Download Focus Group -- Key Messages

Medicare Prescription Drug
Program and Using Part D
Data for Research
Becky Briesacher, PhD
Associate Professor, Medicine
Division of Geriatric Medicine
1
Funding and COI
Supported by grants R01AG028745 and R01AG022362 from the National
Institute on Aging (NIA), and the Harvard Pilgrim Health Care Foundation.
Dr Briesacher is also supported by a Research Scientist Development
Award from the NIA (K01AG031836.
I declare no conflict of interest.
2
"75% of older Americans lack decent,
dependable, private-sector coverage of
prescription drugs. That’s three out of every
four seniors. To those who think prescription
drug coverage isn’t a problem for most
Medicare beneficiaries, I say, think again."
President Bill Clinton
July 1999
3
Career in Part D Research
1) identified high predictability of prescription drug
expenditures from one year to the next2;
2) demonstrated selection into prescription drug coverage
is also predictable, based almost exclusively on observable
health status3;
3) created elasticity estimates that reducing medication
costs by 10% would increase drug utilization by 5.4%6.6%;3 and
4) established Part D effects differ in nursing home setting.
Overview of Presentation
Brief overview of Medicare Part D
Brief overview of Part D data
Description of Medicare Part D evaluation
5
History of Drug Coverage in Medicare
Medicare is health care insurance for elderly and
disabled Americans since 1965
Medicare had 2 notable coverage gaps: LTC and
prescription drugs
– Alternatives include employer/retiree benefits, self-purchased
Medigap plans, Medicare HMO option, Medicaid for the poor,
Military & VA
Medicare Catastrophic Coverage Act of 1988 – first prescription drug program in
Medicare, repealed before implemented.
Part D passed in 2003 and implemented in 2006
~65%-80% of population had drug coverage in 2005
6
Medicare Part D Drug Benefit
Voluntary enrollment unless in Medicaid
– Choose from dozens (~40) of private Rx coverage plans and
Medicare Advantage organizations
– premiums are heavily subsidized, late penalty for late enrollment
Auto-enrolled into Part D if in Medicaid
7
Prescription Drug Coverage Among
Medicare Beneficiaries, 2009
Total Number of Medicare Beneficiaries = 45.2 Million
No Drug Coverage
Other Drug
Coverage1
4.5
million
10%
6.2
million
14%
Stand-Alone
Prescription
Drug Plan
17.5
million
39%
7.9 million
18%
Retiree Drug
Coverage2
Medicare Advantage
Drug Plan
9.2 million
20%
NOTE: Percentages do not sum to 100% due to rounding. 1Includes Veterans Affairs, retiree coverage without RDS, Indian Health
Service, state pharmacy assistance programs, employer plans for active workers, Medigap, multiple sources, and other sources.
2Includes Retiree Drug Subsidy (RDS) coverage and FEHBP and TRICARE retiree coverage.
SOURCE: Centers for Medicare & Medicaid Services, 2009 Enrollment Information (as of February 1, 2009).
Total in
Part D Plans:
26.7 Million
(59%)
Medicare’s “Standard” Drug Benefit in 2009
Plan Pays 15%;
Medicare Pays 80%
5%
… Most plans do not offer the “standard”
benefit, and coverage varies across
most dimensions, including:
$6,154 in Total Drug Costs
($4,350 out-of-pocket)
$3,454 Coverage Gap
(“Doughnut Hole”)
$2,700 in Total Drug Costs
Enrollee
Pays
25%
Plan Pays 75%
$295 Deductible
– Monthly premiums
– Deductibles
– The “doughnut hole”
– Covered drugs and utilization
management restrictions
– Cost sharing for covered drugs
Part D data for research
Since June 2008, Part D data are available to
researchers.
Chronic Condition Data Warehouse (CCW) contains
100% Part D data and is official data source.
– CCW offers chronic disease indicators (21 conditions)
to ID disease cohorts but has data on all Part D
enrollees
Researchers may request random 10% or 20% sample
Part D data are linkable to other Medicare data
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Part D data
Part D data include information about drug (NDC), cost,
pharmacy, provider and benefit information
Data are de-identified to protect identity of beneficiary,
prescriber, pharmacy and plan.
Researchers must select each variable and provide
variable-level justification
Assistance offered through ResDAC
11
12
Part D data
Constructed variables “may not exactly represent the beneficiary
experience at the time of the prescription fill.”
