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Invited Commentary
February 2016

Effect of Medicare Part D on the Availability of Medical Treatment for Patients With Glaucoma

Author Affiliations
  • 1Dean McGee Eye Institute, Department of Ophthalmology, University of Oklahoma College of Medicine, Oklahoma City
  • 2New England Eye Center, Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts
  • 3Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor
JAMA Ophthalmol. 2016;134(2):220-221. doi:10.1001/jamaophthalmol.2015.5176

Can federal legislation affect the availability of medical treatment for our patients with glaucoma? This quandary is the fundamental question asked by Blumberg et al1 in this issue in their assessment of the influence of the introduction of Medicare Part D on rates of prescription drug coverage and out-of-pocket spending for patients who require ocular hypotensive medications. Using data from the Medicare Current Beneficiary Survey (MCBS), they determined that from 2004 to 2005 (the period before Part D was available) to 2007 to 2008 (the period after Part D was available), the percentage of beneficiaries without prescription drug coverage was reduced dramatically for their designations of persons characterized as poor, near poor, and those with higher incomes (from 23% to 4%, 29% to 7%, and 20% to 4%, respectively) but that out-of-pocket costs for ocular hypotensive agents were reduced primarily only for the poor who acquired coverage through Part D.

The study by Blumberg et al1 provides valuable insight regarding the impact of the Part D prescription drug benefit of the Medicare Modernization Act, implemented in 2006. Based on their results, the general answer to the opening question herein appears to be yes. One possible explanation for the dramatic reduction in costs for the lowest-income group was the implementation of automatic assignment to a Part D plan among dual-eligible Medicare beneficiaries who are eligible for both Medicaid and Medicare. This single change leveled the benefits across the states and increased formulary access for many Medicaid patients who had inadequate coverage before 2006.

After adjusting for other covariates in their model, Blumberg et al1 also determined that, both before and after implementation of the drug benefit, the near poor, men, and those living in rural areas or Puerto Rico were more likely to lack prescription drug coverage. Why were certain groups more likely to lack prescription drug coverage even after the introduction of Part D? Unlike the lowest-income group mentioned above, the near poor as defined in this study would not have been actively enrolled in a Part D plan and would have to pay a monthly premium once enrolled, thereby creating barriers to access. Puerto Rico is subject to different rules, with limited federal support, which likely also affected access there. Reasons for men and rural residence are less easily explained. Although the authors speculate on the rationale in their discussion, it will be important (as they acknowledge) to further explore the reasons for the reported disparities and, most important, to seek potential solutions in addressing them.

A lack of prescription drug coverage and even the level of copayments for those with coverage can influence medication adherence. For example, Stein and colleagues2 have shown that compared with an enrollee with commercial health insurance and a mean monthly copayment of $10 for glaucoma medications another enrollee whose mean monthly copayment was $30 had a 22% increased odds of demonstrating a decline in medication adherence of 25% or more from the period before generic latanoprost was available to the period after it became available. Similarly, in the Philadelphia Veterans Affairs Medical Center, a change in the copayment from $2 to $7 for a 30-day supply of lipid-lowering medication adversely influenced adherence.3 Given that so many patients with glaucoma struggle with adherence, the study by Blumberg et al1 highlights how the Medicare Modernization Act has expanded coverage and reduced out-of-pocket expenses, which should result in improvements in the portion of medication adherence related to cost.

One might speculate whether the therapeutic paradigm should be altered in patients with glaucoma and limited or no prescription drug coverage. For example, should such patients be considered for early laser trabeculoplasty? Stein and colleagues4 have reported that laser trabeculoplasty is a more cost-effective treatment option compared with prostaglandin analogues for patients who experience difficulty with adherence. Alternatively, perhaps the future of glaucoma care will include a value-based insurance design in which high-value drugs are provided free of charge or at a very low cost to those with early-stage disease to limit loss of sight and prevent costly future spending on more invasive interventions.

Patients who participate in the MCBS are willing to undergo face-to-face interviews to discuss their medication use. One could hypothesize that this group may be more attentive to their medical care in general and more adherent in filling their prescriptions than others who are unwilling to participate in these types of surveys. Although we cannot be certain, we wonder if the lack of prescription drug coverage before the implementation of Medicare Part D would have been even higher in a different population than those who participated in the MCBS. Therefore, the ophthalmologic community may benefit from additional studies using other data sources to explore this issue.

