Cox E, Motheral BR, Fairman K; Academy for Health Services Research and Health Policy. Meeting.
Abstr Acad Health Serv Res Health Policy Meet. 2001; 18: 153.
Outcomes Research, Express Scripts, Inc., 13900 Riverport Drive, Maryland Heights, Missouri 63043, Phone: (314) 702-7541, Fax: (314) 770-9163, E-mail: ecox@express-scripts.com
RESEARCH OBJECTIVE: To evaluate exhaustion of capped prescription benefits on discontinuation of chronic therapies and therapy continuation once the benefit begins anew the following year.STUDY DESIGN: This study used prescription claims and eligibility data for a Medicare HMO with an annually administered capped prescription benefit of $800. The data covered the time period from January 1, 1997 through December 31, 1998 for over 18,000 continuously enrolled Medicare beneficiaries. Five chronic therapies from the top 10 therapy categories utilized by the population were chosen for evaluation. These therapy categories included: 1)Beta blockers, 2)Calcium channel blockers, 3)Oral estrogen therapy, 4)Antihypertensives, and 5)Antihyperlipidemics. An extended Cox model with the internally defined time-dependent variable of reaching cap was used to analyze the relationship between reaching cap and cessation of prescription claim activity controlling for participant age, gender, and chronic disease score.POPULATION STUDIED: Medicare beneficiaries 65 years of age and older enrolled in a Medicare HMO with capped prescription benefits.PRINCIPAL FINDINGS: The relative risks of cessation of claim activity at any given time for members who exhausted their prescription cap were 2.73 (95% confidence interval [CI], 1.72-4.34) for Beta blockers, 2.34 (95% CI, 1.68-3.26) for Calcium channel blockers, 2.18 (95% CI, 1.40-3.37) for estrogen therapy, 1.99 (95% CI, 1.43-2.75) for antihypertensives, and 2.24 (95% CI, 1.57-3.20) for antihyperlipidemics. While focus groups indicated that members were going outside the system to obtain their medications, claims continued to be processed in every month for 80-90% of individuals who had reached their cap. Among those with cessation in claims activity, those who reached cap were no more or less likely than those who did not reach cap to continue therapy when the benefit began anew the following year.CONCLUSIONS: The exhaustion of prescription coverage does place individuals at a greater risk for cessation of claim activity for chronic therapies considered essential to ones health. The extent to which loss of claim activity represents true discontinuation is unknown.IMPLICATIONS FOR POLICY, DELIVERY, OR PRACTICE: Both cessation of claim activity and cessation of essential therapies raise concerns regarding quality of care. If these findings represent discontinuation of therapy, patient advocacy by plan sponsors and providers to assist members in maximizing their cap and with coverage alternatives after the cap is reached is critical. In the former, drug use review processes are most effective if there is complete capture of prescription claims. Loss of claim activity, due to members going outside the system to obtain their medications, hinders the ability to appropriately monitor prescription use in order to avoid drug interactions and other such adverse events. Plan sponsors should develop systems by which to ensure use of network systems after the cap has been reached.PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundations Changes in Health Care Financing and Organization (HCFO) Initiative
Publication Types:
Keywords:
- Contraceptive Devices
- Health Maintenance Organizations
- Humans
- Managed Care Programs
- Medicare
- Prescriptions, Drug
- economics
- hsrmtgs
Other ID:
UI: 102273463
From Meeting Abstracts