1. MEDICARE PART D: PAST AND PRESENT Juliette Cubanski, Ph.D. Associate Director, Program on Medicare Policy The Henry J. Kaiser Family Foundation MAPRx Congressional Briefing Washington, D.C. October 10, 2012

2. Part A – Hospital Insurance Program –Inpatient hospital, skilled nursing facility, home health, and hospice care Part B – Supplementary Medical Insurance –Physician visits, outpatient hospital, preventive services, home health Part C – Medicare Advantage plans –An alternative to Original Medicare; beneficiaries can enroll in a private plan to receive all Medicare-covered benefits and (often) extra benefits Medicare Part A, Part B, and Part C Exhibit 1

3. History of Medicare and Prescription Drugs, 1965-2006 1965 1970 1975 1980 1985 1990 1995 2000 2005 1969: HEW Task Force on Prescription Drugs 2003: Medicare Prescription Drug, Improvement, and Modernization Act (MMA) signed into law by President Bush 1989: MCCA repealed 1988: Passage of Medicare Catastrophic Coverage Act (MCCA) - includes a drug benefit 1965: Medicare enacted — no prescription drug coverage 2002: Bill to create a Medicare drug benefit (H.R. 4954) passes the House, 221-208; Several competing proposals for a Medicare drug benefit fail to pass the Senate 1993: Clinton proposed a Medicare Drug benefit as part of the Health Security Act 2006: Medicare prescription drug coverage begins 2000: Clinton releases plan to provide drug coverage under a new Medicare Part D 2000: Bill to create a Medicare drug benefit (H.R. 4680) passes the House, 217-214 Exhibit 2

4. The Need for a Medicare Drug Benefit Because of their age and health conditions, Medicare beneficiaries tend to be sicker and use more health care services than others Prior to 2006, Medicare beneficiaries did not have access to a government- subsidized drug benefit through Medicare Existing sources of drug coverage included: –Employer-sponsored retiree health benefits –Individually-purchased Medigap supplemental policies –State Medicaid programs for low-income Medicare beneficiaries –Medicare managed care plans –Veterans Administration, state pharmacy assistance programs, pharmaceutical company assistance programs One-third had no drug coverage in 2004 –Those without coverage used fewer drugs but spent more out-of-pocket than those with coverage –Cost-related non-adherence (skipping/splitting doses, not filling prescriptions) was more common among those without coverage Exhibit 3

5. Medicare Part D – Prescription Drug Benefit Medicare Part D, enacted as part of the Medicare Modernization Act of 2003, took effect in 2006 –Part D is provided exclusively through private plans; benefits are not offered directly through the traditional fee-for-service program –Enrollment in a Part D prescription drug plan is voluntary Beneficiaries may enroll in one of two types of private plans to get the Part D benefit –Stand-alone prescription drug plans (PDPs) to supplement traditional Medicare –Medicare Advantage prescription drug plans Additional subsidies available for people with low incomes and modest assets to help pay for premiums and cost-sharing –Below 150% poverty ($16,755/individual, $22,695/couple in 2012) –Assets less than $11,570/individual, $23,120/couple in 2012 Exhibit 4

6. The Role of CMS in Regulating Part D CMS exercises a great deal of authority over Part D and plays a critical role in regulating and overseeing the program and market operations, including: –Reviewing and approving plan bids annually –Establishing the rules for coverage, subject to law –Regulating plan marketing materials –Monitoring plan behavior and sanctioning plans for violations of rules and regulations –Implementing legislative changes (e.g., closing the “doughnut hole” –Reacting to marketplace, legislative, and political conditions with new rules, guidance, and regulations –Providing consumer information (e.g., the Medicare Plan Finder) Exhibit 5

7. Prescription Drug Coverage Among Medicare Beneficiaries in 2012 Exhibit 6 NOTE: LIS is low-income subsidy. Total Part D and Medicare enrollment based on 2012 intermediate estimates. SOURCE: Kaiser Family Foundation Analysis of data from the 2012 Medicare Trustees report. Total Medicare Enrollment in 2012 = 50.7 million Total Part D Enrollment (excluding employer subsidy) = 32.7 million 26% 43% 22% 9%

8. Medicare Part D Enrollment, 2006-2012 23.2 24.6 25.8 27.9 27.0 29.5 30.9 In millions: Exhibit 7 NOTE: LIS is low-income subsidy. Total Part D and Medicare enrollment based on 2012 intermediate estimates. SOURCE: Kaiser Family Foundation analysis of data from the CMS Medicare Advantage, Cost, PACE, Demo, and Prescription Drug Plan Contract Report - Monthly Summary Report, 2006-2012.

