Medicare Part D may be helping more older Americans with heart failure get meds used to control the disease. A new study of nearly 7,000 older heart failure patients in a big insurance plan found the number of filled prescriptions for standard heart failure meds increased after Part D began in 2006, and the biggest increase was among seniors who previously lacked drug coverage.
The results, which were reported in the American Heart Journal, are the first to show Part D may help more people with heart failure get meds that are recommended to lower the risk of hospitalization and extend lives. The findings, Reuters writes, suggest concerns that drugmakers would be the largest beneficiaries from the program may be unfounded. You may recall that a 2007 report by IMS Health found Part D boosted sales of pricey brand-name cholesterol-lowering statins and ulcer drugs by 5 percent to 7 percent, for example (see here).
The study examined records for 6,950 people age 65 and older who were enrolled in a Pennsylvania Medicare managed care plan between 2003 and 2007. In the year before Part D began, 534 plan members had no coverage, and 4,600 had coverage with quarterly caps of $150 or $350. The remaining 1,800 had coverage through an employer or union, with no cap, the news service reports.
Among those who had lacked coverage, the average number of scrips filled each year rose from 13 to 19, and the percentage who filled at least one scrip for a beta-blocker increased from 45 percent in the two years prior to Part D, to 59 percent in 2006 and 2007. For a beta-blocker plus an ACE inhibitor or ARB, the percentage rose from 21 percent to 32 percent. Plan members who previously had drug coverage with quarterly caps showed smaller increases. The percentage filling a scrip a beta-blocker rose from between 55 and 58 percent to about 63 percent, Reuters continues.
"These findings," wrote Julie Donohue of the University of Pittsburgh Donohue and her colleagues, "are consistent with a major goal of the (Medicare Part D) policy, which was to reduce financial barriers to medication access among the elderly." However, Reuters notes coverage did not erase gaps in use between seniors who previously lacked coverage and those with good benefits through an employer or union. Before and after Part D began, about 45 percent of those such coverage filled scripts for both a beta-blocker and an ACE inhibitor or ARB, according to Reuters, which adds the rate rose among seniors who previously lacked coverage, but was only 32 percent after Part D went into effect.
4 Comments
This study goes along with numerous other studies over the years that have shown the benefits of the Medicare Modernization Act (MMA). Duke University studies had shown the MMA did not change cancer chemotherapy as feared. They showed that millions of dollars were saved and patient quality was still the same. And since oncology drugs accounted for about 69% of total Part B spending on prescription drugs and related services, the Medicare Part D plan made it more important for Medicare cancer patients. The fact that medical oncologists received no reimbursement for providing oral-dose therapy to cancer patients had been the principal barrier to the availability of the oral-dose protocol. Compared to infusional therapy, oral-dose anti-cancer drugs can make receiving cancer treatment more convenient for patients by allowing flexibility in taking medication without disrupting work or other activities. They often resulted in less time (or not time) spent in office-based oncology practices because of the absence of intravenous administration and its related side-effects.
However, Medicare's payment cuts for chemotherapy drugs didn't really change the patterns of treatment. Besides the recent Health Affairs publication (How Medicare's Payment Cuts For Cancer Chemotherapy Drugs Changed Patterns Of Treatment), a survey in Dr. Neil Love's "Patterns of Care" and Newhouse and Earle's previous Michigan/Harvard study (Does reimbursement influence chemotherapy treatment for cancer patients?), they all show results that the Medicare reforms are still not working. An impossible conflict of interest still exists. The existence of profit motive in drug selection has been one of the major factors working against the individualization of cancer chemotherapy. It is way past time to take medical oncologists out of the retail pharmacy business and force them to be doctors again.
Yes, this is good news. Since most betas, ACEs and ARBs (I think) are available as generics, this particular set of drugs would not have been expected to be a huge boon for the industry. Does that seem right?
Perhaps there is a "psychological incentive" knowing there is coverage, even if the rx could be picked up for $4-5 at a chain. Or perhaps the low cost would encourage people to get these in the can before a potential donut hole.
Pursuing just the healthcare cost issue a bit, does anyone know what the gov. is paying manufacturers for, say, a month of atenelol, compared with chain drug stores?
There is a little temporal confounding (if you will) going on here, and it relates to JiM's observation about prices of meds. ARBs (the least well- supported meds as a whole in CHF) are for the most part still branded - certainly there were not generics during the study period. I think only recently one or two have become avaialable as generics. So prior to Part D they were all very expensive.
The ACE inhibitors had mostly become generic, but ramipril was the last to go - not sure I recall the timing on that but seems like it was after Part D. The brand was Altace, and I recall it having some advantage/good data in CHF (that needs a quick fact-check for confirmation - but I'm not doing that today). Other, older ACEs were also proven to benefit, and they were generic.
Beta blockers are a much more complicated group. Only three have been shown to benefit CHF - metopropolol extended-release, carvedilol, and bisoprolol (with much less data supporting the last one). Carvedilol's price dropped very rapidly when the generic became available, but GSK developed a once-daily formulation (based on mimicing pharmacokinetics of the twice daily formulation - not based on primary efficacy studies in CHF) which continues to be expensive. Toprol XL enjoyed limited generic competition, which tended to keep the generic price high. Again I'd have to go back into the archives to recall the exact date the carvedilol and metopropolol ER generics appeared, but I'm pretty certain it was after Part D.
Another potential confounder is the slow pace of clinicians adopting national treatment guidelines. There are a number of recommendations on "must-have" medications for CHF, but I know that physician and/or patient uptake is actually much lower than desirable.
So, some of the increase in adherence may be due to the passage of time (reduction of cost due to appearance of generic, increase in guideline-consistent care), and some may be due to the presence of supplemental coverage through Part D. Obviously to give a good critique of methods, I need to study the journal article. But I wanted to clarify JiM's observation on costs.
Not mentioned in the story is the use of furosemide - which was commonly used for CHF through that period, and had relatively stable (and quite low) pricing as well. If this drug or category (loop diuretics) showed few changes, then the arguement of additional coverage providing for more regular medication use is stronger (in my opinion).
Either way, and for whatever the reason, better adherence to medications recommended in treatment guidelines is an especially good thing in CHF (and a few other "high stakes" chronic conditions). There does appear to be a long way to go based on the stats reported above.