The association between cost sharing, prior authorization, and specialty drug utilization: A systematic review.

BACKGROUND: Specialty drugs are identified by high monthly costs and complexity of administration. Payers use utilization management strategies, including prior authorization and separate tiers with higher cost sharing, to control spending. These strategies can negatively impact patients' health outcomes through treatment initiation delays, medication abandonment, and nonadherence. OBJECTIVE: To examine the effect of patient cost sharing on specialty drug utilization and the effect of prior authorization on treatment delay and specialty drug utilization. METHODS: We conducted a literature search in the period between February 2021 and April 2022 using PubMed for articles published in English without restriction on date of publication. We included research papers with prior authorization and cost sharing for specialty drugs as exposure variables and specialty drug utilization as the outcome variable. Studies were reviewed by 2 independent reviewers and relevant information from eligible studies was extracted using a standardized form and approved by 2 reviewers. Review papers, opinion pieces, and projects without data were excluded. RESULTS: Forty-four studies were included in this review after screening and exclusions, 9 on prior authorization and 35 on cost sharing. Patients with lower cost sharing via patient support programs experienced higher adherence, fewer days to fill prescriptions, and lower discontinuation rates. Similar outcomes were noted for patients on low-income subsidy programs. Increasing cost sharing above $100 was associated with up to 75% abandonment rate for certain specialty drugs. This increased level of cost sharing was also associated with higher discontinuation rates and odds. At the same time, decreasing out-of-pocket costs increased initiation of specialty drugs. However, inconsistent results on impact of cost sharing on medication possession ratio (MPR) and proportion of days covered (PDC) were reported. Some studies reported a negative association between higher costs and MPR and PDC; however, MPR and PDC of cancer specialty drugs did not decrease with higher costs. Significant delays in prescription initiation were reported when prior authorization was needed. CONCLUSIONS: Higher levels of patient cost sharing reduce specialty drug use by increasing medication abandonment while generally decreasing initiation and persistence. Similarly, programs that reduce patient cost sharing increase initiation and persistence. In contrast, cost sharing had an inconsistent and bidirectional effect on MPR and PDC. Prior authorization caused treatment delays, but its effects on specialty drug use varied. More research is needed to examine the effect of cost sharing and prior authorization on long-term health outcomes.

A qualitative exploration of patient preferences for Medicare Part D consultation services offered in a community pharmacy setting.

BACKGROUND: Community pharmacies currently offer Medicare Part D consultation services to help eligible beneficiaries select prescription medication insurance. Despite these service offerings, there is a paucity of information on patient preferences for these service offerings and optimal service delivery from the patient perspective. OBJECTIVES: The objectives of this study were to (1) evaluate patient expectations of and willingness-to-pay (WTP) for community pharmacy Medicare Part D consultation services, (2) identify components of Medicare Part D consultation services associated with service quality, and (3) explore differences in preferences and service expectations between services-experienced and service-naive patients. METHODS: This was a qualitative exploratory study, with data collected using interviews and a follow-up supplemental survey with participants recruited from 5 community pharmacies across the state of Iowa participating in the Community Pharmacy Enhanced Services Network. A total of 17 patients contacted the research team for participation. Interviews were recorded and transcribed, with qualitative data analysis performed using template analysis guided by the SERVQUAL framework. Interview participants were invited to complete a supplemental survey. Descriptive statistics and frequencies were generated for survey items. Service-experienced and service-naive survey responses Pearson chi-square and Welch t tests were used to determine significant differences between service-experienced and service-naive responses for categorical and continuous variables, respectively. RESULTS: In total, all 17 patients who contacted the research team agreed to participate in interviews, with 8 service-experienced and 9 service-naive interviews completed. Template analysis identified 14 subdomains across the SERVQUAL domains. Similarities and differences in service preferences between groups were identified, focusing on patient-pharmacist trust, past service experience, and WTP. All interview participants completed supplemental surveys, with no statistically significant differences between service-experienced and service-naive participant characteristics identified. CONCLUSIONS: Service-experienced patients emphasized components of the service that contribute to service quality and generally reported higher WTP values. Many service-naive patients were unaware community pharmacies provided consultation services, suggesting that pharmacists may benefit from considering how services are offered to patients based on the specific preferences and expectations and consider ways to increase awareness of service offerings.

