Sherry Yang, Pharmacy Student, Class of 2018
Undergraduate Category: Health Sciences Degree Seeking: Doctor of Pharmacy Abstract ID# 1529
Effects of Medicare Part D implementaGon in the long-term care seIng: a systemaGc review Opportunity Background Medicare Part D is a voluntary prescripGon drug benefit implemented in 2006 to improve access to medicaGons to all Medicare enrollees, including those residing in long term care faciliGes. Long-term care residents, however, may have special medicaGon needs since they take more medicaGons, have a higher rate of chronic condiGons, and have more cogniGve impairments. Knowledge regarding the effect that this program has had on long term care residents is sGll relaGvely sparse.
Goal
To evaluate the current literature regarding Medicare Part D, with a focus on the effects that Part D coverage restricGons have on drug classes commonly prescribed in the long-term care seIng.
Sherry Yang, Pharmacy Student, Class of 2018
Results
Eight arGcles met inclusion criteria and were included in this systemaGc review. Part D implementaGon provided sufficient coverage and resulted in a relaGvely low number of rejecGons and uGlizaGon management requirements, but residents who did face coverage restricGons had lower medicaGon conGnuaGon rates and increased medicaGon changes or gaps in use than those without restricGons. There was a decrease in the use of Part D excluded drugs deemed unsafe for elderly, but also an indirect increase in negaGve clinical outcomes. Figure 1. Flow chart summarizing selecGon process for studies included in the systemaGc review Medline Search 73 Results 18 results excluded after title review
55 abstracts reviewed 36 articles excluded after abstract review • Not NH/LTC setting specific (n=9) • Not related to Part D outcomes (n=11) • No medication related outcomes (n=6) • Reviews, opinions, commentary, surveys, news articles (n=8) • Not U.S. based study (n=2)
Approach Methods
Relevant arGcles were idenGfied through a Medline search for literature published between January 2006 and July 2016 and a combinaGon of search term were used to limit search results. Search terms included “medicaGon insurance” or “Part D” and “nursing home(s)” or “long term care.” ArGcles that included these search terms were further evaluated for inclusion and exclusion criteria. Eligible arGcles were then fully reviewed for data extracGon. References
Berry, S.D., et al., Nonbenzodiazepine sleep medica0on use and hip fractures in nursing home residents. JAMA Intern Med, 2013. 173(9): p. 754-61. Briesacher, B.A., et al., Nursing home residents and enrollment in Medicare Part D. J Am Geriatr Soc, 2009. 57(10): p. 1902-7. Briesacher, B.A., et al., Medicare part D's exclusion of benzodiazepines and fracture risk in nursing homes. Arch Intern Med, 2010. 170(8): p. 693-8. Huskamp, H.A., et al., Medicare Part D Generosity and Medica0on Use Among Dual-eligible Nursing Home Residents. Medical Care, 2013. 51. Huskamp, H.A., et al., Rejec0ons of drug claims for nursing home residents under Medicare Part D. Health Aff (Millwood), 2008. 27(2): p. 560-7. Stevenson, D.G., et al., Medicare Part D Claims Rejec0ons for Nursing Home Residents, 2006 to 2010. American Journal of Managed Care, 2013: p. 647-654. Stevenson, D.G., et al., Effect of Part D coverage restric0ons for an0depressants, an0psycho0cs, and cholinesterase inhibitors on related nursing home resident outcomes. J Am Geriatr Soc, 2014. 62(9): p. 1666-74. Golden, A.G., D. Qiu, and B.A. Roos, Medica0on assessments by care managers reveal poten0al safety issues in homebound older adults. Ann Pharmacother, 2011. 45(4): p. 492-8.
Acknowledgements: Becky Briesacher, PhD; Brianne Mui, MPH; Aileen Ochoa, MPH
Results
19 full articles reviewed
Table 1. CharacterisGcs of studies assessing drug insurance in long term care Study Study Design Data Source/Method of Time Period LTC Setting Author Data Collection (Year) Stevenson Retrospective Pharmacy claims from 1 2005-2008 Nursing Home (2014) Cohort Study LTC pharmacy (Omnicare) Stevenson (2013)
Descriptive
Claims from 1 LTC pharmacy (Omnicare)
March 2006March 2010
Huskamp (2013)
QuasiExperimental
Drug claims from Omnicare
2005-2008
Berry (2013)
Case-crossover
Medicare Part A and Medicare Part D claims
Golden (2011)
Home-based Assessments
Home-based Assessments
Briesacher (2010)
QuasiExperimental
Briesacher( 2009)
QuasiExperimental
Huskamp (2008)
Descriptive
Prescription dispensing records from 1 LTC pharmacy; MDS records Prescription dispensing records from 1 LTC pharmacy Claims from 1 LTC pharmacy
Stevenson 2014 (n=70,662 AD; 43,578 AP; 38,199 CI)
Proportion of NH residents by Part D plan coverage Proportion of NH residents with medication change, gap, or stop Proportion of NH residents by Part D plan coverage Probability of medication change or gap
Huskamp 2013 (n = 92,813 NH residents)
8 articles included in systematic review
Dual-eligible NH residents aged 65 and older living in facilities that contracted with Omnicare
Nursing Home and Assisted Living Facility Nursing Home
Medicare Part D rejection claims
July 1, 2007December 31, 2008 August 2009November 2009
Nursing Home
Long stay NH residents age 50 or over with a hip fracture in fee for service Medicare Parts A & D Nursing home eligible older adults enrolled in Florida's Nursing Home Diversion Program, a Medicaid waiver program.
