Introduction of a hexavalent vaccine containing acellular pertussis into the national immunization program for infants in Peru: a cost-consequence analysis of vaccination coverage.

BACKGROUND: Infant vaccination coverage rates in Peru have declined in recent years, exacerbated by the COVID-19 pandemic. Introduction of the fully-liquid diphtheria, tetanus, and acellular pertussis (DTaP)-inactivated polio vaccine (IPV)-hepatitis B (HB)-Haemophilus influenzae type B (Hib) hexavalent vaccine (DTaP-IPV-HB-Hib) in Peru's infant National Immunization Program may help improve coverage. We evaluated costs and healthcare outcomes, including coverage, of switching from a pentavalent vaccine containing whole-cell pertussis component (DTwP-HB-Hib) plus IPV/oral polio vaccine (IPV/OPV) to the hexavalent vaccine for the primary vaccination scheme (2, 4 and 6 months). METHODS: The analysis was performed over a 5-year period on a cohort of children born in Peru in 2020 (N = 494,595). Four scenarios were considered: the pentavalent plus IPV/OPV scheme (S1); replacing the pentavalent plus IPV/OPV scheme with the hexavalent scheme (S2); expanded delivery of the pentavalent plus IPV/OPV scheme (S3); expanded delivery of the hexavalent scheme (S4). Vaccine coverage and incidence of adverse reactions (ARs) were estimated using Monte Carlo simulations and previous estimates from the literature. Cases of vaccine-preventable diseases were estimated using a Markov model. Logistical and healthcare costs associated with these outcomes were estimated. Impact of key variables (including coverage rates, incidence of ARs and vaccine prices) on costs was evaluated in sensitivity analyses. RESULTS: The overall cost from a public health payer perspective associated with the pentavalent plus IPV/OPV vaccine scheme (S1) was estimated at $56,719,350, increasing to $61,324,263 (+ 8.1%), $59,121,545 (+ 4.2%) and $64,872,734 (+ 14.4%) in scenarios S2, S3 and S4, respectively. Compared with the status quo (S1), coverage rates were estimated to increase by 3.1% points with expanded delivery alone, and by 9.4 and 14.3% points, if the hexavalent vaccine is deployed (S2 and S4, respectively). In both scenarios with the hexavalent vaccine (S2 and S4), pertussis cases would also be 5.7% and 8.7% lower, and AR rates would decrease by 32%. The cost per protected child would be reduced when the hexavalent vaccine scheme. Incidence of ARs was an important driver of cost variability in the sensitivity analysis. CONCLUSIONS: Implementation of the hexavalent vaccine in Peru's National Immunization Program has a positive public health cost consequence.

Effects of Medicare Part D coverage gap closure on utilization of branded and generic drugs.

The Affordable Care Act included a provision to gradually eliminate the Medicare prescription drug coverage gap between 2011 and 2020, which substantially lower medication costs in the gap. Using 2007-2016 Medicare claims data, we estimate how filling the gap affects individuals' out-of-pocket spending and medication use, separately for branded and generic drugs. One important difficulty in estimating the policy impact is that around the same time, many blockbuster drugs commonly used by the Medicare population experienced patent expiration and began to see generic entry. Because generic entries affected different therapeutic classes at different times, we run difference-in-differences models by therapeutic category at the beneficiary-month level to isolate the effect of the gap closure from that of generic entry. Overall, we find that filling the gap substantially reduced out-of-pocket spending and increased the use of branded drugs, which had larger discount rates during the analysis period. Beneficiaries reaching the gap, at older ages, or with comorbidities experienced larger reduction in out-of-pocket spending. We show that without accounting for generic entry, the effect of filling the coverage gap on medication use is underestimated for branded drugs and overestimated for generic drugs.

District level inequality in reproductive, maternal, neonatal and child health coverage in India.

