title: Changes in drug utilization during a gap in insurance coverage: an examination of the medicare Part D coverage gap.
abstract: BACKGROUND
  Nations are struggling to expand access to essential medications while curbing rising health and drug spending. While the US government's Medicare Part D drug insurance benefit expanded elderly citizens' access to drugs, it also includes a controversial period called the "coverage gap" during which beneficiaries are fully responsible for drug costs. We examined the impact of entering the coverage gap on drug discontinuation, switching to another drug for the same indication, and drug adherence. While increased discontinuation of and adherence to essential medications is a regrettable response, increased switching to less expensive but therapeutically interchangeable medications is a positive response to minimize costs.
  
  
  RESULTS
  We followed 663,850 Medicare beneficiaries enrolled in Part D or retiree drug plans with prescription and health claims in 2006 and/or 2007 to determine who reached the gap spending threshold, n = 217,131 (33%). In multivariate Cox proportional hazards models, we compared drug discontinuation and switching rates in selected drug classes after reaching the threshold between all 1,993 who had no financial assistance during the coverage gap (exposed) versus 9,965 multivariate propensity score-matched comparators with financial assistance (unexposed). Multivariate logistic regressions compared drug adherence (≤ 80% versus >80% of days covered). Beneficiaries reached the gap spending threshold on average 222 d ±79. At the drug level, exposed beneficiaries were twice as likely to discontinue (hazard ratio [HR]  = 2.00, 95% confidence interval [CI] 1.64-2.43) but less likely to switch a drug (HR  = 0.60, 0.46-0.78) after reaching the threshold. Gap-exposed beneficiaries were slightly more likely to have reduced adherence (OR  = 1.07, 0.98-1.18).
  
  
  CONCLUSIONS
  A lack of financial assistance after reaching the gap spending threshold was associated with a doubling in discontinuing essential medications but not switching drugs in 2006 and 2007. Blunt cost-containment features such as the coverage gap have an adverse impact on drug utilization that may conceivably affect health outcomes.
authors.affiliation: Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, Massachusetts, United States of America. jpolinski@partners.org
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Polinski
authors.forename: William H
authors.initials: WH
authors.lastname: Shrank
authors.forename: Haiden A
authors.initials: HA
authors.lastname: Huskamp
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Glynn
authors.forename: Joshua N
authors.initials: JN
authors.lastname: Liberman
authors.forename: Sebastian
authors.initials: S
authors.lastname: Schneeweiss
mesh_terms: D015331:Cohort Studies; D004363:Drug Utilization / Q000191:economics* / Q000639:trends; D005102:Health Expenditures; D006289:Health Planning Support / Q000191:economics; D006801:Humans; D019458:Insurance Coverage / Q000639:trends*; D016015:Logistic Models; D054524:Medicare Part D / Q000191:economics*; D055553:Prescription Drugs / Q000191:economics; D011306:Prescription Fees; D016016:Proportional Hazards Models; D014481:United States
chemical_list: D055553:Prescription Drugs