Browsing by Subject "Medicare Part D"

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    The intention to enroll in Medicare Part D:an analysis in the pre-medicare eligible population
    (2012-01) Jin, Tao
    Studies suggested that the wide range of drug plan options and the complexity of drug benefits in the Medicare Part D program might have discouraged the enrollment in the Medicare Part D program. This study used the Theory of Planned Behaviors (TPB) as the theoretical framework to understand pre-Medicare eligible individuals’ decisionmaking in the context of Medicare Part D enrollment. Specifically, the objective of this research were (1) to examine correlations between underlying beliefs with attitudes, subjective norms, and perceived behavioral controls variables in the model of the TPB; and (2) to evaluate the strengths of paths among attitudes, subjective norms, perceived behavioral controls, and intentions to enroll in the model of the TPB. This research included focused interviews, pretest study, pilot study, and main study. The instrument was established and evaluated in focused interviews, pretest study, and pilot study. Then a cross-sectional survey design was used in the main study and data was collected by mailed self-administered surveys. The survey was administered to a random sample of 1500 pre-Medicare eligible individuals (62-64 years) living in Minnesota. 689 surveys were returned; 556 out of these 689 surveys were eligible for inclusion criteria. The usable response rate was 40.67%. Descriptive statistics showed that generally pre-Medicare eligible individuals’ evaluations about Medicare Part D (Average score: 3.25 out of 5); their social pressure to enroll in Medicare Part D (Average score: 3.26 out of 5), and their perceived controllability (Average score: 3.34 out of 5) regarding the Medicare Part D enrollment were positive. In addition, their intention to enroll in Medicare Part D was moderately positive (Average score: 3.33 out of 5). Hierarchical regression analyses were employed to explore correlations between underlying beliefs (behavioral beliefs, normative beliefs, and control beliefs) and corresponding factors (attitudes, subjective norms, and perceived behavioral controls) preceding enrollment intentions. The results revealed that (1) “saving money on medications” (a=1.79, p<0.0001) was significantly associated with pre-Medicare eligible individuals’ attitude toward Medicare Part D and this outcome was perceived significantly beneficial for them. (2) “my spouse/significant other” (a=1.54, p<0.0001) and “my parents” (a=0.42, p=0.03) were perceived to approve of Pre-Medicare eligible individuals’ enrollment in Medicare Part D; however, their motivations to comply with their opinions were not significant; (3) Pre-Medicare eligible individuals believed that “mailing materials about drug plans” (a=0.4, p=0.0042) and “consulting with my pharmacy” (a=0.5, p=0.0056) would make is easier for them to enroll in Medicare Part D. Structural equation modeling methods (confirmatory factor analysis and path analysis) were applied to investigate associations between factors (attitudes, subjective norms, and perceived behavioral controls) analyses and pre-Medicare eligible individuals’ enrollment intentions. Results showed that (1) attitude (r=0.39 p<0.001) and subjective norm (r=0.44 p<0.001) were significantly associated with pre-Medicare eligible individuals’ enrollment intentions in Medicare Part D; (2) subjective norm was the stronger predictor (r=0.49) than attitudes (r=0.35) of enrollment intentions in Medicare Part D for male pre-Medicare eligible individuals. However, the difference was not obvious (r attitude-intention=0.42 vs. r subjective norm-intention=0.40) for female individuals; (3) the TPB model had a reasonable good fit of the data to predict Medicare Part D enrollment intentions (R2= 0.616). This study showed that a more favorable evaluation of the Medicare Part D program, and a stronger perception of relevant others’ beliefs regarding enrolling in Medicare Part D drug plans could result in a stronger enrollment intentions of pre- Medicare eligible individuals. This study took the initial step to understand the decisionmaking process surrounding the Medicare Part D program enrollment in those pre- Medicare eligible individuals. Based on an understanding of the decision-making process of the Medicare Part D enrollment, the impact of this study could be enhanced by proving social support for Medicare beneficiaries in enrolling in Medicare programs. However, there was considerable variability in the observed association between behavioral intentions and actual behaviors. Further research is needed to explore the stability between Medicare Part D enrollment intentions of pre-Medicare eligible individuals and their actual enrollment behaviors. That will be more meaningful.
