Not Understanding Medicare Part D Still an Issue; Medication Adherence May Be Improving Overall

There still appears to be some lack of knowledge regarding Medicare’s Part D prescription drug program, although there is evidence that cost-related medication nonadherence may have improved overall, according to two studies in the April 23/30 issue of JAMA.

Before implementation of the Medicare Prescription Drug Improvement and Modernization Act, which was passed by Congress in 2003, millions of individuals who were elderly and disabled had insufficient or no insurance coverage for outpatient medications. “In the face of these economic barriers, several large surveys in the United States have shown that older individuals have resorted to behaviors such as skipping doses, reducing doses, and letting prescriptions go unfilled. Such cost-related medication nonadherence (CRN) is associated with increased risk of myocardial infarction, stroke, and preventable hospitalization,” the authors of the first study write. Since January 2006, Medicare beneficiaries have been able to purchase a prescription drug benefit (Part D), subsidized by Medicare and available through private plans. The impact of Medicare Part D on CRN is unknown.

Jeanne M. Madden, Ph.D., of Harvard Medical School and Harvard Pilgrim Health Care, Boston, and colleagues examined the changes in the prevalences of CRN and spending less on basic needs (such as food) to afford medicines, before and after Part D implementation. The study included information from the Medicare Current Beneficiary Survey (MCBS), in which 24,234 nationally representative, community-dwelling Medicare enrollees were questioned in 2004, 2005, and 2006 (response rate, 72.3 percent).

The researchers found that there was a larger absolute decrease in CRN following Medicare Part D implementation (from 14.1 percent in 2005 to 11.5 percent in 2006) than occurred between 2004 and 2005 (15.2 percent to 14.1 percent, respectively). However, no significant changes in CRN were observed among beneficiaries with fair-to-poor health, despite high baseline CRN prevalence for this group (22.2 percent in 2005) and significant decreases among beneficiaries with good-to-excellent health.

“Overall, our findings suggest that that the intensive medicine needs and financial barriers to access among the sickest beneficiaries may not have been fully addressed by Part D,” the authors write.

There were modest and significant decreases in CRN among lower-income beneficiaries, controlling for changes from 2004 to 2005, but not for higher-income beneficiaries. Significant reductions in spending less on basic needs were observed in both groups (fair-to-poor health; good-to-excellent health).

“In conclusion, we found small but significant population-level decreases in CRN and spending less on basic needs to afford medicines, nearly a year after an unprecedented shift in Medicare policy—the implementation of the Part D drug benefit. Those beneficiaries in poor health or with multiple morbidities who had substantially higher baseline CRN did not experience decreases in CRN associated with Part D implementation, although they did report reductions in spending less on basic needs. Further research is needed to determine which specific aspects of Part D did or did not alleviate the persistent burden of medication costs. Part D claims data, linked to detailed Part D plan characteristics, must be made available to study the impact of the new Medicare drug benefit on actual utilization of medications and health outcomes,” the researchers conclude.

JAMA. 2008; 299[16]:1922-1928.