January 2005June 2007
Nursing Home
Medicare eligible long stay (>4 months) NH residents
January 2005December 2006
Nursing Home
Medicare eligible long stay (>4 months) NH residents
January 1, 2006December 2006
Nursing Home and Assisted Living Facility
Medicare Part D claims in rejected status
Nursing Home and Assisted Living Facility
Dual eligible NH residents aged 65 or older, who resided in facilties that contract with Omnicare
Table 2. Results of studies examining the effect of coverage on medicaGon changes and gaps in use
11 articles excluded after full text review • Not related to Part D outcomes (n=2) • No medication related outcomes (n=1) • Reviews, surveys, opinions, commentary, news articles (n=5) • Serve as background information (n=3)
Unit of Observation
Antipsychotics Coverage No Coverage Restrictions Restrictions
Antidepressants Coverage No Coverage Restrictions Restrictions
Cholinesterase Inhibitors Coverage No Coverage Restrictions Restrictions
10.8%
89.2%
7.6%
92.4%
12.2%
87.8%
35.6%*
33.1%
42.4%*
31.7%
40.2%*
24.6%
3.5%
96.5%
10.2%
89.8%
1.5%
98.5%
39%
29%
33%
28%
30%
22%
* = Difference in groups is statistically significant at P < 0.05; NH = nursing home AD = antidepressants; AP = antipsychotics; CI = cholinesterase inhibitors
Impact Conclusion
Value ProposiFon
There are sGll a limited number of studies assessing the impact that Medicare This systemaGc review serves to provide addiGonal Part D has had on the long-term care seIng. Early studies show that knowledge in an area with relaGvely sparse research coverage restricGons exist but were relaGvely rare for major drug classes, to increase the understanding of the effects of such as anGpsychoGcs, anGdepressants, and cholinesterase inhibitors. Medicare Part D in a specific populaGon. Future However, among nursing home residents with Medicare Part D coverage adjustments to Part D policies can assist in restricGons, medicaGon changes and gaps in use were common, suggesGng opGmizing medicaGon and health outcomes in LTC possible disrupGons in care. residents.
Effects of Medicare Part D implementaGon in the long-term care seIng: a systemaGc review Opportunity Background Medicare Part D is a voluntary prescripGon drug benefit implemented in 2006 to improve access to medicaGons to all Medicare enrollees, including those residing in long term care faciliGes. Long-term care residents, however, may have special medicaGon needs since they take more medicaGons, have a higher rate of chronic condiGons, and have more cogniGve impairments. Knowledge regarding the effect that this program has had on long term care residents is sGll relaGvely sparse.
Goal
To evaluate the current literature regarding Medicare Part D, with a focus on the effects that Part D coverage restricGons have on drug classes commonly prescribed in the long-term care seIng.
Sherry Yang, Pharmacy Student, Class of 2018
Results
Eight arGcles met inclusion criteria and were included in this systemaGc review. Part D implementaGon provided sufficient coverage and resulted in a relaGvely low number of rejecGons and uGlizaGon management requirements, but residents who did face coverage restricGons had lower medicaGon conGnuaGon rates and increased medicaGon changes or gaps in use than those without restricGons. There was a decrease in the use of Part D excluded drugs deemed unsafe for elderly, but also an indirect increase in negaGve clinical outcomes. Figure 1. Flow chart summarizing selecGon process for studies included in the systemaGc review Medline Search 73 Results 18 results excluded after title review
55 abstracts reviewed 36 articles excluded after abstract review • Not NH/LTC setting specific (n=9) • Not related to Part D outcomes (n=11) • No medication related outcomes (n=6) • Reviews, opinions, commentary, surveys, news articles (n=8) • Not U.S. based study (n=2)
Approach Methods
Relevant arGcles were idenGfied through a Medline search for literature published between January 2006 and July 2016 and a combinaGon of search term were used to limit search results. Search terms included “medicaGon insurance” or “Part D” and “nursing home(s)” or “long term care.” ArGcles that included these search terms were further evaluated for inclusion and exclusion criteria. Eligible arGcles were then fully reviewed for data extracGon. References
Berry, S.D., et al., Nonbenzodiazepine sleep medica0on use and hip fractures in nursing home residents. JAMA Intern Med, 2013. 173(9): p. 754-61. Briesacher, B.A., et al., Nursing home residents and enrollment in Medicare Part D. J Am Geriatr Soc, 2009. 57(10): p. 1902-7. Briesacher, B.A., et al., Medicare part D's exclusion of benzodiazepines and fracture risk in nursing homes. Arch Intern Med, 2010. 170(8): p. 693-8. Huskamp, H.A., et al., Medicare Part D Generosity and Medica0on Use Among Dual-eligible Nursing Home Residents. Medical Care, 2013. 51. Huskamp, H.A., et al., Rejec0ons of drug claims for nursing home residents under Medicare Part D. Health Aff (Millwood), 2008. 27(2): p. 560-7. Stevenson, D.G., et al., Medicare Part D Claims Rejec0ons for Nursing Home Residents, 2006 to 2010. American Journal of Managed Care, 2013: p. 647-654. Stevenson, D.G., et al., Effect of Part D coverage restric0ons for an0depressants, an0psycho0cs, and cholinesterase inhibitors on related nursing home resident outcomes. J Am Geriatr Soc, 2014. 62(9): p. 1666-74. Golden, A.G., D. Qiu, and B.A. Roos, Medica0on assessments by care managers reveal poten0al safety issues in homebound older adults. Ann Pharmacother, 2011. 45(4): p. 492-8.
