Examining access to care for younger vs. older dual-eligible adults living in the community.

BACKGROUND: Recent state dual-eligible (Medicare and Medicaid) payment reform demonstrations have included groups of both working-age and older adults, but relatively little is known about how access to care varies between these two populations. OBJECTIVES/HYPOTHESIS: To examine access to a usual source of care for younger and older dual-eligible adults, to analyze whether timely access to several types of care differed in these two populations, and to understand some of the underlying reasons for delayed care among younger and older dual-eligibles. METHODS: Using observations pooled across calendar years 2003-2012 of the Medical Expenditure Panel Survey, this study conducted descriptive and multivariate analyses to examine access to care measures. RESULTS: Younger dual-eligible adults were more likely to encounter problems with accessing medical care, dental care, and prescription medications than older dual-eligible adults. Both groups of dual-eligible adults reported that a lack of affordability, gaps in existing insurance coverage, and difficulty in getting to a provider's office were the most common reasons for delayed access to care. CONCLUSIONS: A lack of affordability for medical care, dental care, and prescription medications suggests that high co-payments and cost sharing for some services may be deterring access to needed care. Younger dual-eligibles were more likely to encounter service coverage gaps than older dual-eligibles. States should monitor Medicare-Medicaid plans to confirm they have adequate provider networks.

Return to work: a critical aspect of care coordination for younger dual eligibles.

BACKGROUND: Annual health care costs for dual eligibles now top $300 billion. Many dual eligibles are under age 65 and their needs differ significantly from retired elderly dual eligibles. For younger dual eligibles, successful return to work is an important objective for coordinated care. OBJECTIVES: To assess relative rates of dual eligibility by age group and program enrollment (SSDI or OASI), and to identify the prevalence among these subgroups of factors associated with return to work. METHODS: Population estimates and logistic regression analysis of the 2010 Medicare Current Beneficiary Survey (MCBS). RESULTS: Although they make up only 16% of the total Medicare beneficiary population, disabled workers under age 65 constitute 42% of all dual eligibles. SSDI beneficiaries under age 45 have 20 times greater odds of receiving Medicaid benefits compared to retirees (AOR = 19.8, 95% CI = 16.2-24.2). The youngest dual eligible adults are more likely to work, have fewer chronic conditions, and report better health status than other dual eligibles. However, they are more likely to report problems with obtaining health care and be dissatisfied with the quality of the care they receive. CONCLUSIONS: Dual eligible workers with disabilities are an important target population for coordinated services because of their high lifetime program costs - many will receive SSDI, SSI, Medicare, and Medicaid benefits for decades. Return to work and continued employment are important policy objectives for younger dual eligibles and should provide the greatest return in terms of reduced dependence on federal disability programs.

Cost-related nonadherence in the Medicare program: the impact of Part D.

BACKGROUND: Cost-related nonadherence (CRN) among Medicare beneficiaries declined after the implementation of the Part D program, but it is unknown whether CRN changes varied on the basis of beneficiaries' change in drug coverage. OBJECTIVE: To determine how CRN changed with the introduction of Part D, and whether CRN changes from 2005 to 2006 varied between newly insured beneficiaries, continuously insured beneficiaries, and continuously uninsured beneficiaries. METHODS: CRN, drug coverage, and beneficiary characteristics in 2005 and 2006 were constructed from merged Medicare Current Beneficiary Survey Access to Care files (sample, n=8935). Change in CRN was modeled using multinomial logistic regression to identify predictors of resolved CRN (reported in 2005 but not in 2006), unresolved CRN (reported in 2005 and 2006), and new CRN (reported in 2006 but not in 2005), relative to no CRN (not reported in 2005 or 2006). RESULTS: Rates of CRN declined from 2005 to 2006 for all beneficiaries, with the greatest reductions (from 22.1% in 2005 to 14.3% in 2006) for newly insured beneficiaries who gained drug coverage through Part D. In adjusted analyses, newly insured beneficiaries were more likely to have resolved CRN (adjusted odds ratio [AOR] =1.7; 95% confidence interval, 1.3-2.2). Younger beneficiaries (under the age of 65 years) and beneficiaries with multiple chronic conditions, poor health, and depression were significantly more likely to report CRN. CONCLUSIONS: Part D coverage reduced but did not eliminate CRN for newly insured beneficiaries. Unresolved CRN persisted for newly insured and continuously uninsured beneficiaries, particularly among disabled beneficiaries.

