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Published byJerome Park Modified over 8 years ago
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From Dunkin Donuts…. To Krispy Kreme: Making a Bigger, Better Donut Hole Group IV
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National Mental Health Association, May 2005
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Problem Statement Structure of cost sharing under Part D negatively impacts quality Dimensions of the problem –Vulnerable beneficiaries most affected –Patients less likely to fill prescriptions –Providers may not provide access to most effective drugs –Alternatively presents a moral hazard
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Rationale Experience with Part D –25% of beneficiaries will experience higher costs –6.9 million projected to reach coverage gap –3.1 million will reach catastrophic coverage –Near-poor (LIS-eligible) less likely to enroll –Duals confront copays for first time –Premiums lower and coverage better than projected
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Rationale Impact on Quality –Cost-related Adherence Uninsured 2.5 times more likely not to fill prescription 16.4% of Medicare recipients did not fill scripts 15.2% of insured did not fill scripts
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Rationale Impact on Quality –Prescribing practices Shoot-the-Moon Under-prescribing
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Stakeholders (1) Who will support this plan? –Seniors –Disease-specific interest groups Who will oppose it? –Seniors with other credible coverage –Seniors without targeted chronic diseases –Other disease-specific interest groups –Working population paying Medicare tax
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Stakeholders (2) Other Supporting Stakeholders –Health care providers –AARP –PhRMA –Pharmaceutical companies –Capitated health care systems –Fiscal conservatives
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Stakeholders (2) Other Opposing Stakeholders –Some specialty health care providers –Some pharmaceutical companies –Fee-for-service health systems –Pharmacies
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Plan of Action Minimizing complications resulting from problematic access to drugs Preserving cost; Improving quality
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Plan of Action High complication chronic diseases Highest evidence standards Long-term cost savings for Medicare Documented evidence of (examples): –Diabetes –Hypertension –Congestive Heart Failure Establish independent advisory group
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Plan of Action CDZ DrugsOther Drugs DeductibleNo? CopaysNo? Coverage GapNoYes; Increased
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Plan of Action NowProposed $2,250$1,750 $5,100 Expand the Donut Hole
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Plan of Action High complication chronic diseases Highest evidence standards Long-term cost savings for Medicare Documented evidence of (examples): –Diabetes –Hypertension –Congestive Heart Failure Establish independent advisory group
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Plan of Action Financing Campaign –Disease-specific interest groups –PhARMA –Capitated health systems Budget Impact –Initial administrative component –Cost-neutral over 5 years –Cost-saving over 10 years to Medicare
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