Acknowledgements: Becky Briesacher, PhD; Brianne Mui, MPH; Aileen Ochoa, MPH
Results
19 full articles reviewed
Table 1. CharacterisGcs of studies assessing drug insurance in long term care Study Study Design Data Source/Method of Time Period LTC Setting Author Data Collection (Year) Stevenson Retrospective Pharmacy claims from 1 2005-2008 Nursing Home (2014) Cohort Study LTC pharmacy (Omnicare) Stevenson (2013)
Descriptive
Claims from 1 LTC pharmacy (Omnicare)
March 2006March 2010
Huskamp (2013)
QuasiExperimental
Drug claims from Omnicare
2005-2008
Berry (2013)
Case-crossover
Medicare Part A and Medicare Part D claims
Golden (2011)
Home-based Assessments
Home-based Assessments
Briesacher (2010)
QuasiExperimental
Briesacher( 2009)
QuasiExperimental
Huskamp (2008)
Descriptive
Prescription dispensing records from 1 LTC pharmacy; MDS records Prescription dispensing records from 1 LTC pharmacy Claims from 1 LTC pharmacy
Stevenson 2014 (n=70,662 AD; 43,578 AP; 38,199 CI)
Proportion of NH residents by Part D plan coverage Proportion of NH residents with medication change, gap, or stop Proportion of NH residents by Part D plan coverage Probability of medication change or gap
Huskamp 2013 (n = 92,813 NH residents)
8 articles included in systematic review
Dual-eligible NH residents aged 65 and older living in facilities that contracted with Omnicare
Nursing Home and Assisted Living Facility Nursing Home
Medicare Part D rejection claims
July 1, 2007December 31, 2008 August 2009November 2009
Nursing Home
Long stay NH residents age 50 or over with a hip fracture in fee for service Medicare Parts A & D Nursing home eligible older adults enrolled in Florida's Nursing Home Diversion Program, a Medicaid waiver program.
January 2005June 2007
Nursing Home
Medicare eligible long stay (>4 months) NH residents
January 2005December 2006
Nursing Home
Medicare eligible long stay (>4 months) NH residents
January 1, 2006December 2006
Nursing Home and Assisted Living Facility
Medicare Part D claims in rejected status
Nursing Home and Assisted Living Facility
Dual eligible NH residents aged 65 or older, who resided in facilties that contract with Omnicare
Table 2. Results of studies examining the effect of coverage on medicaGon changes and gaps in use
11 articles excluded after full text review • Not related to Part D outcomes (n=2) • No medication related outcomes (n=1) • Reviews, surveys, opinions, commentary, news articles (n=5) • Serve as background information (n=3)
Unit of Observation
Antipsychotics Coverage No Coverage Restrictions Restrictions
Antidepressants Coverage No Coverage Restrictions Restrictions
Cholinesterase Inhibitors Coverage No Coverage Restrictions Restrictions
10.8%
89.2%
7.6%
92.4%
12.2%
87.8%
35.6%*
33.1%
42.4%*
31.7%
40.2%*
24.6%
3.5%
96.5%
10.2%
89.8%
1.5%
98.5%
39%
29%
33%
28%
30%
22%
* = Difference in groups is statistically significant at P < 0.05; NH = nursing home AD = antidepressants; AP = antipsychotics; CI = cholinesterase inhibitors
Impact Conclusion
Value ProposiFon
There are sGll a limited number of studies assessing the impact that Medicare This systemaGc review serves to provide addiGonal Part D has had on the long-term care seIng. Early studies show that knowledge in an area with relaGvely sparse research coverage restricGons exist but were relaGvely rare for major drug classes, to increase the understanding of the effects of such as anGpsychoGcs, anGdepressants, and cholinesterase inhibitors. Medicare Part D in a specific populaGon. Future However, among nursing home residents with Medicare Part D coverage adjustments to Part D policies can assist in restricGons, medicaGon changes and gaps in use were common, suggesGng opGmizing medicaGon and health outcomes in LTC possible disrupGons in care. residents.
