Transcript No Rx Coverage - AcademyHealth

Rx Coverage, Use and Spending Among US Seniors:
Where Did Things Stand on the Eve of Part D
Implemention & How Can This Inform Us Now?
___________________________________________________________________________
Dana Gelb Safran, ScD
Director, The Health Institute
Institute for Clinical Research and Health Policy Studies
Tufts-New England Medical Center
Presented at:
AcademyHealth Annual Research Meeting
Seattle, Washington
26 June 2006
Funding: Commonwealth Fund & Kaiser Family Foundation
National Study of Prescription Coverage,
Use and Spending, 2003
___________________________________________________________________________
• Survey of non-institutionalized seniors in 50 states
and the District of Columbia with a focus on 12
“priority” states including:
– 5 states with state-sponsored pharmacy
assistance programs (IL, MI, NY, PA, FL)
– 7 states without programs
(CA, CO, OH, TX, TN, LA, WA)
• These 12 states account for 55% of US elderly
Background
___________________________________________________________________________
• Prior to the study, national data suggested that about
38% of beneficiaries lacked prescription coverage
(MCBS 1999)
• Fiscal pressures were driving private sources of
supplemental coverage to reduce or drop Rx benefits
• States were attempting to fill the gap -- particularly for
low-income seniors
Background (cont’d)
___________________________________________________________________________
• All state Medicaid programs had a drug benefit
• 22 states had implemented state-funded pharmacy
assistance programs and 7 states had discount
programs
• But state-level data on prescription coverage were
unavailable and little known about the experiences of
low-income seniors or variability by state
Sampling
___________________________________________________________________________
• File from the Centers for Medicare and Medicaid Services
(CMS) used for sampling
• Geocoded to the Census Block Group Level
• 3 Sampling strata:
– Full-Medicaid
– Non-Medicaid, Low-income Census Block Group (>13% elderly
below 100% federal poverty level)
– Non-Medicaid, Higher income Census Block Group
Data Collection
___________________________________________________________________________
• Survey administered July through October
2003 (n=36,901)
• Mail and telephone
• English and Spanish
• 51% Response rate (n=17,685)
Principal Study Goals
___________________________________________________________________________
• Ascertain rates and sources of prescription
coverage nationally and by state
• Examine prescription use and spending overall
and for 3 vulnerable subgroups:
• No coverage
• Low-income
• High disease burden
• Examine rates and types of medication nonadherence
Beneficiaries without Drug Benefit,
by
State
(2003)
___________________________________________________________________________
45%
36%
35%
31%
30%
27%
27%
29%
28%
30%
24%
20%
21%
22%
16%
15%
0%
Nat’l
Total
NY PA IL
MI FL CA OH TN LA TX CO WA
States with RX program
Source: Safran et al. Health Affairs April 2005.
States without
Sources of Beneficiaries’ Drug Benefits, by State
___________________________________________________________________________
Medicaid
Employer-Sponsored
HMO
Other Private Coverage
State Drug Program
Other Public Coverage
None
100%
80%
60%
40%
20%
0%
NY
PA
IL
MI
FL
States with RX program
Source: Safran et al. Health Affairs April 2005.
CA
OH
TN
LA
TX
States without
CO
WA
Low-Income Beneficiaries without Drug
Benefit,
by
State
(2003)
___________________________________________________________________________
44%
45%
42%
37%
42%
41%
37%
34%
33%
30%
27% 27%
24%
19%
17%
15%
0%
Total
NY
PA
IL
MI
FL
States with RX program
Source: Safran et al. Health Affairs April 2005.
CA
OH
TN
LA
TX
States without
CO
WA
Prescription Medication Use and Monthly Out-Of Pocket Spending
by Coverage Status, Poverty, and Disease Burden (2003)
___________________________________________________________________________
Total (n=17,569)
No Rx Coverage (27.3%) Low Income (40%) Complex Chronic (31.6%)
97%
100%
89%
89%
77%
73%
75%
67%
46%
50%
49%
54%
52%
46%
36%
35%
41%
32%
31%
25%
0%
Use Rx Medication
Source: Safran et al. Health Affairs April 2005.