Iowa community pharmacies' experiences with Medicaid managed care.

OBJECTIVES: To describe Iowa community pharmacies' experiences and satisfaction with the transition to Medicaid managed care and conduct a qualitative evaluation of the effect of Medicaid managed care on 3 independent community pharmacies. DESIGN: Cross-sectional descriptive study. Mixed methods were used: the quantitative phase was a mailed survey and the qualitative phase involved interviews. SETTING AND PARTICIPANTS: The mail survey was sent to Iowa-registered community pharmacies whose names and addresses were obtained from the Iowa Board of Pharmacy website. Interviews with pharmacists and other pharmacy staff were conducted at 3 Iowa independent community pharmacies. OUTCOME MEASURES: Pharmacy satisfaction and experiences with the Iowa Medicaid managed care program. RESULTS: The 265 returned surveys yielded a 27.4% response rate. Eight pharmacists and pharmacy staff were interviewed in the qualitative phase. Mean satisfaction with the Medicaid managed care organizations (MCOs) was 3.1 on a scale of 1-7, with 1 being extremely dissatisfied, and 7 being extremely satisfied. Respondents were most satisfied with the ease of joining the plans' pharmacy networks (mean = 4.1) and least satisfied with the availability of payment for nondispensing-related services (2.3), plans' communication with patients (2.7), and plans' communication with pharmacies (3.0). Pharmacies also reported problems with patients' access to prescriptions. The MCOs ranked lowest in satisfaction when compared with the largest private payer, the largest Medicare Part D plan, and the previous state-run Medicaid program. The themes that emerged from the interviews were as follows: confusion caused by multiple MCOs, plan-communication challenges, product-coverage challenges, problems related to durable medical equipment, and payment challenges. CONCLUSION: The transition from a state-run fee-for-service Medicaid program to Medicaid managed care in Iowa created many challenges for community pharmacies. Different procedures and product coverage across the 3 MCOs were particularly problematic.

Framework for assessing pharmacy value.

INTRODUCTION: Excess spending and poor quality in the US healthcare system has led to proliferation of performance-based payment models. These models have the potential to enhance value by creating a meritocratic system whereby providers delivering the best patient care are rewarded, while providers failing to provide such care are given incentives to improve. However, early experience suggests that unless these systems are appropriately designed, payments can be withheld from high performers, bonuses paid to low performers, and health disparities can be worsened. Performance-based payments are new to community pharmacies, and opportunity exists to strengthen pharmacy value measurement and potentially avoid problems observed with other performance-based payment models. MODEL CONSTRUCTION AND APPLICATION: This article describes the process by which a framework to assess community pharmacy value was developed, then applies the framework to produce a draft composite pharmacy performance measure. The pharmacy value framework addresses potential shortcomings of existing community pharmacy performance measures through four key principles: 1) theory-based quality and spending measures, 2) scoring which accounts for measure reliability, 3) full risk-adjustment, and 4) a value matrix to identify high and low value pharmacies. Based on these principles, a draft community pharmacy composite performance measure was developed, and was successful in dividing community pharmacies into high, typical, and low value categories. CONCLUSION: By using this framework to develop future composite measures, payers may find closer alignment between performance-based payments and actual pharmacy performance. This early work is intended to encourage further research into the establishment of a scientifically firm foundation for pharmacy performance measurement. More testing is needed to determine reliability, validity, and comparative superiority of any composite measure derived from this framework before it is used to support performance-based pharmacy payment models.

Informal learning processes in support of clinical service delivery in a service-oriented community pharmacy.

