Introduction to the Use of Medicare Part D Data for Research. Minneapolis MAY 15-16, 2013

Transcription

1 Introduction to the Use of Medicare Part D Data for Research Minneapolis MAY 15-16, 2013

2 Educational Objectives of Workshop Understand the Medicare Part D Program and its benefits Understand what demographic, useful enrollment and linking information is available in the new Master Beneficiary Summary File (the updated Denominator File) Become acquainted with the processing of Part D event data Understand the content of the Part D Event File 2

3 Educational Objectives of Workshop Understand the content of the Part D Characteristics Files Understand issues involved with the use of Part D data for research Understand what special Part D variables have been created for researchers and how they were created 3

4 Educational Objectives of Workshop Begin to appreciate the types of research that can be done using the Medicare Part D data Understand the requirements of the Centers for Medicare and Medicaid Services for obtaining and using Part D data 4

5 Description of the Medicare Part D Program

6 Frequently Repeated Acronyms/Names ResDAC Research Data Assistance Center CMS Centers for Medicare and Medicaid Services CCW Chronic Condition Warehouse Buccaneer Computer Systems and Services MMA Medicare Modernization Act PDP Stand-alone Prescription Drug Plan feefor-service MA-PD Medicare Advantage Prescription Drug Plan 6

7 Frequently Repeated Acronyms/Names LIS Low Income Subsidy TrOOP True Out of Pocket Spending ICL Initial Coverage Limit PDE Prescription Drug Event CCL Catastrophic Coverage Limit PDE Prescription Drug Event MBSF Master Beneficiary Summary File 7

8 Medicare Prescription Drug Program Implemented in 2006 as part of the Medicare Modernization Act (MMA) of 2003 Part D is based on a competitive model where beneficiaries can voluntarily purchase drug coverage offered by private plans. Part D plans have flexibility in the design of plan: benefit package (e.g., deductibles/copays, formularies, prior authorization requirements, etc.) Premiums vary by plan. 8

9 Medicare Prescription Drug Program Part D enrollment is for a calendar year. Beneficiaries may choose from multiple plans during annual open enrollment in Oct-Dec of each year Originally, 6% are plan switchers each year; last 2 years = 13%. Plans are state or region-based and each beneficiary has PDPs from which to choose for 2013 Average base monthly premium in 2013 = 31.17; 2012 = $31.08, down from $32.34 in 2011 Percentage of Medicare beneficiaries enrolled in Part D 2006 = 54% 2010 = 59% 2011 = 60% 2012 = 65% 9

10 Medicare Prescription Drug Program Enrollment in Part D is optional, but a penalty for those without creditable coverage who enroll after age 65. Extra Help available for those who qualify; called Low Income Subsidy (LIS) 10

11 Medicare Part D Enrollment 2012 MAPD = Medicare Advantage Prescription Drug PDP = (Fee-for-Service) Prescription Drug Plan Creditable coverage 26% MAPD 24% No creditable coverage 10% PDP 41% 11

12 . Medicare Part D Standard Benefit, 2013 TrOOP Spending $4,750 TrOOP Spending $ TrOOP Spending $325 Enrollee Pays 5% or $2.60- $6.50 co-pay Enrollee Pays 25% 25% coinsurance ($661.25) Catastrophic Medicare Pays 80% Plan Pays 15% Coverage Gap ($3,984.52) Enrollee Pays 47.5% for brand name drugs, and $3,051 79% for Coverage generic Gap drugs Initial Coverage Period Plan Pays 75% ($ ) Deductible Deductible ($325) Enrollee Pays 100% Total drug spending at OOP threshold or CCL $6, Total Drug Spending at ICL $2,970 Total Drug Spending at deductible limit $325 $0 $0 12

13 True Out-of-Pocket Spending (TrOOP) Not the amount the patient paid well almost TrOOP, "True Out of Pocket Costs : the beneficiary s own out-of-pocket spending; that of a family member or official charity; supplemental drug coverage provided through qualifying state pharmacy assistance programs or Part D s lowincome subsidies; and, under CMS s demonstration authority, supplemental drug coverage paid for with MA rebate dollars. TROOP amounts are the medication costs that can be used to calculate beneficiary payments and are used by CCW/Buccaneer to calculate the benefit phase that each drug fill falls into in the PDE data files. 13

14 . Medicare Part D Standard Benefit, 2013 TrOOP Spending $4,750 TrOOP Spending $ TrOOP Spending $325 Enrollee Pays 5% or $2.60- $6.50 co-pay Enrollee Pays 25% 25% coinsurance ($661.25) Catastrophic Medicare Pays 80% Plan Pays 15% Coverage Gap ($3,984.52) Enrollee Pays 47.5% for brand name drugs, and $3,051 79% for Coverage generic Gap drugs Initial Coverage Period Plan Pays 75% ($ ) Deductible Deductible ($325) Enrollee Pays 100% Total drug spending at OOP threshold or CCL $6, Total Drug Spending at ICL $2,970 Total Drug Spending at deductible limit $325 $0 $0 14

15 . Medicare Part D Standard Benefit, 2012 TrOOP Spending $4,700 TrOOP Spending $ TrOOP Spending $320 Enrollee Pays 5% or $2.60- $6.50 co-pay Enrollee Pays 25% 25% coinsurance Catastrophic Medicare Pays 80% Plan Pays 15% Coverage Gap ($3,727.50) Enrollee Pays 50% for brand name drugs, and $3,051 86% for Coverage generic Gap drugs Initial Coverage Period Plan Pays 75% ($ ) Deductible Deductible ($310) Enrollee Pays 100% Total drug spending at OOP threshold $6, Total Drug Spending at ICL $2,930 Total Drug Spending at deductible limit $320 $0 $0 15

