presence, and regional characteristics. About 67 percent of the sample had a PDC of at least 80 percent. An increase in annual statin OOP from $200 (50th percentile) to $240 (75th percentile) was associated with a reduction in the rate of adherent beneficiaries from 67 percent to 56 percent (p<.001). Greater OOP costs for statins are associated with reductions in statin utilization.

Improvements in Medicare Part D Risk Adjustment

The continued success of the Medicare Part D program is contingent on appropriate Medicare payment adjustments for the projected drug costs of Part D plan enrollees. This article describes a major revision of these "risk adjustments," intended to more accurately match payments to costs, especially for high-cost, disadvantaged populations. For the first time actual Part D data are used to calibrate risk adjustment. The sample is Medicare beneficiaries with fee-for-service enrollment in 2007 and Part D standalone prescription drug plan enrollment in 2008 (N = 14,224,301). Part D plan liability expenditures are predicted using demographic and diagnostic factors in a weighted least squares regression. Models for Medicare subpopulations are analyzed. The predictive accuracy of risk adjustment models is evaluated using R and predictive ratio statistics. Based on differences in both mean expenditures and incremental expenditures by diagnosis, separate Part D risk adjustment models are calibrated for 5 Medicare subpopulations: aged not low income; aged low income; nonaged not low income; nonaged low income; and institutionalized. The variation in plan liability drug expenditures (R) explained by these models ranges from 13% to 29%. The 5 separate models accurately predict mean plan liability expenditures ranging from $967 to $1762 across subpopulations and account for differences in incremental disease coefficients by subpopulation. The refined Part D risk adjustment model represents a significant improvement in the accuracy and fairness of payment to Part D plans. The new model provides greater incentives for drug plans to compete for low-income and institutionalized enrollees.

Should Medicare rely on high drug spending as a criterion for medication therapy management programmes?

Abstract Objectives The goal of Medicare Part D medication therapy management programmes (MTMPs) is to optimize medication use by beneficiaries. The Centers for Medicare &amp; Medicaid Services require prescription drug plans (PDPs) to consider numbers of chronic medications and conditions, and total Part D spending when targeting beneficiaries for MTMPs. However, there is no explicit evidence base establishing these criteria. The objectives were to examine the associations of Part D spending with medication use and adherence among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD). Methods This retrospective cross-sectional study used a 5% random sample of Medicare beneficiaries with COPD enrolled in stand-alone PDPs and Medicare Parts A and B in 2006–2007 (n = 72 912). Maintenance medication use and adherence for COPD were measured in three domains: discontinuation, duration of therapy and proportion of days covered. Key findings Proportions of beneficiaries using COPD maintenance medications increased with Part D spending, from 33.4% (quintile 1) to 60.5% (quintile 5), after covariant adjustment. Among maintenance medication users, the adjusted proportions of beneficiaries exhibiting better adherence also increased with spending, with the top 20% of spenders having the highest proportion of beneficiaries exhibiting good adherence. Adjusted proportions of beneficiaries discontinuing medications decreased with increased Part D spending. Conclusions The Part D MTMP spending criterion (US$4000 in 2007; US$3000 in 2010) may be an inappropriate target for identifying Medicare beneficiaries in need of adherence counselling. Findings suggest higher spenders may have learned healthy adherence behaviours, whereas lower spenders may be prone to discontinue medication and/or demonstrate poor adherence behaviours.

The relationship between plan characteristics and Medicare Prescription Drug Plan bids

This article assesses the relationship between plan characteristics and Medicare Prescription Drug Plan (PDP) bids. Medicare PDP information data are used to link plan and geographic data for stand-alone prescription drug plans participating in the Part D programme from 2006 to 2008 (N = 5101). Firm fixed effects models are estimated to measure the relationship between plan characteristics including formularies, beneficiary cost sharing and utilization controls and PDP bids. Firm fixed effects models show a negative inelastic relationship between member cost sharing and plan bids. Among the utilization controls, only prior authorization is associated with lower bids. The use of quantity limits and step therapy is associated with higher bids, although this reflects their likely use for nonpreferred brand name medications. Bids are positively related to the number of preferred brand name medications and specialty medications covered, gap coverage of generics and brand name medications and the regional risk score. Lower bids are associated with higher deductibles and market size.

Standalone or managed care drug plans, postarthroplasty thromboprophylaxis, and risperidone for PTSD

Choice of standalone or managed care drug plans Cline et al.1 reported that “models of health insurance demand and plan choice applied in this context appear to be modestly effective. Rurality and state of residence were particularly important contributors to patients’ decisions.” The study described factors associated with (1) Medicare beneficiaries choosing to enroll in any Medicare Part D prescription drug plan (PDP) and (2) the choice of a Medicare Advantage Prescription Drug plan (MA-PD), given enrollment in Part D. Mailed surveys were sent to a stratified random sample of 5,000 community-dwelling adults aged 65 years or older. Nearly 75% of sample members elected to enroll in one of the Medicare Part D coverage options in 2007, with more than three times as many choosing a standalone PDP compared with an MA-PD (57.2% vs. 17.8%). Rurality, plan price, perceived future need for medications, and preferences emerged as important predictors of choosing to enroll in any Medicare Part D drug plan, while rurality, state of residence, and number of diagnosed medical conditions were associated with the decision to enroll in an MA-PD. Implications. Although rurality was important to patients’ choices in both cases, state of residence and diagnosed medical conditions were important to the MA-PD choice. Reasons for these differences (e.g., state of residence and managed care concentration in those states) should be examined.