The evolving health care system necessitates pharmacy organizations' adjustments by delivering new services and establishing inter-organizational relationships. One approach supporting pharmacy organizations in making changes may be informal learning by technicians, pharmacists, and pharmacy owners. Informal learning is characterized by a four-step cycle including intent to learn, action, feedback, and reflection. This framework helps explain individual and organizational factors that influence learning processes within an organization as well as the individual and organizational outcomes of those learning processes. A case study of an Iowa independent community pharmacy with years of experience in offering patient care services was made. Nine semi-structured interviews with pharmacy personnel revealed initial evidence in support of the informal learning model in practice. Future research could investigate more fully the informal learning model in delivery of patient care services in community pharmacies.

Provider Visits for Asthma: Potential Barriers for Insured Children.

OBJECTIVE: The barriers to provider visits for asthma in insured children are not well understood. Our objective was to examine the relationship between parent, family, and child attributes and asthma visits in insured children. METHODS: This retrospective, cross-sectional analysis of 2007 Medical Expenditure Panel Survey-Household Component data included insured children 0-17 years old reported to have active asthma. We summed the number of provider visits during which asthma was treated or diagnosed to represent the frequency of asthma visits during the year. Probit models were used to estimate the relationship between parent, family, and child attributes and asthma visits. RESULTS: Seventy percent of the 542 children did not have an asthma visit during the year. Children with parents employed full time were 16 percentage points less likely to have an asthma visit than children whose parents were not working (P=.01). CONCLUSION: Many insured children go more than a year without seeing a provider for their asthma, signaling that insurance is not sufficient to guarantee children will receive asthma monitoring. The attributes related to asthma visits suggest potential barriers that providers might want to consider to increase participation in asthma visits.

The role of satisfaction and switching costs in Medicare Part D choices.

BACKGROUND: Most U.S. states had over 50 Medicare Prescription Drug Plans (PDPs) in 2007. Medicare beneficiaries are expected to switch Part D plans based on their health and financial needs; however, the switching rate has been low. Such consumer inertia potentially has negative effects on both beneficiaries and the insurance market, resulting in a critical need to investigate its cause. OBJECTIVES: To 1) describe how Medicare beneficiaries who were satisfied with their current Part D plan differed from those who were not satisfied; 2) examine the effect of switching costs on consideration of switching among Medicare beneficiaries who were dissatisfied with their current Part D plan. METHODS: Data from the 2007 Prescription Drug Study supplement to the Health and Retirement Study (HRS) survey were used in this study. The satisfied and dissatisfied groups were compared in terms of cost variables, switching costs, and perception of Part D complexity. Structural equation modeling was used to examine relationships among switching costs, Part D complexity, cost variables, and consideration of switching for beneficiaries who were dissatisfied with their current Part D coverage. RESULTS: Out of 467 participants, a total of 255 (54.6%) were satisfied with their current Part D plan. The satisfied group paid lower out-of-pocket costs ($50.63 vs. $114.60) and premiums ($30.88 vs. $40.77) than the dissatisfied group. They also had lower switching costs. Only 11.3% of the dissatisfied beneficiaries switched plans. Among respondents who were dissatisfied with their current plan, those who perceived Part D as complex had high switching costs and were less likely to consider switching plans. Out-of-pocket cost did not have a statistically significant association with consideration of switching. CONCLUSIONS: Medicare beneficiaries who were satisfied with their current Part D plans had lower out-of-pocket costs and premiums as well as higher switching costs. Among beneficiaries who were dissatisfied with their current Part D plan, those who had higher switching costs were less likely to consider switching Part D plans.

Factors related to receipt of well-child visits in insured children.

Our objective was to identify factors related to receipt of the recommended number of well-child visits in insured children. We hypothesized parent insurance status would be related to receipt of well-child visits, with those with uninsured parents more likely to have fewer visits than recommended. Data for the study came from the 2007 Medical Expenditure Panel Survey-Household Component. The sample included children <18 years of age with full-year insurance coverage and parents who were insured or uninsured the entire year. The outcome variable indicated whether children had received fewer than the recommended number of well-child visits in physician offices or outpatient departments. Parent, family, and child characteristics were measured. Forty-eight percent of the 4,650 children included in the study had fewer well-child visits than recommended. Children whose parents did not visit a physician during the year and children whose parents had not completed high school were more likely to miss recommended visits. Parent insurance status did not affect well-child visits. We identified child, family, and parent factors influencing well-child visits in insured children, including the parent's own use of physician visits. Contrary to our hypothesis, well-child visits were not influenced by parent insurance status. Determining which insured children are at greater risk of missing recommended well-child visits aids policymakers in identifying those who may benefit from interventions to improve use of preventive care.

