1. The Impact of Medicare Part D on Dual Eligible Psychiatric Patients’ Medication Access and Continuity

2. The Impact of Medicare Part D on Dual Eligible Psychiatric Patients’ Medication Access and Continuity Darrel A. Regier, M.D., M.P.H., APIRE Executive Director Funded by a grant from the American Psychiatric Foundation (APF), with partial funding of APF through a consortium of industry sponsors, including AstraZeneca, Bristol-Meyers-Squibb, Eli Lilly, Forest, Janssen, Pfizer, Sanofi-Aventis, and Wyeth. APIRE had complete discretion and control of the design and conduct of this study and analyses of the resulting data.

3. Background and Rationale Medicare Part D took effect January 1, 2006: 6 million “dual eligibles” moved from Medicaid to Medicare Part D Prescription Drug Plans. 2 million “dual eligibles” with mental illnesses. Disruptions in medication access and continuity expected due to administrative issues, changes in formularies, management and financing. CMS implemented policies to prevent switching stable patients and to ensure access to six protected classes of medications. Critical to monitor this group to track patient care and inform CMS how their policies are being implemented.

4. Study Aims Monitor management of these patients treated by psychiatrists to assess: 1) Medication access and continuity. 2) Administrative functioning/features of PDPs. 3) Clinical consequences of unintended medication disruptions. 4) Inform future Medicare and Medicaid prescription drug coverage and management policies.

5. Study Sampling Design 5,833 psychiatrists were randomly selected from the 55,000 psychiatrists in the AMA Masterfile of Physicians. Clinicians not currently practicing (N=291) and those with undeliverable addresses (N=439) were excluded. Study tracked medication access and continuity Jan 1 - Dec 31, 2006. These findings focus on data from Jan.-April 2006. Responses obtained from 64% of the sample (N=3,247). 35% of respondents (N=1,183 psychiatrists) reported treating at least one dual eligible patient their last typical work week and provided clinically detailed data for this study. 56% of patients-Schizophrenia or Bipolar Disorder diagnosis.

6. Medication Access Problems 18% of patients were previously stable, but required to switch to a different medication than clinically desired/preferred. 22% discontinued or temporarily stopped medications due to changes in prescription drug management or administration. 31% could not access medication refills; 20% could not access new prescriptions. Antipsychotics were most common medications that could not be accessed, followed by antidepressants.

7. Problems With Prescription Drug Plan Administration 27% of all patients had prescription drug exceptions requests or appeals initiated on their behalf. 18% changed or discontinued clinically indicated medications rather than pursue appeals or exceptions. Physicians and their staff spent on average 46 minutes on administrative issues related to prescription drug coverage for every hour of direct patient care provided. Patients with medication access problems required nearly twice as much administrative time (56 versus 30 minutes).

8. Serious Adverse Events After Medication Access Problems/Medication Discontinuations 20% had an Emergency Room visit. 22% had an increase in suicidal ideation or behavior. 1 15% had an increase in violent ideation or behavior. 11% were hospitalized. 3% became homeless for more than 48 hours. 1 Data collected May-Dec 2006 show patients with medication access problems 4 times more likely to have an increase in suicidal ideation or behavior reported compared to those with no access problems (22% versus 5%).

9. 1 Includes being admitted for a psychiatric hospitalization, having an ER visit, being homeless for more than 48 hours, having an increase in suicidal ideation or behavior, having an increase in violent ideation or behavior or physically injuring someone. Specific Medication Access Problems and Significant Adverse Events 1   Significant Adverse Event 1   ER Visit Patient was stable, but switched to different medication Medication discontinued or temporarily stopped Patient couldn’t access new prescription

10. Ongoing Research: Phase III Conducted follow-up studies through end of 2006 that show the problems are continuing. Data have yet to be published. Conducting a multi-state survey of Medicaid plans. Working with health economists to analyze cost data.

11. Summary of Key Findings Significant and widespread problems accessing medications – problems which continued to be high throughout 2006. High rates of medication discontinuations, inability to prescribe clinically indicated medications, and switching previously stable patients to different medications are particularly concerning. These medication access problems were associated with high rates of significant adverse events, posing serious risks to patients. CMS implemented policies to prevent switching stable patients and to ensure access to psychopharmacologic medications. But Part D Prescription Drug Plans are not complying with CMS policies, putting psychiatric patients at greater risk.