Impact of Medicare Part D on antidepressant treatment, medication choice, and adherence among older adults with depression

The Value of Medicare Coverage on Depressive Symptoms Among Older Immigrants

BACKGROUND AND OBJECTIVES

The immigrant population, the primary driver of U.S. population growth, is aging and many immigrants remain uninsured. Lack of health insurance limits access to care, aggravating the already high level of depression for older immigrants. However, there is scarce evidence on how health insurance, particularly Medicare, affects their mental health. Using the Health and Retirement Study, this study examines the effect of Medicare coverage on depressive symptoms of older immigrants in the United States.

RESEARCH DESIGN AND METHODS

Exploiting the fact that many immigrants are not covered by Medicare after passing age 65, we use a difference-in-difference model with propensity score weighting to compare differences in depressive symptoms pre- and post-age-65. We further stratify the sample by socioeconomic status and by race/ethnicity.

RESULTS

Medicare coverage was significantly associated with a reduction in the probability of reporting depressive symptoms for immigrants with low socioeconomic status, especially for those below median wealth levels. The beneficial effect of Medicare coverage was also statistically significant for non-White immigrants-Black, Hispanic, and Asian/Pacific Islander-even when holding socioeconomic status constant.

DISCUSSION AND IMPLICATIONS

Our findings imply that immigration policies that expand health care protection to older immigrants can lead to further health benefits and reduce existing disparities for the aging population. Policy reforms such as providing limited Medicare access to immigrants who paid sufficient taxes but are still awaiting permanent residency status could increase coverage for the uninsured and improve participation of immigrants in the payroll system.

Controlling Pharmaceutical Costs in a Student-Run Free Clinic in a Resource-Limited Patient Setting

Our institution's student-run free clinic has been able to offer medication at no out-of-pocket cost to all patients since it opened in 2004. We have employed two strategies to manage prescription drug costs while simultaneously increasing medication coverage: (1) using Patient Drug Assistance Programs (PDAPs) and (2) developing an institutional-level partnership with pharmaceutical charities for medication subsidization. In this study, we aimed to analyze the financial impact of these measures on the clinic.A query of clinic data over the past 5 years identified 299 active PDAPs, corresponding to 299 fully-subsidized prescriptions. In 2017, there were 35 active PDAPs, increasing to 52 (2018), 62 (2019), and 82 (2020) before a decline to 68 PDAPs in 2021. The company affiliated with the most PDAPs varied annually: GlaxoSmithKline (2017), Lilly (2018, 2019, 2020), and both GlaxoSmithKline and Lilly (2021). The most frequent medications were sitagliptin (2017), insulin (2018, 2019), albuterol (2017, 2018), and dulaglutide (2020, 2021).In addition, data extracted from the private company subsidization program was analyzed for the year 2021. Program membership was $10,000 for institution-wide medication subsidization for all uninsured patients in the hospital system. In total, the clinic was able to acquire 220 medications with a 96% subsidy, corresponding to a direct clinic cost of $2,101.28. Comparatively, the market value of these medications was $52,401.51.Utilization of free drug acquisition programs and partnerships with pharmaceutical charities allowed for an increase in cost-savings and medications provided. Although the process for applying for medication assistance programs is complex, these programs serve as powerful tools for providing medications that may otherwise be unavailable due to cost. Other clinics and healthcare settings with uninsured patients should consider these programs as a means to ease medication cost burden.

Initial antidepressant choice by non-psychiatrists: Learning from large-scale electronic health records

OBJECTIVES

Pharmacological treatment of depression mostly occurs in non-psychiatric settings, but the determinants of initial choice of antidepressant treatment in these settings are unclear. We investigate how non-psychiatrists choose among four antidepressant classes at first prescription (selective serotonin reuptake inhibitors [SSRI], bupropion, mirtazapine, or serotonin-norepinephrine reuptake inhibitors [SNRI]).

METHOD

Using electronic health records (EHRs), we included adult patients at the time of first antidepressant prescription with a co-occurring diagnosis code for a depressive disorder. We selected 64 variables based on a literature search and expert consultation, constructed the variables from either structured codes or through applying natural language processing (NLP), and modeled antidepressant choice using multinomial logistic regression, using SSRI as the reference class.

RESULTS

With 47,528 patients, we observed significant associations for 36 of 64 variables. Many of these associations suggested antidepressants' known pharmacological properties/actions guided choice. For example, there was a decreased likelihood of bupropion prescription among patients with epilepsy (adjusted OR 0.49, 95%CI: 0.41-0.57, p < 0.001), and an increased likelihood of mirtazapine prescription among patients with insomnia (adjusted OR 1.59, 95%CI: 1.40-1.80, p < 0.001).

