State prescription drug monitoring programs and fatal drug overdoses.

OBJECTIVES: To examine the impact of prescription drug monitoring programs (PDMPs) on drug overdose deaths. STUDY DESIGN: We used variation in the timing of state PDMP legislation and implementation to estimate the impact of these programs on drug overdose mortality rates across all drug categories from 1999 to 2014 and separately for each category from 1999 to 2010. Data used include US all-jurisdiction mortality data, estimated population data, and sociodemographic data from the CDC and the US Census Bureau. METHODS: Multivariate regression models were applied to state panel data, including state and year fixed effects and state-specific linear time trends. Preprogram tests were used to assess the common trends assumption underlying our empirical approach. RESULTS: The implementation of PDMPs was not associated with reductions in overall drug overdose or prescription opioid overdose mortality rates relative to expected rates in the absence of PDMPs. For most categories, PDMPs were associated with increased mortality rates, but the associations were statistically insignificant. In a subsample analysis of states with PDMPs in operation for 5 or more years, the programs were found to be associated with significantly higher mortality rates in legal narcotics, illicit drugs, and other and unspecified drugs. CONCLUSIONS: PDMPs were not associated with reductions in drug overdose mortality rates and may be related to increased mortality from illicit drugs and other, unspecified drugs. More comprehensive and prevention-oriented approaches may be needed to effectively reduce drug overdose deaths and avoid fatal overdoses from other drugs used as substitutes for prescription opioids.

Cumulative Advantage, Cumulative Disadvantage, and Evolving Patterns of Late-Life Inequality.

Purpose of the Study: Earlier studies have identified a pattern of cumulative advantage leading to increased within-cohort economic inequality over the life course, but there is a need to better understand how levels of inequality by age have changed in the evolving economic environment of recent decades. We utilized Survey of Income and Program Participation (SIPP) data to compare economic inequality across age groups for 2010 versus 1983-1984. Design and Methods: We examined changing age profiles of inequality using a summary measure of economic resources taking into account income, annuitized value of wealth, and household size. We adjusted for survey underreporting of some income and asset types, based on National Income Accounts and other independent estimates of national aggregates. We examined inequality by age with Gini coefficients. Results: Late-life (65+) inequality increased between the 2 periods, with Gini coefficients remaining higher than during the working years, but with a less steep age difference in inequality in 2010 than in 1983-1984. Inequality increased sharply within each cohort, particularly steeply in Depression-era, war-baby, and leading-edge baby boom cohorts. The top quintile of elderly received increasing shares of most income sources. Implications: Increasing inequality among older people, and especially in cohorts approaching late life, presages upcoming financial challenges for elderly persons in the lower part of the income distribution. Implications of this increasingly high-inequality late-life environment need to be carefully evaluated as changes are considered in Social Security and other safety-net institutions, which moderate impacts of economic forces that drive increasingly disparate late-life economic outcomes.

Estimating the effects of prescription drug coverage for Medicare beneficiaries.

OBJECTIVE: To identify the effect of insurance coverage on prescription utilization by Medicare beneficiaries. DATA SOURCES/STUDY SETTING: Secondary data from the 1999 Medicare Current Beneficiary Survey (MCBS) Cost and Use files, a nationally representative survey of Medicare enrollees. STUDY DESIGN: The paper uses a cross-sectional design with (1) a standard regression framework to estimate the impact of prescription coverage on utilization controlling for potential selection bias with covariate control based on the Diagnostic Cost Group/Hierarchical Condition Category (DCG/HCC) risk adjuster, and (2) a multistage residual inclusion method using instrumental variables to control for selection bias and identify the insurance coverage effect. DATA COLLECTION/EXTRACTION METHODS: Data were extracted from the 1999 MCBS. Study inclusion criteria are community-dwelling MCBS respondents with full-year Medicare enrollment and supplemental medical insurance with or without full-year drug benefits. The final sample totaled 5,270 Medicare beneficiaries. PRINCIPAL FINDINGS: Both the model using the DCG/HCC risk adjuster and the model using the residual inclusion method produced similar results. The estimated price elasticity of demand for prescription drugs for the Medicare beneficiaries in our sample was -0.54. CONCLUSIONS: Our results confirm that selection into prescription coverage is predictable based on observable health. Our results further confirm prior estimates of price sensitivity of prescription drug demand for Medicare beneficiaries, though our estimate is slightly above prior results.

