Medicare Part D low-income subsidies expanded in January 2024, but more needs to be done to ensure that eligible beneficiaries enroll.

BACKGROUND: The Inflation Reduction Act of 2022 extended full low-income subsidies (LIS) to a small group of Medicare Part D recipients with limited assets and incomes between 135% and 150% of the Federal Poverty Level beginning in January 2024. This policy may result in small enrollment gains among beneficiaries eligible for the new benefits, but the biggest problem with the current LIS program is underenrollment across all eligibility groups. Prior research has shown that underenrollment has been a persistent problem since the LIS program began in 2006, yet little has been done to correct the situation. OBJECTIVE: To identify individual-level factors associated with failure to enroll among low-income beneficiaries eligible for both full subsidies and partial subsidies under the LIS program. METHODS: We used 2019 Medicare Current Beneficiary Survey data for the study. The Medicare Current Beneficiary Survey is uniquely suited for this work because it contains administrative data on LIS enrollment plus extensive survey information on financial resources necessary to establish program eligibility. We conducted descriptive and multivariate analyses to identify factors associated with failure to enroll when eligible for either full or partial subsidies. Explanatory variables included sociodemographic characteristics, economic resources, work status, health variables, and source of prescription coverage (for nonsubsidized beneficiaries). RESULTS: In 2019, 73% of beneficiaries eligible for full subsidies under pre-Inflation Reduction Act LIS provisions were enrolled, compared with only 25% eligible for partial subsidies. The number of those estimated to be eligible for full subsidies but not enrolled (N = 3.9 million) was more than double that of those eligible but not enrolled for partial subsidies (N = 1.5 million). Factors associated with failure to enroll (older age, male sex, White race, married, higher education, higher income and assets, and excellent/very good health status) were similar for both groups. In multivariate analyses, the single strongest predictor of failure to enroll was receipt of income from work (odds ratio = 5.50; P < 0.001). Among the nonenrolled, 64% eligible for full subsidies and 75% eligible for partial subsidies maintained unsubsidized Part D coverage. CONCLUSIONS: Significant numbers of low-income Medicare beneficiaries are eligible for Part D subsidies but fail to enroll. Common characteristics distinguishing nonenrollees from enrollees include older age with higher proportions of White individuals, married individuals, higher income and assets, and better overall health. Two promising targets for increasing LIS enrollment are evidence of work income and unsubsidized Part D coverage.

Impact of Updated Clinical Practice Guidelines on Outpatient Treatment for Clostridioides difficile Infection and Associated Clinical Outcomes.

Background: The 2017 Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) Clostridium (Clostridioides) difficile infection (CDI) guideline update recommended treatment with fidaxomicin or vancomycin for CDI. We aimed to examine outpatient CDI treatment utilization before and after the guideline update and compare clinical outcomes associated with fidaxomicin versus vancomycin use. Methods: A pre-post study design was employed using Medicare data. CDI treatment utilization and clinical outcomes (4- and 8-week sustained response, CDI recurrence) were compared between patients indexed from April-September 2017 (preguideline period) and those indexed from April-September 2018 (postguideline period). Clinical outcomes associated with fidaxomicin versus vancomycin were compared using propensity score-matched analyses. Results: From the pre- to postguideline period, metronidazole use decreased (initial CDI: 81.2% to 53.5%; recurrent CDI: 49.7% to 27.6%) while vancomycin (initial CDI: 17.9% to 44.9%; recurrent CDI: 48.1% to 66.4%) and fidaxomicin (initial CDI: 0.87% to 1.63%; recurrent CDI: 2.2% to 6.0%) use increased significantly (P < .001 for all). However, clinical outcomes did not improve. In propensity score-matched analyses, fidaxomicin versus vancomycin users had 4-week sustained response rates that were higher by 13.5% (95% confidence interval [CI], 4.0%-22.9%; P = .0058) and 30.0% (95% CI, 16.8%-44.3%; P = .0002) in initial and recurrent CDI cohorts, respectively. Recurrence rates were numerically lower for fidaxomicin in both cohorts. Conclusions: Vancomycin use increased and metronidazole use decreased after the 2017 guideline update. Fidaxomicin use increased but remained low. Improved outcomes associated with fidaxomicin relative to vancomycin suggest benefits from its greater use in Medicare patients.