Assessing changes in third-party gross margin for a single community pharmacy.

OBJECTIVES To assess changes in prescription gross margin from 2008 to 2011 using a random sample of prescriptions, analyze changes in prescription gross margin from 2008 to 2011 using a market basket of prescription drugs, and investigate impact of changes in prescription mix from 2008 to 2011 on prescription gross margins. DESIGN Longitudinal, retrospective, descriptive case study. SETTING Single independent pharmacy in Iowa City, IA, from March and April of 2008-11. PARTICIPANTS Prescription dispensing records for the pharmacy's largest private and Part D payers by prescription volume, as well as Medicaid and cash payers. INTERVENTION Random sampling and market basket approaches were used for gross margin calculation. MAIN OUTCOME MEASURES Prescription gross margins and generic dispensing rate. RESULTS Data were collected for 2,400 prescription records for the random sample and 4,860 prescriptions for the market basket sample. The median random sample and market basket gross margin dollars (GMDs) from 2008 to 2011 decreased from $9.55 to $7.22 and from $9.60 to $8.50, respectively. The percent of dispensed prescriptions that was generic increased from 62.65% in 2008 to 73.64% in 2011, and GMDs were significantly lower for generic products. CONCLUSION Third-party prescription drug gross margins in the study pharmacy varied substantially by payer and decreased over time. Pharmacies must continue to monitor changes in prescription margins and investigate ways to enhance alternative revenue sources to maintain profitability.

Exploring relationships among pharmacy service use, patronage motives, and patient satisfaction.

OBJECTIVES: To describe and identify significant relationships among pharmacy service use, general and service-specific patient satisfaction, pharmacy patronage motives, and marketing awareness in a service-oriented, independent community pharmacy. DESIGN: Cross-sectional study. SETTING: Midwest United States during May through July 2011. PARTICIPANTS: Stratified random sample of 500 participants. INTERVENTION: Self-reported questionnaire mailed to participants. MAIN OUTCOME MEASURES: Patient satisfaction, pharmacy service use, patronage motives, marketing awareness, and demographics. RESULTS: Study participants were mostly satisfied with the pharmacy services on global and service-specific measures. Patronage motives of relationships, pharmacy atmosphere, and quality previous experience were associated with increased pharmacy service use at the study pharmacy, while a unique service patronage motivation was associated with decreased pharmacy service use at the study pharmacy. Participants citing pharmacy atmosphere and personnel competency as patronage motives did not use pharmacies other than the study pharmacy more often, whereas participants citing unique services as a patronage motive used pharmacies other than the study pharmacy more often. Direct marketing awareness increased pharmacy service awareness but not use. CONCLUSION: Offering unique services may not be enough to bring in patients loyal to all services provided in a pharmacy. Pharmacists should focus on developing strong relationships with patients and conveying competence when delivering appropriate, quality pharmacy services in a professional pharmacy atmosphere.

Three-year financial analysis of pharmacy services at an independent community pharmacy.