Using 5+ Rx
More than 1 MD
More than 1
Pharmacy
Percent of Seniors Nationally Who Spend $100+
Per Month on Drugs, by Source of Drug Coverage
___________________________________________________________________________
50%
39%
40%
37%
32%
30%
28%
27%
18%
20%
14%
10%
10%
0%
Nat'l Total
No Drug
Coverage
Other
Private Ins
Source: Safran et al. Health Affairs April 2005.
State
Pharmacy
Program
HMO
Other
Public Ins
Employer
Medicaid
Nonadherence Due to Cost (2003)
___________________________________________________________________________
18%
Didn't fill Rx 1+
times
16%
Skipped doses
28%
26%
25%
23%
22%
22%
12%
Took smaller
doses
18%
18%
19%
26%
Any cost-related
nonadherence
Total
No Rx Coverage
Source: Safran et al. Health Affairs April 2005.
Low income
37%
35%
35%
Complex chronic
Nonadherence Due to Experiences (2003)
___________________________________________________________________________
Skipped or
stopped because
felt worse
Skipped or
stopped because
not helping
19%
19%
22%
27%
18%
20%
22%
24%
25%
27%
28%
Non-adherence
due to experiences
34%
Total
No Rx Coverage
Source: Safran et al. Health Affairs April 2005.
Low income
Complex chronic
Rates of Cost- and Experience-Related Non-Adherence by
Chronic Condition and Coverage Status
___________________________________________________________________________
Seniors with Coverage
Seniors without Coverage
Cost-Related Non-Adherence (%)
50.3%
50.0%
Experience-Related Non-Adherence (%)
49.0%
51.9%
50.0%
41.8%
40.5%
40.0%
hr
on
ic
on
C
x
pl
e
om
C
x
pl
e
om
C
C
on
ns
i
rt
e
yp
e
H
D
ia
b
HF
C
Source: Safran et al. Health Affairs April 2005.
et
es
0.0%
ia
b
0.0%
D
10.0%
HF
10.0%
hr
on
ic
20.0%
et
es
20.0%
25.5%
ns
i
30.0%
24.4%
31.5%
29.8%
rt
e
26.3%
25.1%
C
30.0%
29.8%
25.9%
28.9%
yp
e
30.0%
34.8%
H
40.0%
Nonadherence Due to Self-Assessed Need (2003)
___________________________________________________________________________
12%
Did not fill because
felt didn't need
15%
14%
16%
9%
Did not fill because
felt too many Rxs
10%
12%
13%
15%
Non-adherence
due to selfassessed need
Total
No Rx Coverage
Source: Safran et al. Health Affairs April 2005.
18%
17%
19%
Low income
Complex chronic
Rates of Nonadherence By Coverage Status, Poverty,
and Disease Burden (2003)
___________________________________________________________________________
26%
Nonadherence due
to cost
37%
35%
35%
25%
27%
28%
Nonadherence due
to experiences
Nonadherence due
to self-assessed
need
15%
18%
17%
19%
40%
Total: Any
Nonadherence
Total
No Rx Coverage
Source: Safran et al. Health Affairs April 2005.
34%
48%
48%
52%
Low income
Complex chronic
Summary and Implications
___________________________________________________________________________
• No question about the critical role that
prescription medicines plan in seniors’ health care
• No question about importance of coverage in
enabling seniors to sustain complex, costly
regimens
• Not all sources of coverage are equally protective
and prevailing sources vary widely by state
• Very large percentage of low-income seniors
lacked coverage (>40% in some states)
Summary & Implications (cont’d)
___________________________________________________________________________
• Enormous potential for LIS program to help
– To date, 1.7 million of estimated ~8 million low-income
(without Medicaid) enrolled
• Positive role played by Medicaid prescription coverage
delineated high stakes in the transition to private plans
• High rates of non-adherence due to cost -- nearly 50%
in vulnerable subgroups lacking coverage underscore
that potential health benefits of Part D are large
• Key role for clinicians around issues of adherence and
integration