Financial incentives tied to Medicare star ratings: impact on influenza vaccination uptake in Medicare beneficiaries.

OBJECTIVES: To evaluate the impact of the star rating bonus payment policy on annual influenza vaccination rates before and after the policy was adopted for Medicare Advantage (MA) plans in 2012. STUDY DESIGN: Observational study using data from the Medicare Current Beneficiary Survey from 2007 to 2015 to test whether the bonus payment policy led to higher flu vaccination rates in MA prescription drug (MAPD) plans vs fee-for-service prescription drug plans (PDPs), which were ineligible for bonus payments. METHODS: Mean preperiod (2007-2011) and postperiod (2012-2015) influenza vaccination rates were compared for enrollees in both types of plans using descriptive and multivariate difference-in-difference (DID) equations. The experimental effect of the MA bonus payment policy was estimated as the interaction between plan type (MAPD plan vs PDP) and period (pre- vs post period) controlling for the main effects of plan type (MAPD vs PDP), timing of the observation (pre- vs post period), and other potential confounders. RESULTS: The study sample included 40,369 person-years of data in the preperiod and 27,703 person-years of data in the post period. Vaccination rates increased by 3.8% in MAPD plans compared with 2.7% in PDPs, leading to a relative MAPD-favored difference that was nonsignificant (P = .31). However, the effect was statistically significant (odds ratio [OR], 1.12; P = .03) in the main multivariate DID model. A larger relative difference was observed among beneficiaries 75 years and older (OR, 1.18; P = .03). CONCLUSIONS: The Medicare bonus payment policy led to a small increase in beneficiaries' flu vaccination rates, suggesting that expanding the star measure set could be an effective way to increase uptake for other recommended adult vaccines.

Can one or two simple questions predict poor medication adherence?

RATIONALE, AIMS, AND OBJECTIVES: Poor adherence to evidence-based medications is a major problem in conventional clinical practise. Better prognostic tools are needed to identify those with the highest likelihood of being non-adherent. The objective of this study is to determine if a 2-item patient activation status (PAS) measure identifies Medicare beneficiaries at risk of poor adherence to drugs typically recommended in treating type 2 diabetes. METHODS: PAS and medication adherence were assessed for respondents to the 2009 Medicare Current Beneficiary Survey and then compared using bivariate and multivariate tests. Participants' PAS was classified as "active," "high effort," "complacent," or "passive" based on how confident they were in identifying needed medical care and whether they brought medication lists to their doctors' visits. Adherence with oral antidiabetic drugs, angiotensin-converting enzyme-inhibitors/angiotensin receptor blockers, and statins was assessed using proportion of days covered (PDC). RESULTS: A total of 940 Medicare beneficiaries with diabetes enrolled in Part D plans in 2009. The overall effect of PAS on medication adherence was small (3% lower PDC for complacent/passive vs active/high effort beneficiaries, P < 0.10). However, interactions of complacent/passive PAS with other characteristics associated with poor adherence identified certain subgroups as especially prone to problematic adherence: age < 65 (PDC -11%, P < 0.05), non-Hispanic black (PDC -13%, P < 0.05), and morbidly obese (-9%, P < 0.10). CONCLUSION: A single question relating to taking medication lists to doctor visits may help identify patient subgroups prone to poor adherence in conventional practise, but larger samples are necessary to validate and extend these findings.

Utilization of Screening Mammograms in the Medicare Population Before and After the Affordable Care Act Implementation.

Objective: This study examined screening mammograms in women aged 65 to 74 years and 75+ years before and after the Affordable Care Act (ACA) implementation. Method: This repeated cross-sectional study of community-dwelling women age 65+ years without a history of breast cancer or mastectomy utilized the Medicare Current Beneficiary Survey and Medicare fee-for-service claims data from 2001 to 2013. We used covariate-adjusted logistic regression with generalized estimating equations, stratified by age group. Results: The adjusted odds of screening mammograms in women aged 65-74 (n = 742) and 75+ years (n = 681) were lower in 2013 (odds ratio [OR]: 0.75, 95% confidence interval [CI]: [0.67, 0.83]; OR: 0.67, 95% CI: [0.60, 0.75], respectively) than the odds of screening mammograms in 2001. Discussion: Annual screening mammograms decreased in women aged 65 to 74 years and 75+ years, despite increased access from the ACA implementation. Future research as to why women are no longer receiving screening mammograms, such as changes in physician specialty guidelines, is warranted.

