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Medicare Catastrophic Coverage Act of 1988 – first prescription drug program in Medicare, repealed before implemented.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