Medicare Part D Cost Sharing and Antipsychotic Drug Use in Two Medicare Advantage Systems FUNG
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Medicare Part D Cost Sharing and Antipsychotic Drug Use in Two Medicare Advantage Systems FUNG

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    Medicare Part D Cost Sharing and Antipsychotic Drug Use in Two Medicare Advantage Systems FUNG Medicare Part D Cost Sharing and Antipsychotic Drug Use in Two Medicare Advantage Systems FUNG Presentation Transcript

    • Medicare Drug Benefits andAntipsychotic Use Among Medicare Advantage Beneficiaries with Schizophrenia Vicki Fung, Ph.D. Mid-Atlantic Permanente Research Institute HMORN May 1, 2012
    • Study TeamVicki Fung, PhD1 Rita Hui, PharmD, MS6Mary Price, MA2 Andy Nierenberg, MD7Alisa B. Busch, MD, MS3,4 Richard Frank, PhD3Mary Beth Landrum, PhD3 Joseph Newhouse, PhD3Bruce Fireman, MA2 John Hsu, MD MBA MSCE3,7William Dow, PhD51 Mid-Atlantic Permanente Research Institute, Mid-Atlantic Permanente Medical Group2 Divisionof Research, Kaiser Permanente Northern California3 Harvard University4 McLean Hospital5 University of California, Berkeley6 Pharmacy Outcomes Research Group, Kaiser Permanente7 Massachusetts General HospitalFunding Support: National Institute of Mental Health (5R01MH090284) and the Alfred P.Sloan FoundationNo other relevant financial relationships to disclose
    • Background Spending on antipsychotic drugs is growing rapidly Medicare Part D introduction was major shift in the financing of antipsychotics Antipsychotics receive formulary protection under Part D, but subject to cost-sharing ACA phases out coverage gap by 2020; however, ACA future remains uncertain, and substantial cost-sharing remains Impact of Part D program on access, quality, and costs for beneficiaries with serious mental illness is unknown
    • Objectives Among Medicare Advantage beneficiaries with schizophrenia, to examine the effects of Part D cost- sharing on:  Total antipsychotic drug spending  Out-of-pocket antipsychotic drug spending  Adherence to antipsychotic drug therapy
    • Methods Historical cohort study:  Community-dwelling beneficiaries enrolled in Medicare Advantage (MA) Prescription Drug plans offered by two plan sponsors: Integrated (IDS) and Non-IDS  Any antipsychotic dispensed in 2006  1+ inpatient or 2+ outpatient diagnoses of schizophrenia 2006-2007 Study period: 2007 Comparison groups:  Low income subsidy (LIS) beneficiaries: No coverage gap  Unsubsidized (Non-LIS) beneficiaries: Coverage gap starting at $2,400 in total drug spending
    • Cost-sharing Levels Initial Coverage Period Coverage Gap Catastrophic Coverage 2007 Up to $2,400 in TDC $2,400 TDC to Above $3,850 OOP $3,850 OOP Full Low Income ≤$2.15/$5.35 ≤$2.15/$5.35 $0 Subsidy (LIS) Non-LIS 3 or 4-tier copay 100% 5% (Non-Integrated MA) (eg, $10 /$20/$45/25%) Non-LIS 2 tier copay 100% $3/$10 (Integrated MA) $11/$40TDC=Total drug costs; OOP=Out-of-Pocket drug costsThe study plans did not include a deductible ($265 in standard benefit)
    • Analyses Monthly drug use outcomes:  Total drug costs (acquisition cost + dispensing fees)  Out-of-pocket drug costs  Adherence: proportion of days covered (PDC) Difference-in-difference estimation  Linear fixed effects (within-person) models  Accounted for “transition period” of 30 days and focused on 30+ days after reaching gap threshold ($2,400 in total drug spending)  Censored subjects in month they reached catastrophic coverage  Fixed effects robust to unmeasured, time-stable confounders
