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Articles   |    
Effects of Medicare Part D on Guideline-Concordant Pharmacotherapy for Bipolar I Disorder Among Dual Beneficiaries
Marguerite E. Burns, Ph.D.; Alisa B. Busch, M.D., M.S.; Jeanne M. Madden, Ph.D.; Robert F. Le Cates, M.A.; Fang Zhang, Ph.D.; Alyce S. Adams, Ph.D.; Dennis Ross-Degnan, Sc.D.; Stephen B. Soumerai, Sc.D.; Haiden A. Huskamp, Ph.D.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300123
View Author and Article Information

Dr. Burns is with the Department of Population Health Sciences, University of Wisconsin, Madison (e-mail: meburns@wisc.edu). Dr. Busch and Dr. Huskamp are with the Department of Health Care Policy, Harvard Medical School, Boston. Dr. Madden, Dr. Zhang, Dr. Ross-Degnan, and Dr. Soumerai are with the Department of Population Medicine, Harvard Medical School. They are also with the Harvard Pilgrim Health Care Institute, where Mr. Le Cates is affiliated. Dr. Adams is with the Division of Research, Kaiser Permanente, Oakland, California. An earlier version of this work was presented at the Association for Public Policy Analysis and Management Annual Research Meeting, November 8–10, 2012, Baltimore, and the Academy Health Annual Research Meeting, June 24, 2013, Baltimore.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objective  In January 2006 insurance coverage for medications shifted from Medicaid to Medicare Part D private drug plans for the six million individuals enrolled in both programs. Dual beneficiaries faced new formularies and utilization management policies. It is unclear whether Part D, compared with Medicaid, relaxed or tightened psychiatric medication management, which could affect receipt of recommended pharmacotherapy, and emergency department use related to treatment discontinuities. This study examined the impact of the transition from Medicaid to Part D on guideline-concordant pharmacotherapy for bipolar I disorder and emergency department use.

Methods  Using interrupted–time-series analysis and Medicaid and Medicare administrative data from 2004 to 2007, the authors analyzed the effect of the coverage transition on receipt of guideline-concordant antimanic medication, guideline-discordant antidepressant monotherapy, and emergency department visits for a nationally representative continuous cohort of 1,431 adults with diagnosed bipolar I disorder.

Results  Sixteen months after the transition to Part D, the proportion of the population with any recommended use of antimanic drugs was an estimated 3.1 percentage points higher than expected once analyses controlled for baseline trends. The monthly proportion of beneficiaries with seven or more days of antidepressant monotherapy was 2.1 percentage points lower than expected. The number of emergency department visits per month temporarily increased by 19% immediately posttransition.

Conclusions  Increased receipt of guideline-concordant pharmacotherapy for bipolar I disorder may reflect relatively less restrictive management of antimanic medications under Part D. The clinical significance of the change is unclear, given the small effect sizes. However, increased emergency department visits merit attention for the Medicaid beneficiaries who continue to transition to Part D.

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Figure 1 Guideline-concordant pharmacotherapy received by dual beneficiaries for bipolar I disorder, 2005–2007a

a The predicted line reflects the regression results for each segment. The counterfactual line continues the pre–Part D trend illustrating the expected trend in the absence of Part D. The Part D phase-in period was December 2005–March 2006 (shaded area). These data points are not included in the regression model. MPR, medication possession ratio.

b Difference of 4.6%, p=.003

c Difference of 4.25%, p=.07

d Difference of –10.96%, p=.04

Figure 2 Monthly emergency department use for any cause among dual beneficiaries with a diagnosis of bipolar I disorder, 2005–2007a

a Mean proportion of the population with any emergency department visit (A) and mean number of visits in the population (B). The predicted line reflects the regression results for each segment. The counterfactual line continues the pre–Part D trend, illustrating the expected trend in the absence of Part D. The Part D phase-in period was December 2005–March 2006 (shaded area). These data points were not included in the regression model.

b The mean difference in number of visits is 19% (.03/.16 visits, p<.05) (bracket).

Anchor for Jump
Table 1Baseline characteristics of dual beneficiaries with a diagnosis of bipolar I disordera
Table Footer Note

a For inclusion in the cohort of 1,431 unique dual beneficiaries, the study criterion was one inpatient or two outpatient diagnoses of bipolar disorder on different dates of service, with at least one of these diagnoses indicating bipolar disorder type I and no diagnosis of schizophrenia. The first observed bipolar disorder diagnosis was required to occur between January and June 2004.

Table Footer Note

b Primary or secondary diagnosis of ICD-9 codes 290.xx–319.xx, 648.3x, or 648.x

Anchor for Jump
Table 2Regression results for receipt of guideline-concordant pharmacotherapy and emergency department visits among dual beneficiaries with bipolar I disorder, 2005–2007
Table Footer Note

a Values are percentage points for use of antimanic and antidepressant medications and number of visits for emergency department use.

Table Footer Note

b Guideline concordant; MPR, medication possession ratio

Table Footer Note

c Mental disorder or substance use disorder

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