Drug Cost Containment Changes and Quality of Care for Mentally Ill Dual Enrollees

描述（由申请人提供）：残疾人，低收入美国人谁收到医疗补助和医疗保险覆盖（即，双重登记者），代表了医疗保险人口中增长最快的部分之一。约三分之一的受益人（估计）。2.5 100万人）患有昂贵的，往往使人衰弱的精神疾病，包括精神分裂症和双相情感障碍。这些双重入组者中药物治疗依从性差导致健康状况恶化和昂贵的下游临床事件，包括因严重精神疾病（SMI）住院。2003年医疗保险现代化法案（MMA）于2006年1月1日将双重登记者的门诊处方药保险责任从个别州医疗补助计划转移到由医疗保险计划资助的私人D部分计划。医疗保险和医疗补助服务中心（CMS）随机分配双重受益人到D部分处方药计划（PDP），保费相对较低。这些独立的PDP可以在计划处方集中包含的处方药的数量和类型上有所不同，并且可以对任何药物处方采用使用管理方法，例如事先授权（PA）。由于每个州都确定了自己的医疗补助覆盖政策，双重受益人在过渡到D部分覆盖之前面临着一系列的药物覆盖福利。例如，在15个州，双重登记者对处方数量有上限。因此，2006年过渡到D部分扩大了药物覆盖范围，消除了代价高昂的不良健康事件的潜在风险因素。然而，大多数州将抗精神病药和抗惊厥药治疗排除在医疗补助事先授权（PA）之外，而PDP通常将PA作为管理药物成本的主要方法。因此，随着药物覆盖责任从州转移到私人计划，双重登记的受益人在获得门诊处方药方面面临的州确定的成本障碍较少，但在获得精神药物方面可能面临更多的计划确定的行政障碍。我们将在四个地理位置不同的大州分别分析D部分的影响：2004年至2007年期间，两个州对处方数量设置了上限，并且自付额相对较高（南卡罗来纳州：每月4张处方的限制;加州：每月6张处方的限制），两个州在同一时期没有上限，自付额相对较低（密苏里州，新泽西）。在目标1中，我们将使用一个强有力的准实验设计，多中断时间序列，以检查这种转变对人口水平的影响：（1）精神药物使用的流行率和持续性;（2）非药物精神病服务的使用;（3）成本。在目标2中，我们在患者水平上使用随机设计来估计覆盖限制对精神病药物使用（包括停药和换药）、精神病门诊和急诊就诊以及费用的影响。在目标3中，我们将使用这两种设计来检查政策变化对精神分裂症和双相情感障碍患者的高危亚组（定义为躯体共病和少数民族状态）的影响。

DESCRIPTION (provided by the applicant): Disabled, low income Americans who receive both Medicaid and Medicare insurance coverage (i.e., dual enrollees), represent one of the fastest growing segments of the Medicare population. About one-third of these beneficiaries (est. 2.5 million) have expensive, often debilitating mental illness, including schizophrenia and bipolar disorder. Poor drug treatment adherence among these dual enrollees leads to worse health and expensive downstream clinical events including hospitalizations for severe mental illness (SMI). The Medicare Modernization Act of 2003 (MMA) transferred the responsibility for outpatient prescription drug coverage for dual enrollees from individual state Medicaid programs to private Part D plans funded by the Medicare program on January 1, 2006. The Centers for Medicare and Medicaid Services (CMS) randomly assigns dual beneficiaries to Part D Prescription Drug Plans (PDPs) with relatively low premiums. These standalone PDPs can vary in the numbers and types of prescription drugs included in the plan formulary and can employ utilization management approaches such as prior authorization (PA) for any drug prescriptions. Because each state determined its own Medicaid coverage policies, dual beneficiaries faced a range of drug coverage benefits prior to their transition to Part D coverage. For example, in 15 states, dual enrollees had caps on the number of prescriptions. Thus, the transition to Part D in 2006 expanded their drug coverage and removed a potential risk factor for costly adverse health events. Most states, however, excluded antipsychotic and anticonvulsant therapy from Medicaid prior authorization (PA), while PDPs often use PA as the primary approach for managing drug costs. Thus, as drug coverage responsibility shifts from states to private plans, dually enrolled beneficiaries face fewer state-determined cost barriers to outpatient prescription drug access, but potentially more plan-determined administrative barriers to psychotropic drug access. We will analyze the impact of Part D separately in four large and geographically diverse states: two that placed caps on the number of prescriptions and had relatively higher copayments between 2004 and 2007 (South Carolina: limit of 4 prescriptions per month; California: limit of 6 per month), and two that had no caps and relatively lower copayments during the same period (Missouri, New Jersey). In Aim 1, we will use a strong quasi-experimental design, Multiple Interrupted Time Series, to examine the population level impacts of this transition on: (1) the prevalence and persistence of psychiatric medication use; (2) use of non-drug psychiatric services; and (3) costs. In Aim 2 we use a randomized design at the patient level to estimate the effect of coverage restrictions on use of psychiatric medications (including discontinuation and switching of medications), psychiatric outpatient and ER visits, and costs. In Aim 3 we will use both designs to examine the impact of the policy changes among at-risk subgroups (defined by somatic comorbidities and minority status) of patients with schizophrenia and bipolar disorder.