RESUMEN
OBJECTIVE: Using the 2016 Medicare Part D coverage gap as an example, we explored effects of increased out-of-pocket costs on adherence to branded dipeptidyl peptidase 4 inhibitors (DPP-4i) in patients without financial subsidies relative to subsidized patients who do not experience increased spending during the gap. We also explored seasonality of reinitiation, because discontinuers may be more likely to reinitiate in January when benefits reset. RESEARCH DESIGN AND METHODS: We identified DPP-4i or sulfonylurea initiators, aged ≥66 years, from a 20% sample of 2015-2016 Medicare claims. Difference-in-differences Poisson regression was used to compare adherence before and after entering the coverage gap between nonsubsidized and subsidized patients. Among discontinuers, monthly hazard ratios (HRs) for reinitiation relative to January 2016 were derived with Cox models. As a second control, we repeated analyses using sulfonylureas, generic low-cost alternatives. RESULTS: In 2016, 8,096 subsidized and 6,173 nonsubsidized DPP-4i initiators entered the coverage gap. For nonsubsidized patients, copayment in the coverage gap was 45% ($227 per DPP-4i prescription), and adherence decreased from 68.4% to 49.0% after gap entry. Accounting for adherence differences in subsidized patients, nonsubsidized patients demonstrated reduced adherence to DPP-4i (difference-in-difference: -16.9%; 95% CI -18.7%, -15.1%) but not sulfonylureas (-1.6%; 95% CI -3.4%, 0.2%). Reinitiation was lowest in the months before January (HR 0.4-0.5) among nonsubsidized DPP-4i patients, demonstrating a strong seasonal pattern. CONCLUSIONS: Increased out-of-pocket costs negatively affect adherence and reinitiation of branded antihyperglycemic drugs among patients without financial subsidies. Despite closure of the coverage gap, affordability remains a concern given increasing list prices for many drugs on Medicare and the growing use of deductibles and coinsurance by commercial health plans.
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Diabetes Mellitus , Costos de los Medicamentos , Hipoglucemiantes/economía , Hipoglucemiantes/uso terapéutico , Medicare Part D , Anciano , Anciano de 80 o más Años , Diabetes Mellitus/tratamiento farmacológico , Diabetes Mellitus/economía , Diabetes Mellitus/epidemiología , Inhibidores de la Dipeptidil-Peptidasa IV/economía , Inhibidores de la Dipeptidil-Peptidasa IV/uso terapéutico , Costos de los Medicamentos/estadística & datos numéricos , Femenino , Gastos en Salud/estadística & datos numéricos , Gastos en Salud/tendencias , Humanos , Masculino , Medicare Part D/economía , Medicare Part D/estadística & datos numéricos , Persona de Mediana Edad , Compuestos de Sulfonilurea/economía , Compuestos de Sulfonilurea/uso terapéutico , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: The opioid epidemic is a severe problem in the world, especially in the United States, where prescription opioid overdose accounts for a quarter of drug overdose deaths. OBJECTIVE: To describe psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in the United States. METHODS: We conducted a retrospective cross-sectional study of the 2016 Medicare Part D claims data and analyzed psychiatrists' prescriptions of: 1) opioids; 2) benzodiazepines, whose concurrent prescription with opioids can cause overdose death; 3) buprenorphine, a partial opioid agonist for treating opioid addiction; 4) and naltrexone microsphere, a once-monthly injectable opioid antagonist to prevent relapse to opioid dependence. Prescribers with 11 or more claims were included in the analysis. RESULTS: In Medicare Part D in 2016, there were a total of 1,131,550 prescribers accounting for 1,480,972,766 total prescriptions and 78,145,305 opioid prescriptions, including 25,528 psychiatrists (2.6% of all prescribers) accounting for 44,684,504 total prescriptions (3.0% of all prescriptions) and 131,115 opioid prescriptions (0.2% of all opioid prescriptions). Psychiatrists accounted for 17.3% of benzodiazepine, 16.3% of buprenorphine, and 33.4% of naltrexone microsphere prescriptions. The opioid prescription rate of psychiatrists was much lower than that of all prescribers (0.3 vs 5.3%). The buprenorphine prescription rate of psychiatrists was much higher than that of all prescribers (2.3 vs. 0.1%). There was a substantial geographical variation across the United States. CONCLUSIONS: The results show that, proportionally, psychiatrists have lower rates of opioid prescription and higher rates of benzodiazepine and buprenorphine prescription.