16 Medicare Part D Standard Benefit Thresholds Benefit Parameters Deductible $250 $275 $310 $310 $320 $325 Initial Coverage Limit $2,250 $2,510 $2,830 $2,840 $2,930 $2,970 TrOOP threshold at catastrophic coverage limit (CCL) $3,600 $4,050 $4,550 $4,550 $4,700 $4,750 Total covered drug expenditure at CCL $5,100 $5, $6,440 $6, $6, $6,950 16

17 Extra Help Low Income Subsidy (LIS) Benefits Help paying Medicare drug plan s monthly premium, any yearly deductible, coinsurance, and/or copayments No coverage gap liability No late enrollment penalty Major Effort on the part of CMS and advocacy groups to inform beneficiaries about the Low Income Subsidy available to them to help pay for Part D services. 17

18 Medicare Part D Enrollment, % 10% 14% No creditable coverage Primary coverage through FEHB, TRICARE, or active worker Covered by employers who receive RDS Other creditable coverage 21% 13% Non-LIS in MA-PD LIS in MA-PD Non-LIS in PDP 4% 17% 3% LIS in PDP 18

19 19

20 Public Use Files Describing the Drug Plans a.k.a., Landscape Files Plan Information File Basic Drugs Formulary File Excluded Drugs Formulary ffle Beneficiary Cost File Geography Locator file Pharmacy Networks File Cannot be linked to beneficiary-level files 20

21 Public Use Files Describing the Plans Some content Stand-alone PDP or MA-PD (Local or Regional) Monthly premium amount Annual deductible amount Initial coverage limit Drugs listed on each plan s formulary and tier placement Enrollee cost-sharing amounts for each drug tier 21

22 Public Use Files Describing the Plans Some content Pharmacy networks for each plan Information on utilization management for each drug: quantity limit, prior authorization required, and step therapy Average monthly prices for Part D drugs To locate and order these files: Systems/Files-for- Order/NonIdentifiableDataFiles/PrescriptionDrugPlan FormularyPharmacyNetworkandPricingInformationFil es.html 22

23 Number of Part D Contracts and Plans

24 Patterns of Enrollment in 2009 and 2011 Difference between PDP and MA-PD, not between years Percent of beneficiaries with Enhanced (v. basic) benefits Plan has no deductible Plan offers some gap coverage PDP MA-PD PDP MA-PD 27% 94% 18% 92% 48% 94% 43% 91% 7% 64% 15% 54% Source: MedPAC analysis of CMS 2008 and 2009 landscape and enrollment data: 24

25 % Non-LIS Enrollees Beneficiary Enrollment by Gap Coverage PDP MA-PD 100% 80% 60% 40% No Gap Coverage Gap Coverage 63.1% 20% 0% 31.4% 21.1% 14.1% 5.8% 13.1%

26 26

27 Phase-in of Reduced Cost Sharing for Brand-name and Generic Drugs, Percent Paid by Beneficiary Brand 50% 47.5% 45% 25% Generic 93% 79% 58% 25% 27

28 Plans Increasingly Use Formularies with Generic, Preferred and Non-preferred Tiers PDPs MA-PDs 1% 1% <1% <1% 1% 1% 3% 5% 1% 1% 3% 5% 6% 9% 59% 69% 79% 87% 81% 73% 87% 85% 83% 81% 18% 11% 4% 22% 19% 17% 24% 1% 6% 10% 7% 8% 9% 8% 8% 2% 1% 1% 1% 1% % Coinsurance Generic/Brand Generic/Preferred/Non-Preferred Two Generics/Two Brands Other NOTE: Calculations are share of all plans, weighted by enrollment. Source: NORC/Georgetown University/Social and Scientific Systems analysis for MedPAC. 28

29 29

30 30

31 Rulemaking for Beneficiary-level Part D Data Final Part D rule published May 28, 2008; Effective June 27, 2008 Adds protections compared with traditional Part A and Part B data regarding beneficiary privacy and commercially sensitive plan data: generally, identifiers (beneficiary, prescriber, pharmacy, plan) are encrypted and cost data are aggregated Minimum data necessary 31

32 Beneficiary-level Part D Data Denominator and Numerator information Denominator/Enrollment information In Master Beneficiary Summary File (MBSF) I will talk about today Segment C of this workshop Information on all Medicare beneficiaries Numerator information: Prescription drug event (PDEs) records for Medicare beneficiaries in Part D Both PDP and MA-PD enrollees Part A and Part B service utilization available only for PDP enrollees Approximately 1 billion drug claims annually Will start discussion today 32

33 Need Help? Contact ResDAC (Research Data Assistance Center) University of Minnesota contract with Centers for Medicare and Medicaid Services (CMS) Goal of ResDAC: to help CMS increase the number of researchers skilled in accessing and using CMS databases for studies of the Medicare and Medicaid programs and beneficiaries 33

34 ResDAC Services - Assistance Desk ResDAC Assistance Desk staffed by Masters trained Technical Advisors who answer questions regarding Medicare and Medicaid data: data access and availability, record layouts, individual variables, location of Medicare and Medicaid program information work with researchers from first inquiry to submission of a complete request to CMS for data support ResDAC website 34

35 ResDAC Services - Training Workshops CMS 101: Introduction to the Use of Medicare Data for Research CMS 102: Introduction to the Use of Medicaid Data for Research 1-2 day specialty workshops CMS 105: Using Cost Report Data for Research CMS 106: Introduction to the Use of Medicare Part D Data for Research CMS 302: Conducting Economic Research Using Medicare Data

36 How to Contact the ResDAC Assistance Desk Phone Toll free: 888-9ResDAC ( ) WEB (information) 36