A Comprehensive Review of Methods to Measure Oral Oncolytic Dose Intensity Using Retrospective Data.

BACKGROUND: Understanding the real-world use of oral oncolytics is essential to assess drug effectiveness. Retrospective analyses using medical and pharmacy claims data allow observation of drug use patterns and health outcomes. However, studies of medication adherence to oral oncolytics may not be sufficient in characterizing exposure because they typically measure refill frequency, not the administered dose or dose changes. Patients who appear fully adherent by traditional measures may be receiving different doses and experiencing differing effectiveness. Relative dose intensity (RDI) is a measure that has been used for intravenous drugs to capture the amount of a particular chemotherapeutic agent administered per unit of time (dose intensity), expressed as the fraction of the amount recommended in evidence-based guidelines. Such a measure would be useful for real-world studies of comparative effectiveness to characterize patient exposure to oral oncolytics. OBJECTIVE: To identify studies that used administrative claims data to measure real-world oral oncolytic dose intensity, RDI, or similar constructs. METHODS: Two health sciences librarians conducted a literature search (PubMed, January 1, 1809-February 6, 2018) including terms in each of the following concept areas: oncology drugs, dosage, and retrospective data sources. At least 2 reviewers scanned each title and abstract of publications retrieved from PubMed. Abstracts that indicated the study reported dose or related concepts and oral oncolytics using retrospective data sources were marked for full-text review. During full-text review, papers were excluded if they did not study oral oncolytics (i.e., only described intravenous chemotherapy); if they did not report drug dosage; or if the study was not retrospective. Resulting studies were included for full-text data extraction. RESULTS: Of the 1,640 publications returned from the search, 41 were marked for full-text review. Full-text review established that 17 studies addressed a concept related to dose of oral oncolytics using retrospective data. Twenty-four studies were excluded: 11 did not measure dose; 9 did not study oral oncolytics; and 4 were not retrospective studies. Among the 17 articles marked for extraction, 5 articles reported dose intensity or RDI using medical records or electronic health record (EHR) data. CONCLUSIONS: This study reveals not only the need for a claims-based measure of dose intensity for oral oncolytics, but also provides a basis for the development of such a measure based on previous EHR-based studies. While several claims data studies have characterized oral oncolytic dosing and duration, we found that no studies combined these dimensions into a single measure such as dose intensity. Methods using EHR data may be translatable to a claims data study. Future research is needed to develop and validate such measures. DISCLOSURES: Novartis Pharmaceuticals provided funding for this study and is a manufacturer of oral onalytics, which is under study in this article. Arcona and Zacker are employees of Novartis. Slejko reports grants from PhRMA, PhRMA Foundation, and Takeda Pharmaceuticals and consulting fees from Pfizer, outside the submitted work. Stuart reports consulting fees from the University of Maryland during the study. The other authors have nothing to disclose. The preliminary findings of this study were presented in a poster at AMCP Nexus 2018, October 22-25, 2018, in Orlando, FL.

Osteoporosis Medication Use: A Comparison of Elderly Females Living in Long-term Care Facilities Versus Community Dwellers.