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    Low Income Subsidy (Lis): An Evaluation Of Expenditure, Utilization And Health Care Outcomes
    (2014-05) Doherty, Del
    BACKGROUND: This study focuses on the Low Income Subsidy (LIS) of the Medicare Part D program. LIS is a federal program which provides government subsidized prescription drug coverage for Medicare beneficiaries in order to reduce or eliminate low- income enrollees' out-of-pocket expenses associated with prescription drugs. A plethora of studies have been conducted on the effect of insurance on health care utilization and the corresponding effect on health and health outcomes. Within the Medicare Part D population, a myriad of studies have shown conflicting results regarding the effects of subsidized cost-sharing on expenditure, utilization and health outcomes. Results from studies specifically comparing deemed vs. non-deemed LIS beneficiaries' expenditure, utilization and health outcomes have been equivocal. OBJECTIVE: To evaluate the impact of subsides on expenditures, medication and health care utilization and health outcomes between LIS groups. METHODS: Using 5% Medicare administrative sample, interrupted time series (differences-in-differences) regression models were developed to evaluate the impact of LIS enrollment (subsidy amount) between LIS groups and estimate changes in utilization and expenditures and for beneficiaries who switched LIS status between 2009 and 2010. RESULTS: The results from this study showed that beneficiaries with no subsidy had significantly higher total health services utilization and expenditure, compared to beneficiaries with no subsidy. However, for beneficiaries who switched LIS status, the effect of LIS on health services utilization was equivocal. For prescription drugs, the results showed a significant increase in medication utilization with increasing subsidy amount (i.e. deemed > non-deemed > non-LIS). Yet, there was virtually no difference in prescription drug expenditures and medication adherence between LIS groups. These results were consistent for beneficiaries who switched LIS status between 2009 and 2010. CONCLUSION: The findings from this study suggests the LIS program, like Part D itself, improves beneficiaries' access to affordable prescription drugs. While there was a positive association between subsidy amount and prescription utilization and expenditure, there was no impact on medication adherence, and the impact of LIS status on health services utilization was equivocal. Essentially, LIS provided no medical spending offsets, consistent with findings in the literature.
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    Medication Utilization of Dual Eligibles Before and After Medicare Part D: Cases of Antidepressants and Antipsychotics
    (2014-05) Kim, Jee-Ae
    Objectives: The study objective is to examine whether medication utilization among dual eligibles was different under Part D compared to Medicaid period by focusing on states which vary baseline state Medicaid policies and wrap-around programs for dual eligibles to access drugs under Part D. The transition of prescription drug benefits to federal Medicare Part D from state Medicaid has potential to affect medication utilization for dual eligibles, beneficiaries for both Medicaid and Medicare programs. Changes in prescription drug benefits under Part D will not equally affect the dual eligible and will differ by states with differences in baseline Medicaid policies and availability of wrap-around programs to access drugs under Part D. The study focuses on antidepressants and antipsychotics. Methods: This study is a pre-post study design with a longitudinal dataset by linking Medicaid data for 2004-2005 and 5% random sample of Medicare data for 2006-2007. The study population is dual eligibles, existing users of antidepressants and of antipsychotics in 2004 and with enrollment from 2004-2007 in eight states. I employ a state-fixed effect model to estimate medication utilization using proportion of days covered (PDC), adjusting for beneficiaries characteristics and health status. I adopt generalized estimation equation (GEE) model for estimating PDC and spline regression for investigating whether changes in PDCs were related to Part D. A stratified analysis is conducted for community based dual eligibles (n=4,703 for antidepressants, n=2,301 for antipsychotics) and nursing home dual eligibles (n=1,504 for antidepressants, n=1,011 for antipsychotics) separately. Results: For antidepressants, adjusted changes in PDC were not significant for most states, except Arkansas community based dual eligibles (p=0.00), Florida nursing home dual eligibles had a significant increase (p=0.03), New Mexico nursing home dual eligibles(p=0.01) under Part D. For antipsychotics, adjusted changes in PDC were not significant in all states except Arkansas community based dual eligibles (p=0.03) and Florida for both groups (p=0.00 for both community based dual eligibles and nursing home dual eligibles). A separate spline regression for states that had significant changes in PDC from the state-fixed effect model indicated that trends in PDC before and after Part D were not significantly different, suggesting that changes were not related to transition to Part D. Conclusions: I did not find empirical support for concerns regarding disruption of medication utilization of the dual eligible under Part D. Although states had different baseline Medicaid polices and wrap-around programs under Part D, lack of significant changes in utilization suggest that minor changes in copayments and refill/prescription limits etc. do not have large effect on medication utilization to antidepressants and antipsychotics.