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Analgésicos Opioides/uso terapéutico , Benzodiazepinas/uso terapéutico , Buprenorfina/uso terapéutico , Prescripciones de Medicamentos/estadística & datos numéricos , Medicare Part D/estadística & datos numéricos , Antagonistas de Narcóticos/uso terapéutico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Psiquiatría/estadística & datos numéricos , Adulto , Estudios Transversales , Humanos , Estudios Retrospectivos , Estados UnidosRESUMEN
Abstract Introduction The opioid epidemic is a severe problem in the world, especially in the United States, where prescription opioid overdose accounts for a quarter of drug overdose deaths. Objective To describe psychiatrists' prescription of opioid, benzodiazepine, and buprenorphine in the United States. Methods We conducted a retrospective cross-sectional study of the 2016 Medicare Part D claims data and analyzed psychiatrists' prescriptions of: 1) opioids; 2) benzodiazepines, whose concurrent prescription with opioids can cause overdose death; 3) buprenorphine, a partial opioid agonist for treating opioid addiction; 4) and naltrexone microsphere, a once-monthly injectable opioid antagonist to prevent relapse to opioid dependence. Prescribers with 11 or more claims were included in the analysis. Results In Medicare Part D in 2016, there were a total of 1,131,550 prescribers accounting for 1,480,972,766 total prescriptions and 78,145,305 opioid prescriptions, including 25,528 psychiatrists (2.6% of all prescribers) accounting for 44,684,504 total prescriptions (3.0% of all prescriptions) and 131,115 opioid prescriptions (0.2% of all opioid prescriptions). Psychiatrists accounted for 17.3% of benzodiazepine, 16.3% of buprenorphine, and 33.4% of naltrexone microsphere prescriptions. The opioid prescription rate of psychiatrists was much lower than that of all prescribers (0.3 vs 5.3%). The buprenorphine prescription rate of psychiatrists was much higher than that of all prescribers (2.3 vs. 0.1%). There was a substantial geographical variation across the United States. Conclusions The results show that, proportionally, psychiatrists have lower rates of opioid prescription and higher rates of benzodiazepine and buprenorphine prescription.
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Adulto , Humanos , Prescripciones de Medicamentos/estadística & datos numéricos , Psiquiatría/estadística & datos numéricos , Benzodiazepinas/uso terapéutico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Buprenorfina/uso terapéutico , Medicare Part D/estadística & datos numéricos , Analgésicos Opioides/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Estados Unidos , Estudios Transversales , Estudios RetrospectivosRESUMEN
OBJECTIVE: To evaluate the effect of dual use of VA/Medicare Part D drug benefits on antihypertensive medication supply in older Veterans with dementia. DATA SOURCES/STUDY SETTING: National, linked 2007-2010 Veterans Affairs (VA) and Medicare utilization and prescription records for 50,763 dementia patients with hypertension. STUDY DESIGN: We used inverse probability of treatment (IPT)-weighted multinomial logistic regression to examine the association of dual prescription use with undersupply and oversupply of antihypertensives. DATA COLLECTION/EXTRACTION METHODS: Veterans Affairs and Part D prescription records were used to classify patients as VA-only, Part D-only, or dual VA/Part D users of antihypertensives and summarize their antihypertensive medication supply in 2010: (1) appropriate supply of all prescribed antihypertensive classes, (2) undersupply of ≥1 class with no oversupply of another class, (3) oversupply of ≥1 class with no undersupply, or (4) both undersupply and oversupply. PRINCIPAL FINDINGS: Dual prescription users were more likely than VA-only users to have undersupply only (aOR = 1.28; 95 percent CI = 1.18-1.39), oversupply only (aOR = 2.38; 95 percent CI = 2.15-2.64), and concurrent under- and oversupply (aOR = 2.89; 95 percent CI = 2.53-3.29), versus appropriate supply of all classes. CONCLUSIONS: Obtaining antihypertensives through both VA and Part D was associated with increased antihypertensive under- and oversupply. Efforts to understand how best to coordinate dual-system prescription use are critically needed.
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Antihipertensivos/uso terapéutico , Demencia/epidemiología , Hipertensión/tratamiento farmacológico , Hipertensión/epidemiología , Medicare Part D/estadística & datos numéricos , United States Department of Veterans Affairs/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Antihipertensivos/administración & dosificación , Femenino , Humanos , Modelos Logísticos , Masculino , Cumplimiento de la Medicación/estadística & datos numéricos , Estados Unidos , United States Department of Veterans Affairs/economíaRESUMEN
OBJECTIVE: To examine the impact of cost-sharing increases on continuity of specialty drug use in Medicare beneficiaries with multiple sclerosis (MS) or rheumatoid arthritis (RA). DATA SOURCES/STUDY SETTING: Five percent Medicare claims data (2007-2010). STUDY DESIGN: Quasi-experimental study examining changes in specialty drug use among a group of Medicare Part D beneficiaries without low-income subsidies (non-LIS) as they transitioned from a 5 percent cost-sharing preperiod to a ≥25 percent cost-sharing postperiod, as compared to changes among a disease-matched contemporaneous control group of patients eligible for full low-income subsidies (LIS), who faced minor cost sharing (≤$6.30 copayment) in both the pre- and postperiods. DATA COLLECTION/EXTRACTION METHODS: Key variables were extracted from Medicare data. PRINCIPAL FINDINGS: Relative to the LIS group, the non-LIS group had a greater increase in incidence of 30-day continuous gaps in any Part D treatment from the lower cost-sharing period to the higher cost-sharing period (MS, absolute increase = 10.1 percent, OR = 1.61, 95% CI 1.19-2.17; RA, absolute increase = 21.9 percent, OR = 2.75, 95% CI 2.15-3.51). The increase in Part D treatment gaps was not offset by increased Part B specialty drug use. CONCLUSIONS: Cost-sharing increases due to specialty tier-level cost sharing were associated with interruptions in MS and RA specialty drug treatments.