BACKGROUND: As India already missed maternal and child health related millennium development goals, the maternal and child health outcomes are a matter of concern to achieve sustainable development goals (SDGs). This study is focused to assess the gap in coverage and inequality of various reproductive, maternal, neonatal and child health (RMNCH) indicators in 640 districts of India, using data from most recent round of National Family Health Survey. METHODS: A composite index named Coverage Gap Index (CGI) was calculated, as the weighted average of eight preventive maternal and child care interventions at different administrative levels. Bivariate and spatial analysis were used to understand the geographical diversity and spatial clustering in districts of India. A socio-economic development index (SDI) was also derived and used to assess the interlinkages between CGI and development. The ratio method was used to assess the socio-economic inequality in CGI and its component at the national level. RESULTS: The average national CGI was 26.23% with the lowest in Kerala (10.48%) and highest in Nagaland (55.07%). Almost half of the Indian districts had CGI above the national average and mainly concentrated in high focus states and north-eastern part. From the geospatial analysis of CGI, 122 districts formed hotspots and 164 districts were in cold spot. The poorest households had 2.5 times higher CGI in comparison to the richest households and rural households have 1.5 times higher CGI as compared to urban households. CONCLUSION: Evidence from the study suggests that many districts in India are lagging in terms of CGI and prioritize to achieve the desired level of maternal and child health outcomes. Efforts are needed to reduce the CGI among the poorest and rural resident which may curtail the inequality.

Analyzing the disparities in the coverage of maternal and child health services: A district-level cross-sectional analysis of Jammu and Kashmir.

BACKGROUND: Improving overall coverage of maternal and child health (MCH) services is essentially required if India in general and Jammu and Kashmir state in particular have to attain the Sustainable Development Goals by the year 2030. Thus, the disparities in coverage of MCH services need to be assessed and addressed. OBJECTIVES: The objective of this study was to examine the variation in coverage rates for a key set of interventions in MCH services and to assess the relationship between coverage gap and socioeconomic development across the districts of Jammu and Kashmir. METHODS: Data from the National Family Health Survey-4 (NFHS-4), 2015-2016, Census of India 2011, and Digest of Statistics Jammu and Kashmir were used to construct two composite indexes of coverage gap and socioeconomic development at district level. Cronbach's alpha was used to assess the internal consistency of indicators used in the two indexes. RESULTS: The overall coverage gap in the state was 28.17%, and the size of coverage gap was largest for family planning interventions (55.8%), followed by treatment of sick children (26.95%) and maternal and newborn care (18.75%), and was smallest for immunization (10.5%). There is a moderate negative correlation between coverage gap and socioeconomic development (r = -0.63, P = 0.01). CONCLUSION: Coverage of MCH services and socioeconomic development has a significant disparity in the districts of Jammu and Kashmir. Resource-rich and more urbanized districts are much ahead of the poor and less urbanized districts in terms of the usage of MCH services.

Coverage gap in maternal and child health services in India: assessing trends and regional deprivation during 1992-2006.

BACKGROUND: Increasing the coverage of key maternal, newborn and child health interventions is essential, if India has to attain Millennium Development Goals 4 and 5. This study assesses the coverage gap in maternal and child health services across states in India during 1992-2006 emphasizing the rural-urban disparities. Additionally, association between the coverage gap and under-5 mortality rate across states are illustrated. METHODS: The three waves of National Family Health Survey (NFHS) conducted during 1992-1993 (NFHS-1), 1998-1999 (NFHS-2) and 2005-2006 (NFHS-3) were used to construct a composite index of coverage gap in four areas of health-care interventions: family planning, maternal and newborn care, immunization and treatment of sick children. RESULTS: The central, eastern and northeastern regions of India reported a higher coverage gap in maternal and child health care services during 1992-2006, while the rural-urban difference in the coverage gap has increased in Gujarat, Haryana, Rajasthan and Kerala over the period. The analysis also shows a significant positive relationship between the coverage gap index and under-five mortality rate across states. CONCLUSION: Region or area-specific focus in order to increase the coverage of maternal and child health care services in India should be the priority of the policy-makers and programme executors.

