Introduction to the Use of Medicare Part D Data for

Research

Minneapolis

MAY 15-16, 2013

Educational Objectives of Workshop

Understand the Medicare Part D Program and its

benefits

Understand what demographic, useful enrollment

and linking information is available in the “new”

Master Beneficiary Summary File (the updated

Denominator File)

Become acquainted with the processing of Part D

event data

Understand the content of the Part D Event File

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Educational Objectives of Workshop

Understand the content of the Part D

Characteristics Files

Understand issues involved with the use of Part D

data for research

Understand what special Part D variables have

been created for researchers and how they were

created

3

Educational Objectives of Workshop

Begin to appreciate the types of research that can

be done using the Medicare Part D data

Understand the requirements of the Centers for

Medicare and Medicaid Services for obtaining and

using Part D data

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Description of the Medicare Part D Program

Frequently Repeated Acronyms/Names

ResDAC – Research Data Assistance Center

CMS – Centers for Medicare and Medicaid Services

CCW – Chronic Condition Warehouse

Buccaneer Computer Systems and Services

MMA – Medicare Modernization Act

PDP – Stand-alone Prescription Drug Plan – fee-for-service

MA-PD – Medicare Advantage Prescription Drug Plan

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Frequently Repeated Acronyms/Names

LIS – Low Income Subsidy

TrOOP – True Out of Pocket Spending

ICL – Initial Coverage Limit

PDE – Prescription Drug Event

CCL – Catastrophic Coverage Limit

PDE – Prescription Drug Event

MBSF – Master Beneficiary Summary File

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Medicare Prescription Drug Program

Implemented in 2006 as part of the Medicare Modernization Act (MMA) of 2003

Part D is based on a competitive model where beneficiaries can voluntarily purchase drug coverage offered by private plans.

Part D plans have flexibility in the design of plan: benefit package (e.g., deductibles/copays, formularies, prior authorization requirements, etc.) Premiums vary by plan.

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Medicare Prescription Drug Program

Part D enrollment is for a calendar year. Beneficiaries may choose from multiple plans during

annual open enrollment in Oct-Dec of each year Originally, 6% are plan switchers each year; last 2

years = 13%. Plans are state or region-based and each beneficiary

has 23-38 PDPs from which to choose for 2013 Average base monthly premium in 2013 = 31.17;

2012 = $31.08, down from $32.34 in 2011 Percentage of Medicare beneficiaries enrolled in Part

D ˗ 2006 = 54% ˗ 2010 = 59% ˗ 2011 = 60% ˗ 2012 = 65%

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Medicare Prescription Drug Program

Enrollment in Part D is optional, but a penalty for those without creditable coverage who enroll after age 65.

“Extra Help” available for those who qualify; called Low Income Subsidy (LIS)

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MAPD24%

PDP41%

No creditable coverage

10%

Creditable coverage

26%

Medicare Part D Enrollment – 2012MAPD = Medicare Advantage Prescription DrugPDP = (Fee-for-Service) Prescription Drug Plan

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Medicare Part D Standard Benefit, 2013

25% coinsurance

.

TrOOP

Spending

$325

$3,051 Coverage Gap

Total drug

spending at

OOP threshold

or CCL

$6,954.52

Total Drug

Spending

at ICL

$2,970

Deductible

TrOOP

Spending

$4,750

TrOOP

Spending

$986.25

Coverage Gap ($3,984.52)

Enrollee Pays 47.5% for brand name

drugs, and 79% for generic drugs

Catastrophic

Medicare Pays 80%

Plan Pays 15%

Initial Coverage Period

Plan Pays 75%

($1.983.75)

Enrollee Pays

25%

($661.25)

Deductible ($325)

Enrollee Pays 100%

Enrollee Pays

5% or $2.60-

$6.50 co-pay

Total Drug

Spending at

deductible

limit

$325

$0 $0 12

True Out-of-Pocket Spending (TrOOP)

TrOOP, "True Out of Pocket Costs“: “the beneficiary’s own out-of-pocket spending; that of a family member or official charity; supplemental drug coverage provided through qualifying state pharmacy assistance programs or Part D’s low-income subsidies; and, under CMS’s demonstration authority, supplemental drug coverage paid for with MA rebate dollars.