OBJECTIVE: This study compares patterns of evidence-based osteoporosis medication use among females in community and long-term care settings enrolled in Medicare Part D.
DESIGN: Pooled cross-sectional study.
SETTING: Medicare beneficiaries enrolled in Medicare Parts A and B, and Part D stand-alone prescription drug plans from January 1, 2006, through December 31, 2008, or death.
PARTICIPANTS: Female Medicare Part D enrollees 70 years of age and older with osteoporosis or prior hip fracture.
INTERVENTIONS: NA.
MAIN OUTCOME MEASUREMENTS: Use of bisphosphonates, calcitonin, teriparatide, and raloxifene was tracked by residential status over the three-year period.
RESULTS: The study sample comprised 96,408 female Part D enrollees with osteoporosis. Prevalence of evidence-based medication use was 42.3% in 2006 and dropped slightly to 40.4% in 2008. In unadjusted comparisons, long-term care residents were significantly less likely to use any osteoporosis medication compared with community dwellers (40.6% vs. 53.1%). After adjustment for differences in individual characteristics, utilization was still lower among long-term care residents (relative risk [RR] = 0.89, 95% confidence interval [CI] 0.87-0.91). Bisphosphonates were the top choice among medication users, but were prescribed much less often to long-term care residents (RR = 0.79, 95% CI 0.75-0.83) compared with community residents.
CONCLUSION: Prevalence of evidence-based osteoporosis medication use is low in older women enrolled in Part D whether community-dwelling or long-term care residents, but long-term nursing facility residents are more likely to be treated with nonbisphosphonates. Many events that may affect osteoporosis medication use occurred after 2008; therefore, future studies using more recent data are warranted to examine osteoporosis medication use after 2008.

Confluencia del pensamiento martiano y marxista desde el análisis de la cultura en Juan Marinello / Convergence of Marxist and Jose Marti-related thinking from the analysis of culture in Juan Marinello Vidaurreta

RESUMEN Juan Marinello Vidaurreta, eminente trabajador de las letras, que no cambió la pluma por la política, sino que hizo de la política incesante gestión de creación espiritual. Vivió tres etapas decisivas de Cuba: los rezagos de la colonia española; la República mediatizada, que combatió; y el socialismo, que ayudó a consolidar. El objetivo es demostrar la confluencia del pensamiento martiano y marxista desde el análisis de la cultura en la obra de Juan Marinello Vidaurreta. Se asumió la concepción dialéctica materialista como metodología general para conocer el objeto de investigación en sus antecedentes y tendencias actuales. Además permitió ampliar el conocimiento sobre el tema objeto de estudio, a través del análisis de texto, el contenido y el discurso; la crítica de fuentes posibilitó extraer inferencias a partir de la teoría preexistente y la información empírica acopiada. El pensamiento marinelliano se fue formando como resultado de la influencia del movimiento progresista cubano, del pensamiento martiano y marxista-leninista, lo más avanzado del pensamiento latinoamericano y universal. Subyace en su obra una concepción integradora y totalizadora de la cultura, de base martiana y marxista.

ABSTRACT Juan Marinello Vidaurreta eminent worker of the letters that did not change the pen by the policy, but that made of the policy, incessant management of spiritual creation. He lived three decisive stages of Cuba: the lags of the Spanish colony; the mediated Republic, which fought; and socialism, which helped to consolidate. The objective is to demonstrate the confluence of Marti's and Marxist thinking from the analysis of culture in the work of Juan Marinello Vidaurreta. The dialectical materialist conception was assumed as general methodology to know the object of research in its antecedents and current trends. In addition it allowed expanding the knowledge on the subject under study, through the analysis of text, content and discourse; the critique of sources made it possible to draw inferences from the preexisting theory and the empirical information collected. Marinellian thought was formed as a result of the influence of the Cuban progressive movement, of Marti and Marxist-Leninist thought, the most advanced of Latin American and universal thought. It underlies in his work an integrative and totalizing conception of the culture, of Marti base and marxist.

Effect of Medication Copayment on Adherence and Discontinuation in Medicare Beneficiaries with Type 2 Diabetes: A Retrospective Administrative Claims Database Analysis.