Unintended Consequences of Increased Out-of-Pocket Costs During Medicare Coverage Gap on Anticoagulant Discontinuation and Stroke.

INTRODUCTION: This study aims to assess the risk of direct oral anticoagulant (DOAC) discontinuation among Medicare beneficiaries with non-valvular atrial fibrillation (NVAF) who reach the Medicare coverage gap stratified by low-income subsidy (LIS) status and the impact of DOAC discontinuation on rates of stroke and systemic embolism (SE) among beneficiaries with increased out-of-pocket (OOP) costs due to not receiving LIS. METHODS: In this retrospective cohort study, Medicare claims data (2015-2020) were used to identify beneficiaries with NVAF who initiated rivaroxaban or apixaban and entered the coverage gap during ≥ 1 year. DOAC discontinuation rates during the coverage gap were stratified by receipt of Medicare Part D Low-Income Subsidy (LIS), a proxy for not experiencing increased OOP costs. Among non-LIS beneficiaries, incidence rates of stroke and SE during the subsequent 12 months were compared between beneficiaries who did and did not discontinue DOAC in the coverage gap. RESULTS: Among 303,695 beneficiaries, mean age was 77.3 years, and 28% received LIS. After adjusting for baseline differences, non-LIS beneficiaries (N = 218,838) had 78% higher risk of discontinuing DOAC during the coverage gap vs. LIS recipients (adjusted hazard ratio [aHR], 1.78; 95% CI [1.73, 1.82]). Among non-LIS beneficiaries, DOAC discontinuation during coverage gap (N = 91,397; 34%) was associated with 14% higher risk of experiencing stroke and SE during the subsequent 12 months (aHR, 1.14; 95% CI [1.08, 1.20]). CONCLUSION: Increased OOP costs during Medicare coverage gap were associated with higher risk of DOAC discontinuation, which in turn was associated with higher risk of stroke and SE among beneficiaries with NVAF.

Five-year impact of Medicare Part D coverage gap reform on drug expenditures and utilization.

OBJECTIVE: To estimate the impact of the Medicare Part D coverage gap reform under the Affordable Care Act (ACA) on the utilization of and expenditures for prescription drugs within the first five years of the policy's implementation. DATA SOURCES: 2008-2015 Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN: We used a difference-in-differences approach to estimate the year-by-year changes in prescription drug use and expenditures before (2006-2010) and after (2011-2015) the ACA's Part D coverage gap reform between Part D beneficiaries not receiving the Low-Income Subsidy (LIS) and those receiving the LIS. DATA COLLECTION: The study sample included Part D beneficiaries (a) aged 65 years or older; (b) not disabled or having end-stage renal disease; (c) continuously enrolled in a Part D plan (d) having at least one prescription fill in a given year. Survey-reported and administrative Part D events data in the MCBS were used for the analyses. PRINCIPAL FINDINGS: After the ACA reform, annual out-of-pocket drug spending significantly decreased by $88 (P < .01) among non-LIS beneficiaries compared to LIS beneficiaries, with growing decreases over time (average decreases of $41 in 2011, $49 in 2012, $105 in 2013, and $135 in 2015, P < .01 or <.05). Changes in out-of-pocket costs were largely driven by significant decreases among brand-name drugs (overall decrease of $106, P < .01). Despite significantly reduced out-of-pocket spending, there were no significant changes in the overall number of 30-day drug fills and total drug spending; however, changes in the use of brand-name and generic drugs were seen after the ACA (increase of 1.9 fills for brand-name drugs and decrease of 2.3 fills for generic drug in 2015, P < .05). CONCLUSIONS: The ACA coverage gap reform has helped to reduce the out-of-pocket drug cost burden for beneficiaries, although it had no noticeable impact on drug use or total drug spending.

Factors Associated with Entering the Prescription Drug Coverage Gap Among Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease.