9. 31 32 29 30 31 30 31 23 34 30 34 31 30 32 35 31 33 28 NOTE: Excludes Medicare Advantage Drug Plans. SOURCE: Kaiser Family Foundation analysis of Centers for Medicare & Medicaid Services (CMS) PDP landscape source file, 2013. 23-29 drug plans (10 states and DC) 30-31 drug plans (18 states) 32 drug plans (14 states) 33-38 drug plans (8 states) 30 CT, MA, RI, VT 29 DE, DC, MD 29 NJ 28 ME, NH Number of Medicare Part D Stand-Alone Prescription Drug Plans, by Region, 2013 32 IA, MN, MT, NE, ND, SD, WY 32 ID, UT 30 OR, WA 38 PA, WV 32 IN, KY 33 AL, TN National Average: 31 drug plans Exhibit 8

10. Number of Medicare Part D Stand-Alone PDPs, by Benchmark Status, 2006-2013 NOTE: Excludes Part D plans in the territories. SOURCE: Georgetown/NORC analysis of CMS PDP landscape source files, 2006-2012, for the Kaiser Family Foundation. EXHIBIT 9 1,429 1,875 1,824 1,576 1,689 1,109 1,041 Exhibit 9 1,045

11. Number of Low-Income Subsidy “Benchmark” Plans Offered by Two Major Part D Sponsors, 2006-2013 NOTES: Counts include combined offerings of merged organizations. SOURCE: Georgetown/NORC analysis of CMS PDP landscape files, 2006-2012, for the Kaiser Family Foundation. UnitedHealthHumana Number of PDP regions (out of 34): Exhibit 10 ~ 2 million LIS enrollees in 2011< 1 million LIS enrollees in 2011

12. Standard Medicare Prescription Drug Benefit, 2013 $325 Deductible Initial Coverage Limit = $2,970 in Total Drug Costs NOTE: *Amount corresponds to the estimated catastrophic coverage limit for non-low-income subsidy enrollees ($6,734 for LIS enrollees), which corresponds to True Out-of-Pocket (TrOOP) spending of $4,750 (the amount used to determine when an enrollee reaches the catastrophic coverage threshold. SOURCE: Kaiser Family Foundation illustration of standard Medicare drug benefit for 2013 (standard benefit parameter update from Centers for Medicare & Medicaid Services, 2012). Amounts rounded to nearest dollar. Plan pays 75% Plan pays 15%; Medicare pays 80% Enrollee pays 5% Enrollee pays 25% Catastrophic Coverage Limit = $6,955* in Estimated Total Drug Costs Brand-name drugs Enrollee pays 47.5%; Plan pays 2.5% 50% manufacturer discount Generic drugs Enrollee pays 79%; Plan pays 21% Exhibit 11 INITIAL COVERAGE PERIOD COVERAGE GAP CATASTROPHIC COVERAGE … But most plans do not offer the “standard” benefit, and coverage varies across most dimensions, including: Monthly premiums Deductibles The “doughnut hole” Covered drugs and utilization management restrictions Cost sharing for covered drugs

13. Cost Sharing for Brand-Name Drugs in the Medicare Part D Coverage Gap, 2010-2020 minus $250 rebate SOURCE: Kaiser Family Foundation analysis of the standard Medicare drug benefit under the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010. Exhibit 12

14. Cost Sharing for Generic Drugs in the Medicare Part D Coverage Gap, 2010-2020 SOURCE: Kaiser Family Foundation analysis of the standard Medicare drug benefit under the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010. Exhibit 13

15. $43.39 $40.72 $39.73 $40.25 $35.22 $32.71 $29.25 $42.46 $41.01 $41.43 $39.40 $38.07 $35.99 $37.98 $40.71 $41.44 $39.40 $41.01 $39.90 $42.71 $42.52 $37.13 $43.47 NOTE: Excludes Medicare Advantage Drug Plans. SOURCE: Kaiser Family Foundation analysis of Centers for Medicare & Medicaid Services (CMS) PDP landscape source file, 2013. $29 to <$38 (8 regions) $38 to <$40 (7 regions) $40 to <$42 (11 regions) $42 to <$46 (8 regions) $37.63 CT, MA, RI, VT $43.54 DE, DC, MD $41.49 NJ $37.14 ME, NH Weighted Average Premium for Medicare Part D Stand-Alone PDPs, by Region, 2013 $39.00 IA, MN, MT, NE, ND, SD, WY $45.90 ID, UT $40.53 OR, WA $40.59 PA, WV $43.68 IN, KY $41.08 AL, TN National Weighted Average: $40.18 Exhibit 14 $38.01

