The effect of the patient protection and Affordable Care Act on the Medicare Part D coverage gap PDF
Preview The effect of the patient protection and Affordable Care Act on the Medicare Part D coverage gap
University of Louisville ThinkIR: The University of Louisville's Institutional Repository Electronic Theses and Dissertations 12-2015 The effect of the patient protection and Affordable Care Act on the Medicare Part D coverage gap as reflected in diabetes medication adherence. Jennifer A. Forristal University of Louisville Follow this and additional works at:https://ir.library.louisville.edu/etd Part of theOther Public Health Commons Recommended Citation Forristal, Jennifer A., "The effect of the patient protection and Affordable Care Act on the Medicare Part D coverage gap as reflected in diabetes medication adherence." (2015).Electronic Theses and Dissertations.Paper 2315. https://doi.org/10.18297/etd/2315 This Doctoral Dissertation is brought to you for free and open access by ThinkIR: The University of Louisville's Institutional Repository. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of ThinkIR: The University of Louisville's Institutional Repository. This title appears here courtesy of the author, who has retained all other copyrights. For more information, please contact [email protected]. THE EFFECT OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT ON THE MEDICARE PART D COVERAGE GAP AS REFLECTED IN DIABETES MEDICATION ADHERENCE By Jennifer A Forristal A Dissertation Submitted to the Faculty of the School of Public Health and Information Sciences of the University of Louisville in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in Public Health Sciences Department of Health Management and Systems Sciences University of Louisville Louisville, Kentucky December 2015 2 THE EFFECT OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT ON THE MEDICARE PART D COVERAGE GAP AS REFLECTED IN DIABETES MEDICATION ADHERENCE By Jennifer A Forristal A Dissertation Approved on November 18, 2015 By the following Dissertation Committee Dissertation Director Barry Wainscott, M.D., MPH Robert Esterhay, M.D. Christian Furman, M.D., MSPH LaQuandra Nesbitt, M.D., MPH ii DEDICATION This is dedicated to my parents who instilled in me a love of learning and the importance of education. iii ACKNOWLEDGEMENTS I would like to thank my committee for their support, insight and constructive criticism throughout this process. I am very grateful to Humana for the use of their data. I want to acknowledge William Fleming for his advice, Fred Brownfield for his support and Yihau Xu for her guidance. I would like to thank my family for their love and support during this process especially my husband, Jamieson and kids, Tyler and Addison, who sacrificed many nights and weekends so I could focus on this work. My parents, Dave and Kathy Dively and siblings, Daniel and Julie have always been a source of strength and encouragement. I would like to thank my friends who have supported me in every endeavor, especially Cyndi, Charlotte, Christine and Megan. I would like to thank all my fellow public health students who suffered right along with me: Robin, Robyn, Katie, Christine, Susan and Leslie, you are truly some of the smartest women I know. I am blessed. Ecclesiastes 12:12 iv ABSTRACT THE EFFECT OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT ON THE MEDICARE PART D COVERAGE GAP AS REFLECTED IN DIABETES MEDICATION ADHERENCE Jennifer Forristal November 18, 2015 Background: This dissertation involves an evaluation of the effect of the Patient Protection and Affordable Care Act (ACA) on diabetic medication adherence as the Medicare Part D coverage gap begins to close. Purpose: The dissertation’s primary research question: will medication adherence for Humana Medicare Part D health plan members filling diabetic medications at Humana’s mail order pharmacy improve as the coverage gap is incrementally closed due to the ACA? The study had 3 objectives: 1) to evaluate diabetes medication adherence of health plan members before they reach the coverage gap and then while they are in the coverage gap, 2) to compare diabetes medication adherence between two similar groups with differing benefit structures, one group with a gap in coverage as opposed to a group with no benefit changes within the year and 3) to examine diabetes medication adherence trend over multiple years as the coverage gap is closed. Methods: A retrospective, pre-post cohort analysis with control group study design was used to assess the study objectives. The control group consisted of low- v income subsidy (LIS) members with no gap in coverage and the treatment group reached the coverage gap. Results: Brand and generic medication users exhibited decreases in adherence once they entered the coverage gap although significant differences were seen for all years in the brand cohort only. The control group exhibited better adherence than the treatment group. The control group also exhibited stable adherence year over year while the treatment group realized a decline. Conclusions: The results of this study indicate that being in the coverage gap was a significant indicator of a decrease in adherence for health plan members on brand diabetic medications. While the study findings showed a decrease rather than an increase in the treatment group medication adherence year over year, the results did indicate no significant changes in the control group. The expectation would be that once the coverage gap is fully closed in 2020, the treatment group would exhibit similar behavior. Both groups exhibited high adherence overall suggesting the mail order dispensing channel could have an effect on adherence. vi TABLE OF CONTENTS DEDICATION ............................................................................................................................................ iii ACKNOWLEDGEMENTS .................................................................................................................... iv ABSTRACT .................................................................................................................................................. v LIST OF TABLES ..................................................................................................................................... ix LIST OF FIGURES ................................................................................................................................... xi CHAPTER 1 .................................................................................................................................................. 1 INTRODUCTION ....................................................................................................................................... 1 Background to the Study ...................................................................................................................... 1 The Importance of Adherence in Public Health ........................................................................... 2 The Importance of Adherence in Diabetes ..................................................................................... 5 The Medicare Modernization Act of 2003 .................................................................................. 