Medical Research: What is the background for this study? What are the main findings?
Dr. Madden: When Medicare Prescription Drug Coverage started in 2006, many experts voiced concerns about disabled patients with serious mental illness making the transition from state Medicaid coverage to Medicare. Our study is one of the first to examine the impact of the transition in mentally ill populations. People living with schizophrenia and bipolar disorder are at high risk of relapse and hospitalization and are especially vulnerable to disruptions in access to their treatments.
We found that the effects of transitioning from Medicaid to Medicare Part D depended on where patients lived. Transition to Part D in states that put limits on Medicaid drug coverage resulted in fewer patients going without treatment.
By contrast, in states with more generous drug coverage, we saw reductions in use, of antipsychotics in particular, after patients shifted to Medicare Part D. This may have been due to new cost controls used within many private Medicare drug plans. Given that most states in the US are in this latter category, with the relatively generous Medicaid drug coverage, we also found reductions in antipsychotic use nation-wide.
Although a very large group of people made that transition from Medicaid to Medicare in 2006, thousands more still transition every year because when disabled people qualify for Medicare, they must wait 2 years for their benefits kick in. Also, many other disabled patients are on Medicaid only and don’t qualify for Medicare. They are of course affected by restrictions on Medicaid coverage, which vary from state to state.
Medical Research: What should clinicians and patients take away from your report?
Dr. Madden: Undertreatment of severe mental illness is widespread and a longstanding concern. Undertreatment may be exacerbated by features of insurance designed to contain costs. Patients know this already. Clinicians need to be sure to be attuned to it and ask about any problems their patients have accessing medications. Working together, patients and clinicians may be able to come up with ways to ensure continuity of treatment.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Madden: Definitely we need to look more closely at how vulnerable patients may be affected by widely used insurance strategies that can create barriers to treatment, such as limits on the number of covered prescriptions per month, “prior authorization” requirements, and, in many commercial plans, high annual deductibles. The health insurance world is constantly shifting, and unfortunately research takes time, but we need to understand the effects of the arrangements that are being used.