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    Pre-Medicare Eligible Individuals’ Decision-Making In Medicare Part D: An Interview Study
    (University of Minnesota, College of Pharmacy, 2010) Jin, Tao; Cline, Richard R.; Hadsall, Ronald S.
    Objectives The objective of this study was to elicit salient beliefs among pre-Medicare eligible individuals regarding (1) the outcomes associated with enrolling in the Medicare Part D program; (2) those referents who might influence participants’ decisions about enrolling in the Part D program; and (3) the perceived barriers and facilitators facing those considering enrolling in the Part D program. Methods Focused interviews were used for collecting data. A sample of 10 persons between 62 and 64 years of age not otherwise enrolled in the Medicare program was recruited. Interviews were audio taped and field notes were taken concurrently. Audio recordings were reviewed to amend field notes until obtaining a thorough reflection of interviews. Field notes were analyzed to elicit a group of beliefs, which were coded into perceived outcomes, the relevant others who might influence Medicare Part D enrollment decisions and perceived facilitators and impediments. By extracting those most frequently mentioned beliefs, modal salient sets of behavioral beliefs, relevant referents, and control beliefs were identified. Results Analyses showed that (1) most pre-Medicare eligible believed that Medicare Part D could “provide drug coverage”, “save money on medications”, and “provide financial and health security in later life”. However, “monthly premiums”, “the formulary with limited drug coverage” and “the complexity of Medicare Part D” were perceived as major disadvantages; (2) immediate family members are most likely to influence pre-Medicare eligible’s decisions about Medicare Part D enrollment; and (3) internet and mailing educational brochures are considered to be most useful resources for Medicare Part D enrollment. Major barriers to enrollment included the complexity and inadequacy of insurance plan information. Conclusion There are multiple factors related to decision-making surrounding the Medicare Part D enrollment. These factors include the advantages and disadvantages of enrolling in Part D, facilitators and barriers to enrolling in Medicare Part D, and significant individuals and groups for pre-Medicare eligible individuals.
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    Retrospective Analysis of Prescription Drug Claims, with Applications to Risk Score Construction and Treatment of Heart Failure in End Stage Renal Disease
    (2015-05) Weinhandl, Eric
    There are more than 450,000 patients receiving chronic dialysis in the US. Patients with end stage renal disease are statutorily eligible for Medicare, regardless of age. Due to high prevalence of poverty, many are dually enrolled in Medicare and Medicaid and are automatically enrolled in Part D (prescription drug insurance). This dissertation comprises 3 studies involving prescription drug claims in dialysis patients. In the first study, I constructed and validated risk scores based on Part D claims in incident and prevalent dialysis patients. Comorbidity indices derived from administrative data are typically based on diagnosed diseases, but the middling sensitivity of diagnosis codes limits the accuracy of these indices. In contrast, prescription drug claims are bona fide evidence of medication dispensation. I investigated aspects of newly developed scores and compared their performance in predicting risk with older scores based on diseases. In the second study, I assessed the efficacy and safety of pharmacologic inhibition of the renin-angiotensin system in dialysis patients with congestive heart failure. ACE inhibitors and ARBs are recommended for the treatment of heart failure with reduced ejection fraction. However, pivotal clinical trials all excluded patients on dialysis. I used propensity score matching to identify matched controls for treated patients that were newly dispensed an ACE inhibitor or ARB shortly after discharge from hospitalization for heart failure. I described the relative hazards of mortality and morbidity with treatment. In the third study, I assessed relative hazards of death and hospitalization associated with 4 ACE inhibitors and 2 ARBs in dialysis patients with congestive heart failure. The existence of class effects is generally presumed, but not necessarily supported by evidence regarding clinical outcomes. I showed that the most widely used agent (lisinopril) in this patient population is not necessarily associated with best outcomes.