What questions were not answered in the study by Blumberg et al1? Patients in their analysis had all filled at least 1 glaucoma prescription medication during the survey year. The study did not comment on the subgroup of patients who received a diagnosis of glaucoma yet had no record of any filled prescriptions for ocular hypotensive medications. Understanding the barriers that result in some patients with glaucoma going untreated is of paramount importance and merits future study.

The study by Blumberg et al1 also did not address prescription refill rates after the implementation of Medicare Part D or the effect of the coverage gap (the so-called doughnut hole) on medication adherence. As the authors emphasize in their discussion, further work is needed in these areas.

Another unanswered question relates to the current influence of Medicare Part D on prescription drug coverage and out-of-pocket expenses. Since the early years of Part D coverage, more tiering of formularies has occurred, even for dual-eligible patients. Although more generic drugs are available now than in 2008, the rapid rise in the cost of generic drugs has garnered the attention of many in health care and Congress,5 and it is possible that (but unknown whether) higher copayments and noncoverage of certain drugs have eroded some of the early positive effects of the program.

Since the introduction of Medicare Part D and the period assessed in the study by Blumberg et al,1 what has been the effect of premium costs, especially for higher-income beneficiaries? Is the increasing enrollment in Medicare Advantage plans influencing pharmacy plans, deductibles, tiering, or copayments?

Blumberg et al1 have provided important information in this study, as well as another recent related publication on cost-related medication nonadherence and cost-saving behaviors among patients with glaucoma.6 These findings will serve as a baseline regarding our understanding of the impact of Medicare Part D on the availability of medical therapy for glaucoma. We encourage them and others to continue to explore some of these remaining unanswered questions and to identify the most effective treatment approaches in patients for whom medication coverage may be limited.

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Article Information

Corresponding Author: Gregory L. Skuta, MD, Dean McGee Eye Institute, Department of Ophthalmology, University of Oklahoma College of Medicine, 608 Stanton L. Young Blvd, Oklahoma City, OK 73104 (greg-skuta@dmei.org).

Published Online: December 23, 2015. doi:10.1001/jamaophthalmol.2015.5176.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Skuta reported participating in committee activities (unrelated to the present work) for the Ophthalmic Mutual Insurance Company. Dr Mattox reported receiving grant support (unrelated to the present work) from Alcon, Allergan, and Transcend. No other disclosures were reported.

References
1.
Blumberg  DM, Prager  AJ, Liebmann  JM.  Variation in prescription drug coverage enrollment among vulnerable beneficiaries with glaucoma before and after the implementation of Medicare Part D [published online December 23, 2015].  JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2015.5090.Google Scholar
2.
Stein  JD, Shekhawat  N, Talwar  N, Balkrishnan  R.  Impact of the introduction of generic latanoprost on glaucoma medication adherence.  Ophthalmology. 2015;122(4):738-747.PubMedGoogle ScholarCrossref
3.
Doshi  JA, Zhu  J, Lee  BY, Kimmel  SE, Volpp  KG.  Impact of a prescription copayment increase on lipid-lowering medication adherence in veterans.  Circulation. 2009;119(3):390-397.PubMedGoogle ScholarCrossref
4.
Stein  JD, Kim  DD, Peck  WW, Giannetti  SM, Hutton  DW.  Cost-effectiveness of medications compared with laser trabeculoplasty in patients with newly diagnosed open-angle glaucoma.  Arch Ophthalmol. 2012;130(4):497-505.PubMedGoogle ScholarCrossref
5.
Appleby  J. No ready-made Rx for rising drug costs. http://khn.org/news/no-ready-made-rx-for-rising-drug-costs. Published October 19, 2015. Accessed November 18, 2015.
6.
Blumberg  DM, Prager  AJ, Liebmann  JM, Cioffi  GA, De Moraes  CG.  Cost-related medication nonadherence and cost-saving behaviors among patients with glaucoma before and after the implementation of Medicare Part D.  JAMA Ophthalmol. 2015;133(9):985-996.PubMedGoogle ScholarCrossref
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