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Generic initiation and antidepressant therapy adherence under Medicare Part D.

ABSTRACT: To assess the effect of initiating antidepressant therapy with a generic prescription on adherence to antidepressant therapy among Medicare patients. A second objective is to assess how the effect might be moderated by the Medicare Part D coverage gap.Adherence to antidepressant therapy was measured by (a lack of) disruption in medication use defined by a gap of 30 days or more in antidepressant possession and monthly days of possession, both measured over 180 days since antidepressant initiation. We used a 5% random sample of Medicare fee-for-service beneficiaries who received a new depression diagnosis in the first half of 2007 and initiated antidepressant therapy within 60 days (n = 16,778). We estimated a Cox proportional hazard model for antidepressant disruption and a mixedeffects linear model for monthly possession. All analyses were stratified by 4 cohorts defined by Part D low-income subsidy (LIS) status and Medicare entitlement (aged vs disabled).Generic initiation was associated with improved adherence among all 4 cohorts, with a stronger effect among the non-LIS patients. Hazard ratios for antidepressant disruption ranged from 0.71 (95% confidence interval [CI], 0.53-0.96) among non-LIS, disabled patients to 0.88 (95% CI, 0.79-0.98) among LIS, aged patients. Generic initiation was associated with increases in days of monthly possession in all 4 cohorts and an additional benefit during the coverage gap for non-LIS patients.Generic initiation can be an important tool to improve adherence to antidepressant treatment among Medicare patients and to mitigate the negative effects of the Part D coverage gap.

SUBMITTER: Bao Y

PROVIDER: S-EPMC3921685 | biostudies-literature | 2013 Dec

REPOSITORIES: biostudies-literature

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Generic initiation and antidepressant therapy adherence under Medicare Part D.

Bao Yuhua Y Ryan Andrew M AM Shao Huibo H Pincus Harold Alan HA Donohue Julie M JM

The American journal of managed care 20131201 12

<h4>Objectives</h4>To assess the effect of initiating antidepressant therapy with a generic prescription on adherence to antidepressant therapy among Medicare patients. A second objective is to assess how the effect might be moderated by the Medicare Part D coverage gap.<h4>Study design and methods</h4>Adherence to antidepressant therapy was measured by (a lack of) disruption in medication use defined by a gap of 30 days or more in antidepressant possession and monthly days of possession, both m ...[more]

PMID: 24512035

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Project description:OBJECTIVES:To examine patterns of generic escitalopram initiation and substitution among Medicare beneficiaries. METHODS:This retrospective new user cohort used a 5% random sample of 2013-2015 Medicare administrative claims data. Fee-for-service Medicare beneficiaries continuously enrolled in Parts A, B, and D during a 6-month washout period prior to their initial generic or brand oral escitalopram prescriptions were included (n = 12,351). The primary outcomes were generic escitalopram treatment initiation, and among brand escitalopram initiators, generic substitution within 12 months. Patient demographics, health service utilization, and prescription level factors were measured and assessed. RESULTS:Among all escitalopram initiators, about 88.2% Medicare beneficiaries initiated generic escitalopram. Beneficiaries who were younger age, male, residing in non-Northeast regions or urban area, in the Part D plan deductible benefit phase, and filling prescriptions at community/retail pharmacies were more likely to initiate generic treatment. Among brand escitalopram initiators (n = 1,464), about 20.7% switched to generic escitalopram, 31.2% switched to another alternative antidepressant, 25.1% discontinued treatment, and 8.7% were lost to follow up or passed away within 12 months after brand initiation. Factors associated with generic escitalopram substitution included region (Midwest vs. Northeast, adjusted hazard ratio (HR) = 1.46, 95% CI = 1.04-2.05), pre-index hospitalization (HR = 1.31; 95% CI = 1.16-1.48) and lower escitalopram average daily dosage (HR = 0.97; 95% CI = 0.95-0.99). CONCLUSIONS:In 2013-2015, almost 90% Medicare beneficiaries initiated generic escitalopram treatment. Among brand escitalopram initiators, about 1 in 5 patients switched to generic escitalopram within 1 year, as compared to 1 in 4 or 1 in 3 who discontinued current or switched to alternative treatment, respectively. Medicare beneficiary's geographic region was independently associated with generic escitalopram initiation and substitution. Findings from this study not only provide up-to-date evidence in generic escitalopram use patterns among Medicare population, but also can guide educational and practice interventions to further increase generic escitalopram use.

