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Many older Americans do not receive needed care for mental health and substance use disorders (MHSUD), and there are substantial racial and ethnic disparities in receipt of this care across the lifespan. Medicare introduced cost-sharing parity for outpatient MHSUD care during the period 2010-14, reducing beneficiaries' out-of-pocket share of MHSUD spending from 50 percent to 20 percent. Among traditional Medicare beneficiaries ages sixty-five and older, we examined changes in MHSUD use and spending during the period 2008-18 for low-income beneficiaries with the cost-sharing reduction versus a control group of beneficiaries with free care throughout the study period among Black, Hispanic, Asian, and American Indian/Alaska Native versus White beneficiaries. Among older Medicare beneficiaries, overall use of MHSUD services increased during this period. For White beneficiaries, MHSUD cost-sharing parity was associated with an increased likelihood of having specialty MHSUD visits and medication use and a reduced likelihood of having unmonitored MHSUD medication use and MHSUD emergency department visits and hospitalizations. However, cost-sharing parity was associated with smaller or no gains in MHSUD services use for racial and ethnic minority beneficiaries compared with White beneficiaries, thus widening racial and ethnic disparities in MHSUD care. [ABSTRACT FROM AUTHOR]

Objectives: To study the impact of eliminating cost sharing for screening mammography on mammography rates in a large Medicare Advantage (MA) health plan which in 2010 eliminated cost sharing in anticipation of the Affordable Care Act mandate.Study Setting: Large MA health maintenance organization offering individual-subscriber MA insurance and employer-supplemented group MA insurance.Study Design: We investigated the impact on breast cancer screening of a policy that eliminated a $20 copayment for screening mammography in 2010 among 53,188 women continuously enrolled from 2007 to 2012 in an individual-subscriber MA plan, compared with 42,473 women with employer-supplemented group MA insurance in the same health maintenance organization who had full screening coverage during this period. We used differences-in-differences analysis to study the impact of cost-sharing elimination on mammography rates.Principal Findings: Annual screening rates declined over time for both groups, with similar trends pre-2010 and a slower decline after 2010 among women whose copayments were eliminated. Among women aged 65-74 years in the individual-subscriber MA plan, 44.9 percent received screening in 2009 compared with 40.9 percent in 2012, while 49.5 percent of women in the employer-supplemented MA plan received screening in 2009 compared with 44.1 percent in 2012, that is, a difference-in-difference effect of 1.4 percentage points less decline in screening among women experiencing the cost-sharing elimination. Effects were concentrated among women without recent screening. There were no differences by neighborhood socioeconomic status or race/ethnicity.Conclusions: Eliminating cost sharing for screening mammography was associated with modesty lower decline in screening rates among women with previously low screening adherence. [ABSTRACT FROM AUTHOR]

Objective There is limited information on the protective value of Medicare Part D low-income subsidies ( LIS). We compared responses to drug costs for LIS recipients with near-poor (≤200 percent of the Federal Poverty Level) and higher income beneficiaries without the LIS. Data Sources/Study Setting Medicare Advantage beneficiaries in 2008. Study Design We examined three drug cost responses using multivariate logistic regression: cost-reducing behaviors (e.g., switching to generics), nonadherence (e.g., not refilling prescriptions), and financial stress (e.g., going without necessities). Data Collection Telephone interviews in a stratified random sample ( N = 1,201, 70 percent response rate). Principal Findings After adjustment, a comparable percentage of unsubsidized near-poor (26 percent) and higher income beneficiaries reported cost-reducing behaviors (23 percent, p = .63); fewer LIS beneficiaries reported cost-reducing behaviors (15 percent, p = .019 vs near-poor). Unsubsidized near-poor beneficiaries were more likely to reduce adherence (8.2 percent) than higher income (3.5 percent, p = .049) and LIS beneficiaries (3.1 percent, p = .027). Near-poor beneficiaries also more frequently experienced financial stress due to drug costs (20 percent) than higher income beneficiaries (11 percent, p = .050) and LIS beneficiaries (11 percent, p = .015). Conclusions Low-income subsidies provide protection from drug cost-related nonadherence and financial stress. Beneficiaries just above the LIS income threshold are most at risk for these potentially adverse behaviors. [ABSTRACT FROM AUTHOR]

Since 2006 numerous insurers have stopped serving the low-income segment of the Medicare Part D program, forcing millions of beneficiaries to change prescription drug plans. Using data from participating plans, we found that Medicare payments do not sufficiently reimburse insurers for the relatively high medication use among this population, creating perverse incentives for plans to avoid this part of the Part D market. Plans can accomplish this by increasing their premiums for all beneficiaries to an amount above regional benchmarks. We demonstrate that improving the accuracy of Medicare's risk and subsidy adjustments could mitigate these perverse incentives. [ABSTRACT FROM AUTHOR]

