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

药物成本控制变化和精神疾病双重参与者的护理质量

• 批准号: 7937098
• 负责人: STEPHEN B SOUMERAI
• 金额: $ 48.81万
• 依托单位: HARVARD PILGRIM HEALTH CARE, INC.
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-09-30 至 2013-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/7937098
• 关键词: Drug; Cost; Containment; Changes; Quality

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.

描述（由申请人提供）：同时接受医疗补助和医疗保险保险的残疾、低收入美国人（即双重参保者）是医疗保险人口中增长最快的群体之一。这些受益人中约有三分之一（约 250 万人）患有昂贵且常常使人衰弱的精神疾病，包括精神分裂症和双相情感障碍。这些双重参与者的药物治疗依从性差会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) 将双重参保者的门诊处方药承保责任从各州医疗补助计划转移到了 2006 年 1 月 1 日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) 将双重受益人随机分配到保费相对较低的 D 部分处方药计划 (PDP)。这些独立的 PDP 计划处方中包含的处方药数量和类型可能有所不同，并且可以采用使用管理方法，例如对任何药物处方进行事先授权 (PA)。由于每个州都确定了自己的医疗补助覆盖政策，因此双重受益人在过渡到 D 部分承保之前面临一系列药物承保福利。例如，在 15 个州，双重登记者对处方数量设有上限。因此，2006 年向 D 部分的过渡扩大了药物覆盖范围，并消除了造成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治疗排除在医疗补助事先授权 (PA) 之外，而 PDP 经常使用 PA 作为管理药品成本的主要方法。因此，随着药物承保责任从国家转移到私人计划，双重登记受益人在门诊处方药获取方面面临的国家确定的成本障碍较少，但在精神药物获取方面可能面临更多计划确定的行政障碍。我们将分别分析 D 部分对四个地域不同的大型州的影响：其中两个州对处方数量设置了上限，并且在 2004 年至 2007 年期间自付额相对较高（南卡罗来纳州：每月 4 份处方；加利福尼亚州：每月 6 份处方）；还有两个州在同一时期没有上限且自付额相对较低（密苏里州、新泽西州）。在目标 1 中，我们将使用强大的准实验设计，即多重中断时间序列，来检验这一转变对人口水平的影响：(1) 精神科药物使用的普遍性和持续性； (2) 使用非药物精神科服务； (3) 成本。在目标 2 中，我们在患者层面使用随机设计来估计承保限制对精神科药物使用（包括停药和换药）、精神科门诊和急诊室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研究政策变化对精神分裂症和双相情感障碍患者的高危亚组（由躯体合并症和少数民族状况定义）的影响。