Changes in drug coverage generosity and untreated serious mental illness: transitioning from Medicaid to Medicare Part D.
Changes in drug coverage generosity and untreated serious mental illness: transitioning from Medicaid to Medicare Part D.
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DOI：
10.1001/jamapsychiatry.2014.1259
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发表时间：
2015-02
期刊：
影响因子：
25.8
通讯作者：
Soumerai SB
中科院分区：
文献类型：
--
作者：
Madden JM;Adams AS;LeCates RF;Ross-Degnan D;Zhang F;Huskamp HA;Gilden DM;Soumerai SB
超过五分之一的双重医疗保险-医疗补助登记的残疾人患有精神分裂症或双相情感障碍（即严重的精神疾病）。他们从医疗补助药物覆盖范围（各州的慷慨程度各不相同）过渡到医疗保险D部分药物福利的影响尚不清楚。每年都有成千上万的人进行这种转变。确定从医疗补助药物福利过渡到医疗保险D部分对严重精神疾病患者药物使用的影响，并确定医疗补助药物上限的影响。在连续入组患者队列（2004-2007年）的时间序列分析中，我们估计了过渡到D部分之前和之后药物使用的变化，比较了限制每月处方量的州与没有处方限制的州。我们使用的医疗补助和医疗保险索赔从5%的国家样本的社区居住，非老年残疾的双重登记与精神分裂症（n = 5554）或双相情感障碍（n = 3675）。精神药物治疗包括抗精神病药治疗精神分裂症，抗精神病药、抗惊厥药和锂治疗双相情感障碍。我们测量了未治疗疾病的月发生率、治疗强度和总体处方药使用情况。在D部分之前，双相情感障碍患者中未经治疗的疾病的患病率在严格上限状态中为30.0%，在无上限状态中为23.8%。在严格上限状态下，D部分后1年未接受治疗的患者比例（相对）下降了17.2%，而在无上限状态下未接受治疗的患者比例没有变化。对于精神分裂症患者，未治疗率（20.6%）在严格上限状态下没有变化，但在无上限状态下增加了23.3%（从11.6%）。在D部分后，严格上限状态下的总体药物使用量大幅增加：双相情感障碍患者的处方填充量比预期高35.5%，精神分裂症患者的处方填充量比预期高17.7%;两个队列中无上限状态下的总体使用量没有变化。从医疗补助过渡到医疗保险D部分对严重精神疾病基本治疗的影响因州而异。在有严格药物福利限制的州，过渡到D部分可能会降低双相情感障碍患者的未治疗疾病率，这些患者的总体药物使用水平较高。对于生活在相对慷慨的无上限医疗补助覆盖范围的州的严重精神疾病患者，D部分后抗精神病药物治疗的机会可能会减少。
More than 1 in 5 disabled people with dual Medicare-Medicaid enrollment have schizophrenia or a bipolar disorder (ie, a serious mental illness). The effect of their transition from Medicaid drug coverage, which varies in generosity across states, to the Medicare Part D drug benefit is unknown. Many thousands make this transition annually. To determine the effect of transitioning from Medicaid drug benefits to Medicare Part D on medication use by patients with a serious mental illness and to determine the influence of Medicaid drug caps. In time-series analysis of continuously enrolled patient cohorts (2004–2007), we estimated changes in medication use before and after transitioning to Part D, comparing states that capped monthly prescription fills with states with no prescription limits. We used Medicaid and Medicare claims from a 5% national sample of community-dwelling, nonelderly disabled dual enrollees with schizophrenia (n = 5554) or bipolar disorder (n = 3675). Psychotropic treatments included antipsychotics for schizophrenia and antipsychotics, anticonvulsants, and lithium for bipolar disorder. We measured monthly rates of untreated illness, intensity of treatment, and overall prescription medication use. Prior to Part D, the prevalence of untreated illness among patients with a bipolar disorder was 30.0% in strict-cap states and 23.8% in no-cap states. In strict-cap states, the proportion of untreated patients decreased by 17.2% (relatively) 1 year after Part D, whereas there was no change in the proportion of untreated patients in no-cap states. For patients with schizophrenia, the untreated rate (20.6%) did not change in strict-cap states, yet it increased by 23.3% (from 11.6%) in no-cap states. Overall medication use increased substantially after Part D in strict-cap states: prescription fills were 35.5% higher among patients with a bipolar disorder and 17.7% higher than predicted among schizophrenic patients; overall use in no-cap states was unchanged in both cohorts. The effects of transitioning from Medicaid to Medicare Part D on essential treatment of serious mental illness vary by state. Transition to Part D in states with strict drug benefit limits may reduce rates of untreated illness among patients with bipolar disorders, who have high levels of overall medication use. Access to antipsychotic treatment may decrease after Part D for patients with a serious mental illness living in states with relatively generous uncapped Medicaid coverage.