Part D data differ from pharmacy claims
– Contains only final status record
Will not include drugs excluded from Part coverage or filled through
3rd party, or not filed as claim (e.g., 100% cash).
2-year lag in availability
E.g., OPTIMIZING CHRONIC DISEASE PREVENTION AND
MANAGEMENT IN ADVANCED DEMENTIA R21HS019579-01: PI Tjia
– $20,000, 9 month lag = Part D data linked to Part A, MDS, and
OSCAR on 200,000 Medicare enrollees with end-stage dementia
in NHs.
13
Part D Data available only on Part D enrollees
Total Number of Medicare Beneficiaries = 45.2 Million, 2009
No Drug Coverage
Other Drug
Coverage1
4.5
million
10%
6.2
million
14%
Stand-Alone
Prescription
Drug Plan
17.5
million
39%
7.9 million
18%
Retiree Drug
Coverage2
Medicare Advantage
Drug Plan
9.2 million
20%
NOTE: Percentages do not sum to 100% due to rounding. 1Includes Veterans Affairs, retiree coverage without RDS, Indian Health
Service, state pharmacy assistance programs, employer plans for active workers, Medigap, multiple sources, and other sources.
2Includes Retiree Drug Subsidy (RDS) coverage and FEHBP and TRICARE retiree coverage.
SOURCE: Centers for Medicare & Medicaid Services, 2009 Enrollment Information (as of February 1, 2009).
Total in
Part D Plans:
26.7 Million
(59%)
Medicare Part D and Changes in
Prescription Drug Use and Cost Burden:
National Estimates for the Medicare
Population, 2000-2007
Becky A. Briesacher, PhD (2)
Yanfang Zhao, MA (4)
Jeanne Madden, PhD (1)
Fang Zhang, PhD (1)
Alyce S. Adams, PhD (3)
Jennifer Tjia, MD, MSCE (2)
Dennis Ross-Degnan, ScD (1)
Jerry H. Gurwitz, MD (2)
Stephen B. Soumerai, ScD (1)
(1) Harvard Medical School and Harvard Pilgrim Health Care Institute;
(2) Div of Geriatric Medicine, Meyers Primary Care Institute and UMass Medical School;
(3) Kaiser Permanente Division of Research;
(4) Duke Translational Nursing Institute, Duke University School of Nursing
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Evaluations of Medicare Part D
Previous evaluations used
– Pharmacy chain data
– Regional Medicare Advantage plan data
Important gap in research on Part D to date:
– Lack of nationally-representative evaluations
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Study Design
Overall Methods
Examined study outcomes over 8 years (2000-2007)
Compared actual post-Part D (2006-2007) outcomes to
projected values (using 2000-2005 data)
Projections based on time-series regressions and
parametric bootstrapping techniques and 10,000
simulations of post-Part D outcomes.
Standardized estimates by fixing population
characteristics
Subgroup analyses -- by demographic & health status
3-year continuous cohort for sensitivity analyses
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Study Design
Data from MCBS
CMS conducts the Medicare Current Beneficiary
Survey
– Since 1991, continuous face-to-face panel survey
– 3-year rotating panels
– >12,000 community-dwelling and institutionalized, elderly and
disabled per year
Rich variety of measures:
– Demographics, income, assets, living arrangements, family
supports, health status and functioning
– Health insurance and drug coverage
– Utilization of services – self-reported and FFS claims
– Costs, copayments, deductibles
– Access to medical care, satisfaction
– Medications self-reported and Part D data, beginning in 200618
Study Design
Sample and Variables
Community-dwelling Medicare enrollees, 2000-2007
– ~11.5K persons/year; total unique individuals, n = 38,777
Study Variables:
– Prescription fills and OOP costs
from MCBS Cost and Use file
self-reported fills (disregarding Part D claims)
– Prescription drug coverage
categorized by coverage status between 2005 and 2007
– no drug coverage in all three years
– gained drug coverage after Part D (in 2006 or 2007)
– had drug coverage in all three years
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Annual Drug Use and Out-of-Pocket Drug Costs
unadjusted means for overall population, 2000-2007
40
Prescription Drug Fills
35
$1,000
OOP Drug Costs
$900
$800
30
$700
25
$600
20
$500
15
$400
$300
10
$200
5
$100
$0
0
2000 2001 2002 2003 2004 2005 2006 2007
2000 2001 2002 2003 2004 2005 2006 2007
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Medical Care. 49(9):834-41, 2011 Sep.