CONCLUSIONS

Broadly speaking, non-psychiatrists' selection of antidepressant class appears to be at least in part guided by clinically relevant pharmacological considerations.

The Impact of Payment Scheme Changes on Medication Adherence and Persistence of Patients Diagnosed with Depression in Korea

As of 1 July 2018, the Korean National Health Insurance Service (NHIS) changed the fee schedule for individual psychotherapy (IP). We sought to analyze the impact of the IP payment scheme changes on the medication adherence and persistence of patients diagnosed with depression in Korea. We utilized the NHIS claims database from 2017 to 2019. Patients who were newly diagnosed with depression and utilized IP and were prescribed antidepressants during the study period were included. Adherence was measured using the medication possession ratio (MPR), and persistence was measured using the length of therapy (LOT) during the follow-up period. Adherence and persistence during the pre-policy period (before the change of the payment scheme, from January 2018 until June 2018) and the post-policy period (after the change, from July 2018 until December 2019) were compared. During the study period, a total of 176,740 patients with depression were identified. The average MPR significantly increased from 0.20 to 0.33 in the pre- and post-policy periods, respectively (p < 0.001). The average LOT of the patients improved considerably from 36 to 56 days in the pre- and post-policy periods, respectively (p < 0.001). Poisson regression analysis showed that patients with depression who were female, 19-34 years of age (vs. 50-64 years or over 64 years), and in the post-policy period were significantly associated with greater adherence and persistence rates. Payment scheme changes were associated with an increased adherence and persistence of medication use among patients diagnosed with depression.

Pharmaceutical policies: effects of regulating drug insurance schemes

BACKGROUND

Drug insurance schemes are systems that provide access to medicines on a prepaid basis and could potentially improve access to essential medicines and reduce out-of-pocket payments for vulnerable populations.

OBJECTIVES

To assess the effects on drug use, drug expenditure, healthcare utilisation and healthcare outcomes of alternative policies for regulating drug insurance schemes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, nine other databases, and two trials registers between November 2014 and September 2020, including a citation search for included studies on 15 September 2021 using Web of Science. We screened reference lists of all the relevant reports that we retrieved and reports from the Background section. Authors of relevant papers, relevant organisations, and discussion lists were contacted to identify additional studies, including unpublished and ongoing studies.

SELECTION CRITERIA

We planned to include randomised trials, non-randomised trials, interrupted time-series studies (including controlled ITS [CITS] and repeated measures [RM] studies), and controlled before-after (CBA) studies. Two review authors independently assessed the search results and reference lists of relevant reports, retrieved the full text of potentially relevant references and independently applied the inclusion criteria to those studies. We resolved disagreements by discussion, and when necessary by including a third review author. We excluded studies of the following pharmaceutical policies covered in other Cochrane Reviews: those that determined how decisions were made about which conditions or drugs were covered; those that placed restrictions on reimbursement for drugs that were covered; and those that regulated out-of-pocket payments for drugs.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included studies and assessed risk of bias for each study, with disagreements being resolved by consensus. We used the criteria suggested by  Cochrane Effective Practice and Organisation of Care (EPOC)  to assess the risk of bias of included studies. For randomised trials, non-randomised trials and controlled before-after studies, we planned to report relative effects. For dichotomous outcomes, we reported the risk ratio (RR) when possible and adjusted for baseline differences in the outcome measures. For interrupted time series and controlled interrupted time-series studies, we computed changes along two dimensions: change in level; and change in slope. We undertook a structured synthesis following the EPOC guidance on this topic, describing the range of effects found in the studies for each category of outcomes.

MAIN RESULTS

We identified 58 studies that met the inclusion criteria (25 interrupted time-series studies and 33 controlled before-after studies). Most of the studies (54) assessed a single policy implemented in the United States (US) healthcare system: Medicare Part D. The other four assessed other drug insurance schemes from Canada and the US, but only one of them provided analysable data for inclusion in the quantitative synthesis. The introduction of drug insurance schemes may increase prescription drug use (low-certainty evidence). On the other hand, Medicare Part D may decrease drug expenditure measured as both out-of-pocket spending and total drug spending (low-certainty evidence). Regarding healthcare utilisation, drug insurance policies (such as Medicare Part D) may lead to a small increase in visits to the emergency department. However, it is uncertain whether this type of policy increases or decreases hospital admissions or outpatient visits by beneficiaries of the scheme because the certainty of the evidence was very low. Likewise, it is uncertain if the policy increases or reduces health outcomes such as mortality because the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

The introduction of drug insurance schemes such as Medicare Part D in the US health system may increase prescription drug use and may decrease out-of-pocket payments by the beneficiaries of the scheme and total drug expenditures. It may also lead to a small increase in visits to the emergency department by the beneficiaries of the policy. Its effects on other healthcare utilisation outcomes and on health outcomes are uncertain because of the very low certainty of the evidence. The applicability of this evidence to settings outside US healthcare is limited.

