University of Pennsylvania, 1223 Blockley Hall, Philadelphia, PA 19104. E-mail:
Am J Manag Care. 2017 Mar;23(3 Suppl):S39-S45.
Medicare Part D specialty drug users not qualifying for low-income subsidies (non-LIS beneficiaries) face high and variable cost sharing during the calendar year. We examined their out-of-pocket (OOP) cost patterns under the existing Part D cost-sharing policies and proposed changes to these policies.
Using 100% Medicare claims data from 2012, we examined mean annual and monthly OOP drug costs for Medicare Part D patients who were full-year users of Part D specialty drugs for rheumatoid arthritis (RA) (n = 1063), multiple sclerosis (MS) (n = 2256), or chronic myeloid leukemia (CML) (n = 1135) under existing policy. Using the same data, we simulated costs under both proposed Medicare Payment Advisory Commission (MedPAC) policy recommendations and our own recommendations.
In 2012, our sample faced mean annual cumulative OOP drug costs (for all medications) of $3949 (RA), $5238 (MS), and $6322 (CML). Mean OOP costs were $977 (RA), $1613 (MS), and $2456 (CML) in January alone. A substantial proportion of total annual OOP prescription spending also occurred during the catastrophic coverage phase (RA: $1229 [31%]; MS: $2456 [47%]; CML: $3546 [56%]). Under proposed MedPAC changes, patients would have faced maximum annual OOP spending of $4700, but mean OOP costs in January and February would have been higher compared with the existing policy. Under our proposed strategy, OOP costs would have been spread evenly over 12 months (≤$392 per month). The potential incremental costs of our proposed strategy would have been $23.55 per non-LIS Part D beneficiary per year.
The existing Part D cost-sharing structure creates a substantial financial burden for specialty drug users, especially early in the year. Implementing both annual and monthly OOP maximum spending limits would result in lower, more consistent OOP costs, potentially increasing patients' ability to access treatments for life-threatening, chronic, and rare diseases.
不符合低收入补贴资格的医疗保险计划 D 部分专科药物使用者（非 LIS 受惠人）在日历年期间面临高昂且可变的自付费用。我们研究了他们在现行医疗保险计划 D 部分自付费用政策下的自付（OOP）费用模式，并提出了对这些政策的修改建议。
使用 2012 年 100%的医疗保险索赔数据，我们研究了全年使用医疗保险计划 D 部分治疗类风湿关节炎（RA）（n = 1063）、多发性硬化症（MS）（n = 2256）或慢性髓性白血病（CML）（n = 1135）的专科药物的医疗保险计划 D 患者的年度和月度 OOP 药物平均成本。使用相同的数据，我们模拟了医疗保险支付咨询委员会（MedPAC）建议的现行政策和我们自己的建议下的成本。
2012 年，我们的样本面临着 3949 美元（RA）、5238 美元（MS）和 6322 美元（CML）的年度累计 OOP 药物费用（所有药物）。仅在 1 月份，OOP 费用就分别达到了 977 美元（RA）、1613 美元（MS）和 2456 美元（CML）。总年度 OOP 处方药支出的很大一部分也发生在灾难性保险覆盖阶段（RA：1229 美元[31%]；MS：2456 美元[47%]；CML：3546 美元[56%]）。根据拟议的 MedPAC 变更，患者将面临最高 4700 美元的年度 OOP 支出，但与现行政策相比，1 月和 2 月的 OOP 费用将更高。根据我们提出的策略，OOP 费用将在 12 个月内平均分摊（≤每月 392 美元）。我们提出的策略的潜在增量成本将是每位非 LIS 医疗保险计划 D 受益人的每年 23.55 美元。
现行的医疗保险计划 D 部分自付费用结构给专科药物使用者带来了巨大的经济负担，尤其是在年初。实施年度和月度 OOP 最高支出限制将导致更低、更一致的 OOP 费用，这可能会提高患者获得危及生命、慢性和罕见疾病治疗的能力。