OBJECTIVE: To assess the financial performance of pharmacy services including vaccinations, cholesterol screenings, medication therapy management (MTM), adherence management services, employee health fairs, and compounding services provided by an independent community pharmacy. METHODS: Three years (2008-10) of pharmacy records were examined to determine the total revenue and costs of each service. Costs included products, materials, labor, marketing, overhead, equipment, reference materials, and fax/phone usage. Costs were allocated to each service using accepted principles (e.g., time for labor). Depending on the service, the total revenue was calculated by multiplying the frequency of the service by the revenue per patient or by adding the total revenue received. A sensitivity analysis was conducted for the adherence management services to account for average dispensing net profit. RESULTS: 7 of 11 pharmacy services showed a net profit each year. Those services include influenza and herpes zoster immunization services, MTM, two adherence management services, employee health fairs, and prescription compounding services. The services that realized a net loss included the pneumococcal immunization service, cholesterol screenings, and two adherence management services. The sensitivity analysis showed that all adherence services had a net gain when average dispensing net profit was included. CONCLUSION: Most of the pharmacist services had an annual positive net gain. It seems likely that these services can be sustained. Further cost management, such as reducing labor costs, could improve the viability of services with net losses. However, even with greater efficiency, external factors such as competition and reimbursement challenge the sustainability of these services.

Does bargaining affect Medicare prescription drug plan reimbursements to independent pharmacies?

OBJECTIVE: To examine how pharmacy bargaining activities affect reimbursement rates in Medicare Part D prescription drug plan (PDP) contracts, controlling for pharmacy quality attributes, market structures, and area socioeconomic status. DESIGN: Cross-sectional study. SETTING: Six Medicare regions throughout the United States between October and December 2009. PARTICIPANTS: Random sample of 1,650 independent pharmacies; 321 returned surveys containing sufficient responses for analysis. INTERVENTION: Pharmacies were surveyed regarding PDP reimbursement rates, costs, and cash prices of two popular prescription drugs (atorvastatin calcium [Lipitor-Pfizer] and lisinopril, 1-month supply of a common strength), as well as pharmacy bargaining activities and quality attributes. Data also were used from the National Council for Prescription Drug Programs pharmacy database, the 2000 U. S. Census, and the 2006 Economic Census on local market structures and area socio-economic status. MAIN OUTCOME MEASURE: PDP reimbursement rates. RESULTS: For the brand-name drug atorvastatin calcium, the PDP reimbursement was positively related to a pharmacy's request for a contract change (ß = 0.887, P < 0.05), whereas other bargaining activities were not significantly related to PDP reimbursement. However, for the generic drug lisinopril, no bargaining activities were found to be significantly related to the PDP reimbursement. CONCLUSION: Pharmacy request for a contract change was associated with higher reimbursement rates for the brand-name drug atorvastatin calcium in PDP contracts, after controlling for pharmacy quality attributes, local market structures, and area socioeconomic status; this finding likely applies to other brand-name drugs because of the structure of the contracts. Our results suggest that independent pharmacies are more likely to acquire higher reimbursement rates by engaging in active bargaining with third-party payers.

Racial variation in willingness to trade financial resources for life-prolonging cancer treatment.

BACKGROUND: Minority patients receive more aggressive care at the end of life, but it is unclear whether this trend is consistent with their preferences. We compared the willingness to use personal financial resources to extend life among white, black, Hispanic, and Asian cancer patients. METHODS: Patients with newly diagnosed lung or colorectal cancer participating in the Cancer Care Outcomes Research and Surveillance observational study were interviewed about myriad aspects of their care, including their willingness to expend personal financial resources to prolong life. We evaluated the association of race/ethnicity with preference for life-extending treatment controlling for clinical, sociodemographic, and psychosocial factors using logistic regression. RESULTS: Among patients (N = 4214), 80% of blacks reported a willingness to spend all resources to extend life, versus 54% of whites, 69% of Hispanics, and 72% of Asians (P<.001). In multivariate analyses, blacks were more likely to opt for expending all financial resources to extend life than whites (odds ratio, 2.41; 95% confidence interval, 1.84-3.17; P < .001). CONCLUSIONS: Black cancer patients are more willing to exhaust personal financial resources to extend life. Delivering quality cancer care requires an understanding of how these preferences impact cancer care and outcomes.

Effect of Medicare Part D and insurance type on Medicare beneficiary access to prescription medication and use of prescription cost-saving measures.

