Dataset Information

Medicare Part D's Effects on Drug Utilization and Out-of-Pocket Costs: A Systematic Review.

ABSTRACT: OBJECTIVE:To update a past systematic review on whether Medicare Part D changed drug utilization and out-of-pocket (OOP) costs overall and within subpopulations, and to identify evidence gaps. DATA SOURCES/STUDY SETTING:Published and gray literature from 2010 to 2015 meeting prespecified screening criteria, including having a comparison group, and utilization or OOP cost outcomes. STUDY DESIGN:We conducted a systematic literature review with a quality assessment. DATA COLLECTION/EXTRACTION METHODS:For each study, we extracted information on study design, data sources, analytic methods, outcomes, and limitations. Because outcome measures vary across studies, we did a qualitative synthesis rather than meta-analysis. PRINCIPAL FINDINGS:Sixty-five studies met screening criteria. Overall, Medicare Part D enrollees have increased drug utilization and decreased OOP costs, but coverage gaps limit the program's impact. Beneficiaries whose insurance becomes more generous after enrollment had disproportionately increased drug utilization and decreased OOP costs. Outcomes among dual-eligibles were mixed. CONCLUSIONS:There is strong evidence on how Medicare Part D and the donut hole coverage gap affect utilization and OOP costs, but weak evidence on how effects vary among dual-eligibles or across diseases. Findings suggest that the Affordable Care Act's provisions to expand coverage and reduce the donut hole should improve patient outcomes.

SUBMITTER: Park YJ

PROVIDER: S-EPMC5583296 | biostudies-other | 2017 Oct

REPOSITORIES: biostudies-other

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Medicare Part D's Effects on Drug Utilization and Out-of-Pocket Costs: A Systematic Review.

Park Young Joo YJ Martin Erika G EG

Health services research 20160801 5

<h4>Objective</h4>To update a past systematic review on whether Medicare Part D changed drug utilization and out-of-pocket (OOP) costs overall and within subpopulations, and to identify evidence gaps.<h4>Data sources/study setting</h4>Published and gray literature from 2010 to 2015 meeting prespecified screening criteria, including having a comparison group, and utilization or OOP cost outcomes.<h4>Study design</h4>We conducted a systematic literature review with a quality assessment.<h4>Data co ...[more]

PMID: 27480577

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Project description:ImportancePrior research has documented the increase in prescription drug rebates and the coincident increase in out-of-pocket burden for patients paying coinsurance tied to list prices.ObjectiveTo describe the out-of-pocket burden on patients with coinsurance and assess its association with pharmaceutical competition, which increases payers' leverage to seek higher rebates.Design, setting, and participantsThis retrospective cohort study used branded prescription drugs with US sales reported by publicly traded companies. The study included drugs with nonmissing, nonnegative rebates between 2014 and 2018 from SSR Health. Data analysis was conducted from June to December 2020.ExposuresLevel of branded and generic competition and calendar year.Main outcomes and measuresRetail price markup (ie, the ratio of rebate to net price) paid by patients at the point of sale and effective out-of-pocket share (ie, coinsurance multiplied by list price divided by net price) of a standard Part D plan. Trends in these outcomes were examined and then stratified by degree of competition.ResultsThere were 3322 unique National Drug Codes in the analysis, representing 232 distinct molecules from 138 therapeutic classes in 34 disease areas. The ratio of rebate to net prices was higher and increased faster for drugs with branded and generic competitors (from 83% to 172%) than for drugs with only branded competitors (from 61% to 115%) and those without generic equivalents (from 33% to 49%). Hypothetical patients paying standard Part D coinsurance on drug list prices would have experienced an effective out-of-pocket share increase from 48% to 64% in the initial coverage phase, and from 10% to 13% in the catastrophic coverage phase between 2014 and 2018. In the coverage gap, the share increased from 92% in 2014 to 98% in 2016 and then decreased to 90% in 2018. Compared with drugs with no competition, effective out-of-pocket share paid by patients grew 50% faster for drugs with branded competitors and 100% faster for those with branded and generic competitors.Conclusions and relevanceThis study found substantial increases in cost-sharing burden for patients paying coinsurance on drug list prices between 2014 and 2018, especially in markets with more pharmaceutical competition. Payers passing rebates through to patients at the point of sale could restore the benefits of competition and rebates.