Project description:BackgroundAlthough the Medicare Part D coverage gap phase-out should reduce cost-related nonadherence (CRN) among seniors with diabetes, preferential generic prescribing may have already decreased CRN, while smaller numbers of patients using more costly branded oral anti-diabetic (OAD) medications remain vulnerable to CRN.ObjectiveTo estimate the effects of cost sharing in the Part D standard (non-LIS) benefit on adherence to different OAD classes, comparing two classes dominated by inexpensive generic medications and two by more costly branded medications.Design and patientsRetrospective cohort study using dispensed prescription data for elderly non-LIS (N=81,047) and LIS (low-income subsidy) (N=150,359) beneficiaries using same class OAD(s) in 2008 and 2009. Logistic regression modeled non-LIS likelihood; LIS and non-LIS patients matched using propensity outcome (N=38,054). Logistic regression, controlling for demographic and health status characteristics, modeled effects of non-LIS coverage on 2009 OAD class adherence.Main measuresMain outcome measures were within-class OAD coverage year adherence, with patients considered adherent when days supplied to calendar days ratio at least 0.8.Key resultsNon-LIS patients had 0.52 and 0.57 times the odds of branded-only DPP-4 Inhibitor (N=1,812; 95 % CI: 0.43, 0.63; P<0.001) and Thiazolidinedione (TZD) (N=6,290; 95 % CI: 0.52, 0.63; P<0.001) adherence. Most patients (N=32,510; 82 %) used OADs in primarily generic classes, where we found no significant (Biguanides; N=21,377) or small differences (Sulfonylureas/Glinides [N=19,240; OR: 0.91; 95 % CI: 0.86, 0.97; P=0.002]) in adherence odds. Crude adherence rates were sub-optimal when CRN was not a factor (Non-LIS/LIS: Biguanides: 65 %/65 %; Sulfonylureas/Glinides: 66 %/68 %; LIS: DPP-4 Inhibitors: 66 %; TZDs: 67 %).ConclusionsGap elimination would not affect generic, but should reduce branded OAD CRN. Branded copayments may continue to lead to CRN. Policy initiatives and benefit changes targeting both cost deterrents for patients with more complex disease and non-cost generic OAD underuse are recommended.

Project description:Importance:The 2019 federal Ending the HIV Epidemic initiative requires a vast expansion of access to antiretroviral therapy (ART) and preexposure prophylaxis (PrEP) for HIV treatment and prevention. However, high prices for ART and PrEP can reduce their affordability and use. Medicare covers 1 in 4 persons living with HIV, and the Medicare Part D drug benefit imposes complicated cost-sharing between patients and other stakeholders. Objective:To determine how the Medicare Part D design distributes the cost burden for ART and PrEP between patients, insurance plans, manufacturers, and Medicare. Design and Setting:Nationwide cross-sectional analyses of first quarter 2019 Medicare formulary and pricing files for 3326 Part D plans were performed. These files contain drug benefit data, including prices and cost-sharing requirements. Main Outcomes and Measures:For 18 ART and 2 PrEP regimens, the out-of-pocket costs for patients and the cost borne by plans, manufacturers, and Medicare were projected for 1 year of treatment or prevention under a 2019 standard Medicare Part D insurance plan. Analyses assumed that patients used the ART or PrEP regimen and no other medications. Results:In 2019, ART prices ranged from $24?010 to $46?770 annually (median price, $35?780), with patients projected to pay 9% to 14% of the cost ($3270-$4350), insurance plans 18% to 24% ($5340-$8450), manufacturers 6% to 11% ($2370-$2750), and Medicare 53% to 67% ($12?770-$31?270). The price of PrEP was $20?570 annually, with patients contributing 15% ($2990), insurance plans 22% ($4570), manufacturers 13% ($2750), and Medicare 50% ($10?260). For beneficiaries with low-income subsidies that cover all patient cost-sharing, Medicare would assume 67% to 76% of ART costs and 65% of PrEP costs. Conclusions and Relevance:Medicare Part D mandates universal ART and PrEP coverage, but high prices (>$35?000 annually for ART and>$20?000 annually for PrEP) and the design of Part D can jeopardize affordability for patients and place most of the cost burden on taxpayers. Under a standard Medicare Part D benefit, patients pay $3000 to $4000 out-of-pocket yearly, unless they qualify for low-income subsidies, and half to two-thirds of the cost of ART and PrEP is borne by Medicare rather than insurance plans or manufacturers. To end the HIV epidemic by 2030, it appears that policies must address both high drug prices and revamp Medicare Part D cost-sharing.

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Generic initiation and antidepressant therapy adherence under Medicare Part D.

Publications

Generic initiation and antidepressant therapy adherence under Medicare Part D.

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