Rx Coverage, Use and Spending Among US Seniors: Where Did Things Stand on the Eve of Part D Implemention & How Can This Inform Us Now? Presented at: AcademyHealth.

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Rx Coverage, Use and Spending Among US Seniors: Where Did Things Stand on the Eve of Part D Implemention & How Can This Inform Us Now? Presented at: AcademyHealth Annual Research Meeting Seattle, Washington 26 June 2006 Funding: Commonwealth Fund & Kaiser Family Foundation Dana Gelb Safran, ScD Director, The Health Institute Institute for Clinical Research and Health Policy Studies Tufts-New England Medical Center ___________________________________________________________________________

National Study of Prescription Coverage, Use and Spending, 2003 Survey of non-institutionalized seniors in 50 states and the District of Columbia with a focus on 12 “priority” states including: –5 states with state-sponsored pharmacy assistance programs (IL, MI, NY, PA, FL) –7 states without programs (CA, CO, OH, TX, TN, LA, WA) These 12 states account for 55% of US elderly ___________________________________________________________________________

Background Prior to the study, national data suggested that about 38% of beneficiaries lacked prescription coverage (MCBS 1999) Fiscal pressures were driving private sources of supplemental coverage to reduce or drop Rx benefits States were attempting to fill the gap -- particularly for low-income seniors ___________________________________________________________________________

Background (cont’d) All state Medicaid programs had a drug benefit 22 states had implemented state-funded pharmacy assistance programs and 7 states had discount programs But state-level data on prescription coverage were unavailable and little known about the experiences of low-income seniors or variability by state ___________________________________________________________________________

Sampling File from the Centers for Medicare and Medicaid Services (CMS) used for sampling Geocoded to the Census Block Group Level 3 Sampling strata: –Full-Medicaid –Non-Medicaid, Low-income Census Block Group (>13% elderly below 100% federal poverty level) –Non-Medicaid, Higher income Census Block Group ___________________________________________________________________________

Data Collection Survey administered July through October 2003 (n=36,901) Mail and telephone English and Spanish 51% Response rate (n=17,685) ___________________________________________________________________________

Principal Study Goals Ascertain rates and sources of prescription coverage nationally and by state Examine prescription use and spending overall and for 3 vulnerable subgroups: No coverage Low-income High disease burden Examine rates and types of medication nonadherence ___________________________________________________________________________

Beneficiaries without Drug Benefit, by State (2003) States with RX program States without ___________________________________________________________________________ Nat’l Total Source: Safran et al. Health Affairs April 2005.

Sources of Beneficiaries’ Drug Benefits, by State States with RX programStates without ___________________________________________________________________________ Source: Safran et al. Health Affairs April 2005.

Low-Income Beneficiaries without Drug Benefit, by State (2003) States with RX programStates without ___________________________________________________________________________ Source: Safran et al. Health Affairs April 2005.

Prescription Medication Use and Monthly Out-Of Pocket Spending by Coverage Status, Poverty, and Disease Burden (2003) ___________________________________________________________________________ Source: Safran et al. Health Affairs April % 25% 50% 75% 100% 89% 97% 77% Use Rx Medication 46% 49% 73% 35% Using 5+ Rx 54% 52% 67% 46% More than 1 MD 31% 41% 36% 32% More than 1 Pharmacy Total (n=17,569)No Rx Coverage (27.3%)Low Income (40%)Complex Chronic (31.6%)

Percent of Seniors Nationally Who Spend $100+ Per Month on Drugs, by Source of Drug Coverage ___________________________________________________________________________ Source: Safran et al. Health Affairs April 2005.

Nonadherence Due to Cost (2003) 35% 26% 37% Any cost-related nonadherence 19% 18% 12% 18% Took smaller doses 22% 16% 23% Skipped doses 25% 26% 18% 28% Didn't fill Rx 1+ times ___________________________________________________________________________ Source: Safran et al. Health Affairs April Total No Rx Coverage Low incomeComplex chronic

Nonadherence Due to Experiences (2003) 34% 28% 25% 27% Non-adherence due to experiences 24% 22% 18% 20% Skipped or stopped because not helping 27% 22% 19% Skipped or stopped because felt worse ___________________________________________________________________________ Source: Safran et al. Health Affairs April Total No Rx Coverage Low incomeComplex chronic

Rates of Cost- and Experience-Related Non-Adherence by Chronic Condition and Coverage Status Cost-Related Non-Adherence (%)Experience-Related Non-Adherence (%) Seniors with Coverage Seniors without Coverage ___________________________________________________________________________ Source: Safran et al. Health Affairs April 2005.

Nonadherence Due to Self-Assessed Need (2003) 19% 17% 15% 18% Non-adherence due to self- assessed need 13% 12% 9% 10% Did not fill because felt too many Rxs 16% 14% 12% 15% Did not fill because felt didn't need ___________________________________________________________________________ Source: Safran et al. Health Affairs April Total No Rx Coverage Low incomeComplex chronic

Rates of Nonadherence By Coverage Status, Poverty, and Disease Burden (2003) 52% 48% 40% 48% Total: Any Nonadherence 19% 17% 15% 18% Nonadherence due to self-assessed need 34% 28% 25% 27% Nonadherence due to experiences 35% 26% 37% Nonadherence due to cost ___________________________________________________________________________ Source: Safran et al. Health Affairs April Total No Rx Coverage Low incomeComplex chronic

Summary and Implications No question about the critical role that prescription medicines plan in seniors’ health care No question about importance of coverage in enabling seniors to sustain complex, costly regimens Not all sources of coverage are equally protective and prevailing sources vary widely by state Very large percentage of low-income seniors lacked coverage (>40% in some states) ___________________________________________________________________________

Summary & Implications (cont’d) Enormous potential for LIS program to help –To date, 1.7 million of estimated ~8 million low-income (without Medicaid) enrolled Positive role played by Medicaid prescription coverage delineated high stakes in the transition to private plans High rates of non-adherence due to cost -- nearly 50% in vulnerable subgroups lacking coverage underscore that potential health benefits of Part D are large Key role for clinicians around issues of adherence and integration ___________________________________________________________________________