INTRODUCTION: Nonadherence to antihyperglycemic agents (AHAs) increases the incidence of morbidity and mortality, as well as healthcare-related costs, in patients with type 2 diabetes (T2D). This study examined the association between medication copayment and adherence and discontinuation among elderly patients with T2D who use generic versus branded AHAs. METHODS: A retrospective, observational cohort study used Medicare administrative claims data (index period: 1 June 2012 to 31 December 2013). Drug copayments were measured as the copayment of the index medication for a 30-day supply after patients met their plan deductible. Patients were stratified into a branded or generic cohort based on the index medication. Adherence was measured by the proportion of days covered (≥ 80%) and discontinuation by a treatment gap of > 60 days in 10 months during the follow-up period. Poisson regressions were conducted for medication adherence and discontinuation, while controlling for demographic, clinical, and comorbid conditions. RESULTS: Overall, 160,250 patients on AHA monotherapy were included in the analysis; 131,594 (82%) were prescribed a generic and 28,656 (18%) a branded AHA with a mean copay of $6 and $41, respectively. Increases in copayment increased nonadherence and discontinuation for branded medications but not for generic AHA medications. In both cohorts, elderly patients (≥ 75 years of age) had a lower risk of nonadherence and discontinuation. Black patients had a higher risk of nonadherence or discontinuing medication. Patients having more frequent inpatient, emergency room, and/or physician visits were at higher risk of nonadherence or discontinuing therapy in the branded and generic cohorts (P < 0.001). CONCLUSION: The impact of drug copayment on adherence and discontinuation varied considerably between branded and generic AHAs. Medicare patients taking branded AHAs had a higher risk of nonadherence with increasing copayment and were more likely to discontinue medication, whereas this association was not observed in patients taking generic medications. FUNDING: Merck & Co, Inc., Kenilworth, NJ, USA. Plain language summary available for this article.

Placement of selected new FDA-approved drugs in Medicare Part D formularies, 2009-2013.

OBJECTIVES: To assess formulary decisions by Part D plans for selected newly approved drugs. STUDY DESIGN: Retrospective cohort study. METHODS: Formulary placement and restrictions were identified for 33 drugs in 8 therapeutic classes (antihyperglycemics, anticoagulants, antiplatelets, disease-modifying agents for multiple sclerosis [MS] and rheumatoid arthritis [RA], chronic obstructive pulmonary disease [COPD] drugs, antiepileptics, and antipsychotics) in 863 Part D plans with continuous CMS contracts between 2009 and 2013. Multivariable models estimated the impact of drug characteristics and Part D plan characteristics on probability of drug adoption and, for adopters, evaluated factors associated with months to adoption and requirements for prior authorization (PA) or step therapy (ST). RESULTS: First Part D formulary placements varied from 2 to 14 months post FDA approval. On average, 56.7% of plans placed each drug within 6 months and 64.1% placed within 1 year of the National Drug Code assignment date. The most rapid adoption was for antipsychotics and antiepileptics. The slowest was for COPD drugs. More than 90% of disease-modifying agents for MS and RA were subject to PA. ST was uncommon except for antihyperglycemic agents. In adjusted analyses, enhanced benefit plans had a 4% higher probability of formulary placement (P <.01), and each additional star in the CMS star rating system increased the probability of adoption by 4% (P <.01). Overall, Medicare Advantage prescription drug plans had higher placement rates due to greater reliance on enhanced plan offerings and higher star ratings. CONCLUSIONS: We found significant heterogeneity in formulary placement and restrictions for 33 new drugs in the Part D marketplace between 2009 and 2013. Further research is necessary to determine whether this pattern applies to other drug classes.

Impact of formulary restrictions on medication intensification in diabetes treatment.

OBJECTIVES: To explore formulary restrictions on noninsulin antihyperglycemic drugs (NIADs) in Medicare Part D plans and to estimate the impact of formulary restrictions on use of NIADs among low-income subsidy (LIS) recipient enrollees with type 2 diabetes (T2D) undergoing treatment intensification. STUDY DESIGN: Retrospective cohort study. METHODS: A cohort of 2919 LIS enrollees with T2D receiving metformin monotherapy during the first quarter of 2012 who intensified treatment later in the year was tracked to assess selection of and days' supply with sulfonylureas, dipeptidyl peptidase-4 (DPP-4) inhibitors, and other NIADs. We tested whether being enrolled in a Part D plan with significant formulary restrictions on sole-source brand name NIADs reduced the likelihood of receiving such agents and, if so, what the impact was on days of therapy with the second agent. A 2-part regression model was estimated with explanatory variables for plan-level restrictions and individual covariates. RESULTS: We found that 63% of study subjects initiated a sulfonylurea, 25% a DPP-4 inhibitor, and 12% another NIAD. Greater restrictions on DPP-4 inhibitors as a class were associated with small reductions in initiation of DPP-4 inhibitors and a concomitant increase in use of sulfonylureas, but neither effect was statistically significant. For individual DPP-4 inhibitors, step therapy requirements on sitagliptin and formulary exclusion of saxagliptin resulted in significant reductions in uptake of the specific drugs but had no significant impact on total days' supply of antihyperglycemic therapy. CONCLUSIONS: Part D formulary restrictions on sole-source brand name NIADs had little impact on patterns of treatment intensification for T2D among LIS recipients enrolled in Medicare Part D plans in 2012.

