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Medicare Drug Program News
Medicare Part D Has Helped More Seniors Take Their
Meds, But Sickest Most Likely to Skip
Many older Americans do not have a good understanding
of the complicated program
 April
22, 2008 - A new study shows Medicare Part D, the prescription drug
program, is still not well understood by many senior citizens, which may
be a key reason there are still seniors skipping their medications due
to the cost, which another study finds. The percentage of seniors guilty of this "cost-related
medication nonadherence," referred to as "CRN," has decreased but not as
much as hoped among the sickest beneficiaries.
The two studies will be published in the April
23/30 issue of the Journal of the American Medical Association (JAMA).
Before implementation of the Medicare Prescription
Drug Improvement and Modernization Act, which was passed by Congress in
2003, millions of individuals who were elderly and disabled had
insufficient or no insurance coverage for outpatient medications.
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“In the face of these economic barriers, several
large surveys in the United States have shown that older individuals
have resorted to behaviors such as skipping doses, reducing doses, and
letting prescriptions go unfilled. Such cost-related medication
nonadherence (CRN) is associated with increased risk of myocardial
infarction, stroke, and preventable hospitalization,” the authors of the
first study write.
Since January 2006, Medicare beneficiaries have
been able to purchase a prescription drug benefit (Part D), subsidized
by Medicare and available through private plans. The impact of Medicare
Part D on CRN is unknown.
Jeanne M. Madden, Ph.D., of Harvard Medical School
and Harvard Pilgrim Health Care, Boston, and colleagues examined the
changes in the prevalences of CRN and spending less on basic needs (such
as food) to afford medicines, before and after Part D implementation.
The study included information from the Medicare Current Beneficiary
Survey (MCBS), in which 24,234 nationally representative,
community-dwelling Medicare enrollees were questioned in 2004, 2005, and
2006 (response rate, 72.3 percent).
The researchers found that there was a larger
absolute decrease in CRN following Medicare Part D implementation (from
14.1 percent in 2005 to 11.5 percent in 2006) than occurred between 2004
and 2005 (15.2 percent to 14.1 percent, respectively).
However, no significant changes in CRN were
observed among beneficiaries with fair-to-poor health, despite high
baseline CRN prevalence for this group (22.2 percent in 2005) and
significant decreases among beneficiaries with good-to-excellent health.
“Overall, our findings suggest that that the
intensive medicine needs and financial barriers to access among the
sickest beneficiaries may not have been fully addressed by Part D,” the
authors write.
There were modest and significant decreases in CRN
among lower-income beneficiaries, controlling for changes from 2004 to
2005, but not for higher-income beneficiaries.
Significant reductions in spending less on basic
needs were observed in both groups (fair-to-poor health;
good-to-excellent health).
“In conclusion, we found small but significant
population-level decreases in CRN and spending less on basic needs to
afford medicines, nearly a year after an unprecedented shift in Medicare
policy - the implementation of the Part D drug benefit. Those
beneficiaries in poor health or with multiple morbidities who had
substantially higher baseline CRN did not experience decreases in CRN
associated with Part D implementation, although they did report
reductions in spending less on basic needs," the researchers say.
"Further research is needed to determine which
specific aspects of Part D did or did not alleviate the persistent
burden of medication costs. Part D claims data, linked to detailed Part
D plan characteristics, must be made available to study the impact of
the new Medicare drug benefit on actual utilization of medications and
health outcomes.”
Limited
Knowledge of Cost-Sharing Requirements of Medicare Part D May Effect
Drug Adherence
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25.4 million
in Part D |
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Overall, about 90 percent of the nation’s
44 million Medicare beneficiaries have drug coverage from
Medicare or another source.
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Enrollees in the large Medicare Advantage Part D
drug plan have a limited knowledge of the plan’s cost-sharing
requirements, and more than one-third report cost-coping behaviors such
as reducing drug adherence or switching to a cheaper drug, according to
the second study in JAMA.