16. Weighted Average Monthly Premiums for Medicare Part D Stand-Alone PDPs, 2006-2013 Exhibit 15 NOTES: Average premiums are weighted by enrollment in each year. Excludes plans in the territories. SOURCE: Georgetown/NORC analysis of data from CMS for the Kaiser Family Foundation. 2006-2013: 55% increase 2012-2013: 7% increase

17. Premiums in Medicare Part D Stand-Alone PDPs with Highest 2012 Enrollment, 2006-2013 PDP Rank in 2012 2012 Enrollment (of 17.7 million) Weighted Average Monthly Premium 1 % Change Number (in millions) % of Total 200620122013 2012- 2013 2006- 2013 AARP MedicareRx Preferred 4,011,35722.6%$26.31$39.85$40.42+1%+54% CCRx Basic1,768,14810.0%$30.94$30.75$33.33+8% Humana Walmart- Preferred 1,511,8508.5%--$15.10$18.50+23%-- Humana PDP Enhanced 1,374,4797.8%$14.73$39.58$43.77+11%+197% Silverscript Basic1,322,8567.5%$28.32$30.24$32.55+8%+15% NOTES: 1 Average premiums are weighted by enrollment in each region for each year. SOURCE: Georgetown/NORC analysis of CMS 2006-2012 PDP Landscape Source Files for the Kaiser Family Foundation. Exhibit 16

18. Costs for Top Brands in Stand-Alone PDPs with Highest 2012 Enrollment in DC Zip Code (20037) SOURCE: Kaiser Family Foundation analysis of data from Medicare Plan Finder. Exhibit 17 (not covered)

19. Median Cost Sharing for Medicare Part D Plans, 2006 and 2012 NOTES: Part D cost-sharing amounts are medians. Analysis excludes generic/brand plans, plans with coinsurance for regular tiers, and plans with flat copayments for specialty tiers. SOURCE: Georgetown/NORC analysis of data from CMS for MedPAC and the Kaiser Family Foundation. Exhibit 18 Generics Preferred brands Non-preferred brands Specialty

20. Medicare Part D Spending and Financing Total Benefit Payments, 2011 = $551 billion NOTE: Numbers do not sum to 100% due to rounding. Total does not include administrative expenses and is net of recoveries. SOURCE: CBO Medicare Baseline, March 2011. 12% 4% 5% 26% 12% 5% Part A Part A and B Part B Part D 23% Part D is funded by premiums, general revenues, and state payments Plans are paid a fixed amount for each enrollee “Reinsurance” payments from the government protect plans from unexpectedly high costs Exhibit 19

21. Exhibit 20 Comparison of Projected and Actual Medicare Part D Benefit Spending, 2006-2013 NOTE: CBO projections are adjusted from fiscal years to calendar years. Medicare Trustees actual spending amounts are adjusted for reconciliation payments. Amounts exclude offsetting receipts from beneficiary premium payments and state “clawback” payments for dual eligibles. All totals include administrative costs. SOURCE: J. Hoadley analysis of data from Congressional Budget Office (July 2004) and 2012 Medicare Trustees Report for the Kaiser Family Foundation. 2003 CBO projections 2012 Medicare Trustees actual estimates (2006-2011) and projections (2012-2013) $13.8$16.3$22.8$26.6$30.6$35.1$43.9$48.2 74%75%68%66%65%63%58% Difference, estimate less actual $ % CBO (2003) and Medicare Trustees (2012) (Billions of Dollars)

22.  Slower overall drug spending growth compared to projections  Slow pipeline for new drugs since the start of Part D  More use of generic drugs since the start of Part D Generic penetration in Part D: 61% in 2007; 75% in 2010  Slow growth in retail drug prices Lower prices due to generic substitution balanced out higher prices for brand drugs  Larger manufacturer rebates and other discounts Trustees say rebates have exceeded expectations  Lower-than-expected Part D enrollment ~90% projected, ~70% actual Factors Affecting Medicare Part D Drug Spending Trends Exhibit 21

23. Medicare Part D: Adding It Up Coverage Out-of-pocket drug spending, use, and access Program spending Choice 90% have drug coverage; 65% through Part D plans 11 million receiving low-income subsidies Out-of-pocket drug spending is generally lower Drug use is higher and cost- related skipping is generally lower ~10% lack drug coverage A few million low-income eligible but without subsidies Some enrollees may pay more – e.g., dual eligibles and those in the coverage gap Lower than initially projected Due partly to lower-than- projected Part D and low-income subsidy enrollment Lots of plans means more options for beneficiaries Lots of plans could lead to confusion and difficulty choosing the best plan Drug prices Lower for those who had no drug coverage prior to Part D Higher for dual eligibles and drugs with no competitors Exhibit 22