Impact of formulary restrictions on medication use and costs.

OBJECTIVES: To evaluate the effects of formulary restrictions on utilization and costs of oral hypoglycemic agents (OHAs), statins, and renin-angiotensin system (RAS) antagonists among low-income subsidy (LIS) recipients in Medicare Part D plans. STUDY DESIGN: We analyzed a 5% sample of 2012 Medicare data from the Chronic Conditions Data Warehouse together with a customized dataset capturing beneficiaries' histories of plan assignment. METHODS: We constructed 3 nonexclusive study cohorts comprising of users of OHAs, statins, and RAS antagonists. Eligible study subjects were LIS recipients randomized to benchmark plans. Formulary restrictions of interest were noncoverage, prior authorization, and step therapy. Study outcomes included generic dispensing rate (GDR), mean cost per prescription fill, and medication adherence based on proportion of days covered (PDC). Random intercept regression models were performed to estimate the effects of formulary restrictions on the study outcomes by drug class. RESULTS: After covariate adjustment, beneficiaries who were subject to formulary restrictions on brand name pioglitazone and single-source brand name dipeptidyl peptidase-4 inhibitors (saxagliptin, sitagliptin, and sitagliptin-metformin) had a GDR 3 percentage points higher and a cost per prescription fill $10.8 less, but similar PDC compared with those who faced no restrictions. Restricting access to brand name atorvastatin and single-source brand name statins (rosuvastatin and ezetimibe-simvastatin) was associated with a GDR 14.9 percentage points higher and a cost per prescription fill $29.6 less, but with no impact on PDC. Restricting use of single-source brand name RAS antagonists (olmesartan, valsartan, and valsartan-hydrochlorothiazide) was associated with a GDR 15.0 percentage points higher, a cost per prescription fill $27.2 less, and a PDC 1.3 percentage points lower. CONCLUSIONS: Placing formulary restrictions on brand name drugs shifts utilization toward generic drugs, lowers the overall cost per prescription fill, and has minimal impact on overall adherence for OHAs, statins, and RAS antagonists among LIS recipients.

Does the offer of free prescriptions increase generic prescribing?

OBJECTIVES: To test if offering zero generic co-pays for oral antidiabetic drugs (OADs) and statins increases generic dispensing for low-income subsidy (LIS) recipients with diabetes enrolled in Medicare Part D. STUDY DESIGN: We analyzed a natural experiment in which LIS recipients were randomized to Part D plans in 2008. Some plans placed selected generic OADs and statins on zero co-pay tiers whereas others did not. Randomization eliminated selection effects which could bias the study findings. METHODS: We analyzed a 5% random sample of Medicare beneficiaries with diabetes from the Chronic Condition Data Warehouse using Part D claims, formulary provisions, and co-pay tiers together with a special file prepared by CMS that identified all randomly assigned LIS recipients in 2008. We calculated proportions using generic drugs in the 2 classes and annual days' supply among users in plans with and without zero co-pay tiers for the country as a whole and California (where zero co-pay plans were particularly popular). RESULTS: We found that the demand for generic OADs was not significantly different in plans with and without zero co-pay tiers. By contrast, a large difference was observed in the percent of LIS recipients using generic statins in plans with zero co-pay tiers (61.4% vs 54.6%; P <.01). However, the difference disappeared once we controlled for formulary restrictions on the most popular brand statin at the time (Lipitor). CONCLUSIONS: This cautionary tale suggests that policy makers should give greater consideration to formulary provisions when evaluating the effects of free generics in value-based insurance designs.

Adherence to Antipsychotic Therapy: Association With Hospitalization and Medicare Spending Among Part D Enrollees With Schizophrenia.

