Medicare Part D Has Scant Effect on Outcomes for Acute MI Patients

Only half of all Medicare patients with acute MI in the United States appear to be taking advantage of Medicare’s “Part D” Prescription Drug Plan at the time of hospital discharge, a new study suggests. But of note, 30-day and 1-year outcomes were fairly similar for patients regardless of whether or not they were enrolled in the Part D program, authors say.

Investigators led by Abhinav Goyal, MD, MHS, of Emory University School of Medicine (Atlanta, GA), combined information from Medicare records and the ACTION Registry-Get With The Guidelines database to identify 59,149 Medicare beneficiaries who were discharged from 502 hospitals after acute MI between 2007 and 2010. Only 49.5% were enrolled in Part D at discharge, though this proportion increased slightly over time (P < .0001 for trend).

The study was published online October 28, 2015, in Circulation: Cardiovascular Quality and Outcomes.

Medicare Part D was designed to both minimize out-of-pocket costs for eligible patients and increase medication adherence, the researchers say, but the study found striking differences between the populations of enrollees and nonenrollees. Namely, those enrolled in Part D were more likely to be in lower income classes and less likely to have additional private or military insurance.

Adjustment Attenuates Risk

Unadjusted analyses show the cumulative incidences of 30-day and 1-year death, all-cause readmission, and MACE (death or readmission for MI or stroke) were actually higher for those enrolled in Part D compared with those who were not, although after adjustment the differences—while still statistically significant—were attenuated (Table 1).

Medication adherence among the subset of patients who were enrolled in Part D for at least 90 days prior to discharge and survived through 1 year ranged from 54.8% for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers to 63.6% for P2Y12 inhibitors, with rates for statins and beta blockers falling in between.

Need to Look Beyond Cost

The authors offer several reasons for why “no clinically meaningful association” was seen between Part D enrollment and clinical outcomes. First, they say, since Part D plans only provide “partial prescription coverage with variable cost sharing structures and gaps in coverage,” it is possible that those eligible for low-income subsidies do not know how to apply and hence remain insufficiently covered.

Also, Goyal and colleagues say that patients will often expend their Part D coverage limits on drugs that either do not improve outcomes or are even contraindicated for them—like NSAIDs, steroids, and some diabetes medications.

Lastly, they point out, “even adequate Part D coverage does not necessarily translate to improved adherence,” as cost may not be the only, or even the largest, barrier to this dilemma. A more comprehensive approach to ensuring patients actually take their prescribed medications will need to be designed, the authors write, with coverage being only one part of a “multifaceted strategy.”

New Data to Answer Future Questions

In an interview with TCTMD, Gregory A. Roth, MD, MPH, of the University of Washington (Seattle, WA), said the true value of the study is the combination of registry and Medicare Part D data. “For the first time, we have information nationally on when patients actually go to the pharmacy and pick up a pill bottle,” he said. “That was information we didn’t have before.”

Regardless of the study’s conclusions, Roth said the findings will encourage the ability to “try and answer questions that we couldn’t answer before.” Additionally, he said this is “a good example of how you don’t always have to have a positive result to show something important.”

Specifically, “it tells us that people who are covered by Medicare Part D, in terms of their health … are maybe a lot more similar to people who have private insurance or other kinds of benefits than we had thought, given the fact that they are not really experiencing a lot of extra health risks over the year after their heart attack,” he said. “That tells us maybe this is a good data source that we can … generalize to the larger population.”
 

Source:
Goyal A, de Lemos JA, Peng SA, et al. Association of patient enrollment in Medicare Part D with outcomes after acute myocardial infarction. Circ Cardiovasc Qual Outcomes.2015; Epub ahead of print.

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