Patients with chronic obstructive pulmonary disease (COPD) need long-term use of COPD medications to manage their conditions. However, COPD patients enrolling in Medicare Advantage plans (MAPs) may enter the coverage gap, resulting in increasing financial burden. The purpose of this study was to identify characteristics of COPD patients who enter the Medicare coverage gap and the factors associated with time to enter the coverage gap. A retrospective cross-sectional study was conducted using a Texas MAP database between 2011 and 2014. Patients aged ≥65 years with a diagnosis of COPD and taking medication to treat COPD were included. Patients were divided into mainly 2 groups: "no gap" versus "gap," based on their pharmacy outpatient spending. Within "gap," patients were further categorized into "coverage gap" and gap with "catastrophic coverage." Multinomial logistic regression was conducted to identify characteristics associated with reaching "coverage gap" and "catastrophic coverage." Cox proportional hazards were performed to evaluate factors associated with time to reaching "coverage gap." A total of 3142 COPD patients were identified: "no gap" (79%) and "gap" (21%). Among patients in "gap," 51% fell into "catastrophic coverage." Age, low-income subsidy (LIS) level, and Centers for Medicare & Medicaid (CMS) risk score were significant factors associated with entering both "coverage gap" and "catastrophic coverage." Younger age, greater CMS risk score, and higher LIS benefit were associated with a higher hazard ratio of reaching the coverage gap. These characteristics may assist health maintenance organizations to identify beneficiaries who can potentially be provided with services with or without counseling on drug utilization.

Homelessness and Medicaid Churn.

Objectives: To identify ICD-10-CM diagnostic codes associated with the social determinants of health (SDOH), determine frequency of use of the code for homelessness across time, and examine the frequency of interrupted periods of Medicaid eligibility (ie, Medicaid churn) for beneficiaries with and without this code. Design: Retrospective data analyses of New York State (NYS) Medicaid claims data for years 2006-2017 to determine reliable indicators of SDOH hypothesized to affect Medicaid churn, and for years 2016-2017 to examine frequency of Medicaid churn among patients with and without an indicator for homelessness. Main Outcome Measures: Any interruption in the eligibility for Medicaid insurance (Medicaid churn), assessed via client identification numbers (CIN) for continuity. Methods: Analyses were conducted to assess the frequency of use and pattern of New York State Medicaid claims submission for SDOH codes. Analyses were conducted for Medicaid claims submitted for years 2016-2017 for Medicaid patients with and without a homeless code (ie, ICD-10-CM Z59.0) in 2017. Results: ICD-9-CM / ICD-10-CM codes for lack of housing / homelessness demonstrated linear reliability over time (ie, for years 2006-2017) with increased usage. In 2016-2017, 22.9% of New York Medicaid patients with a homelessness code in 2017 experienced at least one interruption of Medicaid eligibility, while 18.8% of Medicaid patients without a homelessness code experienced Medicaid churn. Conclusions: Medicaid policies would do well to take into consideration the barriers to continued enrollment for the Medicaid population. Measures ought to be enacted to reduce Medicaid churn, especially for individuals experiencing homelessness.

Are Medicaid Coverage Gaps Associated with Higher Health Care Resource Utilization and Costs in Patients with Schizophrenia?

The objective was to assess the association of Medicaid coverage gaps with health care resource utilization (HRU) and costs of patients with schizophrenia. Patients with schizophrenia were identified from the Medicaid database. The beginning of the first eligible gap was defined as the index date. Per-patient per-month (PPPM) HRU and costs before versus after a gap were assessed, and the association between gap duration and PPPM HRU and costs was examined up to 12 months post index. Together with 95% confidence intervals, HRU differences were reported in rate ratios (RRs), and cost differences were reported in 2016 US dollars. A subgroup of males with substance use disorder (SUD; risk factors for incarceration) also was analyzed. Total PPPM health care costs increased significantly by $711.04 following a coverage gap (P < 0.001). Gaps of 180-365 days were associated with a significant increase in inpatient visits (RR = 1.27; P < 0.001) relative to gaps of <90 days. Gaps of 90-179 days were associated with significantly more PPPM inpatient visits (RR = 1.14; P = 0.024) relative to a gap of <90 days. Inpatient costs were particularly increased for gaps of 180-365 days versus those of <90 days (cost difference = $101.81 PPPM; P = 0.0008). Similar results were found in male patients with SUD, in whom HRU and cost differences appeared larger. In patients with schizophrenia, longer Medicaid coverage gaps were associated with increases in inpatient admissions, emergency room visits, and inpatient costs, particularly among patients with risk factors for incarceration. These results support policies that aim to facilitate Medicaid reinstatement for patients with schizophrenia.