OBJECTIVE: This study examined relationships among antipsychotic adherence, hospitalization, and hospital expenditures in a sample of 13,861 Medicare Part D enrollees with schizophrenia. METHODS: Utilization and expenditure data were obtained from the Centers for Medicare and Medicaid Services Chronic Conditions Warehouse for 2011 and 2012. Adherence was measured with the proportion of days covered and stratified into four categories. Probit regressions and two-part generalized linear models were used to examine relationships between adherence in year 1 and outcomes in year 2. RESULTS: Adherence to antipsychotic therapy was associated with a significantly lower probability of psychiatric hospitalization and significantly lower psychiatric hospital expenditures, with the largest effect sizes observed for the most highly adherent beneficiaries. There was no relationship between antipsychotic adherence and hospitalizations or expenditures for nonpsychiatric conditions. CONCLUSIONS: Adherence to antipsychotics among Medicare Part D enrollees with schizophrenia was associated with significantly lower probability of psychiatric hospitalization and lower hospital expenditures.

The Impact of Coverage Restrictions on Antipsychotic Utilization Among Low-Income Medicare Part D Enrollees.

Prior research demonstrates substantial access problems associated with utilization management and formulary exclusions for antipsychotics in Medicaid, but the use and impact of coverage restrictions for these medications in Medicare Part D remains unknown. We assess the effect of coverage restrictions on antipsychotic utilization in Part D by exploiting a unique natural experiment in which low-income beneficiaries are randomly assigned to prescription drug plans with varying levels of formulary generosity. Despite considerable variation in use of coverage restrictions across Part D plans, we find no evidence that these restrictions significantly deter utilization or reduce access to antipsychotics for low-income beneficiaries.

Do Restrictions on Antipsychotic Use Differ Between Medicare Part D Stand-Alone Versus Medicare Advantage Plans?

OBJECTIVE: The objective of this study was to describe the type of restrictions and differences among antipsychotic users enrolled in Medicare Part D Stand-Alone (PDPs) and Advantage (MAPDs) prescription drug plans. METHODS: This retrospective study used data from Chronic Condition Data Warehouse, comprising a random 5% sample of the Medicare population in 2008. This study used bivariate analyses and multivariate logistical regression models to study differences in formulary restrictions on antipsychotic use between PDP and MAPD enrollees, adjusting for enrollee characteristics. Dependent variables included type of restriction and antipsychotic therapeutic class. The study sample was restricted to continuous Part D enrollees (N = 1,346,978) stratified by plan type, MAPDs (N = 435,591), and PDPs (N = 911,387). RESULTS: According to the bivariate analysis, antipsychotic users enrolled in PDPs were more likely to encounter restrictions (39.8%), compared with those in MAPDs (30.3%). In the multivariate analyses, antipsychotic users in MAPDs were less likely to face any restriction (odds ratio [OR] = 0.75, 95% confidence interval [CI] 0.72-0.78). Furthermore, atypical antipsychotic users in MAPDs were less likely to face any restriction (OR = 0.76, 95% CI 0.73-0.79), while first-generation antipsychotic users in MAPDs were more likely to face any restriction (OR = 1.87, 95% CI 1.32-2.65). Low-income subsidy (LIS) beneficiaries using any antipsychotic were much more likely to face restrictions compared with non-LIS beneficiaries. CONCLUSION: PDP enrollees prescribed antipsychotics were more likely to face formulary restrictions, as opposed to those in MAPDs. LIS beneficiaries enrolled in PDPs faced much higher risk of restricted access to this "protected" drug class.

How Low-Income Subsidy Recipients Respond to Medicare Part D Cost Sharing.

OBJECTIVES: To determine the magnitude and mechanisms of response to Medicare Part D cost sharing by low-income subsidy (LIS) recipients using oral hypoglycemic agents (OHAs) and statins. DATA SOURCES: Medicare data for a 5 percent random sample of beneficiaries with diabetes enrolled in fee-for-service Part D drug plans in 2008. STUDY DESIGN: We evaluated the impact of differences between generic and brand cost sharing rates among cohorts of LIS and non-LIS recipients to determine if wider price spreads increased the generic dispensing rate (GDR) and reduced total drug use and cost. PRINCIPAL FINDINGS: We found little association between cost sharing and aggregate OHA and statin use. In adjusted analyses, non-LIS beneficiaries who paid 46 percent of total OHA costs had 2.5 percent fewer OHA days supply than full benefit dual eligibles who paid just 5 percent of their therapy costs. For statins, the difference in days supply between those facing the lowest and highest cost sharing was 4.6 percent. Higher cost sharing was associated with filling fewer but larger prescriptions for both generics and brands. CONCLUSIONS: Higher generic and brand copays had little association with OHA and statin use among LIS recipients. This implies that modest changes in required cost sharing for these medicines would have very little substantive impact on generic dispensing or utilization patterns among LIS recipients and thus would have little effect on total program spending. At the same time, any increases in out-of-pocket costs would be expected to shift costs and place greater financial burden on low-income beneficiaries, particularly those in poor health.