TROOP amounts are the medication costs that can be used to calculate “beneficiary payments” and are used by CCW/Buccaneer to calculate the benefit phase that each drug fill falls into in the PDE data files.

Not the amount the patient paid – well almost

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Medicare Part D Standard Benefit, 2013

25% coinsurance

.

TrOOP

Spending

$325

$3,051 Coverage Gap

Total drug

spending at

OOP threshold

or CCL

$6,954.52

Total Drug

Spending

at ICL

$2,970

Deductible

TrOOP

Spending

$4,750

TrOOP

Spending

$986.25

Coverage Gap ($3,984.52)

Enrollee Pays 47.5% for brand name

drugs, and 79% for generic drugs

Catastrophic

Medicare Pays 80%

Plan Pays 15%

Initial Coverage Period

Plan Pays 75%

($1.983.75)

Enrollee Pays

25%

($661.25)

Deductible ($325)

Enrollee Pays 100%

Enrollee Pays

5% or $2.60-

$6.50 co-pay

Total Drug

Spending at

deductible

limit

$325

$0 $0 14

Medicare Part D Standard Benefit, 2012

25% coinsurance

.

TrOOP

Spending

$320

$3,051 Coverage Gap

Total drug

spending at

OOP threshold

$6,657.50

Total Drug

Spending

at ICL

$2,930

Deductible

TrOOP

Spending

$4,700

TrOOP

Spending

$972.50

Coverage Gap ($3,727.50)

Enrollee Pays 50% for brand name

drugs, and 86% for generic drugs

Catastrophic

Medicare Pays 80%

Plan Pays 15%

Initial Coverage Period

Plan Pays 75%

($1.957.50)

Enrollee Pays

25%

Deductible ($310)

Enrollee Pays 100%

Enrollee Pays

5% or $2.60-

$6.50 co-pay

Total Drug

Spending at

deductible

limit

$320

$0 $0 15

Medicare Part D Standard Benefit Thresholds

Benefit

Parameters 2006 2008 2010 2011 2012 2013

Deductible $250 $275 $310 $310 $320 $325

Initial

Coverage

Limit $2,250 $2,510 $2,830 $2,840 $2,930 $2,970

TrOOP

threshold at

catastrophic

coverage

limit (CCL) $3,600 $4,050 $4,550 $4,550 $4,700 $4,750

Total

covered

drug

expenditure

at CCL $5,100 $5,726.25 $6,440 $6,447.50 $6,657.50 $6,950

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“Extra Help” – Low Income Subsidy (LIS) Benefits

˗ Help paying Medicare drug plan’s monthly premium,

any yearly deductible, coinsurance, and/or copayments

˗ No coverage gap liability

˗ No late enrollment penalty

Major Effort on the part of CMS and advocacy

groups to inform beneficiaries about the Low

Income Subsidy available to them to help pay for

Part D services.

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10%

14%

13%

3%

17%

4%

21%

17%

Medicare Part D Enrollment, 2010

No creditable coverage

Primary coverage throughFEHB, TRICARE, or activeworkerCovered by employers whoreceive RDS

Other creditable coverage

Non-LIS in MA-PD

LIS in MA-PD

Non-LIS in PDP

LIS in PDP18

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Public Use Files Describing the Drug Plans

Plan Information File

Basic Drugs Formulary File

Excluded Drugs Formulary fFle

Beneficiary Cost File

Geography Locator file

Pharmacy Networks File

Cannot be linked to beneficiary-level files

a.k.a., Landscape Files

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Public Use Files Describing the Plans

Stand-alone PDP or MA-PD (Local or Regional)

Monthly premium amount

Annual deductible amount

Initial coverage limit

Drugs listed on each plan’s formulary and tier placement

Enrollee cost-sharing amounts for each drug tier

Some content

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Public Use Files Describing the Plans

Pharmacy networks for each plan

Information on utilization management for each drug: ˗ quantity limit,

˗ prior authorization required, and

˗ step therapy

Average monthly prices for Part D drugs

To locate and order these files: http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/NonIdentifiableDataFiles/PrescriptionDrugPlanFormularyPharmacyNetworkandPricingInformationFiles.html