In comparison with commercial insurance, Part D
benefits use complex and high levels of cost sharing to help limit drug
costs, including a coverage gap that in 2006 started at $2,250 in total
drug costs and ended after $3,600 of beneficiary out-of-pocket spending.
“In 2006, 85 percent of stand-alone prescription
drug plans and 72 percent of Medicare Advantage Prescription Drug plans
included a coverage gap, meaning that beneficiaries were responsible for
all of their drug costs during the gap. In addition, 91 percent of
stand-alone prescription drug plans and 93 percent of Medicare Advantage
Prescription Drug plans in 2006 had tiered cost sharing prior to the
coverage gap, under which beneficiaries paid more for higher-tier drugs
such as brand-name medications. Failure to understand these complex
benefit structures may limit beneficiaries’ abilities to anticipate or
manage their medication costs,” the authors write.
John Hsu, M.D., M.B.A., M.S.C.E., of Kaiser
Permanente Medical Care Program, Oakland, Calif., and colleagues
investigated beneficiaries’ knowledge of their Part D benefit
structures, including their awareness of the coverage gap, after their
first full year in the program, and cost responses.
Telephone interviews were conducted in 2007 in a
random sample of community-dwelling Kaiser Permanente-Northern
California Medicare Advantage beneficiaries age 65 years or older, with
a gap in coverage if they exceeded $2,250 in drug costs (n = 1,040; 74.9
percent response rate).
A range of self-reported responses to drug costs
was examined, including decreased adherence to prescribed drug use, use
of other cost-coping behaviors (such as switching to lower-cost
medications), and reports of financial burden (such as going without
necessities).
An estimated 40 percent of beneficiaries knew that
their drug plan included a coverage gap. Awareness of the gap increased
with 2006 drug costs.
Approximately 36 percent of beneficiaries reported
changing their behavior because of costs; 26 percent reported any
cost-coping behavior; 15 percent reported decreasing adherence; and 7
percent reported experiencing financial burdens.
The most frequently reported cost-coping behavior
was switching to a cheaper drug (15 percent). Among adherence changes,
the most frequently reported behavior was not refilling a prescription
(8 percent).
In further analyses, beneficiaries with lower
household income more frequently reported cost responses. Compared with
beneficiaries who were unaware of having a coverage gap, those who were
aware more frequently reported any cost response, but had fewer reports
of borrowing money or going without necessities.
“...the low levels of knowledge found in this study
reinforce the need for both improved education and tools for Part D
beneficiaries. Lack of knowledge or [lack of planning] could limit
potential intended cost-sharing effects of encouraging more judicious
resource use. Lack of awareness also may limit beneficiaries’ ability to
avoid higher drug costs. Increased efforts by Medicare and health plans
to educate beneficiaries on the details of their Part D cost-sharing
structures and levels are needed,” the authors write.
Editorial: Medicare Part D - a
successful start with room for improvement
In an accompanying editorial, Dana P. Goldman,
Ph.D., of the RAND Corporation, Santa Monica, Calif., and the National
Bureau of Economic Research, Cambridge, Mass., and Geoffrey F. Joyce,
Ph.D., of the RAND Corporation, comment on the studies in this week’s
JAMA regarding Medicare Part D.
“The primary objective of the Medicare
Modernization Act was to provide seniors with affordable coverage for
their prescription medications. This goal has been largely achieved, as
more than 90 percent of Medicare beneficiaries now have prescription
drug coverage at least as generous as the Standard Part D benefit. The
fact that average premiums are substantially lower than initial
projections provides some evidence that the market is working. The
articles by Hsu et al and by Madden et al document beneficiary confusion
and problems with adherence—issues that are not likely to be endemic but
still must be monitored. It may be that some features of the Part D
benefit, especially the dreaded doughnut hole [the gap in the standard
benefit under Part D], are ripe for redesign.”
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