The caregiver stress process and health outcomes.

OBJECTIVE: The authors examine the impact of two caregiving stressors, care receivers' behavior problems (an objective stressor) and caregivers' feelings of overload (a subjective stressor), on three dimensions of caregiver health. METHOD: The participants were 234 primary caregivers of elderly relatives with dementia living in the community who completed a comprehensive interview about their current care situation, including stressors and health. RESULTS: Higher levels of both objective and subjective stressors were associated with all three dimensions of caregiver health: poorer self-reported health, more negative health behaviors, and greater use of health care services. The association between objective stressors and health was mediated by caregivers' feelings of overload. CONCLUSIONS: These findings demonstrate caregivers' vulnerability to the effects of stressors across three dimensions of health and also underscore the importance of subjective appraisals of stress.

Life on the edge: patterns of formal and informal help to older adults in the United States and Sweden.

OBJECTIVE: Our objective in this study was to compare assistance received by individuals in the United States and Sweden with characteristics associated with low, moderate, or high 1-year placement risk in the United States. METHODS: We used longitudinal nationally representative data from 4,579 participants aged 75 years and older in the 1992 and 1993 waves of the Medicare Current Beneficiary Survey (MCBS) and cross-sectional data from 1,379 individuals aged 75 years and older in the Swedish Aging at Home (AH) national survey for comparative purposes. We developed a logistic regression equation using U.S. data to identify individuals with 3 levels (low, moderate, or high) of predicted 1-year institutional placement risk. Groups with the same characteristics were identified in the Swedish sample and compared on formal and informal assistance received. RESULTS: Formal service utilization was higher in Swedish sample, whereas informal service use is lower overall. Individuals with characteristics associated with high placement risk received more formal and less informal assistance in Sweden relative to the United States. DISCUSSION: Differences suggest formal services supplement informal support in the United States and that formal and informal services are complementary in Sweden.

Riding the rollercoaster: the ups and downs in out-of-pocket spending under the standard Medicare drug benefit.

This study projects how much Medicare beneficiaries who sign up for the standard Part D drug benefit in 2006 will pay in quarterly out-of-pocket payments through 2008. In the first year we estimate that about 38 percent of enrollees will hit the benefit's no-coverage zone, known as the "doughnut hole," and that 14 percent will exceed the catastrophic threshold. Because drug spending is highly persistent over time, beneficiaries who experience the biggest gaps in coverage are likely to do so year after year, with potentially serious financial consequences.

The quality of antipsychotic drug prescribing in nursing homes.

BACKGROUND: The prescribing of antipsychotic drugs has been increasing in nursing homes (NHs) since the availability of second-generation antipsychotic agents, also known as the atypicals, but there is little information on the appropriateness of such prescribing. METHODS: A retrospective analysis using the nationally representative data set of the Medicare Current Beneficiary Survey merged to Minimum Data Sets assessments, medication administration records, and Medicare claims. We identified a sample of 2.5 million Medicare beneficiaries in NHs during 2000-2001 (unweighted n = 1096) to assess prevalence of antipsychotic use, rates of adherence to NH prescribing guidelines, and changes in behavioral symptoms. RESULTS: Approximately 693 000 (unweighted n = 302), or 27.6%, of all Medicare beneficiaries in NHs received at least 1 prescription for antipsychotics during the study period: 20.3% received atypicals only; 3.7%, conventionals only; and 3.6%, both atypicals and conventionals. Less than half (41.8%) of treated residents received antipsychotic therapy in accordance with NH prescribing guidelines. One (23.4%) in 4 patients had no appropriate indication, 17.2% had daily doses exceeding recommended levels, and 17.6% had both inappropriate indications and high dosing. Patients receiving antipsychotic therapy within guidelines were no more likely to achieve stability or improvement in behavioral symptoms than were those taking antipsychotics outside the guidelines. CONCLUSIONS: This study detected the highest level of antipsychotic use in NHs in over a decade. Most atypicals were prescribed outside the prescribing guidelines and for doses and indications without strong clinical evidence. Failure to detect positive relationships between behavioral symptoms and antipsychotic therapy raises questions about the appropriateness of prescribing.