    • Study Population Non-Integrated MA Integrated MA Non-LI S Non-LIS (Gap) LIS (Gap) LISTotal N 1,672 2,234 321 547Age: <65 68% 85% 56% 86% 65-74 21% 11% 27% 9% 75+ 11% 4% 18% 6%Gender: Female 52% 50% 65% 52%Any of the chronic conditions below (2006-2007)* 50% 54% 36% 32%Coronary artery disease 9% 10% 6% 6%Chronic obstructive pulmonary disorder 21% 25% 11% 11%Diabetes 34% 36% 25% 22%Heart Failure 11% 10% 6% 4%Mean Comorbidity (RxHCC) score (SD) 1.54 1.78 1.46 1.73
    • Antipsychotic Drug Use in 2007 Non-Integrated MA Integrated MA Non-LIS Non-LIS (Gap) LIS (Gap) LISTotal N 1,672 2,234 321 547Drug spending Reached coverage gap threshold 47% 75% 44% 69% Reached catastrophic coverage threshold 11% 40% 15% 41%Adherence Mean antipsychotic PDC 64.8 79.1 74.3 81.0 Adherent: PDC>80% 46% 66% 61% 73%Antipsychotic drug use Atypical antipsychotic use 62% 82% 54% 76% Conventional antipsychotic use 43% 31% 50% 35% Use of both 15% 17% 12% 16% No Use 10% 4% 8% 6%
    • Percent Reaching the Gap Threshold Non-Integrated MA Integrated MA
    • Changes in Antipsychotic Use Before and After Reaching the Gap Threshold Diff-in-diff: Non-LIS (Gap) LIS Non-LIS (Gap) – LISNon-Integrated MA Diff 95% CI Diff 95% CI Diff 95% CITotal drug spending ($) -$97 (-110, -83) $37 (28, 46) -$133 (-149, -117)Out-of-pocket spending ($) $93 (88, 98) -$1 (-4, 3) $94 (88, 99)PDC (percentage points) -18. 4 (-19.7, -17.1) 1.8 (0.9, 2.7) -20.2 (-21.8, -18.6)Integrated MA Diff 95% CI Diff 95% CI Diff 95% CITotal drug spending ($) $78 (-32, 189) $226 (136, 316) -$147 (-238, -57)Out-of-pocket spending ($) $155 (131, 179) $13 (-3, 32) $142 (122, 161)PDC (percentage points) -0.2 (-4.3, 3.9) 5.7 (2.4, 9.1) -5.9 (-9.3, -2.5)
    • Monthly Changes in Adherence (PDC) Non-Integrated MA Subjects with a Schizophrenia Diagnosis 10.0 (PDC - PDC 1-month Pre-Gap) 5.0 0.0 Change in PDC -5.0 -10.0 Basic LIS -15.0 -20.0 -25.0 -30.0 -5 -4 -3 -2 -1 0 1 2 3 4 5 Month from Gap-Month (=0) Integrated MA 10.0 (PDC - PDC 1-month Pre-Gap) 5.0 0.0 Change in PDC -5.0 Basic -10.0 -15.0 LIS -20.0 -25.0 -30.0 -5 -4 -3 -2 -1 0 1 2 3 4 5 Month from Gap-Month (=0)
    • Limitations Non-random allocation of drug benefits; unobserved differences between groups  Focus on patients with documented diagnoses and drug use  Fixed effects estimation robust to time constant unobserved differences Measures of drug adherence based on dispensing data Conducted within MA drug plans offered by two Part D plan sponsors; generalizability could be limited Preliminary work – next steps: impact of these drug use changes on clinical outcomes and net medical spending
    • Conclusions Substantial differences between LIS and Non-LIS beneficiaries The LIS appears to be protective against cost-related non- adherence in both settings The gap is associated with large increases in out-of-pocket costs for antipsychotics However, changes in therapy adherence varied by setting  Large declines in adherence in non-integrated setting
    • Implications Work is needed to determine the clinical and economic impact of these drug use changes and potential delivery structure mechanisms that mitigate adverse cost-sharing effects Need to identify benefit designs and care delivery models that increase the value of drug coverage for vulnerable populations and minimize unintended effects