OBJECTIVES: To examine how prescription drug access and use of prescription cost-saving measures changed after Medicare Part D was implemented and to determine their predictors in Medicare beneficiaries with different insurance types. DESIGN: Repeated cross-sectional study. SETTING: United States in 2005 and 2007. PATIENTS: Medicare beneficiaries aged 65 years or older (n = 1,220 in 2005 and n = 1,024 in 2007). INTERVENTION: Web-based surveys using nonprobability samples. MAIN OUTCOME MEASURES: Access to prescription drugs and use of seven costsaving measures. RESULTS: Significantly fewer participants stopped taking a prescription because of cost, applied to an assistance program, received free prescription samples, and had limited prescription access in 2007 compared with 2005. Use of cost-saving measures by Medicare Part D patients was more comparable with that by uninsured participants than patients with employer-based drug coverage. One-third of all participants and almost one-half of Medicare Part D participants had requested a less expensive prescription. Among those participants, 70% received a less expensive prescription and most thought it worked about the same as the more expensive prescription. CONCLUSION: Prescription drug access and use of cost-saving measures improved somewhat following the implementation of Medicare Part D, but some access problems continued to exist for Part D participants. Requests for less expensive prescriptions were common and frequently resulted in satisfactory switches.

Patients' experiences with care for lung cancer and colorectal cancer: findings from the Cancer Care Outcomes Research and Surveillance Consortium.

PURPOSE: To assess patients' experiences with cancer care, ratings of their quality of care, and correlates of these assessments. PATIENTS AND METHODS: For 4,093 patients with lung cancer and 3,685 patients with colorectal cancer in multiple US regions and health care delivery systems, we conducted telephone surveys of patients or their surrogates in English, Spanish, or Chinese at 4 to 7 months after diagnosis. The surveys assessed ratings of the overall quality of cancer care and experiences with three domains of interpersonal care (physician communication, nursing care, and coordination and responsiveness of care). RESULTS: English-speaking Asian/Pacific Islander patients and Chinese-speaking patients and those in worse health reported significantly worse adjusted experiences with all three domains of interpersonal care, whereas white, black, and Hispanic patients reported generally similar experiences with interpersonal care. The overall quality of cancer care was rated as excellent by 44.4% of patients with lung cancer and 53.0% of patients with colorectal cancer, and these ratings were most strongly correlated with positive experiences with coordination and responsiveness of care (Spearman rank coefficients of 0.49 and 0.42 for lung and colorectal cancer, respectively). After multivariate adjustment, excellent ratings were less common for each cancer among black patients, English-speaking Asian/Pacific Islander patients, Chinese-speaking patients, and patients reporting worse health status (all P ≤ .05). CONCLUSION: Patients' reports and ratings of care differed significantly by race, language, and health status. Efforts to improve patients' experiences with cancer care should focus on problems affecting Asian and Pacific Islander patients and those in worse health.

Impact of cost sharing on prescription drugs used by Medicare beneficiaries.

BACKGROUND: Incentive-based prescription drug cost sharing can encourage seniors to use generic medications. Little information exists about prescription drug cost sharing and generic use in employer-sponsored plans after the implementation of Medicare Part D. OBJECTIVES: To compare prescription drug cost sharing across prescription insurance type for Medicare beneficiaries after Medicare Part D, to assess the impact of that cost sharing on the number of medications used, and to examine how generic utilization rates differ before and after Medicare Part D and across the type of insurance. METHODS: This longitudinal study of Medicare beneficiaries aged 65 years and older used Web-based surveys administered in 2005 and 2007 by Harris Interactive((R)) to collect information on prescription drug coverage and medication use. Co-payment plans were categorized as low, medium, or high co-payment plans. Multiple regression was used to assess the impact of co-payment rank on the number of prescription drugs. t-Tests and analysis of variance were used to compare generic use over time and between coverage types. RESULTS: One thousand two hundred twenty and 1024 respondents completed the baseline and follow-up surveys, respectively. Among 3-tier co-payment plans, brand drug co-payments were higher for Part D plans ($26 for preferred brand and $55 for nonpreferred brand) than employer-based plans ($20 for preferred brand and $39 for nonpreferred brand). Co-payment was not a significant predictor for the number of prescription drugs. Generic use was lowest among beneficiaries in employer plans both before and after Part D. In 2007, generic use among beneficiaries with Part D was not significantly different from the generic use for beneficiaries with no drug coverage. CONCLUSIONS: Medicare beneficiaries in Part D had higher cost sharing amounts than those with employer coverage, but higher cost sharing was not significantly linked to lower prescription use. Generic use for Part D beneficiaries was higher than that for beneficiaries with employer coverage but the same as that for beneficiaries without drug coverage.

