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Harvard Medical School (Harvard.edu)

By MARY WALLAN

January 16, 2015

Uneven impact found for those with serious mental illness in transition from Medicaid to Medicare Part D

When Medicare Prescription Drug Coverage started in 2006, many experts voiced concerns about disabled patients with serious mental illness making the transition from Medicaid to Medicare.

A new study by Harvard Medical School researchers at the Harvard Pilgrim Health Care Institute is one of the first to examine the impact of the transition in mentally ill populations. It found that effects on the use of essential and sometimes lifesaving drugs for these patients varied greatly by state. Mentally ill patients transitioning from Medicaid to Medicare Part D in states with strict limits on coverage benefited from the change, while those transitioning from states with more generous coverage had less satisfactory outcomes. The results were published online in JAMA Psychiatry on Jan. 14.

The study performed time-series analysis for patients spanning 2004 - 2007, comparing states that capped monthly prescription fills to states with no prescription limits. Researchers considered Medicaid and Medicare claims for 9,229 patients who lived in the community, were under 65 years old, disabled, enrolled in both Medicaid and Medicare, and who had schizophrenia or bipolar disorder.
The study found the effects of transitioning from Medicaid to Medicare Part D depended on where patients lived.

Transition to Part D in states with limited drug coverage reduced the number of cases of untreated mental illness, which can result in hospitalization and suicide. By contrast, antipsychotic treatments decreased after implementation of Medicare Part D for patients living in states with more generous drug coverage, probably because the new Medicare drug plans also used cost controls that inhibit medication use. Given that most states in the US are in this latter category, with relatively generous Medicaid drug coverage, the authors also found significant and worrisome reductions in antipsychotic use nation-wide.

"To the best of our knowledge, this is the first study of Medicare Part D to examine barriers to mental health treatment for the vulnerable under-65 population with severe mental illness," said Jeanne Madden, first author of the paper and HMS instructor in population medicine at Harvard Pilgrim Health Care Institute. "It highlights the impact of different state Medicaid policies regarding prescription coverage. It also suggests the potential harmful effects of cost shifting strategies sometimes used in Medicare prescription coverage for these patients."

Senior author Steve Soumerai, HMS professor of population medicine at Harvard Pilgrim Health Care Institute, added, "Now the Affordable Care Act is changing insurance for prescription drugs very rapidly. A lot of people have gained health insurance recently, but harmful prescription caps and very high deductibles for needed drugs are widely used. We need to look at whether barriers to treatment, such as the high cost sharing allowed under the ACA, might put vulnerable patients at risk of poor health and institutionalization."

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