Effect of prescription drug coverage on health of the elderly

Analyzing health outcomes measured as bounded counts

This paper assesses analytical strategies that respect the bounded-count nature of health outcomes encountered often in empirical applications. Absent in the literature is a comprehensive discussion and critique of strategies for analyzing and understanding such data. The paper's goal is to provide an in-depth consideration of prominent issues arising in and strategies for undertaking such analyses, emphasizing the merits and limitations of various analytical tools empirical researchers may contemplate. Three main topics are covered. First, bounded-count health outcomes' measurement properties are reviewed and their implications assessed. Second, issues arising when bounded-count outcomes are the objects of concern in evaluations are described. Third, the (conditional) probability and moment structures of bounded-count outcomes are derived and corresponding specification and estimation strategies presented with particular attention to partial effects. Many questions may be asked of such data in health research and a researcher's choice of analytical method is often consequential.

Prescription Drug Insurance and Cost-Related Medication Nonadherence Among Lesbian, Gay, and Bisexual Individuals in Canada

Purpose: This study estimates the frequency of uninsurance for prescription drugs and cost-related medication nonadherence (CRNA) among lesbian, gay, and bisexual (LGB) persons in Canada, compared with the heterosexual population. Methods: Logistic regression was used to quantify associations between sexual orientation, insurance status, and CRNA within the national probability-based Canadian Community Health Survey, 2015-2016. This sample included 98,413 individuals aged 15-80 years, including 2803 LGB individuals. Results: From our sample of Canadians, 22.2% of LGB respondents reported being uninsured for prescription drugs, compared with 20.0% of heterosexual persons (unadjusted odds ratio [UOR] 1.00, 95% confidence interval [CI] 0.75-1.33). LGB individuals had more than twice the odds of reporting CRNA compared with heterosexual individuals (UOR 2.48, 95% CI 1.99-3.10). This disparity was most pronounced among bisexual respondents, who had over three times the odds of reporting CRNA in comparison to heterosexual respondents (UOR 3.45, 95% CI 2.65-4.51). The odds ratio (OR) for CRNA comparing bisexual with heterosexual individuals remained statistically significant after adjustment for race/ethnicity, gender/sex, and age (OR 2.67, 95% CI 1.97-3.61) and was further attenuated with adjustment for partnership status, employment status, income, educational attainment, prescription drug insurance status, general health status, and immigration status (OR 2.09, 95% CI 1.51-2.89). Conclusion: LGB Canadians reported more CRNA but comparable prescription drug insurance frequencies to heterosexual persons. Factors pertaining to medication access (e.g., income, partnership status) and health needs appear to be the most important contributors to disparities.

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.

Medicare Part D Implementation and Associated Health Impact Among Older Adults in the United States

This study examined the effect of Medicare (Part D) implementation on health outcomes among U.S. older adults. Study participants were initially extracted from the 2004–2008 Health and Retirement Study (HRS). Data from respondents who further participated in the HRS 2005–2007 Prescription Drug Study were analyzed (N = 746). This was a retrospective pre-post design with a treatment and a control group. The difference-in-differences approach with panel ordered logistic regressions was used to examine the Part D effect on three patient health outcomes before and after the implementation, controlling for patient sociodemographic characteristics. People with continuous Part D enrollment from 2006–2008 were less likely to have a worse self-rated health than those who were not enrolled in Part D (odds ratio [OR] = 0.48; p < .05). A higher Charlson Comorbidity Index score was associated with a higher likelihood of having worse self-rated overall health, worse mental health, and worse activities of daily living impairment (ORs = 1.12, 1.17, and 1.36, respectively; all ps < .001). The Part D implementation appears to have a positive effect on older adults’ overall health outcomes. A decrease in out-of-pocket cost for health care may encourage older adults to utilize more needed medications, which in turn helped maintain better health.

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.

Impact of Medicare Part D on out-of-pocket drug costs and medical use for patients with cancer

BACKGROUND

Medicare Part D was designed to reduce out-of-pocket (OOP) costs for Medicare beneficiaries, but to the authors' knowledge the extent to which this occurred for patients with cancer has not been measured to date. The objective of the current study was to examine the impact of Medicare Part D eligibility on OOP cost for prescription drugs and use of medical services among patients with cancer.

METHODS

Using the Medical Expenditure Panel Survey (MEPS) for the years 2002 through 2010, a differences-in-differences analysis estimated the effects of Medicare Part D eligibility on OOP pharmaceutical costs and medical use. The authors compared per capita OOP cost and use between Medicare beneficiaries (aged ≥65 years) with cancer to near-elderly patients aged 55 years to 64 years with cancer. Statistical weights were used to generate nationally representative estimates.

RESULTS

A total of 1878 near-elderly and 4729 individuals with Medicare were included (total of 6607 individuals). The mean OOP pharmaceutical cost for Medicare beneficiaries before the enactment of Part D was $1158 (standard error, ±$52) and decreased to $501 (standard error, ±$30), a decline of 43%. Compared with changes in OOP pharmaceutical costs for nonelderly patients with cancer over the same period, the implementation of Medicare Part D was associated with a further reduction of $356 per person. Medicare Part D appeared to have no significant impact on the use of medications, hospitalizations, or emergency department visits, but was associated with a reduction of 1.55 in outpatient visits.