Doughnut holes and price controls.

In 2003 citizens of Canada, the United Kingdom, and France paid an average of 34-59 percent of what Americans paid for a similar market basket of pharmaceuticals. If the Medicare program were to pay comparable prices for pharmaceuticals, it would be possible to eliminate the "doughnut hole" in its prescription drug benefit and keep Medicare drug spending within the overall limits established by Congress. This provides Congress with a clear choice: reduce the level of cost sharing and improve beneficiaries' access to pharmaceuticals, or allow the pharmaceutical industry to use the higher prices to fund research and development and to engage in other activities.

The economies of scale for nursing home care.

Using a modified hybrid short-term operating cost function and a national sample of nursing homes in 1994, the authors examined the scale economies of nursing home care. The results show that scale economies exist for Medicare postacute care, with an elasticity of -0.15 and an optimal scale of around 4,000 patient days annually. However, more than 68 percent of nursing homes in the analytic sample produced Medicare days at a level below the optimal scale. The financial pressures resulting from the implementation of a prospective payment system for Medicare skilled nursing facilities may further reduce the quantity of Medicare days served by nursing homes. In addition, the results show that chain-owned nursing homes do not have lower short-term operating costs than do independent facilities. This indicates that the rationale behind recent increasing horizontal integration among nursing homes may not be seeking greater cost efficiency but some other consideration.

Health insurance for Americans approaching age sixty-five: an analysis of options for incremental reform.

This article provides a systematic evaluation of the options for incremental health insurance reforms aimed at older Americans nearing age sixty-five. It presents three basic arguments for giving special consideration to this age group: (1) early retirement and its effect on access to employer insurance; (2) changes in health and health care expenses associated with increasing age; (3) the vulnerability to unexpected economic or health "shocks" that will affect people throughout their retirement. The analysis of policy options begins by specifying criteria for evaluating alternative approaches to reform. The proposed criteria emphasize that reforms for this age group should be designed to fit with other financial plans and decisions made during such a transitional stage of life. Policy options should be judged according to fundamental goals such as equity and efficiency, not simply ranked according to the number of uninsured who will gain coverage. After offering a comprehensive catalog and evaluation of available options, the analysis identifies and discusses a preferred approach-which preserves choices while offering universal and subsidized access to Medicare before age sixty-five.

Participation and crowd-out in a Medicare drug benefit: simulation estimates.

This article provides information on likely participation in the Medicare prescription drug plan and expected crowd-out. We use a microsimulation model based on data from the MCBS to estimate the costs and benefits of a Medicare drug plan, including the benefits from reductions in risk. The simulations are repeated using different combinations of benefits and subsidies. In addition, the simulations explore the effects of different behavioral parameters for moral hazard (the extent to which participants increase drug spending in response to reduced costs) and risk aversion (the extent to which participants would be willing to pay to avoid risk) to identify the impact of these factors on participation and crowd-out.

Does prospective payment really contain nursing home costs?

OBJECTIVE: To examine whether nursing homes would behave more efficiently, without compromising their quality of care, under prospective payment. DATA SOURCES: Four data sets for 1994: the Skilled Nursing Facility Minimum Data Set, the Online Survey Certification and Reporting System file, the Area Resource File, and the Hospital Wage Indices File. A national sample of 4,635 nursing homes is included in the analysis. STUDY DESIGN: Using a modified hybrid functional form to estimate nursing home costs, we distinguish our study from previous research by controlling for quality differences (related to both care and life) and addressing the issues of output and quality endogeneity, as well as using more recent national data. Factor analysis was used to operationalize quality variables. To address the endogeneity problems, instrumental measures were created for nursing home output and quality variables. PRINCIPAL FINDINGS: Nursing homes in states using prospective payment systems do not have lower costs than their counterpart facilities under retrospective cost-based payment systems, after quality differences among facilities are controlled for and the endogeneity problem of quality variables is addressed. CONCLUSIONS: The effects of prospective payment on nursing home cost reduction may be through quality cuts, rather than cost efficiency. If nursing home payments under prospective payment systems are not adjusted for quality, nursing homes may respond by cutting their quality levels, rather than controlling costs. Future outcomes research may provide useful insights into the adjustment of quality in the design of prospective payment for nursing home care.