Factors associated with independent pharmacy owners' satisfaction with Medicare Part D contracts.

BACKGROUND: As Medicare Part D contracts apply pressure on the profitability of independent pharmacies, there is concern about their owners' willingness to sign such contracts. Identifying factors affecting independent pharmacy owners' satisfaction with Medicare Part D contracts could inform policy makers in managing Medicare Part D. OBJECTIVES: (1) To identify influences on independent pharmacy owners' satisfaction with Medicare Part D contracts and (2) to characterize comments made by independent pharmacy owners about Medicare Part D. METHODS: This cross-sectional study used a mail survey of independent pharmacy owners in 15 states comprising 6 Medicare regions to collect information on their most- and least-favorable Medicare Part D contracts, including satisfaction, contract management activities, market position, pharmacy operation, and specific payment levels on brand and generic drugs. RESULTS: Of the 1649 surveys mailed, 296 surveys were analyzed. The regression models for satisfaction with both the least and the most-favorable Part D contracts were significant (P<0.05). A different set of significant influences on satisfaction was identified for each regression model. For the most-favorable contract, influences were contending and equity. For the least-favorable contract, influences were negotiation, equity, generic rate bonus, and medication therapy management (MTM) payment. About one-third of the survey respondents made at least 1 comment. The most frequent themes in the comments were that Medicare Part D reimbursement rate is too low (28%) and that contracts are offered without negotiation in a "take it or leave it" manner (20%). CONCLUSION: Equity, contending, negotiation, generic rate bonus, and MTM payments were identified as the influences of independent pharmacy owners' satisfaction toward Medicare Part D contracts. Generic rate bonus and MTM payment provide additional financial incentives to less financially favorable contracts and, in turn, contribute to independent pharmacy owner's satisfaction toward these contracts.

Retail pharmacy market structure and insurer-independent pharmacy bargaining in the Medicare Part D era.

OBJECTIVE: To examine whether local area pharmacy market structure influences contract terms between prescription drug plans (PDPs) and pharmacies under Part D. DATA: Data were collected and compiled from four sources: a national mail survey to independent pharmacies, National Councilfor Prescription Drug Programs (NCPDP) Pharmacy database, 2000 U.S. Census data, and 2006 Economic Census data. RESULTS: Reimbursements varied substantially across pharmacies. Reimbursement for 20mg Lipitor (30 tablets) ranged from $62.40 to $154.80, and for 10mg Lisinopril (30 tablets), it ranged from $1.05 to $18. For brand-name drug Lipitor, local area pharmacy ownership concentration had a consistent positive effect on pharmacy bargaining power across model specifications (estimates between 0.084 and 0.097), while local area per capita income had a consistent negative effect on pharmacy bargaining power across specifications(-0.149 to -0.153). Few statistically significant relationships were found for generic drug Lisinopril. CONCLUSION: Significant variation exists in PDP reimbursement and pharmacy bargaining power with PDPs. Pharmacy bargaining power is negatively related to the competition level and the income level in the area. These relationships are stronger for brand name than for generics. As contract offers tend to be non-negotiable, variation in reimbursements and pharmacy bargaining power reflect differences in initial insurer contract offerings. Such observations fit Rubinstein's subgame perfect equilibrium model. IMPLICATION: Our results suggest pharmacies at the most risk of closing due to low reimbursements are in areas with many competing pharmacies. This implies that closures related to Part D changes will have limited effect on Medicare beneficiaries' access to pharmacies.