Trends in Serious Psychological Distress and Outpatient Mental Health Care of US Adults

IMPORTANCE

Reports of a recent increase in US outpatient mental health care raise questions about whether it has been driven by rising rates of psychological distress and whether mental health treatment has become either more or less focused on people with higher levels of distress.

OBJECTIVE

To characterize national trends in serious psychological distress and trends in outpatient mental health service use by adults with and without serious psychological distress.

DESIGN, SETTING, AND PARTICIPANTS

The 2004-2005, 2009-2010, and 2014-2015 Medical Expenditure Panel Surveys (MEPS) were nationally representative surveys taken in US households. The analysis was limited to participants 18 years or older. Dates of this analysis were February 2018 to April 2018.

MAIN OUTCOMES AND MEASURES

Annual national trends in the percentages of adults with serious psychological distress (Kessler 6 scale score ≥13), outpatient mental health service use (outpatient visit with a mental disorder diagnosis, psychotherapy visit, or psychotropic medication), and type of psychotropic medication use (antidepressants, anxiolytics/sedatives, antipsychotics, mood stabilizers, and stimulants). Age- and sex-adjusted odds ratios of the associations of survey period with the odds of serious psychological distress, outpatient mental health service use, and outpatient mental health service use were stratified by level of psychological distress.

RESULTS

The analysis involved 139 862 adult participants from the 2004-2005, 2009-2010, and 2014-2015 MEPS, including 51.67% women, 48.33% men, 67.11% white adults, and 32.89% nonwhite adults, with an overall mean (SE) age of 46.41 (0.14) years. Serious psychological distress declined overall from 4.82% (2004-2005) to 3.71% (2014-2015), including significant declines among young (3.94% to 3.07%), middle-aged (5.52% to 4.36%), and older adults (5.24% to 3.79%); men (3.94% to 3.09%) and women (5.64% to 4.29%); and major racial/ethnic groups (white, 4.52% to 3.82%; African American, 5.12% to 3.64%; Hispanic, 6.03% to 3.55%; and other, 5.22% to 3.26%). Overall, the percentage of adults receiving any outpatient mental health service increased from 19.08% (2004-2005) to 23.00% (2014-2015) (adjusted odds ratio, 1.25; 95% CI, 1.17-1.34). Although the proportionate increase in outpatient mental health service use for adults with serious psychological distress (54.17% to 68.40%) was larger than that for adults with less serious or no psychological distress (17.26% to 21.08%), the absolute increase in outpatient mental health service use was almost completely the result of growth in outpatient mental health service use by individuals with less serious or no psychological distress.

CONCLUSIONS AND RELEVANCE

The recent increase in outpatient mental health service use occurred during a period of decline in serious psychological distress. Adults with less serious psychological distress accounted for most of the absolute increase in outpatient mental health service use, while adults with serious psychological distress experienced a greater relative increase in outpatient mental health service use.

Continuing versus New Antidepressant Use in Older Adults: US Prescribing Trends from 2006 to 2015

Objectives

Antidepressant use has increased in older adults recently. This study examines the trends of antidepressant prescribing by prescription status (continuing vs. new prescriptions).

Methods

Data were collected from 2006-2015 National Ambulatory Medical Care Survey (NAMCS), a nationally representative sample of office-based outpatient visits. I limited the sample to adults aged 65 or older (n=10,708 unweighted). Using a repeated cross-sectional design with survey sampling techniques, prevalence rates of antidepressant prescriptions were estimated by prescription status. Stratified analyses were also performed by key variables (e.g., age, gender, and race/ethnicity).

Results

Continuing antidepressant prescriptions increased over time significantly (OR=1.07; 95% CI, 1.03-1.11), and no temporal trend was found in new antidepressant prescriptions. In stratified analyses, the increasing trends of continuing antidepressant prescriptions were pronounced in visits to primary care physicians (OR=1.06; 95% CI, 1.01-1.12).

Conclusion

Increasing antidepressant prescribing trends were found in continuing prescriptions. Continued antidepressant prescribing among older adults should be monitored for appropriate use.

