Association Between the Part D Coverage Gap and Adverse Health Outcomes

Authors

  • Jennifer M. Polinski ScD, MPH,

    Corresponding author
    1. Harvard Medical School, Boston, Massachusetts
    • Divisions of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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  • William H. Shrank MD, MSHS,

    1. Divisions of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
    2. Harvard Medical School, Boston, Massachusetts
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  • Robert J. Glynn PhD, ScD,

    1. Divisions of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
    2. Preventive Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
    3. Harvard Medical School, Boston, Massachusetts
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  • Haiden A. Huskamp PhD,

    1. Harvard Medical School, Boston, Massachusetts
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  • M. Christopher Roebuck MBA,

    1. RxEconomics, Sparks, Maryland
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  • Sebastian Schneeweiss MD, ScD

    1. Divisions of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
    2. Harvard Medical School, Boston, Massachusetts
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Address correspondence to Jennifer M. Polinski, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 1620 Tremont Street, Suite 3030, Boston, MA 02120. E-mail: jpolinski@partners.org

Abstract

Objectives

To determine whether Part D coverage gap entry is associated with risk of death or hospitalization for cardiovascular outcomes.

Design

Prospective cohort study. Beneficiaries entered the study upon reaching the coverage gap spending threshold and were observed until an outcome reaching the threshold for catastrophic coverage occurred or year's end. Nine thousand four hundred thirty-six exposed individuals (those who were responsible for drug costs in the gap) were compared with 9,436 unexposed individuals (those who received financial assistance) based on propensity score (PS) or high-dimensional propensity score (hdPS).

Setting

Medicare Part D drug insurance.

Participants

Three hundred three thousand nine hundred seventy-eight Medicare beneficiaries aged 65 and older in 2006 and 2007 with linked prescription and medical claims who enrolled in stand-alone Part D or retiree drug plans and reached the gap spending threshold.

Measurements

Rates of death and hospitalization for any of five cardiovascular outcomes, including acute coronary syndrome with revascularization (ACS), after reaching the coverage gap spending threshold were compared using Cox proportional hazards models.

Results

In PS-matched analyses, exposed beneficiaries had higher, albeit not significantly so, hazard of death (hazard ratio (HR) = 1.25, 95% confidence interval (CI) = 0.98–1.59) and ACS (HR = 1.16, 95% CI = 0.83–1.62) than unexposed beneficiaries. hdPS-matched analyses minimized residual confounding and confirmed results (death: HR = 0.99, 95% CI = 0.78–1.24; ACS: HR = 1.07, 95% CI = 0.81–1.41). Exposed beneficiaries were no more or less likely to experience other outcomes than were those who were unexposed.

Conclusion

During the short-term coverage gap period, having no financial assistance to pay for drugs was not associated with greater risk of death or hospitalization for cardiovascular causes, although long-term health consequences remain unclear.

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