Medicare Part D Data for Research Minneapolis MAY 15-16, 2013 - - PowerPoint PPT Presentation

Introduction to the Use of Medicare Part D Data for Research

Minneapolis MAY 15-16, 2013

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

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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

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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

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Description of the Medicare Part D Program

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 – fee-

for-service

• MA-PD – Medicare Advantage Prescription Drug

Plan

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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

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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.

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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 23-38 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%

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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)

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MAPD 24% PDP 41% No creditable coverage 10% Creditable coverage 26%

Medicare Part D Enrollment – 2012

MAPD = Medicare Advantage Prescription Drug PDP = (Fee-for-Service) Prescription Drug Plan

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Medicare Part D Standard Benefit, 2013

25% coinsurance

.

TrOOP Spendin ending $325 325

$3,051 1 Coverage age Gap

Tot

• tal

al drug ug spend nding ing at OOP OOP thres hreshold

• ld
• r CCL

L $6,95 ,954.52 4.52 Tot

• tal

al Drug ug Spendin ending at ICL $2,9 ,970 70

Deducti uctible

TrOOP Spendin ending $4,75 ,750 TrOOP Spendin ending

$986.25 25 Coverage age Gap ($3,984. 4.52 52) Enrollee ee Pa Pays 47.5% % for brand d name drugs, s, and 79% for generic ic drugs Cata tastr strophic phic Medicar icare e Pa Pays 80% Plan Pa Pays 15 15% Initi tial al Coverage erage Period

• d

Plan Pa Pays s 75% ($1. 1.983. 83.75) 5) Enrollee ee Pa Pays 25 25% ($661.25) 5) Deducti uctible e ($325) 5) Enrollee ee Pa Pays 100% Enrollee ee Pa Pays 5% or $2.60- $6.50 co-pa pay

Tot

• tal

al Drug ug Spendin ending g at dedu ductib ctible le limit $325 325 $0 $0 $0 $0

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True Out-of-Pocket Spending (TrOOP)

• 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 low- income 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.

Not the amount the patient paid – well almost

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Medicare Part D Standard Benefit, 2013

25% coinsurance

.

TrOOP Spendin ending $325 325

$3,051 1 Coverage age Gap

Tot

• tal

al drug ug spend nding ing at OOP OOP thres resho hold ld

• r CCL

L $6,95 ,954.52 4.52 Tot

• tal

al Drug ug Spendin ending at ICL $2,9 ,970 70

Deducti uctible

TrOOP Spendin ending $4,75 ,750 TrOOP Spendin ending

$986.25 25 Coverage age Gap ($3,984. 4.52 52) Enrollee ee Pa Pays 47.5% % for brand d name drugs, s, and 79% for generic ic drugs Cata tastr strophic phic Medicar icare e Pa Pays 80% Plan Pa Pays 15 15% Initi tial al Coverage erage Period

• d

Plan Pa Pays s 75% ($1. 1.983. 83.75) 5) Enrollee ee Pa Pays 25 25% ($661.25) 5) Deducti uctible e ($325) 5) Enrollee ee Pa Pays 100% Enrollee ee Pa Pays 5% or $2.60- $6.50 co-pa pay

Tot

• tal

al Drug ug Spendin ending g at dedu ductib ctible le limit $325 325 $0 $0 $0 $0

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Medicare Part D Standard Benefit, 2012

25% coinsurance

.

TrOOP Spendin ending $320 320

$3,051 1 Coverage age Gap

Tot

• tal

al drug ug spend nding ing at OOP thres resho hold ld $6,65 ,657.50 .50 Tot

• tal

al Drug ug Spendin ending at ICL $2,93 ,930

Deducti uctible

TrOOP Spendin ending $4,70 ,700 TrOOP Spendin ending

$972.50 50 Coverage age Gap ($3,727.50) 0) Enrollee ee Pa Pays 50% for brand d name e drugs, s, and 86% for generic ic drugs Cata tastr strophic phic Medicar icare e Pa Pays 80% Plan Pa Pays 15 15% Initi tial al Coverage erage Period

• d

Plan Pa Pays s 75% ($1. 1.957.50) 0) Enrollee ee Pa Pays 25% 25% Deducti uctible e ($310) 0) Enrollee ee Pa Pays 100% Enrollee ee Pa Pays 5% or $2.60- $6.50 co-pa pay

Tot

• tal

al Drug ug Spendin ending g at dedu ductib ctible le limit $320 320 $0 $0 $0 $0

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Medicare Part D Standard Benefit Thresholds

Benefit Parameters 2006 2008 2010 2011 2012 2013 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 $5,726.25 $6,440 $6,447.50 $6,657.50 $6,950

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“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.