Project description:ImportanceLittle is known about how out-of-pocket burden differs between Medicare and commercial insurance for ultra-expensive drugs.ObjectiveTo investigate out-of-pocket spending for ultra-expensive drugs in the Medicare Part D program vs commercial insurance.Design, setting, and participantsThis was a retrospective, population-based cohort study of individuals using ultra-expensive drugs included in a 20% nationally random sample of prescription drug claims from Medicare Part D and individuals aged 45 to 64 years using ultra-expensive drugs included in a large national convenience sample of outpatient pharmaceutical claims from commercial insurance plans. Claims data from 2013 through 2019 were used, and data were analyzed in February 2023.Main outcomes and measuresClaims-weighted mean out-of-pocket spending per beneficiary per drug by insurance type, plan, and age.ResultsIn 2019, 37 324 and 24 159 individuals using ultra-expensive drugs were identified in the 20% Part D and commercial samples, respectively (mean [SD] age, 66.2 [11.7] years; 54.9% female). A statistically significant higher share of commercial enrollees vs Part D beneficiaries were female (61.0% vs 51.0%; P < .001), and a statistically significantly lower share were using 3 or more branded medications (28.7% vs 42.6%; P < .001). Mean out-of-pocket spending per beneficiary per drug in 2019 was $4478 in Part D (median [IQR], $4169 [$3369-$5947]) compared with $1821 for commercial (median [IQR], $1272 [$703-$1924]); these differences were statistically significant every year. Differences in out-of-pocket spending comparing commercial enrollees aged 60 to 64 years and Part D beneficiaries aged 65 to 69 years exhibited similar magnitudes and trends. By plan, mean out-of-pocket spending per beneficiary per drug in 2019 was $4301 (median [IQR], $4131 [$3000-$6048]) in Medicare Advantage prescription drug (MAPD) plans, $4575 (median [IQR], $4190 [$3305-$5799]) in stand-alone prescription drug plans (PDPs), $1208 (median [IQR], $752 [$317-$1240]) in health maintenance organization plans, $1569 (median [IQR], $838 [$481-$1472]) in preferred provider organization plans, and $4077 (median [IQR], $2882 [$1075-$4226]) in high-deductible health plans. There were no statistically significant differences between MAPD plans and stand-alone PDPs in any study year. Mean out-of-pocket spending was statistically significantly higher in MAPD plans compared with health maintenance organization plans and in stand-alone PDPs compared with preferred provider organization plans in each study year.Conclusions and relevanceThis cohort study demonstrated that the $2000 out-of-pocket cap included in the Inflation Reduction Act may substantially moderate the potential increase in spending faced by individuals who use ultra-expensive drugs when moving from commercial insurance to Part D coverage.

Project description:ImportanceList prices set by manufacturers for brand-name prescription drugs in the US have been increasing faster than inflation, although confidential manufacturer rebates offset some of these increases. Most commercially insured patients pay at least some out-of-pocket costs for prescription drugs, and higher patient spending is associated with lower adherence and worse health outcomes.ObjectiveTo examine whether price changes for brand-name drugs are correlated with changes in patient out-of-pocket spending and whether this association varies by insurance benefit design.Design, setting, and participantsA cohort study of 79 brand-name drugs with available pricing data from January 2015 to December 2017 was conducted, with data obtained from a national commercial insurance claims database.ExposuresChange in the list prices set by manufacturers and estimated net prices after rebates among non-Medicaid payers.Main outcomes and measuresChange in median out-of-pocket spending among all patients and stratified by insurance pharmacy benefit design, including high-deductible insurance plans and plans with any amount of deductibles or coinsurance.ResultsAmong 79 drugs, median increases were 16.7% (interquartile range [IQR], 13.6%-21.1%) for list prices, 5.4% (IQR, -3.9% to 11.7%) for net prices, and 3.5% (IQR, 1.4%-9.1%) for out-of-pocket spending from 2015 to 2017. Changes in list prices were correlated with changes in net prices (r = 0.34; P = .002). Overall, changes in out-of-pocket spending were not correlated with changes in list prices (r = 0.14; P = .22) or net prices (r = 0.04; P = .71). Among 53.7% of patients who paid any drug deductible or coinsurance, median out-of-pocket spending increased by 15.0%, and changes were moderately correlated with changes in list prices (r = 0.38; P = .001) but not net prices (r = 0.06; P = .62).Conclusions and relevanceSome commercially insured patients who pay only prescription drug copayments appear to be insulated from increases in drug prices. However, more than half of patients pay deductibles or coinsurance and may experience substantial increases in out-of-pocket spending when drug prices increase. Among these patients, there was no evidence that manufacturer rebates to insurers are associated with patients' out-of-pocket spending. Policies to rein in unregulated annual increases in list prices for brand-name drugs may have important consequences for patient out-of-pocket spending.

Dataset Information

Medicare Part D's Effects on Drug Utilization and Out-of-Pocket Costs: A Systematic Review.

Publications

Medicare Part D's Effects on Drug Utilization and Out-of-Pocket Costs: A Systematic Review.

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