PDP or MA-PD? Medicare part D enrollment decisions in CMS Region 25

Background The Medicare Prescription Drug Improvement and Modernization Act of 2003 provides outpatient prescription drug coverage for Medicare beneficiaries through private insurers. This coverage is available through 2 primary venues: stand-alone prescription drug plans (PDPs) and integrated managed care (or Medicare Advantage) plans that also provide prescription drug coverage (MA-PDs). Objectives The first objective was to describe factors associated with Medicare beneficiaries choosing to enroll in any Medicare part D PDP. The second objective was to describe factors associated with the choice of an MA-PD, given enrollment in the part D program. Methods The study used a cross-sectional, survey design. Data were collected from a stratified random sample of 5000 community-dwelling adults, aged 65 years and older in the Center for Medicaid and Medicare Services Region 25. Data were collected by means of a mailed questionnaire. Data analyses included univariate and bivariate descriptive statistics and multivariate probit modeling. Results The overall adjusted response rate was 50.2% (2309 of 4603). Data from 1490 respondents (32.4% of those attempted) were analyzed in this study. Nearly 75% of sample members elected to enroll in one of the Medicare part D coverage options in 2007, with more than 3 times as many choosing a PDP compared with a MA-PD option (57.2% vs 17.8%). A variety of variables including rurality, plan price, perceived future need for medications, and preferences emerged as important predictors of choosing to enroll in any Medicare part D drug plan, whereas rurality, state of residence, and number of diagnosed medical conditions were associated with the decision to enroll in a MA-PD. Conclusions Models of health insurance demand and plan choice applied in this context appear to be modestly effective. Rurality and state of residence were particularly important contributors to both of these decisions, as were a variety of individual characteristics.

Adverse Selection In The Medicare Prescription Drug Program

The Medicare Part D drug benefit created choices for beneficiaries among many prescription drug plans with varying levels of coverage. As a result, Medicare enrollees with high prescription drug costs have strong incentives to enroll in Part D, especially in plans with more comprehensive coverage. To measure this potential problem of "adverse selection," which could threaten plans' finances, we compared baseline characteristics among groups of beneficiaries with various drug coverage arrangements in 2006. We found some significant differences. For example, enrollees in stand-alone prescription drug plans, especially in plans offering benefits in the coverage gap, or "doughnut hole," had higher baseline drug costs and worse health than enrollees in Medicare Advantage prescription drug plans. Although risk-adjusted payments and other measures have been put in place to account for selection, these patterns could adversely affect future Medicare costs and should be watched carefully.

Potential opportunity cost of neglecting to annually reassess Medicare Part D standalone prescription drug plan offerings: The price of contentment?

ObjectivesTo determine the (1) potential cost difference (opportunity cost [OC]) to Medicare-eligible beneficiaries enrolled in the lowest-cost standalone prescription drug plan (PDP) in 2007 between the cost of such plan in 2008 and the lowest-cost plan in 2008 and the (2) percentage of PDPs with the lowest estimated annual cost (EAC) in both 2007 and 2008. DesignDescriptive exploratory study. SettingUnited States during 2007 and 2008. Patients50 patients were randomly selected from a database of Medicare-eligible beneficiaries. InterventionPharmacy claims records for each study patient were obtained during the period January 1 to June 30, 2007. Patient medication profiles were generated using these data and entered into the Medicare Plan Finder Tool (www.medicare.gov) to obtain the EAC of each PDP from 2007 and 2008 in all 34 Medicare Part D regions. Main outcome measuresThe 2008 EAC of the lowest-cost PDP from 2007 was recorded. OC was determined by subtracting the 2008 EAC of the lowest-cost PDP in 2008 from the 2008 EAC of the lowest-cost PDP in 2007 for each patient in each region. The percentage of PDPs that had the lowest EAC in both 2007 and 2008 was recorded. ResultsThe 2008 EACs of the lowest-cost PDPs from 2007 were significantly higher (P < 0.001) than the lowest-cost PDPs of 2008 within all 34 Medicare regions. The mean OC ranged from $276 to $562 nationally. Only 12% of plans were the lowest-cost PDP in both 2007 and 2008. ConclusionMedicare beneficiaries should reevaluate PDP offerings annually during the open enrollment period; failure to do so may increase avoidable out-of-pocket costs.