Examining patient-provider relationship (PPR) quality and patient activation in the Medicare population.

BACKGROUND: Patient activation describes an individual's willingness and ability to take actions to independently manage health. Additional qualities of the relationship between a patient and provider may play a role in patient decision-making and motivation. AIMS: (1) To describe patient characteristics for groups who perceive different quality levels of PPR. (2) To examine the association and determine the effect of PPR on patient activation. METHODS: The Medicare Current Beneficiary Surveys was used to gather information on patient confidence, information seeking behaviors, and PPR. Scores for each variable set were categorized and described. Odds ratios were calculated using multinomial logistic regression models adjusting for sociodemographic variables. RESULTS: The study included 15,185 beneficiaries, 4198 (27.6 %) were categorized as low PPR, 6752 (44.5 %) were moderate PPR, and 4235 (27.9 %) high PPR. Adjusting for covariates, patients with moderate PPR and high PPR were more likely to have higher confidence when making healthcare decisions and exhibit information seeking behaviors compared to low PPR beneficiaries. DISCUSSION: This study supports the notion that patients with stronger relationships with their providers are also more active in healthcare decisions. After adjusting for gender, race, age, education, and income, high-quality PPR was still found to be associated with increased levels of activation in the Medicare population. CONCLUSIONS: High-quality patient-provider relationships are associated with improved patient confidence and information seeking behaviors. Provider-centered strategies to improve patients' connections to their physicians may motivate patients to engage in the healthcare process.

Quantifying the Cost of Disability Transitions in Medicare.

OBJECTIVE: To investigate the impact of disability transitions on annual Medicare Part A and B cost. METHOD: We analyzed 6,385 community-dwelling beneficiaries who were continuously enrolled in fee-for-service Medicare Part A and B from 2008 to 2009. We estimated adjusted effects of disability transitions on Medicare cost using a generalized linear model. RESULTS: Transitions to more severe disability states were associated with significantly higher average annual Medicare cost ranging from US$2,639 to US$5,405. Lower spending levels were observed for beneficiaries with improvements in functioning. Beneficiaries who transitioned from severe to moderate activities of daily living (ADLs) disability cost significantly less (-US$6,045) than those who remained severely disabled. DISCUSSION: Interventions aimed at preventing disability progression and efforts to restore functional capacity are promising strategies for containing costs and generating savings for Medicare. Future research is needed to assess the longer term impact of disability in association with the progression of chronic conditions.

Redaction of Substance Abuse Claims in Medicare Research Files Affects Spending Outcomes for Nearly One in Five Beneficiaries with Serious Mental Illness.

OBJECTIVE: To assess the impact of substance abuse claims redaction on Medicare spending estimates for beneficiaries with serious mental illness. DATA SOURCES: The 2012 claims and unredacted beneficiary-level Medicare spending totals from CMS's Chronic Conditions Warehouse. STUDY DESIGN: We identified beneficiaries with claims affected by the redaction by comparing claims-based spending estimates to unredacted spending totals. Differences in characteristics of beneficiaries with and without redacted claims were examined in bivariate analyses. PRINCIPAL FINDINGS: Claims-based spending totals differed from unredacted totals for 19.7 percent of the cohort. Part A spending for those with redacted claims was underreported by 57.0 percent. Characteristics of beneficiaries with and without redacted claims differed significantly. CONCLUSIONS: Researchers who rely on Medicare claims to analyze spending outcomes for beneficiaries with serious mental illness should be aware of the potential for bias due to nonrandom redaction of substance abuse data.