The impact of Medicare Part D on cognitive functioning at older ages

Research has shown that the establishment of Medicare prescription drug benefit in 2006 leads to improvement in medication adherence and mortality outcomes. Despite a clear connection between physical/mental health and the risk of dementia, little is known about the extent to which this reform has affected the cognitive functioning of the elderly. Using data from the Health and Retirement Study and difference-in-differences approach, this study provides the first evidence on the cognition-enhancing effects of Medicare Part D. Our estimates show that Part D implementation is associated with 1.6% increase in cognitive functioning or 1.1-year delay of cognitive aging among benefit-eligible persons. Further analyses indicate that most of the cognitive benefits accrue to the vulnerable populations who previously lacked prescription drug coverage, and that a reduction in cardiovascular mortality is the most likely pathway through which the expansion improved cognitive functioning.

National Trends in Antidepressant, Benzodiazepine, and Other Sedative-Hypnotic Treatment of Older Adults in Psychiatric and Primary Care

OBJECTIVE

To describe how use of antidepressants, benzodiazepines, and other anxiolytic/sedative-hypnotics among older adults (age ≥ 65 years) has changed over time among visits to primary care providers and psychiatrists.

METHODS

Data were from the National Ambulatory Medical Care Survey (years 2003-2005 and 2010-2012), a nationally representative cross-section of outpatient physician visits. Analysis focused on visits to primary care providers (n = 14,282) and psychiatrists (n = 1,095) at which an antidepressant, benzodiazepine, or other anxiolytic/sedative-hypnotic was prescribed, which were stratified by demographic and clinical characteristic (including ICD-9-CM diagnosis) and compared across study intervals. Odds of medication use were calculated for each stratum, adjusting for demographic and clinical characteristics.

RESULTS

The visit rate by older adults to primary care providers where any of the medications were prescribed rose from 16.4% to 21.8% (adjusted odds ratio [AOR] = 1.43, P < .001) while remaining steady among psychiatrists (75.4% vs 68.5%; AOR = 0.69, P = .11). Primary care visits rose for antidepressants (9.9% to 12.3%; AOR = 1.28, P = .01) and other anxiolytic/sedative-hypnotics (3.4% to 4.7%; AOR = 1.39, P = .01), but the largest growth was among benzodiazepines (5.6% to 8.7%; AOR = 1.62, P < .001). Among patients in primary care, increases primarily occurred among men, non-Hispanic white patients, and those with pain diagnoses as well as those with no mental health or pain diagnoses.

CONCLUSIONS

From 2003 to 2012, use of the most common psychotropic medications among older adults seen in primary care increased, with concentration among patients with no mental health or pain diagnosis. As the population of older adults grows and receives mental health treatment in primary care, it is critical to examine the appropriateness of psychotropic use.

Medicare Part D's Effects on Drug Utilization and Out-of-Pocket Costs: A Systematic Review

OBJECTIVE

To update a past systematic review on whether Medicare Part D changed drug utilization and out-of-pocket (OOP) costs overall and within subpopulations, and to identify evidence gaps.

DATA SOURCES/STUDY SETTING

Published and gray literature from 2010 to 2015 meeting prespecified screening criteria, including having a comparison group, and utilization or OOP cost outcomes.

STUDY DESIGN

We conducted a systematic literature review with a quality assessment.

DATA COLLECTION/EXTRACTION METHODS

For each study, we extracted information on study design, data sources, analytic methods, outcomes, and limitations. Because outcome measures vary across studies, we did a qualitative synthesis rather than meta-analysis.

PRINCIPAL FINDINGS

Sixty-five studies met screening criteria. Overall, Medicare Part D enrollees have increased drug utilization and decreased OOP costs, but coverage gaps limit the program's impact. Beneficiaries whose insurance becomes more generous after enrollment had disproportionately increased drug utilization and decreased OOP costs. Outcomes among dual-eligibles were mixed.

CONCLUSIONS

There is strong evidence on how Medicare Part D and the donut hole coverage gap affect utilization and OOP costs, but weak evidence on how effects vary among dual-eligibles or across diseases. Findings suggest that the Affordable Care Act's provisions to expand coverage and reduce the donut hole should improve patient outcomes.

How payment scheme affects patients' adherence to medications? A systematic review

BACKGROUND

A previous systematic review reported that increase in patients' medication cost-sharing reduced patients' adherence to medication. However, a study among patients with medication subsidies who received medication at no cost found that medication nonadherence was also high. To our knowledge, no study has evaluated the influence of different medication payment schemes on patients' medication adherence.