Beneficiary price sensitivity in the Medicare prescription drug plan market

The Medicare stand-alone prescription drug plan (PDP) came into existence in 2006 as part of the Medicare prescription drug benefit. It is the most popular plan type among Medicare drug plans and large numbers of plans are available to all beneficiaries. In this article we present the first analysis of beneficiary price sensitivity in the PDP market. Our estimate of elasticity of enrollment with respect to premium, -1.45, is larger in magnitude than has been found in the Medicare HMO market. This high degree of beneficiary price sensitivity for PDPs is consistent with relatively low product differentiation, low fixed costs of entry in the PDP market, and the fact that, in contrast to changing HMOs, beneficiaries can select a PDP without disrupting doctor-patient relationships.

Nothing for something? Estimating cost and value for beneficiaries from recent medicare spending increases on HMO payments and drug benefits

The Medicare Modernization Act of 2003 added a new outpatient prescription drug benefit to Medicare and increased payments to HMOs. We estimate a nested logit model of plan choice to quantify the welfare benefits from these two expansion paths. We find that the addition of stand-alone prescription drug plans was welfare improving and produced nine times as much value per government dollar as the increase in payments to HMOs. In light of these results, we suggest that HMO bidding procedures should be modified to reduce payments to HMOs by about $67 billion over the next 10 years.

Medicare Part D

Medicare Part D

Analysis of national annual variation in total patient out-of-pocket Medicare Part D stand-alone prescription drug plan costs from 2007 to 2008

Objective: This is the first study to compare total Medicare Part D (MPD) stand-alone prescription drug plan (PDP) estimated annual costs (EAC) between 2007 and 2008 in all MPD regions of the US using a patient cohort of Medicare-eligible patients.Methods: A total of 50 patients were selected at random from a database of Medicare-eligible patients. Each patient profile, based on pharmacy claims data, was entered into the Medicare website and the EAC of each PDP in each of the 34 MPD regions was obtained. The lowest, 25th percentile, median and highest EAC plans were obtained for each patient in each region for 2007 and 2008. Pair-wise, within-region, between-year comparisons were made using the Wilcoxon Signed-Ranks test.Results: Annual trends were variable between MPD regions. Only the highest EAC showed significant decreases in some regions, while all other comparisons showed no change or an increase in regional costs.Conclusions: Out-of-pocket Medicare prescription drug costs increased from 2007 to 2008. Increases in plan costs highlight the need for annual re-evaluation of PDP costs so that the patient is able to obtain the lowest cost plan each year. The decrease in the highest cost plan may suggest improvements in formulary coverage.

Attribute substitution in early enrollment decisions into Medicare prescription drug plans

Stand-alone outpatient prescription drug plans (PDPs), introduced in January 2006, have become the most popular source for coverage of outpatient prescription drugs under Medicare relative to other available Medicare plan types (e.g. Medicare Advantage drug plans). Using county-level enrollment figures from the Centers for Medicare & Medicaid Services linked to other public sources, we study attribute substitution in beneficiary decision-making with respect to PDP enrollment. To do so, we relate county-level PDP market share to county-level political support for the administration implementing the new benefit (the Bush Administration), controlling for socio-demographic and market characteristics. We find statistically significant evidence that greater support for the Bush administration is associated with increased PDP market share.

Medication Therapy Management Survey of the Prescription Drug Plans

To evaluate the preliminary development and implementation plans for medication therapy management (MTM) services across plan sponsors for the Medicare Part D Prescription Drug Plans (PDPs) and provide pharmacists with insights for MTM development. Cross-sectional survey. United States. 307 individual contacts from Medicare Advantage or stand-alone PDPs. A survey comprising questions about the PDP demographics, plans and implementation, beneficiary eligibility criteria, scope of services, providers of services, and payment structure for MTM services was e-mailed and mailed in November 2005. Descriptive and bivariate analysis of survey items. A total of 97 usable surveys were completed, a 31.5% response rate. Almost all respondents had a plan in place for MTM services. The majority of PDPs perceived that MTM would have a moderate benefit to their organization. Most PDPs planned to focus efforts on diabetes, heart failure, and other forms of cardiovascular disease. Overwhelmingly, PDPs planned to follow the Centers for Medicare & Medicaid Services (CMS) mandate for criteria regarding beneficiary eligibility. Only 8.2% of respondents planned to use a "traditional" pharmacist, such as a community, long-term care, hospital, or clinic pharmacist. The majority of PDPs (53.6%) planned to employ managed care pharmacists to administer MTM services. Pharmacists are eager to implement MTM services and are looking for PDPs to provide a path of implementation and reimbursement. Many PDPs were planning to deliver MTM services internally using health professional staff, thereby limiting the extent of participation of community, long-term care, hospital and health-system, and clinic-based pharmacists. Further research and advocacy are required to ensure that MTM services accomplish the true intent of the congressional and CMS mandates.