Medication adherence among chronic condition patients in the Medicaid coverage gap.

BACKGROUND: People with incomes below the Federal Poverty Level (FPL) do not qualify for health insurance subsidies and may not be eligible for Medicaid. Patients in this Medicaid Coverage Gap may have difficulty paying for their medications. OBJECTIVE: To estimate medication adherence and the prevalence of underinsurance among chronic condition patients in the Medicaid Coverage Gap. METHODS: A retrospective cohort study was conducted using 2014-2016 data extracted from the Medical Expenditure Panel Survey. The sample included non-elderly patients with prescription fills (≥2) for at least one of five chronic conditions (hypertension, hyperlipidemia, diabetes, depression and anxiety disorder) and income below the FPL. Medication adherence was measured using Medication Possession Ratio (MPR), and adjusted using patient demographics, health conditions, and health care utilization. The prevalence of underinsurance also was examined. RESULTS: Of the 316 patients, 60.4% were female, with an average age of 50, and an average of 3 health conditions. The weighted MPR was 72.0% and 44.6% had an adjusted MRP ≥80%. Nearly 80% of the patients were either continuously uninsured (21.6%) or underinsured (59.0%). CONCLUSIONS: A significant proportion of chronic condition patients in Medicaid Coverage Gap were underinsured and less than half were adherent to their medications.

Effect of coverage gap on healthcare utilization among Medicare beneficiaries with chronic obstructive pulmonary disorder.

OBJECTIVE: To evaluate the association between the Medicare coverage gap with hospitalization, emergency room (ER) visits, and time to hospitalization in chronic obstructive pulmonary disease (COPD) patients. METHODS: Retrospective cohort study using data from a Medicare Advantage (MA) plan. Patients with ≥1 claim for COPD at baseline, ≥65 years, continuous 24-months enrollment and without any cancer/end stage renal disease diagnosis were eligible. Patients not reaching the coverage gap (no coverage gap) were matched and compared to those reaching the coverage gap and those reaching catastrophic coverage in separate analyses. Chi-square tests and Cox proportional hazards model were used to compare outcomes across matched cohorts. RESULTS: In total, 3142 COPD patients were identified (79% no coverage gap, 10% coverage gap, and 11% catastrophic coverage). Compared to the no coverage gap group, a larger number of beneficiaries in the coverage gap group had ≥1 hospitalization (26% vs 32%, p < .05), ≥ 1 ER visits (43% vs 49%, p < .05), and ≥1 hospitalization/ER (total visit) (47% vs 54%, p < .05), respectively. Compared to the no coverage gap group, a greater number of beneficiaries in catastrophic coverage had ≥1 ER visit (45% vs 53%, p < .05) or ≥1 total visits (48% vs 56%, p < .05), respectively. Time to hospitalization was shorter among those entering the coverage gap as compared to the no coverage gap [Hazards Ratio (HR) = 1.5; p = .040]. CONCLUSIONS: COPD patients entering the coverage gap and catastrophic coverage were associated with increased utilization of healthcare services. Entering the coverage gap was also associated with shorter time to hospitalization as compared to the no coverage gap.

Vaccine exemptions and the kindergarten vaccination coverage gap.