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10% 14% 13% 3% 17% 4% 21% 17%

Medicare Part D Enrollment, 2010

No creditable coverage Primary coverage through FEHB, TRICARE, or active worker Covered by employers who receive RDS Other creditable coverage Non-LIS in MA-PD LIS in MA-PD Non-LIS in PDP LIS in PDP

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Public Use Files Describing the Drug Plans

• 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

a.k.a., Landscape Files

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Public Use Files Describing the Plans

• 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

Some content

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Public Use Files Describing the Plans

• 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:

http://www.cms.gov/Research-Statistics-Data-and- Systems/Files-for- Order/NonIdentifiableDataFiles/PrescriptionDrugPlan FormularyPharmacyNetworkandPricingInformationFil es.html Some content

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Number of Part D Contracts and Plans

2006 - 2012

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Patterns of Enrollment in 2009 and 2011

Difference between PDP and MA-PD, not between years

2009 2011

Percent of beneficiaries with PDP MA-PD PDP MA-PD

Enhanced (v. basic) benefits 27% 94% 18% 92% Plan has no deductible 48% 94% 43% 91% Plan offers some gap coverage 7% 64% 15% 54%

Source: MedPAC analysis of CMS 2008 and 2009 landscape and enrollment data: http://www.cms.hhs.gov/PrescriptionDrugCovGenIn/

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Beneficiary Enrollment by Gap Coverage PDP MA-PD

5.8% 14.1% 13.1% 21.1% 31.4% 63.1%

0% 20% 40% 60% 80% 100% 2006 2007 2008 2006 2007 2008

% Non-LIS Enrollees

No Gap Coverage Gap Coverage 25

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Phase-in of Reduced Cost Sharing for Brand-name and Generic Drugs, 2011–20

Percent Paid by Beneficiary

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2011 2013 2016 2020 Brand 50% 47.5% 45% 25% Generic 93% 79% 58% 25%

Plans Increasingly Use Formularies with Generic, Preferred and Non-preferred Tiers

1% 5% 1% 1% 7% 2% 10% 22% 19% 17% 1% 1% 18% 11% 4% 6% 24% 8% 9% 8% 8% 81% 87% 79% 69% 59% 73% 87% 85% 83% 81% 3% 6% 9%

2006 2007 2008 2009 2010 2006 2007 2008 2009 2010

25% Coinsurance Generic/Brand Generic/Preferred/Non-Preferred Two Generics/Two Brands Other

PDPs MA MA-PDs

NOTE: Calculations are share of all plans, weighted by enrollment. Source: NORC/Georgetown University/Social and Scientific Systems analysis for MedPAC.

1% 1% <1% <1% 1% 3% 5% 1% 1% 1%

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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

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Beneficiary-level Part D Data

• 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

Denominator and Numerator information

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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
• f researchers skilled in accessing and using CMS

databases for studies of the Medicare and Medicaid programs and beneficiaries

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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

• f a complete request to CMS for data

˗ support ResDAC website

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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 ng Cost st Repor

• rt

t Data a for Resear search h ˗ CMS 106: Introd

• duc

ucti tion

• n to the Use of Medicare

are Pa Part t D Da Data a for Resear search ˗ CMS 302: Condu ducting cting Econom

• mic

ic Resear search h Using ng Medicar are Data

How to Contact the ResDAC Assistance Desk

• Phone

˗ Toll free: 888-9ResDAC (888-973-7322)

• Email

˗ resdac@umn.edu

• WEB

˗ www.resdac.org (information)

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