Some content

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Number of Part D Contracts and Plans 2006 - 2012

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Patterns of Enrollment in 2009 and 2011 Difference between PDP and MA-PD, not between years

2009 2011

Percent of

beneficiaries with PDP MA-PD PDP MA-PD

Enhanced (v. basic)

benefits 27% 94% 18% 92%

Plan has no

deductible 48% 94% 43% 91%

Plan offers some

gap coverage 7% 64% 15% 54%

Source: MedPAC analysis of CMS 2008 and 2009 landscape and enrollment data: http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/ 24

Beneficiary Enrollment by Gap Coverage PDP MA-PD

5.8%14.1% 13.1%

21.1%

31.4%

63.1%

0%

20%

40%

60%

80%

100%

2006 2007 2008 2006 2007 2008

% N

on

-LIS

En

rollees

No Gap

Coverage

Gap Coverage

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Phase-in of Reduced Cost Sharing for Brand-name and Generic Drugs, 2011–20

Percent Paid by Beneficiary

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2011 2013 2016 2020

Brand 50% 47.5% 45% 25%

Generic 93% 79% 58% 25%

Plans Increasingly Use Formularies with Generic, Preferred and Non-preferred Tiers

1%

5%

1%1%7% 2%

10%22% 19% 17%

1%

1%

18%11%

4%

6%24%

8% 9% 8% 8%

81%87%79%

69%59%

73%

87% 85% 83% 81%

3% 6% 9%

2006 2007 2008 2009 2010 2006 2007 2008 2009 2010

25% Coinsurance Generic/Brand

Generic/Preferred/Non-Preferred Two Generics/Two Brands

Other

PDPs MA-PDs

NOTE: Calculations are share of all plans, weighted by enrollment. Source: NORC/Georgetown University/Social and Scientific Systems analysis for MedPAC.

1% 1% <1% <1% 1% 3% 5% 1% 1% 1%

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29

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Rulemaking for Beneficiary-level Part D Data

Final Part D rule published May 28, 2008;

Effective June 27, 2008

˗ Adds protections compared with traditional Part A and

Part B data regarding beneficiary privacy and

commercially sensitive plan data: generally, identifiers

(beneficiary, prescriber, pharmacy, plan) are encrypted

and cost data are aggregated

˗ Minimum data necessary

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Beneficiary-level Part D Data

Denominator/Enrollment information ˗ In Master Beneficiary Summary File (MBSF)

˗ I will talk about today Segment C of this workshop

˗ Information on all Medicare beneficiaries

Numerator information: Prescription drug event (PDEs) records for Medicare beneficiaries in Part D ˗ Both PDP and MA-PD enrollees

˗ Part A and Part B service utilization available only for PDP enrollees

˗ Approximately 1 billion drug claims annually

˗ Will start discussion today

Denominator and Numerator information

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Need Help? – Contact ResDAC (Research Data Assistance Center)

University of Minnesota contract with Centers for

Medicare and Medicaid Services (CMS)

Goal of ResDAC: to help CMS increase the number

of researchers skilled in accessing and using CMS

databases for studies of the Medicare and

Medicaid programs and beneficiaries

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ResDAC Services - Assistance Desk

ResDAC Assistance Desk staffed by Masters

trained Technical Advisors who

˗ answer questions regarding Medicare and Medicaid

data: data access and availability, record layouts,

individual variables, location of Medicare and Medicaid

program information

˗ work with researchers from first inquiry to submission

of a complete request to CMS for data

˗ support ResDAC website

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ResDAC Services - Training Workshops

CMS 101: Introduction to the Use of Medicare Data

for Research

CMS 102: Introduction to the Use of Medicaid Data

for Research

1-2 day “specialty” workshops

˗ CMS 105: Using Cost Report Data for Research

˗ CMS 106: Introduction to the Use of Medicare Part D

Data for Research

˗ CMS 302: Conducting Economic Research Using

Medicare Data

How to Contact the ResDAC Assistance Desk

Phone

˗ Toll free: 888-9ResDAC (888-973-7322)

Email

˗ resdac@umn.edu

WEB

˗ www.resdac.org (information)

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