OBJECTIVE

This study aims to review research reporting the influence of payment schemes and their association with patients' medication adherence behavior.

METHODS

This study was conducted using systematic review of published articles. Relevant published articles were located through three electronic databases Medline, ProQuest Medical Library, and ScienceDirect since inception to February 2015. Included articles were then reviewed and summarized narratively.

RESULTS

Of the total of 2,683 articles located, 21 were included in the final analysis. There were four types of medication payment schemes reported in the included studies: 1) out-of-pocket expenditure or copayments; 2) drug coverage or insurance benefit; 3) prescription cap; and 4) medication subsidies. Our review found that patients with "lower self-paying constraint" were more likely to adhere to their medication (adherence rate ranged between 28.5% and 94.3%). Surprisingly, the adherence rate among patients who received medication as fully subsidized was similar (rate between 34% and 84.6%) as that of other payment schemes. The studies that evaluated patients with fully subsidized payment scheme found that the medication adherence was poor among patients with nonsevere illness.

CONCLUSION

Although medication adherence was improved with the reduction of cost-sharing such as lower copayment, higher drug coverage, and prescription cap, patients with full-medication subsidies payment scheme (received medication at no cost) were also found to have poor adherence to their medication. Future studies comparing factors that may influence patients' adherence to medication among patients who received medication subsidies should be done to develop strategies to overcome medication nonadherence.

Perceived symptom targets of antidepressants, anxiolytics, and sedatives: the search for modifiable factors that improve adherence

Expectations about treatment and beliefs about illness influence adherence in physical disorders, but the extent to which this occurs in mood disorders is unknown. Identifying modifiable factors, such as beliefs, may improve adherence to mood disorder medications. Data from the Collaborative Psychiatric Epidemiology Surveys were used to examine relationships among perceived symptom targets of medication (mood only, non-mood only, mood, and non-mood) and self-reported adherence to antidepressants, anxiolytics, and sedatives. The sample included 807 community-dwelling individuals with and without depression and anxiety who regularly took one of these medications in the year before the survey. Slightly over half (53.2 %) of respondents were adherent. Perceived medication purpose was only significantly related to adherence among Latino respondents. Latino respondents who viewed their symptom target as non-mood only were the most adherent. Perceived symptom targets of medications were not associated with most patients' adherence behaviors for antidepressants, anxiolytics, and sedatives.

Optimizing the Use of Aripiprazole Augmentation in the Treatment of Major Depressive Disorder: From Clinical Trials to Clinical Practice

Major depressive disorder (MDD) is a recurrent, chronic, and devastating disorder leading to serious impairment in functional capacity as well as increasing public health care costs. In the previous decade, switching therapy and dose adjustment of ongoing antidepressants was the most frequently chosen subsequent treatment option for MDD. However, such recommendations were not based on firmly proven efficacy data from well-designed, placebo-controlled, randomized clinical trials (RCTs) but on practical grounds and clinical reasoning. Aripiprazole augmentation has been dramatically increasing in clinical practice owing to its unique action mechanisms as well as proven efficacy and safety from adequately powered and well-controlled RCTs. Despite the increased use of aripiprazole in depression, limited clinical information and knowledge interfere with proper and efficient use of aripiprazole augmentation for MDD. The objective of the present review was to enhance clinicians' current understanding of aripiprazole augmentation and how to optimize the use of this therapy in the treatment of MDD.

Value-Based Benefit Design to Improve Medication Adherence for Employees with Anxiety or Depression

BACKGROUND

Through reduced out-of-pocket costs and wellness offerings, value-based benefit design (VBBD) is a promising strategy to improve medication adherence and other health-related outcomes across populations. There is limited evidence, however, of the effectiveness of these policy-level changes among individuals with anxiety or depression.

OBJECTIVES

To assess the impact of a multifaceted VBBD policy that incorporates waived copayments, wellness offerings, and on-site services on medication adherence among plan members with anxiety or depression, and to explore how this intervention and its resulting improved adherence affects other health-related outcomes.

METHODS

A retrospective longitudinal pre/post design was utilized to measure outcomes before and after the VBBD policy change. Repeated measures statistical regression models with correlated error terms were utilized to evaluate outcomes among employees of a self-insured global health company and their spouses (N = 529) who had anxiety or depression after the VBBD policy change. A multivariable linear regression model was chosen as the best fit to evaluate a change in medication possession ratio (MPR) after comparing parameters for several distributions. The repeated measures multivariable regression models were adjusted for baseline MPR and potential confounders, including continuous age, sex, continuous modified Charlson Comorbidity Index, and the continuous number of prescriptions filled that year. The outcomes were assessed for the 1 year before the policy change (January 1, 2011, through December 31, 2011) and for 2 years after the change (January 1, 2012, through December 31, 2013). The primary outcome was a change in MPR. The secondary outcomes included healthcare utilization, medical or pharmacy costs, the initiation of medication, generic medication use, and employee absenteeism (the total number of sick days).

