Joyce West, Ph.D., director of the APA Practice Research Network: Drug
plans failed to have transition policies in effect for the 6 million
dual-eligible beneficiaries affected by the change.
Credit: Sylvia Johnson
Medicare Part D beneficiaries with mental illness continued to have
difficulty obtaining needed medications throughout the first full year of the
program, according to recently released data.
Patients with psychiatric illness who are dually eligible for the Medicaid
and Medicare programs experienced serious barriers throughout 2006 as they
moved from the Medicaid program to the Medicare part D prescription drug
program. The findings, from an as-yet-unpublished study by the American
Psychiatric Institute for Research and Education (APIRE), expanded on data
documenting access problems in the first four months of the transition. That
APIRE study assessed Part D access until May 2006 and was published in the May
American Journal of Psychiatry.
The latest APIRE report, presented in part during APA's annual meeting in
May, concluded that access shortcomings identified in the first four months of
the Part D transition continued throughout the first year and in some cases
worsened as the year went on.
"It was shocking that the rates of medication access problems
continued," said Joyce West, Ph.D., director of the APA Practice
Research Network and one of the study's authors.
The study was the first to compile clinically detailed, national data on
the impact of drug-plan management practices under Medicare Part D on
dual-eligible psychiatric patients' medication access, compliance, and
The survey of 1,183 psychiatrists in the first eight months of the year and
another 1,600 in the last four months reported clinically detailed information
on one systematically selected dual-eligible Part D patient under each
psychiatrist's care. Each psychiatrist reviewed a six-week time period to
identify if there was a medication-access problem.
The researchers randomly selected 5,833 psychiatrists from the AMA's
physician master file of all U.S. psychiatrists, and 1,183 of those responded
and met the study criteria.
The study found that 46 percent of patients had problems filling their
prescriptions in the last four months of 2006, up from 40 percent reported in
the first four months of 2006. The number of psychiatrists who reported
changing or discontinuing their patients' clinically indicated medications
rather than pursuing appeals or exceptions rose to 25 percent from 19 percent
in the first four months of the program. The number of psychiatrists who had
to ask drug plans for exemptions to their rules for patients in need rose to
36 percent from 27 percent in the first four months of the year.
Other access problems that appeared to worsen included difficulty accessing
medication refills, which rose from 30.6 percent in the first four months to
43 percent in the later months. Patients who were stable taking clinically
indicated and desired medications but were required toswitch to a different
medication because clinically preferred medication refills were not covered or
approved rose from 18.3 percent to 28 percent.
The study further found the number of patients who discontinued or
temporarily stoppedtaking medication because of prescription drug coverage
limits or "management issues" rose from 22.3 percent to 29
One of the few areas of improvement appeared in a reduced amount of time
psychiatrists reported devoting to Part D-related paperwork as a percentage of
their overall patient care. That time share dropped from 45 percent in the
first four months to 34 percent of overall patient care time in the last four
months of the year.
"The time has gone down a bit but it is still considerable,"
The study was funded by the American Psychiatric Foundation and a
pharmaceutical industry coalition. APIRE maintained total control of the
design, execution, and analysis of the study data.
Although the study results are limited by its observational design, West
noted, there is a "strong relationship" between that approach and
establishing a causal relationship.
The full-year study findings appear to show that the widespread access
problems reported during the rollout of Part D continued for at least the
first full year of the program. They add quantifiable data to anecdotal
reports that drug plans failed to have transition policies in effect for the 6
million dual-eligible beneficiaries affected by the change. Two million
dual-eligible beneficiaries have mental illness.
West said that she met with Centers for Medicare and Medicaid Services
(CMS) officials in charge of the Part D program and that they were
particularly concerned about drug plans requiring patients to switch to
similar but lower-cost drugs. Federal policy prohibits the insurance companies
from mandating such changes.
The study authors also described data indicating that the access problems
and the drug-plan policies linked to them appeared to occur "fairly
consistently across all plans," West said.
"This is not a case of a few bad apples," she pointed out.
She noted that although most of Part D plans include features designed to
improve care for patients with mental illness, they don't seem to be working
APIRE has provided all of the study data to APA's Department of Government
Relations to discuss with members of Congress and federal health
policy-makers. The data have featured prominently in discussions between APA
and members of Congress on efforts to maintain the "protected
status" of six drug classes in Part D—which means that drug plans
are required to cover them—when some members of Congress discussed
removing some of those protections earlier this year.
The authors have submitted their full-year study results for journal
The study of the earlier Part D data, "Medication Access and
Continuity: The Experiences of Dual-Eligible Psychiatric Patients During the
First Four Months of the Medicare Prescription Drug Benefit" is posted