Objective. To compare drug costs and adherence among Medicare beneficiaries with the standard Part D coverage gap versus supplemental gap coverage in 2006. Data Sources. Pharmacy data from Medicare Advantage Prescription Drug (MAPD) plans. Study Design. Parallel analyses comparing beneficiaries aged 65+ with diabetes in an integrated MAPD with a gap versus no gap ( n=28,780); and in a network-model MAPD with a gap versus generic-only coverage during the gap ( n=14,984). Principal Findings. Drug spending was 3 percent (95 percent confidence interval [CI]: 1–4 percent) and 4 percent (CI: 1–6 percent) lower among beneficiaries with a gap versus full or generic-only gap coverage, respectively. Out-of-pocket expenditures were 189 percent higher (CI: 185–193 percent) and adherence to three chronic drug classes was lower among those with a gap versus no gap (e.g., odds ratio=0.83, CI: 0.79–0.88, for oral diabetes drugs). Annual out-of-pocket spending was 14 percent higher (CI: 10–17 percent) for beneficiaries with a gap versus generic-only gap coverage, but levels of adherence were similar. Conclusions. Among Medicare beneficiaries with diabetes, having the Part D coverage gap resulted in lower total drug costs, but higher out-of-pocket spending and worse adherence compared with having no gap. Having generic-only coverage during the gap appeared to confer limited benefits compared with having no gap coverage. [ABSTRACT FROM AUTHOR]

The article presents a study to determine Medicare beneficiaries' knowledge of the benefits and cost responses of the Medicare Advantage Prescription Drug plan in the U.S. The study measured awareness of the coverage gap and cost-coping behaviors such as switching medications, non-adherence and the forgoing of basic needs by the elderly in the U.S. The design, setting and participants of the telephone interview study are defined. Research showed a 40% awareness of a coverage gap in the drug plan by those interviewed, while 30% reported engaging in one of the cost-coping behaviors measured.

Background: Patients face increasing insurance restrictions on prescription drugs, including generic-only coverage. There are no generic inhaled corticosteroids (ICS), which are a mainstay of asthma therapy, and patients pay the full price for these drugs under generic-only policies. We examined changes in ICS use following the introduction of generic-only coverage in a Medicare Advantage population from 2003-2004. Methods: Subjects were age 65+, with asthma, prior ICS use, and no chronic obstructive pulmonary disorder (n = 1,802). In 2004, 74.0% switched from having a $30 brand-copayment plan to a generic-only coverage plan (restricted coverage); 26% had $15-25 brand copayments in 2003-2004 (unrestricted coverage). Using linear difference-in-difference models, we examined annual changes in ICS use (measured by days-of-supply dispensed). There was a lower-cost ICS available within the study setting and we also examined changes in drug choice (higher- vs. lower-cost ICS). In multivariable models we adjusted for socio-demographic, clinical, and asthma characteristics. Results: In 2003 subjects had an average of 188 days of ICS supply. Restricted compared with unrestricted coverage was associated with reductions in ICS use from 2003-2004 (-15.5 days-of-supply, 95% confidence interval (CI): -25.0 to -6.0). Among patients using higher-cost ICS drugs in 2003 (n = 662), more restricted versus unrestricted coverage subjects switched to the lower-cost ICS in 2004 (39.8% vs. 10.3%). Restricted coverage was not associated with decreased ICS use (2003-2004) among patients who switched to the lower-cost ICS (18.7 days-of-supply, CI: -27.5 to 65.0), but was among patients who did not switch (-38.6 days-of-supply, CI: -57.0 to -20.3). In addition, restricted coverage was associated with decreases in ICS use among patients with both higher- and lower-risk asthma (-15.0 days-of-supply, CI: - 41.4 to 11.44; and -15.6 days-of-supply, CI: -25.8 to -5.3, respectively). Conclusion: In this elderly population, patients reduced their already low ICS use in response to losing drug coverage. Switching to the lower-cost ICS mitigated reductions in use among patients who previously used higher-cost drugs. Additional work is needed to assess barriers to switching ICS drugs and the clinical effects of these drug use changes. [ABSTRACT FROM AUTHOR]

Before the implementation of cost-sharing parity in Medicare, beneficiaries faced higher cost sharing for mental health services than for other medical services. The Medicare Improvements for Patients and Providers Act of 2008 phased in cost-sharing reductions in Medicare for outpatient mental health services in the period 2010-14. Using data for 2006-15 from the Medical Expenditure Panel Survey and difference-indifferences analyses, we assessed whether this reduction in mental health cost sharing was associated with changes in specialty and primary care outpatient mental health visits and psychotropic medication fills. We compared people with Medicare and with private insurance before and after parity implementation. Medicare beneficiaries' use of psychotropic medication increased after the implementation of cost-sharing parity, but we did not detect a change in visits. Changes in the use of psychotropic medications were greater among people with probable serious mental illness and among Medicare beneficiaries who did not report having supplemental coverage. The increased medication use could signal improvements in mental health care access among Medicare beneficiaries, especially among the subgroups most likely to benefit from the policy change. [ABSTRACT FROM AUTHOR]