Medicare prescription drug plan coverage of pharmacotherapies for opioid and alcohol dependence in WA.

OBJECTIVES: Pharmacotherapeutic treatments for drug addiction offer new options, but only if they are affordable for patients. The objective of this study is to assess the current availability and cost of five common antiaddiction medications in the largest federal medication insurance program in the US, Medicare Part D. METHODS: In early 2010, we collected coverage and cost data from 41 Medicare Part D prescription drug plans (PDPs) and 45 Medicare Advantage Plans (MAPs) in Washington State. RESULTS: The great majority of Medicare plans (82-100%) covered common pharmacotherapeutic treatments for drug addiction. These Medicare plans typically placed patent protected medications on their highest formulary tiers, leading to relatively high patient co-payments during the initial Part D coverage period. For example, median monthly co-payments for buprenorphine (Suboxone®) were about $46 for PDPs, and about $56 for MAPs. CONCLUSION: While Medicare prescription plans usually cover pharmacotherapeutic treatments for drug addiction, high co-payments can limit access. For example, beneficiaries without supplemental coverage who use Vivitrol® would exceed their initial coverage cap in 7-8 months, reaching the "doughnut hole" in their Part D coverage and becoming responsible for the full cost of the medication (over $900 per month). The 2010 Patient Protection and Affordable Care Act will gradually eliminate this coverage gap, and loss of patent protection for other antiaddiction medications (Suboxone® and Campral®) should also drive down patient costs, improving access and compliance.

The association between class of antipsychotic and rates of hospitalization: results of a retrospective analysis of data from the 2005 Medicare current beneficiary survey.

BACKGROUND: When second-generation antipsychotics (SGAs), also called atypical antipsychotics, were introduced in the 1990s, early research suggested that these drugs offered better tolerability and adherence than first-generation antipsychotics (FGAs), or typical antipsychotics. This presumably would reduce the need for hospital services. However, health research to test this hypothesis has focused mostly on psychiatric readmissions. OBJECTIVE: The objective of this study was to compare rates of all-cause hospitalization among patients receiving different classes of antipsychotics (SGAs, FGAs, both, or neither) in a large, all-ages sample of both institutionalized and noninstitutionalized Medicare beneficiaries. METHODS: We examined the 2005 Medicare Current Beneficiary Survey Cost and Use file for 11,236 survey participants. Antipsychotic utilization was characterized in terms of class: FGA (ie, chlorpromazine, fluphenazine, haloperidol, loxapine, perphenazine, thiothixene, thioridazine, or trifluoperazine) or SGA (ie, aripiprazole, clozapine, olanzapine, quetiapine, risperidone, or ziprasidone). Hospitalization was defined in terms of whether a Medicare beneficiary was admitted to the hospital for any reason in 2005, and was measured in terms of the number of hospital visits. In our final model, we included the following confounding variables: disability status (> or =1 limitation in activities of daily living), Rosow-Breslau impairment score (difficulty with walking, stooping, crouching, kneeling, or doing heavy housework), cognitive impairment (diagnosis of Alzheimer's disease or memory loss that interfered with daily activity), and health behavior variables (body mass index and smoking status). RESULTS: A total of 3.5% of Medicare beneficiaries (1.3 million) filled > or =1 prescription for an antipsychotic medication in 2005. Controlling for demographic, socioeconomic, health, and disability variables, SGA-only users were more than twice as likely (odds ratio [OR] = 2.2 [95% CI, 1.7-2.9]) and combination users were more than 6 times as likely (OR = 6.3 [95% CI, 2.4-16.2]) as nonusers to be hospitalized. The odds of FGA users being hospitalized were not significantly different from nonusers (OR = 1.4 [95% CI, 0.7-2.8]). CONCLUSIONS: This analysis yielded provocative, but by no means conclusive, evidence that SGAs as a class are not necessarily superior to FGAs in mitigating patient's use of hospital services under real-world conditions. Systematic analysis of this relationship with a large, multiple-year sample of Medicare beneficiaries is warranted.