BACKGROUND: Vaccination requirements for kindergarten entry vary by state, but all states require 2 doses of measles containing vaccine (MCV) at kindergarten entry. OBJECTIVE: To assess (i) national MCV vaccination coverage for children who had attended kindergarten; (ii) the extent to which undervaccination after kindergarten entry is attributable to parents' requests for an exemption; (iii) the extent to which undervaccinated children had missed opportunities to be administered missing vaccine doses among children whose parent did not request an exemption; and (iv) the vaccination coverage gap between the "highest achievable" MCV coverage and actual MCV coverage among children who had attended kindergarten. METHODS: A national survey of 1465 parents of 5-7year-old children was conducted during October 2013 through March 2014. Vaccination coverage estimates are based provider-reported vaccination histories. Children have a "missed opportunity" for MCV if they were not up-to-date and if there were dates on which other vaccines were administered but not MCV. The "highest achievable" MCV vaccination coverage rate is 100% minus the sum of the percentages of (i) undervaccinated children with parents who requested an exemption; and (ii) undervaccinated children with parents who did not request an exemption and whose vaccination statuses were assessed during a kindergarten grace period or period when they were provisionally enrolled in kindergarten. RESULTS: Among all children undervaccinated for MCV, 2.7% were attributable to having a parent who requested an exemption. Among children who were undervaccinated for MCV and whose parent did not request an exemption, 41.6% had a missed opportunity for MCV. The highest achievable MCV coverage was 98.6%, actual MCV coverage was 90.9%, and the kindergarten vaccination gap was 7.7%. CONCLUSION: Vaccination coverage may be increased by schools fully implementing state kindergarten vaccination laws, and by providers assessing children's vaccination status at every clinic visit, and administering missed vaccine doses.

Improving Neonatal Care: A Global Perspective.

Each year, approximately 2.7 million babies die during the neonatal period; more than 90% of these deaths occur in developing countries, largely from preventable causes. The known, evidence-based, simple, low-cost interventions that may improve neonatal survival often have low or unknown baseline coverage rates. Gaps in coverage of essential interventions and in quality of care may be amenable to improvement strategies. However, often these gaps are not easily identified. A variety of international organizations have recommended key indicators of quality and established roadmaps for improving neonatal outcomes. Quality improvement at the facility level is an area for future investment.

Medicare Part D's Effects on Drug Utilization and Out-of-Pocket Costs: A Systematic Review.

OBJECTIVE: To update a past systematic review on whether Medicare Part D changed drug utilization and out-of-pocket (OOP) costs overall and within subpopulations, and to identify evidence gaps. DATA SOURCES/STUDY SETTING: Published and gray literature from 2010 to 2015 meeting prespecified screening criteria, including having a comparison group, and utilization or OOP cost outcomes. STUDY DESIGN: We conducted a systematic literature review with a quality assessment. DATA COLLECTION/EXTRACTION METHODS: For each study, we extracted information on study design, data sources, analytic methods, outcomes, and limitations. Because outcome measures vary across studies, we did a qualitative synthesis rather than meta-analysis. PRINCIPAL FINDINGS: Sixty-five studies met screening criteria. Overall, Medicare Part D enrollees have increased drug utilization and decreased OOP costs, but coverage gaps limit the program's impact. Beneficiaries whose insurance becomes more generous after enrollment had disproportionately increased drug utilization and decreased OOP costs. Outcomes among dual-eligibles were mixed. CONCLUSIONS: There is strong evidence on how Medicare Part D and the donut hole coverage gap affect utilization and OOP costs, but weak evidence on how effects vary among dual-eligibles or across diseases. Findings suggest that the Affordable Care Act's provisions to expand coverage and reduce the donut hole should improve patient outcomes.

Uninsured In Texas, Then And Now.

A sociologist chronicles how uninsurance and health reform have affected one Texas family for over a decade.

Disparity in maternal, newborn and child health services in high focus states in India: a district-level cross-sectional analysis.