10 The Patient Protection and Affordable Care Act ...................................................................... 11 The Effect of Cost-Sharing and Copayments on Adherence ................................................ 12 Proposed Reform Effects .................................................................................................................. 15 Statement of the Problem .................................................................................................................. 16 Purpose of the Study ........................................................................................................................... 17 Research Question and Hypotheses ............................................................................................... 18 Summary ................................................................................................................................................. 19 CHAPTER 2 ............................................................................................................................................... 21 LITERATURE REVIEW ...................................................................................................................... 21 Theoretical Framework ...................................................................................................................... 21 Economic Theory ................................................................................................................................. 21 Andersen's Behavioral Model of Health Services Use ............................................................ 23 CHAPTER 3 ............................................................................................................................................... 29 METHODS ................................................................................................................................................. 29 Study Design ......................................................................................................................................... 29 Population .............................................................................................................................................. 29 Eligibility Criteria ................................................................................................................................ 31 Description of study variables ......................................................................................................... 33 a) Independent Variable ................................................................................................................ 33 b) Dependent Variable or Outcome Measure ........................................................................ 36 Propensity Score Matching ............................................................................................................... 39 Data analyses required to address objectives: ............................................................................ 41 Confidentiality ...................................................................................................................................... 43 Summary ................................................................................................................................................. 43 CHAPTER 4 ............................................................................................................................................... 45 RESULTS ................................................................................................................................................... 45 Study Population .................................................................................................................................. 45 Coverage gap ......................................................................................................................................... 49 Coverage gap month ........................................................................................................................... 49 Descriptive analyses of pre-coverage gap and within coverage gap medication adherence ................................................................................................................................................ 53 Propensity score matching ................................................................................................................ 56 Descriptive analyses of propensity score matched control and treatment groups .......... 63 vii Diabetic medication adherence across plan years ..................................................................... 64 Summary ................................................................................................................................................. 66 CHAPTER 5 ............................................................................................................................................... 67 DISCUSSION ............................................................................................................................................ 67 Coverage Gap ........................................................................................................................................ 67 Pre-coverage gap and within coverage gap medication adherence ..................................... 72 Demographics for propensity score matched groups ............................................................... 75 Medication adherence in control and treatment groups .......................................................... 76 Medication adherence across plan years ...................................................................................... 78 Strengths and Limitations ................................................................................................................. 80 Findings and recommendations for future research ................................................................. 81 Summary ................................................................................................................................................. 83 REFERENCES .......................................................................................................................................... 85 APPENDIX I .............................................................................................................................................. 89 GLOSSARY ............................................................................................................................................... 89 APPENDIX II ............................................................................................................................................ 91 UNIVERSITY OF LOUISVILLE INSTITUTIONAL REVIEW BOARD DETERMINATION ................................................................................................................................ 91 CURRICULUM VITAE ........................................................................................................................ 94 viii
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