The exclusion of the benzodiazepine class of medications under Medicare's
Part D drug program may have affected a large number of beneficiaries,
according to the first study assessing the extent of use of these types of
drugs before Part D took effect.
Congress decided to exclude benzodiazepines from prescription drug coverage
when it created Medicare's Part D program in 2003. The impact of that
decision, sharply criticized by APA, had been unclear due to the lack of solid
But a study published in the April Psychiatric Services has
provided crucial pieces of data aimed at showing the impact of the Medicare
policy on the use of benzodiazepines and potential substitute drugs.
The study, by researchers from Pharmaceutical Health Services Research at
the University of Maryland, is based on analysis of the 2002 Medicare Current
Beneficiary Survey, an in-person national survey of Medicare beneficiaries by
the Centers for Medicare and Medicaid Services (CMS) that matched responses to
patient records. This continuing study of Medicare beneficiaries provided
national estimates of benzodiazepine use and expenditures among Medicare
The baseline patient information, which dated from before Medicare offered
extensive drug coverage, tracked benzodiazepine use among the
Medicare-eligible population, including those who had drug coverage under
Medicaid or private insurers and those with no drug insurance coverage.
Study data showed that nearly 14 percent of Medicare beneficiaries received
at least one benzodiazepine prescription. It also concluded that being a
woman, having chronic mental illness, being under age 65, and having a low
income were significantly associated with benzodiazepine use in the Medicare
The researchers also found that in 2002 benzodiazepine users spent an
average of $189.58 on benzodiazepines. The annual mean benzodiazepine spending
was highest among beneficiaries with Medicaid ($277.59) and lowest among
beneficiaries with no drug coverage ($141.48). Beneficiaries with anxiety
disorders spent $310 on benzodiazepines annually—more than those with
any other chronic conditions for which the drug is commonly used.
Beneficiaries with supplemental drug coverage were more likely than those
without such coverage to use potential benzodiazepine substitute classes
rather than benzodiazepines.
The findings led the authors to conclude that not only were benzodiazepines
widely used by Medicare beneficiaries but also that drug coverage influences
access to benzodiazepines and potential substitute classes.
"These findings have important implications for identifying
beneficiaries potentially affected by the exclusion of benzodiazepine coverage
under Medicare Part D," the authors wrote.
The research also added data to previous estimates that benzodiazepines
were prescribed for an estimated 1.7 million of the so-called dual-eligible
patients under Medicaid. The start of the Part D program in 2006 moved their
drug coverage to Medicare, although all Medicaid programs added coverage for
benzodiazepines through stateonly funding. CMS notified states in 2007 that
they could receive federal Medicaid matching funds if they elected to
supplement the Medicare drug benefit and cover benzodiazepines. However,
Medicare recipients who were not eligible for Medicaid were not so
"When Part D went into effect, we got a lot of calls from people who
couldn't get their benzos covered," said Paul Precht, policy director of
the Medicare Rights Center, a consumer-rights group based in New york.
The decision to exclude benzodiazepines from Part D coverage stemmed from
concerns about their safety and reports of inappropriate use. The legislative
origins of the ban date back to the 1990 exclusion of these drugs from federal
reimbursement under Medicaid, leaving states to pay the full cost of the drugs
since that time.
"Although there are some concerns for [benzodiazepine] use in the
elderly population, there is also appropriate usage—and a legal
exclusion like this doesn't distinguish between people who need this medicine
and people who don't," Precht said.
The researchers described their study as having definite"
limitations" but emphasized that it is designed to provide a
benchmark for benzodiazepine utilization and expenditures before
implementation of Part D.
"Additional work is needed to analyze the impact of drug coverage
changes on discontinuation of benzodiazepines as well as of switching to more
potent or more expensive therapeutic substitutes, including
sedative-hypnotics, antidepressants, and select antipsychotics with sedative
properties," the authors wrote.
The negative impact of the exclusion for patients with mental illness has
been an ongoing concern of APA, according to Nicholas Meyers, director of
APA's Department of Government Relations. It has been trying to find a
regulatory or legislative solution to the problem. Both the House and Senate
have had bills (HR 3025 and S 137) introduced in the current Congress to
expand Part D coverage to include benzodiazepines, but neither bill has
Stevan Gressitt, M.D., medical director of the Office of Adult Mental
Health Services in the Maine Department of Health and Human Services, struck a
cautionary note. The study would have been more informative and addressed
lingering health concerns about overuse of benzodiazepines if it had
chronicled the length of time patients were using the drugs. His office has
found that in Maine the duration of prescriptions for what is supposed to be a
short-term drug has been increasing.
"That's not good," he said.
"Benzodiazepine Use and Expenditures for Medicare
Beneficiaries and the Implications of Medicare Part D Exclusions" is