Changes in Annual Rx Fills and OOP Drug Costs
Following Part D Implementation (overall population)
Means (95% Confidence Intervals)
Outcome
measure
2006 Rx fills
OOP drug
costs
2007 Rx fills
OOP drug
costs
Actual
Standardized
N
Observed Observed*
Observed
Mean
Mean
Standardized
Predicted
Mean
31.0
(30.3 to 31.7)
34,798
34.3
32.8
34,798
499.4
474.9
38,777
36.5
35.0
31.6
(30.9 to 32.3)
38,777
500.9
475.9
623.7
(590.0 to 657.1)
Difference
between
Standardized
Observed and
Predicted
1.8
(1.1 to 2.5)
617.7
-142.80
(578.1 to 657.4) (-182.5 to -103.1)
3.4
(2.7 to 4.1)
-147.8
(-181.2 to -114.1)
P value
<.001
<.001
<.001
<.001
• Standardization to hold 2000 population characteristics stable
• Predictions used autoregressive models based on 2000-2005 historical trends
• Confidence intervals were constructed by creating 10,000 simulated outcomes using
bootstrap method
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Medical Care. 49(9):834-41, 2011 Sep.
Subgroup Analyses: Annual Prescription Drug Fills
absolute differences between observed and predicted means
Excellent to Good Health
Fair to Poor Health
>=3 morbidities
>=3 morbidities
1-2 morbidities
2007
301+% FPL
2006
301+% FPL
201-300% FPL
201-300% FPL
151-200% FPL
151-200% FPL
101-150% FPL
101-150% FPL
0-100% FPL
0-100% FPL
Medicaid
Medicaid
Metropolitan
Metropolitan
Rural
Rural
White/non-Hispanic
White/non-Hispanic
Black/non-Hispanic
Black/non-Hispanic
Hispanic
Hispanic
Non-elderly disabled
Non-elderly disabled
Elderly
Elderly
0
2
4
6
Number
8
10
2007
2006
1-2 morbidities
12
0
2
4
6
Number
Medical Care. 49(9):834-41, 2011 Sep.
8
10
12
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Subgroup Analyses: Annual OOP Drug Costs
absolute differences between observed and predicted means
Excellent to Good Health
Fair to Poor Health
>=3 morbidities
>=3 morbidities
1-2 morbidities
1-2 morbidities
2007
301+% FPL
2006
201-300% FPL
201-300% FPL
151-200% FPL
151-200% FPL
101-150% FPL
101-150% FPL
0-100% FPL
0-100% FPL
Medicaid
Medicaid
Metropolitan
Metropolitan
Rural
Rural
White/non-Hispanic
White/non-Hispanic
Black/non-Hispanic
Black/non-Hispanic
Hispanic
Hispanic
Non-elderly disabled
Non-elderly disabled
Elderly
Elderly
$0
-$100
-$200
Dollars
-$300
2007
301+% FPL
-$400
2006
$0
-$100
-$200
Dollars
Medical Care. 49(9):834-41, 2011 Sep.
-$300
-$400
23
Changes in Annual Fills and OOP Rx Costs among
3-year Cohorts, by Insurance Status, 2005-2007
Mean Rx Fills
Mean Rx OOP Costs
$1,400
45
37.1
2005
40
37.3
$1,005
2006
2007
$1,000
26.0
25
$800
$672
20
15
2005
32.5
2007
30
$1,200
32.7
2006
35
39.0
$569
10.4
11.3 11.9
$600
$557
$510 $499
$370
10
$359
$294
$400
5
$200
0
No drug coverage
Gained drug
Always had drug
coverage after Part
coverage
D
Gained drug
Always had drug
coverage after
Part D
coverage
$0
No drug coverage
Gained drug
coverage after
Part D
Medical Care. 49(9):834-41, 2011 Sep.
Always had drug
coverage
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My Current Part D Research
NIH-National Institute on Aging (R01AG028745)
(Co-Investigator)
Changes in Cardiovascular Care and Outcomes in Eight
Years after Medicare Part D
 Developing R01 to conduct clinical trial on Part D
enrollment protocols in nursing home setting
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