Risk factors of self-reported adverse drug events among Medicare enrollees before and after Medicare Part D / Factores de riesgo de eventos adversas medicamentosos autoreportados entre asegurados en Medicare antes y después de Medicare Part D

Objectives: Quantify risk factors for self-reported adverse drug events (ADEs) after the implementation of Medicare Part D, quantify self-reported ADEs before and after Medicare Part D and quantify the association between self-reported ADEs and increased use of prescription medication. Methods: The design was a longitudinal study including an internet survey before Medicare Part D in 2005 (n=1220) and a follow-up survey in 2007 (n=1024), with n=436 responding to both surveys. Harris Interactive® invited individuals in their online panel to participate in this study. Individuals who were 65 or older, English speakers, US residents and enrolled in Medicare were included. Data collected and used in analysis included self-reported ADE, socio-demographics, self-rated health, number of medications, symptoms experienced, concern and necessity beliefs about medicines, number of pharmacies, and whether doses were skipped or stopped to save money. Results: In 2007, reporting an ADE was related to concern beliefs, symptoms experienced and age. ADEs were experienced by 18% of respondents in 2005 and 20.4% in 2007. The average number of medications increased from 3.82 (SD=2.82) in 2005 to 4.32 (SD=3.20) in 2007 (t= -5.77, p<0.001). Among respondents who answered both surveys (n=436), 18.4% reported an ADE in 2005 while 24.3% reported an ADE in 2007. The increase in self-reported ADE was related to concern beliefs (OR=1.12, 95%CI=1.05, 1.19) and symptoms experienced (OR= 3.27, 95%CI=1.60, 6.69), not number of medications (OR=1.04, 95%CI=0.77, 1.41). Conclusion: Discussing elderly patients' beliefs about their medicines may affect their medication expectations, symptom interpretation and attributions and future medication attributions (AU)

Objetivos: Cuantificar los factores de riesgo para eventos adversos medicamentosos (ADE) auto-reportados después de la implantación de Medicare Part D, cuantificar los ADE auto-reportados antes y después de Medicare Part D, y cuantificar la asociación entre ADE auto-reportados y el aumento del uso de medicamentos prescritos. Métodos: El diseño fue un estudio longitudinal incluyendo un cuestionario por internet antes de Medicare Part D en 2005 (n=1220) y una investigación de seguimiento en 2007 (n=1024), con n=436 que respondieron a los dos cuestionarios. Harris Interactive® invitó a individuos de su panel on-line a participar en este estudio. Se incluyó a individuos que tenían 65 o más 65 años, anglo-parlantes, residentes en USA y beneficiarios de Medicare. Los datos recogidos y utilizados en el análisis incluyeron los ADE auto-reportados, socio-demografía, salud auto-relatada, número de medicamentos, síntomas que sufrían, preocupaciones y creencia de la necesidad de medicinas, número de farmacias, y si se saltaban dosis o abandonaban para ahorrar dinero. Resultados: En 2007, las ADE comunicadas estaban relacionadas con creencias de problemas, síntomas manifestados y la edad. Los ADE fueron padecidos por un 18% de los respondentes en 2005 y 20,4% en 2007. La media de medicamentos aumentó de 3,82 (SD=2,82) en 2005 a 4,32 (SD=3,20) en 2007 (t= -5.77, p<0.001). Entre los respondentes que contestaron los dos cuestionarios (n=436), el 18,4% comunicó un ADE en 2005 mientras que el 24,3% comunicó un ADE en 2007. El aumento de ADE auto-reportados estaba relacionado con las creencias de problemas (OR=1.12, 95%CI=1.05, 1.19) y los síntomas manifestados (OR= 3.27, 95%CI=1.60, 6.69), pero no con el número de medicamentos (OR=1.04, 95%CI=0.77, 1.41). Conclusión: Discutir con los ancianos sus creencias sobre medicamentos puede afectar sus expectativas sobre su medicación, interpretación y atribuciones de síntomas, y futuras atribuciones de medicación (AU)