title: Clinically unintended medication switches and inability to prescribe preferred medications under Medicare Part D.
abstract: Medicare Part D has expanded medication access; however, there is some evidence that dually eligible psychiatric patients have experienced medication access problems. The aim of this study was to characterize medication switches and access problems for dually eligible psychiatric patients and associations with adverse events, including emergency department visits, hospitalizations, homelessness, and incarceration. Reports on 986 systematically sampled, dually eligible patients were obtained from a random sample of practicing psychiatrists. A total of 27.6% of previously stable patients had to switch medications because clinically indicated and preferred refills were not covered or approved. An additional 14.0% were unable to have clinically indicated/preferred medications prescribed because of drug coverage/approval. Adjusting for case-mix, switched patients (p = 0.0009) and patients with problems obtaining clinically indicated medications (p = 0.0004) had significantly higher adverse event rates. Patients at greatest risk were prescribed a medication in a different class or could not be prescribed clinically-indicated atypical antipsychotics, other antidepressants, mood stabilizers, or stimulants. Patients with problems obtaining clinically preferred/indicated antipsychotics had a 17.6 times increased odds (p = 0.0039) of adverse events. These findings call for caution in medication switches for stable patients and support prescription drug policies promoting access to clinically indicated medications and continuity for clinically stable patients.
authors.affiliation: American Psychiatric Institute for Research and Education, Arlington, VA 22209, USA. jwest@psych.org
authors.forename: Joyce C
authors.initials: JC
authors.lastname: West
authors.forename: Donald S
authors.initials: DS
authors.lastname: Rae
authors.forename: Ramin
authors.initials: R
authors.lastname: Mojtabai
authors.forename: Maritza
authors.initials: M
authors.lastname: Rubio-Stipec
authors.forename: Julie A
authors.initials: JA
authors.lastname: Kreyenbuhl
authors.forename: Carol L
authors.initials: CL
authors.lastname: Alter
authors.forename: Stephen
authors.initials: S
authors.lastname: Crystal
mesh_terms: D000328:Adult; D018687:Antidepressive Agents, Second-Generation / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D014150:Antipsychotic Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D011307:Drug Prescriptions / Q000191:economics; D057915:Drug Substitution / Q000009:adverse effects* / Q000191:economics; D004608:Eligibility Determination; D005260:Female; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D007356:Insurance, Pharmaceutical Services / Q000191:economics; D008297:Male; D054524:Medicare Part D; D001523:Mental Disorders / Q000188:drug therapy* / Q000191:economics; D008875:Middle Aged; D055553:Prescription Drugs / Q000008:administration & dosage* / Q000009:adverse effects* / Q000191:economics; D014481:United States
chemical_list: D018687:Antidepressive Agents, Second-Generation; D014150:Antipsychotic Agents; D055553:Prescription Drugs