RESULTS

The implementation of the VBBD strategy was associated with a significant increase in average MPR (0.65 vs 0.61 in the pre-VBBD period; P = .004), the initiation of new medications for anxiety or depression (31.4% vs 29.5%, respectively; P = .033), and the filling of generic medications for anxiety or depression (85.1% vs 80.5%, respectively; P <.001). A multivariable adjusted analysis revealed a 0.05 increase in MPR after the benefit enhancement (P = .002). Healthcare utilization, costs, and absenteeism were not statistically different before and after the VBBD policy change.

CONCLUSION

The VBBD strategy was associated with improved medication adherence and cost-conscious medication use. Future analyses should explore whether these trends persist over time, and if they can further impact healthcare utilization, cost, and absenteeism.

Does prescription drug coverage improve mental health? Evidence from Medicare Part D

The introduction of the Medicare Prescription Drug program (Part D) in 2006 resulted in a significant increase in access to coverage for older adults in the U.S. Several studies have documented the impact of this program on prescription drug utilization, expenditures and medication adherence among older adults. However, few studies have evaluated the extent to which these changes have affected the health of seniors. In this study we use data from the Health and Retirement Study to identify the impact of the Medicare Part D program on mental health. Using a difference-in-difference approach, we find that the program significantly reduced depressive symptoms among older adults. We explore the mechanisms through which this effect operates and evaluate heterogeneity in impact.

Prescription drug insurance coverage and patient health outcomes: a systematic review

Previous reviews have shown that changes in prescription drug insurance benefits can affect medication use and adherence. We conducted a systematic review of the literature to identify studies addressing the association between prescription drug coverage and health outcomes. Studies were included if they collected empirical data on expansions or restrictions of prescription drug coverage and if they reported clinical outcomes. We found 23 studies demonstrating that broader prescription drug insurance reduces use of other health care services and has a positive impact on patient outcomes. Coverage gaps or caps on drug insurance generally led to worse outcomes. States should consider implementing the Affordable Care Act expansions in drug coverage to improve the health of low-income patients receiving state-based health insurance.

Racial differences in antilipemic use and lipid control in high-risk older adults: post-Medicare Part D

BACKGROUND

Older blacks are less likely to receive guideline-recommended antilipemic therapy and achieve lipid control than older whites because, in part, of out-of-pocket costs. We sought to determine whether racial differences in antilipemic use and lipid control narrowed after Medicare Part D's implementation.

METHODS

This before-after study included 1,091 black and white adults 70 years or older with coronary heart disease and/or diabetes mellitus from the Health Aging and Body Composition Study. Primary outcomes were antilipemic use and low-density lipoprotein cholesterol control. Key independent variables were race, time (pre-Part D vs post-Part D), and their interaction.

RESULTS

Before Part D, fewer blacks than whites reported taking an antilipemic (32.70% vs 49.35%), and this difference was sustained after Part D (blacks 48.30% vs whites 64.57%). Multivariable generalized estimating equations confirmed no post-Part D change in racial differences in antilipemic use (adjusted ratio of the odds ratio 1.07, 95% CI 0.79-1.45). Compared with whites, more blacks had poor lipid control both before Part D (24.30% vs 12.36%, respectively) and after Part D (24.46% vs 13.72%, respectively), with no post-Part D change in racial differences in lipid control (adjusted ratio of the odds ratio 0.82, 95% CI 0.51-1.33).

CONCLUSION

Although antilipemic use increased after Medicare Part D for both races, this policy change was associated with a change neither in lipid control for either racial group nor in the racial differences in antilipemic use or lipid control.

Brand-name prescription drug use among Veterans Affairs and Medicare Part D patients with diabetes: a national cohort comparison

BACKGROUND

Medicare Part D and the U.S. Department of Veterans Affairs (VA) use different approaches to manage prescription drug benefits, with implications for spending. Medicare relies on private plans with distinct formularies, whereas the VA administers its own benefit using a national formulary.

OBJECTIVE

To compare overall and regional rates of brand-name drug use among older adults with diabetes in Medicare and the VA.

DESIGN

Retrospective cohort.

SETTING

Medicare and the VA, 2008.

PATIENTS

1,061,095 Medicare Part D beneficiaries and 510,485 veterans aged 65 years or older with diabetes.