CONCLUSIONS

Medicare D has reduced OOP prescription drug costs and outpatient visits for seniors with cancer beyond trends observed for younger patients, with no major impact on the use of other medical services noted.

Acute myocardial infarction rehospitalization of the medicare fee-for-service patient: a state-level analysis exploring 30-day readmission factors

PURPOSE OF THE STUDY

Acute myocardial infarction (AMI) readmission among the older adults is frequent and costly to the Medicare Trust Fund and to the patient in preventable suffering. In this study, we explore factors that are associated with states having AMI readmission rates that are higher than the U.S. national rate.

PRIMARY PRACTICE SETTING(S)

Acute inpatient hospital settings.

METHODOLOGY AND SAMPLE

Multivariate regression analysis of 50 state-level data is used. The dependent variable AMI 30-day readmission worse than U.S. rate is based on adult Medicare fee-for-service patients hospitalized with a primary discharge diagnosis of AMI and for which a subsequent all-cause readmission occurred within 30 days of their last discharge.

RESULTS

We find one key variable--states with more β-blocker prescription given at discharge--that is significantly associated with a decrease in probability in states ranking "worse" on AMI 30-day readmission. Whereas, states with more total days of care per 1,000 Medicare enrollees, more community hospital outpatient visits per 1,000 population, and greater aspirin prescription given at discharge have a greater probability for AMI 30-day readmission to be "worse" than the U.S. national rate.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Case management programs targeting efficient medication reconciliation from the hospital setting to the transfer setting can potentially help minimize readmission for patients highly dependent on β-blockers for improved clinical outcomes. This intervention may be more effective than other factors to improve state-level hospital status on AMI 30-day readmission. Factors such as total days of care per 1,000 Medicare enrollees, more community hospital outpatient visits per 1,000 populations, and greater aspirin prescription given at discharge may not be as important as β-blocker prescription given at discharge.

Heart failure rehospitalization of the Medicare FFS patient: a state-level analysis exploring 30-day readmission factors

PURPOSE OF STUDY

Heart failure readmission among the elderly is frequent and costly to both the patient and the Medicare trust fund. In this study, the authors explore the factors that are associated with states having heart failure readmission rates that are higher than the U.S. national rate.

PRIMARY PRACTICE SETTING(S)

Acute inpatient hospital settings.

METHODOLOGY AND SAMPLE

50 state-level data and multivariate regression analysis is used. The dependent variable Heart Failure 30-day Readmission Worse than U.S. Rate is based on adult Medicare Fee-for-Service patients hospitalized with a primary discharge diagnosis of heart failure and for which a subsequent inpatient readmission occurred within 30 days of their last discharge.

RESULTS

One key variable found--states with a higher resident population speaking a primary language other than English at home--that is significantly associated with a decrease in probability in states ranking "worse" on heart failure 30-day readmission. Whereas, states with a higher median income, more total days of care per 1,000 Medicare enrollees, and a greater percentage of Medicare enrollees with prescription drug coverage have a greater probability for heart failure 30-day readmission to be "worse" than the U.S. national rate.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Case management interventions targeting health literacy may be more effective than other factors to improve state-level hospital status on heart failure 30-day readmission. Factors such as total days of care per 1,000 Medicare enrollees and improving patient access to postdischarge medication(s) may not be as important as literacy. Interventions aimed to prevent disparities should consider higher income population groups as vulnerable for readmission.

The impact of Medicare Part D on out-of-pocket costs for prescription drugs, medication utilization, health resource utilization, and preference-based health utility

OBJECTIVES

To quantify the impact of Medicare Part D eligibility on medication utilization, emergency department use, hospitalization, and preference-based health utility among civilian noninstitutionalized Medicare beneficiaries.

STUDY DESIGN

Difference-in-differences analyses were used to estimate the effects of Part D eligibility on health outcomes by comparing a 12-month period before and after Part D implementation using the Medical Expenditure Panel Survey. Models adjusted for sociodemographic characteristics and health status and compared Medicare beneficiaries aged 65 and older with near elderly aged 55-63 years old.

PRINCIPAL FINDINGS

Five hundred and fifty-six elderly and 549 near elderly were included. After adjustment, Part D was associated with a U.S.$179.86 (p=.034) reduction in out-of-pocket costs and an increase of 2.05 prescriptions (p=.081) per patient year. The associations between Part D and emergency department use, hospitalizations, and preference-based health utility did not suggest cost offsets and were not statistically significant.

CONCLUSIONS

Although there was a substantial reduction in out-of-pocket costs and a moderate increase in medication utilization among Medicare beneficiaries during the first year after Part D, there was no evidence of improvement in emergency department use, hospitalizations, or preference-based health utility for those eligible for Part D during its first year of implementation.