Medicare Prescription Drug Program and Using Part D

Data for Research

Becky Briesacher, PhD

Associate Professor, Medicine

Division of Geriatric Medicine

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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.

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"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 ClintonJuly 1999

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

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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Medicare Catastrophic Coverage Act of 1988 – first prescription drug program in Medicare, repealed before implemented.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

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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

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 Number of Medicare Beneficiaries = 45.2 Million

Total in Part D Plans:

26.7 Million(59%)

Medicare AdvantageDrug Plan

Retiree Drug Coverage2

No Drug Coverage

Other Drug Coverage1

4.5million

10%

7.9 million18%

6.2million

14%

Prescription Drug Coverage Among Medicare Beneficiaries, 2009

9.2 million20%

Stand-Alone Prescription

Drug Plan

17.5million

39%

Medicare’s “Standard” Drug Benefit in 2009

… Most plans do not offer the “standard” benefit, and coverage varies across most dimensions, including:

– Monthly premiums

– Deductibles

– The “doughnut hole”

– Covered drugs and utilization management restrictions

– Cost sharing for covered drugs

$295 Deductible

$2,700 in Total Drug Costs

$3,454 Coverage Gap (“Doughnut Hole”)

Plan Pays 75%

Plan Pays 15%; Medicare Pays 80%

$6,154 in Total Drug Costs($4,350 out-of-pocket)

Enrollee Pays 25%

5%

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

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Part D dataConstructed 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.

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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 Number of Medicare Beneficiaries = 45.2 Million, 2009

Total in Part D Plans:

26.7 Million(59%)

Medicare AdvantageDrug Plan

Retiree Drug Coverage2

No Drug Coverage

Other Drug Coverage1

4.5million

10%

7.9 million18%

6.2million

14%

Part D Data available only on Part D enrollees

9.2 million20%

Stand-Alone Prescription

Drug Plan

17.5million

39%

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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

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 DesignOverall 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 DesignData 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 2006

Study DesignSample 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 Costsunadjusted means for overall population, 2000-2007

2000 2001 2002 2003 2004 2005 2006 20070

5

10

15

20

25

30

35

40

2000 2001 2002 2003 2004 2005 2006 2007$0

$100

$200

$300

$400

$500

$600

$700

$800

$900

$1,000Prescription Drug Fills OOP Drug Costs

Medical Care. 49(9):834-41, 2011 Sep.

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Changes in Annual Rx Fills and OOP Drug Costs Following Part D Implementation (overall population)

Means (95% Confidence Intervals)Difference between

Standardized Observed and

PredictedOutcome measure

N Observed

ActualObserved

Mean

StandardizedObserved*

Mean

StandardizedPredicted

MeanP value

2006 Rx fills 34,798 34.3 32.831.0

(30.3 to 31.7)1.8

(1.1 to 2.5)<.001

OOP drug costs

34,798 499.4 474.9617.7

(578.1 to 657.4)-142.80

(-182.5 to -103.1)<.001

2007 Rx fills 38,777 36.5 35.031.6

(30.9 to 32.3)3.4

(2.7 to 4.1)<.001

OOP drug costs

38,777 500.9 475.9623.7

(590.0 to 657.1)-147.8

(-181.2 to -114.1)<.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

Medical Care. 49(9):834-41, 2011 Sep.

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Subgroup Analyses: Annual Prescription Drug Fills

absolute differences between observed and predicted means

Elderly

Non-elderly disabled

Hispanic

Black/non-Hispanic

White/non-Hispanic

Rural

Metropolitan

Medicaid

0-100% FPL

101-150% FPL

151-200% FPL

201-300% FPL

301+% FPL

1-2 morbidities

>=3 morbidities

0 2 4 6 8 10 12

Excellent to Good Health

2007

2006

Number

Elderly

Non-elderly disabled

Hispanic

Black/non-Hispanic

White/non-Hispanic

Rural

Metropolitan

Medicaid

0-100% FPL

101-150% FPL

151-200% FPL

201-300% FPL

301+% FPL

1-2 morbidities

>=3 morbidities

0 2 4 6 8 10 12

Fair to Poor Health

20072006

Number Medical Care. 49(9):834-41, 2011 Sep.

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Subgroup Analyses: Annual OOP Drug Costs absolute differences between observed and predicted means

Elderly

Non-elderly disabled

Hispanic

Black/non-Hispanic

White/non-Hispanic

Rural

Metropolitan

Medicaid

0-100% FPL

101-150% FPL

151-200% FPL

201-300% FPL

301+% FPL

1-2 morbidities

>=3 morbidities

-$400-$300-$200-$100$0

Excellent to Good Health

2007

2006

Dollars

Elderly

Non-elderly disabled

Hispanic

Black/non-Hispanic

White/non-Hispanic

Rural

Metropolitan

Medicaid

0-100% FPL

101-150% FPL

151-200% FPL

201-300% FPL

301+% FPL

1-2 morbidities

>=3 morbidities

-$400-$300-$200-$100$0

Fair to Poor Health

2007

2006

Dollars

Medical Care. 49(9):834-41, 2011 Sep.

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Changes in Annual Fills and OOP Rx Costs among 3-year Cohorts, by Insurance Status, 2005-2007

No drug cov-erage

Gained drug coverage after

Part D

Always had drug coverage

0

5

10

15

20

25

30

35

40

45

10.4

26.0

32.5

11.3

32.7

37.3

11.9

37.1 39.02005 2006

2007

No drug coverage Gained drug coverage after

Part D

Always had drug coverage

$0

$200

$400

$600

$800

$1,000

$1,200

$370

$1,005

$557

$294

$672

$510

$359

$569

$499

2005

2006

2007

Gained drug coverage after

Part D

Always had drug coverage

Mean Rx Fills Mean Rx OOP Costs

Medical Care. 49(9):834-41, 2011 Sep.

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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