MEASUREMENTS

Percentage of patients taking oral hypoglycemics, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) who filled brand-name drug prescriptions and percentage of patients taking long-acting insulins who filled analogue prescriptions. Sociodemographic- and health status-adjusted hospital referral region (HRR) brand-name drug use was compared, and changes in spending were calculated if use of brand-name drugs in 1 system mirrored the other.

RESULTS

Brand-name drug use in Medicare was 2 to 3 times that in the VA: 35.3% versus 12.7% for oral hypoglycemics, 50.7% versus 18.2% for statins, 42.5% versus 20.8% for ACE inhibitors or ARBs, and 75.1% versus 27.0% for insulin analogues. Adjusted HRR-level brand-name statin use ranged (from the 5th to 95th percentiles) from 41.0% to 58.3% in Medicare and 6.2% to 38.2% in the VA. For each drug group, the 95th-percentile HRR in the VA had lower brand-name drug use than the 5th-percentile HRR in Medicare. Medicare spending in this population would have been $1.4 billion less if brand-name drug use matched that of the VA.

LIMITATION

This analysis cannot fully describe the factors underlying differences in brand-name drug use.

CONCLUSION

Medicare beneficiaries with diabetes use 2 to 3 times more brand-name drugs than a comparable group within the VA, at substantial excess cost.

Cost sharing and decreased branded oral anti-diabetic medication adherence among elderly Part D Medicare beneficiaries

BACKGROUND

Although the Medicare Part D coverage gap phase-out should reduce cost-related nonadherence (CRN) among seniors with diabetes, preferential generic prescribing may have already decreased CRN, while smaller numbers of patients using more costly branded oral anti-diabetic (OAD) medications remain vulnerable to CRN.

OBJECTIVE

To estimate the effects of cost sharing in the Part D standard (non-LIS) benefit on adherence to different OAD classes, comparing two classes dominated by inexpensive generic medications and two by more costly branded medications.

DESIGN AND PATIENTS

Retrospective cohort study using dispensed prescription data for elderly non-LIS (N=81,047) and LIS (low-income subsidy) (N=150,359) beneficiaries using same class OAD(s) in 2008 and 2009. Logistic regression modeled non-LIS likelihood; LIS and non-LIS patients matched using propensity outcome (N=38,054). Logistic regression, controlling for demographic and health status characteristics, modeled effects of non-LIS coverage on 2009 OAD class adherence.

MAIN MEASURES

Main outcome measures were within-class OAD coverage year adherence, with patients considered adherent when days supplied to calendar days ratio at least 0.8.

KEY RESULTS

Non-LIS patients had 0.52 and 0.57 times the odds of branded-only DPP-4 Inhibitor (N=1,812; 95 % CI: 0.43, 0.63; P<0.001) and Thiazolidinedione (TZD) (N=6,290; 95 % CI: 0.52, 0.63; P<0.001) adherence. Most patients (N=32,510; 82 %) used OADs in primarily generic classes, where we found no significant (Biguanides; N=21,377) or small differences (Sulfonylureas/Glinides [N=19,240; OR: 0.91; 95 % CI: 0.86, 0.97; P=0.002]) in adherence odds. Crude adherence rates were sub-optimal when CRN was not a factor (Non-LIS/LIS: Biguanides: 65 %/65 %; Sulfonylureas/Glinides: 66 %/68 %; LIS: DPP-4 Inhibitors: 66 %; TZDs: 67 %).

CONCLUSIONS

Gap elimination would not affect generic, but should reduce branded OAD CRN. Branded copayments may continue to lead to CRN. Policy initiatives and benefit changes targeting both cost deterrents for patients with more complex disease and non-cost generic OAD underuse are recommended.

The impact of Medicare prescription drug coverage on the use of antidementia drugs

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.

Effects of Medicare Part D coverage gap on medication and medical treatment among elderly beneficiaries with depression

CONTEXT

Maintenance antidepressant pharmacotherapy in late life prevents recurrent episodes of major depression. The coverage gap in Medicare Part D could increase the likelihood of reducing appropriate use of antidepressants, thereby exposing older adults to an increased risk for relapse of depressive episodes.

OBJECTIVES

To determine whether (1) beneficiaries reduce antidepressant use in the gap, (2) the reduction in antidepressant use is similar to the reduction in heart failure medications and antidiabetics, (3) the provision of generic coverage reduces the risk of reduction of medication use, and (4) medical spending increases in the gap.

DESIGN

Observational before-after study with a comparison group design.