OBJECTIVES: To examine the level and trend in the coverage gap of a set of interventions of maternal and child health services using a summary index and to assess the disparity in usage of maternal and child health services in the districts of high focus states of India. DESIGN: Data for the present study are taken from the Annual Health Survey (AHS), 2010-2013 and Census of India, 2011. SETTINGS: This study used secondary data from states having higher mortality and fertility rates, termed as high focus states in India. PARTICIPANTS: District-level information regarding children aged 12-23 months and ever married women aged 15-49 years has been extracted from the AHS (2010-2013), and household amenities, female literacy and main workforce information has been obtained from the Census of India 2011. MEASURES: 2 summary indexes were calculated first for maternal and child health services and another for socioeconomic and development status, using data from AHS and Census. Cronbach's α was used to assess the internal consistency of the items used in the index. RESULTS: The result shows that the coverage gap is highest in Uttar Pradesh (37%) and lowest in Madhya Pradesh (21%). Converge gap and socioeconomic development are negatively correlated (r=-0.49, p=0.01). The average coverage gap was highest in the lowest quintile of socioeconomic development. There was an absolute change of 1.5% per year in coverage gap during 2009-2013. In regression analysis, the coefficient of determination was 0.24, ß=-30.05, p=0.01 for a negative relationship between socioeconomic development and coverage gap. CONCLUSIONS: There is a significant disparity in the usage of maternal and child healthcare services in the districts of India. Resource-rich people (urban residents and richest quintile) are way ahead of marginalised people (rural residents and poorest quintile) in the usage of healthcare services.

Medicare Part D coverage gap: race, gender, and cost-related medication nonadherence.

This study examined whether the Medicare Part D coverage gap directly and indirectly affects the relationship between race, gender, and cost-related nonadherence (CRN). Using a nationally representative sample (N = 1,157), this study found that racial disparities in CRN existed under Medicare Part D. However, reaching the coverage gap mediated differences in CRN between older Blacks and Whites. The coverage gap was associated with CRN and poorer health and lower income were associated with CRN after accounting for coverage gap status. Findings highlight the need to help vulnerable populations avoid CRN and for greater consideration of racial inequities in future policy decisions.

Potential impact of pharmacist interventions to reduce cost for Medicare Part D beneficiaries.

The objective was to determine the impact of simulated pharmacist interventions on out-of-pocket cost, time to coverage gap, and cost per patient to the Medicare Part D program using actual patient cases from an adult general medicine clinic. Medication profiles of 100 randomly selected Medicare-eligible patients from a university-affiliated general internal medicine clinic were reviewed by a pharmacist to identify opportunities to cost-maximize the patients' therapies based on the plan. An online Part-D calculator, Aetna Medicare Rx Essentials, was used as the standard plan to determine medication cost and time to gap. The primary analysis was comparison of the patients' pre-review and post-review out-of-pocket cost, time to coverage gap, and cost to Medicare. A total of 65 patients had at least 1 simulated pharmacist cost intervention. The most common intervention was substituting for a less costly generic, followed by substituting a generic for a brand name. Projected patient cost savings was $476 per year. The average time to coverage gap was increased by 0.7 ±1.2 months. This study illustrates that the pharmacists may be able to reduce cost to some patients as well as to the Medicare Part D program.

Digesting the doughnut hole.

Despite its success, Medicare Part D has been widely criticized for the gap in coverage, the so-called "doughnut hole". We compare the use of prescription drugs among beneficiaries subject to the coverage gap with usage among beneficiaries who are not exposed to it. We find that the coverage gap does, indeed, disrupt the use of prescription drugs among seniors with diabetes. But the declines in usage are modest and concentrated among higher cost, brand-name medications. Demand for high cost medications such as antipsychotics, antiasthmatics, and drugs of the central nervous system decline by 8-18% in the coverage gap, while use of lower cost medications with high generic penetration such as beta blockers, ACE inhibitors and antidepressants decline by 3-5% after reaching the gap. More importantly, lower adherence to medications is not associated with increases in medical service use.