Jones Kristine, Siegel Carole, Bertollo Dave N, Samuels Judith
Statistical and Services Research Division, New York State Office of Mental Health, Nathan S. Kline Institute, 140 Old Orangeburg Rd., Orangeburg, NY 10962, USA.
Psychiatr Serv. 2009 Apr;60(4):512-9. doi: 10.1176/ps.2009.60.4.512.
The 2003 Medicare Modernization Act shifted medication coverage from Medicaid to Medicare for persons dually eligible for both programs. This study examined the extent to which access to psychiatric and concomitant medications was reduced for dually eligible individuals in New York State. It also examined the extent to which consumer copayments and state costs were changed when the act was implemented in 2006.
Data were from psychiatric medication Medicaid claims in 2002 for the 36,842 dually eligible adults with severe mental illness and from the 2006 formulary data of New York State's 15 prescription drug plans available after the Medicare Modernization Act was implemented. The study simulated how dually eligible persons in New York State would fare under the plans' random and best-fit enrollment scenarios, taking into account the additional coverage provided by New York State's 2006 safety net policy.
Implementation of the Medication Modernization Act reduced drug availability and increased usage restrictions. A study-defined generosity measure estimated a 51%+/-19% reduction in access. Dually eligible individuals with depression experienced the largest treatment gap. Cost changes to the state were essentially budget neutral, primarily because of the required claw-back payment. Consumer copayments increased percentage-wise, but actual dollar amounts remained small; increases were higher under best-fit enrollment compared with random enrollment.
Without a generous safety net policy, dually eligible beneficiaries, especially those with depression, are likely to experience large gaps in their medication coverage and somewhat higher out-of-pocket costs. Treatment gaps were somewhat reduced by placement in best-fit plans, and such placement resulted in no added financial burden to the state. However, this resulted in higher consumer copayments--payments that are small in the actual dollar amount but that might have an impact on spending and on medication access for a largely poor consumer group.
2003年的《医疗保险现代化法案》将双重符合两个项目资格者的药物保险从医疗补助计划转移至医疗保险计划。本研究调查了纽约州双重符合资格者获得精神科药物及伴随用药的机会减少的程度。同时还研究了2006年该法案实施后消费者自付费用和州成本的变化程度。
数据来自2002年36,842名患有严重精神疾病的双重符合资格成年人的精神科药物医疗补助索赔，以及医疗保险现代化法案实施后纽约州15个处方药计划的2006年处方集数据。该研究模拟了纽约州双重符合资格者在计划的随机和最佳匹配参保方案下的情况，同时考虑了纽约州2006年安全网政策提供的额外保险。
《药物现代化法案》的实施减少了药物可及性并增加了使用限制。一项研究定义的慷慨度指标估计可及性降低了51%±19%。患有抑郁症的双重符合资格者经历的治疗差距最大。州成本变化基本保持预算中性，主要是因为有要求的追回款项。消费者自付费用按百分比增加，但实际金额仍然较小；与随机参保相比，最佳匹配参保下的增加幅度更高。
如果没有慷慨的安全网政策，双重符合资格的受益人，尤其是患有抑郁症的人，可能在药物保险方面出现很大差距，自付费用也会有所增加。通过纳入最佳匹配计划，治疗差距有所缩小，且这种纳入未给州带来额外的财政负担。然而，这导致消费者自付费用增加——实际金额虽小，但可能会对一个主要为贫困消费者群体的支出和药物可及性产生影响。