SETTING AND PATIENTS

A 5% random sample of US Medicare beneficiaries 65 years or older with depression (n = 65,223) enrolled in stand-alone Part D plans in 2007.

MAIN OUTCOME MEASURES

Antidepressant pharmacotherapy, physician, outpatient, and inpatient spending.

RESULTS

Being in the gap was associated with comparable reductions in the use of antidepressants, heart failure medications, and antidiabetics. Relative to the comparison group (those who had full coverage in the gap because of Medicare coverage or low-income subsidies), the no-coverage group reduced their monthly antidepressant prescriptions by 12.1% (95% CI, 9.9%-14.3%) from the pregap level, whereas they reduced use of heart failure drugs and antidiabetics by 12.9% and 13.4%, respectively. Those with generic drug coverage in the gap reduced their monthly antidepressant prescriptions by 6.9% (95% CI, 4.8%-9.1%); this decrease was entirely attributable to the reduction in the use of brand-name antidepressants. Medicare spending on medical care did not increase for either group relative to the comparison group.

CONCLUSIONS

The Medicare Part D coverage gap was associated with modest reductions in the use of antidepressants. Those with generic coverage reduced their use of brand-name drugs and did not switch from brand-name to generic drugs. The reduction in antidepressant use was not associated with an increase in nondrug medical spending.

Medicare part D research and policy highlights, 2012: impact and insights

BACKGROUND

In the 6 years since the implementation of Medicare Part D in the United States, the program has been reported to improve quality, offer better beneficiary protections, and lower drug costs.

OBJECTIVE

The purpose of this article was to highlight the latest key peer-reviewed research findings on Medicare Part D and major public policy initiatives for Part D for 2012.

METHODS

PubMed was searched for studies on Medicare Part D published in 2011 in biomedical/scientific, peer-reviewed, English-language journals. For the policy update, sources included the Federal Register, the Medicare Prescription Drug Benefit Manual, the 2012 Final Call Letter, and guidance from the Centers for Medicare and Medicaid Services.

RESULTS

Medicare Part D has been associated with increased medication utilization, reduced out-of-pocket expenditures, and an overall decrease in cost-related non-adherence and nonpersistence. Its impact on reduction in non-drug utilization of health services has been more apparent after the transition year in 2006 and among subsets of Medicare beneficiaries. Recent policy changes promise to make Part D more user-friendly, simplify choice, and offer greater protection to beneficiaries. The coverage gap will phase out by 2020. Both the quality rating system for prescription drug plans and medication therapy management programs were enhanced.

CONCLUSIONS

Although Part D was designed to improve drug benefits, improvements may be needed in plan selection and simplification, quality assessment (especially with regard to long-term impact and health outcomes), evidence-based improvements in medication therapy management, and disparities among priority subpopulations. Medicare Parts A, B, and D could be coordinated to offset costs by increasing medication expenses and decreasing expenses for nonprescription medical services, thereby improving the overall cost-effectiveness of the Medicare program.

Medicare Part D's effect on the under- and overuse of medications: a systematic review

OBJECTIVES

To evaluate the literature regarding the effect of Medicare Part D on the under- and overuse of specific medications and corresponding health outcomes.

DESIGN

Systematic review.

SETTING

Medline search of the peer-reviewed literature from January 1, 2006, to October 8, 2010.

PARTICIPANTS

Medicare beneficiaries who obtained drug insurance from the Part D program.

MEASUREMENTS

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.

RESULTS

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.

CONCLUSION

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.

Health care for patients with serious mental illness: family medicine's role

Numerous studies document disproportionate physical morbidity and premature death among people with serious mental illness. Although suicide remains an important cause of mortality for this population, cardiovascular disease is the leading cause of death. Cardiovascular death among those with serious mental illness is 2 to 3 times that of the general population. This vulnerability is commonly attributed to underlying mental illness and behavior. Some excess disease and deaths result from poor access to and use of quality health care. Negative cardiometabolic effects of newer psychotropic medications augment these trends by increasing rates of obesity, diabetes, and hyperlipidemia among those treated. Researchers have developed innovative care models aimed at minimizing the disparate health outcomes of patients with serious mental illness. Most strive to enhance access to primary care, but publications on this topic appear almost exclusively in the psychiatric literature. A focus on primary care for the prevention of excess cardiometabolic morbidity and mortality in this population is appropriate, but depends on primary care physicians' understanding of the problem, involvement in the solutions, and collaboration with psychiatrists. We review health outcomes of the seriously mentally ill and models designed to improve these outcomes. We propose specific strategies for Family Medicine clinicians and researchers to address this problem.